College  of  ^fjpsficiang  anb  ^urgeong 


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in  2010  with  funding  from 
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http://www.archive.org/details/manualforpracticOObrya 


A    MANUAL 


PRACTICE  OF  SURGERY. 


BY 

THOMAS   BRYANT,    F.K.C.S, 

MEMBER  OF  THE    COUNCIL    AND  COURT  OF  EXAMINKKS  OF    THE    ROYAL    COLLEfiE  OF  SURGEONS;    SENIOR 

SURGEON   TO,   AND   LECTURER  ON   SUROKRY    AT.   GUV'S   HOSPITAL;   MEMB.   CORRESPOND. 

DE   LA   SOClfiTE   DK  CIURURGIE   1)E   PARIS. 


WITH    SEVEN     HUNDRED    AND    TWENTY-SEVEN    ILLUSTRATIONS, 


FOUKTH   EDITION,  THOEOUGHLY  REVISED. 


PHILADELPHIA: 
HENRY   C.   LEA'S    SON    &    CO. 

1885. 


-^ 


<rp  .   ^ 


PBIN'TED   BV 
ELECTRuTYPEU   BY 

p  rr,T^,.c^^r>xT  William  J.  Doenan, 

^^ESTC■OTT  &  Thomson, 

Philadelpbui. 


AMERICAN  PUBLISHERS'  NOTICE. 


American  surgeons  have  unmistakal)ly  signified  their  appreeiation  of  Mr. 
Bryant's  Practice  of  Star/crt/  by  demanding  four  editions  sinee  1879.  The  tJiird 
Ameriean  edition,  like  the  second,  was  reprinted  from  the  third  English  edition, 
and  in  order  to  cover  the  advances  in  Surgery  made  in  the  interval,  it  was 
subjected  to  a  very  thorough  revision  by  Dr.  John  B.  Roberts,  a  former  pupil 
of  ^Ir.  Bryant.  It  has  been  thought  well  to  reprint  the  fourth  English  edition 
without  alteration,  since  it  comes  fresh  from  the  pen  of  the  Author,  and  it 
may  be  noted  that  he  has  seen  fit  to  accept  many  of  Dr.  Roberts'  additions. 
The  two  volumes  of  the  English  edition  have  been  arranged  to  occupy  one  iu 
the  American  reprint — a  change  which  conduces  both  to  convenience  in  hand- 
ling and  comfort  in  reading. 

November,  1884. 


PREFACE  TO  SECOND  EDITION. 


A  SECOND  EDITION  of  this  manual  having  been  called  for,  I  have  availed 
myself  of  the  opportunity  to  make  some  alterations  in  the  substance  a-s  well  as  in 
the  arrangement  of  the  work,  and,  with  a  view  to  its  improvement,  have  recast 
the  materials  and  revised  the  whole.  I  have  also,  to  make  the  work  more  com- 
plete, added  much  new  matter,  including  chapters  on  diseases  and  injuries  of  the 
eye  and  ear,  some  remarks  on  dental  surgery,  on  the  diagnosis  of  ovarian  tumors, 
and  on  deformities,  together  with  at  least  one  hundred  new  wood-cuts. 

I  am  well  aware  that  I  have  foiled  to  realize  in  the  execution  of  mv  ta.-k  the 
ideal  standard  I  at  starting  proposed  to  myself,  and  I  knew,  when  I  first  under- 
took to  write  the  book,  how  difficult  it  was  to  compress  the  treatment  of  the  vast 
range  of  subjects  included  under  the  title  of  "Surgery"  into  one  volume,  but  mv 
object  was  to  oifer  such  an  epitome  of  the  main  princi])les  and  methods  of  practice 
as  should  be  serviceable  to  the  student  and  practitioner ;  and  from  the  recej)tion 
the  first  edition  of  this  work,  published  in  Xoveml^er,  1872,  has  met  with  in  Creat 
Britain  and  America,  I  feel  justified  in  saying  that  I  have  not  failed  in  the  attempt, 
and  that  the  book  supplied  a  want  felt  by  the  professional  public. 

To  the  many  reviewers  who  have  acknowledged  my  labors  so  fairly  and  so 
fully  my  thanks  are  clearly  due,  but  still  more  to  the  profession,  which  has  wel- 
comed my  humble  services  so  kindly. 

Fully  alive,  therefore,  to  the  generous  appreciation  of  my  past  Mork,  and  assur- 
ing my  readers  that  no  pains  have  been  spared  to  bring  the  present  up  to  as  high 
a  standard  as  my  time  and  opportunities  have  allowed,  I  submit  it  in  all  confidence 
to  the  kind  consideration  of  my  professional  brethren  as  no  unworthy  exposition 
of  modern  British  surgery. 

In  its  execution  I  have  endeavoretl  to  acknowledge  on  all  occasions  the  claims 
of  othei*s  and  whatever  merit  or  novelty  may  attach  to  their  views  or  operations, 

V 


vi  PREFACE  TO  SECOND  ELITIOX. 

for  mv  w\:^h  has  been  to  represent  not  so  iniu ii  iny  tjwn  opinion,  as  the  position 
of  surgery  at  the  time  I  write. 

It  Kiilv  remains  for  me  to  express  once  more  my  obligations  to  Mr.  Thomas 
Turner,  the  treasurer  of  Guy's  Hospital,  by  Mhose  kindness  the  materials  in  the 
unrivalled  collections  of  that  institution  were  placed  at  my  disposal ;  to  my  col- 
leagues, Drs.  Moxon,  Goodhart,  and  Purves,  Messrs.  Howse,  C.  Higgens,  and 
Moon  ;    and  to  Mr.  Wesley,  the  artist  who  has  so  ably  illustrated    these  pages. 

Since  I  first  undertook  this  work  deatli  has  deprived  me  of  two  colleagues, 
Mr.  Poland  and  Dr.  Phillips,  lioth  nf  whnm  rendered  me  many  friendly  services 
and  much  valualjle  assistance.     I  refer  to  their  names  with  gratitude  and  regret. 

53  Upper  Beook  .Street,  GR0i5VEX0R  SquARE, 
March,  1876. 


CONTENTS 


LIST   OF  ILLUSTRATIONS. 


INTRODUCTORY    CHAPTER. 


Definition  of  Surjfery— How  to  Investigate  a  Case — Points  for  Inquiry 
in  Surirical  Cases li 


CHAPTER   I. 

Wounds  —  Repair —  Inflaininatiou  — Abscess — Sinus  and  Fistula— Ulcers 
and  Sores— Bed-sores — Mortification — Hospital  Gang-rene— Erysipe- 
las—Krytheina— Traumatic  Fever — Septictemia  and  Pyieniia— Hectic 
Fever 23 


FIG.  PAOE 

1.  riacoid  cells 26 

2.  Diagram  illustrating  the  process  of  re- 

pair    27 

3.  Irrigating      apparatus       for      washing 

wounds 33 

4.  The  interrupted  suture 35 

5.  The  continuetl   suture 35 

6.  The  twisted  suture 36 

7.  The  quilled  suture 36 


FIG.  FAiiE 

8.  The  button  suture 36 

9.  Leiter's  metallic  coil  for  heat  or  cold    .  49 

10.  Pus-corpuscles 68 

11.  Abscess  knife 69 

12.  Sinus  scissors 72 

13.  14.  Tliermographs  of  erysipelas      ...  85 

15.  Thermograph  of  pytemia 92 

16,  17,  18,  19.  Thermographs  of  traumatic 

fever 92 


CHAPTER  II. 

Animal  Poisons— Poisoned  "Wounds — Insect-sting-s — Hydrophobia— Glan- 
dcr.s — Malignant  Pustule,  or  Charbon— Syphilis— Inoculation  and 
Syphilization— Vaccine-Syphilis 100 

20.  Anatomical  tubercle 101       23.  Hereditary  syphilis       116 

21.  Bacilli  from  charbon 108      24.  Syphilitic" teeth 117 

22.  Syphilitic  deposit  in  testicle 112      25.  Healthv  teeth 118 


CHAPTER   III. 


Tumors :    Innocent,    Semi-Malignant, 
Tumors— Cysts— The  3Iicroscopical 


26.  Fattv  tumor 126 

27.  Diffused  lipoma 126 

28.  Molluscum  fibrosum  .            127 

29.  Fibrous  tumor 128 

30.  Enchondromatous  tumor 128 

31.  Adenoid  tumor 129 

32.  Sarcoma  of  bone 131 

33.  Melanotic  sarcoma 132 

34.  Epithelial  cancer  of  stump 136 

35.  Rodent  cancer 1.37 

36.  Colloid  tumor  of  breast,  with  section     •  138 


Cancerous— Cancer— Granulation 
Anatomy  of  Tumors 120 

37.  Fungating  follicular  tumor 141 

38.  Serous  cyst  of  neck 142 

39.  Sebaceous  tumors  and  horn  in  scalp  .    .  145 

40.  Microscopical  anatomy  of  osteoma,  en- 

chondroma 148 

41.  Ditto,  adenoma 149 

42.  Ditto,  lymphoma 150 

43.  Ditto,  sarcoma 151 

44.  Ditto,  myxoma 152 

45.  Ditto,  carcinoma 153 


Vll 


viii  COSTEXTS   WITH  LIST  OF  ILLUSTRATIONS. 

SURGERY  OF  THE  CUTANEOUS  SYSTEM. 
chaptp:r  IV. 

Contusions— Arrow   AYoxiuds— Burns    and    Scalds— Skin-grafting— Chil- 
blains—Frostbite— Boils— Carbuncle— AVarts— Moles— Corns— Bunions 

— IngroAVu  Toe-Xail—Onycbia—Elepliantiasis— Parasites 1  Jo 

FlCi.  PAGE         FIG.  PAGE 

46.  Eib  pierced  bv  arrow 157      56,  57.  Growth  of  black  skin  when  grafted 

47.  Axillary  cicatrix  after  burn 161                          on  sore  of  white  man 166 

48.  Mode  of  applying  extension   after   its               58.  Bunion 174 

division   ." 161      59.  Toe-cap  for  cure  of  bunion 1.4 

49.  Effects  of  burn  on  neck 162      60.  Ingrown  toe-nail 176 

50.  Cheloid  of  Alibert      163      61.  Acute  onychia 176 

51.  Cheloid  of  Addison 163      62.  Chronic  onychia         •        •. ^1^ 

52.  Congenital  cicatrix  of  lip,  nose.  etc.   .    .     163      63.  Horny  growth  beneath  nail 177 

53.  54.  Cicatrization  of  sores  by  skin-graft-                64.  Ungual  exostosis .  177 

ing '. 165      65.  Elephantiasis  Arabum  before  operation .  178 

55.  Scissors'^ for  skin-grafting 165      66.  Elephantiasis  Arabum  after  operation  .  178 

I  67.  Guinea-worm  bleb 179 


SURGERY  OF  THE  LYMPHATIC  SYSTEM. 

CHAPTER  V. 

Inflammation   of  the   LjTiiphatics   and   their  (ilands— Diseases   of  the 
Thyroid  Gland 181 

68.  Exophthalmic  goitre 185      70.  Microscopical    appearance  'of    thyroid 

69.  Pedunculated  thyroidal  tumor    ....    187  ,  glands 187 


SURGERY  OF  THE  >'ERYOUS  SYSTEM. 

CHAPTER  VI. 

Injuries  of  the  Head— Contusions  and  Wounds  of  the  Scalp— Blood 
Tumors— Ostitis— Injuries  of  the  Cranium— Concussion  of  the  Brain 
—Injuries  of  the  Brain  and  its  3Iembranes  complicating  Fracture- 
Compression  of  the  Brain— Encephalitis— Trei)hining— Diseases  of 
the  Scalp  and  Cranium— Trismus  and  Tetanus— Delirium  Tremens— 
Shock  and  CoUapse— Feigned  Disease 189 

71    Gutter-Shaped  fracture  of  skull  ....  192  77.  Extravasation   of   blood   between  bone 

72.  Saucer-shaped  ditto 192  and  dura  mater 202 

73.  Comminuted  fracture  of  skull     ....  193  78.  Section  of  skull,  with  cranial  contents.  203 

74.  Fracture  of  base  of  skull 194  79.  Hernia  cerebri 206 

75.  Fracture  of  anterior  fossa  of  the  base  of  80,  81,  82.  Operation  of  trephining     ...    212 

the  skull 196      83.  Meningocele  at  root  of  nose 2L 

76.  Punctured  wound  of  skull 196  ,  84.  Encephalocele    . 217 

I  85.  Necrosis  of  frontal  bone 218 

CHAPTER  VII. 

Injuries  and  Diseases  of  the  Spine— Spina  Bifida— Concussion— Intra- 
spinal Inflammation— Spinal  Paralysis  after  Concussion— Fractures 
and  Dislocations  of  the  Spine— Wounds  and  Sprains— Curvature  of 
the  Spine— Injuries  and  Diseases  of  the  Nerves— Xeuralgia,  Tic 
Douloureux— Neuroma 229 

86  Dissection  of  spina  bifida 229   I   91.  Dislocation  of  spine  forward 238 

87  Double  spina  bifida 230      92.  Fracture  of  spine 238 

88.  Cured  spina  bifida 230      93.  Fracture   of    spine    and     displacement 

89,  90.  Congenital  coccygeal  tumors     .    .    •    232  i  backward 238 


COSTKSTS    WITH   LIST  OF  1  LLrsTIiATIOSS. 


IX 


CHAPTER   \ \\.—  0>,it!nu,J. 


FIO.  I'Ai.K 

94,  95.  Lateral  curvature  of  spine  ....  *244 

96,  97.  Anj;iil;ir  curvature  of  .-.pine     .    .    .  24") 

98,99,100.    Disrasi- ot  rervical  vertebne   .  240 

101.  Synostosis  ol"  ribs  to  vertebra'    ....  247 


102.  Kif^id  spine  of  spinal  disense     ....  247 
10.'}.  Child  suppiirtint^lMMly  in  spinal  disease.  247 
104,  105.  Sa_vre'sapi)uratus  for  spinal  curva- 
ture    247 


CILMTHll    VIII. 


Tlie  Kyo  I']xaiM!iiatioii  of  tlio  Hall 
At'CiuniiHulatioii  -.\<'nt«'iH'ss  aii<l 
juries  of  tlu'  Kye— OperatioiLS  .    . 


aii<l    its   ApiM'ii«Iafi:os— KcfVactum— 
Fi«»l<l  ol"   \'isioii     l>is<'as<'S   aii<l  Iii- 


10(i.   Lielireich's  ophtiialtnosrope 257  115. 

107.  hulirett     ophtlialuioscopie     e.xamina- 

tiou 258  IIG. 

108.  Acconiinodation  and  refraction  ....  2(51 

109.  Oldliaiu's  <)i)litluilnioscope 2«3  117. 

110.  Position  of  patient  for  minor  oplillial-  118. 

niic  operations 290  119. 

111.  Position  for  major  ophthalmic  f)pera-  120. 

tions 290  121. 

112.  ('onij)ressoriuni  forceps 293  122. 

113.  C'ompressorinm  forceps  applied     .    .    .  293 

114.  Wile  speculum 295  ,   123. 


(irooved  director  for  slitting  canalicu- 
lus      296 

Instruments  for  operations  for  strabis- 
mus        .300 

Instruments  for  iridectomy 304 

De  Wecker's  scissors 306 

Artificial  pupils 306 

Instruments  for  extraction  of  cataract .  308 

Incisions  for  extraction  of  cataract    .    .  309 
Instnunents  for   removal   of   cataract 

with  scoop 311 

Extirpation  scissors 313 


AftVftioiis  of  the  Ear 


CHAPTER  TX. 
-External — 3Iiddle— Internal— Deaf- 3Intism 


322 


124.  Congenital  occlusion  of  external  audi-  127.  Hfematoma  auris 324 

tory  canal 322      128.  Cheloid  tumor  of  ear 324 

125.  Politzer's  method  of  examining  middle  129.  Microscopical  appearances  of  same  .    .  324 

ear 322      130.  Syringing  ear 326 

126.  Effects  of  injury  on  ear 323      131.  Appearance  of  niembrana  tympani  .    .  332 


SURGERY  OF  THE  CIRCULATORY  SYSTEM. 

CHAPTER  X. 

Wounds  of  the  Heart  and  Arteries— Hemorrhag-e  and  its  Treatment— 
Siirj»ieal  Hreniostatios- Transfusion — Diseases  of  tlie  Arteries— Em- 
holisni— Aneurism— Nieviis—Lig:ation  of  Arteries — Special  Aneurisms.  338 


132.  EflPects  of  natural  haemostatics    ....  3-10 

133,  134.  Effects  of  contusion  on  an  artery  .  .341 

135.  Effects  of  ligation  on  an  artery     .    .    .  312 

136.  Effects  of  toreion  on  artery 312 

137.  Application  of  ligature  to  artery;  tour- 

nicpiet,  torsion  forceps,  etc  ....  345 

1.38.  Different  modes  of  acupressure     .    •    .  346 

139.  Tlie  femoral  artery  twisted .347 

140.  Speir's  artery  constrictor 347 

141.  Koussel's  injecting  apparatus     ....  351 

142.  Inflammatory    chantje    in    artery    pre- 

ceding atheroma 353 

143.  Atheroma  of  artery 353 

144.  Section   of  artery   plugged  by  an   em- 

bolus      356 

145.  .Sacculated  traumatic  aneurism    .    .    .  .357 

146.  Multiple  aneurisms 358 

147.  Laminated  clot  from  aneurism  ....  359 

148.  Section  through  cured  .'ineurism    .    .    .  360 

149.  Mode  of  applying  pressure  to  femoral 

artery  for  cure  of  aneurism     .    .    .  .'■>64 

150.  Weiss's  double  pad  for  pressure    .    .    .  364 

151.  Coles'  pad  for  elastic  pressure    ....  .364 

152.  Dix's  mode  of  compressing  artery    .    .  368 

153.  Different  operations  for  aneurism    .    .  369 


154,  155.  Collateral  circulation  in  the  lower 
extremity  after  application  of  a  lig- 
ature to  external  iliac  artery  .    .    .  374 

156.  Different   forms  of  arterio-venous  an- 

eurism       374 

157.  Aneurismal  varix  of  axillary  vessels   .  375 

158.  Cock's  case  of  arterio-venous  aneurism.  376 

159.  Cirsoid  aneurism  of  temporal  artery    .  377 

160.  Cirsoid  aneurism  of  foot 377 

161.  Degenerating  nsevus 378 

162.  Mode  of  ligating  nievus 379 

163.  Effects  of  nsevus  of  upper  lip    ....  379 

164.  165.  Modes  of  ligating  large  ni¥vi        .  380 

166.  Needle  for  applying  subcutaneous  liga- 

ture to  na'vus 380 

167.  Application  of  ligature  to  artery  .    .    .  382 

168.  Best  form  of  aneurism  needle   ....  382 

169.  Incision  for  ligation  of  aorta  or  com- 

mon iliac  artery 383 

170.  Operation  of  ligating  common  carotid 

and  facial  arteries 386 

171.  Operation   of  ligating  the  subclavian 

and  lingual  arteries 389 

172.  Lisation  of  axillarv  arterv 390 

173.  174.  Lisation  of  brachial'arterv  .    390,  391 


CONTENTS   WITH  LIST  OF  ILLUSTRATIONS. 


CHAPTER    X.—  Confinued. 


175.  Ligation  of  radial  artery  (upper  third) .  392 

176.  Ligation  of  radial  and  ulnar  arteries  .  392 

177.  Ligation  of  external  iliac  and  femoral 

arteries 393 


178.  Ligation  of  posterior  tibial  artery    .    .  396 

179.  Ditto  behind  malleolus   ....'...  397 

180.  Ligation  of  anterior  tibial  artery     .    .  397 

181.  Ligation  of  dorsalis  pedis 398 


CHAPTER  XL 
Injuries  and  Diseases  of  the  Veins— Venesection 

182.  Obstruction  of  inferior  vena  cava    .    .    403  I   184,  185.  Venesection 

183.  Varicose  veins 404  | 


398 

407 


SURGERY  OF  THE  DIGESTIVE  ORGANS. 

CHAPTER   Xn. 
Affections  of  the  Lips,  Mouth,  Tongue,  Pahite,  and  Tonsil 


409 


186.  Congenital  fissure  of  lower  lip  and  jaw. 

187.  Formation  of  upper  jaw 

188.  Central  fissure  of  lip 

189.  190,191.  Degrees  of  single  harelip  .    . 
192,   193.  Double  harelip 

194.  Position    of   [)atient   for   operation    of 

harelip 

195.  Operation  for  single  harelip 

196.  Hainsby's  truss  for  harelij) 

197.  198.  Collis'  operation  for  harelip     .    • 

199.  Malgaigne's  operation 

200,  201.  Operation  for  double  harelip    .    . 
202,  203,  204.  Tiie  same  with  projecting  in- 
termaxillary bones    

205,  206,  207.  Cheiloplastic   operations  ibr 
deformed  mouth 

208.  Cancer  of  lower  lip 

209,  210.  Operation  for  formation  of  new 

lip .•    • 

211.  Hypertrophy  of  mucous  glands  of  lip  . 

212.  Hypertrophy  of  lip 


409 

213. 

409 

214. 

409 

215. 

410 

216. 

410 

217. 

218. 

411 

219. 

411 

411 

220. 

412 

221. 

412 

412 

222. 

412 

223. 

224, 

412 

226, 

413 

228. 

413 

229. 

414 

230. 

414 

231. 

Cancrum  oris 415 

Ranula  or  sublingual  cyst 416 

Salivary  calculus 417 

Submaxillary  tumor 418 

Ichthyosis  of  tongue 422 

0})eration  for  removal  of  tongue  .  .  .  431 
Different    operations    lor    removal    of 

tongue 431 

T.  Smith's  gag  ._ 432 

Fergusson's   knives  for  operations  on 

palate 432 

Paring   edges  of  fissured  palate  after 

introduction  of  sutures     .    .        .    .  433 

Needles  employed  in  fissured  j)alate  .  433 

225.  Operation  for  fissured  palate  .  .  434 
227.  Fergusson's    operation    on    hard 

palate 435 

Trendelenburg's  tracheal  tampon     .    .  436 

Tonsil  guillotine 437 

Operation  on  tonsil  with  guillotine  .    .  438 

Kemoval  of  tonsil  with  knife    ....  438 


CHAPTER  XIIL 

Diseases  of  the  Gums,  Jaws,  Teeth,  Pharynx,  and  CEsophagus- 
Surgery— Affections  of  the  Pliarynx  and  (Esophagus  .... 

232.  Necrosis  of  lower  jaw  with  condyloid 

process 440 

233.  Fibrous  epulis  from  gum 441 

234.  Epulis  springing  from  bone 441 

235.  Tooth  odontome 441 

236.  Odontome  after  removal 441 

237.  The  same  in  section 441 

238.  Dentigerous    cyst  of    u^jper  jaw  with 

tooth 443 

239.  The  same  of  lower  jaw 443 

240.  Dentigerous  tumor  of  upper  jaw  .    .    .  444 

241.  242.  Enchoudromatous  tumor  of  upper 

jaw • 

243,  244.  Lines  of  incision  for  removal  of 
upper  jaw   ■    •    •  _ 

245.  Saw  for  operation  on  jaw 

246.  Lion  forceps  for  the  same 

247.  Periosteal  sarcoma  of  lower  jaw  .    .    . 

248.  Fibro-cellidar  tumor  of  lower  jaw  .    . 

249.  250.  Fibro-cystic  disease  of  lower  jaw. 

251.  Dislocation  f)f  lower  jaw 

252.  Reduction  of  dislocation  of  lower  jaw. 

253.  254.  Bandage  and  splint  for  fracture 

of  lower  jaw 451 


-Dental 


444 

445 

445 
445 
446 
446 
446 
449 
449 


255.  Thomas'  mode  of  adjusting  fracture  of 
lower  jaw 

256.  Moon's  interdental  splint 

257.  Metal  caps  for  the  same 

258.  Hammond's  wire  sj)lint  for  fracture  of 
jaw  ....    .        ........ 

259.  Hammond's  wire  splint  applied   .    .    . 

260.  Vertical  section  of  tooth 

261.  Development  of  lower  molar  tooth  .    . 

262.  Odontoplastic  odontome 

263.  Radicular  odontome 

264.  Dentigerous  cyst  not  involving  antrum 

265.  Denticle 

266.  Defective  teeth 

267.  Pointed  teeth 

268.  Child's  jaws,  showing  the  development 
of  tiie  })ermanent  teeth 

269.  Mouth  mirror  and  searcher  for  exami- 
nation of  teeth 

270.  Progress  of  decay  in  teeth 

271.  Rhizodontropy 

272.  Pivoting  with  vent 

273.  Manner  of  holding  tootii  forceps  .    .    . 


439 


451 
452 
452 

452 

452 
454 
454 
456 
457 
457 
458 
459 
460 


461 

468 
470 
470 
470 
476 


CONTENTS    Wrril   LIST  OF  ILLI'STIIATIOSS. 


XI 


CHAPTER    \U{.—  Co,itinur,l. 

PIO.  I'AUK  ,  Vm.  PAOE 

274.  Stump  lorieps 477  |  278.  Qisoplia^eal    b<iiif,'ie  witli    metal   oliv- 

275.  Sfdop  i'k'v:it<prs 477  I  arv  end.s 4,S2 

276.  Kevdlviim   pliaryiigual   lonvps  lor  re-  '  271).  Ilorseluiir  pr<)l)ang  for  extracting   for- 

moviiig  I'oreign  l)<Hlie^^ 4S((  ^  eign  Ixtdien  from  tesopliaguH    .    .    .     4)S2 

277.  Impacted  pudding  in  u-sopliagus  .    .    .    481  '  280.  Money  probang,  with  .sponge     ....    482 


CII.MTKK    XIV. 

Iigiiries  oi'  tlio  Alulonu'n  siimI  its  Contents— Wounds  iiiv<»lviii^  Paricti'S 
and  >is(M'ra— Abnormal  Anus,  F<'<'al  Fistula— FoiUMj^n  liodios  in  tli«" 
Sttnnacli  and  lnt<*stiiuvs — (ilastrotoniy  anil  Ciastrostoniy  — Intestinal 
Obstruction — AtMitc  Internal  Stranj;ulation  of  tlie  liowel — Intus- 
susf«'ptions  —  Laparotomy —  Fiit<'rotoiny — Colectomy— Colotomy—Kx- 
eision  of  the  l*yb>rus— Tap|nn}.r  tlu'  Intestine— Tapping-  the  Alulo- 
n»en— Hy<latid  Tumors — Tumors  of  the  Umbilicus 


483 


281. 
282. 

283. 
284. 


285. 


Position  of  alxlominal  viscera  .... 

Lembert's  suture  in  wounds  of  intes- 
tines      

Czernv's  suture 

Piece  of  iron  wire  discliarged  through 
abdominal  walls  after  having  been 
swalliiwed 

Plate  with  teeth  passed  per  anum     .    . 


493 

494 
494 


497 
497 


28r).  Intestine  strangulated  by  a  band  .    .  502 

287.  Ileo-colic  intussuscejition .506 

288.  Operation  of  enterotomy 508 

289.  Mode  of  fastening  bowel  to  integument 

in  the  .same 509 

290.  Thermograpii  of  ca.se  of  enterotomv    .  509 

291.  Colotomv ".    .  512 


CHAPTER  XV. 

Hernia— Abdominal  —  Irreducible  —  Incarcerated  —  Ruptured — Straiijaru- 
lated  —  Taxis  —  Herniotomy  or  Ivelotomy — Multiple  and  Displaced 
Hernia— Injtuiual  Hernia— Radical  Cure  of  Hernia— Femoral  Hernia 
—Obturator  Hernia — Umbilical  Hernia— Trusses     


292.  Congenital  scrotal  hernia 524 

293.  Congenital  hernia  of  the  cord    ....  524 

294.  Congenital  scrotal  hernia,  with  hour- 

glass contraction    ...        ....  524 

295.  Acquired  congenital  form  of  hernia     .  524 

296.  Acquired  hernial  sac 524 

297.  I)isj)laced  hernia — .second  variety     .    .  525 

298.  Third  variety \    .    .  525 

299.  Fourth  variety      525 

300.  Reduction  en  iikix.h: 525 

301.  Oblique  inguinal  liernia 527 

302.  Direct  inguinal  hernia 527 

303.  Femoral  hernia 528 

304.  Author's  pad  for  tru.ss 529 

305.  306.  Met'hanisni  of  strangulation  of  the 

bowel 532 

307.  Effects  of  strangulation  of  the  bowel  .  534 


309. 


310. 
311. 
312, 


314. 

315. 

316. 
317. 
318. 
319. 


Stricture  of  bowel,   result  of  strangu- 
lated hernia 535 

A.  Key's  operation  for  liernia ;   b.  Rel- 
ative  position   of    the   abdominal 

rings  from  within 539 

Hernia  knives 540 

Spica  bandage 542 

313.  Second   variety  of  displaced  her- 
nia (Bell's) 544 

Interstitial    hernia  with  ruptured  neck 

of  heinial  sac — third  variety  .    .    .     545 
Intra-parietal  or  fourth  variety  of  dis- 
placed liernia 546 

Wood's  operation  for  radical  cure     .    .    550 
Obturator  hernia;  external  view  .    .    .    555 

The  same  ;  internal  view 555 

Congenital  umbilical  liernia 556 


CHAPTER  XVI. 

Surgrery  of  the  Anus  and  Rectum— Malformations — Injuries  of  Rectum — 
Foreign  Bodies— Diseases  of  Rectum  and  Anus — Fissure  and  Pain- 
ful Ulcer  of  Anus— Anal  Abscess  and  Fistula  in  Recto — Hemorrhoids 
or  Piles— Treatment— Prolapsus  Recti— Rectal  Polypus— Ulceration 
and  Stricture  of  Rectum— Excision  of  Lower  End  of  Rectum— Feed- 
inj"  and  3Iedication  by  Rectum 


320.  Rectum    ending   in   cul-de-sac    above 

anus 561 

321.  Enormously  distended  rectum  in  man 

after  operation  for  imperforate  rec- 
tum in  infancy 562 

322.  Speculum  for  examination  of  rectum  .    566 

323.  Operation  for  anal  fistula 570 


561 


324.  Internal  hemorrhoids 572 

325,  326.  Forceps  for  hemorrhoids   ....  574 

327.  Clamp  for  hemorrhoids 574 

328.  Prolajjsus  recti 576 

329.  Villous  polyj)us  of  rectum 578 

330.  Microscopical  drawing  of  the  same      .  578 

331.  Cancerous  stricture  of  rectum   ....  581 


xii  CONTEXTS   WITH  LIST  OF  ILLUSTRATIONS. 


SURGERY  OF  THE  RESPIRATORY  SYSTEM. 

CHAPTER   XVII. 

Surgical  Affections  of  the  Xose— Wounds— Fracture— Epistaxis—Liimnia 
—Lupus— Cancer— Rhinoscopy— Foreign  Bodies— Xasal  Calculi— Poly- 
pus—Ozgena — Disease  of  Frontal  Sinus— Rhinoplasty 586 

FIG.  PAGE         FIG.  PAGE 

332.  Kepair  of  incised  wound  of  nose    .    .    .    586      339.  Removal  of  nasal  polypi  by  noose  .    .    591 

333.  Forceps  and  nose  truss  for  treatment  of  340.  Cancer  of  nose 592 

deformed  nose 586  341.  Enostosis  of  frontal  sinus 595 

334.  Nasal  douche 587  342.  Enostosis  after  removal 595 

335.  Bellocq's  canula  for  plugging  nostrils  .  588  j  343.  Diagram  of  flap  for  rhinoplastic  opera- 
•336.  Lupus  of  nose 589  I                   tion      596 

337.  Form  of  flap  for  formation  of  new  nose    589      344.  Appearance  of  face  after  formation  of 

338.  Tube   for   insufflation   of  tannin   into  I  new  nose 597 

nose 591   1 

CHAPTER    XVIII. 

Surg-ical  Affections  of  the  Larynx  and  Trachea— Wounds  of  Throat — 
Foreign  Bodies  in  W^indpipe— Scald  of  Larynx — Excision  of  Larynx 
— Bronchotomy — Tracheotomy — Laryugotomy 597 

345.  Bone  in  larynx ....  601  350.  Durham's  canula  and  pilot 609 

346.  Date-stone  impacted  in  right  bronchus.  601  351.  Bryant's  canula 609 

347.  Gross'  trachea  forceps 602  352.  Tracheal     aspirator     for     removal    of 

348.  Laryngoscopic  examination C)0o  lymph  and  foreign  bodies  ....    609 

349.  Operation  of  tracheotomy (308 

CHAPTER   XIX. 

Surgery  of  the  Chest — Contiisions — Rupture  of  the  Pectoral  Muscle — 
Fractured  Rihs — Wounds  of  the  Chest — Tapping  the  Chest — Apnoea 
or  Asphyxia — Drowning— Treatment  of  Apnoea  or  Asphyxia 611 

353.  Mode  of  strapping  che.st  in  fractured  354.  Position  of  patient  for  ejection  of  fluids 

ribs 613  ,  in  case  of  drowning 619 


355.  Artificial  respiration  by  direct  method.    620 


SURGERY  OF  THE  URINO-GENITAL  SYSTEM. 

CHAPTER  XX. 

Diseases  of  the  Kidney— Stone— Xephrotomy—Xephritis— Hsematuria— 
Suppression  of  L^rine— Stone  in  the  Kidney— Renal  Surgery— Para- 
centesis of  the  Kidney— Nephrotomy— Xephrectomy—Nephrorraphy  622 

356.  Urinary  disease  from  obstructed  ureter.    623      357.  Clover's  bladder  evacuator 626 

CHAPTER   XXI. 

Diseases  of  the  Bladder  and  Prostate— Irritable  Bladder— Inflammation 
—Ulceration  —  Tubercular  Disease  —  Tumors  —  Cancers  — Atony— Yes- 
ico-Intestinal  Fistula— Incontinence  of  Urine— Diseases  of  tlie  Pros- 
tate— Inflammation — Abscesses — Hypertropliy 632 

358.  Sacculated  bladder 634  364.  Dermoid  growth  removed   from  blad- 

359.  Syphon  mode  of  washing  out  bladder  .  635  der,  etc ■    •  640 

360.  Villous  growth  in  bladder 637  365.  Microscopical  section  of  skin  covering 

361.  Polypoid  outgrowths  from  bladder  .    .  637  growth 641 

362.  Thompson's  bladder  forceps 639  \  366.  Enlargement  of  third  lobe  of  prostate  .  647 

363.  Rectal  dilator  for  raising  bladder  out  !  367.  Prostato-vesical  calculus 650 

of  pelvis 640  [ 


coyTKSTs  wrrif  list  or  riJ.rsrn.iTioxs. 


XIII 


CIlAITKIl    XXII. 

Stone  in  tli4'  Itlatltirr,  and  its  Tri'atnM-nl  I  rinai'>  I  >«'|»osits  — l{«*nal  <'al- 
i-uli  Lit  lioiil  i-i|i(  i«-s  Lit  li<>toMi.\  Lit  hot  rit  >  S«>iii-<-«'s  4»t'  I>ifli<-ult>  in 
ljtliotoMi>,  and  li<»\v  to  A\oi4l  tlwin  <>lli«-i-  <>|MTations  ('ans<->  of 
l>4-alli  al't<T  Lithotomy  Stoii4>  iii  th<*  l-'cinah*  ItlatlUcr  —  Forci^^n 
HtMlit'S   in    the   IthMlth'i* r>.")l 


FUi. 

368. 
3»)<.t. 
37(1. 
371. 
37  J. 
37:?. 
374, 
o<0. 
377. 
378. 
379. 

380. 
381. 
382. 
383. 


PACiE  FKi. 

Kpitluliiiiii  rri'iii  iiriiiiuv  passages    .    .  Col  384, 

S|(«.Tiii:itiizn:i  iiiul  \a;ri":»l  epillioliiiiii    .  (iol  386, 

riiiiaiv  I'a.sts <i.^2  388. 

I'laii's' tir)2  :}89. 

Iric  arid 6.")3  .TJO. 

O.xalaU-  ..f  liiiu' 6o3  391. 

37 .J.  I'iiospl.atos 6o3  392. 

TvrosiiK'  aiul  leiu-ine 6o4  393. 

Cystine 6o4  394. 

Renal  calculus 055  395. 

Uric  a<'i(i  calcnlus  witli  oxalate  of  lime 

nucleus 656  396. 

Mull)errv  calculus  and  section  ....  657 

Mi.xed  calculus 658  397. 

Cystic  oxide  calculus 658 

Phospliatic  calculus  on  piece  of  cathe-  398, 

ter 658  , 


666 


385.  Catheters 

387.  Operation  of  litliotrity 

Litliotritc  and  cvacuator 

Stalls  for  lithotomy 

Knives  for  same 

Scoops  for  same 

Blunt  gorfiet 

Lithotomy  IjraceleLs 

Lateral  lithotomy  witii  curved  staff  .    . 
Lateral    lithotomy   with   straight  .staH" 

(Key's   operation  J 

Calculus  removed  from  female  hiadder 

per  vaginam 

Portion  of  catheter  removed  from  male 

hiadder 

Stiletto  removed  from  female  bladder  . 


I'AOK 

661 

mi 

6<;9 
671 
671 
672 
672 
672 
t;73 


674 

680 

681 
682 


CHAPTER    XXIII. 

Surg'ery  of  tin'  I'rrtlira— Obstruction— Organic  Stri<'turo  — Urotlirotoniy 
—  C"onii)li<*ations  of  Stricture —  C'ifatricial  or  Traumatic  Stricture- 
Causes  of  Death  from  Stricture— Ruptured  Urethra— Spasnuxlic 
Stricture— Inflammatory  Stricture.  Retention  of  Urine— As  a  Symp- 
tom of  Enlarj;«'d  Prostate  and  in  the  Ag-ed— As  a  Result  <)f  an 
Elon.u'ate*!  and  Adherent  Prepuce — From  Org-anic  or  Ci<*atricial 
Stricture— Puncture  of  the  Bladder  per  Rectum — Extravasation  <)f 
Urine —  Retention  from  Impacted  Urethral  Calculus  —  Urethral 
"Shock"  and   "Fever"     6S2 


399.  Stricture  of  urethra 


683 


400 
401 
402 
403 
404 


Olivarv  elastic  catheter 685 


Mode  of  fastening  catheter  in  bladder.  687 

Richardsoti's  urethral  dilator    ....  688 

Urethrotome  with  guide  bougie    .    .    .  689 

Syme's  perineal  catlieter 690 

405.  Grooved  staff  for  Wheelhouse's  opera- 
tion    690 


406.  Teale's  probe  gorget 690 

407.  Wheelhouse's  operation 691 

403.  Cock's  operation  of  tapping  urethra  in 

perin.i'um 692 

409.  Urinary  fistula      695 

410.  Operation  of  puncturing  bladder  per 

rectum 704 


CHAPTER   XXIV. 

Affections  of  the  Genital  Orj«:ans — Phim<»sis— Circumcision— Paraphimo- 
sis— Amputation  of  the  Penis  — Injuries  to  P<'nis— 3Ialforniation  of 
the  Urino-(i<'nital  ()r<ians.  Lo<'al  Venereal  I)is<'ase — fionorrlnea — 
Chorde*' — <»<»norrh<eaI  Rheumatism— Herpes  Preputial  is — Chancre — 
Phayethena — Hydrocele — Hs^^niatocele.  I>iseases  of  the  Testi<'le — 
Inflammation  of  the  Testicle — Epididymitis— Orchitis— Tubercular 
Disease — Hernia— Cystic  Disease — Cancer— Scrotal  Tumors— Castra- 
tion— Varico<*ele— Affections  of  tlie  Scrotum— < Edema — Eleplianti- 
a.sis—Canc«'r— Sterility— 3Iale  Impotence  and   Spermatorrluea      ... 


411.  Operation  for  phimosis 7('8 

412.  Circumcision  i  first  stej)! 709 

413.  Operation  for  paraphimosis 709 

414.  Stump  after  amputation  of  the  penis 

by  Hilton's  method 710 

415.  Corpus   spongiosum    projecting    from 

urethra  after  injurv 711 


416.  Ectoj>ion  vesica-  in  male 

417.  The  same  in  female 

418.  Perineo-scrotal  hypospadias 

419.  B,  c,  D.  E.    Operation  for  perineo-scro- 

tal hypospadias      

420.  Encysted  hydrocele  of  cord 

421.  Tapping  hydrocele 


708 

ri2 

-1  o 

rii 

ri3 
r2.5 

•26 


xiv  CONTENTS   WITH  LIST  OF  ILLUSTRATIONS. 

CHAPTER    XXlX.—  Contunmf. 

no.  PAGE  FIG.  PAGE 

422.  Mode  of  suspending  testes  with  hand-  426.  Strapping  testicle 749 

kerchief 735      427.  Testicle  in  perinaeum  ...  ...    750 

423.  Hernia  of  testis  following  tubercular  428.  Varicocele 750 

disease 741      429.  Morgan's  suspender  for  varicocele    .    .    751 

424.  Cystic  disease  of  testicle 743      430.  Elephantiasis  of  scrotum 752 

425.  Cancer  of  testicle 744 

CHAPTER   XXV. 

Surgical  Affections  of  Female  Genitals— AVoiinrts— Adherent  Labia— 
Viilviti.s  —  Xonia  —  Xnevi  —  Hernia—  Labial  Absce.sse.s — Labial  Cysts — 
Tumors  —  Cancer  —  Lupn.s — Syphilis- Imperforate  Hymen— Enlargred 
Clitoris  — Clitorirtectomy — Kiipture  of  the  Peiinteum  —  Prolapse  of 
Uterus— Vesico-  and  Ilecto-Vaj^inal  Fistulae 756 

431.  Central  rupture  of  the  perinaeum  .    .    .    758  !  435,  436.  Mode  of  paring  edges  of  vaginal 

432.  Operation  for  ruptured  perinaeum     .    .    759  fistula 761 

433.  Position  of  patient   for  operation   for  437.  Introduction  of  sutures  in  vaginal   fis- 

vesico- vaginal  fistula 761  tula 762 

434.  Self-retaining  speculum  for  the  same  .    761      438.  Speculum  dilator  for  female  urethra    .    763 

CHAPTER   XXVI. 

Diseases  and  Tumors  of  the  Breast— Inflammation— Mammitis— Mam- 
mary Abscess — Induration  —Tumors— Hypertrophy —Cancer — Cystic 
Tumor— Galactocele 763 

439.  Submammary  abscess 766  446.  Cystic  tumor  in  breast  with  intra-cystic 

4r40.  Adenoid  tumor  of  breast  dissected   .    .  769                     growth 774 

441.  Cystic  adenocele 770  447.  Cystic  carcinoma 775 

442.  Solid  adenocele 770  448.  Section  of  sarcomatous  tumor  of  breast.  776 

443.  Hypertrophy  of  breast 770  449.  Open  cancer  of  breast 776 

444.  Section  of  infiltrating  cancer 772  450.  Excision  of  breast 779 

445.  Section  of  tuberous  ditto 772 


CHAPTER  XXVII. 
Ovarian   Disease  and  Ovariotomy— Hysterectomy 780 

451.  Trocar  and  eanula  for  tapping  ovarian  '  453.  Omental  clamp  forceps 789 

cyst  with  sliding  forceps 788      454.  Tait's  clamp  for  hysterectomy  ....    793 

452.  Nelaton's  cyst  forceps 788  , 

THE  SURGERY  OF  THE  MUSCULAR  AND  OSSEOUS  SYSTEMS. 

CHAPTER   XXVIII. 

Affections  of  the  Muscles  and  Tendons— Contusions— Compound  Lacer- 
ation—Dislocation of  Muscles  and  Tendons— Rupture  of  Tendons- 
Wounds  of  Tendons— Inflammation  of  Muscle— Atrophy  of  Muscle- 
Writer's  Cramp— Tumors  in  3Iuscle— Ossification  of  3Iuscle— Rider's 
Bone— Tumors  of  Tendon— Inflammation  of  Tendons— Affections  of 
BursiB  Mucosae,  Synovial  Cysts,  Ganjflion 795 

455.  Rupture  of  rectus  femoris 795  |  463.  Semi-solid  bursa 805 

456.  Thumb  torn  out 796  464.  Bursa  sloughing  from  over  patella  .    .  805 

457.  Ruptured  long  tendon  of  biceps   .    .    .  797  465.  Compound  ganglion  of  hand  and  fore- 

458.  459.  Chronic  inflammation  of  muscle  .  799  arm 810 

460.  Instrument  for  writer's  cramp   ....    801      466.  Lipoma  of  the  palm  simulating  gan- 

461.  Rider's  bone 803  glion 811 

462.  Cancerous  tumor  of  hand 803 


coyTKyrs  with  list  or  ii.i.rsTiiATioys. 


XV 


CIlAl'TKIt     \\l\ 

Ortlioi»;i'(li«-  Siiryorv  "  <lMb-l\M»t  I'lat-l-'oot  Ivihm-U-I\ii«m' — T«*iiotoiiiy 
tor  (  out  i'a«-t«'<l  Liiiil>  (Out  rai-t  ion  of  tii«>  l''iii;;«'r.s  lti;;i«|  Atrophy  — 
N\r\-\«MU 811 

H...  fAi.K         KKi.  ,.A(iE 

4()7.  Types  of  tlie  (lifleioiit  kimis  ol"  (li-ri. nil-                47").   Little's  slioe  for  talipes 819 

ilies  of  the  li:mii>.  aiul  leet    ....  SlU  -17»).    iMvies-CJollev's  splint  for  talipes  .    .    .  81U 

4().S.  Talipes  e<|iiiniis SU  177.   K.xtreiiie    e.xuinple   of   talipes    e<|iiino- 

4(J'J.  ('oii>;eiiital  varus SI  1                       varus H20 

470.  Etpiino-varus .si')  47S.  The  same  jls  remedied  by  operation  820 

471.  Talipes     valgus,    cou^^eiiital     and     ac-                 47'.).   Portions  of  bone  removetl S20 

i|uired S].")  4S0.  Spurious  talipes  val;;us    ......  S'Jl 

47"J.  Talipes  oaleaneus,  eon<;enital    and   ac-  4Sl.  O^^ston's  operation  for  j^enu  valjjum  S2'2 

ipiired SKi  48"J.  Limh  before  and  after  Macewen's  ope- 

47.).   Mode  of  stretehing  tendons  by  .strap-  ration 822 

piuic •*^17  483.  ('ap   and   band   for  extension  in  wry- 

•174.   lUahanau's  splint  for  talipes     ....  817  neck 824 


CHAPTER  XXX. 

Sprains— Contu.sioii.s   and   AVotiiid.s   of  Joints — Dislocations— Soparatioii 
<>f  Kpiphysi's— Conj-renital   3Ialforiiiatioiis  of  Joints 825 


484.  False  joint  alter  dislocation  of  head  of  5U4. 

fenuir      827 

485.  Dislocation  of  sternal  end  of  clavicle 

forward 

486.  Dislocation  of  scapula 

487.  Dislocation  of  hea<l  of  humerus  down- 

ward and  forward 

488.  Subcoracoid  dislocation  of  head  of  the 

humerus 

489.  Subglenoid  dislocation  of  head  of  hu- 

merus   

490.  Dislocation   of  head   of  humerus   be- 

neath clavicle  and   beneath  spine 
of  scapula  

491.  Subspinous  dislocation  of  head  of  hu- 

merus   

492.  Mode  of  re<lucing  dislocations  of  head 

of  humerus  bv  manipulation  .    .    . 

493.  (love  hitch    .    .    ". 

494.  Reduction    l)y    extension    of  arm    up- 

ward     

495.  Dislocation  of  head  of  humerus  with 

fracture 

496.  Dislocation  of  radius  and  ulna  back- 

ward     

497.  Dislocation    of  radius   and    ulna    out- 

ward      

498.  Dislocation    of    radius   and    ulna   for- 

ward      

499.  Dislocation  of  head  of  radius  forward  . 

500.  Dislocation  of  head  of  radius  backward. 

501.  Displacement    of    lower   epiphysis    of 

humerus  backward 

502.  Dislocation  of  hand  forward 

503.  Dislocation    of  hand   and   radius   for- 

ward oti'  ulna 840 


505. 

830 

506. 

832 

507. 

508, 

833  j 

510. 

833  ' 

511. 

833 

512, 

514. 

834 

515, 

834 

517. 

518, 

835  i 

836 

520. 

836 

521. 

837 

522. 

838 

523. 

838 

524. 

i 

525. 

838 

839 

526. 

839 

527. 

840 

528. 

840 

529, 

Puzzle  toy  for  reduction  of  dislocation 

of  phalanges 841 

Levis'  apparatus  for  the  same  ....  842 
Recent  dorsal  dislocation  of  femur  .  .  842 
Rent  in  capsule  in  dorsal  dislocation  .  842 
509.  llio-sciatic  forms  of  dislocation  of 

head  of  femur 843 

Dislocation  of  head  of  femur  on  dor- 
sum   844 

Dislocation  into  the  sciatic  notch  .  .  .  844 
513.  Diagrams  showing  shortening  of 

limb  in  dislocation  backward  .  .  .  844 
Dislocation  into  foramen  ovale  ....  844 
516.    Dislocation    into   foramen   ovale 

and  upon  os  pubis 845 

Dislocation  upon  os  pubis 845 

519.  Method   of  reducing  dislocations 

of  head  of  femur  by  manipulation  .    846 
Dislocation  of  the  tibia  and  fibula  for- 
ward      849 

Displacement    of  the    leg    bones  with 

lower  epiphysis  of  femur  inward  .  849 
Appearance  of  foot  and  ankle  in  I'ott's 

fracture 850 

Dislocation  of  foot  inward  with   frac- 
ture of  inner  malleolus 850 

Dislocation  of  foot  backward  •  •  •  .  .  851 
Astragalus    driven    upward    between 

malleoli ....    852 

Dislocation  of  foot  inward  oH'  the  as- 
tragalus   853 

Compound  dislocation  of  astragalus  .  .  854 
Dislocation  of  the  astragalus  outward  .  855 
530,  531.  Congenital    displacement   of 

head  of  femur 856  . 


CHAPTER    XXXL 
Fractures 857 


532.  Varietiesof  complete  fractures  .    .    .    .  857 

53.3.  Incomplete  fracture  of  clavicle  ....  858 

534.  Incomplete  fracture  of  parietal  bone  .  858 

535.  Impacted  fracture  of  neck  of  femur  .    .  858 

536.  Bavarian  or  immovable  splint  ....  865 

537.  False  joint  in  humerus 868 

53S.  Hyperostosis  of  the  tibia 869 


539.  Fracture  of  scapula S72 

540.  Fracture  of  neck  of  scapula 872 

541.  Fracture  of  head  and   tuberosities  of 

humerus 873 

542.  Impacted  fracture  of  head  of  humerus.  873 

543.  Separation  of  shaft  of  humerus  ott'  up- 

per epipiiysis 873 


XVI 


CONTENTS   WITH  LIST  OF  ILLUSTRATIONS. 


CHAPTER  XXXl.—  Coiithwcd. 


FIG. 

544. 
545. 
546. 

547. 


548. 
549. 
550. 

551. 
552. 

553. 

554. 

555. 

556. 
557. 

558. 

559. 

560. 


561. 
562. 
563. 
564. 

565. 

566. 
567. 

568. 


Fracture  of  surgical  neck  of  liumerus  . 

Splint  for  fracture  of  humerus  .    .    .    . 

Comminuted  fracture  of  condyles  of 
humerus . 

Comminuted  fracture  of  lower  epiphy- 
sis of  humerus,  with  displacement 
of  bone  and  dislocation  inward  of 
radius  and  ulna 

Arrest  of  growth  in  humerus  after  in- 


.)ury 


Displacement  of  hand  with  the  lower 
epiphysis  of  the  radius  backward  . 

Fracture  and  backward  rotation  of 
lower  end  of  radius  (Colles'  frac- 
ture)     

Ajjjiearance  of  hand  and  wrist  in  Col- 
les' fracture 

Fracture  of  radius,  with  displacement 
forward 

Examples  of  Colles'  fracture     .... 

Fractured  end  of  radius  and  styloid 
process 

Splint  for  fracture  of  fore-arm  .... 

Carr's  splint  for  fracture  of  fore-arm    . 

Gordon's  splint  for  fracture  of  fore- 
arm ...        

Radius  and  ulna  consolidated  together 
alter  fracture 

Fracture  of  coronoid  process  and  head 
of  radius , 

Compound  dislocation  of  ulna  and  pro- 
jection of  shall  of  radius  forward, 
following  displacement  backward 
of  the  hand  with  epiphysis  of  ra- 
dius   

Stromeyer's  cushitm 

Fracture  of  jielvis  in  a  child 

Fracture  of  pelvis 

Head  of  femur  driven  through  acetab- 
ulum     

Intracapsular  fracture  of  neck  of  femur 
showing  ligamentous  repair    .    .    . 

Impacted  fracture  of  neck  of  femur  .    . 

Comminuted  fracture  of  upper  end  of 
femur  following  imj)action  of  neck. 

Figure  showing  elevation  of  trochanter 
in  impacted  fracture 


PAGE    I     FIG.  ] 

874  I  569.  Bryant's  test  line  for  shortening  or  frac- 

875  I  ture  of  neck  of  thigh-bone  .... 

i  570.  Intracapsular     fracture     of    neck     of 

876  thigh-bone   repaired 

571.  Doubly  impacted   fracture  of  neck  of 
thigh-bone  ....    

572.  Gurdon  Buck's  sjtlint  with  weight  for 

877  fracture  of  neck  of  thigh-bone  .    . 

573.  Author's  double  splint  for  Iracture  of 

877  neck  or  shaft  of  femur  or  hip  disease 

574.  575.  Absorption    of    neck    of    lemur 

878  after  fracture  witii    corresponding 
healthy    femur    for   com|iarison    . 

576.  Separation  of  epi^)hysis  of  great  tro- 
chanter of  femur 

577.  Drawing  of  the  same  during  life  .    .    . 

878  578.  Impacted  fracture  of  shaft  of  femur  .    . 

579.  Liston's  splint  with  foot-piece  for  frac- 
ture of  thigh 

580.  Hodgen's  splint  for  the  same     .... 

581.  C.  de   Morgan's   splint   for   the   same, 

879  with  improvements 

879      582.  Treatment  of  fracture  of  femur  by  ver- 

879  tical  extension 

583.  Immovable    bandage    for   fracture   of 

tliigli  

584.  Fracture  of  condyles  of  femur  .... 
881      585.  Separation  of  lower  epijjhysis  of  femur. 

586.  Multiple  fracture  of  patella 

881  587.  Fracture  of  patella 

588.  Fracture  of  patella  united  by  bone    .    . 

589.  Splint    lor    fracture    of    patella,   with 
elastic  compression 

590.  Middlesex  Hospital  splint  for  fracture 

882  of  patella 

882      591.  Arrest  of  growth  in  shaft  of  tibia  with 

884  bowing  of  fibula,  following  injury 

884  to  upper  epiphysis  of  tibia  .... 

592.  Splint  for  fracture  of  tibia 

593.  Splint  for  fracture  of  fibula 

594.  V-shaped  fracture  of  tibia 

885  595.  Process  of  setting  fracture  of  leg  .    .    . 

886  596.  Apparatus  for  fixing  and  swinging  a 
fracture  of  leg 

597.  Maclntyre's  splint  and  Salter's  swing  . 

598.  Kathan  Smith's  anterior  wire  splint  for 
fracture  of  leg 


889 
889 

890 


890 
S90 
891 

892 
892 

893 

893 


894 
894 
894 
895 
896 
896 

896 

S97 


898 
899 
899 
899 
900 

900 
901 

901 


CHAPTP]R  XXXII. 

Diseases  of  the  Joints— Pathologieal  Clianges— Diseases  of  Special 
Joints — Treatment — Excision  and  Anipntatioii — Loose  Cartilag-es  in 
Joints — Khenniatic  or  Chronic  Osteo-Athritis— Joint  Disease  Asso- 
ciated with  Nervous  Affections — Acute  Bursitis  and  Suppuration 
around   Joints 905 


599.  Shedding  of  articular  cartilage  in  artic- 

ular ostitis      909 

600.  Section  of  bone  showing  rarefaction  of 

new  bone 909 

601.  Necrosis  of  head  of  femur 913 

602.  Separation  of  upper  ei>iphysis  of  femur    913 

603.  Apparent  elongation  of  lower  extrem- 

ity from  oAduction  of  fenuir    .    .    .    914 

604.  ^6ducted  lower  extremity  in  hip  dis- 

ease  914 

605.  Apparent  shortening  of  lower  extrem- 

ity from  ac/duction  of  femur   .    .    .     914 

606.  ylc/ducled  lower  extremity  in  hip  dis- 

ease   914 


607.  Displacement   of    femora    on    dorsum 

from   disease — front  view   .... 

608.  The  same — side  view 

609.  Lordosis  in  hip  disease,  with   patient 

erect 

610.  The  same  patient — lordosis  eflfaced  .    . 

611.  Lordosis   in   hip  disease,  with   patient 

standing 

612.  The  same — remedied 

613.  Position   of    lower    extremity    in    ne- 

glected hip-joint  disease 

614.  Synostosis  of  hip-joint 

615.  Arrest  of  growth  in  neck  of  femur  fol- 

lowing articidar  ostitis 


914 
914 


915 
915 


915 
915 

915 
916 

916 


CONTENTS    Willi    LIST  o/'   I l.l.ls'li:ATI()NS. 


xvn 


("IIAITKK    XX 

KKI,  1-A(.K 

(ilti.   Apiifuraiici' of  kiiri'-joiiU  in  synovitis  .  '■)! 
(>17.   Aiipi'iiranco  of  kiu'c-inim    in  articular 

ostitis it  17 

t>lS.   Appi-aranri'   ol'    foot    at'irr    ri'inovai   of 

scaplioiil,  fiilioitl,  ami   tliiiT  cnnei- 

forni  l)ont's 918 

()19.   AiMonnt   of  Ik'xioii   in  t-lliow  afti-r  re- 

coviTv  from  tiist-aso it'JO 

t)'20.    I)()nl)!c  splint  as  appliod  in  hij)  disoasf  !)'J"J 
621.  Thomas'  posti-rior  splint    lor   hip  ilis- 

c-asf 9-J2 

(i22.   Ik'ad  of  foniiir  altnvd  liy  disease     .    .  !>2o 

()2;}.   linniovahk-  splint  for  hip  discasi-      .    .  1)24 

624.  Modi'  of  applyint;-  vxtonsion   to   lower 

extremity  in  hip  disease 1124 

625.  Anehylosis  of  hip-joint  at  ri^dit  angles  1(24 

626.  Position  of  lind>  after  Adams'  opera- 

tion    924 

627.  Instruments   employed    for  subeulane- 

ons  division  of  nei-k  of  thigh-l)one  925 

628.  Line  of  seetion  of  neek   of  thigh-hone 

in  Adams'  operation 925 

629.  Splint  for  diseased  knee-joint     ....  926 

(i.SO.  Thomas'  knee  splint    .    ". 92(> 

().'>!.  The  same — applied      926 


.X  I  I. —  ( 'onlinittd. 


7      6:52. 

6:i3. 
6.S4. 

6:^5, 
6.>C>. 
637. 

638. 

639. 
640. 

641. 
642. 

643. 

644. 
645. 
646. 

647. 


PAOK 

Ilavarian   splint,  as  rompleted   for  dis- 

eii.se  of  knee 927 

CJowan's  exeision  saw 931 

Abscess  in  liead  of  tiFiia  with  necrosis, 

hnrrowing  into  knee-joint    ....  9.33 

Splint  for  excision  of  knee 936 

Foot  after  removal  of  aslraf^aUis  .    .    .  9.37 
Abscess  cavity  witii  secpiestrnin  in  head 

of  humerus 938 

Parts  removed   by  resection  of  elbow- 
joint     .    .    .    ". 939 

Necrosis  of  head  and  neck  of  radius   .  939 
Vertical  incision  for  excision  of  elbow- 
joint 940 

Splint  for  excision  of  elbow 940 

Section  of  loose  cartilage  removed  from 

knee-joint 943 

Microscojiical  appearance  of  loose  car- 
tilages        944 

Osteo-arthritis  (jf  knee-joint 946 

Osteo-arthritis  of  head  of  tibia     .    .    .  946 
Changes  in  hip-joint  tlie  result  of  osteo- 
arthritis    947 

Ankle  the  seat  of  osteo-arthritis  .    .    .  947 


CHAPTER    XXXIII. 

l)isea.s«'s  of  tlu*  B<nios— Iiirtaiimuitioii — Absce.s.s— Peri«>stitis  and  Endos- 
titis — NocTosis— Caries — Tumors — Osteitis  Deforniaiis 949 


648.  Superficial  necrosis  of  frontal  bone  fol- 

lowing wound  caused  by  gnawing 

of  a  ferret ".  ".    .    .    .     950 

649.  Periosteal  necrosis  of  tibia  following 

periostitis 950 

650.  Necrosis  of  shaft  of  tibia  resulting  from 

endostitis,  with  shell  of  new  bone 
surrounding  it 950 

651.  Necrosed  leg,  with  probes  inserted  into 

cloaca^  leading  to  dead  bone    .    .    .     950 

652.  Necrosis  of  shaft  of  tibia 951 

653.  Necrosis  of  articular  lamella  of  bone  .    951 

654.  Sclerosis  of  bone 952 

655.  Abscess  in  head  of  tibia 954 

656.  New  bone  formed  beneath   periosteum 

resulting  from  periostitis     ....     955 

657.  Upjier  iialf  of  humerus  separated  from 

upper  epii)hysis  thrown  oft"  by  nat- 
ural processes 958 

658.  Instruments  employed  in  operation  of 

se(iuestrotomy 959 

659.  Arrest  of  growth  in  til)ia  after  removal 

of  necrosed  shaft 960 


660.  Hollow  in  face   after  escape  of  bony 

tumor ".962 

661.  Tumor  as  discharged 962 

()62.   Exostosis  of  femur,  with  section   .    .    .  963 

663.  Periosteal  exostosis 963 

6t)4.  Enchondromatous  tumor 964 

665.   Enchondromatous  tumors  of  hand    .    .  964 

iSiS^.  Periosteal  sarcoma 965 

667.  Osteo-chondroma  of  fennir 965 

668.  The  above  during  life 965 

669.  Myeloid  disease  of  femur 966 

670.  Myeloid  tinnors  of  bone 966 

671.  Cancer  of  shaft   of  femur  with    frac- 

ture   966 

672.  Periosteal  cancer  of  tibia 967 

673.  Osteoid  cancer  of  bone 967 

674.  Epithelial  cancer  attacking  bone  .    .    .  967 

675.  Cancer  of  skin  inva<ling  bone   ....  968 

676.  Hypertrophy  and  atrophy  of  bone  .    .  969 

677.  Section  of  normal  bone 971 

678.  Section  of  bone  affected   with   molli- 

ties 971 

679.  Osteitis  deformans 974 


CHAPTER   XXXIV. 
On  Gunshot  Injuries— Osteotomy— Bone-Setting 975 

680.  English  and  foreign  bullets 976  I  683.  Gunshot    wound   of  skull,    wound   of 

681.  Nelaton's    probe,    Coxeter's   extractor,  j  exit 982 

and  Lecomte's  stylet-pince     .    .         981      684,  685,   Fracture  of  vitreous  table  of  skull 

682.  Gunshot    wound   of    skull,    wound   of  j  without  fracture  of  external  table  .    983 

entrance 982  ' 


CHAPTER   XXXV. 
Ansesthetics 993 


686.  Junker's  chloroform  inhaler 

687,  688.  An.-iesthetic  inhalers   . 

B 


.    996      689.  Richardson'^  spray  apparatus 
.    996 


XVlll 


CONTENTS    WITH  LIST  OF  ILLUSTRATIONS. 


CHAPTEK   XXXVI. 
Amputation — Preparation  and  Cleaning-  of  Spong^es 


FIG. 

690. 

691. 
692. 
693. 

694. 

69o. 
696. 

697. 

698. 
699. 
700. 

701. 
702. 
703. 
704. 

705. 


706. 

707. 
708. 


Surgeon  and  his  :i.ssistants  arranged 
for  operation 

Flap  amputation  oi'  tliigii  ...... 

Tliigii  stump,  vvitli  splint 

Thigh  stump,  witli  splint  for  exten- 
sion   

Mode  of  dressing  stump  by  irrigation 
witii  trougli  and  water-ran  .... 

Teale's  amputation       

Carden's  amj)utation  througii  the  con- 
dyles of  femur 

Amputation  of  leg  by  skin  Haps  and 
circular  division  of  muscles    .    .    . 

Stump  after  amputation  of  leg  .... 

Amputation  at  shoulder-joint    .... 

Amputation  througii  arm  by  flap  ope- 
ration   

Amputation  at  elbow-joint 

Stump  after  amputation  at  elbow-joint 

Amputation  of  fore-arm 

Diagram  of  hand  showing  joints,  as 
guide  to  amjiutation  of  fingei's  .    . 

Hand  after  amputation  of  part  of 
thumb,  index,  and  two  outer  fin- 
gers  

Lister's  abdominal  tourniquet    .    .    .    . 

Amputation  at  hip-joint 

Furneaux  Jordan's  method  of  amputa- 
tion at  liip-joint 


i'.A.(ii'; 

FIG. 

709. 

1005 

710. 

1006 

1007 

711. 

1007 

712. 

1007 

loos 

713. 

1009 

714. 

1009 

715. 

1010 

716. 

1010 

717 

718 

1011 

719 

1011 

1011 

720 

1012 

721 

1013 

722 

723 

1013 

724 

1014 

1014 

725 

726 

1015 

727 

Stump  alter  amputation  at  knee-joint  . 

Stephen  Smilli's  method  of  ampu- 
tating   

Posterior  aspect  of  stump  after  Smith's 
method  of  amputating  at  knee- 
joint     

Foot  after  amputation  of  four  outer 
toes,  with  metatarsal,  two  external 
cuneiform  and  cuboid  bones    .    .    . 

Surgical  guides  to  foot  as  expressed  by 
its  anatomy 

Stump  alter  Hey's  amputation  .... 

Cliopart's  amputation  of  foot     .... 

Stump  alter  Chopart's  amputation    .    . 

Tripier's  am])utation  of  the  foot    .    .    . 

Stump  after  Syme's  amputation     .    .    . 

Pirogofl's  amputation — heel  Hap  with 
calcis 

Pirogoff's  amputation  —  division  of 
malleoli 

Stnmjj  alter  Pirogoff's  amputation   .    . 

Stump     alter     circular     operation    of 

tliigli .••••.■•• 

Stump  after  Hap  operation  of  thigh  .  . 
Stump  with  ])atella  after  amputation  at 

knee-joint 

Conical  stump 

Necrosis  of  stump 

Bursa  over  end  of  stump 


999 

I'.\OE 

1016 
1017 

1017 

1018 

1018 
1019 
1020 
1020 
1021 
1023 

1023 

1023 
1023 

1024 
1024 

1024 
1024 
1025 
1026 


""  Onlv  the  association  of  medicine  with  surc^ery  forms  the  perfect  physician. 
The  physician  who  is  deficient  in  the  knowledge  of  one  of  these  brandies 
resembles  a  bird  with  bnt  one  wing." 

Art  of  Life  (Ayur  Veda):  early  Sanscrit,  first  century  of  Christian  era. 


"  I  dressed  his  wound,  and  God  healed  it." 

Ambroise  Pare. 


"All  that  we  have  to  do  is  not  to  obstruct  Nature  in  the  execution  of 
those  offices,  to  which  she  is  generally  fully  equal,  in  which  we  can  lend  her 
no  assistance  beyond  removing  impediments  out  of  her  way." 

P.  Pott,  1773. 


"  Surgerv  consists  in  curing  a  disease    rather  than  in  the  removal    of  it    by 

mechanical    means.       But  so  differently  do  most  think  upon  this  subject  that  a 

surgeon  who  performs  most  operations  and  gives  most  pain  is  commonly  thought 

the  best." 

John  Hunter,  MS.  Lectures,  1787. 


THE 


PRACTICE  OF  SURGERY. 


INTRODUCTORY   CHAPTER. 


SrR<}ERY  is  of  a  twofold  nature.  It  is  a  science  and  also  an  art — a  department  that 
■requires  to  bo  known,  and  another  to  be  practised.  The  science  embraces  a  knowledtre 
of  the  character,  the  causes,  and  the  effects  of  disease  and  injur}',  and  also  of  the  pro- 
cesses by  which  they  are  best  repaired  ;  the  art  consists  of  the  treatment  of  diseases  or 
injuries  as  they  present  themselves,  which,  to  be  successful,  must  be  based  upon  the  sci- 
ence. At  the  bedside  the  phenomena  of  disease  must  be  studied,  its  symptoms  recofrnized 
and  duly  weighed;  in  the  post-mortem  room  its  effects  are  to  be  traced.  The  great  object 
(if  the  student,  therefore,  should  be  clinical  and  pathological  investigation,  the  study  of 
the  living  and  the  dead,  since  it  is  by  these  alone  he  can  hope  to  acquire  a  solid  ba.sis  on 
which  to  ground  his  practice. 

The  e.xternal  features  of  a  local  disease  may  appear  the  same  to  the  student  as  to  the 
most  accomplished  surgeon  ;  whereas  the  phenomena  of  disease  are  often  perceptible  to 
the  latter  alone,  the  acquired  art  of  observation  and  the  unconscious  influence  of  experi- 
ence giving  to  the  mind  of  the  one  a  power  of  recognition  and  interpretation  which  is 
denied  to  others. 

It  is  to  the  acquisition  of  this  power,  therefore,  that  the  student  should  devote  his 
energies,  and  to  this  end  cultivate  the  art  of  observation,  for  by  it  he  will  not  only  gain 
the  power  of  seeing  correctly,  but  also  of  interpreting  the  meaning  of  what  he  sees,  and 
will  thereby  acquire  a  diagnostic  acumen  which  cannot  otherwise  be  obtained. 

It  is  now  necessary  to  consider  by  what  method  a  correct  opinion  can  be  formed  in 
any  given  instance,  how  sources  of  fallacy  are  best  eliminated  and  a  good  diagnosis  estab- 
lished, for  it  cannot  be  too  forcibly  impressed  upon  a  student's  mind  that  the  treatment 
of  a  ca.se  will  not  be  successful  unless  based  on  a  clear  understanding  of  its  wants,  and 
that  the.se  can  never  be  duly  appreciated  where  a  correct  diagnosis  of  its  nature  has  not 
been  made. 

The  mind  of  the  surgeon  should  invariably  be  judicial ;  it  should  possess  nothing  of 
the  advocate,  but  be  so  regulated  as  to  be  able  to  put  aside  all  prejudices  and  precon- 
ceived ideas,  and  avoid  the  advocacy  of  all  unsupported  theories  and  hypotheses  ;  it  should 
be  open  to  accept  clinical  phenomena  as  they  are  observed,  and  arrive  at  a  conclusion 
cautiously  and  clearly  after  duly  balancing  the  facts  of  the  case,  and  carefully  weighing 
the  possibilities  and  probabilities  of  its  nature. 

To  form  a  diagnosis  of  a  case  mainly  on  probabilities  as  indicated  by  symptoms  may 
be  a  ready,  but  it  will  always  prove  a  rash,  proceeding.  To  form  it  on  possibilities  will 
be  a  safe,  although  perhaps  a  less  expeditious,  course.  The  surgeon  who  acts  upon  the 
first  method  must  at  times  fall  into  grave  errors,  although  his  diagnosis  will  often  appear 
brilliant  and  may  be  successful ;  while  he  who  habitually  forms  an  opinion  after  taking 
into  consideration  every  possibility  of  the  case,  and  comes  to  a  result  by  a  process  of 
exclusion,  must  surely,  on  the  whole,  be  more  certain  in  his  ends,  as  he  will  be  safer  and 
sounder  in  his  practice.  I  lay  down,  therefore,  the  following  proposition  as  a  guiding 
principle  of  investigation  applicable  alike  to  all  cases  of  injury  as  well  as  of  disease : 

That  in  the.  dtaf/nom's  of  a  case  every  possibility  of  its  nature  shonld  be  entertained,  and 
a  conclusir>n  arrived  at  by  a  jtre,ccss  of  elimination  ;  each  possibility  should  be  separately 
considered  and  iceighed,  and  the  most  j)robable  Jinally  accepted,  a  diaffnosis  wholly  framed 
on  probabilities  being  most  hazardous. 

2  17 


1 8  INTR  OD  UCTION. 

For  example,  a  tumor  at  the  femoral  ring  may  ^>o.s>- //>(//  l)e  either  an  aV).scess,  an  aneur- 
ism, a  varix,  cyst,  hernia,  enlarged  gland,  or  a  new  growth.  An  abdominal  tumor  may 
be  ovarian,  uterine,  peritoneal,  vesical,  splenic,  f'ajcal,  renal,  or  hydatid.  Its  probable 
nature  will  be  best  arrived  at  by  eliminating  each  of  these  possibilities  seriatim  after  a  due 
consideration  of  all  its  clinical  symptoms,  the  most  probable  diagnosis  being  finally 
accepted  on  evidence  both  negative  and  positive. 

With  the  above  great  principle  of  practice  as  a  guide  in  clinical  investigation,  I  now 
proceed  to  consider  how  any  injury  or  disease  is  to  be  investigated,  confining  my  observa- 
tions to  classes  of  injury  and  disease.  I  do  not  propose,  however,  to  point  out  here  the 
exact  mode  in  which  it  is  well  to  examine  a  cage  or  to  report  it — for  a  report  is  only  a 
written  examination — although  at  pages  21-23  an  outline  will  be  seen  which  may  prob- 
ably be  found  of  service.  I  drew  it  out  many  years  ago,  when  surgical  registrar  at  Guy's, 
where  it  has  been  generally  followed  ever  since. 

How  TO  Investigate  a  Case. 

When  a  surgeon  is  callt'd  to  a  patient,  his  questions  naturally  apply  first  of  all  to  the 
seat  of  disease  or  injury.  Is  it  in  the  head,  chest,  abdomen,  or  extreniities  ?  He  will 
then  ask  as  to  its  duration  or  when  the  injury  was  received  ;  or  when  was  the  disease 
discovered?  If  a  case  of  injury,  his  inquiries  would  tend  to  elicit  the  exact  mode  of  its 
production,  the  force  employed,  and  the  character  of  the  instrument  by  which  it  was  pro- 
duced ;  for  these  points  are  of  essential  importance  under  all  circumstances,  and  in  head 
injuries  they  often  give  the  key  to  the  solution  of  many  questions.  By  these  means  the 
exact  seat  of  injury  will  probably  be  indicated,  and  the  surgeon  will  be  led  to  make  a  close 
examination  of  the  injured  part;  but  he  should  never  fail  to  assure  himself  that  all  other 
parts  of  the  body  are  sound  and  in  working  order,  and  that  no  other  is  involved  in  disease 
or  is  the  subject  of  injury  ;  for  it  would  be  a  forlorn  hope  to  amputate  for  a  crushed  limb 
when  associated  with  a  ruptured  liver,  or  to  reduce  a  dislocated  joint  when  combined  with 
some  fatal  internal  lesion. 

In  a  case  of  injury  to  or  disease  of  the  head  or  nervous  system,  the  most  important 
point  the  surgeon  has  to  determine  has  reference  to  the  exact  seat  of  the  affection.  Is  it 
confined  to  the  soft  parts  covering  the  bone,  or  are  the  contents  of  the  skull  in  any  way 
involved?  because,  in  the  former,  the  affection  is  comparatively  of  small  importance; 
whereas,  in  the  latter,  its  gravity  cannot  be  too  highly  estimated.  Scalp  wounds,  however 
severe,  have,  as  a  rule,  a  successful  ending;  whilst  brain  injuries,  however  trivial,  should 
always  be  regarded  with  apprehension,  for  they  may  lead  to  the  most  serious  complications. 

When  no  signs  of  brain  disturbance  after  an  injury  have  been  observed,  the  diagnosis 
is  not  difficult ;  for  without  symptoms,  local  or  general,  a  surgeon  may  be  excused  from 
entertaining  the  idea  of  brain  complication,  although  he  should  know  that  cases  of  frac- 
tured base  have  taken  place  without  any  symptoms  to  suggest  the  presence  of  such  an 
injury.  AVhen  indications  of  brain  disturbance  exist,  the  difficulty  arises;  for  it  cannot 
be  too  firmly  impressed  on  the  student's  mind  that  the  same  symptoms  may  be  produced 
by  concussion  as  by  compression  of  the  brain,  and  that  bone  pressing  on  the  brain,  and 
blood  effused  upon  its  surface  or  within  its  structure,  give  rise  to  precii^ely  the  same  phe- 
nomena ;  he  should  know  that  the  symptoms  produced  l)y  apoplexy  the  result  of  a  rup- 
tured vessel,  and  by  hremorrhage  into  the  brain  from  an  injury,  are  almost  identical,  and 
that  those  produced  by  what  is  called  functional  disturbance  of  the  brain  closely  resemble 
those  caused  by  organic  mischief.  Whilst,  therefore,  it  is  imperative  on  the  student  of 
surgery  to  remember  that  a  variety  of  different  conditions  may  give  rise  to  apparently 
identical  clinical  symptoms,  he  must  know  that  the  clinical  history  of  each  of  these  cases 
will  on  inquiry  be  found  to  differ  widely,  and  that  it  is  to  the  collateral  evidence  of  the 
case  he  must  look  to  find  the  right  clue  to  a  successful  diagnosis. 

Where  no  clinical  history  can  be  obtained,  the  difficulties  of  diagnosis  are  indeed 
great ;  thus,  when  a  surgeon  is  called  to  see  a  man  who  has  been  found  in  the  street 
insensible, who  is,  in  fact,  in  an  apoplectic  condition,  and  has,  at  the  same  time,  some 
external  evidence  of  injury  to  his  skull,  and  may  perhaps  al.so  smell  of  spirits.  The 
questions  that  arise  in  the  surgeon's  mind  under  these  circumstances  are  very  conflicting. 
Did  this  man  have  a  fit  and  then  fall,  or  are  the  symptoms  due  to  a  brain  injury  the 
result  of  an  accident?  Was  he  knocked  down  and  injured,  or  was  the  injury  the  conse- 
quence of  a  fall  ?  Are  the  symptoms  caused  by  drunkenness,  or  how  far  are  they  com- 
plicated with  it  ?  Are  they  the  result  of  blood-poisoning  from  kidney  disease,  or  poison- 
ing by  opium  ? 


ISriinDrcTlos.  19 

To  unravel  all  tlicso  jmitits  <;rfat  caic  and  iliMiiminatiiiii  art"  n'<jtiir('(l.  Ttxi  much, 
indeoil,  cannot  l>i'  hcstowcil  upon  tlu-  task,  hecaust-  to  treat  an  apoplectic  seizure  or  u  case 
of  severe  brain  injury  Ironi  external  violence  tor  drunkenness  is  a  j;rave  error;  hut, 
unfortunately,  it  is  one  whi(di  is  not  unconinion.  To  mistake  drunkenness  for  apoplexy 
or  severe  head  injury  is,  perhaps,  a  less  jrrave,  althoujrh  it  is,  without  doubt,  a  serious, 
fault.  As  a  matter  of  policy,  however,  it  is  L'enerally  a  wis*'  rule  to  rej^ard  all  these  .su.s- 
]>icious  cases  from  the  more  serious  point  of  view,  and  to  watch  and  wait  for  }«vmptom.s 
to  indicate  the  ]»ractice  that  should  be  pursued. 

What  I  wish,  therefore,  to  imj)res8  upon  the  student  is  the  necessity  of  bearing:  in 
mind  that  all  these  different  conditions  alluded  to  prc^^ent  to  the  sur<rcon  many  features 
in  common,  and  that  a  correct  diapiosis  can  only  be  arrived  at  by  a  |»roc(;ss  <jf  exclusion. 
The  possibilities  of  the  case  luivintr  thus  been  reviewed,  the  i)rr)babilities  can  only  be 
weiL'hed  by  a  riiriil  in(|uiry,  even  into  the  minutest  circumstances  that  can  be  ascertained. 

In  cases  of  local  jiaralysis  the  ditheiilties  of  diairnosis  are  very  great.  Is  the  cause  a  rin- 
/m/ one — that  is,  is  it  in  the  brain  or  cord?  or  is  it  p'riji/icnr/ — at  the  terminati<m  of  the 
nerves?  or  is  it  foca/  without  being  (|uite  ))eripheral  ?  If  one  or  two  of  the  former  causes  l>e 
in  operation,  the  history  of  the  case  will  probably  form  a  true  guide  to  the  surgeon,  ami  in 
the  latter  some  local  injury  to  the  nerves  .supplying  the  part,  .some  tumor  or  atieurism 
pressing  upon  the  nerves,  will  probably  be  found  ;  or  percliance  it  may  be  a  case  of  lead 
palsy  or  infantile  paralysis.  But,  under  any  circumstances,  a  true  diagnosis  can  only  be 
made  by  eliminating  from  consideration  the  many  possible  causes  and  adopting  the  most 
probable. 

Again,  if  ahoiild  be  an  invariable  riih-  of  practice  in  every  case  of  injury  or  ili^ase  to 
compare  tin-  sound  vith  the  affected  sid<:  of  tlu-  body.  In  the  diagnosis  of  a  dislocation  or 
fracture,  the  information  gained  by  the  comparison  often  furnishes  at  a  glance  to  tlie 
experienced  eye  a  true  suggestion  as  to  tlie  nature  of  the  accident,  and  in  joint  disease 
any  effusion  into  a  joint  or  enlargement  of  the  bones  is.  as  a  rule,  readily  detected. 

The  nature  of  the  disease  or  injury  being  thus  suggested  to  the  mind  througli  tlie 
eye,  the  suggestion  remains  to  be  confirmed  or  corrected  by  a  careful  manual  examina- 
tion, by  the  other  clinical  symptoms,  and  by  the  history  of  the  case,  the  facts  elicited  by 
the  sight,  by  the  liand.  and  by  the  ear  being  made  separately  available,  and  the  conclu- 
sion drawn  after  a  careful  balancing  of  the  probabilities  and  possibilities  of  the  case.  The 
diagnosis  will  be  well  established  when  all  these  different  modes  of  investigation  lead  to 
one  conclusion. 

In  surgery,  as  in  medicine,  tlie  student  must  educate  the  eye  to  see  and  the  hand  to 
feel,  and  the  task  is  by  no  means  .simple  or  easy  ;  indeed,  it  is  one  of  the  mo.st  difficult  to 
learn,  and  cannot  be  begun  too  early  in  his  professional  career.  Reading  will  not  help,  nor 
thought  aid:  personal  experience  at  the  bedside  alone  will  supply  the  want. 

To  recognize  the  existence  of  a  wound  or  the  deformity  of  a  broken  bone  may  not  be 
difficult,  but  to  read  aright  the  endless  phenomena  which  a  wound  presents,  and  to  make 
out  the  character  or  tendency  of  a  fracture,  require  much  experience.  To  .see  that  a 
swelling  exists  in  a  part  is  open  to  the  uneducated  eye.  but  to  recognize  the  various 
aspects  that  different  tumors  assume,  to  make  out  their  form,  position,  and  attachments, 
to  estimate  their  consistence,  to  recognize  the  fluctuation  of  fluid,  whether  superficial  or 
deep,  and  to  detect  pulsation,  require  considerable  tactile  pf)wer  and  long  education. 
What  education  alscj  is  demanded  in  order  to  read  the  phenomena  presented  in  diseases  of 
the  eye  or  the  skin  !  ''  No  study  of  the  written  observations  of  others  could  enable  any  to 
appreciate  those  endless  varieties  of  the  pulse  which  entirelj"  bafile  description,  or  to  distin- 
guish between  the  warmth  of  the  skin  excited  by  various  accidental  causes  and  the  pun- 
gent heat  accompanying  the  first  stage  of  pneumonia,  or  acquaint  him  with  the  .shrunk  and 
shrivelled  features  derived  from  the  long-continued  disease  of  the  abdominal  viscera,  the 
white  anil  bloated  countenance  often  attendant  on  changes  in  the  functions  or  structure 
of  the  kiilney.  the  squalid  and  mottled  com])lexion  of  the  cachexia  dependent  upon  the 
united  effects  of  mercury  and  syphilis,  the  palli<l  face  of  hjvmorrhage.  the  waxen  hue  of 
amenorrhdca.  the  dingy  whiteness  of  malignant  disease,  the  vacant  lassitude  of  fever,  me 
purple  cheek  of  pneumonia,  the  bright  flush  of  phthisis,  the  contracted  features  and  cor- 
rugated brow  of  tetanus  ;  all  which  shades  of  countenance,  with  many  more  that  might 
be  enumerated,  are  distinctly  rec<^gnized  by  the  experienced  eye."  Yet  all  this,  and 
something  more,  is  to  be  acquired  by  means  of  trained  ob.servation,  and  no  labor  on  the 
students  ]iart  should  be  considered  too  great  for  its  attainment. 

Diathesis. — This  subject  claims  the  attention  of  the  surgeon,  on  account  of  its 
undoubted   bearing  on   practical    surgery.      In  the  strumous,  scrofulous^  and   tuberculous 


20  INTRODUCTION. 

diatheses — all  of  which  appear  to  be  closely  allied — there  is.  no  doubt,  a  tendency  to 
glandular  enlarirenient,  the  formation  of  caseous  deposits,  and  a  low  kind  of  inflamma- 
tory action,  whether  in  the  bones,  joints,  skin,  or  lungs ;  but  beyond  these  clinical  facts 
we  know  nothing.  Disease  in  subjects  who  have  these  diatheses  is  precisely  identical  in 
its  e.'^sential  nature  with  the  same  disease  in  others  who  have  them  not.  It  may  be 
modified  in  its  course  by  the  diathesis,  but  it  is  the  same.  These  names  have,  likewise, 
no  special  signification  when  applied  to  local  affections. 

It  is  important  to  bear  this  fact  in  mind,  for  there  can  be  little  doubt  that  the  expres- 
sions •'  .strumous  disease  "  and  "  scrofulous  disease"  have  had  an  injurious  influence  on  the 
practice  of  surgery.  They  have  too  often  led  the  surgeon  (and  misled  the  public)  to 
regard  a  local  aflection  in  a  strumous  or  scrofulous  subject  as  incurable,  as  depending  on 
some  constitutional  condition,  and  not  on  a  local  cause.  In  disease  of  the  joints  this 
error  has  been  much  felt,  and  should  be  rejected. 

The  investigations  of  Drs.  .Sanderson  and  Fox  in  England,  and  Dr.  Waldenburg 
abroad,  tend,  Viowever,  to  show  that  the  scrn/itlous  diathesis,  in  which  there  is  a  tendency 
to  inflammation  of  a  low  type,  gives  rise,  under  some  circumstances,  to  /uberctilosis,  and 
that  local  inflammatory  affections  of  a  chronic  nature  are  specially  prone  to  be  followed 
by  tuberculous  disease.^  The  gray  granulations  or  tubercles  are  apparentlj-  derived  from 
some  pre-existing  inflammation  ;  from  the  absorption  into  the  blood  of  the  caseous  or 
cheesi/  deposits  which  are  supposed  to  be  the  residue  of  an  antecedent  inflammatory  action 
— whether  in  the  bones,  joints,  glands,  or  lungs,  and  these  are  subsequently  disseminated 
in  the  form  of  miliary  tubercle.  Niemeyer,  indeed,  maintains  that  "  the  formation  of 
tubercle  never  takes  place  unless  preceded  by  pneumonia  terminating  in  ca.seous  infiltra- 
tion of  the  pulmonary  tissue."  To  the  surgeon  this  a.spect  of  the  case  is  of  immense 
importance,  for  it  is  clearly  his  duty,  under  the.se  circumstances,  to  hasten  the  recovery 
of  local  suppurative  disease  as  much  as  possible,  and,  where  this  cannot  be  carried  out, 
to  remove  it.  For  let  it  be  once  shown  that  local  disease  has  a  direct  influence  in  pro- 
ducing constitutional  dyscrasia — call  it  by  what  name  we  will — and  the  necessity  of  deal- 
ing actively  with  chronic  local  affections  becomes  a  duty.  I  have  occasionally  acted 
upon  this  principle  with  the  best  results,  and  in  more  than  one  case  in  which  there  was 
progressive  lung  mischief  associated  with  a  disorganized  knee  have  found  the  lung  affec- 
tion speedily  sub.side  after  amputation.  It  must  likewise  be  admitted  that  a  local  dis- 
ease in  a  strumous  subject  may  be  as  amenable  to  treatment  as  it  is  in  a  more  healthy 
one.  The  treatment  may,  indeed,  require  some  modification  from  the  fact  of  its  occur- 
ring in  such  a  subject,  but  the  principles  of  practice  in  both  the  strumous  and  the  non- 
strumous  are  the  same,  although  we  know  that  in  the  former  all  diseased  action  is  of  a 
low  type,  and  that  there  is  always  a  greater  tendency  to  degenerative  changes  than  we 
find  in  other  subjects-.  Some  pathologists  have  been  bold  enough  to  say  that  the  scrofu- 
lous diathesis  is  the  consequence  of  hereditary  syphilis,  but  evidence  is  wanting  to  sub- 
stantiate this  view. 

HsBinophilia,  or  the  humorrhogic  diathesis,  as  the  result  of  heredity,  is  a  subject 
of  peculiar  interest  to  the  surgeon,  and  is  to  be  distinguished  from  a  temporary  disposi- 
tion to  bleed,  Avhich  is  present  in  purpura  or  leucaemia,  and  is  often  acquired.  It  attacks 
the  boys  of  a  family  rather  than  the  girls,  and  when  bleeders  beget  children  all,  as  a 
rule,  appear  healthy,  but  when  the  girls  have  families  their  boys,  as  a  rule,  are  bleeders. 
It  may  appear  at  the  very  earliest  period  of  life.  It  manifests  its  presence  by  a  pecu- 
liar tendency  to  bleeding  on  the  .slightest  provocation,  and  by  the  difficulty  there  is  in 
arresting  haemorrhage  when  it  does  take  place.  The  surgeon  should  always  have  before 
him  the  possibility  of  his  patient  being  a  .subject  of  this  diathesis ;  for.  although  it 
would  not  prevent  the  performance  of  any  operation  essential  to  save  life,  it  would 
materially  affect  the  que.stion  of  operating  for  any  reason  of  expediency,  and  would 
influence  the  practice  adopted. 

The  bleeding  may  take  place  from  any  part  of  the  body  or  into  any  cavity.  It  may 
be  venous  or  arterial,  and  may  occur  without  any  definite  cause  or  follow  some  .slight 
injury.  The  swelling  of  the  joints  which  takes  place  in  this  affection  in  some  cases  is 
due  to  haemorrhage,  but  in  others  to  serum.  In  a  drawing  in  my  possession  the  syno- 
vial membrane  was  found  after  death  covered  with  beautiful  fine  fringes  stained  a  deep- 
orange  color  from  effused  blood.  Sir  W.  Jenner  states  that  in  those  cases  "  the  tissues 
are  soft,  and  Ijruise  easily  ;  the  blood  is  slow  in  coagulating,  although  it  coagulates  as 
firmly  as  in  health — that  is.  blood  is  formed  rapidly,  and  there  is  a  tendency  to  plethora 
of  the  small  vessels — and  that  when  the  patient  is  looking  his  best,  injuries  have  the 
^Die  Tuberculose  und  Scro/ulose,  von  Dr.  L.  Waldenburg  'Berlin,  18G9j. 


ISTIiODVi'TIOS.  21 

worst  effect  uiiil  si>oiitaiieous  haMimrrliajres  arc  most  likely  to  occur."  In  this  disease, 
thorctbre,  ho  advises  a  mercurial  and  saline  jiurjie  (.'Very  three  weeks,  dry  food,  with  a 
considerable  j)orti(»n  nt"  dry  lihrinoiis  meats,  and  plenty  nf  open-air  exercise,  ^jreat  care 
heinir  fthserveil  to  avoid  injurit.-s.  The  bleeding;,  as  a  niU;,  ceases  .spontaneous! v.  In  the 
ae<|uired  disease  iron  is  of  threat  value. 

Cachexise. — D"  they  exist?  I.s  there  any  drtinite  aspect  associate*!  with  any 
tleliiiite  disease?  Is  there  a  eancerou.s  cachexia?  I  have  little  hesitation  in  statin;^  that 
in  practice  no  such  tiling  can  be  established,  and  that  a  larL'e  number  of  patients  suHcr- 
ini^  from  cancer  are  as  healthy-lookinir  as  any  other  (;lass.  if  not  often  healthier.  There 
can  be  no  doubt  that  a  patient  suilerinir  iVom  cancer  which,  by  its  discharfres  or  ilevelop- 
ment.  interferes  with  the  important  functions  of  life  and  undermines  his  powers,  has  an 
anxious,  drawn,  bloodless,  and  waxy  appearance  ;  l»ut  so  has  the  suVjject  of  any  orfraiiic 
disease  which  interferes  with  the  function.s  of  dijrestion  and  assimilation,  and  particularly 
the  subject  of  intestinal  disease.  The  patient  exhausted  by  suppuration,  by  .spinal,  bone, 
or  joint  mischief,  the  man  or  woman  who  from  drink,  syphilis,  or  mercury  (.separately  or 
coml)ined)  is  gradually  bein<r  broutrht  down  to  death's  door,  has  a  cachexia  more  or  less 
peculiar  according  to  the  oriran  involved  in  the  disea.se  and  the  special  constitution  of  the 
patient ;  but  it  is  nierely  the  condition  of  looking  ill.  Clinically,  I  read  the  meaning  of 
a  cachexia  as  •"  looking  ill,"  perhaps  very  ill.  from  some  long-standing  or  shiwlv-acting 
cause  ;  but  it  has  no  other  definite  signification  than  "  looking  ill  "  from  cancer,  "  look- 
ing ill  '  from  abdominal,  rectal,  suppurative,  or  syphilitic  disease. 


Points  for  Inquiry  in  Surgical,  Cases. 

Dise.ise  or  Injury.  ^  Date  when  seen.  Result. 

NAMK,  age,  occupation,  residence,  general  healtli.  habits,  and  aspect.  In  some  cases,  hereditary 
liistorv. 

HIHITORY  OF  PRESENT  DISEASE  OR  I  X.J  TRY.— Its  assigned  cause  or  nietliod  of  production. 

ORDER  OF  SUCCESSION  OF  SYMPTOMS,  with  their  former  treatment,  and  date  of  any 
marked  chaiiije  in  eitlier  svmptoins  or  treatment. 

PR?:SENT  CONDITION  AND  APPEARANCES,  passing  in  review  and  noting  when  irregular 
the  condition  of  intellect,  senses,  and  nervous  system.  Organs  of  respiration  and  circulation. 
Pulse — frecjuencv,  tbrce,  volume,  eoinpre.ssibility,  distinctness,  and  rhythm.  Temperature.  Di- 
gestive Organs — tonirue,  apjjetite,  bowels.  Urino-<renital  Organs — urine,  catamenia.  Integu- 
ments— eruptions,  moist  or  dry  ;  aljove  or  below  natural  heat.  Locomotive  organs — bones,  joints, 
and  muscles;  whether  ])aralvzed  or  in  imdue  action. 

PREVIOUS  DISEASES  OR  INJURIES,  with  their  dates.     Treatment. 

PROGRESS  OF  THE  CASE. — Note  carefully  any  cliange  in  the  old  or  the  appearance  of  new 
symptoms,  with  the  date  of  chan.tre  and  treatment,  by  medicine,  diet.  etc..  etc.  Carefully  fill  in 
the  result,  and  date  of  departure;  if  unfavorable,  the  condition  on  post-mortem  examination. 
NoTK. — As  the  value  of  a  report  depends  upon  its  conciseness,  together  with  the  accuracy  and 
munber  of  recorded  observations,  it  is  unnecessary  to  write  one  unless  an  appreciable  change  in 
the  symptoms  exists. 

SPECIAL  POINTS   FOR   OBSERVATION. 
HP2RNIA. — Variety  and  character — its   position,  period  of  existence,  assigned  cause,  and   form; 

whetiier  previously  irreducible,  and  if  a  truss  had  been  worn. 

When  Str.wgil.xted,  give  the  symptoms,  general  and  local,  dating  from  the  exact  period  of 

strangulation,  the  first  appearance  of  sickness,  character  of  vomit. 

Previovs   and   Pkesext   Condition. — If  by  taxin,  state  wbether  forcible,  and   how  long 

applied,  with  or  withoiU  chloroform ;  when  by  operation,  if  sac  was  opened  or  not — if  opened, 

irhyf  its  contents  and  their  apjjcarances.     On  reduction,  note  the  time  from  the  first  symptoms 

of  strangidation ;  succe,ss.  immediate  and  final. 
"WOUNDS. — Variety,  position,  extent,  and  depth ;  how  and  with  what  produced  ;  when  on  sra/p,  if 

exposing  bone.     Complications — hemorrhage,  etc.     Treatment  and  result— whether  imited  by 

adhesion  or  srranulation. 
TETANUS. — Idiopathic  or  traumatic,  partial  or  seneral ;  time  of  appearance  after  injury;  position 

and  condition  of  wound.     Death — wiiether  from  spasm  or  exhaustion. 
DISLOCATIONS. — Form  and  position;  simple  or  compound;  how  and  when  producetl ;  previous 

treatment. 

Symptoms,  seneral  appearance  and  position  of  the  limb;  moliility.  pain,  amount  of  injury  to 

soft  parts.     Treatment — time  after  injury:  iiy  manipulation  or  extension:  mode  of  appli("ation 

of  extension,  with  its  direction  and  duration ;  chloroform,  additional  means  employed.     Result, 

immediate  and  final. 
FRACTUKES. — Simple  or  com|)ound,or  comminuted:  how  and  when  produced;  position  and  direc- 
tion of  the  line  of  fracture;  its  tendency;  amount  of  injury  to  vessels  and  soft  parts;  in  compound, 


22  INTRODUCTION. 

note  position  and  extent  of  wound  ;  if  jirodiued  Vn-  tlie  primary  force  or  broken  bone,  wliat 
vessels,  nerves,  or  joints  are  involved.     Constitutional  symptoms 

Treatmknt. — Sand  bajjs,  standi  bandajje,  splints,  form  of  splint  applied;  date  of  application. 
Note  the  date  of  any  clian<^e  of  local  or  jreneral  treatment. 

FRACTUKKD  8KULL. — Position;  kind  of  injury  and  direction  of  the  force;  if  attended  by 
hiemorrhage,  its  amount,  and  whether  from  nose,  mouth,  ear,  or  external  wound.  Give  evi- 
dence, if  anv,  of  brain  mischief 

IN  SUSPECTED  FRACTUKED  BASE.— Paralysis  of  facial  nerve;  flow  of  blood  or  serum  from 
ear,  with  the  time  of  its  first  a})pearance  after  the  injury  and  its  duration;  condition  of  hearing; 
state  of  vision,  and  of  pupils;  presence  of  subconjunctival  luemorrhage.  If  complicated  with 
internal  injury,  as  concuffsiitn,  co)iipressimt,  etc.,  carefully  report  symptoms  in  their  order  of  succes- 
sion, and  whether  immediately  following  the  injury  or  not ;  the  duration  and  amf)unt  of  uncon- 
sciousness, insensibility;  paralysis,  its  position,  motion,  sensation,  or  both;  condition  of  sphinc- 
ters; character  and  innnber  of  pulse,  respiration;  condition  <>f  skin.     Treatment,  etc. 

DISEASED  BONE. — Part  atiected ;  duration;  cause,  as  external  injury,  syphilis,  mercury;  extent; 
superficial  or  deep,  partial  or  general ;  previous  treatment,  especially  as  regards  operations. 

Present  Symptoms  and  Appearances. — Condition  of  dead  bone  or  s^equeMruin,  fixed  or 
loose  ;  number  and  position  of  openings,  or  external  cloactr,  with  the  date  of  their  first  appearance. 
Treatment. — If  by  operation,  its  immediate  success. 

DISEASES  OF  JOINTS. — Part  afiected  ;  date  of  first  discovery;  a.ssigned  cause,  as  injury.  Note 
the  early  symptoms  in  the  order  of  their  appearance,  and  date  of  any  fresh  symptom  or  marked 
change;  if  pain  or  uneasiness  preceded  swelling,  or  was  coeval  with  it ;  if  the  former,  how  long? 
Rapidity  of  progress;  previous  treatment,  and  its  effects. 

Present  Appearances. — Position  of  joint ;  if  flexed,  the  angle  of  flexure;  size  and  shape. 
Character  OP  Swelling. — Uniform  or  bulging;  nianipular  indications,  hard,  soft,  elastic, 
or  fluctuating;  mobility,  amount;  if  attended  with  grating,  etc.;  in  the  knee-joint,  note  if  the 
patella  be  free  or  not ;  if  free,  the  sensation  felt  on  moving  it ;  condition  of  skin  ;  if  fistulous 
openings  exist,  their  position,  number,  and  character  of  their  discharge ;  deep  or  superficial ; 
note  the  date  of  their  first  appearance,  and  if  natural  or  artificial.  Pain,  acute  or  gnawing;  its 
position,  general  or  local;  if  aggravated  liy  motion  or  interarticular  pressure;  if  increased  at 
night.  Sleep,  if  disturbed  liy  crying  or  starting  of  the  limb  ;  sympathetic  pain,  and  its  position; 
condition  of  muscles  of  limb;  constitutional  symptoms.     Treatment. 

STRICTURE. — Organic  or  traumatic ;  duration  and  assigned  ca«se,  especially  as  regards  gonorrhoea; 
use  of  injections,  or  accident ;  if  previously  treated  by  catheter;  complications,  as  abscess,  fistula, 
with  their  position  and  date  of  appearance. 

RETENTION. — Mention  period  of  retention  ;  preceding  symptoms,  and  cause,  as  stricture,  calculus, 
{)aralysis,  abscess,  prostatic  disease,  etc.  Constitutional  and  local  symptoms ;  previous  and  pres- 
ent treatment ;  puncture  per  rectum,  note  the  date  of  removal  of  the  canula  and  arrest  of  tlie 
flow  of  urine  through  the  wound. 

EXTR.VVASATION. — Cause,  over-distension  or  accident;  duration  of  retention  before  urethra  gave 
way,  and  period  that  elapsed  before  being  seen.  Describe  the  appearances  and  extent  of  parts 
infiltrated  ;  constitutional  symptoms  and  treatment. 

VENEREAL  DISE.\SE. — Chancre,  duration  ;  position,  glandular,  urethral,  coronal,  or  frsenal — 
external,  internal,  or  fringing  preputial ;  character,  indurated,  non-indurated,  aphthous,  raised, 
excavated,  irritable,  phageda?nic,  or  sloughing;  tubercle;  condition  of  inguinal  glands,  indurated 
or  inflamed.     Prevloiia  treatmenl,  particularly  as  regards  mercury. 

Complications. — Note  the  date  or  appearance  and  situation  of  each  or  any  of  the  complica- 
tions; the  order  and  time  of  their  occurrence  after  the  primary  sore.  Present  appearance  and 
treatment  of  each. 

GoNORRHCE.\.^Date  of  contraction;  former  treatment,  especially  as  regards  injections,  copaiba, 
etc.  Complication.s,  and  their  duration;  in  epididymitis,  if  following  suppressed  discharge;  use 
of  injections,  copaiba,  or  violent  exercise. 

STONE  IN  BL.\DDER. — When  discovered;  date  of  earliest  symptoms;  if  preceded  by  the  pas- 
sage of  sand;  amount  of  irritability  of  bladder;  character  of  urine;  constitutional  and  local 
symptoms.  Treatment — litlmtrity  or  lithotomy;  in  latter,  note  any  peculiarity ;  date  of  arrest 
of  the  flow  of  urine  through  the  wnund. 

TUMOR. —  Date  of  its  discovery  and  size;  rapidity  of  growth;  general  and  local  symptoms,  in  their 
order  of  appearance.  (Jeneral  health  prior  to  discovery,  and  since;  hereditary  tendency; 
assigned  cause;  depressing  influences.  In  mammary  tumors,  number  of  children;  date  of  birth 
of  last;  if  ever  suckled  with  aflected  breast,  when?  condition  of  the  catamenia;  if  ceased,  how 
long  ?     Previous  treatment,  and  success. 

Pre.sent  Condition  and  Appearances.— Position  of  tumor;  size,  shape;  external  aspect 
and  condition  of  skin;  pain,  and  its  character;  condition  of  lymphatic  glands;  manipular  indi- 
cations ;  mobilitv,  when  in  breast,  whether  moved  by  traction  of  the  nipple ;  feel  hard,  elastic, 
etc.,  etc.     Constitutional  symptoms. 

Treatment. — In  recurrent  growths,  give  the  date  of  former  operations;  date  when  healed, 
and  of  its  first  reappearance  and  position. 
DPER.\TIONS. — Describe  position,  direction,  and  number  of  external  incisions;  the  steps  of  the 
operation  as  performed;  its  duration  ;  number  of  vessels  tied  or  twisted,  and  amount  of  haemor- 
rhage. In  amputations,  the  part  amputated,  and  position  of  amputation.  In  flap  operations, 
give  the  position  of  the  flaps ;  whether  anterior,  posterior,  or  lateral ;  whether  performed  by 
perforation  or  external  incision.  In  the  c<'nd)ined  flap  and  circular,  note  the  position  of  the 
skin  flaps;  in  all  note  the  result  and  character  of  stump. 


LSCl^JJIt   W'JlWDS.  23 

("llAl'TKli    1. 
ON  WOrXPS.  Ki:i'All{.  am>  infi.a.mmatmin 

KkiiM  a  clitiii-al  jioiiit  ot"  vit-w.  wounds  may  !•(.■  divided  intd  tlic  Open  and  tluSubCU- 
ta>neOUS,  if  «e  i-xi'ludt-  those  liy  wliitli  uidiiial  |ii»is(iiis  are  iiitrodiiccil  into  tlic  >\-t<iii. 
such  as  dissi'ftiiiu  whuihIs,  the  stin<rs  ot"  insects,  hites  of  snakes  and  rahifl  animals,  and 
the  wouiuls  which  afford  an  entrance  to  the  {loison  of  jrlanders.  mali<rnant  jiustule.  and 
hist.  hut  not  least,  syphilis.  The  term  "nj)<,i'\\s  applied  to  all  injuries  caused  ]>\ 
external  violence — the  result  either  of  accident  or.  as  in  an  oj»erati(»n.  of  desifrn — in 
which  there  is  a  solution  of  continuity  in  the  soft  ti.-sues.  and  in  which  the  deeper  parts 
are  exposed  to  the  influence  of  the  air  through  a  more  or  less  ga[»in<r  orifice.  The  term 
^^  xtibcutaiu'ous"  is  applied  to  such  injuries  as  follow  external  viftlenee,  in  which  the  deeper 
tissues,  bones,  or  viscera  are  broken,  ruptured,  lacerated,  or  crushed,  without  any  breach 
in  the  continuity  of  the  std't  parts  covering  them,  and  consequently  without  their  exposure 
to  the  influence  of  tlie  external  air.  as  well  as  to  such  operations  as  may  be  made  by  the 
surgeon  through  a  small  external  or  open  wound,  as  in  tenotomy,  myotomy,  and  oste- 
otomy. 

■•  Open  "  wounds  are  more  serious,  as  a  rule,  than  the  '•  subcutaneous."  though  the 
latter,  when  large  vessels  and  viscera  are  concerned,  are  among  the  gravest  injuries  the 
surgeon  has  to  deal  with.  Open  wounds,  moreover,  heal  by  a  more  complicated  process 
than  the  subcutaneous,  and  are  exposed  to  risks  from  which  the  latter  are  free. 

Classification  of  Open  Wounds. 

When  made  by  a  sharp-edged  instrument,  either  by  accident  or  in  an  operation, 
wounds  are  said  to  be  iiuised ;  when  inflicted  by  a  blunt  instrument  that  tears,  they  are 
called  lacerated;  and  when  caused  by  one  that  bruises,  contused.  Wounds  caused  bv  the 
thrust  of  a  pointed  instrument  are  called  punctured,  though  when  the  weapon  is  sharp 
the  tissues  are  simply  pierced  and  cut  deeply  ;  but  when  blunt,  irregular  in  shape,  or 
increasing  in  diameter  from  the  point  toward  the  handle,  the  soft  parts  are  forced  asunder 
as  by  a  wedge,  and  are  consequently  stretched  and  contused.  A  jiunctured  wound  under 
some  circumstances  approaches  the  character  of  the  incised,  and  under  other  circum- 
stances that  of  the  contused,  form  of  injury.  As  a  matter  of  fact,  however,  nearly  all 
wounds  of  Sijft  parts  are  more  or  less  contused,  those  inflicted  with  a  very  sharp  instru- 
ment being,  of  course,  the  least  so. 

Simple  or  Complicated. — A  wound  is  called  -simple"  when  it  has  been  made 
by  a  clean,  sharp-edged  instrument  in  a  healthy  subject,  and  when  there  is  nothing  in  the 
nature  of  the  wound  itself  or  in  the  state  of  the  patient  to  prevent  or  retard  repair,  pro- 
vided that  the  injured  part  be  placed  in  a  favorable  position  for  the  reparative  process  to 
be  carried  out.  The  wound  is  called  "  compIicat€<V  when  there  are  foreign  bodies  lodged 
in  the  part  interfering  with  repair ;  when  it  is  attended  with  haemorrhage,  with  much 
contusion  or  laceration  of  tissue  ;  or  wten  from  the  peculiarity  of  the  patient  there  are 
nervous  symptoms,  severe  pain,  constitutional  disturbance,  or  local  inflammation  ;  or  when 
repair  is  interfered  with  by  the  presence  of  such  complications  as  bad  health  or  old  age. 

Incised  Wounds. 

Open  incised  icounds  are  best  seen  as  the  result  of  operations,  but  they  may  also  be 
well  studied  as  clean  cuts  accidentally  made  with  sharp-edged  instruments.  They  may 
f/ape  from  the  ela.«-ticity  or  contractility  of  the  tissues  divided,  may  /died  from  the  division 
or  wound  of  small  or  large  vessels,  and  may  give  rise  to  variable  degrees  of  pain  accord- 
ing to  the  number  or  character  of  the  nerves  involved,  and  according  to  the  susceptibility 
of  the  patient. 

The  amount  of  "  gaping  "  in  a  wound  varies  with  the  tissue  divided.  Skin,  which  is 
the  most  elastic  tissue  in  the  body,  retracts  when  divided  far  more  than  other  tissues,  and 
transverse  wounds  of  skin  gape  more  than  those  which  are  longitudinal.  Arfen'cs.  when 
wounded  transversely  or  obliquely,  gape  much,  and  when  completely  divided  acro.s3 
retract  far  into  the  tissues.     Divided  veins  retract  less  than  arteries.     ^Iuscies,  when  their 


24  LOCyiL  AND  CONSTITUTIONAL  EFFECTS  OF  INCISED  WOUNDS. 

fibres  are  cut  across,  shorten  rapidly  by  contraction,  and  thus  aid  tl)e  gaping  of  a  wound. 
Fibrous  fissaes  and  nerves  when  divided  retract  but  little.  All  wounds,  however,  which 
are  made  in  parts  in  a  state  of  tension  gape  much,  and  tissues  which  are  on  the  stretch 
when  divided  retract,  far  more  than  they  would  do  if  tliey  were  relaxed.  Thus,  an 
incision  made  into  the  full  breast  of  a  suckling  woman  will  probably  by  gaping  ajjpear 
as  wide  as  it  is  long;  while  one  made  into  the  same  organ  in  a  flaccid  state  would  gape 
but  little.  Some  tissues,  on  the  other  hand,  never  gape  on  division  ;  this  is  best  seen  in 
wounds  of  the  palm  of  the  hand  and  of  the  sole  of  tlie  foot. 

The  surgeon  takes  advantage  of  these  known  conditions  of  gaping  and  retraction  of 
tissues,  and  in  his  operations  so  places  on  the  stretch  the  parts  to  be  divided  as  to  enable 
him  to  make  a  clean  and  decisive  section  of  the  tissues  with  which  he  is  dealing,  a  single 
sweep  of  the  knife,  made  under  these  circumstances,  doing  the  work  of  many  when  made 
under  others  less  favorable. 

Hsemorrhage  from  Incised   Wounds.— The  "  bleeding"  that  attends  an 

incised  wound  depends  princi])ally  upon  the  size,  Jiumber,  and  character  of  the  ves- 
sels that  are  divided,  although  it  may  be  influenced  by  the  personal  peculiarities  of  the 
patient,  and  more  particularly  by  the  fact  of  his  being  a  "  bleeder"  or  not ;  or,  in  other 
words,  by  his  being  or  not  being  a  subject  of  the  "  hsemorrhagic  diathesis."  The  condi- 
tion of  the  wounded  part,  moreover,  whether  inflamed  or  otherwise  more  than  normally 
supplied  with  blood,  has  some  influence,  and  the  effects  of  position  mu.st  always  be  taken 
into  account. 

Putting  aside,  however,  those  peculiarities,  constitutional  and  local,  the  myriads  of 
vessels  that  are  divided  in  a  wound  made  in  a  healthy  subject  with  sound  tissues  rapidly, 
if  not  instantaneously,  close  on  the  removal  of  the  dividing  medium  ;  for  it  is  a  fact  that 
capillary  bleeding  after  an  incised  wound  rapidly  ceases  by  natural  processes.  That  which 
goes  by  the  name  of  ''haemorrhage"  is  due  to  the  issue  of  blood  from  wounded  arteries  of 
some  size  or  from  wounded  veins,  and  the  bleeding,  if  it  does  not  prove  rapidly  fatal, 
persists  till  nature's  haemostatic  processes — unassisted  or  assisted  by  art — have  time 
to  act. 

Pain  of  Incised  Wounds. — The  "  pain"  attending  an  incised  wound  varies  in 
its  nature  and  degree  according  to  the  position  of  the  wound  and  the  tissue  wounded. 
Some  portions  of  the  body,  such  as  the  skin  of  the  face  and  fingers,  the  orifices  of  the 
mucous  tracts,  the  periosteum,  and  tense  tendons,  are  far  more  sensitive  than  the  skin  of 
the  back  and  buttocks,  the  bones  and  the  fasciae.  The  sensibility  of  the  patient  has  like- 
wise much  to  do  with  the  degree  of  pain  experienced ;  so  also  has  the  condition  of  the 
nervous  sy.stem  at  the  time  at  which  the  wound  is  received.  Not  only  may  one  subject 
of  an  operation  be  far  more  sensitive  than  another,  but  the  same  subject  may  feel  pain 
more  acutely  at  one  time  than  at  another,  the  general  condition  of  the  physical  powers, 
and  more  particularly  of  the  nervous  system,  greatly  influencing  sensibility.  Unexpected 
or  unseen  wounds,  or  wounds  received  during  drunkenness  or  when  the  mind  is  intent  on 
other  things,  as  in  the  excitement  of  battle,  are  often  unfelt  or  I'elt  but  slightly;  whereas 
when  the  mind  of  a  patient  is  fixed  upon  the  performance  of  an  operation  the  evil  influ- 
ence of  anticipation  aggravates  his  suff'ering. 

Local  and  Constitutional  Effects  of  Incised  Wounds. 

The  "local  eff'eots"  of  a  simple  incised  wound  on  a  healthy  subject  may  extend  little 
beyond  the  breach  of  surface  and  the  slight  pain  and  bleeding  which  attend  the  injury. 
The  "  constitutional  effects"  may  be  so  slight  as  to  be  unobserved.  In  a  general  way, 
however,  local  as  well  as  constitutional  effects  show  themselves,  and  these  are  greatly 
influenced  by  the  extent  of  the  wound,  the  general  condition  of  the  patient,  and  the 
treatment  to  which  the  injured  part  and  the  patient  have  been   subjected. 

Local  Effects. — These  are  best  studied  in  a  deep  incised  cut  which  has  passed 
through  skin,  subcutaneous  fat,  and  fascia. 

The  wound,  directly  after  its  infliction,  will  gape,  and  after  the  lapse  of  but  a  brief  inter- 
val of  time  this  gaping  will  increase  so  that  the  subcutaneous  fat  will  appear  as  if  it 
were  being  pressed  out  of  its  position,  and  as  if  the  divided  edge  of  the  skin  were  retract- 
ing from  it  and  becoming  everted.  Within  an  hour,  or  an  hour  and  a  half,  the  edges  of 
the  wound  will  be  seen  to  be  swo/Ien  and  slightly  retf,  from  increased  vascularity  ;  and  if 
the  connective  tissue  of  the  wounded  part  is  loose,  as  in  the  eyelid  or  male  genital  organs, 
it  will  be  puff'ed  up  and  cedematous.  To  the  patient  the  part  will  feel  hot  and  stiff",  and 
it  will  be  the  seat  of  a  dull,  aching,  or  burning  pain.     The  edges  of  the  wound  will  also 


LOCAL    A.\I>   coSSTirrTloSAL    L !' 1' I'J "I'S   Ol'  ISnsLI)   W'Ol'SDS.  2'' 

'inilialilv  )•<-•  nmri'  .sensitive,  th»'  aiiKUint  oi'  pain  <l<|Kiiiliiijr  iniicli  ii]iiiti  the  tuition  of  the 
parts  and  upon  the  treatment  to  whieh  tlit-y  liavc  \>vv\\  sulyi-cted.  If  the  e(lf;e.s  <»f  the 
wmuihI  have  lieeii  stitehfd  toiretlier  and  the  parts  are  Miiich  swnMen  and  (I'deniatous,  tht-re 
will  he  tension  upon  the  wuiind  and  a  dis|i(isitiiin  to  se|iarate  and  jrape.  In  a  healthv 
suhjeet,  however,  when  repair  jjoes  on  well,  all  these  loeal  phenomena  will  snhside  and 
disappear  in  the  course  of  two.  three,  or  lour  days,  aceordin;;  to  the;  rapidity  and  perfci-- 
tion  of  the  healiuL'  proei-ss.  and  a  eure  will  then  take  j)laee.  But  should  the  loeal  jdic- 
nnmenu  ahove  deseriltetl  he  more  persistent,  increase  in  severity,  spread  lieyond  the 
niaririns  of  the  wound  and  surnjundinji  parts,  or  alter  in  character  for  the  worst;,  what 
has  heen  a  phvsioloirieal  ri'parative  j»rocess  will  jtass  into  a  ])athido^ical  or  di.sea.sed  one, 
and   the   jiarts   will   then   he   sai<l   to   he   '"inflamed." 

Constitutional  Effects. — The  '-constitutional  jilienomena"  associated  with  the.se 
local  chauL'o  vary  ureatiy.  In  some  suhjccts  a  trivial  local  injury,  a  mere  cut.  may  jrive 
rise  either  to  a  more  or  less  severe  "  shock"  or  to  a  disturhance  of  the  nervous  system 
whieh  ex])resses  itself  in  convulsions ;  whereas  in  other  persons  a  severe  and  exten- 
sive wound  may  he  folli»wed  hy  few,  if  any,  constitutional  .symptoms. 

'•  SiKK'K.  " — The  f^radations  of  shock  and  collapse  are  innumerahle,  and  the  symjJtoms 
1)V  which  they  are  characterizA-d  vary  from  a  passing  faintness  or  disturbance  of  the 
hearts  action  to  final  syncope.  The  state  of  collapse  may  he  refranh-d  as  a  chronic  syn- 
cope. Patients  may  umjuestionahly  die  from  ".shock"  followiufr  slight  injuries  or  minor 
operations,  though  no  satisfactory  ca>ise  for  death  may  subsetiuently  he  discovered,  the 
lieart's  action  being  suddenly  stopped  thntugh  some  central  nervous  influence. 

The  degree  of '-shock"  that  attends  an  accident  or  operation  depends,  as  a  rule,  upon 
the  imitortance  in  tlie  animal  economy  of  the  organ  injured,  the  extent  and  nature  of  the 
violence  which  the  tissues  have  sustained,  the  size  of  the  blood-vessels  which  have  been 
involved,  and  the  amount  of  blood  which  has  been  lost.  A  patient  in  good  health  will 
bear  a  severe  wound  or  operation  with  little  shock  ;  while  another  with  di.seased  viscera, 
and  more  particularly  with  diseased  kidneys,  will  be  subjected  to  severe  .shock  from  even 
a  trivial  injury. 

The  age  and  constitutional  condition  of  the  patient  have  an  important  influence  under 
all  circumstances. 

"Reaction." — When  what  has  been  described  as  the  period  of '-shock'  after  an 
acci'lental  or  opeiative  wound  has  passed  away,  the  stage  of  "  reaction  "  is  readied;  and 
in  a  general  sense  it  may  be  assumed  that  the  intensity  of  this  stage  is  fairly  governed  by 
the  intensity  of  that  whicli  preceded  it — that  is  to  say,  where  there  has  been  little  shock 
there  will  be  but  feeble  reaction  ;  and  where  the  .shock  has  been  severe  or  prolonged  the 
stage  of  reaction  will  be  of  a  like  type.  Still,  this  rule^as  innumerable  exceptions,  and 
these  exceptions  seem  to  depend  more  on  the  individual  peculiarities  of  the  patient  than 
anything  else:  one  person,  after  a  slight  injur}'  or  operation,  experiences  little  .shock,  but 
sliarp  reaction  ;  while  another,  suff'ering  from  a  severe  injury  or  operation,  will  have  a 
prolonged  stage  of  .shock,  followed  by  no  more  reaction  than  seems  to  be  neces.sary  to 
restore  the  circulation  to  its  normal  condition,  and  to  allow  the  functions  of  the  body  to 
work  efficiently. 

Children  and  women  and  the  subjects  of  neurotic  tendencies  always  react  rapidly  and 
in  a  marked  way  from  all  kinds  of  shock,  whether  mental  or  physical ;  but,  as  a  rule, 
they  do  well.  The  rigors,  nervous  trenil)lings,  and  fears  which  are  often  met  with  in 
nervous  stibjects  after  operations,  and  which  often  cause  alarm,  are  but  rarely  followed  by 
any  bad  results. 

The  si/iitj>foni:i  of  reaction,  in  their  mildest  expres.sion.  are  simply  those  of  the  restora- 
tion of  the  circulatory  and  nervous  functions  to  their  normal  condition,  the  heart,  with 
the  circulation  generally,  so  rallying  from  the  dejiressed  condition  into  which  it  has  been 
thrown  by  the  -  shock  "  of  the  accident  or  operation  as  to  come  up  to  the  usual  standanl 
of  health,  and  the  nervous  system  so  recovering  from  the  temporary  state  of  depression, 
if  not  of  uncon.sciousness,  into  which  it  has  been  cast  as  to  resume  its  normal  power  of 
governing  and  controlling  the  actions  of  the  body  over  which  it  presides.  The  reparative 
process,  conse(|uently.  under  the.se  circumstances  may  be  expected  to  go  on  uninter- 
ruptedly to  a  successful  issue.  The  w(jund  will  undergo  repair  and  heal,  and  the  subject 
of  the  wound  will  suflfer  little  or  no  constitutional  evil  beyond  that  occasioned  directly  by 
the  injury.  The  stage  of  reaction  in  a  clinical  sense  will  then  be  normal ;  it  will  be  such 
as  may  be  sai'l  fairly  to  balance  tliat  of  shock,  and  to  tend  toward  recovery. 

Traumatic  Fever. — "When  the  symptoms  of  reaction,  either  with  respect  to  inten- 
sity or  duration,  exceed  the  normal  standard  :  when  the  circulatory  system  acts  power- 


26 


PROCESS  OF  REPAIR  IN  WOUNDS. 


fully  and  rapidly,  the  respirations  increase  in  quickness,  the  brain  and  special  senses 
become  abnormally  active,  and  the  temperature  of  the  body  rises  and  remains  above  that 
of  health  ;  and  when  with  this  elevation  of  temperature  the  functions  of  the  body  gener- 
ally are  disturbed  and  work  badly,  as  indicated  by  thirst,  a  foul  tongue,  loss  of  appetite, 
constipation,  diminished  secretion  of  urine,  want  of  sleep,  or  disturbed  rest, — "  traumatic 
fever"  is  said  to  exist. 

This  fever  may  show  itself  the  day  after  the  injury  or  operation  or  may  not  appear 
till  the  second  day,  and  it  may  last  for  twenty-four,  forty-eight,  or  seventy-two  hours. 
When  the  case  is  going  on  satisfactorily  toward  recovery,  the  fever  seldom  lasts  beyond 
this  period.  Should  the  symptoms,  however,  continue,  dangers  are  to  be  apprehended 
and  difficulties  looked  for.  When  the  fever  runs  on  into  the  fifth  or  sixth  day,  the  sur- 
geon may  be  sure  that  some  complication  is  present ;  and  should  the  symptoms  be  still 
more  fixed,  the  probabilities  are  that  the  case  is  not  only  badly  complicated,  but  that  it 
will  pass  on  to  a  fatal  issue. 

Temperature  Chart. — Under  all  circumstances,  and  in  the  treatment  of  every 
wound,  accidental  or  operative,  the  eye  of  the  surgeon  should  be  steadily  fixed  on  the 
temperature  chart,  such  a  chart  aff"ording  the  surest  indication  of  the  advance  or  presence 
of  any  such  complication. 


Process  of  Repair  in  Wounds. 

Before  entering  into  details,  it  is  well  to  know,  as  a  primary  truth,  that  the  processes  of 
repair  are  identical  in  all  tissues  ;  that  the  reparative  process  in  bone  or  muscle,  integu- 
ment or  tendon,  soft  or  hard  parts,  is  the  same,  such  modifications  alone  showing  them- 
selves as  necessarily  appertain  to  the  anatomy  of  the  tissue  or  to  the  special  circumstance 
of  its  position.  Thus,  tissues  that  are  highly  vascular  may  undergo  more  rapid  and  more 
perfect  repair  than  others  less  fortunately  circumstanced,  and  bone  tissue  may  require 
more  time  to  unite  than  skin  ;  yet  in  all  the  process  is  alike.  Let  us,  therefore,  inquire 
what  the  process  is,  and  see  what  changes  take  place  in  parts  undergoing  repair,  and  then 
look  at  them  where  they  are  best  seen — where  an  incision  is  made  through  the  skin  and 
the  edges  are  brought  together. 

The  chief  points  that  can  be  observed  have  reference  to  the  capillaries.  In  them,  at 
the  margin  of  the  wound,  the  blood  will  be  found  coagulated  up  to  the  nearest  anastomosis, 
and  the  ci^pillary  vessels  in  the  neighborhood  will  be  seen  to  be  dilated.  This  dilatation 
is  caused  by  the  increase  of  pressui-e  to  which  the  capillaries  have  been  subjected  by  the 
altered  circulation  of  the  blood  in  the  immediate  vicinity  of  the  wound.  When  wounds 
unite  by  mimrdiate  union,  no  otfter  changes  than  these  take  place,  beyond  the  gradual 
restoration  of  the  capillary  circulation  through  the  parts  that  have  been  divided  ;  and 
under  such  somewhat  rare  circumstances  no  scar  or  cicatrix  is  left.  The  soft  parts  at  first 
simply  adhere  together,  and  subsequently  become  continuous. 

Adhesive  Lesion. — Should  the  wound  unite  by  what  is  called  adhesive  union  or 
primary  adhesion  (the  "  first  intention  "  of  John  Hunter),  in 
Fig.  1.  which  a  cicatrix  is  formed,  other  changes  are  to  be  seen  ; 

and  these  take  place  in  the  connective  tissue,  in  which  the 
vessels  of  the  part  ramify.  They  consist  of  cell  multiplica- 
tion, and  under  the  circumstances  supposed  we  find  between 
the  edges  of  the  wound  a  vast  accumulation  of  cells,  filling 
up  in  various  degrees  the  spaces  of  this  wounded  tissue.  It 
is  through  these  cells  that  cicatrization  takes  place.  The  cells 
are  in  part  simple  nucleated  cells,  which  may  be  called  "  em- 
bryo cells  "  with  connective-tissue  corpuscles,  and  they  con- 
tain a  nucleus  and  nucleoli,  Klein's  placoid  cells  (vide  Fig.  1). 
Whether  this  cell  multijilication  depends  iipon  changes  in 
the  cell  itself,  as  Virchow  affirms,  or  whether  the  cells  are  the 
white  corpuscles  of  the  blood  which  have  escaped  by  exuda- 
tion from  the  capillaries,  as  Cohnheim  would  lead  us  to  believe, 

A  Group  of  Placoids  In  Different  I  do  not  noW  Care  tO  inquire.  All  admit,  however,  the  multi- 
wandering. '^°(^//er  Gow'V/^/n?*!}  plication  of  cells  in  the  affected  tissues  (vide  Fig.  2).  Pro- 
fessor Redfern  writes,  "  The  facts  must  be  recognized :  the 
floating  blood  cells  are  really  the  very  cells  which  once  formed  the  substance  of  the  lym- 
phatic glands,  the  spleen,  and  other  organs,  and  they  do  in  fact  move  through  the  walls 
of  the  blood  passages  and  wander  about  freely  in  what  are  called  solid  tissues."     When 


PROCESS   OF  Hh'I'A/n    /.V    W'OIWDS. 


27 


we  recolli'i-t  Ikiw  |i(iitir;ilplc  iIm-  tissues  iif  an  animal  arc,  wt-  .shall  ccaw  to  be  startled  at 
seeintr  tlu-m  lu-i-Mnu-  tin-  scat  ul'  iMitirdy  ntw  deposits,  or  timlin^  thoin  traversed  by 
mi'.^ratin^  blctod  eorjmscles  as  freely   as  a   cnlluid   is  |ienetrated   by   a  crystalloid. 


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Cicatrization. — Let  us  now  inquire  briefly  how  cicatrization  proceeds,  and  note 
that  it  is  in  the  cells  that  the  most  important  changes  are  to  be  recognized.  Those 
nearest  the  injured  part  gradually  assume  a  spindle  shape,  and  the  intercellular  tissue 
into  which  tlu'se  spindle-shaped  cells  are  infiltrated  becomes  denser.  The  spindle-shaped 
cells  then  gradually  change  into  ordinary  connective-tissue  corpuscles,  and  in  this  way 
new  cicatrical  tissue  is  formed.  This  new  tissue,  however,  again  undergoes  change.* — 
changes  of  consolidation.  The  intercellular  tissue  becomes  gradually  more  condensed, 
and  the  spindle-.shaped  cells  assume  the  flat  shape  of  connective-tissue  corpuscles  and  in 
a  measure  disappear,  the  nucleus  alone  often  remaining.  The  fluid  that  existed  in  the 
newly-formed  tissue  is  absorbed,  and  the  new  cicatrix  by  degrees  becomes  firmer  and 
denser,  gradually  contracting ;  so  that  at  last  the  delicate  scar  of  a  large  wound  becomes 
solid  and  compact.  The  cicatrix  in  smaller  wounds  appears  only  as  a  thin  red,  and  at  a 
later  period  as  a  white,  line. 

Changes  in  the  capillaries  of  tlie  ])art  are,  however,  going  on  during  all  this  period, 
hut  how  far  all  the  changes  that  have  been  briefly  described  are  due  directly  to  the  capil- 


28  PROCESS  OF  REPAIR  IN   WOUNDS. 

lary  action  is  not  yet  determined.  If  Cohnheim's  views  be  adopted,  it  is  to  the  capil- 
laries that  the  chief  action  in  the  tissues  must  be  ascribed ;  but  if  those  of  other  patholo- 
gists, such  as  Yirchow  and  Billroth,  be  accepted,  the  capillary  action  takes  a  secondary 
place  and  the  cell  elements  take  the  leading  one.  On  either  theory  the  importance  of  the 
capillaries  cannot  be  overlooked 

With  regard  to  the  changes  in  the  capillaries,  it  has  been  already  pointed  out  that  at 
the  beginning  of  the  reparative  process  the  capillaries  of  the  part  become  sealed  and  the 
collateral  circulation  in  the  neighborhood  becomes  irregular  and  pressed  upon,  and  that 
the  coagula  in  these  obliterated  capillaries  become  reabsorbed,  or  possibly  reorganized,  as 
repair  progresses,  since  it  is  certain  that  the  capillary  network  soon  becomes  continuous 
through  the  newly-formed  cicatricial  tissue,  and  that  the  capillary  meshes  of  the  one  side 
join,  by  loops  projected  through  the  new  tissue,  similar  meshes  of  the  opposite  one. 

What  injiuence  the  nerves  of  the  ]m)t  have  upon  the  reparative  process  we  do  not 
know.  That  they  have  an  important  influence  there  can  be  little  doubt,  since  all  physi- 
ologists recognize  their  power  upon  secretion  and  nutrition  ;  the  vaso-motor  nerves  doubt- 
less have  the  greater  power.  But  we  must  learn  something  more  of  nerve  power  gen- 
erally and  nerve  distribution — something  of  the  way  in  which  the  nerves  terminate  in 
the  tissues,  and  what  relation  they  bear  to  the  capillaries — before  we  can  hope  to  find  out 
or  understand  the  exact  influence  nerve  supply  has  on  repair. 

Repair  by  Granulation. — All  wounds  do  not,  however,  heal  by  immediate  union 
or  by  primary  adhesion — /.  ^.,  first  intention  ;  and  wounds  that  gape  cannot  so  unite.  The 
process  of  repair  in  them  differs,  therefore,  somewhat  in  its  character  from  the  process  in 
those  which  we  have  been  considering:  it  takes  phi ce  hy  (jramdation^  or  the  "second 
intention  of  Hunter."  If  we  closely  examine  the  surface  of  a  wound  thus  exposed,  we 
shall  find  that  it  becomes,  within  a  few  hours  of  its  exposure,  covered  with  a  film  of  a 
peculiar  gelatinous,  grayish-white  appearance,  which  will  be  seen,  with  the  aid  of  the 
microscope,  to  be  composed  of  granulation  cells  or  white  blood  cells,  "  Hunter's  plastic 
lymph."  After  an  interval  of  some  hours  the  parts  covered  with  this  gelatinous  grayish 
film  become  more  vascular,  as  indicated  by  redness,  and  the  surface  more  even.  The  film 
itself  assumes  a  tougher  character,  and  a  yellow  fluid,  which  is  mixed  with  small  yellow 
sloughs  of  fibrinous  tissue,  is  secreted.  The  wound  begins  "  to  clean,"  and  to  have  a 
smooth  and  consistent  surface.  After  the  lapse  of  another  day,  or  some  days,  perhaps, 
this  .surface  is  covered  with  a  number  of  elevations,  known  by  the  name  of  grmndations, 
varying  in  size  from  a  millet-seed  to  a  hemp-seed,  the  smaller  being  highly  vascular  and 
red,  the  larger  being,  as  a  rule,  paler  and  more  bloodless.  The  wound  at  this  time  is 
"granulating."  and  the  secretion  from  it  is  now  of  a  creamy-yellow  character,  and  is 
called  pus.  The  granulations  are  made  up  of  cells  called  granulation  cells,  which  resem- 
ble inflammatory  lymph  cells,  and  each  granulation  contains  a  vessel  the  walls  of  which 
consist  of  a  thin  membrane  in  which  nuclei  are  embedded.  "  Some  of  these  nuclei  are 
arranged  longitudinally,  others  transversely,  to  the  axis  of  the  vessels.  In  the  develop- 
ment of  these  vessels  changes  occur  answering  to  those  seen  in  ordinary  embryonic 
development.  Organization  makes  some  progress  before  ever  blood  comes  to  the  very 
substance  of  the  growing  part,  for  the  form  of  cells  may  be  assumed  before  the  granu- 
lations become  vascular.  But  for  their  continuous  active  growth  and  development  fresh 
material  from  blood,  and  that  brought  close  to  them,  is  essential.  For  this  the  blood 
vessels  are  formed,  and  their  size  and  number  appear  always  proportionate  to  the  volume 
and  rapidity  of  life  of  the  granulations.  No  instance  would  show  the  relation  of  blood 
to  an  actively  growing  or  developing  part  better  than  it  is  shown  in  one  of  the  vascular 
loops  of  a  granulation  embedded  among  the  crowd  of  living  cells  and  maintaining  their 
continual  mutations.  Nor  is  it  in  any  case  plainer  than  in  that  of  granulations  that  the 
supply  of  food  in  a  part  is  proportionate  to  the  activity  of  its  changes,  and  not  to  its 
mere  ".structural  development.  The  va.scular  loops  lie  embedded  among  the  simplest  pri- 
mary cells,  or,  when  granulations  degenerate,  among  structures  of  yet  lower  organization  ; 
and  as  the  .structures  are  developed  and  connective  tissue  formed,  so  the  blood  vessels 
become  less  numerous,  till  the  whole  of  the  new  material  a.ssumes  the  paleness  and  low 
vascularity  of  a  common  scar  "  (Paget). 

Forrnation  of  New  Skin. — If,  at  this  time,  when  the  granulations  have  attained 
to  the  level  of  the  skin,  we  look  to  the  margins  of  the  wound,  we  shall  see  a  dry  red 
band  of  newly-formed  tissue,  with  an  outer  border  of  a  blui.sh-white  color  where  it  comes 
into  contact  with  sound  integument.  This  band  is  the  new  skin  forming,  and  is  caused 
by  the  gradual  growth  of  the  epidermis  from  the  margin  of  the  sound  skin  toward  the 
centre  of  the  sore.     Such  a  process  is  called  ''cicatrization.''     The  cicatrix  is  at  first  red, 


rnocKss  OF  iiki'MR  is  worsns.  29 

as  ill  the  linear  t-icutrix,  t(»  wliicli  \vc  li!iv(!  ain-aily  aliudcMj,  }»iit  as  it  cdntracts  it  hnh.-^e- 
(jui'iitly  licrniiR'S  j)ak'r,  iimiH'  r(tiiij)a(.-t,  and  aillicri'nt.  Tlic  iiatnn;  of  tin;  s(;ar  kt  cicatrix 
varies  witli  tlic  tissue  in  wliicli  it  is  turincfl,  the  \ww  coniicctin*;  UKMliiirn  under  all  cir- 
cunistanci's  havinj;  a  powerful  tendency  to  approach  (he  peculiar  charact«-r  of  the  tissue 
in  which  it  is  placed.  'I'hus,  a  cicatrix  in  the  skin  in  time  closely  reseinhles  true  skin; 
a  cicatrix  in  hone,  trui'  l)one  ;  and  a  cicatrix  in  tendon  heconies  tou^h  and  hard  like 
tendon.  I'lider  all  circumstances  the  con.s(didatin;j;  reparative  material  partakes  of  the 
charailir   nl'  the   parts    wliich   it   connects. 

Secondary  Adhesion. — When  two  granulating;  surl'aces  are  brought  together 
and  union  takes  place  lictwec!i  them,  /lealiin/  hi/  •'  xtcoin/tin/  ml/icsio/i,"  or  hy  t/ic  •■  lliinl 
intent  inn."  is  said  to  occur.  The  process  of  rej>air,  under  these  circumstances,  is  similar 
to  that  of  imnu'diate  uv  adhesive  union,  the  two  layers  of  granulations  adhering,  either 
directly  or  hy  means  of  some  new  material,  as  two  surfaces  of  divided  tissue.  'I'he  cafiil- 
laries  and  cmliryo  cells,  under  both  circumstances,  undergo  changes  such  as  have  been 
described.  For  this  form  of  union  to  take  ])lace,  the  granulations,  however,  must  be 
liealthy. 

Scabbing. — ^\'lleM  wounds  Ileal  •'  1)1/  seiil/ljiiit/,"  granulations  do  not  form.  In  this 
proces.s  the  reparative  material  which  is  poured  out  undergoe.s  at  once  similar  changes  to 
tho.se  already  described  as  taking  place  in  adhesive  union,  and  the  wound  cicatrizes  rap- 
idly beneath  the  scab ;  for  the  .serum  of  the  blood,  when  cffu.sed  on  the  surface  of  a 
wound,  is  of  a  highly  plastic  character,  and  quickly  coagulates  to  form  a  film  of  a  j»ro- 
tective  nature,  under  which  repair  may  rapidly  proceed,  the  embryo  cells,  with  this — 
Hunter's '' plastic  lymph"' — being  the  medium  of  repair.  The  treatment  of  sujierficial 
wounds  is  based  upon  the  knowledge  of  this  process,  and  the  value  of  felt,  cotton-wool, 
or  any  similar  material,  when  applied  to  an  open  wound,  entirely  depends  upon  this 
plastic  property  of  serum.  Repair  by  scabbing  is  doubtless  the  best  form  of  healing, 
although    it    is,   uiii'nrtuiiatcly.  somewhat    rarely   obtained. 

The  Nature  of  the  Heahng  Process  is  physiological,  and  resembles  closely  that 
of  development  and  growth.  The  changes  in  the  cell-elements  which  have  been  described 
in  repair,  and  the  gradual  development  of  the  most  elementary  tissue  into  cicatricial 
tissue  or  higher  structures  of  the  human  body,  are  similar  in  nature,  if  not  in  form,  to 
those  which  are  witnessed  in  the  embryo  when  the  blastoderm  cells,  or  primary  nucleated 
mass  of  protoplasm,  in  the  ovum,  grow,  develop,  and  differentiate  into  the  various  struc- 
tures of  the  human   animal. 

For  the  healing  processes  there  must  be  a  sufficient  blood  supply  for  nourishment,  and 
there  mu.st  likewise  be  a  regulating  force  to  control  and  direct  the  formative  process ; 
and  this  lorce  doubtless  comes  from  the  nerves. 

When  the  vascular  supply  is  deficient,  growth  or  development  must  suffer  and  the 
physiological  process  of  repair  cannot  go  on;  when  the  vascular  supply  is  in  excess, 
what  would  have  been  a  physiological  becomes  a  pathological  process,  and  the  part 
undergoing  repair  after  injury  is  said  to  be  "inflamed."  The  process  of  construction, 
under  these  circumstances,  ceases,  and  that  of  (lesfmction  may  ensue ;  or  there  may  be 
changes  in  the  now  inflamed  but  formerly  repairing  wound  or  granulating  surface,  which 
will  be  considered  under  the  heading  of  '•  Diseases  of  Granulations.'  What  I  would 
now  impress  upon  the  reader  is  that  whatever  action  is  required  for  the  healing  proce.«s 
is  physiological,  and  is  just  equal  to  its  purpose ;  when  it  is  excessive,  it  becomes  patho- 
logical, and  is  known  as  "inflammation."  Inflammation,  when  it  attacks  a  wound,  at 
first  checks  repair,  and  later  on  brings  about  disorganizing  changes  ;  inflammation,  under 
all  cireumstanees.  has  a  destructive  tendency. 

Regeneration  of  Tissues. — It  has  already  been  pointed  out  that  the  proce.«.«e.s 
of  repair  are  identical  in  all  tissues,  that  the  re])arative  process  in  bone  or  muscle,  integu- 
ment or  tendon,  capillary  or  nerve,  is  the  same,  such  modifications  alone  showing  them- 
selves as  necessarily  appertain  to  the  histology  of  the  tissues  ;  and  it  is  well  that  this 
physiological  truth  should  be  fully  recognized.  At  the  .same  time,  it  is  to  be  e<jually 
recognized  that  all  tissues  are  not  formed  out  of  cicatricial  or  connective  tissue,  but  that 
the  higher  forms  of  structures,  such  as  muscle,  nerve,  bone,  etc..  are  repaired  by  the 
regenerating  influence  of  the  injured  tissue  itself,  new  cells  springing  or  growing  by  a 
kind  of  budding  process  from  the  divided  ends  of  the  injured  part,  the  new  cells  in  con- 
tact with  or  poured  out  by  the  injured  tissue,  whether  as  embryo  cells,  connective-tissue 
cells,  nerve  cells,  mu.scle  cells,  or  bone  cells,  being  so  influenced  by  the  tissue  with  which 
they  are  in  contact,  and  from  which  they  probably  originated,  that  they  anatomically 
partake  of  its  nature  and  bring  about  its  repair. 


30  SOURCES  OF  INTERFERENCE   WITH  HEALING    OF   WOUNDS. 

Repair  of  Muscle. — When  muacnlar  h'ssHc  is  wounded  or  more  or  less  destroyed, 
0.  Weber  tells  us  that  it  may  be  restored,  and  that  the  young  muscular  fibres  are  formed 
out  of  the  old  by  the  division  of  the  protoplasmic  material  of  their  extremities,  the  repair 
of  muscle  being  thus  brought  about  by  agencies  closely  simulating  those  of  fcetal  develop^ 
ment.  Gussenbauer  gives  a  drawing  of  the  process.  Billroth,  however,  asserts  strongly 
that  he  has  never  seen  anything  which  he  could  regard  as  a  re-formation  of  muscular 
fibres,  and  that  the  cicatrix  in  muscle  is  almost  entirely  connective  tissue,'  the  extremi- 
ties of  the  muscular  fibres,  after  division  and  repair,  uniting  with  the  cicatricial  tissue  in 
the  same  way  as  they  do  with  the  tendons.  My  own  observations  go  to  confirm  those  of 
Billrotli. 

Repair  of  Nerves. — There  is  good  reason  to  believe  that  an  injured,  or  even  a 
divided,  nerve  may  be  thoroughly  repaired,  since  conclusive  evidence  has  in  recent  times 
been  adduced  to  prove  that  such  a  large  trunk  as  the  median,  the  ulnar,  or  the  great  sci- 
atic may  be  divided,  and  subsequently  so  joined  by  surgical  skill  as  to  secure,  after  the 
lapse  of  a  certain  interval  of  time,  perfect  union  of  the  divided  ends,  as  proved  by  the 
complete  restoration  of  the  functions  of  the  nerve  in  their  phvsiological  perfection.'^ 

It  is  likewise  true  that  new  cicatricial  tissues  become  sensitive,  and  that  parts 
which  by  accident  or  operation  have  been  deprived  of  the  influence  of  one  nerve  regain 
their  sensibility,  either  by  the  growth  of  new  nerves,  or  by  the  assumption  on  the  part 
of  another  branch  of  the  same  nerve  or  of  another  nerve  of  the  physiological  functions 
of  the  one  that  has  been  destroyed. 

From  these  facts  the  conclusion  is  clear  that  nerve  tissue  must  be  regenerated,  and 
that  the  divided  ends  of  nerve  must  reunite  by  new  nerve  material.  It  seems,  moreover, 
highly  probable  that  new  nerves  may  develop.  In  a  physiological  point  of  view,  these 
facts  are  not  only  very  remarkable,  but  they  tend  to  demonstrate  the  perfection  of  the 
reparative  process,  since,  to  allow  of  the  conduction  of  nerve  force  to  and  from  the 
nerve  centres,  very  powerful  conductors  are  unquestionably  required. 

The  process  by  which  this  repair  is  brought  about  has  been  carefully  studied  by 
SchiflF,  Hjelt,  and  others,  and  is  much  after  the  following  fashion,  as  given  by  Billroth  -.^ 
"  There  is  first  of  all  a  degeneration  of  the  medullary  sheath,  possibly  also  of  the  axis- 
cylinder,  for  a  certain  distance  from  the  injury,  which  is  quickly  followed  by  the  pro- 
duction of  cells  in  the  neurilemma  ;  these  develop  into  spindle  cells,  and  spread  into  the 
tissue  which  intervenes  between  the  nerve  fibrils,  and  which  extends  also  between  the 
cut  extremities  of  the  nerves.  From  these  cells,  as  in  the  embryo,  nerve  fibres  are 
developed,  and  these  nerve  fibres  ultimately  cannot  be  distinguished  from  ordinary  nerve 
fibres." 

Sources  op  Interference  with  Healing  of  Wounds. 

The  diff'erent  modes  of  healing,  and  the  processes  by  which  injured  tissues  are 
repaired,  having  been  fully  described,  I  propose  to  consider  the  causes  that  interfere  with, 
retard,  or  prevent  repair ;  and  these  may  be  found  either  in  the  "  ivovvd  itself,''  in  the 
"  sithjert  of  tlie  wound,"  or  in  "  its  treatment." 

Local  Causes. — Among  the  causes  which  exist  in  the  wound  itself,  the  p?'ese?ice 
of  (nil/  foreign  matter  whatever  must  be  placed  first,  since  it  is  clear  that  where  such  is 
found,  even  to  a  limited  extent,  repair  by  immediate,  primary,  or  quick  union  is  impossi- 
ble. The  foreign  matter  not  only  by  its  presence  mechanically  prevents  the  adhesion  of 
the  surfaces  between  which  it  is  placed,  but  also  acts  as  an  irritant  or  as  a  promoter  of 
septic  changes,  and  thus  excites  an  action  in  the  wound  which  is  not  reparative,  but 
inflammatory.  The  truth  of  this  general  rule  is  not  disproved  by  the  fact  that  in  excep- 
tional cases  foreign  bodies  become  encysted  in  tissues  and  give  rise  to  but  little  trouble. 

The  occurrence  or  j)ersistence  of  hleedlng  in  the  wound  is  a  second  local  cause  of  non- 
repair, the  reparative  process  not  commencing  until  all  bleeding,  even  capillary  oozing, 
has  been  arrested.  When  the  hsemorrhage  is  great,  this  interference  may  be  serious ; 
and  even  when  little,  it  is  enough  to  retard  and  prevent  the  reparative  process  from  being 
carried  out.  Blood,  if  eff'used  to  any  extent  between  the  sides  of  a  wound,  interferes 
with  the  reparative  process  much  in  the  same  way  as  does  a  foreign  body,  and  forbids  all 
healing  by  quick  or  primary  adhesion.  If  eff'used  in  very  small  quantities  between  the 
divided  surfaces,  it  may  at  times  possibly  change  into  cicatricial  tissue  and  form  a  band 
of  union  between  the  divided  parts,  and  under  these  conditions  it  may  become  organized, 

'  Syd.  Soc,  Billroth,  Surfj.  Path.,  vol.  i.  s.  151. 

^  Vifh.  Dr.  Weir  Mitchell  in  the  American  Journal  of  Med.  Science  for  April,  1876;  Clinical 
Soclely'x  Trans.,  vol.  xii.  'Billroth,  vol.  i.  p.  152. 


sofriich's  OF  isri:iii'i:itES'('i':  wrru  iii.m.im;  of  wovsds.  .31 

as  wlit'ii    jiiMircil   uiit    nil    tin-    hrain  ;   l)iit.  as   a    nili',  llic    cniisiini  nf  iiiiich    hlooj    into   u 
wniiiiilcii  |>art  is  a  rctanlcr  of  n-pair  or  a  cause  of"  iioii-rf|iair. 

Wlicii  a  wound  lias  to  lical  l>y  granulation,  a  dot  ol"  hlood.  as  a  (.'overin^.  kept  aseptic, 
is  ItcncHcial.  .sincr  it  ai'ts  as  a  protector  to  tiie  surface  of  the  wouiul  and  allows  the 
^ranulatinu;  process  to  f^o  on  uninterruptedly.  It  has  heen  saiti  that  such  clots  hecoiiie 
oriranized,  hut  it  is  far  more  prohahle  that  llicy  simply  act,  as  ahove  descriheil.  as  a  pr<j- 
tection  to  surl'aces  that  are  ^'ranulatinu. 

A  ri)iifiisr(/  tir  Inn  liilrii  surface  in  a  wound  is  a  third  local  cause  of  non-repair,  and  it 
is  well  to  recounize  this  imjtortant  fact,  since,  with  such  a  coiiditii>n  of  parts,  the  surp;eon 
knows  that  immediate  or  primary  union  of  the  wotmd  is  not  t(»  he  expected.  I'nder 
these  circumstances  a  lim?  of  treatment  will  he  indicated  which  will  he  far  more  likely  to 
he  efficient  than  one  l)ased  on  the  hope  of  ohtaining  <|uick  repair.  When  the  contusion 
or  hu'cration  is  sliiiht,  tin;  hope  of  securing;  ju-imary  unioti  of  the  divided  parts  may, 
indeed,  he  entertained  ;  hut  when  it  is  threat,  such  a  hope  would  he  alto^^ether  <rroundle»8. 
The  gradations  of  contusi<in  and  laceration  hetwecn  these  two  extremes  are  numherle.ss ; 
but  it  will  he  wiser  for  the  surgeon  to  believe,  and  upon  such  a  belief  to  act,  that  in  ct)n- 
tiised  and  lacerated  wounds  the  prospect  of  obtaininjj^  quick  union  is  slight,  than  for  him 
to  act  upon  an  opposite  view,  and  attempt  to  obtain,  in  .severe  cases,  a  mode  of  healing 
the  occurrence  of  which  is  improbable  if  not  impossible. 

Tn  a  contuse*!  or  lacerated  wouml  the  surgeon  should  mentally  .see  dying  or  dead 
matter  which  of  necessity  must  be  separated  from  the  living  ])arts  and  got  rid  of,  either 
by  molecular  disintegration  or  by  a  coarser  slougliing  process,  before  the  act  of  healing 
can  rightly  be  .said  to  begin,  and  under  these  circumstances  he  will  at  once  recognize 
the  futility  of  entertaining  a  hope  of  obtaining  the  repair  of  the  wound  by  quick 
union. 

Constitutional  Causes. — Of  the  causes  of  non-repair  which  are  to  be  put  down 
to  the  account  of  the  subject  of  the  wound,  '■'•  ngc''  is  all-imp(jrtant,  the  reparative  pro- 
cess in  a  man  the  wrong  side  of  fifty  being  conducted  with  less  vigor  than  in  one  who  is 
on  the  right.  In  the  very  old  repair  is  at  its  lowest  mark.  The  same  remarks  are  applic- 
able to  patients  who  are  the  subject  of  '•  orfjdnic  discum^  or  of  dpgeniratue  chdu'ips  in 
their  tissues,  and  especially  to  fat  and  soft-tissued  people,  the  old  in  years  or  in  infirmi- 
ties not  possessing  the  recuperative  powers  of  the  young  and  vigorous.  Under  these 
circumstances,  in  the  case  of  a  wound  resulting  from  accident  or  operation  in  a  patient 
over  fifty  years  of  age  or  in  one  in  ill-health,  it  would  be  wrong  for  a  surgeon  to  expect 
or  to  rely  upon  securing  a  mode  of  repair  which  in  a  younger  or  healthier  subject  he 
might  reasonably  look  for.  People  who  are  advanced  in  years  or  who  are  feeble  from 
frailty  or  disease,  particularly  visceral  disease,  have  no,  or  an  insufficient,  capital  at  the 
bank  of  health  to  draw  upon.  Of  all  subjects  for  wounds,  whether  accidental  or  opera- 
tive, the  ha})itu:il  drunkard  is  the  worst. 

Defects  in  Treatment. — Of  the  causes  of  non-repair  which  are  to  be  attributed 
to  treatment,  a  want  of  due  care  in  maintaining  the  injured  or  wounded  part  in  a  state 
of  rest  claims  the  first  place  ;  for  in  such  a  delicate  process  as  is  that  of  repair  it  is  plain 
that  in  any  movement  of  the  injured  part,  whether  in  the  way  of  separation  of  surfaces 
or  by  manipulation,  the  process  may  be  interfered  with  or  retarded  or  the  work  already 
accomplished  may  be  undone.  Tt  is  certain  that  the  best  and  most  rapid  repair  of  an 
injured  part  takes  place  when  the  wounded  tissue  is  kept  in  an  absolutely  immovable 
position,  and  when  the  wounded  surface  is  protected  from  all  external  influences  that  can 
possibly  interfere  with  the  physiological  reparative  process.  It  therefore  clearly  behooves 
the  surgeon  to  have  this  great  truth  always  before  him,  in  order  that  he  may  adapt  his 
treatment  to  the  requirements  of  the  case,  and  not  have  to  blame  hini.self  for  a  want  of 
care  in  maintaining  that  ab.solute  immobility  of  the  wounded  or  cut  part  which  is  essen- 
tial for  rapid,  or  even  good,  repair. 

Tn  the  treatment  of  fractures  the  evil  effects  of  want  of  rest  and  immobility  of  the 
broken  bones  are  well  exemplified,  but  it  is  to  be  remembered  that  the  same  want  of  rest 
and  immobility  is  as  pernicious  in  wounds  of  the  soft  as  in  those  of  the  hard  parts — in 
wounds  of  the  surface  as  in  those  of  the  deeper  structures.  The  term  '•  want  of  rest  " 
is  here  used  in  its  fullest  sense,  as  want  of  that  thorough  immobility  of  tissue  and  non- 
interference which  are  all-important  for  the  rapid  ]terfection  of  the  physiological  repara- 
tive process. 

Gaping  of  W^Ound. — Again,  if  the  edges  of  a  wound  are  allowed  either  to  gape 
or  to  have  too  much  tension  upon  them,  repair  will  be  interfered  with,  the  parts  in  both 
cases,  from  either  want  of  care  in  their  adaptation  or  want  of  caution  in  not  making  due 


32  TREATMEST  OF   WOUyDS. 

provision  for  the  escape  of  the  redundant  fluids  (drainage),  or  from  some  over-action 
(inflammation),  not  being  allowed  to  remain  at  rest  and  undergo  repair. 

Oier-ucfioii  in  the  vessels  of  a  part  which  is  undergoing  repair — that  is.  inflammation 
-^always  has  an  evil  influence.  When  it  shows  itself  early  in  the  case,  it  prevents 
repair;  and  when  manifested  at  a  later  period,  it  retards  the  healing  process,  or  even 
causes  its  retrogression.  Indeed,  under  all  circumstances  when  the  vascular  action  of  a 
part  which  is  undergoing  repair  exceeds  what  is  essential  for  the  steady  perfection  of  the 
process,  the  repair  of  that  part  is  interfered  with.  Inflammation,  when  it  attacks  a 
wound,  at  first  checks  repair,  subsequently  undoes  it.  and  at  a  still  later  period  brings 
aibout  di.sorganizing  changes ;  under  all  circumstances  it  has  a  destructive  tendency. 

The  student,  having  learned  how  wounded  parts  heal  by  nature  s  processes,  and  more 
particularly  how  .simple  incised  and  open  wounds  are  repaired — and  having,  moreover, 
learned  to  recognize  some  of  the  most  important  influences  which  retard,  if  they  do  not 
arrest,  repair — will  readily  understand  the  more  favorable  conditions  under  which  repair 
can  be  carried  out.  and,  what  is  more,  will  at  once  appreciate  the  surgical  requirements 
of  the  case  he  may  have  to  treat,  so  that,  as  a  surgeon,  he  may  know  when  and  where 
to  apply  his  art.  how  he  can  help  nature  in  her  beneficent  action,  and  how  he  can  best 
guard  against  the  intrusion  of  any  outside  influences  that  may  tell  asainst  the  steady 
progress  of  the  reparative  process.  For  it  cannot  be  too  strongly  asserted  that  the  best 
surgeon  is  the  one  who  best  understands  natural  processes  in  the  repair  of  parts  and  who 
knows  how  to  use  them  to  the  greatest  advantage,  who  recognizes  the  fact  that  these 
natural  processes  are  exact  and  when  applied  to  the  healing  of  wounds  undeviating :  who 
knows  that  if  he  is  to  utilize  these  natural  processes  to  the  full  he  must  bring  up  his  art 
of  curing  to  nature's  line,  under  the  conviction  that  nature  never  .systematically  bends  her- 
self or  puts  forth  her  hand  to  help  the  curer.  tha,t  she  never  deviates  from  her  path — that 
if,  using  Dr.  Richardson's  words,  ••  we  do  not  molest  her  she  goes  on.  as  we  say,  naturally 
toward  a  cure  ;  if  we  molest  her  a  very  little,  she  goes  on.  and  the  molestation  is  but  little 
shown  ;  if  we  molest  her  vehemently,  she  still  goes  on.  showing  molestation  in  proportion 
to  disturbance,  nature  under  all  circumstances  going  her  own  way.  caring  just  as  little  for 
ease  as  for  pain,  for  life  as  for  death.'"  When  a  bone  is  broken,  nature  will  heal  it  quite 
irrespectively  of  the  position  in  which  it  is  placed  :  when  a  knuckle  of  bowel  is  strangu- 
lated, nature  will  cast  it  ofi"  quite  regardless  of  the  eff"ects  of  such  a  sloughing  act.  But 
the  surgeon  who  knows  this  knows,  moreover,  that  the  same  natural  process  will  work  on 
when  the  bone  is  "  set  "  in  a  right  position  and  maintained  there  by  art.  and  that  the 
slouehing  may  be  avoided  when  the  strangulated  bowel  is  relieved  by  art  from  its  false 
position  and  placed  where  it  can  be  best  repaired  by  natures  means. 

Treatzviext  of  Wouxds. 

In  the  treatment  of  a  simple  cut  or  incised  wound  in  which  there  is  no  dirt  or  foreign 
matter  to  keep  the  edges  of  the  wound  asunder  and  to  act  as  an  irritant,  in  which  there 
is  no  hjemorrhage  beyond  capillary  or  venous  bleedings,  which  can  be  aiTested  by  eleva- 
tion of  the  part,  moderate  pressure,  or  the  application  of  a  cold  or  hot  sponge,  the  sur- 
geon has  simply  to  cleanse  the  wound,  bring  its  edges  carefully  together,  and  adopt  means 
to  keep  them  so :  while  at  the  same  time  he  makes  such  provision  for  the  protection  of 
the  wotind  as  may  secure  it  from  injury  from  without  or  within,  and  may  allow  the 
reparative  process  which  has  been  described  as  taking  place  in  primary  union  to  be 
quietly  perfected. 

In  more  xev-re  irounds  a  similar  practice  is  to  be  advocated,  though  some  care  may  be 
called  for  in  cleansing  the  wound,  more  caution  required  in  the  arrest  of  bleeding,  and 
more  ingenuity  demanded  in  bringing  the  edges  of  the  wound  together,  as  well  as  in  so 
fixing  the  injured  part  in  position  that  the  patient  may  be  comfortable,  while  the  wound 
is  kept  immobile  and  protected  from  such  injurious  outside  influences  as  would  interfere 
with  the  healing  act.  Provision,  moreover,  will  have  to  be  made  for  efiicient  drainage — 
that  is,  for  the  free  exit  of  such  sanguineous  or  serous  fluids  as  are  commonly  exuded 
after  severe  wounds  or  operations,  and  the  retention  of  which  always  proves  injurious. 

Upon  each  and  all  of  these  points,  therefore,  a  few  lines  may  not  be  without  value. 

On  Cleansing  Wounds. — After  full  examination  of  a  wounded  part,  and  careful 
consideration  as  to  the  mode  of  its  production,  the  extent  of  injury,  and  the  require- 
ments of  the  case  for  cure,  the  wound  should  be  cleansed.  This  should  be  efl"ected  with 
all  completeness  and  gentleness,  .since,  on  the  one  hand,  everything  like  a  foreign  body 
between  the  lips  of  a  wound  would  of  necessity  prevent  quick  or  primary  union,  and 


ti:i:atmi:st  of  worsDSi. 


33 


would   ill   all   pi-nl.al.ilit y  I'liivf   injiuiniis  t<i  the  .sul).se(|U(Mit   prop^oss  of  the  case;  wliilo, 

on  the   other  iiaiid,  aiiytliiii;.'  like   rou^diiiess  wouM   he   (Iftrimeiilal  to  thr  already  injiircil 

tissues.      'I'd   etVect    this   eleausinir  with  i:en- 

tleness,   a   stream   of  water   medicated    with 

soiue   atitise|tti(t    is   the    hest    means   for   tlie 

surfreon  to  i-mploy.  ami  this  stream  may  he 

broutrht  to  hear  ujion   the  part  hy  iisinjr  tlie 

irrij;atiuj;-hottle  or  the   irriiratinfr-ean   (Fifr. 

W)    I  luive   here    tiirured.       The    stream    of 

fluid  washes  away  hlood  with   all  lijrht  for- 

eijzn    matter,    and    what    cannot    he    washed 

away   may  he   removed  with   finjit'rs  or  \\)Y- 

cej>s.      In    j;unshot    wounds    special    forceps 

and  otlier  instruments  may  he  rerpiired. 

Those  who  helieve  atmospheric  trerms  to 
he  the  (diief  cause  of  inflammation  and  sup- 
puration, or  of  most,  if  n(»t  all.  tlm  ills  to 
wliieh  wounded  flesh  is  heir,  will  employ  the 
means  that  are  supjtosed  to  he  capable  of  de- 
strovinj;  such  maliuiiant  foreign  visitors,  and 
for  this  purpose  will  use  the  spray  of  carbolic 
acid,  one  part  in  forty,  or  other  antiseptic,  to 
kill  the  irernis  in  the  air  as  they  approach 
tlie  wound,  and  will  dress  the  wound  with  the 
carbolic  lotion,  carbolic  irauze,  protective,  and 
waterproofiuLT.  according  to  directions  lairl 
down  in  a  future  page  (vi(h^  Listerian  method 
of  dressino;  wounds) ;  whereas  those  who 
disregard  atmospheric  germs,  and  yet  highly  value  means  for  purifying  wound  surfaces, 
will  use  antiseptic  irrigation  of  the  wound  with  a  lotion  of  carbolic  acid  1  to  20,  of 
thymol  1  to  100(1.  of  chloride  of  zinc  20  grains  to  tlie  ounce  (originally  used  by  Mr.  C 
de  Morgan  many  years  ago),  or  of  iodine,  made  by  adding  10  drops  of  the  liquor  iodi  to 
the  ounce  of  water.  I  have  employed  the  iodine  lotion  for  years,  and  prefer  it  to  any 
other.  It  is  always  at  hand,  and  is  both  simple  and  effectual  as  a  wound  cleanser.  The 
lotion  may  be  used  warm,  and  it  has  the  advantage  of  not  only  cleansing  the  wound  in 
the  fullest  sense  of  the  term — for  iodine  is  an  antiseptic — but  it  has  a  marked  tendency 
to  arrest  all  capillary  bleeding  or  oozing.  I  use  it  in  about  the  proportions  given  above, 
but  the  best  practical  guide  is  to  pour  the  solution  or  tincture  into  a  basinful  of  water,  so 
as  to  make  tlu'  lattt'r  of  a  light  sherry  color. 

Arrest  of  Bleeding. — It  is  well  that  haemorrhage  should  be  effectually  arrested 
by  some  of  the  various  means  which  the  surgeon  has  at  his  command  before  the  edges 
of  a  wound  are  brought  together,  and  it  is  wise  to  have  even  capillary  bleeding  stopped, 
when  it  is  possible  :  for  blood  effused  in  even  limited  (juantities  between  the  surfaces  of 
an  incised  wmmd  is  to  be  regarded  much  in  the  light  of  a  foreign  body,  and  as  forming 
an  obstacle  to  repair,  more  particularly  when  primary  union  of  the  wound  is  to  be  sought 
for.  Indeed,  it  was  on  this  account  that  I  was  first  led  to  employ.  f(jr  cleansing  wounds, 
the  iodine  water  to  which  I  have  drawn  attention,  and  which  I  cannot  too  strongly  recom- 
mend for  general  adoption.  A  sponge  wrung  out  of  this  lotion  (made  with  hot  water), 
and  held  to  a  wound  for  a  minute,  completely  checks  all  oozing  of  blood,  and  tends  more 
than  anything  else,  except  prolonged  exposure  to  the  atmosphere,  to  the  formation  of 
that  glaze  upon  the  surface  of  the  wound  which  so  much  conduces  to  satisfactorv  repair. 


Irrigatiiig-Bottle  and  Apjjaratus. 


On  the  Question  of  Repair  by  Primary  or  Secondary  Adhesion. 

When  the  surgeon  has  cleansed  the  wound,  removed  what  foreign  bodies  may  have 
been  present,  and  stopped  all  bleeding,  he  has  to  decide  upon  the  means  whereby  the 
reparative  process  may  be  best  heljied,  and  as  a  primary  point  to  determine  either  the 
feasibility  or  expediency  of  attempting  to  obtain  quick  or  primary  ituion  of  the  cut  parts, 
or  the  wisdom  of  looking  to  their  repair  by  the  slower  npen^  (jruinihiting  process. 

When  the  wound  is  f)f  the  indued  kind,  the  question  is  not  difficult  to  answer :  for  it 
may  with  confidence  be  asserted  that,  with  few  exceptions,  in  all  wounds  of  this  descrip- 
tion, whether  superficial  or  deep,  accidental  or  the  result  of  operation,  repair  by  quick  or 
.3 


34  TREATMENT  TO  HELP  QUICK  OB  PRIMARY   UNION. 

primary  union  is  to  be  desired,  and,  what  is  more,  may  be  expected  if  the  subject  of  the 
wound  be  healthy  and  not  too  old,  and  if  nature's  reparative  process  be  so  aided  by  sur- 
gical art  as  to  be  allowed  to  take  its  course  without  interference. 

The  cleaner  the  cut  is,  the  greater  is  the  probability  of  its  uniting  by  quick  repair ; 
the  more  ragged,  contused,  and  lacerated  the  margins  of  the  wound  are,  the  less  are  the 
prospects  of  obtaining  primary  union  and  the  less  the  wisdom  of  making  the  attempt. 
Between  these  two  extremes  are  innumerable  gradations.  Where  there  is  a  doubt  about 
the  wisdom  of  making  the  attempt  to  secure  primary  union  in  deep,  contused,  and  lacer- 
ated wounds,  let  the  decision'  be  against  it ;  and  when  the  doubt  applies  to  the  more 
superficial  or  hopeful  class  of  wounds,  let  it  be  decided  in  its  favor.  Care  must,  however, 
be  taken  in  these  as  in  all  cases  to  give  up  the  attempt  on  the  appearance  of  the  slightest 
local  or  constitutional  symptoms.  It  is  also  necessary  to  bear  in  mind  that  by  drawing 
together  the  parts  by  sutures,  etc.,  some  retained  blood,  serum,  or  sloughing  tissue  may 
keep  them  in  a  state  of  unrest^  either  by  tending  to  separate  the  lips  of  the  wound  and 
exciting  tension,  or  by  undergoing  chemical  changes  and  decomposition  and  thus  favoring 
the  production  of  some  septictemic  or  pygemic  conditions.  For  it  must  be  recognized  that 
whilst  in  the  cleanest  incised  wound  there  maij  be  no  death  of  the  divided  tissues,  and 
consequently  no  animal  matter  to  undergo  chemical  changes  or  putrefactive  decomposi- 
tion, in  the  contused  and  lacerated  there  mud  (jf  necessity  be  more  or  less. 

When  tissue  dies,  it  must  be  shed  or  cast  off  fro)n  the  living  parts  before  the  physio- 
logical reparative  or  uniting  process  can  take  its  course.  AYhen  this  dead  tissue  has  been 
separated  from  the  living,  it  ceases  at  once  to  be  influenced  by  the  vital  processes  by 
which  it  had  been  built  up,  kept  clean,  and  eventually  cast  off;  it  consequently  becomes 
subject  to  the  physical  laws  of  all  dead  matter,  and  undergoes  chemical  changes — which 
means  too  often  decomposition. 

The  object  of  the  surgeon,  therefore,  in  the  treatment  of  these  cases  of  wound  in  which 
the  death  of  tissue  is  to  be  expected,  and  cannot  be  prevented,  is  to  neutralize  as  far  as 
possible  the  evil  influence  of  its  death  and  probable  decomposition.  This  is  to  be  achieved 
by  so  dealing  with  the  injured  part  that  the  dead  tissue  may  find  a  free  outlet  for  its  dis- 
charge, and  by  rejecting  all  such  applications  or  dressings  as  are  likely  to  help  putrefac- 
tive decomposition,  at  the  same  time  employing  means  and  agents  likely  to  neutralize  its 
pernicious  influence  and  to  control,  in  a  measure,  the  process  of  decay. 

Treatment  to  Help  Quick  or  Primary  Union. 

To  promote  the  primary  union  of  a  wound,  the  surgeon  has  six  cardinal  indications  to 
follow : 

1 .  To  cleanse  the  wound. 

2.  To  arrest  all  bleeding. 

3.  To  effect  coaptation'of  the  two  divided  surfaces  of  the  wound,  the  deep  parts  as 
well  as  the  edges. 

4.  To  maintain  the  wounded  parts  in  a  position  of  immobility  beneficial  to  the  natural 
process  of  repair  as  well  as  comfortable  to  the  patient. 

5.  To  secure  drainage  of  the  wound  by  providing  for  the  escape  of  such  dead  tissue 
as  may  be  thrown  off,  as  well  as  of  all  fluids  that  are  not  required  for  repair. 

6.  To  protect  the  external  wound  from  all  such  outside  influences  as  may  be  preju- 
dicial. 

The  first  two  indications  have  been  already  considered — viz.,  the  cleansing  of  the 
wound  and  the  arrest  of  bleeding  (pp.  32,  33).  In  all  forms  of  wound,  and  for  every 
form,  of  healing,  attention  to  these  points  is  most  important ;  but  when  quick  or  primary 
union  is  to  be  expected,  it  is  all-essential. 

Third  Indication  :   The  Coaptation  of  the  Edges  and   Surfaces  of  a 

Wound. 

The  coaptation  of  the  two  divided  surfaces  of  the  wound  may  be  efficiently  carried 
out  in  superficial  or  not  deep  wounds  by  means  of  sutures  and  adhesive  plaster,  sepa- 
rately or  combined.  When,  by  the  use  of  trustworthy  adhesive  plaster,  the  object  sought 
for  can  be  obtained,  sutures  are  not  called  for  ;  and  when  sutures  are  used,  the  form  of 
suture  that  carries  out  tlu>  object  in  view  in  the  simplest  way  is  the  best. 

Interrupted  Suture. — When  the  wound  is  supeyJrciaL  the  sutures  need  not  be 
introduced  deeply  ;  but  when  the  wound  is  deeji,  the  practice  of  bringing  the  edges  of 


ruiiu)  isDicATioy. 


.35 


V\r..   1. 


flo  it. 


How  tiot  to  do  a 


The  Interrupted  Suture. 


till'  wiiiirnl,  ami  not  the  il('i"|icr  |iaits,  lu^tllicr  is  IVaiiulit  with  <laiii;iT,  .siiicr  the  ic]iair  ))y 
priinarv  uiiii»ii  wliicli  is  loiikcil  lur  caiiiKit  take  place,  ami  lict wocii  the  sc)iaiat(;(l  surt'aceH 
(if  till'  (li'i'piT  |>arts  til'  till'  wiMiml  hldnd,  siTHiii,  <ir  iiillaiiiiiialury  fluids  will  ciilli-ct  ami 
^ive  risi'  ti»  tntulilc.  Ilciicc  in  (Iccp  wiiiuids  the  sutures  sliuiild  citlier  he  all  iiitniduccd 
dee])ly  or  di'e[)  as  well  as  siiiicriieial  sutures  siiould  he  employed. 

The  infi'nii/tfrd  (Fij;.  4)  is  the  most  useful  I'onii  of  suture,  and  it  is  ap|)lieahle  to 
anpirflciii/  ■,\<  well  as  to  deej)  wounds.  It  ean  ]h'  made 
with  a  ciirvtMldr  straight  needle,  aeetU'dini;  to  convenience, 
armed  with  a  siuj^le  thread  ol"  well-wa.\ed  silk,  wire,  or 
lishing-<;ut.  the  tine  silk  line  sold  Ity  tai-kle-iuakcrs  hein^j; 
the  best  tor  ordinary  purposes.  The  needle  should  he 
introduced  throu>;h  one  side  of  the  wound  ohliipu'ly  from 
without  inward,  and  made  to  ])ass  through  the  opjiosite 
side  in  the  rever.se  direction  i'miu  within  outward.  The 
knot  of  the  suture  slioiild  he  hnuiuht  to  one  side  of  the 
wound,  as  shown  in  lig.  4.  In  the  xnpcijicidl  it  should  be 
inserted  with  sufficient  depth  and  closeness  to  bring  the 
.surfaces  and  edges  of  tlie  ])art  accurately  and  closely 
together,  and  it  should  be  tied  with  enough  Ibrce  to  carry 
out  these  objects,  but  not  with  more,  since  to  tie  a  suture 
as  a  surgeon  would  a  ligature  is  to  do  harm,  as  the  suture 
would  cut  rapidly  through  the  strangulated  tissues,  and  in 
so  doing  irritate  the  ])art  instead  of  helping  repair. 

In  tlcrp  wounds  the  suturse  must  be  inserted  deeply,  as  in  hare-lip  operations,  and 
introduced  well  away  from  the  edges  of  the  separated  tissues,  so  that  when  they  are 
tightened  the  deeper  parts  as  well  as  the  superficial  will  be  brought  effectually  into  appo- 
sition. In  some  cases  deep  and  superficial  sutures  may  l^e  made  to  alternate.  Superficial 
sutures  should  include  neither  muscles  nor  deep  fascia. 

A  double-reef  knot  is  usually  employed,  but  a  "granny"  (Fig.  137)  is  by  no  means  a 
bad  one  to  make,  since  it  is  a  slip-knot  and  can  be  tightened  at  pleasure  by  a  third  tie. 

In  the  majority  of  cases  in  which  sutures  are  employed  it  is  an  excellent  plan  to 
alternate  the  sutures  with  strapping;  a  narrow  band  of  the  latter  carefully  adjusted 
between  the  stitches  not  only  materially  aids  the  adaptation  of  the  edges  of  the  wound, 
but,  if  well  applied,  tends  to  prevent  ten,sion  and  to  immobilize  the  wounded  structure, 
while  at  the  same  time  it  acts  in  the  way  of  affording  local  pressure  to  the  deeper  parts 
of  the  wound.  In  operations  on  the  breast  the  advantages  of  this  practice  are  well 
exemplified. 

Continued  Suture, — The  uninterrupted,  continued,  or  Glover's  suture  (Fig.  5), 
the  stitch  of  the  sem|»«;tress,  is  valuable  in  all  cases  in  which  a  very  close  aiid  accurate 
adaptation  of  the  margins  of  the  wound  is  wanted,  as 
in  wound  of  the  intestine,  as  well  as  in  those  of  the 
eyelids  and  face  generally  ;  indeed,  a  clean  wound  of 
these  parts,  superficial  or  deep,  may  be  so  accurately 
and  well  adjusted  by  means  of  a  fine  needle  and 
thread  as  to  leave  but  a  minimum  of  scar.  In  opera- 
tions about  the  lip  the  same  remark  is  applicable, 
although  in  these  care  .should  be  observed  to  intro- 
duce the  sutures  deeply  and  well  away  from  the  mar- 
gins of  the  wound.  In  operations  for  phymosis  in  the 
adult  this  form  of  suture  is  likewise  of  great  value,  as 
it  not  only  expedites  recovery,  but  does  much  to  make 
the  result   of  the  operation   more  artistic.     In    these 

cases  the  fine  carbolized  gut  suture  may  be  used.  The  stitches  should  be  removed  on  the 
third  or  fourth  day.  They  may  often  be  taken  out  of  the  face  on  the  second.  If  left  in 
long,  they  are  ajit  to  set  up  irritation   and  ulceration. 

Twisted  Suture. — The  twisted  suture  (Fig.  G)  is  of  value  in  certain  operations 
on  the  lijis  and  cheeks,  and  in  other  parts  where  difficulty  is  experienced  in  bringing  the 
parts  together,  since  by  its  use  more  force  can  be  brought  to  bear  upon  the  margins  of 
the  wound,  and  their  adaptation  can  thus  be  rendered  more  perfect.  This  form  of  suture 
was  in  former  times  the  one  commonly  employed  in  hare-lip  operations,  but  it  is  not  so 
now.  I  have  for  years  discarded  it  in  favor  of  the  interrupted  suture  of  silkworm  gut, 
or  wire,  and   employ  it  only  in  cases  in  which   exceptional  difficulty  is  experienced  ia 


Fig. 


The  Continued  Suture  as  .Applied  to  the 
Intestine. 


36 


THIRD  INDICATION. 


bringing  the  parts  togotlior.     It  is  iisoful.  liowever,  in  (•liciluplastic  operations,  as  ■well  as 
in  the  Pirogoff  anil   Cliopart's  an)putations.     To  apply  it,  some  fine  pins  with  flat  heads, 

silk,  anil   cutting  pliers  are   wanted.      The   pins  are   em- 
FiG.  6.  ployed  to  bring  the   surfaces  of  the   wound   in   contact, 

and  their  points  should  be  introduced  half  an  inch  or 
ninre  from  the  margin  of  the  wound,  and  passed  deeply 
and  obliquely,  in  lip  operations,  through  the  thickness  of 
the  ti.ssues  down  to,  but  not  through,  the  lining  mucous 
membrane  (Fig.  G).  They  should  then  be  made  to  pass 
through  the  opposite  side  and  brought  out  through  the 
skin  at  a  corresponding  point.  A  piece  of  silk  passed  as 
a  figure-of-8  should  be  twisted  around  the  two  ends. 
The  wound  may  next  be  drawn  together;  and  should  the 
apposition  of  the  surfaces  be  imperfect,  the  pins  should 
The  Twisted  .Suture.  be  taken  out  and  the  parts  be  readjusted,  and  in  this  lies 

■  the  great  advantage  of  this  form  of  suture.  After  the 
silk  has  been  tied  in  knots  and  the  ends  cut  off',  the  points  of  the  pins  should  be  removed 
and  the  soft  parts  protected  from  the  ends,  if  necessary,  b}'  the  introduction  beneath  them 
of  a  small  piece  of  lint  or  strapping.  Instead  of  silk  being  twisted  round  the  pins,  a  sec- 
tion of  an  india-rubber  tube  in  the  form  of  a  ring  has  been  employed  by  3Ir.  Kigal,  and 
the  late  W.  L.  Atlee  of  Philadelphia.  The  ring  is  slipped  over  the  ends  of  the  pin,  and 
serves  by  its  elasticity  to  keep  the  parts  together. 

Quilled  Suture. — This  form  of  suture  (Fig.  7)  is  applicable  where  deep  wounds 
have  to  be  Vtcil   held  together  along  their  whole  line,  and  more  particularly  for  a  brief 

period,  .say  two  or  three  days.      In 
Fig.  7.  ruptured  perineum  it  used  to  be  in 

general  use  combined  with  super- 
ficial sutures,  but  the  interrupted 
sutures  of  silkworm  gut,  introduced 
well  away  from  the  margins  of  the 
wound  and  inserted  deeph,  are 
]>robably  to  lie  preferred. 

For  the  application  of  this  su- 
ture, a  strong  curved  needle  with 
an  eye  at  the  end  and  threaded  is 
to  be  inserted  at  least  three-quar- 
ters of  an  inch  from  one  margin  of 
the  wound  and  made  to  pass  well 
down  to  its  depths,  then  brought 
out  through  the  other  margin  in  a 
corresponding  line.  The  loop  of  the 
suture  should  now  be  caught  and 
held  and  the  needle  withdrawn  ;  a  ])iece  of  bougie,  cut  the  required  length,  being  intro- 
duced into  the  loop,  is  fixed  by  drawing  the  free  ends  of  the  ligature  home  (Fig.  7  a). 
A  second  or  third  suture  can  be  applied  in  the  same  way.  A  second  piece  of  bougie 
ought  then  to  be  tied  on  the  opposite  margin  of  the  wound,  the  parts  having  been  well 
cleansed  previously  and  carefully  adjusted.  The  surfaces  of  the  wound  are  only  to  be 
held  closely  in  apposition,  and  must  not  be  pressed  too  firmly  ;  otherwise,  the  bougies 
will  set  up  ulceration.  Superficial  sutures  may  subsequently  be  intro- 
duced into  the  edges  of  the  wound  (Fig.  7  B). 

For  the  quill  suture  good  fishing-gut  is  better  than  silk  or  wire,  as 
it  is  strong  and  unirritating.  Before  u.se  it  should  be  soaked  in  water,  to 
make  it  limp  ;  it  can  be  readily  tied  or  fastened  with  a  .shot.  The  loops 
of  the  (juill  suture  .should  generally  be  divided  on  the  fifth  or  sixth  day, 
but  this  depends  on  the  amount  of  irritation  caused  by  the  bougie. 

The  Button  Suture,  as  a  variety  of  the  quill,  is  useful  in  some 
amputations,  as  the  thigh,  where  the  surgeon  is  desirous  of  keeping  the 
bases  of  the  flaps  together,  and  in  breast  cases  and  in  hare-lip  or  other  lip 
operations  (Fig.  S"). 

Material   for   Sutures. — With    respect   to  the  material  used  for 
sutures,  silk,  wire,  silkworm   gut,  prepared    catgut,  or  horsehair  are  each 
good  in  certain  cases  when  rightly  selected.     "When  there  is  little  tension  on  the  sutures, 


The  Quilled  Suture. 


Fig.  8. 


Button  8uturt 


For  inn  isinrAnny.  37 

silk  or  wire  may  be  iniliffi-rently  employe*!,  the  umi»unt  of  irritutiori  exerted  by  one  or  the 
otiier  materiul  ile|ieii«liii^  more  upon  tension  than  on  any  other  condition.  I  have  hiii^ 
proved  this  to  n>y  own  .satist'uction  by  testing  both  form.s  of  suture  in  the  same  subject 
through  a  h»nj^  series  of  cases. 

ill  jilnstic  operations  silkworm  ;rut  well  .softened  in  water  before  use  is  to  be  recom- 
meiideil  ;  it  holds  well,  and  seems  to  irritate  far  U'ss  than  any  other  material.  In  ca.ses 
of  ruptured  perineum  and  in  operations  for  va<:iiial  tistula  and  fissured  |ialate  it  should 
always  be  used.  In  the  latter  class  of  cases,  where  the  .soft  palate  alone  is  involved, 
horsehair  is  good,  but  it  is  not  strong  enough  to  resist  much  teiisi(»n. 

In  plastic  operations,  in  which  some  skill  may  be  called  for  in  adjusting  the  parts,  wire 
sutures  may  be  seb'cted,  since  they  can  be  twisted  and  untwist«'d  with  facility,  and  the  sur- 
geon can  coiisc(|ueiitly  readjust  the  margiii>  of  the  wound  as  re<juired  to  his  .satisfaction. 

Prepared  catgut  is  not  a  reliable  material  f(jr  sutures,  since  it  is  uncertain  as  to  its 
retaining  power  and  is  apt  when  sodden  to  yield  ;  it  is,  however,  u.seful  as  a  suture  in 
holding  j»arts  together  for  a  brief  period  where  there  is  no  tension,  and  where  there  may 
be  a  difficulty  in  removing  the  stitches  subsequently.  In  operations  on  the  penis  it  is 
of  special  value. 

Value  of  Pressure. — The  effectual  carrying  out  of  the  third  indication  in  the 
treatment  of  inciseil  wound.s — viz.,  the  coaptation  of  the  two  divided  surfaces  of  the 
wound,  deep  parts  as  well  as  edges — is  not.  however,  always  to  be  accomplished  by  means 
of  sutures  and  strapping,  however  well  selected  and  applied  these  may  be.  Other  means 
are  constantly  demanded,  and  of  the.se  well-directed  j>ris.siire  is  the  most  important,  as 
ably  advocated  by  (iamgee.  Indeed,  the  value  of  pressure  in  the  treatment  of  all 
wounds  is  worthy  of  more  consideration  than  it  has  received.  By  it  the  surfaces  of 
divided  parts  are  kept  together,  and  particularly  the  deeper  surfaces  :  mobility  of  the 
injured  tissues  is  checked,  if  not  prevented;  the  vessels  of  the  wounded  parts  are  sup- 
ported; and  the  evil  influence  of  blood-stasis,  with  its  effect,  effusion,  is  neutralized. 
Under  the.se  circumstances  repair  is  helped,  and  nature's  proces.ses  are  permitted  to  go  on 
under  more  favorable  conditions.  With  this  view  of  the  value  of  pressure,  well  applied 
pads  of  lint,  absorbent  cotton-wool,  gauze,  or  sponge,  saturated  or  not  with  .some  anti- 
septic drug,  should  be  carefully  adjusted  over  the  flaps  of  all  wounds  when  such  exist, 
and  over  tlie  surfaces  of  others.  The.se  pads  are  kept  in  position  by  means  of  strapping 
or  bandages,  aided  by  splints  when  the  extremities  are  involved.  After  the  removal  of 
a  breast  or  tumor,  the  value  of  a  well-adjusted  pad,  and  more  particularly  of  sponge 
wrung  out  of  iodine  or  carbolic  water,  cannot  be  too  highly  praised.  After  an  amputa- 
tion, the  use  of  a  splint  adjusted  to  the  stump,  and  pressure  well  applied  to  the  bases  of 
the  flaps,  not  to  the  edges,  should  never  be  omitted. 

Fourth  Indication. 

The  Maintenance  of  Wounded  Parts  in  such  a  Position  of  Tmmn- 
biUty  as  may  be  Favorable  to  the  Natural  Process  of  Repair  and 

Comfortable  to  the  Patient  is  the  fourth  indication  ill  the  treatment  of  incised 
wounds :  and.  to  say  the  least,  this  is  as  important  as  the  preceding  indication,  since,  if 
neglected,  the  benefit  that  might  be  expected  from  efficiently  coaptating  the  wound  could 
not  be  realized,  and  the  process  of  repair  in  the  wounded  part  would  of  necessity  be 
checked,  if  not  altogether  prevented. 

To  carry  out  this  indication.  immoliiUtt/  of  the  wounded  part  is  of  the  first  importance, 
and  its  position  next.  The  position  is  always  selected  with  the  object  of  giving  ease  to 
the  patient  and  of  preventing  pain  :  of  relaxing  the  wounded  tissues,  and  so  guarding 
against  any  tendency  to  bring  about  a  separation  of  the  edges  of  the  wound,  as  in  cut- 
throat cases;  and  last,  but  not  least,  of  encouraging  the  return  of  the  venous  blood  from 
,  e  wounded  parts  toward  the  heart.  Thus,  in  wounds  of  the  trunk  the  horizontal  posi- 
tic  is  the  right  one  to  be  maintained,  and  in  those  of  the  extremities  flexion  and  eleva- 
tion of  the  limb ;  in  wounds  of  the  lower  extremity  the  foot  should  be  kept  higher  than 
the  knee,  and  the  knee  than  the  hip ;  and  in  those  of  the  upper  extremity  the  .same  prin- 
ciples of  practice  should  be  fidlowed.  the  elbow  being  generally  flexed.  Under  all  cir- 
cumstances wounded  limbs  should  be  fixed  upon  splints,  with  the  view  of  immobilizing 
them,  and,  as  a  rule,  they  should  be  swung.  This  practice  adds  greatly  to  the  comfort 
of  the  patients  by  allowing  them  to  move  their  trunks  without  their  wounded  extremities, 
and  without,  therefore,  interfering  with  repair.  It  should  be  added,  however,  that  the 
question  of  position  ought  always  to  be  considered  in  reference  to  x\iQ  fifth  indication — - 


38  FIFTH  IXDJCATTOX. 

namely,  the  necessity  of  providing  efficient  means  for  the  removal  of  the  superfluous 
fluids  of  the  part,  and  for  the  escape  of  disintegrated  dead  tissue  which  may  have  to  h-i 
discharged,  or,  in  other  words,  for  draliiage. 

Fifth  Indication:   Drainage. 

Drainage,  or  the  making  of  due  provision  for  the  escape  from  the  wound  of  disin- 
tegrated dead  tissue,  with  such  fluids  as  are  not  required  for  repair,  and  which,  if  left, 
might  prove  injurious,  is  of  primary  importance  in  the  treatment  of  all,  and  more  par- 
ticularly of  deep,  wounds.  It  should  never  escape  the  attention  of  the  surgeon.  In 
scalp  wounds  and  those  about  the  eyelids,  though  they  may  appear  trivial,  it  is  of  as 
much  importance  as  it  is  in  the  wounds  that  involve  deeper  parts  and  seem  more  severe ; 
for  in  the  one  case,  as  in  the  other,  pent-up  fluids  not  only  separate  tissues  which  are 
intended  to  unite,  give  rise  to  pain  b}'  producing  tension,  and  consequently  cause  consti- 
tutional irritation,  but  they  are  prone  to  excite  inflammation  in  the  part,  and  ultimately 
to  undergo  septic  changes,  which  in  their  turn  may  give  rise  to  blood-poisoning  in  the 
form  of  septicfemia  or  pyaemia. 

No  other  than  trivial  wounds,  consequently,  should  be  completely  covered  in.  and 
deep  ones  very  rarely.  Some  corner,  and  preferably  that  which  is  the  most  dependent — 
some  interval  between  the  sutures  or  strips  of  the  pla.ster — should  always  be  left  open 
for  the  escape  of  disintegrated  tissues  and  of  superfluous  fluids,  such  as  blood  or  serum, 
and  where  deeper  structures  are  involved  some  conducting  material,  or  ''  drainage-tube," 
should  be  introduced.  The  best  is  a  tube  of  india-rubber  perforated  at  intervals  (as 
originally  suggested  by  Chassaignac.  1855).  of  a. size  varying  with  the  cavity  or  wound 
to  be  drained  ;  but  in  some  cases  a  strand  of  carbolized  catgut  or  horsehair,  a  roll  of  gutta- 
percha skin,  or  a  piece  of  lint  saturated  with  carbolic  or  terebene  oil  will  do  as  well.  In 
abdominal  cases,  as  after  ovariotomy,  a  perforated  glass  tube  is  of  great  value,  while 
under  other  circum.stances  an  elastic  catheter  will  answer  the  purpose.  The  particular 
mode  of  accomplishing  the  object  is  of  little  importance,  so  long  as  the  object  itself  is 
secured. 

Caution  in  Use  of  Drainage -Tube. — In  using  a  drainage-tube,  however,  the 
surgeon  nfust  remember  that  it  is  not  to  be  made  a  seton.  and  that  the  sole  justification 
for  its  use  is  to  drain  the  fluids  from  the  deep  tissues.  For  this  purpose  the  tube  is  to 
be  made  to  dip  deeply  enough  into  the  wound,  but  no  more :  it  is  not  to  be  made  a  cause 
of  irritation.  The  size  of  the  tube  is  to  be  regulated  by  the  requirements  of  the  case  ; 
several  short  tubes  are  often  better  than  a  long  one.  Care  is  also  to  be  taken  that  the 
outer  ends  of  the  tubes  are  left  free  ;  when  covered,  they  .should  be  covered  but  lightly, 
and  then  with  some  absorbent  cotton,  oakum,  sponge,  or  gauze.  As  a  rule,  however, 
they  should  be  left  open. 

Position  of  Tube. — In  using  the  tube,  when  the  end  is  cut  off"  level  with  the 
wound,  the  outer  extremity  should  be  held  by  means  of  loops  of  carbolized  silk,  perfo- 
rating its  walls  and  secured  externally  by  strapping  or  other  means.  The  tubes  should 
always  be  introduced  at  what  will  be  the  most  dependent  part  of  the  wound  when  the 
patient  is  in  the  recumbent  position,  and  they  should  be  taken  away  as  soon  as  they  have 
answered  their  purpose.  When  quick  or  primary  union  has  taken  place,  they  may  safely 
be  removed  at  the  end  of  twenty-four  or  forty-eight  hours ;  but  when  suppuration  is 
present,  they  must  be  left  longer — sometimes  even  till  the  cavity  has  nearly  closed. 
A  drainage-tube  should,  however,  be  shortened  as  rapidly  as  the  progress  of  the  ca.se  will 
allow,  the  shortening  of  the  tube  and  the  clo.sing  of  the  cavity  of  the  wound  from  below 
going  on  together. 

It  is  to  be  noted  that  at  the  present  day  the  use  of  drainage,  whether  by  tubes  or 
other  material,  is  suggested  with  the  view  of  jrrevcntwg  suppuration  in  the  treatment  of 
deep  wounds ;  whereas  in  former  times,  when  Chassaignac  introduced  his  tubes,  it  was 
for  the  treatment  of  wounds  and  cavities  in  which  suppuration  already  existed. 

The  value  of  the  principle  is.  however,  equally  great  in  both  classes  of  cases.  When 
carbolic  acid  is  used  as  a  wound-dres.sing.  whether  as  a  .sprav  or  as  a  lotion,  or  when 
chloride-of-zinc  lotion  is  employed,  the  use  of  the  drainage-tube  is  more  necessary  than 
it  is  when  other  forms  of  dres.sing  are  employed,  since  under  the  stimulating  influences 
of  the.se  drugs  there  is.  as  Lister  tells  us.  more  eff"usion  of  plasma  than  is  to  be  looked 
for  in  other  circumstances. 

Caution  in  the  Closure  of  Wounds. — Whenever  a  wound  is  dosed,  with  the 
view  either  of  obtaining  rapid  or  primary  union  or  of  converting  an  open  as  far  as  possi- 


o.\  Tin:  sh-cn.M)  ni:i:ssrya  of  a  cr.oshn  wnrxn.  39 

ble  intii  a  siilx-iitaiuMdis  wuhihI,  the  iiutst  careful  iri.speetioii  is  called  for,  tr)  fruard  apainKt, 
and  even  to  anticipate,  truiiMe.  In  these  cases  the  wound  siioiild  he  opened  <»n  the  sli;rht- 
est  approach  ol"  local  tension  or  overaction  with  elevation  of  temperature  and  traumatic 
fever,  since  su(di  local  and  constitutional  disturhance  will  jiroltalily  he  i'oiind  t«»  he  due  to 
tin-  retention  of  some  of  the  fluids  of  tlu;  pari  that  are  in  excess  of  what  i.s  wanted  ibr 
rejiair,  and  can  he  relieved  only  hy  the  evacuation  of  su(di  retained  suhstanccs. 

Sixth  Indication:   The  Protection  of  the  Wounds,  etc. 

The  protection  «d'  the  external  wound  from  all  such  otitside  influences  as  may  be 
prejudicial  to  the  proL'ress  of  natural  repair  is  the  sixth  and  last  indication  for  the  sur- 
f^eon  to  follow  ;  and  it  is  in  itself  as  important  as  the  five  which  have  preceded  it,  since 
it  includes  the  use  of  all  means  hy  wliich  the  wound  can  he  protected  from  outside 
injury,  as  well  as  the  dressing  proper  or  covering:  of  the  wound. 

For  purposes  of  protection,  most  wounds  re(|uire  a  coverin<r;  and  when  they  are  on 
the  extremities  or  other  exposed  parts,  they  also  need  some  cradle  or  other  mechanical 
uiipliance  to  ki-e])  off  the  weight  of  the  hedclothes.  In  wounds  of  the  face,  however, 
coverings  are  rarely  re(juired  ;  for  all  surgectus  are  familiar  with  the  fact  that  there  are 
no  wounds,  operative  or  accidental,  that  do  so  well  as  these  without  any  external  appli- 
cation, provided  that  they  have  been  carefully  brought  together  and  adjusted.  Indeed,  it 
IS  probably  from  a  knowledge  of  these  f:icts  that  the  "/len  nu'f/iod  .of  treating  wounds  ha.s 
been  advocated.  This  method  cannot,  however,  be  recommended,  except  for  wounds  of 
the  face.  For  some  years  past  I  have  been  in  the  habit  of  dressing  all  wounds  with  dry 
absorbent  lint  or  with  lint  soaked  in  a  mixture  of  tercbene  one  part  and  olive  oil  three 
parts,  and  have  every  reason  to  be  satisfied  with  the  practice.  I  simply  cover  the  oiled 
lint  with  a  second  piece  of  dry  lint  and  fix  the  whole  with  a  retentive  bandage,  room 
being  left  for  drainage  in  all  cases  in  which  quick  union  is  not  to  be  expected,  either  by 
loosely  covering  one  corner  of  the  wound  which  is  left  open  or  by  perforating  the  lint 
covering  the  wound,  to  allow  of  the  protrusion  of  the  end  of  the  drainage-tube.  Cotton- 
wool of  the  absorbent  kind  is  then  arranged  about  the  tube,  to  absorb  all  fluids  that 
escape,  but  not  in  any  way  to  arrest  their  flow,  since  to  insert  a  drainage-tube  and  then 
smother  up  its  orifice  seems  inconsistent  practice. 

When  the  sf)ray-and-gauze  system  (^Liskri'am)  is  adopted,  all  the  precautions  required 
for  security  must  be  observed,  the  principle  upon  which  this  system  is  based  being  one 
of  exclusion,  not  only  of  air,  but  of  all  germs  that  nuiy  be  floating  in  it.  and  which  are 
supposed  to  be  the  cause  of  suppuration  and  of  the  decomposition  of  organic  fluids. 

Wet  applications,  and  more  particularly  watery  ones,  are  now  seldom  used,  and  cannot 
be  recommended,  since  it  is  well  known  that  by  moisture  decomposition  is  encouraged. 
When  they  are  employed,  they  should  be  medicated — that  is,  they  should  contain  some 
drug  which  has  an  influence  in  preventing  or  arresting  decomposition,  or  in  neutralizing 
the  evil  effects  of  the  chemical  changes  which  are  sure  to  take  place  either  in  the  con- 
tused or  devitalized  tissues  or  in  the  poured-out  fluids,  whether  blood,  .serum,  or  pus.  The 
best  of  these  drugs  are  chloride  of  zinc,  carbolic  acid,  boracic  acid,  alcohol,  terebene, 
thymol,  iodine,  the  permanganate  of  potash,  and  iodoform. 

On  the  Second  Dressing  of  a  Closed  Wound. 

No  fixed  period  can  be  named  when  the  first  dressing  should  be  removed  from  and  a 
second  applied  to  a  wound  which  is  being  treated  with  the  view  of  oVjtaining  healing  by 
"  quick  "  or  primary  adhesion.  But  this  is  certain — that  no  interference  .should  be 
allowed  under  a  week  unless  there  is  some  indication,  either  in  the  form  of  local  discom- 
fort or  pain,  or  some  constitutional  symptom,  such  as  an  elevation  of  temperature  with 
febrile  disturbance,  to  justify  the  act.  In  truth,  to  use  a  legal  phra.se,  the  surgeon 
should  in  all  cases  show  cause  why  he  should  interfere  before  he  does  so ;  for  it  is  not  to 
be  denied  that  in  changing  dressing,  even  with  the  gentlest  and  most  skilled  manipula- 
tion; there  mu.st  of  necessity  be  some  interference  with  the  reparative  process,  some  slight 
tearing  away  of  the  new  reparative  material,  some  taking  away  of  support  where  support 
is  essential  or  removal  of  Local  pressure  where  such  is  needed  ;  in  fact,  there  must  always 
be  some  injurious  influence  upon  the  healing  part  which  should  not  be  permitted  without 
a  compensatory  good  effect. 

A  wound  treated  for  repair  by  juimary  adhesion,  if  left  alone,  will  probably,  under 
favorable  circumstances,  heal  within  the  week  ;  and  a  large  wound,  such  as  that  made  in 


40  ON  THE  SECOND  DRESSING    OE  A    CLOSED    WOUND. 

ovariotomy,  in  excision  of  the  breast,  or  in  anipntation,  will  lieal  witliin  two  weeks  under 
the  best  conditions.  If  it  does  not,  it  is  because  tliere  is  something  wrontr  with  the 
patient's  general  condition,  or  something  wrong  in  the  wound,  or  more  particularly  in  its 
treatment ;  for  the  primary  dressing  of  the  wound  should  liave  been  such  as  to  render 
early  interference  with  it  unnecessary. 

To  recapitulate:  (1)  the  edges  and  surfaces  of  the  wound  should  be  carefully  adjusted 
and  fixed  together;  (2)  complete  immobility  of  the  injured  part  should  be  guaranteed  by 
the  judicious  application  of  splints,  pads,  and  bandages;  (3)  the  limb  or  wounded  part 
should  be  placed  in  the  most  comfortable  position  for  the  patient,  as  well  as  in  that  which 
is  iilost  favorable  for  repair  ;  (4)  due  provision  should  be  made  for  the  effectual  drainage 
of  the  wound,  and  care  should  be  taken  that  the  effect  of  drainage  is  not  neutralized  by 
any  external  application  or  dressing ;  and,  lastly  (5),  such  dressings  or  external  coverings 
should  be  employed  as  will  protect  the  wound  from  external  injury  and  guard  against  or 
neutralize  the  decomposition  of  such  fluids  as  may  be  poured  out. 

A  wound,  however  large,  dressed  pffechtollij  on  these  principles,  will  probably  not 
require  dressing  for  a  week,  or  will  not  need  more  than  the  removal  of  the  absorbent 
material  which  has  been  placed  to  catch  the  secretion  which  has  drained  away  from  the 
wound,  and  will  be  found,  when  dressed,  to  be  well  or  nearly  well.  A  wound,  however 
small,  dressed  ineffectually,  will  probably  be  unhealed  and  suppurating. 

The  nearer  the  surgeon  can  approach  perfection  in  his  first  dressing,  the  more  success- 
ful will  he  be  in  his  practice,  and  the  larger  will  be  his  proportion  of  cures  by  primary 
adhesion. 

When  a  spcond  dressing  is  called  for,  the  surgeon  should  have  at  hand  everything 
which  may  be  required  for  the  purpose — lint,  prepared  in  size  and  .shape,  and  steeped  in 
whatever  dressing  he  may  have  arranged  to  use;  scissors,  forceps,  bandages,  strapping, 
absorbent  cotton,  trays,  and  irrigators,  whether  in  the  shape  of  a  can  or  in  that  of  a  dress- 
ing-bottle (Fig.  3,  p.  33). 

Removal  of  Dressings. — When  the  wound  is  large  and  water  is  to  be  used  in 
quantities,  he  should  have  a  piece  of  waterproofing  to  place  beneath  the  part  or  patient, 
and  such  assistants  as  may  be  required.  He  is  then  to  remove  the  external  dressings  ; 
and  in  doing  this,  as  in  every  subsequent  procedure,  he  is  to  employ  the  utmost  gentle- 
ness. He  should,  however,  beforehand  place  his  patient  in  the  most  comfortable  position 
he  can,  and  then  place  himself  comfortably  ;  for  no  surgeon  can  do  his  work  well  if  he  is 
in  a  constrained  posture. 

In  removing  external  dressings  some  time  is  often  required,  but  it  must  be  granted  ; 
for  when  dressings  are  glued  to  a  wound  by  blood  or  secretion,  they  must  be  softened 
with  water — or,  rather,  medicated  water — before  they  can  be  taken  away  without  doing 
harm.  Having  taken  off  the  external  dressings,  rolled  them  up,  sent  them  away,  or 
thrown  them  into  a  basin  of  antiseptic  fluid,  and  having  exposed  the  wound  with  its 
sutures,  and  the  strapping  which  possibly  was  applied  for  adjusting  purposes,  the  surgeon 
is  then  to  cleanse  the  part ;  and  for  this  object  he  cannot  do  better  than  use  the  absorbent 
cotton,  either  dry  or  wetted  with  the  medicated  lotion.  The  sutures  should  then  be  cut 
and  withdrawn,  care  being  observed  not  to  drag  a  long  loop  of  suture  covered  with  dry 
secretion  through  the  tissues,  but  to  cut  it  off  close  to  the  skin  through  which  it  will 
have  to  pass.  When  the  union  of  the  wound  appears  weak,  or  when,  on  an  early  day 
after  the  first  dressing,  the  second  is  being  made,  support  should  be  given  to  the  tissues 
by  the  application  of  a  piece  of  well-adjusted  strapping  as  each  suture  is  taken  away,  a 
second  and  third,  or  more,  pieces  being  successively  applied  as  the  dressing  proceeds. 

Removal  of  Sutures. — If  the  sutures  are  not  irritating  and  the  wound  has  not 
healed  well,  they  should  be  left  alone.  In  deep  wounds  the  surgeon  .should  never  be  in 
a  hurry  to  remove  sutures,  whether  they  are  irritating  or  not,  for  if  he  remove  them 
before  good  repair  has  taken  place  the  wound  will  gape,  and  under  such  circumstances 
the  prospect  of  securing  repair  by  ])rimary  adhesion  will  have  disappeared  ;  and  even 
when  the  sutures  are  cutting  through  from  overstretching  of  the  part,  it  is,  as  a  rule, 
well  to  let  them  alone  as  long  as  they  have  any  influence  in  holding  large  flaps  together 
or  in  preventing  wide  separation.  At  the  same  time,  all  sutures  should  be  removed  as 
soon  as  they  have  answered  the  purpose  for  which  they  were  introduced,  or  when  all 
hope  of  their  fulfilling  it  has  passed  away.  The  removal  of  a  stitch  from  a  wound  which 
is  suffering  from  the  irritation  cau.sed  by  tension,  and  possibly  from  some  collection  of 
fluid,  is  always  wise. 

AVhen  splints  have  been  used  to  support  and  to  ensure  the  immobility  of  wounded 
parts,  they  should  not  be  removed  unless  for  some  urgent  cause.     It  is  to  be  assumed 


(•<)STrsi:i>  AM)  L.\('i:n.iTi:i>  wounds.  41 

tliul  tlit'V  wtTi'  s(i  ;i|i|ilii'il  at  tirsi  In  allow  I  lie  siir;^t'i)ii  tn  rciiiosc.  wlicii  riocessary,  tiit; 
oxtiTiial  (Invssiiii^  witliuiit  iiitcrrcriiiij:  with  tliciii.  With  tlic  saim-  vii-w,  of  pn-veritiii^  tlic 
not'i'ssitv  <»i  its  t-arly  rt'iiioval,  a  splint  sliuiild  Itr  covfrccl  with  s<mic  protective,  siicli  as 
gutta-porciia  or  oiled  silk. 

'I'o  eoiiiplete  the  seeoinl  dressiiiL',  ;i  IVesh  piece  ol'  lint  soakcil  in  the  tcreheiic  and  oil. 
or  other  selected  application,  is  to  he  laid  on  tlu!  wound,  and  tlie  external  parts  covered 
as  after  tlie  first  dressiiiL:,  the  surireon  taking'  care  to  sec  tliat  cHicient  means  are  employed 
tor  the  external  protection,  the  inmioliilii  y,  and  u'oo<l  drainaLfc,  of  the  wound. 

Subsequent  Dressings. 

'i'lic  third  and  later  dressiims  of  a  wonnd  iimst  he  ::<ivcrned  hy  tlie  same  ])rinciple.s 
whiidi  have  heen  laid  (h)wn  for  tlui  second,  ami  they  are  to  he  conductetl  in  the  same 
<|iiiet,  ficntlo,  and  yet  decided,  maniuir.  They  arc  not  likely  to  he  very  iiunicrons  shonld 
])riinary  adhesion  he  ohtained  ;  and  when  that  lio])e  has  fled,  they  must  \n'.  carried  out 
(hiily,  or  ])ossihly  more  often.  They  will,  howcviM',  then  have  to  be  conducted  on  very 
similar  principles,  although  with  different  objects. 

Contused  and  Lacerated  Wounds. 

These  wounds,  from  a  clinical  ])oint  of  view,  should  be  classed  to«i;ether,  since,  in  both, 
the  ed^es  of  the  wound  are,  as  a  rule,  so  injured  as  to  be  irregular  and  the  seat  of  ecchy- 
mosis,  and  since,  in  both,  before  repair  can  practically  begin,  death  of  some  of  the  injured 
surface,  or  of  some  of  the  surrounding  subcutaneous  or  other  tissue,  or  margins  or  flaps 
of  the  wound,  is  to  be  expected. 

In  the  confused  wound  the  breach  of  surface  is  brought  about  by  a  blunt  in.strument, 
moving  with  a  greater  or  less  velocity  ;  and  the  extent  of  bruising  or  contusion  of  the 
soft  ])arts  in  the  neighborhood  of  the  wound  will  be  found  to  vary  with  the  size  of  the 
instrument  which  inflicted  the  injury,  and  with  the  force  of  its  impact.  When  the  mis- 
sile is  large,  the  extent  of  injury  will  be  proportionate  ;  and  w'hen  the  velocity  is  great, 
the  area  of  contusion  around  the  edges  of  the  wound  will  be  lessened  as  the  extent  of 
wound  will  be  increased. 

The  most  typical  examples  of  contused  wounds  of  all  kinds  are  met  with  in  military 
practice,  and  are  caused  by  the  impact  of  spent  balls  or  fragments  of  shell. 

Lacrrdtiil  wounds  are  generally  brought  about  by  a  tearing  or  biting  process,  and 
are  characterized  by  great  irregularity  of  the  lacerated  ti.ssues  from  the  skin  down- 
ward ;  this  irregularity  depends  much  upon  the  diflferent  degrees  of  elasticity  of  the  parts 
torn,  skin,  arteries,  muscles,  and  tendons  all  behaving  difl'erently  when  submitted  to  a 
lacerating  force. 

In  ontasrd  wounds  the  area  of  injury  generally  extends  fiir  beyond  the  area  of  the 
breach  of  surface  ;  and  when  death  of  tissue  follows,  it  may  spread  widely.  In  htrenitiij 
wouiuls  the  area  of  injtiry  is  generally  more  localized,  though  this  remark  is  not  applic- 
able to  wouiuls  in  which  muscles  and  tendons  are  involved.  When,  for  instance,  a  finger 
or  thumb  is  torn  off",  the  tendons  connected  with  the  injured  part  may  separate  at  their 
muscular  origins  in  the  fore-arm. 

HsBmorrhage. — In  both  contused  and  lacerated  wounds  there  is  less  primary 
haemorrhage  than  there  is  in  those  of  the  incised  variety  ;  the  contudng  force  so  affects 
the  vessels  at  the  seat  of  injury  as  to  favor  the  coagulation  of  the  blood  about  their 
open  mouths,  or  so  ru])tures  the  inner  and  middle  coats  of  the  bruised  vessels  as  to 
mechanically  interfere  with  the  flow  of  blood,  and  thus  encourage  the  formation  of  a  elot 
by  which  the  lumen  of  the  injured  artery  may  become  occluded  ;  the  kiverating  force 
likewise  irregularly  divides  the  different  coats  of  the  vessel  and  its  sheath — even  in  the 
case  of  a  large  artery — and  thus  favors  the  coagulation  of  the  blood  at  the  seat  of  Jacera- 
tion.  This  temjiorary  plug  of  the  vessels  is  generally  sufficient  to  close  the  orifice  until 
nature's  ])ermanent  h;emostatic  processes  have  had  time  to  act  and  to  .seal  the  vessel  {cid<; 
Chapter  X.). 

Secondary  H/EMORRH.vge. — In  contused  wouiuls  there  is  a  far  greater  proneness  to 
secoiulary  h.vmorrhage  than  is  met  with  in  any  other  form  of  wound,  the  contusing  force 
often  primarily  injuring,  but  not  opening,  an  artery,  yet  so  destroying  the  vitality  of  its 
coats  as  to  excite  an  inflammatory,  sloughing,  or  ulcerating  process,  which  in  its  turn  may 
open  the  vessel  and  give  rise  to  secondary  hasmorrhage.  Contused  wounds  are  for  this 
reason  of  a  more  dangerous  character  than  lacerated  wounds. 


42  TREATMENT  OF  OPEN  WOUNDS. 

Subcutaneous  Contused  Wounds — that  is,  severe  contusions  of  soft  parts 

without  breach  of  surface  or,  exposure  of  the  injured  tissue  from  either  the  impact  of 
blunt  instruments,  the  passage  of  a  wheel  over  the  part,  or  other  force — are  at  times 
more  grave  than  those  in  which  a  breach  of  surface  exists.  The  gravity  of  these  cases 
is  best  seen  by  studying  the  effects  of  such  kinds  of  injury  upon  the  abdominal  and 
pelvic  viscera,  an  unbroken  and  apparently  uninjured  outside  surface  often  covering  a 
fatal  subcutaneous  rupture  of  a  solid  viscus  or  a  laceration  of  a  hollow  one.  The  same 
fact  may  be  also  well  seen  in  severe  injuries  to  extremities,  where  from  a  contusing  force 
an  artery  may  be  stretched,  bruised,  or  lacerated,  large  veins  may  be  torn  across,  nerves 
injured,  and  muscular  and  other  tissues  irreparably  damaged.  The  amount  of  harm 
which  deep  tissues  may  have  sustained  in  any  given  injury  can.  therefore,  onlv  be  esti- 
mated by  a  correct  appreciation  of  the  force  which  has  been  applied,  and  of  the  position 
and  condition  of  the  injured  part  at  the  time  of  the  reception  of  the  injury.  It  can 
never  be  made  out  by  simple  in.spection  of  outside  appearances.  Such  injuries  always 
demand  great  care  in  their  treatment. 

Treatment  of  Contused,  Lacerated,  and  other  Wounds  which 
Heal  by  Granulation. 

The  principles  upon  which  the  treatment  of  contused,  lacerated,  or  (ipen  wounds  is 
based  are  the  same  as  have  been  laid  down  and  explained  in  considering  the  treatment 
of  incised  wounds,  though  they  may  require  soiue  modifications  in  their  application,  on 
account  of  the  altered  circumstances  in  which  they  have  to  be  carried  out.  For  example, 
in  a  deep  lacerated  wound  the  surgeon  will  have  to  cleanse  it  and  arrest  bleeding,  as  in  an 
incised  wound  ;  but  he  will  not  have  to  adju.st  the  divided  surfaces  and  applv  sutures  in 
the  same  careful  way  that  he  would  be  called  upon  to  do  if  a  "  quick  union  "  was  to  be 
looked  and  worked  for.  He  will  remember  that  this  change  of  practice  is  demanded  in 
contused  and  lacerated  wounds  because  there  must  of  necessitv  be  more  or  less  sloughing 
or  molecular  disintegration  of  the  lacerated  tissue  and  contused  parts  around,  and  that, 
as  a  con.sequence,  it  becomes  a  matter  of  primar\'  importance  to  leave  the  wound  open 
for  the  free  discharge  of  all  such  tissues  as  may  have  been  destroyed  or  may  die,  as 
well  as  for  the  evacuation  of  the  fluids  which  must  be  poured  out  in  the  reparative  pro- 
cess. 

He  will,  however,  in  this  class  of  eases,  as  in  the  former,  secure  immobility  of  the 
wounded  part  and  fix  it  in  the  position  which  will  be  easiest  to  the  patient  and  most  con- 
ducive to  the  healing,  and  he  will  not  forget  to  make  the  fullest  provision  for  the  drain- 
age of  the  wound  from  its  lowest  depths.  He  will,  moreover,  have  to  be  additionally 
careful  in  the  dressing  of  the  wound,  since  it  is  an  open  one.  because,  from  such,  septic 
matter  is  more  rapidly  absorbed  before  the  process  of  granulation  has  commenced ;  and 
when  it  has  commenced,  such  a  wound  is  readily  influenced  by  external  applications. 

In  one  instance  the  wound  may  have  to  be  regarded  and  treated  as  an  open  one  from 
the  first,  the  excavated  surface  being  filled  in  with  a  light  dressing,  as  if  it  were  a  sur- 
face wound.  In  another,  where  there  is  a  tendency  for  the  surface  edges  to  fall  together 
and  unite,  and  where  this  union  would  be  injurious  by  interfering  with  the  free  evacua- 
tion of  such  di.scharges  as  are  to  be  looked  for  from  the  wound,  or  with  the  escape  of 
sloughs  of  destroyed  tissue,  the  dressing  may  have  to  be  inserted  between  the  lips  of  the 
wound,  or  even  down  to  its  bottom,  for  it  is  essential  in  these  cases  that  the  wound 
should  not  be  closed  and  that  a  free  vent  for  all  fluids  should  be  maintained :  whilst  in  a 
third  case  the  provision  for  free  drainage  may.  from  the  position  of  the  wound,  be  so 
imperfect  that  a  special  opening  ( counter-opening)  may  be  called  for  at  the  most  depend- 
ent situation  of  the  injured  parts,  or  at  some  other  position  which  the  ingenuity  of  the  sur- 
geon may  suggest.  Under  all  circumstances,  wounds  such  as  these,  which  are  not  expected 
to  heal  by  quick  union,  should  be  so  dressed  as  to  allow  of  the  free  egress  of  all  secre- 
tions without  disti;rbing  the  parts. 

The  primary  dressing  which  I  am  in  the  habit  of  employing  for  fresh  wounds  is,  as 
alreadv  mentioned,  lint  or  absorbent  cotton  saturated  Avith  a  mixture  of  terebene  one 
piart  and  olive  oil  three  parts,  the  saturated  dressing  being  covered  with  another  layer  of 
drv  lint  or  cotton.  Where  a  wound  has  to  be  lightly  filled  with  some  dres.sing.  I  use  the 
absorbent  cotton  semi-saturated  with  the  same  terebene-and-oil  mixture,  and  a  light  pad 
of  the  absorbent  cotton  applied  over  the  whole  and  held  in  position  by  a  retentive  band- 
age ;  and  even  when  a  drainage-tube  or  drain-orifice  exists,  the  same  light  dressing  is 
useful  to  absorb  sjich  fluids  as  may  escape  externally     In  some  cases  a  soft  sponge  which 


PUyCTURlI)    WnUSDS.  43 

has  hccii  wniiit,'  (tut  of  iodine  or  carliolic  lotion  is  a  j,'oo(I  Hultsfitutc  lor  the  w;nl  of 
absoi'lx-nt   cnttoii. 

Ill  rasi's  of  iiKtri'  .sovcrc  woiimls.  wlicn-  a  l"r<i'  liow  of  fluiil  is  to  he  ex|»c'fte<l.  ami 
wliere  tlie  ilaiiL'er  oC  its  retention  would  l»e  ^rreal.the  o|ieniii;_'  u{  the  draina^e-tuhe  of 
discLiari:injr-oriliee  sliould  he  lel't  i'ree.  In  th»?  dressiii;;  u['  all  stuiii|ts  and  most  deep 
iiieised  or  laceiatt'd  wounds  this  practice  shoiilrl  he  followed,  since  it  eiiahles  the  suTjreoii 
to  lirinj;  the  parts  more  accurately  to;,'^ellier  than  Wfiuld  otluMwise  he  advisal*le.  ami  to 
keep  them  ipiiet,  and  in  apposition  hy  ineaiis  (d"  pressun;  applied  over  the  whole  of  tho 
wound,  except  tho  drain-oritice.  This  method  has  likewise  tin;  additional  f^reat  a<lvaiitafre 
of  allowinir  the  surj^eoii  to  leave  the  wound  undistiirhed  i'or  some  days,  jirohahly  for  a 
week,  and  to  postpone  his  first  dnsssinj^  till  a  pi!rir)d  when  nature's  reparative  jirocess  will 
have  had  time  to  shut  ott'  the  wounded  part  frr)m  the  deeper  tissues,  and  to  do  much  in 
the  direction  of  its  repair.  There  should  always  be  a  reason  for  dressin;;  a  wound. 
Jh-essinu  as  a  routine  jtractice  is  not  to  be  coniniended  ;  it  should  always  be  deferred 
till    it    is   re(|uired. 

\\  (lunds  must  ho  kept  <l<fiii  under  all  circunistaiiccs,  an<l  lice  IVoni  every  septic  risk  ; 
hut  a  wound  must  he  kojit  >iititt  if  repair  is  to  f;o  on  steadily,  and  this  (piiet  is  as  necessary 
for  till'  lacerated  as  it  is  for  the  cleaner  kinds  of  wound.  A  form  of  dressinj^  such  as  ha.s 
been  doscril»od  has  advantages  over  many  others,  for  it  renders  early  and  frerjuent  dress- 
ings of  the  wound  unnecessary. 

Punctured  Wounds. 

Punctured  wounds,  when  made  with  .sharp-cutting  instruments,  are  deep  inclsrtl 
wounds,  and  when  with  blunt  or  wedge-shaped  tools  deep  ctiiitinit.il  wounds.  They  differ 
from  other  incised  and  contused  wounds  in  their  depth  and  in  tlie  uncertainty  which,  a.* 
a  consequence,  follows  with  respect  to  the  tissues  that  are  wounded,  but,  above  all,  in  the 
difficulties  whicli  are  always  experienced  in  providing  for  the  efficient  evacuation  of 
blood,  serum,  or  broken-down  tissue,  where  drainage  is  needed.  These  difficulties  are 
clearly  due  to  the  external  orifice  of  the  wound  Iteing  but  small  in  proportion  to  tlie 
depth  of  the  penetration. 

When  a  punctured  wound  is  made  with  a  clian^  shitrp  instrvment  into  the  healthy 
tissues  of  a  healthy  suVjject,  harm  may  not  be  anticipated  ;  indeed,  quick  repair  may 
be  looked  for  with  almost  as  much  confidence  as  if  the  wound  had  been  of  the  more 
simple  incised  kind.  This  observation  is  coiifirmod  by  the  general  experience  of  all  who 
practise  subcutaneous  surgery,  although  wlien  large  vessels  or  nerves  are  wounded 
troubles  may  arise  which  are  not  lessened  by  being  hidden. 

When,  however,  a  punctured  wound  is  made  by  a  hhinf  anti  tcedge-Hliapeil ,  or  possibly 
a  ilirti/,  instrument,  the  wound  will  be  of  the  contused  kind,  and,  being  so,  it  will  partake 
of  the  disadvantages  of  such  wounds  in  addition  to  those  which  appertain  to  it  as  a  punc- 
tured wound.  It  will  conse(juently,  being  contused,  be  associated  with  death  of  some  of 
the  injured  tissues,  for  the  escape  of  which  due  provi.sion  will  be  required,  and  it  can 
only  he  expected  to  heal  b}'  the  second  or  third  intention.  Being  a  punctured  wound, 
it  will,  moreover,  exhibit  the  difficulties  of  providing  for  proper  drainage  under  circum- 
stances in  which  efficient  drainage  is  particularly  called  for.  As  a  con.secjuence  of  these 
conditions,  special  dangers  are  developed  W'hich  can  only  be  rightly  met  by  a  full  recog- 
nition of  their  nature  and  of  the  requirements  essential  to  their  prevention. 

When  tense  fascijv;  are  punctured — such  as  are  found  in  the  palm  of  the  hand,  sole 
of  the  foot,  and  scalp — or  when  deep  muscles  bound  down  by  fa.sciae,  as  in  the  thigh,  are 
involved  and  secondary  inflammation  ensues,  the  case  is  often  very  serious.  Punctured 
wounds  of  cavities  are  wor.se  than  those  of  the  soft  parts  covering  bones,  in  the  .same 
way  that  all  other  wounds  of  cavities  are  graver,  as  well  as  from  the  fact  that  in  punc- 
tured wounds  there  is  more  uncertainty  as  to  the  nature  of  the  parts  wounded,  and  that 
with  this  uncertainty  there  are.  of  course,  loss  clear  indications  for  treatment. 

Treatment  of  Punctured  Wounds. — There  is  no  form  of  wound  which  the 

surgeon  has  to  treat  in  which  a  greater  uncertainty  exists  as  to  the  results  of  treatment 
than  in  the  punctured,  and  all  punctured  wounds  should  be  dealt  with,  therefore,  with 
the  greatest  caution.  When  the  wound  has  been  accidentally  inflicted  with  a  clean, 
sharp  instrument,  and  when  it  is  treated,  as  it  should  be,  like  any  other  clean  wound, 
with  moderate  compression  and  the  application  of  a  dry  or  antiseptic  dres.«ing.  such  as 
terebene  and  oil,  and  is  then  left  yirotected  and  at  rest  to  heal,  there  will  be  every  pros- 
pect of  repair  going  on  as  satisfactorily  as  in  wounds  which  surgeons  daily  inflict  in  their 


44  TREATMENT  OF  OPEN   WOUNDS. 

operations  of  tenotomy  and  osteotomy.  Even  when  the  wound  is  of  the  contused  kind 
and  repair  by  '•  quick  union  "  is  not  to  be  looked  fur,  tlie  surgeon  is  probably  justified  in 
employing  the  same  means,  although  in  doing  so  lie  must  be  keenly  alive  to  the  risks  of 
the  case  and  the  dangers  of  the  practice  adopted.  He  must  be  ready,  on  the  appearance 
of  any  swelling,  pain,  heat,  or  redness,  and  more  particularly  of  any  elevation  of  temper- 
ature, to  remove  all  dressings,  expose  the  wound,  and  adopt  means  to  give  vent  to  the 
pent-up  fluids  of  the  part  and  relieve  the  local  irritation  caused  by  their  retention  ;  by 
so  doing  he  will  jtut  an  end  to  tension  of  the  tissues,  and  probably  check  the  further 
absorption  of  substances  which,  if  not  already  decomposing  and  undergoing  chemical 
changes,  may  soon  do  so  and  give  rise  to  septicjvmia  and  blood-poisoning. 

In  one  case  this  may  be  done  by  reopening  the  external  orifice  of  the  wound  ;  in 
another,  by  enlarging  it ;  whilst  in  a  third,  a  fre.sh  r)pening  may  be  called  for  in  the  most 
dependent  point  of  the  injured  region.  Under  all  circumstances,  however,  the  object  is 
the  same — to  give  vent  to  pent-up  fluids,  whether  inflammatory  or  otherwise.  At  the 
same  time,  the  injured  part  should  be  raised,  to  encourage  the  venous  circulation  through 
the  limb,  and  pain  should  be  relieved  by  the  local  application  of  warmth  and  moi.sture, 
whether  in  the  form  of  a  compress  or  in  that  of  a  fomentation  mixed  with  sedatives, 
such  as  opium  or  poppy  decoctions. 

Cold  rarely  gives  comfort  in  these  cases,  and  it  certainly  does  no  good  toward  checking 
inflammatory  action,  which,  if  occasioned  by  retained  .secretion,  is  only  to  be  relieved  by 
its  removal.  For  the  same  reason  leeches  are  rarely  applicable,  although  in  a  plethoric 
and  vigorous  patient  they  may  be  permissible  ;  but  even  in  such  the  judicious  use  of 
small  and  repeated  doses  of  sulphate  of  magnesia  has  a  more  powerful  efl^ect  for  good, 
with  less  risk  of  doing  harm. 

In  the  treatment  of  all  punctured  wounds  it  must  be  remembered  that,  as  the  chief 
danger  lies  in  the  dilficulty  of  providing  efiicient  drainage,  the  result  turns  upon  the 
completeness  with  which  this  necessity  is  met.  The  surgeon  who,  on  the  first  appearance 
of  local  or  general  symptoms  indicative  of  the  presence  of  retained  serum  or  other  fluids, 
makes  an  outlet  by  one  of  the  means  which  have  been  suggested,  will  be  more  successful 
than  one  who,  from  timidity  or  other  cause,  leaves  the  case  to  run  its  course  till  a  large 
inflammatory  abscess  has  formed.  In  all  punctured  wounds  which  do  not  heal  c|uickly 
by  primary  union,  and  in  which  secondary  inflammation  occurs,  with  its  necessary  effusion, 
an  outlet  should  be  made  for  the  fluids  of  the  part  as  soon  as  the  fact  of  their  retention 
is  clear.  When  thecae  of  tendons,  fascia?,  and  fibrous  coverings,  as  of  bones,  are  in- 
volved, the  necessity  of  providing  for  this  outlet  is  more  important,  if  possible,  than 
when  the  softer  tissues  are  implicated,  and  an  incision  into  the  deep  parts  for  the  evacu- 
ation of  simple  serum,  by  relieving  tension,  will  often  prevent  both  the  extension  of 
the  inflammation  and  the  destruction  of  tissue. 


Tooth  Wounds. 

Tooth  wounds  are  usually  punctured,  and  rarely  other  than  contused.  They  may,  as 
may  all  other  kinds,  prove  to  be  poisoned  wounds,  but  to  them  I  do  not  refer.  They 
differ  widely  in  their  character,  and,  whilst  one  case  may  appear  as  a  simple  clean  punc- 
tured wound,  another  may  exhibit  all  the  worst  features  of  the  contused  or  lacerated 
variety. 

They  are  to  be  dealt  with  as  punctured  or  contused  wounds,  each  ca.se  being  treated 
on  its  own  merits. 

Treatment  of  an  Open  or  Granulating  Wound. 

When  a  wound  is  granulating,  and  consequently  suppurating,  it  should  be  kept  clean, 
as  should  all  wounds,  and  it  .^^hould  be  dressed  with  such  a  material  as  may  be.st  protect 
the  granulations  from  outside  injurious  influences  and  allow  the  cicatrizing  process  to  go 
on  without  hindrance.  The  granulations  themselves  should  never  for  purpo.ses  of  clean- 
liness be  touched  by  any  coarse  material  harder  than  a  camel-hair  pencil,  but  should  be 
washed  by  means  of  a  stream  of  some  antiseptic  fluid  allowed  to  flow  from  either  the 
irrigating-bottle  or  dressing-can  (Fig.  8).  In  my  own  practice  iodine  water  is  generally 
used.  When  the  granulating  process  is  not  of  a  healthy  type,  but  shows  either  deficiency 
or  excess  of  power  or  some  morbid  action,  medicated  lotions  and  constitutional  treatment 
may  be  required,  to  which  attention  will  be  directed  farther  on. 


Srr.riM,    rilEATMKNT  Ol'    Wol'SDS.  45 

Treatment  of  Wounds  to  Promote  Healing  by  Secondary 

Adhesion. 

As  ill  tlio  tri'utiin'iit  u['  a  IVcsli  wouikI  tn  nlitaiii  a  ''(jiiick  or  |»riiiiarv  adlicsioii"  the 
sur;riM)ii  lias  siiiiitly  to  cleans^  tlic  wound  after  arrest iii<r  Ideediii;.',  ami  to  liriii^^  tlu!  two 
surfaces  into  elose  a|i|io.sition  l»y  the  siinph'st  means,  and  keep  them  so.  thus  in  the  treat- 
ment of"  a  ease  in  whi(di  healing  hy  seeomhiry  adhesion  is  s<Mi<.'ht  for  he  has  siinplv  to 
hrinji  to<;etiier  the  two  jiraniihitiiij;  surfaces,  ch'ansed  from  all  impurities  hy  such  iiicuns 
as  are  sujj:j;ested  hy  the  special  re(Hiireinents  of  tlu;  case,  and  to  leave  tlieiii  to  unite.  In 
haredip  or  other  lip  operations,  where  (piick  union  has  heeii  iiii.ssed  and  secondary  adhe- 
sion is  souiiht  for,  it  may  he  ohtained  hy  the  introduction  of  deep  sutures,  or  even  pins; 
in  dei'p  flesh  wounds  or  after  operations,  as  on  the  breast,  hy  means  of  strapping  well 
applied;  ami  in  stumps,  after  am])utation,  by  means  of  splints.  ])a(ls.  and  handag(?s.  In 
all  cases,  the  imiiKthility  <d' tlu;  jiart  treated  is  suhse(|ueiitly  to  he  rigidly  atteudcMl  to.  and 
time  must  hi'  given  for  iinliiii  to  (•(im|il('te  itself  hefore  llie  dressing  is  disturbed. 

The  Special  Treatment  of  Wounds. 

To  estimate  correctly — with  the  light  of  our  present  kuowledtre — the  value  of  any 
special  method  of  treating  wcninds,  it  is  neces.sary  to  keep  constantly  in  mind  the  sijc 
j)(iiii/s  to  which  attention  has  been  directed,  since  these  points  are  essential  juinciples  of 
practice  which  should  be  follow I'd  under  all  circumstances.  Indeed,  so  essential  are  they 
that  the  value  of  any  sj)ecial  method  of  treating  wounds  may  be  tested  by  them,  and  the 
method  regarded  as  good,  bad,  or  indifferent  according  to  the  measure  or  degree  in  which 
it  fulfils  the  re((uirements  enumerated  (r/V/e  page  'M).  A  mode  of  dressing  which  satis- 
fies all  these  re(juiremeiits  or  indications  in  a  simple  and  efficient  w^ay  must  be  regarded 
as  perfect,  and  a  mode  which  embodies  in  itself  the  greater  number  of  these  requirements 
should  be  regarded  with  greater  favor  than  another  in  which  these  requirements  are  less 
efiieiently  fulfilled. 

With  this  standard  of  comparison  ever  prominent,  I  will  now  proceed  to  consider  the 
more  important  special  modes  of  treating  wounds. 

The  Treatment  of  Wounds  by  Occlusion  (the  Smothering 

System). 

This  was,  without  doubt,  the  favorite  method  of  dressing  fresh  wounds  among  the 
older  surgeons,  and  in  proof  of  this  it  is  only  necessary  to  refer  to  the  classical  works  of 
John  Bell  to  read  how  the  processes  of  miii(di/)/iiiij,  (U(j(x(iiig.  {nainn'iii/.  and  riaifrlzlin/ 
were  carried  out. 

This  method  was  doubtless  the  outcome  of  much  observation,  and  was  based  on  what 
was  seen  daily  in  the  healing  of  the  wounds  of  animals  by  one  of  the  natural  methods  of 
repair — that  of  scabbing.  '•  This  mode  of  healing  under  a  scab"  "  is  the  most  natural 
and  in  some  cases  the  best  of  all  the  healing  processes.  Very  commonly,  in  animals,  if  a 
wound  l)c  left  wide  open,  the  blood  and  other  exudations  from  it  dry  on  its  surface,  and. 
entangling  dust  and  other  foreign  bodies,  form  an  air-tight  and  adherent  covering,  under 
which  scabbing  takes  place,  and  which  is  cast  off  when  the  healing  is  complete.  The 
exact  nature  of  the  process  has  not  been  watched,  but  it  seems  to  consist  in  little  more 
than  the  formation  of  cuticle  on  the  wounded  surface,  and  it  has  the  advantage  that,  as 
no  granulations  are  produced,  there  is  little  or  no  contraction  of  the  scar.  In  man  the 
same  process  is  less  frequent ;  it  is  more  apt  to  be  spoiled  by  inflammation,  producing 
exudations  under  the  scab,  which  either  detach  it  or  prevent  the  healing  of  the  surface 
beneath  it.  Sometimes,  however,  the  blood  shed  from  a  wound  coagulates  and  dries  on 
it,  and,  remaining  as  a  scab,  permits  healing  nnder  it;  or  if  this  does  not  happen,  a  simi- 
larly effective  scab  may  be  formed  by  the  serous  fluid  or  lymph  by  which  the  surface  of 
an  exposed  wound  usually  becomes  glazed  ;  or,  more  rarely,  the  pus  of  a  granulating 
wound  may  scab,  and  sound  healing  take  place  beneath  it " 

''  To  obtain  healing  under  a  scab,  if  the  wound  be  recent  the  blood  and  exuded 
fluids,  or  if  it  be  granulating  the  pus,  should  be  left  expo.sed  to  the  air  till  it  dries  on  the 
wound,  adhering  to  the  edges  and  surface  and  comphfehj  cjccludituj  them  from  the  air." 

"  There  seems,  however,  to  be  a  proneness  to  inflammation  which  makes  the  healing 
under  a  scab  precarious,  and  less  generally  obtainable  than  one  could  wish  it.    No  morbid 


46  SPECIAL   TREATMENT  OF   WOUNDS. 

exudation  sliould  take  place  under  a  scab  once  formed  ;  everytliing  of  tlie  kind  painfully 
compresses  the  wound  and  retards  its  healing " 

kSuch  is  the  mechanism  of  healing-  under  a  scab,  and  such  are  souie  of  the  methods 
by  which  it  can  be  brought  about.  In  Sir  A.  Cooper's  time  (1820-40),  with  the  same 
olaject,  wounds  were  often  sealed  with  lint  or  other  material  saturated  with  blood,  and  in 
more  recent  days  they  have  been  covered  with  collodion  alone  or  applied  on  linen,  with 
colloid  styptic,  with  tannin  in  powder,  with  dry  earth  or  peat,  with  l*eruvian  or  Friar's 
balsam,  with  cotton-wool  medicated  or  otherwise.  In  some  country  districts  coal-tar  is 
used  for  the  same  purpose,  and  with  the  same  view,  (yhassaignac's  arrangement,  by 
which  a  wound  was  hermetically  sealed  from  the  air  by  consecutive  layers  of  plaster 
covered  in  with  charpie  or  cotton-wool,  has  also  been  employed.  The  object  of  each 
variety  of  this  form  of  dressing  is  the  same — viz.,  the  complete  occlusion  of  atmonpheric 
air — and  in  each  an  attempt  is  made  to  place  an  open  wound  as  much  as  possible  in  the 
position  of  one  which  is  closed  or  subcutaneous. 

Cotton  Dressing. — In  recent  times  this  method  has  attracted  much  attention 
under  the  form  of  the  "  cotton  dressing,"  which  was  introduced  in  1853  by  Burggraeve 
of  (rhent  and  advocated  by  Ilavoth.  In  their  hands  it  was  carried  out  by  the  immediate 
application  of  splints  thickly  padded  with  cotton-wool  to  the  wound  and  injured  limb, 
and  by  not  interfering  with  the  injured  part  for  four  or  six  days.  If  there  was  at  th,e 
end  of  that  time  neither  inflammation  nor  suppuration,  but  a  firm  scab,  the  wound  was 
let  alone,  and  only  the  surrounding  wool  was  renu)ved.  If  suppuration  was  present,  the 
wound  was  dressed  with  cerate.  This  method  has  been  described  by  Schultes  as  the 
methodical  application  of  so-called  healing  by  scabbing  extended  to  large  wounds. 

Dr.  Graf  uses  cotton-wool  and  tannin,  the  latter  being  spread  over  the  wound  in  a  layer 
as  thick  as  the  back  of  a  knife  ;  he  leaves  the  dressing  untouched  from  four  to  fourteen 
days.  He  and  Fleck  of  Dresden  regard  tannin  as  a  simple  and  cheap  antiseptic  and  dis- 
infectant, and  as  an  unirritating  haemostatic.  Both  surgeons  advocate  this  method  of 
treating  wounds  in  military  surgery.  Alphonse  Guerin  uses  cotton-wool  with  the  view 
of  filtering  the  air  from  germs  before  it  reaches  the  wounded  surface,  and  he  applies  the 
wool  by  smothering  the  wounded  part  or  limb  with  many  layers,  and  leaving  it  undis- 
turbed for  twenty-four  or  thirty  days  unless  some  extraordinary  complication  should  arise 
— for  the  detection  of  which  a  close  watch  is  always  kept — to  induce  him  to  remove  it. 
Before  he  applies  the  dressing  he  washes  the  wound  with  cauiphorated  alcohol  or  carbolic 
acid,  and  in  an  amputation  introduces  the  wool  between  the  flaps.  When  the  dressing  is 
removed,  there  is  generally  a  healthy  granulating  surface  with  a  little  sweet  pus  covering 
it,  and  the  granulations,  in  the  case  of  a  stump,  have  probably  driven  out  the  cotton-wool. 
This  method  has  the  advantage  of  giving  rest  to  the  wounded  parts  ;  the  gentle  and 
elastic  pressure  exerted  by  the  wool  is  also  beneficial,  as  are  likewise  the  constant  temper- 
ature maintained  and  the  freedom  from  pain  which  is  the  result  of  these  conditions. 

Oilier  employs  the  same  dressing  as  Guerin,  but  he,  in  addition,  sprinkles  the  wadding 
with  carbolic  acid.  According  to  either  plan,  the  dressing  is  a  close  one,  and  is  based  on 
■occlusion  of  the  part  from  air,  with  antiseptic  precautions. 

Summary. — If  we  bring  this  method  of  treating  wounds  by  "  occlusion  "  to  the  test 
laid  down  at  the  commencement  of  this  section,  it  will  be  found  that  it  fairly  well  fulfils 
three  out  of  the  last  four  essential  principles  of  practice,  but  fails  entirely  in  the  most 
important,  the  fifth — that  of  drainage.  That  is  to  say,  excepting  in  A.  Guerin's  practice, 
it  inchides  the  careful  adaptation  of  the  surfaces  of  the  wound,  ensures  rest  and  immo- 
bility of  the  part  for  some  days,  and  provides  for  the  protection  of  the  wound  from  out- 
side influences  and  for  antisepsis,  but  it  fails  entirely  in  making  the  smallest  provision 
for  "  drainage  ;"  so  that,  as  Syme  cleverly  expressed  it,  "  there  can  be  little  difficulty  in 
perceiving  why  the  sealing  up  of  wounds  should  be  the  most  certain  means  of  keeping 
them  open." 

Under  these  circumstances  the  conclusion  is  clear  that,  whilst  this  may  be  a  safe  and 
•wise  practice  to  adopt  in  small  or  superficial  wounds,  it  is  a  risky  and  somewhat  danger- 
ous uiethod  to  follow  in  the  treatment  of  those  which  are  deep  and  complicated  unless 
very  closely  watched.  It  .should  never  be  employed  in  any  case  in  which  the  wound  is 
more  than  superficial  uidess  the  probability  of  the  part  healing  by  immediate  union  can 
with  good  confidence  be  nuiintained,  and  it  should  never  be  employed  at  all  unless  the 
surgeon,  carefully  watching  the  temperature  of  the  patient  and  the  local  and  general 
symptoms  of  the  case,  is  prepared  to  at  once  expose  the  wound,  if  necessary,  and  to 
evacuate  any  pent-up  fluid  that  may  be  present.  For  my  own  part,  whenever  I  seal  a 
wound  with  the  hope  of  securing  a  good  result  by  allowing  the  parts  to  heal  quickly,  as  in  a 


Tin-:  oi'ES  ji:/:atmj:\t  or  woiwns,  47 

8iil)('ut:mouus  or  cldsiMl  wound,  I  never  do  more  than  seal  it  witli  lint  soaked  with  hh)od 
or  Kriar  s  balsam,  and  I  take  f;ood  eare  to  have  the  parts  otherwise  well  exposed  to  obser- 
vation, in  order  that  I  may,  if"  warned  by  the  a])pearanee  of  any  hical  symptom,  such  as 
swellinj;,  heat,  or  jiain,  or  ol'  any  p'lieral  symptom,  such  as  increase  of  temperature  or 
fever,  remove  the  scab,  real  or  artificial,  and  j^ive  free  vent  to  the  pent-up  fluids.  ],  more- 
over, never  adopt  the  method  for  any  other  than  a  very  clean  an<l  recent  wound. 

As  a  ireneral  mode  of  practice  this  treatment  by  occlusion  is  not  to  be  advr)(.-ateil  ;  irj 
exceptional  cases  it  may  bo  employed,  but  then  otdy  with  extreme  caution.  In  most 
deep  and  complicated  wounds  it  should  be  rejected.  It  is  only  applicable  in  the  very 
earliest  treatment  of  wounds. 

The  Open  Treatment  of  Wounds,  or  Treatment  by  Exposure. 

This  method  was  first  systematically  carried  out  by  a  ^'ienna  surireon  named  Vencenz 
von  Kern  in  the  betrinninj;  of  this  century,  and  more  recently  by  Bartscher  and  \'ezin  in 
lS5t),  and  by  Burow  in  180G.  The.se  German  surgeons  were  led  to  adopt  this  mode  of 
treatment  by  careful  observation  of  the  healing  process  in  wounds,  and  more  particularly 
by  the  bad  results  which  followed  the  ordinary  methods  of  dressing  by  occlusion,  as  then 
em]>loyed  in  continental  towns,  by  the  use  of  bandages,  charpie,  lint,  etc.  The  system 
of  dressing  wounds  by  what  has  been  described  as  the  "  smotherinir  method,'  in  which 
no  air  could  get  in  or  fluid  get  out,  gave  way  to  the  ■'  open  method,"'  in  which  the  free 
access  of  air  was  the  main  end  sought  for,  and  drainage  the  second.  The  success  which 
attended  this  practice  was,  moreover,  considerable,  since  Bartscher  and  Vezin  had  only- 
three  deaths  out  of  thirty  amputations,  and  Burow  three  out  of  ninety-four.  The 
method,  nevertheless,  did  not  make  headway,  and  it  does  not  seem  to  have  been  followed 
as  a  rule  of  practice  by  any  surgeon  except  Messrs.  Teale  of  Leeds,  Professor  Humj)hry 
of  Cambridge.  Dr.  R.  W.  KriJnlein  of  Zurich,  and  some  members  of  the  Surgical  Society 
of  Mrtscow. 

Teale  and  Humphry  in  1850  and  18G0  (Brit.  Med.  Joh?-h. ),  Krbnlein  in  1872,  and  the 
Mcscow  Surgical  Society  in  1877,  have  given  their  respective  experiences  and  recommen- 
dations in  regfard  to  this  method  of  dressing. 

Von  Kern's  practice  consisted  in  freely  exposing  the  wounded  surfaces  to  the  air  and 
simply  keeping  the  edges  of  the  wound  in  position  by  means  of  sponges.  Vezin  applied 
no  kind  of  means  for  uniting  wounds.  Burow  used  sutures,  but  in  such  a  way  that  they 
could  be  readily  loosened  in  case  of  distension.  Professor  Huinphr}'  wrote : '  '"It  is 
well  known  that  wounds  of  the  face  commonly  heal  up  in  their  whole  length  by  first 
intention.  This  is  due,  in  great  measure,  to  the  vital  qualities  of  the  parts,  and  in  some 
degree  also,  I  apprehend,  to  the  fact  that  they  are  usually  left  exposed  to  the  air.  their 
edges  being  held  in  contact  merely  by  sutures.  For  some  years  we  have  adopted  this 
plan  after  amputations  and  all,  or  nearly  all,  other  operations.  The  integuments  are 
united  by  sutures  placed  at  intervals  of  about  an  inch,  and  the  wound,  as  well  as  the 
adjacent  surface,  is  left  quite  exposed  to  the  air,  no  plaster,  bandage,  or  dressing  of  any- 
kind  being  placed  upon  it.  All  the  irritation,  the  galling  pressure,  the  retention  of  heat, 
and  other  inconveniences  resulting  from  bandages  and  plaster  are  thus  avoided.  The  edge 
of  the  wound  and  the  surrounding  skin  being  uncovered,  the  eye  can  take  cognizance  of 
what  is  going  on,  and  we  can  cut  a  stitch  here  and  there  when  required,  can  keep  the 
part  clean,  or  take  other  measures,  without  difiiculty.  Forasmuch  as  no  dressings  are 
applied,  there  are  none  to  be  removed.  The  suffering  which  used  to  be  caused  by  the 
dressing  of  wounds  after  operations  is  got  rid  of.  In  many  cases  I  do  not  touch  the 
wound,  except  for  the  purpose  of  removing  the  sutures,  from  the  day  of  the  operation." 
We  decidedly  have  more  frequent  union  by  first  intention  than  when  we  were  in  the 
habit  of  applying  dressings  to  the  wounds.  If  suppuration  takes  place,  an  early  and 
free  vent  should  be  aff'orded  to  the  pus  by  cutting  the  stitches  and  opening  the  wound  : 
and  care  .should  be  taken  to  keep  the  wound  clean.  "  Large  open  wounds — that  is.  where 
portions  of  the  skin  have  been  removed,  so  that  the  edges  cannot  be  approximated — are 
in  our  hospital  (Cambridge)  not  unfrequently  left  exposed  to  the  air  without  any  cover- 
ing. A  dry  crust  or  scab  forms  upon  them,  beneath  which  cicatrization  goes  on,  and  we 
find  that  the  healing  often  proceeds  more  quickly  in  this  way  than  when  the  part  is  kept 
moist  and  the  products  of  the  wound  are  continually  flowing  away  into  the  dressings.  " 

Krlinlein  tells  us,  after  analyzing  six  thousand  cases,  that  the  open  method  has 
proved  superior  to  all  others,  and  demonstrates  that  the  mortality  of  amputations,  which 
^Humphry,  British  Med.  Jownal,  October  27,  1860. 


48  THE  OPEy  TREATMENT  OF   WOUNDS. 

by  former  methods  had  been  fifty-one  per  cent.,  fell  by  the  open  treatment  of  wounds  to 
twenty  per  cent.  ;  and  Rose,  who  is  the  present  director  of  the  clinic  at  Zurich,  follows 
Kronlein.  He  exposes  all  his  wounds  to  a  fresh  current  of  air.  which  is  maintained  by 
means  of  open  doors  and  windows.  He  regards  stitches  and  bandages  of  all  kinds  as 
interferences  to  be  avoided,  and  trusts  to  absolute  rt-sf  of  the  part  after  afrefid  arrest  of 
hh-ediiKj,  to  provision  for  thorough  (h-ainuge^  and  to  ncnijudous  chanliness.  The  wounded 
limb  after  an  amputation  is  kept  in  one  position  on  a  cushion  so  protected  by  mackintosh 
that  the  discharges  may  easily  escape  into  a  vessel  placed  to  receive  them. 

Some  of  the  practitioners  of  this  system  are  somewhat  inconsistent,  since  they  advo- 
cate the  frequent  ablution  of  the  exposed  wound  with  carbolic  water,  or  its  protection  by 
pouring  over  it  the  balsam  of  Peru  ;  and  C.  Thiersch  adds  that  whether  the  wound  lies 
quite  free,  or  is  covered  with  a  piece  of  oiled  silk,  or  with  a  water  compress,  cold  or 
warm,  does  not  appear  to  be  of  importance  if  only  free  escape  of  the  secretions  is  not 
affected  thereby;  we  may  also,  he  says,  add  irrigation  without  changing  the  character  of 
the  dressing,  as  practised  by  Bardeleben,  and  the  permanent  water-bath  may  also  be  of 
use.  Thiersch,  moreover,  adds  that  in  cases  of  compound  fracture  and  gunshot  injurioi< 
— since  the  free  escape  of  secretions  is  one  of  the  most  important  points  in  their  treat- 
ment— wounds  may  be  enlarged  by  incisions,  abscesses  opened,  counter-openings  made, 
and  even  free  openings  into  wounded  joints  or  resection  practised. 

The  conclusions  of  the  Moscow  committee  are  also  favorable  to  the  practice,  and  mav 
be  condensed  as  follows:  The  essential  feature  of  treatment  by  ((erafioii,  as  this  commit- 
tee calls  it,  consists  in  avoiding  all  local  appliances  for  excluding  air.  and  in  placing 
wounds  in  conditions  favorable  for  free  and  direct  contact  with  the  atmosphere.  Lint 
and  other  such  substances  should  never  be  used.  Repair  by  primary  union  .should  alwavs 
be  sought  for  when  possible.  Catgut  ligatures  and  metallic  sutures  should  be  employed. 
The  advocates  of  this  system  believe  that  the  '•  Lister  dressings"  are  injurious,  but  that 
the  antiseptics  employed  counteract  the  baneful  effects  of  the  coverings. 

Summary. — The  results  of  this  open  treatment  are  evidently  satisfactory,  and,  judged 
by  the  essential  points  to  which  attention  has  been  directed,  the  open  treatment  of 
wounds  may  be  advocated,  for  it  includes  careful  adaptation  of  parts  after  arrest  of  all 
bleeding  and  due  provision  for  thorough  drainage;  but,  on  the  other  hand, It  takes  little 
care  to  guard  against  mobility  of  the  wounded  parts  and  disregards  antiseptic  applica- 
tions and  precautions. 

The  neglect  is,  however,  probably  due  to  the  justifiable  impression  that  if  drainage 
be  provided  for  there  will  be,  in  the  deeper  parts,  no  retained  dead  tissues  or  fluids  to 
decompose  or  undergo  chemical  change,  and  that  a  free  current  of  air  upon  the  surface 
of  the  wound  is  the  best  guarantee  against  septic  changes  of  its  fluids.  Lideed,  Profes- 
sor Humphry  clearly  indicated  this  when  he  described  how  large  open  wounds  by  this 
system  heal  more  ((uickly  than  when  the  part  was  covered  and  kept  moist. 

Some  of  the  advocates  of  this  system  believe  the  open  treatment  to  be  more  adapted 
to  wounds  in  which  union  by  stcoudar//  adhesion  is  to  be  expected,  since  they  as.sert  that 
if  an  open  wound  be  maintained  in  a  condition  of  perfect  freedom  from  all  irritating 
causes,  .such  as  foreign  bodies,  dirt,  and  decomposing  elements,  granulations  will  form, 
and  that  suppuration  is  not  an  essential  part  of  their  formation.    . 

For  my  own  part,  after  a  careful  review  of  the  whole  question,  I  must  regard  the 
open  treatment  of  wounds  as  being  far  superior  to  any  other  in  which  due  provision  is 
not  made  for  perfect  drainage ;  but  at  the  same  time  I  fail  to  see  its  advantages  over 
some  others,  and  more  particularly  over  that  which  I  adopt,  in  which  all  the  advantages 
of  the  open  system  are  secured,  and  in  which,  in  addition,  the  wounded  part  is  effectually 
guarded  again.st  mobility  and  external  injury,  while  at  the  same  time  due  provision  is 
made  by  means  of  a  light  antiseptic  dressing  against  the  possibility  of  any  septic  changes 
taking  place  at  the  surface  as  well  as  in  the  deeper  portions  of  the  wound. 

The  recent  investigations  of  Pasteur^  tend  greatly  to  support  the  advocacy  of  this 
open  dressing,  since  he  claims  to  have  proved  '•  that  it  is  the  oxgen  of  the  air  which 
weakens  or  extinguishes  germ  virulence."  Pasteur's  experiments  confirm  those  of  Dr. 
Downs  and  Mr.  Blunt  obtained  in  1877,  and  those  obtained  by  Tyndall  in  1881,  whereby 
the  influence  of  sunlight  in  arresting  the  development  of  bacteria  was  shown. 

The  treatment  of  wounds  by  ^^  irric/atifnr  must  be  regarded  as  only  a  variety  in  form 
of  the  open  treatment,  since  its  essential  advantage  consists  in  the  cleansing  and  thorough 
draining  of  the  wounds  of  all  secretions  and  impurities.     The  mode  of  carrying  out  this 
method  will  be  described  under  the  heading  "  Water  Dressing." 
'  Acad,  of  Med.,  Lancet,  November  6,  1880. 


sr/yiAL  rni.A  rMi.sr  or  worsDs. 


49 


III  iruii^lint  wiiiiiiil-  <if'  liiiilis  ami  in  >Ioii;rliiiij.'  or  iiiihfalthy  stiiiii|is  or  wounds  this 
njodi'  of  tivatiiii'iit  liy  irrij.'atioii  is  viTV  satisfactory.  It  lias  been  fiiijilov<*<l  at  (Jiiv'h 
Hospital  for  a  ijuartfr  of  a  iH-iilury,  and  can  bo  reconi mended.  Esniarch  speaks  lii<rlily 
of  it  ill  military  surgery. 


Fig.  9. 


On  Water  Dressing  with  and  without  Antiseptics  in  Solution. 

Ill  \^'l^\  the  late  Mr.  Syme  ])ul>lished  a  pap»'r  in  the  Eillnhiirgh  Mnliml  imd  Snrr/irul 
Jnunml,  .luly.  in  which  he  iKiinted  out  the  evils  of  such  old  methods  of  dressing  wounds 
as  those  of  mundifyinir.  di<:esting,  incarniiij.'.  and  cicatrizin};,  and  recommended  that 
wounds  should  he  liirhtly  dressed  with  wet  lint  or  other  simple  dressing  after  their  edges 
ha<l  lu'cn  adjusteil  and  well  brought  together  l»y  stitches.  To  this  surgeon,  in  connection 
with  Mr.  liiston,  may  he  pnthahly  attrilmtcd  the  iiitrodiietitui  into  Hritish  surgery  of  the 
use  of  water  dressing  for  wounds  generally. 

The  practice  was  very  rapidly  taken  hold  of  and  adopted,  every  thoughtful  surgeon 
having  recognized  the  evils  that  atteii<lcd  the  niethfids  in  which  wounds  were  smothered 
with  masses  of  charjiie.  lint,  or  otlu-r  material,  and  left  to  heal  as  best  they  could  under 
cover  of  such  dressing  saturated  with  blood,  serum,  or  pus. 

The  practice,  moreover,  was  simple  and  cleanly,  and  when  perfected  wa.s  comfortable 
to  the  patient  to  whiun  it  was  applied — that  is.  it  became  .so  as  .soon  a.s  the  value  of  a 
piece  of  oiled  silk  or  thin  gutta-percha  tissue,  applied  over  the  wet  lint,  was  recognized, 
the  wet  lint  without  this  addition  having  soon  become  dry,  and  what  might  have  been 
at  first  a  wet  dressing  became  thus  converted  into  a  dry  one. 

The  water  dressing  likewise  soon  took  the  place  of  poultices,  for  by  one.  as  by  the 
other,  warmth  and  moisture  were  applied  to  the  wound. 

In  1835.  ten  years  after  the  publication  of  Symes  paper,  M.  Josse,  a  hospital  surgeon 
of  Amiens,  published  a  book  on  the  use  of  cold  water  in  surgical  dressings,  and  advo- 
cated its  use — fjrsf.  as  a  trustworthy  and  efficient  means  for  the  control  of  inflammation 
in  parts  not  wounded  ;and  Mcmdhj,  as  a  dressing  for  wounds. 

'•  If  we  had  the  choice,"  he  .says,  referring  to  the  treatment  of  the  first  class  of  cases 
in  which  there  is  no  wound,  ''it  might  be  established  as  a  general  principle  that  we  ought 
to  employ  water  by  aff"usion  with  a  continual 
stream,  but  the  nature  of  the  parts  or  of  the 
disea.se  may  prevent  this  and  oblige  us  to  recur 
to  another  method ;  thus,  linen  moistened  with 
water  and  renewed  without  ceasing  may  to  a 
certain  degre  prove  a  substitute  for  the  affu- 
sions, but  this  mode  requires  much  attention."' 
He  subset juently  describes  his  own  method  :  '"A 
vessel  with  a  cock  near  its  base  is  filled  with 
water  and  placed  upon  a  narrow  and  high  table, 
near  the  patients  bed,  in  such  a  position  that  it 
shall  be  about  a  foot  and  a  half  above  the  dis- 
eased limb,  beneath  which  a  cerecloth  is  spread, 
intended  to  guard  the  bed  and  facilitate  the  flow 
of  the  water,  which  is  received  in  a  bucket  placed 
near  for  that  purpose,  and  into  which  the  ex- 
tremity of  the  cerecloth  descends.  The  diseased 
part  should  then  be  placed  in  the  most  conveni- 
ent position  ;  it  should  be  lightly  covered  with 
compresses ;  an  additional  piece  of  linen  should 
surround  the  cock  by  one  of  its  extremities,  while 
the  other  is  extended  over  the  highest  point  of 
the  apparatus.  This  is  designed  to  prevent  the 
water  from  falling  with  all  its  weight  on  the  dis- 
eased part,  and  rather  to  disperse  it  over  a  larger 
surface." 

I  have  described  this  method  of  using  cold  water  fully,  for  it  is  one  now  recognized 
as  the  treatment  by  "  irrigation."'  which,  whether  employed  as  cold  affusion  to  check 
inflammation  in  injured  parts,  as  in  joints,  or  to  keep  wounds  clean,  is  of  great  value. 

M.  Josse  likewise  declared  '"that  when  cold  water  is  applied  directly  after  the  injury, 
before  reaction  has  taken  place,  and  where  it  can  be  maintained  with  energy  proportionate 
4 


50  THE  DRY  DRESSING    OF   WOUNDS. 

to  the  occasion,  the  phenomena  of  reaction  will  be  prevented  :  heat.  pain,  and  swelling 
will  be  subdued,  and,  conseriuently,  sympathetic  fever  will  not  take  place  ;  but  when  the 
cold  has  not  been  applied  before  the  development  of  the  inflammatory  symptoms,  they 
will  .still  be  conquered  by  its  eflScient  use."  In  these  cf^iinions  most  surgeons  will  agree ; 
but  cold  is  not  now  often  employed  in  the  manner  described,  the  introduction  of  ice  and 
ice-bags  having  led  to  the  adoption  of  simpler  and  more  effective  methods  of  application. 
The  metallic  coil  of  Leiter  of  A'ienna  is  probably  the  best  method  of  applying  cold.  I 
have  used  it  freely,  and  like  it  much.  It  seems  to  embody  in  itself  all  the  advantages, 
without  the  disadvantages,  of  all  other  known  methods  of  refrigerating  a  part.  It  is 
also  equally  valuable  for  the  application  of  heat  (vide  Fig.  9). 

But.  however  valuable  cold-water  compresses  or  bandages,  hot  fomentations,  or  a  warm- 
water  dressing  ma}'  be  as  applications  to  parts  that  have  been  injured,  bruised,  or  inflamed, 
they  cannot  be  .strongly  recommended  as  dressings  to  part.^  in  which  wounds  exist  ;  for  it  is 
now  a  fairly  well  recognized  fact  that  water,  ^)^>-  .sr,  helps  better  than  anything  else  to  en- 
courage in  an  injured  or  half-dying  tissue,  as  well  as  in  the  secretions  of  a  wounded  part, 
chemical  and  fermentative  changes  by  means  of  which  septic  poisons  are  generated  or  made 
to  flourish,  and  from  the  absorption  of  which  blood  poisoning  is  known  to  follow. 

Water  holding  some  antiseptic  substance  in  solution  may.  however,  be  used,  the 
antiseptic  preventing  or  neutralizing  the  septic  changes  which  the  water  by  itself  might 
encourage. 

In  wounds,  therefore,  that  are  much  complicated  with  contu.sion  and  laceration  of 
parts,  and  to  which  hot  or  cold  fomentations  seem  applicable,  these  medicated-water 
dres.sings  may  be  emploj'ed,  it  being  left  to  the  fancy  of  the  surgeon  whether  he  shall 
use  carbolic  acid  1  in  20  of  water,  boracic  acid  1  in  50,  salicylic  acid  1  in  50,  thymol  1  in 
1000,  iodine  tincture  1  in  80,  or  iodine  liquor  1  in  160,  or  permanganate*of  potash 
1  part  to  50. 

Value  of  Oily  Dressings. — For  my  own  pai-t.  I  have  for  years  given  up  u.sing 
water  as  a  dressing  for  wounds,  whether  with  or  without  antiseptic  substances,  for  I  have 
found  that  oily  solutions  of  the  same  substances  have  advantages' over  the  watery  prep- 
arations which  render  them  far  safer  and  more  satisfactory.  Oily  antiseptic  applications 
are  without  doubt  the  best  dressings  for  wounds  which  we  possess,  and  of  these  one  com- 
posed of  terebene  one  part  and  olive  oil  three  or  four  parts  deserves,  as  already  men- 
tioned, the  preference. 

The  Dry  Dressing  of  Wounds. 

A  dry  dressing  to  a  wound  is  to  be  preferred  to  one  of  which  simple  water  forms 
a  part,  .since  with  it  the  sanguineous  or  serous  exudations  are  more  or  less  absorbed  and 
rendered  inert,  and  the  surface  of  the  wound  is  kept  quiet  and  protected  as  by  a  scab 
from  outside  injurious  influences ;  whereas  with  a  water  dressing  the  injured  surface  of 
the  wound  and  the  wound-exudations  are  encouraged  to  undergo  chemical  and  fermenta- 
tive changes  by  which  the  risks  of  absorption  of  septic  matter  or  poison  are  much 
increased  and  the  dangers  of  the  simplest  wound  greatly  enhanced. 

If  the  drv  dressing  be  composed  of  some  absorbent  material,  such  as  the  absorbent 
cotton  or  lint,  and  impregnated  with  an  antiseptic  sub.stance.  such  as  boracic  or  salicylic 
acid  or  iodoform,  its  efficacy  will  be  increased,  since  the  dressing,  under  these  circum- 
stances, may  be  left  untouched  for  some  days,  even  for  a  week,  and  the  healing  of  the 
part  will  not,  therefore,  be  interfered  with.  Pvepair.  as  a  consequence,  will  go  on  with 
greater  rapidity  and  certainty,  the  secondary  wound  dangers  will  be  diminished,  and  the 
ultimate  issue  of  the  case  will  be  rendered  more  satisfactory. 

When  a  wound  is  nnall  and  the  surgeon  has  no  doubt  as  to  the  propriety  of  seeking 
to  obtain  its  immediate  union,  the  dry  dressing  can  be  recommended  :  for  it.  withoiit 
doubt,  helps  better  than  any  other  to  bring  about  the  "  quick  union  "  which  is  wanted. 

When  the  wound  is  Inrr/e  or  deep,  the  same  recommendation  cannot  be  made,  and  the 
dry  dressings,  if  used,  should  only  be  so  after  every  care  has  been  taken  to  provide  for 
the  free  drainage  of  the  part.  They  should,  moreover,  only  be  employed  when  there  is 
a  reasonable  hope  of  the  parts  healing  by  primary  union. 

When  a  wound  is  much  lacerated  or  cfinfmed.  dry  dressings  are  not  applicable,  since 
in  such  no  surgeon  would  entertain  the  thoughts  of  repair  being  brought  about  by  rapid 
union  ;  and  where  this  hope  cannot  reasonably  be  entertained,  the  use  of  the  dry  dress- 
inirs  should  be  discarded.  In  brief,  in  all  wounds,  small  or  large,  when  repair  by  '■  quick 
union  "  mav  reasonablv  be  looked  for.  dry  dressings  are  applicable,  due  provision  having 


ALCnlKil.K-   DUKSSLSC    OF    WOl'SDS.  51 

been   iiiailL'  iur   .'tViciciit    draiiia;^*'.      In   all    lacerated,  contUHcd,  or  iJ«'t.'p  wounds   in  wliich 
repair  by  granulation  is  to  be  expected,  tbese  dressings  art-  imt  to  be  reconmiendcil. 

Earth  Dressings. 

Karth  as  a  ilrcssini:  fur  \v(iuiMi>  lias  (b»ubtless  been  used  by  savaj^e  nations  from  an 
oarlv  perioil  of  the  wdrld's  history,  but  it  was  first  brouf^ht  before  tbe  notii-e  of  surj^jeons 
by  i)r.  Addiufll  Ih'ws.in  <»f  IMiiladelpbia,  I'nited  States,  in  1.S72,  and  from  bis  w<irk  u|»oii 
the  subjeet  it  seems  that  he  first  resorted  to  this  niodt;  of  treatment  in  ISCK.  i)r.  Ilew- 
son  was  first  led  to  employ  the  earth  as  a  deodorizer  in  a  bad  example  of  eompound 
fraiture  of  the  let',  and,  as  the  result  in  this  ea.se  was  f^ood  in  all  respects,  Ije  bejran  to 
employ  it  as  a  primary  dressing  to  wounds.  The  earth  u.sed  l)y  Dr.  Hewson  was  dried 
yellow  ferruginous  «day  which  had  been  well  sifted  through  a  fine  fiour-sieve.  and  he 
claims  for  its  use  many  a<lvantages.  He  maintains  that  it  is  '•  cool  and  plea.saiit''  to  the 
patient  as  a  local  application,  and  that  it  has  a  markc<l  influence  in  soothing  jiain.  In 
burn  and  in  carbuncle  cases  this  relief  is  very  striking. 

Dr.  llewson  has  satisfied  himself  that  earth,  besides  being  a  deodorizer,  lia.s  a  marked 
influence  in  preventing  putrefaction  ;  that  in  no  ca.se  does  it  provoke  or  aggravate  inflam 
niatory  action  in  a  wound,  but  that  in  many  it  retards  or  arrests  it;  and,  above  all.  tliat 
it  ]»romotes  the  healing  process  in  wounds  of  every  description,  as  well  as  in  ulcers.  The 
way  in  which  the  clay  acts  as  a  dressing  may  not  be  clear,  but  it  seems  reasonable,  from 
the  evidence  adduced  by  Dr.  llewson  and  others,  to  conclude  that  it  has  by  its  powers  of 
ab.sorbing  gases,  and  more  jiarticularly  ammonia,  a  chemical  action  upon  the  part  to  wliich 
it  is  applied,  and  that  by  virtue  of  this  action  it  is  "an  efticient  means  of  <lelaying  decay 
and  putrefaction,  and  of  preventing  fermentation  in  animal  tissue."  Besides  this,  it 
excludes  air  from  the  wounded  tissues,  absorbs  moisture  and  excess  of  discharges,  and 
helps  in  a  measure  to  give  support  to  wounded  i)arts. 

The  dres.sing  is  applied  directly  to  the  wounded  or  ulcerated  surface  by  dusting  over 
it  the  pulverized  clay,  or  in  the  case  of  a  stump  by  placing  it  upon  a  bed  of  dry  clay  in 
a  box  extemporized  of  binder's  board,  and  by  completely  covering  in  the  whole  surface 
Vjy  some  more  clay.  In  some  cases,  when  the  clay  becomes  saturated  with  discharge,  the 
dre.ssing  has  to  be  renewed  daily  ;  in  others,  it  may  be  left  for  two  or  more  days. 

Upon  the  whole,  this  mode  of  practice  has  not  extended  far  beyond  the  sphere 
occupied  by  its  originator,  and  it  does  not  seem  to  possess  any  advantages  over  the  more 
cleanly  and  simple  processes  which  are  now  at  the  disposal  of  surgeons.  Some  years  ago, 
when  Dr  Hewson  was  in  Londijn,  I  was  tempted  to  give  the  method  a  trial,  but  I  .soon 
gave  it  up,  as  experience  was  not  in  its  favor.  The  dirtiness  of  the  dressing  was  not 
compen.sated  for  by  any  advantage.  This,  however,  may  have  been  becau.se  I  was  unable 
to  obtain  the  right  kind  of  ferruginous  clay. 

Alcoholic  Dressing  of  Wounds. 

Hippocrates,  Paracelsus,  and  others  emjdoyed  wine  as  a  dressing  to  wounds,  and 
they  did  so  under  the  idea  that  it  dried  the  part,  and  with  the  belief  that  a  dry  condi- 
tion was  nearer  a  state  of  health,  whilst  humidity  was  nearer  that  of  di.sease.  Their 
followers  used  wine  in  which  astringents  were  dissolved,  such  as  gall-nuts,  oak-bark,  etc. 
All  did  so,  moreover,  with  the  view  of  arresting  bleeding.  In  more  recent  times  the 
alcohol  dressing  has  been  made  popular  by  Nelaton,  who  used  it  largely  and  found  it  of 
value.  It  may  be  applied  in  the  form  of  simple  alcohol,  or,  which  seems  preferable,  in 
that  of  the  camphorated  spirit  of  wine,  as  originally  used  by  Dionis. 

The  dressing  is  said  to  be  a  coagulant  and  astringent,  and.  with  such  properties,  to  favor 
primary  adhesion.  In  open  wounds  it  is  said  to  act  as  a  healthy  stimulant  to  the  granu- 
lations and  as  a  disinfectant,  thus  helping  repair  and  guarding  against  septica;mic  changes 
and  other  wound  complications.  Nelaton  employed  compresses  saturated  with  alcohol, 
and  he  believed  the  camphorated  spirit  to  be  u.seful  only  in  proportion  to  the  alcohol  it 
containetl. 

M.  Chedevergne  asserts  "that  camphorated  spirit  of  wine  is,  without  contradiction, 
the  best  disinfectant  that  can  be  found  for  the  treatment  of  wounds  and  ulcers  ;  and  lie 
makes  this  statement  after  a  careful  investigation  into  the  value  of  every  known  antisep- 
tic, not  excluding  carbolic  acid.  The  spirit  is  supposed  to  have  the  power  of  dissolving 
the  pus  cell,  of  obviating  its  tendency  to  decompose,  and  of  closing  any  open  vessels. 

Maisonneuve   bathes    the    raw  surface  of  the  wound  with   the   spirit,   and,  having 


52  ANTISEPTIC  IRRIGATIOX  OF   WOUXDS. 

brought  the  divided  edges  together  and  adjusted  them  with  sutures  or  adhesive  plaster 
so  placed  as  to  allow  of  the  free  escape  of  discharges,  envelops  the  whole  in  a  Vjandage 
steeped  in  tincture  of  arnica,  and  at  times  he  applies  over  the  whole  the  apjiaratus  for 
''pneumatic  aspiration."  which  will  be  again  referred  to.  The  disinfecting  and  cleansing 
power  of  the  spirit,  applied  in  this  manner,  probably  helps  the  draining  influence  of  the 
aspirator. 

Upon  the  whole,  the  alcohol  dressing  may  be  favorably  regarded,  whether  simple 
alcohol  or  spirits  of  camphor  be  employed.  It  has.  without  doubt,  a  cleansing,  and  prob- 
ably a  disinfecting,  influence  on  a  wounded  surface ;  while,  at  the  same  time,  it  helps 
materially  to  arrest  capillary  bleeding  and  that  serous  oozing  which  is  so  detrimental  to 
primary  union.  In  its  use,  however,  the  surgeon  should  never  be  induced  to  forget 
the  value  of  the  other  essential  points  of  practice  to  which  attention  has  been  drawn, 
and  particularly  drainage. 

Pneumatic  Aspiration  or  Occlusion. 

3Iaisonneuve"s  method  of  •■  pneumatic  aspiration."  which  he  employed  with  some  suc- 
cess before  1867.  and  J.  Guerin's  plan  of  eff'ecting  'pneumatic  occlusion."  promulgated  in 
1865.  were  practised  thus  :  Assuming  an  amputation  of  the  thigh  to  have  been  just  per- 
formed and  the  vessels  secured,  the  edges  of  the  wound  are  brought  together  and  held  in 
apposition  with  adhesive  plaster,  but  without  sutures.  A  hood  of  vulcanized  india-rubber 
is  then  passed  over  the  stump  several  inches — a  foot,  if  .space  allows — from  the  estremitv. 
It  is  essential  that  the  aperture  of  the  india-rubber  cap  should  fit  the  limb  accuratelv.  but 
the  crown  or  lower  part  may  hang  some  distance  from  the  wound.  To  the  centre  of  the  crown 
of  the  india-rubber  cap  is  attached  a  tube  of  similar  material  about  two  or  three  feet  long, 
fitted  by  its  opposite  extremity,  through  a  metallic  canula.  in  a  rubber  plug,  which  fits  into 
a  gallon  glass  jar.  A  second  metallic  tube  pierces  the  india-rubber  plug  and  is  connected 
with  another  vulcanized  tube  of  convenient  length  attached  to  a  brass  exhausting-pump. 
A  few  strokes  of  the  piston  morning  and  evening  sufiice  to  draw  the  discharges  from  the 
stump  into  the  jar.  where,  in  the  absence  of  air,  they  accumulate  without  danger  of 
decompo.sition ;  while  the  healing  of  the  wound  is  facilitated  by  the  accurate  and 
immovable  adaptation  of  its  surfaces  and  the  exclusion  of  air.  This  practice  of  Maison- 
neuve's  has  three  main  objects  in  view,  all  of  which  are  good — first,  to  check  the  forma- 
tion of  matter ;  second,  to  prevent  its  decomposition  when  formed  ;  and  third,  to  prevent 
its  poisonous  action  on  the  system  by  entrance  into  the  circulation.  It  is  essentially 
based  upon  the  principle  of  "drainage."  and  in  that  point  of  view  is  vahiable.  In  excep- 
tional cases,  and  particularly  in  certain  cases  of  amputation,  it  ma}"  be  employed,  but  as 
a  general  mode  of  treating  stumps  it  does  not  appear  to  possess  such  advantages  over 
simpler  methods  as  to  make  up  for  the  difficulties  and  expense  of  its  employment. 

Antiseptic  Irrigation  of  Wounds. 

The  value  of  the  antiseptic  irrigation  of  wounds  is  not  at  the  present  day  likely  to  be 
disputed  by  any  surgeon,  and  a  difference  of  opinion  is  only  probable  as  to  the  antiseptic 
which  shall  be  used,  the  mode  of  its  application,  and  the  character  of  the  wound  to  which  it 
is  applicable.  Every  surgeon  seeks  to  make  and  to  keep  his  patients  wounds  as  clean  as 
possible  and  by  means  of  antiseptic  solutions  or  applications  to  destroy,  neutralize,  or 
guard  against  any  and  every  outside  or  local  influence  that  can  pos.sibly  bring  about  or 
encourage  chemical  or  fermentative  changes  in  a  wound.  It  is  true  that  within  the  last 
few  vears  a  school  of  surtreons  has  Ijeen  forn>ed  the  members  of  which  talk  of  •■  antiseptic 
surgery"  and  claim  for  themselves  the  title  of  "  antiseptic  surgeons,"  as  if  it  were  applic- 
able to  themselves  alone,  or  rather  to  such  of  their  body  as  have  a  belief  in  the  germ 
theory  as  a  cause  of  mo.st.  if  not  all,  the  surgical  ills  to  which  wounded  flesh  is  heir,  who 
assert  rather  loudly  and  dogmatically  that  "  antiseptic  surgery"  mu.st  .stand  or  fall  with 
the  theory  upon  which  their  practice  is  based,  that  no  unbeliever  in  the  theory  is  likely 
to  carry  out  the  practice  with  any  probability  of  success,  since  it  is  only  \>\  a  staunch 
believer  in  the  theory  that  care  and  attention  to  every  detail  of  treatment  sufficient  to 
bring  about  a  good  result  is  likely  to  be  given.  It  is  true,  also,  that  the  results  claimed 
for  this  practice  are  great — very  great,  beyond  all  previous  belief;  that,  according  to 
these  gentlemen,  operations  which  in  former  times  were  looked  upon  as  dangerous  can 
now  be  undertaken  with  a  '■•  certninti/"'  of  success,  and  that  others  which  have  hitherto 
been  regarded  as  unjustifiable  are  now  legitimate  and  safe.      In  fact,  the  upholders  of 


Asrixi'.i'i'ic  ini'ji; Alios  or  wor.xns.  53 

this  tln'urv  and  :i(I(i|)tcr,s  of  this  |tr:ictic«'  maiiitaiii  lliat  i'X|ilnratiiry  ami  <i|M'rative 
ineasun-s  wliicli  liavt;  ht-i'ii  n-f^ardfil  as  hciii^'  hi'V'Miti  tlie  |ir(»viii<;(!  <j1'  tin;  Hiir^'cMri 
luav  now  1)1'  raliiily  ami  (juictiy  iindiTtakcii  with  :i  ••moni/  n'rtdinlt/"  u\'  heiti<^  fVtIlowcd 
l)V  ii  ,u;t"»d  rt'Siilt.  Thus  it  is  that  our  saiij;iiiiie  rim/nriH  talk  of  futtiiij;  into  ln-althy 
joints  with  tlu'  ••<■'  r/ninti/"  that  no  danger  will  follow,  and  dcudarc;  that  jTrcat  opiTations 
upon  the  lioncs  of  tin-  knee  may  hf  undertaken  with  the  f'eelinir  that  in  so  doiri;:  we  ilo 
not  suhjeet  the  patient  "to  any  risk  whatirver;"  that,  a  wecl^e-shapefl  pit;ce  <d'  hone  may 
he  taken  from  a  deformed  I'emur  with  the  confidetK^e  that  so  j)rodueed  a  compouii)l  frac- 
ture is  "perfeellv  safe"  and  '"  without  risk  ;  '  and  last,  hut  not  least,  that  the  peritoneal 
cavity,  under  antiseptic  preeaution.s,  may  he  opened  '•v:ifh  iui/nmifi/." 

I  need  hardly  say  that  much  of  this  is  hold  assertion  and  nothiiifr  more,  and  that  it 
is  apparently  due  to  the  sanfriiine  temjicrament  whieli  seems  uttaehed  to  thos*;  who  pin 
their  faith  to  a  takin<;  theory  ami  adopt  the  practice  whieh  is  has<;il  upon  it  in  hlind  del'er- 
enee  to  the  authority  of  its  distinguished  oriiiinator  ;  for  facts,  calmly  looked  at.  neither 
hy  their  nuniher  run-  hy  their  weiirht  justify  these  conclusions,  hut  irresistihly  sufr^zest 
that  an  enormous  superstructure  has  been  rai.sed  by  the  intreiiuity  of  its  builders  upon  u 
narrow  foundation,  and  that  srood  results  have  been  too  hastily  attributed  to  causes  whieli 
have  been  but  some  of  the  factors  of  a  work  to  whieh  others  efjually  potent  for  good 
have,  without  doubt,  contril)uted. 

Facts,  indeed,  have  been  employed  by  our  self-styled  "antiseptic"  friends,  as  legal 
advocates  use  small  data  which  tell  in  their  favor,  to  su])j»ort  the  cause  they  have  in 
hand,  but  not  as  the  judge  who  has  to  weigh  evidence  and  with  an  unbiased  mind  give 
judgment.  It  is  only  by  this  explanation  that  we  can  understand  how  the  '-antiseptic 
■surgeon,"  when  he  gets  a  good  result,  is  so  fond  of  asserting  that  such  could  not  have 
been  brought  about  by  any  other  form  of  practice  than  that  which  he  adopted,  and 
when  he  is  attemi)ting  an  operation  which  may  in  all  truth  be  called  experimental,  if  not 
rash,  maintains  that  he  undertakes  it  ^^  nndf-r  the  sjira?/^'  with  all  confidence  and  with  a 
"  moral  certainty  "  of  meeting  with  success.  We  must  admit,  however,  that  surgery  is 
now  much  more  successful  than  it  was  twenty  years  ago,  and  that  of  the  many  factors 
which  have  brought  about  this  result  the  employment  of  antiseptics  stands  forenio.st ; 
and  if  we  are  not  altogether  indebted  to  Mr.  Lister  for  their  use,  we  are  un<|uestionably 
iiulel)ted  to  him  ior  the  able  and  persistent  manner  in  which  he  has  both  advocated  their 
employment  and  demonstrated  their  value.  All  honor,  therefore,  to  the  name  of  Lister 
for  having  helped  more  than  any  one  else  to  establish  the  value  of  anti.septic  drugs  and 
antiseptic  precautions  in  the  practice  of  surgery  all  over  the  world.  Let  tho.se  who  smile 
at  his  theory  join  with  those  who  believe  in  it  in  giving  him  this  just  meed  of  prai.se.  and 
let  those  who  do  not  believe  in  the  efficacy  of  the  "  spray"  do  their  best  to  prove  to  those 
who  do  that  all  the  advantages  of  the  "  anti.septic  system"  can  be  obtained  by  simpler 
means  than  by  its  use. 

Among  these  means  what  must  be  called  '•  antiseptic  irrigation"  of  wounds,  in  my 
judgment,  stands  foremost.  Antiseptic  irrigati(Ui  means  the  washing  of  a  wound  with 
an  antiseptic  solution  with  the  view  of  destroying  any  and  every  germ  or  element  that 
might  possibly  set  up  chemical  or  fermentative  changes  in  its  secretions.  It  is  as 
applicable  to  fresh  wounds,  accidental  or  operative,  as  it  is  to  the  suppurative  or  foul, 
and  it  is  as  valuable  as  a  preventive  as  it  is  as  a  curative  means. 

In  my  own  practice  the  solution  employed  is,  as  has  already  been  mentioned,  iodine 
water — that  is,  a  mixture  of  the  tincture  of  iodine  aiul  water  in  the  pro])ortioiis  of  1 
part  to  80,  or  of  the  licjuor  1  in  160 — and  after  operations  this  should  be  applied  hot.  It 
may  be  used  by  means  of  the  irrigating-bottle  as  drawn  at  page  38,  Fig.  3,  or  by  means 
of  sponging.  Where  sponges  are  employed  they  should  be  well  soaked  in  this  fluid,  and 
subsequently,  before  the  wound  is  dressed,  should  be  used  to  ab.sorb  all  excess ;  for  this 
lotion,  when  employed  warm,  has  more  power  than  any  other  of  which  I  know  to  check 
capillary  bleeding,  and  to  bring  about  that  desirable  '■  glazing"  of  a  wounded  surface 
which  is  so  valuable  as  a  first  step  toward  quick  or  rapid  repair.  In  suppurating  wounds 
the  same  lotion  cleanses  better  than  anything  else,  and  has  the  power  of  destroying  germs 
of  evil  as  well  as  other  more  vaunted  gormici<les.  For  the  irrigation  of  a  chronic  abscess 
or  sinus  it  is  equally  to  be  advocated  :  indeed,  as  a  purifying  and  antiseptic  lotion  for  all 
wounds  of  exfernal  parts,  as  well  as  for  all  suppurating  cavities,  it  can  be  highly  recom- 
mended. I  have  employed  it  for  years  past  as  a  purifying  agent,  but  without  germicidal 
intentions,  with  excellent  results  ;  and,  although  I  have  .seen  much  of  the  spray  and  car- 
bolic-acid practice,  I  cannot  yet  see  that  its  results  are  better  than  my  own.  Those  who 
prefer  carbolic  acid  as   an  antiseptic  can  use  it  in  the  same  way  in  the  strength  of  1  in 


64  THE  LISTERIAN  METHOD   OF  DRESSING    WOUNDS. 

30  or  40,  and  thymol,  boracic  acid,  chloride  of  zinc,  oil  of  eucalyptus,  or  any  other 
known  antiseptic,  may  be  similarly  employed. 

The  essential  feature  of  the  practice  consists  in  the  thorough  ablution  of  the  wounded 
or  diseased  part  with  the  anti.septic  solution  after  the  arrest  of  all  bleeding,  the  drying  of 
the  surface  of  the  wound  as  far  as  possible  with  an  antiseptic  hot  sponge  applied  with 
njoderate  pressure,  and  subsequently  the  careful  dressing  of  the  wound  with  some  anti- 
septic substance  in  the  way  that  was  described  in  an  early  page  ("  Protection  of 
Wounds"). 

The  Listerian  Method  of  Dressing  Wounds. 

This  methed  is  founded  on  the  theory  that  the  fermentation  of  the  discharges  of 
wounds  is  due  to  the  introduction  into  them  from  without  of 

"  those  viewless  beings 
Who.se  mansion  is  the  smallest  jiarticle 
Of  tlie  impa.ssive  atmosphere," 

now  known  as  micro-organisms  or  bacteria.  The  practice,  which  is  based  upon  the  theory, 
is  framed  solely  and  wholly  with  the  view  of  destroying  those  aerial  enemies  by  means 
of  the  familiar  cloud  of  carbolized  spray  (1  in  40)  hp/ore  they  reach  the  wound,  and  by 
the  carbolic  solution  (1  in  20)  when  they  have  alighted  on  or  entered  it.  the  green  pro- 
tective gauze,  carbolized  catgut,  and  other  paraphernalia  being  emploj'ed  with  the  oV)ject 
of  guarding  against  the  introduction  of  the  same  dangerous  foes  during  the  sub.sequent 
progress  of  the  case. 

This  method,  which  at  its  birth  was  named  •'  antiseptic,"  is  how  designated  "  the 
aseptic,"  but  the  change  is  not  acceptable,  .since  it  contains  an  assumption  of  superiority 
of  '•  the  Listerian"  over  other  forms  of  good  antiseptic  surgery  when  the  object  of  all  is 
the  prevention,  exclusion,  and  destruction  of  the  causes  of  fermentation  in  wounds. 

The  sponsors  of  the  new  term  have  evidently  forgotten  that  Pasteur  has  proved  that 
'•  it  is  the  oxygen  of  the  air  weakens  or  extingui.shes  germs  ;"  that  Downes  and  Tyndall 
have  .shown  that  "  sunlight  arrests  development  of  bacteria  ;"  that  Lister  has  admitted 
''  the  probability  that  putrefaction  in  wounds  is  due  rather  to  the  septic  matter  in  a  con- 
centrated form  than  to  the  diffused  condition  in  which  it  exists  either  in  water  or  in  air ;" 
that  the  spray  is,  beyond  all  question,  the  least  important  of  our  antiseptics ;  that  bac- 
teria are  unable  to  grow  in  normal  serum  and  can  only  develop  in  that  liquid  when  it 
has  been  vitiated,  whether  by  the  addition  of  water  or  by  the  action  of  .<mall  quantities 
of  the  acrid  products  of  putrefaction  ;"  and  last,  but  not  least,  ''  that  the  tissues  of  a 
healthy  living  body  have  a  power  of  counteracting  the  energies  of  bacteria  in  their 
vicinity  and  preventing  their  development." 

The  surgeon  who  adopts  the  method  must  "  act  as  if  all  the  particles  made  visible  by  a 
sunbeam  were  noxious,  falling  like  snowflakes  during  every  operation  and  every  dressing, 
seeking  to  insinuate  themselves  into  the  wound  at  every  crevice.  His  aim  should  be  to 
destroy  the  intruders  and  effectually  exclude  their  thronging  companions." 

To  do  this,  the  sl-in  of  ihe  patient  over  and  in  the  neighborhood  of  the  intended  wound 
should  be  thoroughly  washed  with  carbolic  water  (1  in  20),  which  must  be  allowed  to  act 
for  some  little  time,  because  the  antiseptic  has  to  mix  with  the  fatty  matters  and  to 
penetrate  into  the  folds  of  the  skin,  and  the  micro-organi.sms  may  be  pecliliarly  resistant. 
The  lianch  of  the  operator  are  likewise  to  be  cleansed  with  the  same  lotion,  special  care 
being  observed  with  the  nails  and  the  folds  of  skin  about  them.  For  the  purification  of 
the  instruments  a  porcelain  or  tin  trottgh  is  provided  and  filled  with  the  1-20  solution,  and 
into  this  the  instruments  to  be  employed  should  be  laid  for  at  least  half  an  hour  before 
the  operation. 

••  The  sponges  are  washed  in  the  1-40  carbolic  solution.  After  the  operation  they  are 
rinsed  in  water  and  then  placed  in  a  jar  of  1-20  .solution  till  required  again;  then  the 
1-20  solution  is  squeezed  out,  and  the  sponge,  when  washed  in  the  1-40  lotion,  is  ready 
for  use.  These  sponges  may  be  used  for  a  long  time — till,  in  fact,  they  wear  out.  In 
some  cases  they  get  clogged  with  fibrine.  To  get  rid  of  this,  the  sponge  is  placed  in  a 
trough  containing  water  and  left  for  some  days.  The  fibrine  putrefies,  and  can  then  be 
washed  out  readily.  The  sponge  is  then  placed  in  a  jar  containing  the  1-20  carbolic 
lotion,  and  is  ready  for  use  when  required."' 

^  From  W.  Watson  Clievne's  able  article  in  Ashhnrst's  International  EncycIop<rdia  of  Surgery. 


THE  Lisii:i:i AS  Mi:iii(>i>  or  nnrssfM.    \\(H\J)s.  55 

'•  The  /iiiiificiitinii  (if  till  (ilr  is  ('tt('(!ti'(l  hy  means  (if  a  spray  of  carhfilic  acid.  The 
s|>rav  is  product'd  hy  driving  u  rapid  current  oi'  air  tlirou^h  the  iiarnjw  orifice  of  a  hori- 
zontal tnhe,  which  is  phiced  over  the  orifice  of  u  more  or  lesH  vertical  one.  The  air, 
rushing'  over  the  opening;  in  the  vertical  tuhe,  sucks  the  air  out  of  that  ;  and  if  the  lower 
end  tlips  into  a  fluid,  the  fluid  is  sucked  up  and  e.xpelled  iVom  the  narrow  orifice  in  the 
fonii  of  fmclv-divided  particles  ctr  spray.  At  present  steam  sprays  are  employed.  The 
fluid  ill  the  retort  is  1--0  watery  solution  of  carholic  acid,  and  tiiis  mi.xin^'  with  the  Hteain 
iVom  the  Itoiler,  forms  a  spray  (d'  ahout  l-!>0.  The  spray  is  emj)loye<l  during;  the  whole 
ojicration — fill,  in  I'act,  the  dressing  has  been  securely  applied. 

"The  operation  havinj;  been  performed  with  the  precautions  detailed,  the  lnrnntrrluKjr 
niiisl  /if  (ii-nstril.  This  is  done  hy  means  ol"  li<;atures  (d"  carliolized  eatfrut.  'I'here  are 
two  kiiuls  (d'  catiTut  which  are  at  present  employed — the  carholized  eat<rut,'  which  was 
that  first  intPnluce«l  hy  .Nlr.  Lister,  and  the  chromic-acid  jrut."  which  lasts  longer  in  the 
tissues  than  the  former  and  is  more  rapidly  and  easily  jirepared.  All  Ideedin^'  points  are 
tied,  and  the  liiraturcs  cut  short.  There  is  no  excuse  for  leaving:  any  bleeding  vessels,  a.s 
the  ligatures  eau.se  no  trouble  afterward." 

"  With  the  view  of  excluding  organisms  nfter  llic  opcrdtlmt,  the  material  usually 
employed  is  the  carbolic  gauze.  This  is  ordinary  tarlatan  impregnated  with  a  mixture  of 
one  part  of  carl)olie  acid,  four  parts  of  resin,  and  four  parts  of  paraffin.  If  the  cotton 
material  were  merely  dipped  in  carbolic  acid  or  carbolic  lotion,  the  antiseptic  would  very 
(|uicklv  volatilize  or  be  washed  out  by  the  discharge.  It  is  neces.sary,  therefore,  to  have 
the  antiseptic  stored  up,  so  that  it  may  last  for  .some  time.  This  is  the  purpose  of  the 
resin.  Resin  and  carbolic  acid  have  a  much  greater  affinity  than  water  and  carbolic  acid. 
Water,  therefore,  may  pass  over  a  mixture  of  resin  and  carbolic  acid  for  a  considerable 
time  without  washing  out  all  the  anti.septic.  If  the  gauze  were  impregnated  with  resin 
and  carbolic  acid  alone,  it  would  be  so  .sticky  as  to  be  useless ;  and  therefore  paraffin  is 
added  to  it  in  sufficient  (juantities  to  do  away  with  its  .stickiness.  As  the  gauze  at  ordiiuiry 
temperatures  does  not  give  off"  much  carbolic  acid,  dust  which  falls  on  it  is  not  deprived 
of  its  fermenting  property  ;  and  if  a  piece  of  gauze  covered  with  dust  is  applied  over  the 
orifice  of  a  drainage-tube,  this  dust  may  pass  into  the  wound  and  entirely  defeat  the 
object  of  the  whole  treatment.  On  the  other  hand,  the  watery  solution  of  carbolic  acid 
acts  very  rapidly,  and  hence  all  that  is  neces.sary  is  to  dip  the  layers  of  the  gauze  which 
go  next  the  wound  in  the  1.-40  lotion.  Lest  the  carbolic  acid  should  evaporate,  the  gauze, 
if  it  is  to  be  kept  for  some  time,  is  preserved  in  closely-shutting  tin  boxes. 

"  Carbolic  acid  is  a  powerful  irritant,  and  applied  directly  to  a  wound  it  will  retard,  or 
even  prevent,  healing.  With  the  view  of  overcoming  this  difficulty.  Mr.  Lister  inter- 
poses a  material  impervious  to  carbolic  acid  between  the  wound  and  the  gauze  dressing. 
This  material  is  termed  the  protective.  It  is  ordinary  oiled  silk  coated  on  both  sides 
with  a  thick  layer  of  copal  varnish  ;  outside  this  a  .solution  of  dextrine  is  bru.shed, 
because  water  runs  off!"  from  the  material  without  the  dextrine  just  as  from  a  duck's 
back,  whereas  the  dextrine  dissolves  in  the  lotion  and  the  protective  is  equally  and  per- 
fectly moistened.  This  protective  is  cut  a  little  larger  than  the  wound,  dipped  in  the 
lotion,  and  applied  over  it.  Outside  the  protective  we  have  the  wet  gauze,  larger  than 
the  protective  and  overlapping  it  in  all  directions,  both  together  being  called  the  '  deep 
dressing.' 

••  When  used  as  a  dressing,  the  carbolic  gauze  is  packed  into  the  hollows  around  the 
wound,  and  then  a  regular  dressing  is  applied.  This  consists  of  the  gauze  folded  in  eight 
layers,  beneath  the  outer  layer  of  which  is  placed  a  piece  of  mackintosh  cloth — what  is 
known  as  hat-lining.  The  object  of  this  is  to  make  the  discharge  traverse  the  whole  of 
the  dressing  and  not  pass  directly  through,  as  would  be  the  case  were  the  mackintosh 
absent.  If  there  were  no  mackintosh,  the  discharge,  always  passing  through  one  part, 
would  wash  out  all  the  antiseptic  in  a  very  short  time,  and  putrefaction  would  rapidly 
occur.  To  avoid  this  risk  a  large  quantity  of  gauze  would  be  necessary,  and  this  would 
increase  the  expense  of  the  treatment  very  much  ;  whereas  by  the  use  of  the  mackintosh 
the  discharge  is  made  to  pass  from  the  centre  to  the  edge  of  the  dressing — that  is, 
through  a  mass  of  gauze  equal  in  thickness  to  the  distance  from  the  centre  to  the  edge 
of  the  dressing.  The  same  piece  of  mackintosh  may  be  used  several  times — till,  in  fact, 
it  wears  out.  After  the  dressing  has  been  removed  it  is  taken  out.  sponged  with  carbolic 
lotion,  and  introduced  into  the  new  dressing.  Thus,  though  an  expensive  material,  when 
divided  over  a  number  of  dressings,  its  expense  becomes  very  little.  Expense  is  also 
saved  by   preserving  the  large  pieces  of   gauze  used  in   the  dressings.     They  may  be 

1  Lancd,  April  3,  1869.  *  Ibid.,  February  5,  1881. 


56  SUBCUTANEOUS   WOUNDS. 

washed  and  recharged  with  the  carbolic-acid  mixture.  These  dressings  should  be  large, 
and  should  overlap  the  wound  for  a  considerable  distance  in  every  direction. 

''  The  dressing  is  ftistened  on  by  a  bandage.  This  may  be  made  of  carbolic  gauze, 
which  is  light,  cheap,  and  u.seful  in  many  ways.  But  a  cheaper  bandage,  and  one  suiB- 
ciently  convenient — indeed,  more  convenient  than  the  carbolic-gauze  bandage  in  many 
ways — may  be  made  of  thin  muslin.  As  the  dressing  may  not  remain  closely  applied  to 
the  skin  during  all  the  movements  of  the  ])atient,  more  especially  in  the  necii,  chest,  or 
groins,  there  is  a  certain  risk  that  air  unacted  on  by  the  antiseptic  may  pass  under  the 
dressing  and  reach  the  woimd,  carrying  active  septic  dust  along  with  it.  This  danger  is 
obviated  by  applying  an  elastic  bandage  along  the  edge  of  the  dressing.  This  may  be 
put  sufficiently  on  the  stretch  to  keep  the  edge  of  the  dressing  accurately  in  contact  with 
the  skin  without  pressing  injuriously  or  interfering  with  the  circulation  in  the  part. 
Pins  are  put  in  along  the  edge  of  the  dressing,  fastening  the  dressing  and  the  bandages 
together  at  the  important  points.  Safety-pins  are  the  best  for  the  purpose,  as  common 
pins  are  apt  to  get  buried  and  lost  in  the  gauze." 

In  accidental  wounds,  to  extirpate  the  germs,  the  wound  should  be  washed  in  and  out 
with  the  1-20  carbolic  lotion,  a  syringe  being  employed  in  a  case  of  compound  fracture 
or  gunshot  wound.  "  Care  must  be  taken  to  have  the  external  wound  freely  open,  so 
that  the  injected  fluid  may  escape  readily ;  for  otherwise  there  would  be  a  danger  of  the 
fluid  penetrating  among  the  layers  of  the  cellular  tissue  and  causing  inflammation,  or 
even  gangrene.     It  is  well  to  squeeze  out  all  the  blood  clots." 

During  an  operation  the  surgeon  should  have  .spread  near  him  towels  saturated  with 
the  1-20  carbolic  lotion,  upon  which  to  place  all  instruments  he  may  be  using;  a  basin, 
containing  the  1-40  solution,  should  likewise  be  at  hand  to  enable  the  surgeon  to  purify 
his  hands  and  instruments  should  they  have  been  contaminated  with  septic  dust.  All 
instruments  and  sponges  should  be  handed  through  the  carbolic  spray. 

The  surijeon  should  know,  however,  for  his  comfort,  "that  there  are  comparatively  few 
particles  capable  of  causing  fermentation  in  ordinary  air,"  that  '•  where  no  spray  is  at 
hand  the  aseptic  method  may  still  be  carried  out,  and  that  the  spra}'  is  the  least  essential 
part  of  the  method  as  at  present  emploj'ed.  The  most  essential  part  of  the  treatment  is 
the  thorough  purification  of  everything  which  comes  in  contact  with  the  wound.  The 
introduction  of  an  unpurified  instrument  into  a  wound  is  a  much  worse  error,  and  one 
far  more  likely  to  be  followed  by  bad  results,  than  the  momentary  deflection  or  cessation 
of  the  spray." 

"  The  dressing  is  always  changed  on  the  day  following  the  operation,  and  afterward 
the  rule  is  that,  if  at  the  hour  of  the  ordinary  visit  discharge  is  found  at  the  edge  of  the 
dressing,  it  is  changed ;  if  not,  it  is  left  till  the  next  day,  when  the  same  rule  is  followed. 
The  dres.sing  is  never  left  longer  than  a  week  unchanged.  In  changing  the  dressings  the 
spray  is  used." 

If  the  surgeon  does  not  have  a  spray  at  hand  for  the  purpose  of  changing  the 
dressings,  and  it  is  necessary  to  expose  the  wound,  it  is  pleasant  to  be  told  "  that  it 
is  well,  by  means  of  a  syringe,  to  let  a  current  of  carbolic  lotion  flow  over  it  when  it  is 
exposed." 

In  fact,  it  may  now  be  said  that  the  Listerian  mode  of  dressing  has  had  its  day, 
though  the  principle  upon  which  it  is  based  survives,  and  is  likely  to  do  so.  The  anti- 
septic irrigation  of  wounds,  as  considered  in  the  previous  section,  is  simpler  and  equally 
effectual. 

Subcutaneous  Wounds. 

When  John  Hunter,  in  1704,  in  describing  injuries,  divided  them  into  those  in  which 
the  injured  parts  do  not  communicate  externally,  as  sprains,  bruises,  simple  fractures  of 
bones,  or  divisions  of  tendons,  and  those  which  have  an  external  communication,  as  com- 
pound fractures  and  wounds  of  all  kinds,  and  laid  it  down  as  a  law  that  the  injuries  of 
the  first  class  seldom  inflame,  whilst  those  of  the  second  commonly  both  inflame  and  sup- 
purate, he  established  a  principle  of  which,  "indeed,  it  seems  hardly  possible  to  exaggerate 
the  importance  "  (Paget),  and  laid  the  foundation  of  a  branch  of  surgical  practice  now 
known  as  uMbcufaneons  sniyfny.  Why  it  is  that  extensive  injuries  to  soft  parts,  when 
covered  with  skin,  should  undergo  quiet  and  thorough  repair  with  little  or  no  constitu- 
tional disturbance  may  not  be  clear,  but  daily  experience  teaches  us  that  dislocations  of 
large  joints,  fractures  of  bones,  severe  contusions  and  lacerations  of  soft  parts  associated 
with  copious  local  haamorrhages,  and  even  cru.shes  of  all  the  subcutaneous  tissues  of  a 
foot  or  hand,  as  a  rule,  do  well  provided  that  they  are  not  interfered  with  by  meddle- 


SUBCUTANEOUS    WOUNDS.  57 

xiiiH'  jtnict ice.  hut  arc  [ilacnl  in  tlir  iiiusi  I'.ivor.ilili!  |ni>itiori  I'nr  natural  rc|)air  tu  carry 
(lilt  its  silent  work  ;  wlicrcas  the  same  cxiicricncc  tells  lis  witli  no  uncertain  voice  that 
the  presence  nt"  a  wound,  however  small,  may  chanj^e  matters  all  round  and  turn  an 
injury  which,  had  it  heeii  siihciitaiicous,  mij^ht  have  hecn  n!<;arded  as  trivial  into  one  of 
a  serious  and  coni]ilicated  kind.  This  I'act  is  widl  exemplilicd  in  the  difi'ereiit  course 
asuallv   taken   hy   a  simple  and   a  compound   dislocation   or  fracture. 

What  there  is  in  tin-  air  that  makes  this  with'  difVereiice  is  now,  as  it  ev<?r  has  heen, 
open  to  ari;umcnt  ;  and  whether  it  is  tht!  stimiilatinir  or  (diemical  influence  of  the  oxyj^en, 
the  irritating-  influence  of  atuKtspheric;  jfernis,  the  len<;th  ol"  time  the  part  is  exposed 
rather  than  the  mere  I'act  of  exposure,  or  some  other  cause,  may  be  subject  of  dispute. 
In  modern  times  the  <;erm  theory  has  found  much  favor  and  has  been  the  fashic>n,  and 
attempts  have  heen  made  to  assign  to  the  presence  of  germs  every  evil  influence,  and  tw 
regard  tluMii  as  the  cause  of  inflamniation  and  suppuration  in  every  o|»cn  wound.  Hut 
this  view  can  hardly  be  sustained;  Inr,  on  the  one  hand,  even  in  subcutaneous  injuries, 
in  which  no  air  can  get  in,  inflammation  and  suppuration  may  ensue,  while,  on  the  other 
hand,  in  even  severe  examples  of  fractured  ribs  complicated  with  (Miiphysema  over  the 
chest,  l>ody,  head,  and  extremities — in  ca.ses  in  which  the  wholt;  cellular  tissue  of  the 
body  seems  infiltrated  with  unfiltered  air  under  mo.st  unfavorable  circumstances — it  is 
(|uite  exceptional  lor  any  inflammation  of  the  infiltrated  parts  to  take  place,  [ndeed,  I 
may  say  that  I  have  never  seen  an  instance  in  which  it  occurred. 

Effects  of  Injection  of  Air  into  Tissues. — As  corroborative  evidence  I  may 
refer  to  some  observations  made  in  1S.")7  by  .Malgaigne,  who,  to  test  this  f|uestion,  made 
animals  emphysematous  with  common  unfiltered  air  and  then  fractured  their  bones, 
divided  their  tendons,  and  opened  their  joints  subcntancoutili/ :  though  the  parts  operated 
upon  were  surrounded  with  air  no  inflammation  followed.  I  may  refer  also  to  the  experi- 
ments of  Wegner  (^Lan;/eiiback^6  Archives,  vol.  xx.),  who  injected  air  derived  from  the 
post-mortem  room  into  the  subcutaneous  tissue  of  rabbits  with  impunity. 

For  my  own  part,  I  am  disposed  to  think  it  is  not  the  mere  exposure  of  a  wounded 
part  ttj  the  influence  of  air  that  does  the  harm,  but  its  prolonged  exposure,  since  it  is 
certain  that  where  wounds  are  sealed  rapidly  after  the  receipt  of  an  injury,  and  are  thus 
placed  much  in  the  position  of  subcutaneous  injuries,  repair  goes  on  silently  and  well. 
Even  bad  compound  fractures,  when  sealed  early  i'rom  the  influence  of  air,  heal,  as  a  rule, 
like  subcutaneous  injuries. 

Repair  of  Subcutaneous  Wounds. — Tt  may  be  accepted  as  a  truth  that  sub- 
cutaneous Wounds  art^  repaired  much  in  the  same  way  as  open  wounds  that  heal  by 
quick  or  primary  union — that  is,  when  the  wounded  hard  or  soft  tissues  are  brought  or 
kept  in  contact,  they  simply  reunite.  The  process  of  repair  in  both  cases  is  a  quiet 
physiological  one  not  unlike  that  of  development  and  growth.  The  action  that  attends 
the  process  is  just  enough  to  bring  about  the  required  result,  but  no  more.  AVhen  it  is 
excessive,  inflammation  is  said  to  exist;  and  this  inflammation,  in  subcutaneous  as  in 
open  wounds,  always  ])revents,  checks,  arrests,  or  undoes  the  work  of  repair.  In  truth, 
the  less  there  is  of  inflammation  in  a  wounded  part,  subcutaneous  or  open,  the  more  per- 
fect and  steady  is  the  reparative  process.  When  inflamniation  takes  place  in  the  site  of 
some  subcutaneous  operation,  the  process  of  repair  is  likely  to  be  interfered  with,  if  not 
arrested  ;  for,  as  Paget  observes,  "the  more  manifest  are  the  signs  of  inflammation,  the 
less  is  the  (juantity  of  theproper  reparative  material,  and  the  slower,  in  the  end,  is  the 
process  of  repair." 

To  Paget  and  W.  Adams  in  England  we  are  chiefly  indebted  for  our  knowledge  of 
this  subject,  and  I  shall  use  as  much  as  possible  Adamss  description  of  this  process,  as 
published  in  1800  in  his  work  on  the  Reparative  Process  of  Human  Tendons  after  Divis- 
ion. His  investigations  have  confirmed  those  of  Paget,  as  well  as  added  to  our  stock  of 
knowledge. 

Where  tendons  are  subcutaueously  divided  and  drawn  asunder,  their  repair  takes 
place  as  follows : 

When  such  a  tendon  as  the  tendo  Achillis  is  divided  subcutaueously,  the  divided 
ends  separate,  in  an  infant  for  half  an  inch  and  in  an  adult  from  one  to  two  inches,  the 
degree  depending  much  upon  the  healthy  condition  of  the  divided  muscle  and  the  amount 
of  movement  subsequently  permitted  in  the  ankle-joint. 

The  reparative  process  begins  by  increased  vascularity  in  the  sheath  of  the  tendon, 
which  is  followed  by  the  infiltration  of  a  blastematous  material  into  the  spaces  between 
the  fibrous  elements  of  the  sheath.  This  nuiterial  exhi))its  the  development  of  innumer- 
able small  nuclei,  a  few  cells  of  large  size  and  irregular  form,  with  granular  contents,  or, 


58  TREATMEyr  OF  SUBCUTAyEOl'S    wouyDS. 

perhaps,  with  one  or  more  nuclei  and  studded  with  minute  molecules  of  oil.  A  blastema- 
tous  material  in  which  the  cell  form.s  do  not  develop  beyond  the  stage  of  nuclei  appears 
to  be  the  proper  reparative  material  from  which  new  tendon  is  developed.  This  nucleated 
blastema  soon  becomes  vascular,  capillary  vessels  havinir  been  seen  in  it  on  the  eighteenth 
day  ;  the  nuclei  assume  an  elongated,  spindle-,  or  oat-shaped  form,  and  are  seen,  after  the 
addition  of  acetic  acid,  to  be  arranged  in  parallel  linear  series.  The  tissue  becomes  grad- 
ually more  fibrillated.  and  at  last  fibrous,  a  solid  bond  of  union  subsef|uently  forming 
between  the  divided  extremities  of  the  tendon.  The  uniting  medium  is  tough  to  the 
touch,  but  to  the  eye  presents,  even  for  at  least  three  years,  a  grayish,  translucent  appear- 
ance, distinguishing  it  at  once  from  the  glistening  old  tendon.  This  new  tissue  remains 
during  life,  and  has  little  tendency  to  contract  subsequently.  Adams's  observations 
rather  led  him  to  the  conclu.sion  that  the  required  portion  of  new  tendon  is  to  be  obtained 
during  a  lengthened  period  of  formation — that  is,  about  two  to  three  weeks — under  the 
ordinary  conditions  of  health  ;  but  in  paralytic  cases,  as  in  others  of  feeble  health,  this 
period  may  be  doubled. 

Adams  informs  us,  also,  that  the  divided  extremities  of  the  old  tendon  take  no  active 
part  in  the  reparative  process  during  its  earlier  stages,  although  at  the  later  the  cut  ends 
become  rounded  and  their  structure  softened.  They  become  enlarged  and  exhibit  a  tend- 
ency to  split,  and  thin  streaks  of  new  material  similar  to  that  already  described  are  seen 
between  their  fibres;  the  ends  are  joined  by  these  means.  At  a  later  period  the  bulbous 
enlargement  gradually  diminishes. 

When  a  tendon  is  divided  a  second  time,  there  is  but  little  separation  of  its  ends  ; 
and  this  is  probably  due  to  adhesion  of  the  new  tendon  to  the  neighboring  fibro-cellular 
tissue,  in  which  fact  is  found  an  explanation  of  the  unsatisfactory  results  of  second 
operations. 

There  is  no  reason  for  believing  that  in  the  treatment  of  deformities  by  tenotomy 
direct  approximation  and  reunion  of  the  divided  extremities  of  the  tendon  must  first  be 
obtained,  and  that  the  required  elongation  is  afterward  to  be  procured  by  gradual 
mechanical  extension  of  the  new  connecting  medium,  as  we  would  stretch  a  piece  of 
india-rubber. 

When  much  blood  is  effused  between  the  divided  ends  of  the  tendon,  it  has  to  be 
absorbed  ;  it  acts  merely  as  a  foreign  body  in  the  part,  and  retards  repair. 

Treatment  of  Subcutaneous  Wounds. 

When  rightly  treated,  these  wounds  are  generally  repaired  readily,  and.  as  Hunter 
asserted,  without  inflammation  ;  but  when  not  rightly  treated.  "  the  subcutaneous  action 
of  a  wound  is  not  of  itself  a  sufficient  protection  against  inflammatory  complications,  and 
a  clumsily-performed  subcutaneous  operation  may  be  as  dangerous  as  an  open  wound — 
sometimes  even  more  so'  (W.  Adams). 

In  the  treatment  of  these  as  of  open  wounds  there  are.  consequently,  essential  points 
of  practice  to  be  ob.served  in  order  that  good  results  may  be  obtained,  and  they  are  not 
unlike  those  which  have  been  laid  down  for  the  treatment  of  open  wounds — that  is  to  say, 
the  injured  parts  are  to  be  placed  as  far  as  possible  in  a  position  of  ea.se,  and  in  which  the 
contact  of  the  divided  tissues  is  assured  when  contact  is  called  for.  The  parts  are,  moreover, 
to  be  fixed,  by  splints,  bandages,  or  other  dressings,  in  a  condition  of  absolute  immobility. 
The  seat  of  injury  is  to  be  protected  from  all  outside  injurious  influences  and  to  be  sup- 
ported by  moderate  pressure,  and.  what  is  more,  is  to  be  undisturbed,  in  order  that  neither 
by  manipulation  nor  movement  shall  repair  be  retarded;  for  a  subcutaneous  wound  is  as 
susceptible  to  injury  from  mechanical  interference  as  is  an  open  wound.  In  treating  the 
wounds  made  by  the  operations  of  subcutaneous  surgery  the  same  principles  of  practice 
are  applicable,  and  they  are  well  summed  up  by  Adams  as  follows : 

The  conditions  requisite  to  render  the  subcutaneous  operations  exempt  from  inflam- 
mation are  as  follows:  1.  That  the  knife  used  must  be  of  small  size;  2.  That  the  oper- 
ation must  be  performed  quickly  and  readily,  with  decision  rather  than  force,  and  with  as 
little  disturbance  to  the  soft  parts  as  possible  ;  3.  That  the  wound  must  be  immediately 
clo.sed  and  a  compress  and  bandage  applied,  so  as  to  prevent  eff'usion  and  to  support  the 
part ;  4.  That  perfect  (juiescence  to  the  part  be  ensured  for  three  or  four  days,  and  the 
dressing  remain  undisturbed.  When  all  these  conditions  are  strictly  observed,  it  matters 
little  whether  large  muscles  or  tendons  or  ligaments  are  divided,  or  even  whether  the 
larger  joints  of  the  body  are  opened.  From  all  this  it  is  to  be  gathered  that  to  the  treat- 
ment  of  subcutaneous  wounds,   whether  of  accidental  or  operative  origin,  ••  position," 


VUMl'l.lCATloSS  (,F    worsDs.  59 

•  iiiiiiiohility.  '  "  pressure  "  to  sii|i|Miit    the   |i:irt,  and  "  time  '  for  repair  to   perfeet   itself, 
are  tiie  four  essential  re(|uisite>  In  In-  provided  for. 

Complications  of  Wounds. 

On  the  well-l'ounded  assiiuiplioii  that  a  wound,  wlien  made  int<»  healthy  tissue.s  in 
a  hi'althy  suhjeet.  will  heal  hy  natural  proees.ses  if  jdaeed  in  tlu;  luost  favorable  position 
for  ri'pair  aiul  //o/  interjirnl  uit/i,  it  cannot  well  he  disputed,  when  a  wound  doe.s  not  lieul 
thus  kindly,  that  there  must  be  some  ob.staele  or  hindrance  to  its  natural  progress  ;  and 
this  will  doubtless  be  i'ouiul  either  in  the  nature  oi"  the  wound  it.self,  or  the  mode  in 
which  it  has  been  treated,  or  in  the  peculiarities  of  the  subject  of  the  wound,  rir  the  sur- 
rouudinirs  of  the  case. 

When  the  hindrance  is  due  to  the  "  uohik/  ifsc//"'  or  to  it.s  ''  /rctUmcnf,"  it  may  be 
that  some  foreiLMi  body  has  been  left  to  irritate;  that  the  h;c'morrha];re  which  ensued 
"  primarily  "'  on  its  receipt  has  not  been  effectually  arrested,  and  that  a  clot  has  formed 
between  the  edjres  of  the  wound;  that  a  •'recurring"  bleedin/z  has  taken  place  within 
a  day  or  so  after  the  intliction  of  the  wound  and  its  first  dressing  from  srune  inifierfection 
in  the  treatment  of  the  bleedinj:  vessel  ftr  from  excessive  reaction  ;  or  that  a  collection 
of  serum  has  been  allowed  to  form  in  the  depths  of  the  injured  tissues.  In  most  of 
these  ea.ses  the  causes  of  non-repair  are  clearly  referable  to  a  want  of  care  or  skill  on  the 
part  of  the  surgeon  who  has  had  the  early  treatment  of  the  case,  and  must  be  set  down 
as  jtreventable  causes.  By  want  of  care  the  edges  of  the  wound  may  not  have  been 
properly  adjusted  or  kept  in  apposition,  the  injured  limb  may  not  have  been  made 
immobile,  and  as  a  result  spasmodic  muscular  movements  and  jumpings  of  the  limb  may 
have  been  excited  ;  or  an  insufficient  provision  may  have  been  made  for  drainage,  and.  as 
a  consef{uence.  tlie  wound  may  have  been  irritated  by  retained  secretions,  and  po.ssibly 
made  to  inflame  by  the  "  teiision  "  which  the  retained  secretions  have  produced.  Harm 
may  also  have  been  brought  about  by  the  want  of  due  attention  to  the  dressing  of  the 
wound,  and  to  its  efficient  protection  from  outside  injurious  influences.  Other  cause  of 
non-repair  may  be  the  unsuitable  character  of  the  dressing  u.sed  or  the  position  in  which 
the  wound  has  been  placed. 

When  the  obstacle  to  natural  repair  exists  in  the  ^^  suhjrcf  of  the  womur'  or  in  the 
surroundings  of  the  case,  it  may  perhaps  be  found  in  the  age,  temperament,  or  feebleness 
of  the  patient,  as  expressed  by  deficiency  in  the  healing  act,  excess  of  pain,  or  inflamma- 
tion of  the  wounded  parts,  or,  again,  in  the  unhealthy  atmospheric  condition  of  the 
patient's  chamber  or  residence,  or  in  the  unsuitable  character  of  the  patient's  food,  or 
in  want  of  proper  nursing.  Under  any  circumstances,  the  ob.stacle  to  repair  will  be 
found  in  one  or  more  of  these  causes,  and  it  is  for  the  watchful  eye  of  the  surgeon  to 
discover  the  particular  defect,  in  order  that  he  may  apply  the  proper  remedy. 

It  is  well,  however,  for  the  student  to  recognize  the  fact  that  most  of  the  causes  of 
want  of  repair  are  preventable,  and  that  they  are,  as  a  rule,  due  to  some  want  of  care  in 
the  primary  dressing  of  the  wound  ;  let  it  be  repeated,  therefore,  that  in  all  cases  and 
under  all  circumstances  too  much  care  cannot  be  bestowed  upon  the  management  of  fresh 
or  recent  wounds  to  carry  out  the  essential  points  of  treatment  to  which  attention  has 
been  so  often  drawn. 

Consecutive  Haemorrhage. — This  form  of  bleeding  is  that  which  takes  place 
within  twenty-four  or  forty-eight  hours  after  the  reception  of  the  wound.  When  it 
occurs,  it  is  of  little  consequence  whether  it  is  to  be  attributed  to  some  imperfection  of 
the  means  employed  to  check  the  primary  haemorrhage,  or  to  the  reopening,  during  the 
period  of  reaction,  of  a  vessel  which  had  been  temporarily  sealed  by  a  clot  at  an  earlier 
period  of  the  case.  It  has  to  be  dealt  with,  and  with  decision.  When  trifling  in  amount, 
it  need  not  be  regarded  with  anxiety,  and  more  particularly  when  there  is  room  for  the 
blood  to  escape  through  the  drainage-opening  or  tube,  although  even  then  it  will  be  well 
for  the  surgeon  to  see  that  the  wounded  part  is  elevated  and  watched.  If  the  bleeding 
vessel  be  a  small  or  cutaneous  one.  these  means  will  probably  be  enough  ;  if.  however, 
the  bleeding  is  persistent,  or  if  the  parts  about  the  wound  swell  and  become  tense  and 
painful,  and  more  particularly  if  pallor  of  the  .skin,  feebleness  of  pulse,  restlessness,  and 
other  signs  of  collapse  furnish  definite  signs  and  symptoms  of  loss  of  blood,  the  wound 
must  be  opened,  the  clots  turned  out.  the  source  of  the  bleeding  looked  for.  and  the  vessel 
secured. 

At  times  the  mere  opening  and  exposure  of  the  wound  will  arrest  bleeding,  and  under 
these  circumstances,  when  the  bleeding  vessel  cannot  be  found,  it  is  well  to  have  the 


60  COMPLICATIONS  OF   WOUNDS. 

parts  exposed  for  a  few  hours,  and  eitlier  to  bring  them  together  again  when  they  have 
glazed  and  when  most  chances  of  bleeding  have  passed,  or  to  leave  them  open  to  granu- 
late. The  wound  should,  however,  be  left  open  under  only  exceptional  circumstances — 
when  the  hope  of  quick  union  is  very  small  or  when  such  union  is  undesirable. 

When  tlie  bleeding  vessel  has  been  found,  it  is  to  be  secured,  and  the  wound  treated 
as  a  fresh  one  and  reclosed.  At  times,  where  oozing  of  blood  is  persistent,  moderate 
pressure  upon  a  wound  does  much  good,  and  this  may  be  well  applied  by  means  of  an 
ordinary  or  a  rubber  bandage  over  a  sponge  or  elastic  antiseptic  pad.  Care  must  be 
taken,  however,  that  the  pressure  be  not  too  great. 

Secondary  Hsemorrhage. — This  is  the  form  of  bleeding  which  occurs  after 
the  lapse  of  two  or  three  days.  It  may  occasionally  be  due  to  the  existence  of  the 
hjxjmorrhage  diathesis,  but  is  more  commonly  owing  to  some  ulceration  of  the  vessel  in 
the  line  of  ligation  before  the  vessel  itself  has  been  closed  by  natural  processes,  or  to 
some  sloughing  of  the  end  of  the  divided  artery  or  vein,  with  or  without  sloughing  of  the 
wound  itself;  to  some  imperfection  in  the  means  employed  for  the  arrest  of  the  primary 
bleeding,  or  to  the  accidental  separation  of  a  ligature.  When  it  takes  place  in  a  wound 
that  appears  to  be  healthy,  and  in  which  the  reparative  process  seems  to  have  progressed 
in  a  satisfactory  manner,  the  h;emorrhage  will  probably  be  found  to  have  come  from  a 
vessel  that  has  been  imperfectly  secured  or  the  end  of  which  has  been  irreparably  injured, 
and  under  these  circumstances,  if  the  bleeding  be  profuse  and  evidently  from  a  large 
artery,  the  wound  must  be  reopened  and  the  bleeding  orifice  sought  for  and  dealt  with  as 
in  the  original  wound.  But  if,  on  the  other  hand,  the  bleeding  is  not  severe  and  the 
probabilities  of  the  case  are  that  the  vessel  is  not  large,  the  injured  limb  should  be  raised 
and  moderate  pressure  applied  ;  for  by  such  means  there  will  be  a  good  prospect  of  a 
successful  issue  being  obtained.  Should  a  recurrence  of  the  bleeding,  however,  occur, 
and  the  effects  of  loss  of  blood  show  themselves,  the  wound  must  be  reopened  and  the 
bleeding  vessel  secured.  When  the  bleeding  comes  from  a  vessel  which,  with  the  sur- 
rounding tissues,  has  sloughed,  it  is  a  better  practice  to  secure  the  vessel  at  a  distance  from 
the  wound.  When,  however,  the  bleeding  takes  place  in  a  case  in  which  an  artery  has 
been  tvcl  In  its  contuiuiff/,  the  surgeon  should  delay  reopening  the  wound,  unless  the  evi- 
dence be  strong  that  the  blood  comes  from  the  supplying  or  afferent  trunk,  since  experi- 
ence has  fairly  taught  us  that  in  a  large  number  of  these  cases  the  blood  comes  from  the 
lower  or  distal  orifice  of  the  ligatured  vessel,  and  that  under  such  circumstances  it  may 
be  readily  arrested  by  the  elevation  of  the  limb  and  well-applied  pressure.  In  all  cases, 
however,  when  the  bleeding  is  recurrent  and  persistent,  the  wounded  vessel  should  be 
looked  for  and  secured  either  at  the  seat  of  bleeding  or,  when  this  is  either  diificult  or 
dangerous,  at  a  higher  point. 

Pain. — There  is  no  effect  of  wound  or  operation  which  varies  more  in  degree  than 
pain.  In  one  case  the  subject  of  a  simple  wound  will  suffer  much  pain,  while  another 
individual  with  a  severe  wound  will  experience  but  little.  Persons  vary  greatly  in  regard 
to  nervous  susceptibility;  nevertheless,  pain  is  under  all  circumstances  a  serious  symptom 
and  a  grave  evil,  for  it  tends  to  depress  the  moral  and  physical  forces  of  the  strongest 
patient,  and  to  exhaust  even  to  death  the  feeble  powers  of  the  fragile.  I  am  convinced 
that  I  have  known  pain  to  kill. 

In  all  wounds,  therefore,  operative  or  otherwise,  it  is  important  that  pain  should  be 
guarded  against ;  and  for  this  object  surgeons  can  do  much  by  care  and  forethought. 
The  wounded  parts  should  be  rendered  immobile,  well  protected,  and  so  placed  as  to  give 
rise  to  the  least  inconvenience  or  distress.  The  dressings,  likewise,  should  be  so  regulated 
as  to  give  comfort.  In  most  wounds,  and  after  most  operations,  some  pain  will  be  neces- 
sarily experienced,  but  as  a  general  rule  it  will  subside  in  the  course  of  one  or  two  hours. 
To  relieve  this  symptom,  however,  it  is  well  to  give  opium  in  some  of  its  forms;  and  for 
this  purpose,  after  an  operation  in  which  an  auEesthetic  has  been  used,  it  is  an  excellent 
plan  to  introduce  into  the  rectum,  before  the  'patient  becomes  conscious,  a  suppository 
containing  from  one-third  to  one-half  a  grain  of  morphia.  The  anodyne  begins  to  exer- 
cise its  calming  influence  before  the  effects  of  the  anaesthetic  have  quite  passed  off,  and 
in  some  instances  the  action  of  the  two  drugs  appears  to  be  continuous.  In  other  cases 
the  subcutaneous  injection  of  a  ><}naU  dose  of  morphia  may  be  resorted  to,  or  a  full  dose 
of  the  same  drug  may  be  given  by  the  mouth.  Under  all  circumstances,  the  early  pain 
after  a  wound  or  operation  is  to  be  subdued. 

Causes  of  Persistent  Pain. — When  the  pain  is  persistent  and  continuous  after 
the  healing  process  has  progressed  or  perfected  itself,  some  nerve  complication  may  be 
suspected."    It  nnxy  be  that  some  nerve  branch  has  been  included  in  the  ligature  placed 


DEFECTS  IS  HE  A  Lisa   PROCESS.  61 

arouixl  a  vi-ssrl,  <»r  some  iitrv»-  trunk  may  Ix-  >•)  iiiv<»lv<(l  in  tlie  cicatrix  of"  tlu-  wound  or 
so  liountl  to  l)one  or  fascia  as  to  be  kept  continually  irritated  or  even  inflamed,  or  it  may 
be  tliat  no  definite  cause  for  the  pain  can  lie  made  out.  when  the  case,  for  want  of  better 
knowK'dtre.  is  ret:arded  as  neuraifric. 

When  the  cause  of  the  pain  can  be  dfttrmitn'd,  tliis  shouhl  lie  removed  ;  and  whi-n  no 
cause  can  be  ascertained,  the  sur^'con  may  be  justified  in  cuttin<:  down  on  the  affected  nerve 
and  stretchinir  it  or  in  subcutaneously  dividinj;  it,  as  su<r<;ested  by  Ilaticock.  As  constitu- 
tional n-medii's  narcotics  may  f»e  given,  with  tonics  such  as  <|uinine,  iron,  or  arsenic. 

Muscular  Spasms. — The  muscuhir  spasm.s  or  twitchings  which  foUow  wo\inds, 
and  iiion  particularlv  amputations,  can  <renerally  be  prevented  by  the  careful  apidication 
\j\'  splints  aiul  well-ilirected  jiressure.  They  should  be  put  down  as  preventable  sources 
of  distress,  and  should  be  guarded  against  in  tlie  early  dressing  of  the  ca.se.  Well- 
adjusted  pressure,  with  rest  of  the  injured  part,  is  the  one  thing  to  be  relied  upon  to 
jirevent  and  relieve  this  .symptom,  and  it  rarely  fails.  The  judicious  use  of  narcotics 
should,  at   the  same  time,  not  be  neglected. 

Defects  in  the  Healing  Process  and  Diseases  of  Granulation. 

Defects  in  the  healing  process  may  show  themselves  in  either  " dijicifury''  or  '^•excesa'' 
of  action,  or  in  some  morliid  state  of  the  granulating  wound. 

Deficiency  of  Action. — In  the  old  and  in  the  very  feeble,  whether  from  di.sease 
or  otherwise,  deficiency  in  the  reparative  power  is  to  be  expected,  since  for  repair  a  bal- 
ance of  reserve  force  at  the  Vjank  of  health  is  requisite,  and  where  such  a  balance  is 
absent  the  extra  force  required  for  healing  will  be  deficient.  Wounds  in  subjects  such 
as  these,  consequently,  simply  fail  to  heal,  or  heal  slowly  or  in  the  worst  way,  their  fail- 
ure resulting  from  a  want  of  either  the  right  quantity  or  the  right  kind  of  nutritive 
supply  and  nerve  force.  In  wounds  in  which  quick  union  is  aimed  at  the  parts  which 
have  been  brought  together  will  simply  not  unite,  and  they  will  remain  together  only  as 
long  as  they  are  held  in  position  by  the  mechanical  means  emnloyed  for  the  purpose. 

In  the  young  and  in  the  middle-aged  the  same  failure  in  repair  is  likewise  at  times 
seen  in  cases  of  hare-lip  or  other  plastic  operations  in  which  quick  union  is  needed  for 
success;  the  parts  do  not  unite  by  primary  adhesion,  but  gape  and  granulate,  and  the 
operations  consequently  fail.  In  such  patients,  also,  fractures  sometimes  fail  to  unite  as 
they  ought,  or  unite  but  slowly  :  and  this  ma}'  be  the  case  even  when  no  definite  cause  for 
the  deficiency  in  the  reparative  process  can  be  detected.  In  all  such  in.stances,  however, 
there  is  want  of  power  from  some  general  or  local  caii.se,  which  must  be  detected  before 
treatment  can  be  rationally  or  successfully  applied. 

In  wounds  in  which  union  by  primary  adhesion  is  looked  for.  the  failure  ma}-  be 
partial  or  complete.  When  it  is  complftf.,  the  wound  must  be  regarded  and  treated  as  an 
open  one  ;  and  under  these  circumstances  the  sutures  should  be  removed  and  the  surface 
clean.sed  and  kept  clean,  and  then  stimulated  by  some  dressing,  such  as  carbolized  oil  1 
to  -io.  terebene  and  oil  1  to  -i.  boracic  acid  lotion  1  to  lU.  or  boracic  acid  ointment  1  to  5  ; 
or  chloral  or  chlorate  of  potassium  lotion  10  grains  to  the  ounce.  At  the  same  time,  the 
wounded  part  should  be  placed  in  the  most  comfortable  position,  and  in  that  which  will 
be  mo.st  favorable  for  the  process  of  repair.  The  constitutional  treatment  .should  like- 
wise be  of  a  tonic  and  stimulating  character,  with  good,  abundant,  though  simple,  food, 
and  with  wine  or  spirits  in  sufficient  quantity  to  aid  digestion  and  to  enable  the  feeble 
heart  to  send  its  contents  to  the  nerve  centres,  to  give  them  force,  and  to  the  digestive 
apparatus,  to  enable  it  to  utilize  the  food  and  pass  on  waste  matter.  The  patient  at  the 
same  time  should  be  placed  in  the  best  hyLnoiiic  surroundiiiLrs. 

Treatment  when  Partial  Union  has  taken  Place. — When,  however,  the 

failure  in  primary  adhesion  is  not  complete,  but  j»irfinl.  and  when  there  is  the  .smallest 
foundation  for  the  hope  that  by  keeping  the  parts  together  the  required  repair  may  yet  be 
secured,  the  sutures  should  be  left  in  position,  the  wound  cleansed  with  some  medicated 
anti.septic  lotion,  and,  if  necessary,  either  another  suture  introduced  or  some  other  means 
employed  to  bring  and  to  keep  the  parts  well  together.  Even  should  failure  follow  the 
attempt  to  gain  primary  adhesion,  success  may  crown  an  effort  made  to  secure  secondary 
adhesion  of  the  granulatings  surfaces  or  union  by  the  third  intention. 

AVhere  the  cause  of  non-union  is  local  and  only  temporary,  these  measures  will  often 
succeed,  and  will  turn  what  seemed  to  be  a  failure  into  a  satisfactory  result.  In  hare-lip. 
and  in  mo.st  plastic  operations,  a  rigid  adherence  to  this  surgery  of  hope  and  discretion 
is  to  be  highly  commended. 


62  DEFECTS  IN  HEALING   PROCESS. 

Defects  in  the  Healing  Process  from  Excess  of  Action  or  Inflamma- 
tion.— Wluiii  excess  of  action  takes  place  in  a  wound  in  which  repair  by  primary  adhe- 
.sion  is  looked  for,  disappointment,  in  all  probability,  will  be  the  result  ;  for  whenever 
there  is  in  a  wounded  part  more  vascular  action  than  is  required  for  the  reparative  pro- 
cess to  perfect  its  work,  repair  is  first  interfered  with,  then  stopped,  and  finally  the 
wound,  when  not  held  toircther  mechanically  by  sutures,  strappinji,  or  bandages,  gapes  or 
opens. 

When  excess  of  action  or  inflammation  attacks  an  open,  wound  that  is  granulating 
and  cicatrizing,  repair  likewise  ceases;  the  granulations,  instead  of  presenting  a  healthy, 
florid  appearance  and  secreting  a  bland,  creamy  ])us,  become  oedematous  or  glazed,  what 
has  been  a  granulating  becomes  an  ulcerating  surface,  and  the  secretion  from  the  wound 
changes  from  pus  to  a  thin  serous  discharge,  with  more  or  less  dehru  of  tissue.  The 
thin  red  marginal  line,  with  its  cicatrizing  edge  extending  on  to  the  granulating  surface, 
presents  a  more  or  less  extended  area  of  vascular  congestion,  this  being,  when  the  action 
is  Nthrnir,  red  to  an  extreme  degree,  but  when  asfhtu'f;  tending  toward  blue,  the  redness 
•shading  off"  in  intensity  toward  the  blue  lividity  of  congestion.  The  surrounding  parts, 
moreover,  will  under  these  circumstances  be  tense  from  inflammatory  eff'usion.  hot  and 
painful  when  the  inflammation  is  acute  ;  but  when  this  is  of  a  lower  tyi)e,  they  will  be 
a'dematous,  boggy,  less  painful  because  less  tense  and  less  hot.  When  the  local  inflam- 
mation is  sthenic,  the  constitutional  disturbance  will  coincide  with  it  in  type,  and  the 
symptoms  will  be  those  of  inflammatory  fever ;  Avhcii  the  local  action  is  of  a  low  and 
asthenic  form,  the  constitutional  symptoms  will  partake  of  the  same  nature,  and  will 
approach  those  of  low  fever. 

It  is  to  be  known,  and  also  remembered,  that  the  acute  or  i^theuic  form  of  inflamma- 
tion, as  a  rule,  attacks  a  wound  when  newly  made  and  is  generally  excited  by  some  local 
cause — possibly  from  the  original  injury,  more  probably  from  some  imperfection  in  its 
primary  dressing,  and  most  probably  from  the  retention  of  some  irritating  fluid  in  the 
depths  of  the  wound  from  want  of  proper  drainage.  This  is  more  likely  to  occur  in 
wounds  of  certain  parts  or  tissues — as  in  wounds  of  joints,  wounds  of  large  cavities,  and 
deep  punctured  wounds — than  in  lesions  ol'  another  character. 

The  asthenic  form  of  inflammation,  as  a  rule,  attacks  wounds  at  a  more  advanced 
period — when  the  first  eff'ort  at  natural  repair  has  been  made  and  has  more  or  less  suc- 
ceeded, and  when  it  might  seem  as  if  the  effort  to  repair  the  part  and  the  power  to  efl'ect 
that  repair  were  not  commensurate.  At  any  rate,  in  the  treatment  of  these  two  forms 
of  inflammation  when  attacking  wounds,  it  will  be  safe  to  assume  that  such  is  the  fact ; 
for  while  in  the  acute  or  sthenic  variety  a  local  cause  for  its  production  should  be  looked 
for  in  order  that  it  may  be  remedied,  in  the  asthenic  or  later  kind  the  recognition  of  the 
fact  that  the  inflammation  is  due  to  a  (Icficifiicy  of  general  jiower  is  all-important. 

Treatment  of  Inflammation  Affecting  Wounds. — Tn  the  sfhenir  form  of 

inflammation  the  local  and  general  action  is  to  be  subdued  by  giving  free  vent  to  pent- 
up  fluids  by  the  local  application  of  ice  or  of  some  other  means  of  applying  cold,  by  the 
local  abstraction  of  blood,  and  by  free  purgation.  In  the  latter  purpose  there  is  nothing 
better,  after  a  good  purge,  than  repeated  small  doses  of  a  saline  cathartic,  such  as  Epsom 
salts.     When  suppuration  takes  place,  it  must  be  suitably  dealt  with. 

In  the  asthenic  form  general  tonics  with  stimulants  and  nutritious  food  are  essential ; 
locally,  absolute  cleanliness,  the  free  exposure  of  the  wound  for  purposes  of  drainage, 
and  the  constant  use  of  such  stimulating  antiseptic  applications  as  the  nature  of  the  case 
may  suggest,  with,  possibly,  warm  medicated  irrigation,  should  be  employed.  Cold, 
locally  applied,  is  rarely  beneficial. 

Diseases  of  Granulations. 

When  an  open  wound  heals  or  a  cavity  fills  up  with  reparative  material,  it  does  so  by 
a  process  of  granulation  ;  and  when  this  process  takes  place  in  a  healthy  subject  and 
under  favorable  conditions,  the  granulations  present  certain  appearances  known  as  healthy. 
When,  however,  the  same  kind  of  repair  is  being  effected  in  a  feeble  or  diseased  subject 
or  under  circumstances  which  are  not  favorable  for  its  progress,  the  granulations  present 
different  appearances,  these  being,  as  it  Avere,  pathohx/ical,  in  contradistinction  to  those 
which  are  seen  when  the  ordinary  jihi/sioJngical  process  of  repair  is  being  carried  out — a 
process  which  is  very  closely  allied  to,  if  not  identical  with,  that  of  development  and 
growth. 

In  a  healthy  surface  the  granulations  appear  as  small  conical  masses  of  granulation 


JUS/.AShS   OF  t;i:A.\lLAT/'K\S.  i]:i 

tis.siu'  cfivficil  witli  a  tliiti  laytT  of  j>iis  crlls.  'J'lii'V  an-  of  a  l»ri;rlit  florid-ri'il  colnr,  and 
are  tViiiL'i'il  at  their  skin  Ixmler  witli  tlie  well-known  thin  hhie  line  which  is  so  indieutive 
tit"  healthy  '•  e'eatri/.ation.'  Diirini:  the  whoh-  ot"  tin-  healinj;  process  this  appearance  is 
luaintaineil.  the  only  visihle  elian^e  heinj;  the  trrailiial  <liniiniition  of  tlie  f:raiiulatin<4  sur- 
face liy  the  steaily  approach  ot"  the  "thin  hlue  line"  towanl  the  centre.  llealthv  wounds 
underiro  contraction  at  the  rate  ot  troni  one  to  one  and  a  halt'  inches  a  wer-k.  In  the 
dit^erent  ap|»earances  of  these  •rrunulations  under  <li verse  circumstances,  the  educated  eve 
of  the  surireon  can  ra])idly  read  not  only  every  iniportunt  chan<:e  in  the  Imdilv  condition 
of  the  patient,  hut  almost  every  variation,  from  day  to  day.  in  the  patient's  health.  I 
have  heeii  huitr  in  the  habit  of  de.serihin<r  a  granulating;  surface  as  a  kind  of  weatlier- 
frlass  or  harometer  of  health  in  which  the  surgeon  can  read  in  the  changed  a|>pearance  of 
the  granulations  themselves,  and  of  the  ''•  thin  hlue  line"  of  cicatrization,  the  slightest 
deviations  from  the  healthy  tyjie;  for  while  it  is  true  that  as  long  as  a  granulating  surface 
is  healing  kindly  the  inference  is  correct  that  the  subject  of  the  "  sore"  is  liealtliv,  it  i.s 
ei|ually  certain,  when  the  surface  lias  deviated  from  the  healthy  ]»ath.  that  there  is  .some- 
thing wrong  either  in  the  patient,  in  the  part  itself,  or  in  its  treatment.  Thus,  in  a  patient 
who  is  aniomic,  the  granulations  will  he  pale  and  bloodless;  an<]  when  this  condition  has 
been  id"  long  >tantling,  they  will  lose  their  small  conical  form  and  ajipear  as  coarse  watery 
elevations.  When  there  is  any  interference  with  the  return  of  the  venous  blood  from  the 
granulating  i)art.  from  either  heart  disease,  the  dependent  position  of  the  limb,  or  the 
improper  u.so  or  bad  application  of  bandages  or  other  mechanical  appliances,  the  granu- 
lations will  appear  '•  congested  "  to  variable  degrees,  and  may  even  bleed.  They  may  be 
so  full  of  venous  blood  as  to  put  on  the  purple  appearance  which  suggested  to  the  old 
authors  the  name  of  the  '"juniper  ulcer,''  the  granulations  looking  blue  or  black  as  a 
juniper.     When  the  ulcer  bleeds,  it  is  generally  called  Jtumorrhiijic. 

WJien  the  reparative  power  is  feeble  and  granulations  form,  they  will  be  of  a  pale, 
watery,  (edematous  character,  and  the  discharge  from  them  will  not  be  normal  pus.  but  a 
seropurulent  tluid  ;  the  granulations  that  form  are  of  a  weak  type,  and  the  sore  then  con- 
stitutes what  is  wrongly  called  a  "  weak"  ulcer. 

When  from  some  constitutional  or  local  cause  the  reparative  process  is  more  deticient 
in  force,  the  surface  of  the  sore  will  either  present  a  few  ill-formed  and  feeble  granulating 
spots  or  appear  smooth  and  apparently  wanting  in  granulations  altogether,  and  look  to  the 
eye  not  unlike  the  tense  mucous  surface  of  the  pharynx.  In  other  cases,  in  which  this 
deficiency  in  force  is  greater,  the  sore  may  present  a  greenish,  dirty-colored  surface,  dis- 
charging an  acrid  or  putrid  substance  which  is  clearly  blood  and  serum  mixed  with  the 
decomposing  elements  of  dead  tissue,  the  ill-formed  granulation  or  granulative  tis.sue  in 
these  cases  dying  superficially  as  soon  as  formed,  for  want  of  power  to  live  and  develop. 

In  still  more  extreme  cases  of  deficiency  of  power,  what  may  have  been  a  reparative 
process  not  only  ceases  to  be  so.  but  becomes  retrograde ;  what  had  been  a  co7istructive 
changes  into  a  fleatructue  force,  and  the  tissues  that  should  have  been  repaired  break 
down  and  undergo  molecular  disintegration  :  the  sore,  instead  of  healing,  becomes  an 
ulcer,  the  new  tissue  dying  from  want  of  vitality. 

On  the  other  hand,  exi-fn^i  of  action  may  at  times  aifect  a  healing  sore ;  and  when  it 
does  so,  it  aft'ects  the  granulating  process  as  much  as  it  has  been  .shown  to  do  a  wound  in 
which  quick  union  or  primary  adhesion  is  sought  for.  In  the  stage  of  irritation,  or  fhat 
in  which  the  granulation  tissue  is  simply  overstimulated,  overaction  shows  it.self  in  an 
excess  of  secretion  from  the  granulating  surface,  in  the  shape  of  pus.  and  probably  in 
some  increase  in  the  size  and  redness  of  the  granulations  themselves ;  and  when  this  is 
other  than  a  passing  condition  from  some  temporary  cause,  it  will  soon  become  one  of 
inflammation. 

When  inflammation  attacks  a  granulating  sore,  changes  will  occur  similar  to  those 
which  have  been  described  as  taking  place  ^vhen  it  affects  a  healing  wound.  Physiolog- 
ically there  will  be  an  arrest  of  the  healing  process,  an  arrest  of  seereti(»n  from  the  granu- 
lations, and,  if  the  action  be  lasting,  a  change  from  what  had  been  a  healing  process  to 
one  of  ulceration.  The  ulceration  will  be  more  or  less  rapid  and  associated  with  all  the 
local  and  general  phenomena  of  inflammation,  such  as  redness  and  heat  of  the  margins 
of  the  sore  and  the  adjoining  tissues,  with  pain  and  swelling.  The  degree  and  character 
of  the  inflammation  regulate  these  appearances ;  an  inflamed  sore  or  granulating  surface 
presents  as  many  different  aspects  as  there  are  degrees  or  kinds  of  inflammation,  for 
inflammation  must  be  regarded  as  an  accidental  complication  of  the  sore,  and  it  may 
attack  it  in  any  stage  of  its  progress  or  in  any  condition. 

At  times  the  granulating  force  may  be  in  excess  and  so  act  as  to  prevent  repair.     The 


64  ON  INFLAMMATION. 

graiiulatioiis  .sprout  above  and  beyond  tlie  inargins  in  which  tlie  "  outifying "  action  is 
carried  out.  and  appear  either  as  elevated  luxuriant  growths  in  the  centre  of  a  sore  or  at 
the  orifice  of  a  sinus,  or  as  overhanging  florid  granulations  at  the  cicatrizing  border.  In 
these  cases  there  is  simply  an  excess  of  force,  and  this  excess  exliibits  itself  in  fungous 
granulations. 

Again,  a  granulating  wound,  when  of  longstanding,  may  show  on  its  surface  or  in  its 
surroundings  evidence  of  the  existence  of  many  constitutional  or  specific  conditions — that 
is  to  say,  a  chronic  sore  in  a  patient  who  has  a  syphilitic  taint  may  present  features  by 
which  the  presence  of  the  syphilitic  poison  can  be  recognized,  and  a  chronic  sore  in  a 
scrofulous  subject  will  manifest  conditions  which,  if  not  special,  as  in  the  .syphilitic,  will 
be  clear  enough  to  indicate  sufficient  feebleness  and  torpidity  of  action  to  suggest  the 
existence  of  some  general  dyscrasia. 

On  Inflammation. 

When  a  visible  part  is  inflamed,  there  are  four  notable  phenomena  to  be  observed — 
namely,  redness,  heat,  pain,  and  swelling — and  these  four  symptoms  are  all  associated 
with,  if  they  are  not  directly  due  to,  an  active  congestion  of  the  capillaries,  with  more  or 
less  blood  stasis  of  the  inflamed  tissue.  This  hypersiemia,  or  congestion,  is,  moreover, 
accompanied  with  cell  changes  in  the  seat  of  inflammation.  There  is  likewise  an  arrest 
or  annihilation  of  the  functions  of  the  part,  and  in  the  case  of  a  wound  an  arrest  of  its 
repair,  and  later  on  destructive  changes.  Redness  and  heat  are  the  most  typical  of  these 
four  symptoms,  and  heat  is  the  more  characteristic,  increase  of  heat  being,  without 
doubt,  the  most  important  clinical  local  symptom  of  inflammation. 

The  ^'' reditesit"  may  be  localized  or  diffused,  of  a  bright-red  color  or  of  a  livid  hue, 
the  former  tint  indicating  a  healthy  or  sthenic,  the  latter  (evidencing  want  of  power)  an 
asthenic,  inflammation.  It  is  clearly  due  to  the  capillary  injection  of  the  part,  for  in  the 
sthenic  form  the  circulation  through  the  capillaries  is  more  active  than  it  is  in  the  asthenic. 
in  which  the  dusky  congested  livid  color  suggests  blood  stasis. 

The  "  increase  of  heat "  is  probably  due  to  the  accelerated  flow  of  overheated  blood 
through  the  hyperajmic  tissues,  as  well  as  to  increased  activity  in  the  tissue  changes  of 
the  inflamed  part  ;  but  the  local  heat  probably  is  never  greater  than  that  of  the  blood. 
John  Hunter's  sagacious  utterance  on  the  sul)ject  one  hundred  years  ago—"  that  a  local 
inflammation  cannot  raise  the  temperature  of  an  inflamed  part  above  the  source  of  the 
circulation  " — being  declared  by  Sanderson  now  to  be  correct  both  in  fact  and  theory. 

The  '■'■  swe-Iling''  or  ''■hardness'"  is  to  be  explained  by  the  nature  of  the  tissue  involved 
and  the  degree  of  blood  stasis  which  is  attained  in  the  tissues.  The  serum  of  the  blood, 
with  its  coagulable  lymph,  passively  exudes  from  the  gorged  capillaries  into  the  con- 
nective tissue  of  the  inflamed  part  in  the  early  stage  of  inflammation  when  the  stasis  is 
incomplete,  and  the  emigration  of  the  white  blood  corpuscles  or  leucocytes  or  proto- 
plasmic atoms  follows  when  it  is  more  so.  Absolute  death  of  the  involved  tissue  takes 
place  when  the  circulation  through  the  capillaries  is  entirely  stopped,  the  exudation  from 
the  slowly-flowing  blood  stream  of  corpuscular  liquid  being,  in  the  words  of  Sanderson, 
*' the  central  phenomenon  of  inflammation." 

'"  Ffxin  "  is  a  symptom  which  vai'ies  much  as  to  its  character  as  well  as  to  its  intensity, 
and  depends  a  great  deal  upon  the  amount  of  tension  in  the  inflamed  part.  In  inflamma- 
tion of  the  bone,  periosteum,  or  of  any  part  bound  down  by  an  unresisting  fibrous  tissue, 
such  as  the  coat  of  the  testis,  the  sclerotic  of  the  eye,  or  the  socket  of  a  tooth,  the  pain 
is  intense  ;  in  rheumatism  in  which  the  fibrous  structures  of  the  joints  are  inflamed  it  is 
also  marked.  Probably  it  is  caused  by  direct  pressure  on  the  extremities  of  the  nerves 
of  the  stretched  or  tense  tissue. 

We  thus  have  redness,  heat,  streUinff.  and  pain  as  symptoms  of  overaction  of  a  part, 
or  what  is  called  in  flam  mat  ion,  and  they  one  and  all  appear  to  be  direct  consequences  of 
extreme  capillary  vascularity  of  the  tissue,  whether  that  be  the  result  of  a  wound  or  not. 
The  blood  stream  through  an  inflamed  limb  has  been  demonstrated  by  experiment  to 
exceed  the  normal  flow  in  the  proportion  of  something  like  four  to  one.  These  symptoms 
may  manifest  themselves  in  every  degree  of  severity,  their  extent  depending  upon  the 
intensity  of  the  inflammatory  action  and  the  nature  of  the  tissues  that  are  involved. 
When  a  loose  tissue  is  involved,  the  redness  will  be  much  marked  and  the  swelling  will 
probably  be  rapid,  but  the  pain  will  certainly  be  slight,  as  the  tension  of  the  part  is 
rarely  .severe.  When  the  connective  tissue  situated  beneath  a  dense  fascia  is  the  seat  of 
inflammation,  or  when  bone  is  involved,  the  redness  may  be  absent  and  the  swelling  com- 


Oy   ISILAMMATIOS.  66 

par;iti\  t'ly  sli^^ht,  since  the  peculiarities  of  the  part  affected  prevent  their  being  man- 
itesteil  ;  but  the  pain  will  probably  be  severe,  fur  the  ten.si(jn  of  the  tissues  and  the 
pressure  ujton  the  nerves  of  the  jiart  will  under  such  circumstances  be  necessarily  {rreat. 

When  the  intiainniation  is  acM/r  or  rapid,  all  these  syinptonis  manifest  themselves  with 
great  rapidity,  and  the  results  of  the  action  are  <|uiekly  shown  :  when  it  is  slow  <jr  cUronic, 
they  are  less  clearly  marked. 

As.sociated  with  these  local  symptoms  of  inflammation  there  will  always  be  .some 
constitutional  disturbance,  which  is  known  as  iiijidininntnri/ /» n  r.  This  fever  may  man- 
ifest itself  in  all  de<rrees  of  severity,  its  intensity  dependiu'r  much  upon  the  character 
of  the  inflammation  and  its  seat.  When  a  local  affection  is  iicnh'  or  of  a  xtfieitir  nature, 
the  constitutional  disturliance  will  be  severe;  when  ilinmlr.  it  will  probably  be  mild;  and 
when  tist/it  iiir.  it  will  be  markeil  by  >rri'at  depression.  It  may  show  itself,  therefore,  only 
as  a  slii^ht  febrile  state,  or  it  may  be  marked  by  the  severest  .symjitoms. 

••  Takin<.r,  for  instance,  a  case  of  severe  compound  fracture,  without  much  hasmorrhage, 
in  a  person  otherwise  sound  and  stronjr,  as  a  type  of  the  affection,  we  find  that  before 
twenty-four  hours  have  elapsed  from  the  time  of  injury  his  <reneral  system  Vjegins  to  be 
thus  affected :  He  feels  hot  or  alternately  very  hot  and  chilly.  His  skin  and  lips  and 
mouth  are  dry.  lie  passes  urine  in  less  (juantity.  but  of  a  higher  color,  than  usual. 
His  pulse  is  (|uickened.  A  sense  of  general  di.sorder  gains  upon  him.  He  becomes  rest- 
less and  intolerant  of  disturbance.  Signs  of  drought  increase  with  him.  His  urine 
becomes  scantier  and  more  colored.  His  .skin  feels  hotter  to  the  surgeon's  hand,  and  his 
pul.se.  whether  full  or  hard,  is  ({uicker  and  stronger  than  before.  He  craves  more  and 
more  for  water.  Ilis  face  has  a  flushed,  anxious  look.  He  is  thoroughly  uncomfortable, 
for  the  most  ])art  feeling  distressingly  hot,  but  at  irregular  intervals  feeling  touches  of 
chilline.s.s — sometimes  even  of  such  cold  that  he  shivers  with  it.  His  sleep  is  troubled 
and  unrefreshing,  or  as  night  comes  on  he  gets  delirious.  His  tongue,  besides  being  dry, 
is  furred.  If  his  bowels  act  (which  commonly  they  are  inapt  to  do  without  laxatives), 
the  excretions  are  morbidly  offensive.  Gradually  these  .symptoms  give  way  ;  in  proportion 
as  the  injured  limb  ceases  to  be  tense  and  passes  into  suppuration,  the  skin  and  mouth 
become  moist  again  ;  the  excretions  lo.se  their  concentrated  character  ;  the  hard  pulse  soft- 
ens and  the  heart's  action  becomes  quiet ;  the  nervous  system  is  no  longer  restless  ;  the  look 
of  trouble  passes  from  the  countenance,  and  the  patient  can  again  take  solid  food.'  ' 

There  can  be  little  doubt  that  these  symptoms  are  clearly  due  to  an  increase  in  the 
temperature  of  the  blood,  and  that  their  severity  is  measured  by  it.  This  is,  indeed,  as 
Simon  has  so  aptly  expressed  it,  "  the  essential  fact  of  inflammatory  fever.  It  is  to  this 
fact  that  the  familiar  language  of  feverishness  bears  witnes.s — the  thirst,  the  scantv 
urine,  the  heat  and  the  shivering,  the  troubled  brain,  the  excited  circulation.  As  the 
blood  gets  hotter  and  hotter,  more  and  more  do  these  symptoms  become  developed.  As 
the  blcjod  subseijuently  gets  cooler,  ^o.  more  and  more,  do  they  decline.  " 

Average  Temperature. — The  average  temperature  of  the  healthy  human  body, 
according  to  the  Wunderlicli.  is  'JS.G°  F.  or  37°  C,  but  the  range  between,  97  and  99,  is 
quite  consistent  with  health.  A  febrile  condition  arises  from  an  increase  of  temperature 
accompanied  by  more  or  less  constitutional  disturbance. 

Excess  of  Temperature. — It  seems  from  Dr.  Montgomery's  observations,  made 
for  Mr.  Simon,  that  ■•  febrile  excesses  of  bodily  temperature  range  perhaps  to  ten  degrees 
above  the  normal  heat  of  the  blood ;  the  '  crisis '  of  a  febrile  state  consists  in  a  rapid  and 
generally  continuous  reduction,  the  •  lysis '  in  a  slow  and  generally  di.scontinuous  reduc- 
tion, of  this  abnormal  temperature."  With  respect  to  the  causes  of  this  greater  heat  of 
blood,  it  is  probable  that  the  fever  originates  in  the  tissues  themselves  and  is  a  disorder 
of  protoplasm,  the  results  of  inquiry  showing  "  that  either  continuously  during  the 
intensity  of  feverishness.  or  else  more  abruptly  when  feveri.shness  begins  to  subside, 
there  can  commonly  be  traced  in  the  excretions  an  excess,  more  or  less  considerable,  of 
those  nitrogenous,  sulphurized,  and  phosphorized  products  which  emanate  from  textural 
and  humoral  waste ;  that  this  increa.sed  elimination  is  observed  even  when  ingestion  has 
been  reduced  to  a  minimum  ;  and  that  febrile  excretions  do,  therefore,  as  a  rule,  undoubt- 
edly attest  an  increased  devitalization  of  bodily  material."  The  febrile  process  is  then 
clearly  a  disorder  of  nutrition  in  which,  in  man,  the  exchange  of  nitrogen  exceeds  the 
normal  expenditure  by  nearly  three-(|uarters,  and  in  which  there  is  likewi.<e  an  exces.sive 
discharge  of  carbonic  acid.  The  discharge  of  nitrogen  is  evidently  due  to  the  disintegra- 
tion of  tissue,  or  possibly  of  blood.  This  fact  explains  the  rapid  waste  of  body  which 
takes  place  in  fever.  The  blood  coagulates  with  what  is  generallv  described  as  a  "  buffy 
'  Simon's  art.,  Holmes's  System  of  Surgery  (second  edition »,  vol.  i.  p.  26. 


66  THE  EFFECTS  OF  INFLAMMATION  ON  THE  TISSUES. 

coat,"  and  it  seems  highly  probable  that  under  these  circumstances  it  contains  more  than 
its  normal  complement  of  fibrin.  There  is  good  reason  also  to  believe  that  this  '■  bulTy 
coat"  is  due  to  the  fact  that  the  blood  corpuscles  subside  in  the  liijuor  sanguinis  during 
coagulation,  leaving  the  upper  portion  of  the  clot  colorless.  What  this  increase  of  fibrin 
in  the  blood  in  inflammation  means  is  a  question  that  remains  to  be  decided.  Some  pathol- 
ogists believe  that  the  blood  is  excellent  in  proportion  as  it  is  fibriniferous  ;  that  solidi- 
fying fibrin  is  almost  incipient  tissue  ;  that  the  fibrinous  crust,  as  drawn  in  inflammation, 
is  the  sign  of  its  being  specially  adapted  to  the  purpose  of  additional  growth  ;  while 
Simon,  with  others,  holds  "  that  the  blood  yields  more  fibrin,  not  in  proportion  as  it  is 
ripe  and  perfect,  but  rather  in  proportion  to  quite  opposite  conditions ;  that  an  increased 
yield  of  fibrin  portrays,  not  perfection,  but  post-perfection,  in  the  blood ;  that  it  corre- 
sponds, not  to  the  rise,  but  to  the  decline,  of  albuminous  material ;  that  the  relations  are 
not  with  repair,  but  with  waste ;  that  its  significance  is  that  of  something  intermediate 
between  life  and  excretion  ;  that  the  fibriniferousness  of  the  blood  is  undiminished — 
probably  even  increased — by  bleeding;  that  it  is  greatly  developed  during  starvation, 
during  violent  fatigue,  during  diseases  essentially  ana?mic ;  that  its  increase  under  these 
circumstances  of  exhaustion,  weakness,  and  inanition  is  to  the  full  as  great  as  its  increase 
during  inflammation." 

"  These  latter  views  seem  to  be  most  in  accord  with  truth  and  with  the  general  chem- 
istry of  inflammatory  fever.  They  seem  to  indicate  that  the  fibriniferousness  of  the 
blood  in  inflammation  represents  action  of  devitalization  and  decay  in  some  albuminous 
material.  Whether  this  changing  material  be  the  inflamed  texture  gradually  dissolving 
itself  into  the  blood,  or  be  the  albumen  of  the  fevered  blood  itself  undergoing  accelerated 
waste,  cannot  in  the  present  state  of  knowledge  be  even  approximately  stated  "  (Simon), 

The  Effects  of  Inflammation  on  the  Tissues. 

More  or  less  complete  xtasis  of  hlood  in  the  inflamed  tissue  is  the  first  eff"ect  of  inflam- 
mation, as  hyperaemia  with  greater  activity  in  the  circulation  of  the  part  is  the  first  symp- 
tom. With  this  stasis  there  is  a  slowing  of  the  blood  stream  through  the  dilated  capil- 
laries, with  a  crowding  together  of  the  white  corpuscles  or  leucocytes  along  their  wall.s, 
and  later  on  a  migration  of  these  same  cells  from  the  vessels  into  the  tissues. 

Blood  Stasis. — When  the  sta.sis  is  more  than  transitor}'.  the  red  blood  cells  them- 
selves may  extravasate  into  the  tissues  with  the  leucocytes :  and  when  the  stasis  is  com- 
plete, death  of  the  tissue  in  which  the  choked  capillaries  exist  ensues,  "  sta.sis  being  the 
mechanism  by  which  inflammation  kills"  fSanderson). 

Effusion. — The  effusion  which  takes  place  into  a  tissue  the  seat  of  inflammation  is 
clearly  due  to  stasis.  •  It  begins  from  the  moment  that  the  damaged  vessels  are  dis- 
tended with  blood  and  the  internal  surfaces  of  the  walls  pressed  upon  by  their  contents  " 
(Sanderson ),  and  it  varies  with  the  activity,  character,  or  specific  nature  of  the  inflamma- 
tion. When  the  inflammation  is  of  a  healthy  or  .sthenic  kind,  it  tends  toward  the  fibrinous 
variety,  producing  plastic  infiltration  of  the  part ;  when  of  a  feeble  or  ayfhenic  form,  the 
serous  and  corpuscular  elements  predominate.  In  the  former  case  the  soft  tissues  appear 
firm  and  dense,  and  in  the  latter  soft  and  fedematous. 

ReCOVer57"  by  Resolution. — In  healthy  subjects  this  plastic  material  may  be 
reabsorbed  and  the  ti.-.-ue  into  which  it  had  been  infiltrated  left  perfectly  sound,  recovery 
then  taking  place  b}'  what  is  termed  resolution;  in  exceptional  instances  the  jilastic  mate- 
rial may  become  organized. 

Other  Effects  of  Inflammation. — In  unhealthy  subjects,  or  in  cases  of  intense 
infianmiatiori.  in  wliidi  ri.->\i(  is  destroyed  from  blood  stasis,  the  infiltrating  material,  with 
the  inflamed  tissue,  either  undergoes  destructive  changes  and  breaks  up — when  what  is 
known  as  "  sitppKrafion  "  takes  place — or  the  tissue  as  a  whole  or  in  part  dies  or  "  mortifies.'' 
The  act  of  sirppifiiiflnn  means  the  formation  of  pus  and  the.destruction  of  the  inflamed  tissue. 

Mortification. — The  death  of  a  part  from  inflammation  means  its  moyV{/7ca/io».; 
when  the  action  is  a  spreading  one,  it  is  called  '■'■  govf/rene"  ox  ^'' sloughing  phui/edsena" 
and  the  dead  part  thrown  ofl"  is  called  a  "  slovgh."'  The  death  of  bone  is  called  "  necro- 
.s/s,"  and  the  dead  piece  of  bone  a  "  sequestrum.''''  When  a  portion  of  tissue  dies,  the 
dead  is  separated  from  the  living  piece  by  a  process  known  as  that  of  "  ulceration^'  ulcera- 
tion of  a  part  meaning  its  molecular  death.  When  ulceration  spreads,  an  ulcer  is  said  to 
exist ;   when  this  undergoes  repair,  it  does  so  by  granulation. 

"■Resolution,"  "suppuration."  -ulceration,"  and  "mortification"  are  the  four  events 
of  inflammation. 


A  use  ESS. 


67 


Fk;.  10. 


Pus  i'^  il'f  |'r"«lii«i  of  iiiflainmation,  and  it  consists  of  leucocytes,  granules,  and  the 
lilnis  of  the  inflamed  tissue  floating  in  serum.  Cohnheim  considers  the  leucocytes  to  be 
the  sole  source  of  j.urulent  infiltration,  and  Strieker  helieves  that  the  f<jrnution  of  pus 
is  svnonvmous  with  disintegration  of  tissue,  the  cells  of  the  inflamed  jiart  hy  the  act  of 
inflammation  being  made  to  return  to  their  emhryonic  state,  and  the  amndtoid  protofdas- 
mic  mati-rial  «d'  which  tluy  are  eoinjtosed  forming,  hy  suhdivision,  amo.d)f»id  cells.  The 
inflamed  tissues  hy  these  changes  are  transformed  into  jtus  corpuscles. 

l*us.  when  seen  upon  the  surface  of  a  granulating  wound,  varies  with  the  condition 
of  the  wound.  Wlu-n  the  granulating  tissue  is  healthy,  the  pus  will  he  healthy — that  is, 
it  will  appear  as  a  yellowish-white  creanjdike  fluid  with  a  sickly  snudl  and  an  alkaline 
reaction.  I'nder  the  microscope  the  cells  will  appear  like  leucocytes.  When  the  wound 
is  inflamed,  leococytes  will  be  present,  hut  under 
changed  condition."* — that  is,  they  will  appear  as 
nucleated  cells,  with  two  to  five  nuclei  (Fig.  lOj 
mixed  with  granules  and  the  debris  of  the  inflamed 
tissue;  under  other  circumstances  the  jius  nuiy  Vtc 
mi.xed  with  hlood.  In  indolent  sores,  where  th'' 
granulating  jiower  is  at  a  minimum,  the  pus  cells  will 
be  few  and  the  .>;erum  in  which   they  float   abundant. 

Living  pus  is  composed  -f  leucocytes  and  serum 
— li((Uor  puris  ;  dead  pus  is  made  up  of  nucleated 
cells  containing  from  two  to  five  nuclei,  granules,  and 
serum.  The  leucocytes  show  their  anueboid  move- 
ments in  the  living,  but  not  in  the  dead.  pus.  All 
pus  is  soluble  in  alkalies  and  has  an  alkaline  reaction. 
Acetic  action  dissolves  the  nucleus  of  a  leucocyte,  but  renders  clearer  the  nuclei  of  a 
dead  pus  cell.  The  pus  of  a  chronic  abscess  is  not  only  dead,  but  undergoing  degenera- 
tion ;  its  cells  are  large  and  full  of  fat  cells.  The  fluid  in  which  the  pus  cells  float  like- 
wise contains  fat  and  granules  in  abundance. 

Accidental  elements  may  be  found  mixed  with  pus  under  exceptional  conditions,  such 
as  cholesterine  plates  and  bone  and  other  tissue  elements :  when  vibrios  and  micrococci 
exists,  the  pus  is  undergoing  chemical  and  fermentative  changes. 

Varieties  of  Pus. — Pus,  when  thick  and  creamy,  is  known  as  '■  healthy."  or  laufl- 
ohh.Yn>.  when  thin  and  water}' and  containing  ill-formed  pu.s-cells.  it  is  called  •' puri- 
form  fluid,"  this  condition  being  generally  indicative  of  want  of  power;  when  it  is 
blood-stained,  it  is  called  •'  sanious ;  '  when  thin  and  acrid,  ••  ichorous ;"  and  when  it  con- 
tains flakes  of  curdy  lymph.  "  curdy.''  Pus  from  the  interior  of  a  bone  is  oily,  contain- 
ing, as  Brandsby  Cooper  showed,  granular  phosphate  of  linie.  Pus  from  the  brain  is 
often  green,  from  the  liver  brown,  the  debris  of  broken-down  tissue  in  different  propor- 
tions and  of  different  kinds  giving  these  appearances. 


\.  I'us  corpuscles  iiuatinitied  •^■>0  diaineter- . 
h.  >-jLn\e  iiui'ie  trausparent  with  acetic  acid. 
((.  fell-wall.  b.  Nucleus.  c.  Nucleolus. 
(A/ler  Leliert.) 


ABSCESS. 

A  circnmscribfd  collection  of  pus  in  any  tissue  is  called  an  "  abscess."  When  pus  is 
not  circumscribed,  but  diff"used  in  the  connective  tissue  beneath  the  skin,  between  mus- 
cles, or  along  tendons,  and  iiifiltratea  a  part,  diffused  suppuration  is  said  to  exist,  this 
latter  condition  always  indicating  want  of  power. 

Varieties. — An  abscess  is  always  the  result  of  an  inflammatory  process.  When  it 
forms  rapitUy  and  is  associated  with  severe  local  as  well  as  constitutional  symptoms,  it  is 
known  as  an  "  acute  abscess ;"  when  it  is  of  slow  formation  and  the  symptoms  attending 
its  prog'ress  are  mild,  it  is  called  a  '"chronic  or  cold  abscess  ;"'  but  there  are  many  inter- 
mediate forms.  In  an  "acute"'  abscess  the  pus  and  broken-down  tissue  are  circumscribed 
by  the  organization  of  the  coagulable  lymph  and  the  parts  around  are  infiltrated  with 
serum,  as  indicated  by  pitting  on  pressure.  In  a  'chronic"  abscess  the  walls  are  thick, 
from  the  organisation  of  the  inflammatory  products,  whereby  nature  checks  the  extension 
of  the  disease  and  forms  what  surgeons  of  old  called  the  "  pyogenic"  membrane,  whifh 
is  well  exenijilitied  in  chronic  abscess  in  bone. 

An  Acute  Abscess  is  invariably  preceded  by  the  constitutional  .symptoms  of 
inflammatory  fever,  and  is  accompanied  by  the  usual  local  phenomena  of  inflammation, 
such  as  pain,  redness,  heat,  and  swelling.  As  the  abscess  forms  the  local  symptoms 
become  intensified,  and  perhaps  concentrated  :  the  pain  alters  in  character,  becom- 
ing   at    first    dull    and    heavy,    and    then    throbbing ;     the    fever    symptoms    also    sub- 


68  ABSCESS. 

side,  or  rather  intermit,  and  a  shivering  fit  or  rigor  more  or  less  well  marked, 
followed  by  heat,  and  possibly  sweating,  takes  its  place.  The  swelling,  moreover, 
which  was  previously  diffused,  becomes  more  localized ;  a  soft,  and  possibly  tender, 
spot,  with  a  surrounding  area  of  oedema,  shows  itself,  and  the  parts  covering  it  begin 
to  thin.  With  the  fingers  of  one  hand  steadily  kept  flat  upon  the  swelling,  and 
those  of  the  other  made  to  press  upon  it  in  another  part,  the  walls  of  the  abscess 
will  be  made  to  rise  against  the  fixed  fingers  and  a  sense  of  "  fluctuation  "  be 
given,  this  feeling  of  fluctuation  indicating  the  presence  of  fluid,  and,  in  this  particular 
case,  of  pus.  Under  these  circumstances  the  "  pointing  "  of  the  abscess  will  soon  take 
place ;  meaning  by  this,  the  thinning  of  the  part  covering  in  the  abscess  in  the  direction 
of  least  resistance,  the  subsequent  bursting  or  sloughing  of  the  skin,  and  the  discharge 
of  the  abscess  cavity's  contents.  When  the  pus  has  been  evacuated,  the  walls  of  the 
abscess,  by  their  natural  elasticity,  fall  together  or  collapse,  the  external  wound  closes, 
and  the  abscess  either  heals  or  contracts  into  a  sinus  or  narrow  canal,  sometimes  called  a 
fistula.  When  the  pus  is  daeii-seatcd.^  or  bound  down  by  fascia  or  periosteum,  what  is 
called  "  hurrourimj  "  takes  place  ;  the  matter  makes  its  way  between  the  soft  parts,  where 
the  least  resistance  is  met  with,  and  opens  either  into  a  mucous  passage,  serous  cavity,  or 
joint.  Abscesses  beneath  the  periosteum  constantly  open  into  joints ;  those  beneath  the 
abdominal  muscles  or  within  the  abdomen,  into  the  intestinal  canal;  and  others  in  the 
extremities  may  burrow  beneath  the  muscles  and  make  their  way  to  the  surface  a  long 
way  from  the  original  seat  of  the  disease.  In  disease  of  the  dorsal  vertebrae  an  abscess 
may  burrow  beneath  the  abdominal  fascia,  extend  behind  the  sheath  of  the  psoas  muscle, 
Poupart's  ligament,  and  deep  fascia  of  the  thigh,  and  open  on  the  inside  or  outside  of  the 
thigh  ;  whilst  in  other  cases  it  may  pass  into  the  pelvis  and  out  again  at  the  sciatic  notch, 
and  appear  in  the  buttock  as  a  "gluteal  abscess."  In  disease  of  the  lumbar  vertebme  an 
abscess  may  also  form,  burrow  between  the  abdominal  muscles,  and  appear  in  the  front 
of  the  abdomen  above  Poupart's  ligament.  An  abscess  beneath  the  scalp  may  undermine 
the  whole  scalp  tissue  ;  one  behind  the  fascia  and  muscles  of  the  pharynx  may  spread  so 
as  to  cause  a  large  post-pharyngeal  tumor  and  cause  death  by  suff"oeation  ;  while  deep- 
seated  abscesses  of  the  neck  may  burrow  into  the  thorax,  and  thus  produce  fatal  mischief. 
These  instances  serve  to  show  how  pus,  when  confined  beneath  a  strong  membrane,  will 
burrow  along  the  cellular  tissue  of  a  part  to  find  some  outlet,  and  how  necessary  it  is  for 
the  surgeon  to  be  aware  of  the  fact  in  order  that  he  may  stop  the  process  or  trace  the 
cause  of  the  disease  to  its  source. 

The  "  diagnosis  "  of  an  acute  abscess  ought  not  to  be  difficult ;  but  when  the  abscess 
is  chronic,  the  same  cannot  be  said.  Every  hospital  surgeon  can  record  errors  of 
diagnosis  in  which  chronic  deep-seated  abscesses  have  been  mistaken  for  cancerous  or 
sarcomatous  growths,  and  even  for  aneurism,  and  in  which  breasts  have  been  removed  for 
cancer  which  were  the  subjects  of  chronic  abscesses.  The  knowledge  of  these  past  errors, 
it  is  hoped,  will  do  much  toward  guarding  against  their  future  perpetration  ;  but  the  best 
security  is  caution  and  a  diagnosis  of  the  case  by  the  process  of  reasoning  by  exclusion 
as  laid  down  on  pages  17,  18. 

Chronic  (djscesses  are  of  remarkably  slow  formation  and  give  rise  to  very  little  consti- 
tutional disturbance  or  local  symptoms  other  than  swelling  ;  indeed,  except  mechanically, 
they  seem  to  be  of  little  annoyance  unless  they  are  secondary  to  some  organic  disease. 
Even  then  it  is  astonishing  to  what  a  size  a  chronic  abscess  will  sometimes  attain  before 
it  is  discovered  or  complained  of.  In  spinal  cases  this  is  often  verified.  In  children, 
also,  large  abscesses  form  in  the  same  quiet  way.  They  are,  however,  never  met  with  in 
the  robust  and  strong.  Abscesses  connected  with  enlarged  glands  are  peculiarly  passive 
in  their  progress,  and  cause  pain  only  when  they  begin  to  make  their  way  through  the 
skin.  Those,  again,  which  occur  in  chronic  joint  disease  when  the  disease  seems  to  be 
undergoing  recovery  show  themselves  in  the  same  quiet  way.  Sir  J.  Paget'  has  described 
these  as  "  residual  abscesses."  They  seem  to  be  a  simple  breaking  down  of  old  inflamma- 
tory products  poured  out  in  the  cellular  tissue  during  the  more  active  period  of  the  dis- 
ease, and  which  had  failed  to  be  reabsorbed  or  to  become  organized,  mtich  in  the  same 
way  as  a  scar  may  break  down  after  a  fever. 

Absorption  of  Pus. — Pus  may  be  absorbed,  the  serous  fluid  in  which  the  cells 
float  being  taken  up  and  the  cells  left  to  wither,  these  subsequently  forming  a  pultaceous, 
and  at  a  later  date  a  cretaceous,  mass.  Clinically,  however,  pus  may  disappear  altogether 
and  leave  no  external  evidence  of  its  former  existence.  The  fact  is  now  clearly  recog- 
nized by  surgeons,  and  the'  absorption  of  pus  is  constantly  seen  in  the  eye  in  hypopyon, 

*  Clinical  Led.,  second  edition,  1879. 


ABSCESS.  69 

as  well  as  in  the  <lisa|i|>far:iii(('  of  |>t'iiustcal  ciilarpements  ami  cliroriic  siihciitaneous 
abscrssfs.  'I'liis  result,  liiiwt'vcr,  fan  nrilv  he  expeetc*!  in  (•hmnir  cases  wliicli  arc  not  con- 
nected with  <loe|i-seate(l  oriranic  miscliief". 

Thkatm  KN  T. — In  all  cases  of  acute  siijipiiration  the  ahscess  shoiihl  he  (i|ieiie<l  as  sotm 
as  it  has  iurnietl.  antl  in  many  instances  of  acute  local  inflaniniation  the  iiiflaniinatory 
fluids  should  he  let  out  as  soon  as  they  have  heen  effused,  with  the  view  of  (dieckiiif^  the 
infiainniatory  action  and  of  •ruardiri'r  ajrainst  the  evil  effects  of  •' tension  '  upon  the 
involved  tissues.  In  acute  iuHaiuination  almut  the  thec;e  of  tendons  of  the  hand  and 
foot  or  of  the  j)erio.steuiu  this  practice  should  he  hinding,  since  an  early  incision  in  such 
cases,  by  relievinjr  tension,  often  saves  tissue  and  cuts  short  disea.se.  The  ah.scess  should 
be  opened,  also,  where  it  is  pointing,  and  the  inflained  part  cut  into  where  it  is  most  tense 
and  can  be  well  drained  ;  and  this  pntceeding  is  best  effected  with  a  straight  narrow  hla- 
toury.  such  as  the  pocket-ca.se  finger-knife,  unless  the  abscess  be  small,  when  a  double- 
edged  knife,  such  as  that  illustrated  in  Fig.  11.  should  be  employed.  The  incision  in 
both  cases   should   be  made  by  means  of  a 

vertical  puiu-ture  into   the  ah.scess  cavity. Fio.  11. 

followed  by  a  free  cut  outward,  the  open- 
ing being  large  enough  to  allow  a  ready 
escape   of  all  pent-up  fluid  and    the  subse- 

(luent  irriiration  of  the  abscess  cavity  with 
'  •     1-'  1  •  •      1      •  4  I>ouble-€dced  Abscess  Knife  with  droove  in  < 'mri- 

some   iodine  or  other  antisc]>tic  lotion.      A  (full-sized). 

piece  of  lint  .soaked  in  terebene  or  carbolic 

oil,  or  a  drainage-tube,  should  then  be  introduced  into  the  abscess  cavity  to  ensure  the 

escape  of  any  effused  fluids  that  may  subse((uently  be  poured  out,  and  the  parts  in  which 

the  abscess  exists  should  be  made  immobile  by  splints  and  bandages.     By  such  treatment 

the  abscess  cavity  may  be  expected  naturally  to  contract,  its  walls  to  unite,  and  recovery 

to  take  place. 

During  the  formation  of  an  abseess.  fomentation,  poultices,  and  warm-water  dressings 
give  comfort  and  may  be  used.  They  are  only  admissible,  however,  when  suppuration 
and  external  discharge  may  be  expected.  When  absorption  is  probable,  as  in  certain 
residual  or  chronic  abscesses,  such  means  should  not  be  employed,  but  rather  ab.solute 
rest  of  the  affected  part  and  an  absence  of  all  irritating  applications,  tonic  treatment  and 
regimen  being  the  chief  general  means  upon  which  reliance  can  be  placed. 

Use  of  Aspirator. — To  help  this  desirable  result,  it  is  a  good  practice  to  draw  off 
the  pus  frniu  a  chronic  abscess  with  the  aspirator  of  Dieulafoy.  I  have  done  this  on 
many  occasions  with  a  good  result,  and  no  re-collection  has  taken  place,  but  as  often  as 
not  the  fluid  reaccumulated  and  a  free  incision  was  subsequently  necessary.  Whenever 
an  abscess  is  opened,  the  incision  should  be  free  enough  to  admit  of  a  ready  outlet  of  its 
contents  and  to  prevent  any  reaecunnilation. 

Treatment  of  Deep  Abscess. — Wherever  burrowing  suppuration  in  a  part  can 
be  detected,  the  sooner  an  external  outlet  is  made  the  better,  whether  that  burrowing  be 
beneath  the  scalp,  behind  the  pharynx,  among  the  deep  cervical  tissues,  in  the  thecae  of 
tendons,  between  the  layers  of  muscles  of  an  extremity,  or  beneath  the  periosteum  ;  and 
this  is  more  especially  requisite  when  the  suppuration  occurs  about  joints  or  beneath  the 
deep  fascia,  and  particularly  the  fascia?  of  the  perin^eum  and  anus. 

Superficial  abscesses  ought  always  to  be  opened.  On  the  neck  and  face  the  line  of 
incision  should  be  made  to  correspond  with  the  course  of  the  superficial  skin  muscles  or 
the  lines  or  folds  of  the  part,  the  deformity  re.'julting  from  the  cicatrix  being  thereby 
greatly  diminished ;  but  in  other  cases  the  incision  must  be  in  the  best  direction  for 
emptying  the  cavity.  In  all  abscesses  the  puncture  should  be  made  where  the  abscess 
is  '•  pointing "'  or  the  integument  is  thinnest,  and  where  this  indication  is  absent  at  the 
most  dependent  part  of  the  abscess.  The  operator  should  always  avoid  dividing  super- 
ficial veins  and  nerves,  the  position  of  the  former  being  made  out  by  intercepting  the 
flow  of  blood  through  them  by  the  pressure  of  the  finger.  Deep  vessels  and  nerves 
should  be  carefully  avoided,  their  anatomical  position  being  always  remembered.  When 
ab.scesses  have  to  be  opened  in  the  neighborhood  of  these  important  structures,  the 
incision  .should  be  made  parallel  to  them. 

Mode  of  Opening  Abscesses. — In  opening  an  abscess  a  plunge  ought  not  to 
be  made.  The  operator  >houl«l  mark  the  point  of  intended  puncture  with  his  eye.  then, 
introducing  his  instrument  with  decision  through  the  soft  parts  into  the  cavity,  make  the 
incision  of  the  required  length  by  cutting  outward  as  soon  as  pus  oozes  upward  by  the 
sides  of  the  instrument.     To  do  this  sleepily  is  to  give  unnecessary  pain,  whereas  to  do 


70  ABSCESS. 

it  with  a  stab  or  plunge  only  causes  unnecessary  alarm.  It  should  be  done,  as  ought 
every  other  act  of  surgery,  with  confidence  and  decision,  boldness  and  rapidity  of  action 
being  governed  by  caution  and  made  subservient  to  safety. 

To  open  an  abscess  that  is  pointing  (or  which  has  a  cavity  to  be  felt)  by  dissecting 
down  upon  it  is  a  had  practice,  although  in  deep-seated  abscesses  which  are  covered  by 
parts  which  it  would  be  dangerous  to  wound,  where  .surgical  interference  is  called  for, 
such  a  method  may  be  the  best,  extreme  caution  being  requisite  under  circumstances  of 
extreme  danger.  In  such  cases  the  surgeon  should  follow  Mr.  Hilton's  method  of  open- 
ing deep-seated  abscesses,  which  has  been  practised  at  Guy's  for  man}-  years. 

In  deep-.seated  abscesses  in  the  axilla,  .•^ays  Hilton  (Li^ctures  on  Rent.  1803),  "  I  cut 
with  a  lancet  through  the  skin  and  cellular  tissue  of  the  axilla,  about  half  or  three- 
quarters  of  an  inch  behind  the  axillary  edge  of  the  great  pectoral  mu.scle.  At  this  point 
we  can  meet  with  no  blood  vessels.  Then  I  push  a  grooved  probe  or  grooved  director 
upward  into  the  swelling  in  the  axilla  ;  and  if  you  watch  the  groove,  a  little  opaque 
serum  or  pus  will  show  itself.  Take  a  blunt  (not  a  sharp)  instrument,  such  as  a  pair  of 
dres.sing-forceps,  and  run  the  clo.sed  blades  along  the  groove  in  the  probe  or  director  into 
the  swelling.  Now,  opening  the  handles,  you  at  the  same  time  open  the  blades,  situated 
within  the  abscess,  and  so  tear  open  the  abscess.  Lastly,  by  keeping  open  the  blades  of 
the  forceps  during  the  withdrawal  of  the  instrument,  you  leave  a  lacerated  tract  or  canal 
communicating  with  the  collection  of  pus,  which  will  not  readily  unite  and  will  permit 
the  easy  exit  of  matter."  In  this  way  deep  cervical  and  post-pharyngeal  abscesses,  deep 
abscesses  of  the  thigh,  leg,  and  fore-arm,  may  be  fearlessly  opened. 

After-Treatment. — When  an  abscess  has  been  opened,  it  should  be  left  to  dis- 
charge by  itself.  Any  squeezing  or  pressing  upon  the  walls  of  the  abscess  is  vxnneces- 
sary  and  injurious.  In  some  a  piece  of  oiled  lint  should  be  introduced  between  the 
edges  of  the  wound  to  prevent  their  closure,  more  particularly  when  the  deep  fascia  has 
been  opened  ;  whilst  in  others  of  large  size  the  introduction  of  a  drainage-tube  made  of 
a  piece  of  india-rubber  tubing  perforated  at  intervals  may  be  re([uired  ;  in  all.  provision 
for  drainage  should  be  made. 

Tonics  and  good  feeding  are  always  essential  elements  in  the  treatment,  .sedatives 
being  given  only  when  required. 

When  a  chronic  abscpss  requires  opening — a  question  which  in  every  case  should  be 
well  considered — a  free  incision  should  be  made  into  its  cavity,  its  contents  evacuated, 
and  the  cavity  well  washed  with  some  antiseptic  lotion.  For  this  latter  purpose  a  mixture 
of  one  or  two  drachms  of  the  tincture  of  iodine  to  each  pint  of  tepid  water  is  the  best ; 
a  drainage-tube  should  then  be  introduced,  care  being  taken  that  if  air  entei's  its  exit  also 
can  be  guaranteed.     The  abscess  should  be  wa.shed  out  daily. 

When  the  Listerian  method  of  dressing  wounds  is  employed,  the  abscess  cavity  must 
be  opened  under  the  spray,  drained  with  proper-sized  drainage-tubes,  and  covered  with 
the  gauze  and  protective.  An  excellent  plan  likewise  consists  in  making  a  free  opening 
into  the  abscess,  previously  covered  with  a  piece  of  lint  soaked  in  carbolic  oil  (one  part 
of  acid  to  twenty  of  olive  oil),  beneath  which  the  pus  flows  away  ;  in  this  manner  no 
air  is  admitted.  In  the  subsequent  dressings  care  must  be  taken  to  keep  the  opening 
surrounded  with  the  vapor  of  the  acid,  and  the  lint  should  be  removed  only  to  be  re- 
placed by  a  freshly-steeped  piece.  No  pressure  should  be  made  upon  the  walls  of  the 
abscess  for  the  purpose  of  empt3'ing  its  cavity  without  the  opening  being  covered  with 
carbolic  oil.  I  have,  however,  used,  in  several  cases,  olive  oil  alone  with  e(juall3'  good 
results. 

Suppurating  ovarian  and  hydatid  cysts  may  be  treated  as  large  abscesses  and  with 
considerable  success.  Empyemata  or  abscesses  in  the  chest  can  also  be  dealt  with  on  the 
same  principle,  by  a  free  opening  into  the  thorax  and  a  free  outlet  for  the  pus.  In  these 
cases  the  drainage-tube  is  of  great  value,  care  being  necessary  to  drop  one  end  of  it  well 
down  to  the  bottom  of  the  cavity. 

The  drainage-tube  was  suggested  by  M.  Chassaignac,  and  is  simply  a  small  india- 
rubber  tube  perforated  every  half  inch  or  so  with  holes  to  allow  of  the  free  escape  of 
the  pus.  When  large  cavities  are  opened,  they  should  be  washed  out  at  intervals  with 
an  iodine  lotion  or  other  antiseptic  fluid,  so  that  nothing  like  decomposition,  as  indicated 
by  foetor.  may  be  allowed.  With  this  precaution,  large  suppurating  cavities  can  be  dealt 
with  successfully. 

Hsemorrhage  into  Abscess  Cavities. — When  veins  and  large  arteries  are 
opened  by  ulceration  into  abscesses — an  accident  of  occasional  occurrence — they  should 
be  treated  on  the  principle  laid  down  in  the  chapter  on  hsemorrhage ;  *'.  e.,  if  the  bleeding 


ARREST  OF  ACUTK  ISFLAMM ATKtS.  71 

vessel  he  lar<re,  it  slmulil  Ik-  secureil,  when  |i(»ssil)le,  at  tin-  |Miiiit  at  which  it  has  <;ivcn 
way.  either  by  lijjature  nr  tor.-iuii  ;  mikI  it'  >iiiall,  flic  hreiiiniihaL'i-  can  easily  )»(•  arrested 
by  pressure. 

Abscesses  Associated  with  Enlarged  Glands. — ciironie  abscesses  a.s.so- 

eiatcil  with  irlainliilar  ciilMrLrciiiciit  luol  imt  he  i>|miiii1  iimhr  >oiiie  eircuiiistanees,  because 
with  cniistitutioiial  trcatimnt  they  i)f'tcii  <lisa|)|iear ;  yet  they  shuuhJ  be  so  treated  as  soon 
as  it  is  eh'ar  that  they  will,  if  let  alone,  open  by  natural  jirocesses.  in  onler  to  save  the 
uirlv  cicatrix  that  tiikes  place  umler  these  circumstances  from  ulceration  of  the  skin.  The 
surp'ou  slmuhl  make  a  small  puncture  in  the  best  line  t<j  allow  of  the  exit  of  the  pus 
antl  to  prevent  disfimirement.  (ientle  pressure  with  cottctti-wool  over  the  part  afterward 
often  luistens  the  recovery.  In  subjects  of  the  hiemorrhagie  diathesis  an  abscess  may  l)e 
opened  by  the  cautery  or  caiiula. 

Arrest  of  Acute  Inflammation  by  the  Obstruction  of  the  Main 

Artery  of  the  Part. 

To  arrest  acute  inflammation  in  a  limb,  the  delijjration  of  the  main  artery  of  the  limb 
or  the  arrest  of  the  circulation  through  it  by  jtre.ssure  upon  the  artery  has  been  adopted. 
])r.  Campbell  of  New  (Jrleaiis  speaks  liighly  of  the  practice,  and  even  affirms  that  no 
portion  of  an  extremity  should  be  amputated  for  destructive  inflammation  without  tbi.s 
experiment  beintr  attem])te<l.  0\\  the  suggestion  of  the  late  Mr.  Maunder  of  the  London 
Hosj)ital,  Mr.  Little  in  ISGT  api)lied  a  ligature  to  the  femoral  artery  for  acute  suppura- 
tion of  tlie  knee  with  a  success  sufllicient  to  prove  the  value  of  the  practice.  3Ir.  >Iaun- 
der  hiuLself  afterward  had  a  similar  successful  result  C"  Lettsom.  Lect.,"  Lunot.  1875). 
The  late  Mr.  Moore  of  the  Middlesex  Hospital  also  acupres.sed  the  brachial  artery  with  a 
good  result.  Previous  to  these  cases,  however,  as  early  as  1813,  Dr.  Onderdonk  of 
America  ligatured  the  femoral  in  a  case  of  wound  of  the  knee-joint  to  check  acute  inflam- 
mation, and  others  since  his  time  have  followed  his  practice.  It  is  a  method  of  treatment 
certainly  worthy  of  attention,  inasmuch  as  to  cut  off  the  supply  of  blood  to  an  inflamed 
part  when  too  much  is  pa.ssing  to  it  is  sound  in  theory,  and  to  do  the  .same  to  starve  out 
the  disease  is  equally  scientific.  In  ele|)hantiasis  Arabum  the  practice  does  not  .seem  to 
be  without  its  good  effect,  and  in  acute  di.sease  it  is  certainly  admissible. 

I  well  remember  as  a  student  observing,  under  the  care  of  the  late  Mr.  Bransby 
Cooper,  a  serious  case  of  compound  fracture  of  the  leg  complicated  with  a  severe  lacera- 
tion of  the  thigh  and  division  of  the  femoral  artery  of  the  .same  side.  He  was  in  doubt 
as  to  the  practice  he  ought  to  follow,  not  knowing  whether  with  the  divided  femoral  the 
supply  of  blood  would  be  sufficient  to  repair  the  compound  fracture.  The  success  of  the 
case,  however,  proved  that  the  fear  was  groundless,  for  repair  went  on  uninterruptedly, 
and  a  good  limb  was  the  result.  The  patient  was  a  man  of  middle  age.  In  1873  I  also 
treateil  with  uninterrupted  success  a  case  of  compound  fracture  of  the  humerus  into  the 
elbow-joint  in  a  man  where  the  brachial  artery  was  obstructed,  in  which  recovery  with  a 
movaltle  joint  was  accomplished. 

With  respect  to  the  treatment  of  inflammation  by  the  Jiijitnl  compression  of  the  main 
arterial  trunks  leading  to  the  injured  or  diseased  parts,  it  must  be  recorded  that  in  18G1 
Dr.  T.  Vanzetti  of  Padua  wrote  a  paper  on  the  subject,  which  Mr.  .*>.  Gamgee  has  trans- 
lated in  his  work  On  FrnctnnH  (1871).  He  was  led  to  ap])ly  this  treatment  to  cases  of 
inflammatory  disease  from  its  success  in  the  treatment  of  aneurisms.  He  asserts  that 
compression  will  cure  every  incipient  inflammation,  and  check  it  even  when  advanced ; 
and  he  adduces  cases  of  phlegmonous  erysipelas  and  acute  arthritis  of  the  hand  success- 
fully treated  by  such  a  process.  He  adds,  however,  that  -  in  the  treatment  of  aneurisms, 
as  of  inflammations,  compression  can  never  become  a  normal  method  until  it  be  always 
and  exclusively  effected  with  the  finger.' 

SINUS  AND  FISTULA. 

A  Fistula  is  an  unnatural  communication  between  a  normal  cavity  or  canal  and  the 
outside  of  the  body  or  with  a  second  cavity  or  canal. 

A  Sinus  is  a  narrow  and  often  tortuous  suppurating  tract  with  oidy  one  orifice. 

Amongst  the  Jisful^  there  are  the  vesico-vaginal  and  the  recto-vaginal  fistula?  in 
women  :  the  recto-vesical  in  men  ;  gastric  and  biliary  fistuhu,  fa?cal  and  anal  fistulae, 
salivary  fistula,  and  urinary  fistula  ;  there  are  also  the  congenital.  1»ronchial,  or  umbilical 
fistula.     The  acquired  fistula?  are  either  due  primarily  to  some  suppurative  or  ulcerative 


72  STNUS  AXD  FISTULA. 

process  or  to  mechanical  violence,  operati%'e  or  otherwise,  and  subsequently  to  a  want  of 
repair.  When  passages  are  close  together,  the  fistula  in  some  cases  may  be  short  and 
direct,  whilst  in  others  it  will  be  narrow  or  tortuous ;  the  orifice  of  the  fistula  may  vary 
much  in  size.  When  the  cavity  or  canal  is  deeply  placed  or  the  inner  opening  deeply 
situated,  the  fistula  may  be  a  long  narrow  tract.  When  the  fistula  is  of  recfut  origin 
and  lined  with  granulations  discharging  pus.  the  walls  will  be  soft,  and  will  readilv  bleed 
on  manipulation.  When  old.  they  will  be  smooth  and  hard,  or  "  callous."'  and  non-sensi- 
tive, and  will  secrete  a  thin,  watery,  non-purulent  fluid.  This  fluid  is.  moreover,  mixed 
with  the  contents  of  the  cavity  or  tract  with  which  the  fistula  communicates,  the  dis- 
charge tending  to  keep  the  fistula  open. 

The  exfermil  opening  of  a  fistula  or  sinus  presents  very  different  appearances.  It 
mav  appear  as  a  direct  or  as  a  valvular  opening,  or  may  be  depressed  or  raised.  When 
leading  down  to  a  foreign  body  or  to  bone,  the  external  orifice  will  be  surrounded  by 
weak  granulations.  Sometimes  it  may  scab  over  for  a  time,  and  then  reopen  by  the  force 
of  the  retained  fluid.  The  mtemal  opening  of  a  fistula  mostly  appears  as  a  defined  orifice. 
Causes  of  Sinus. — Abscess  is  the  most  common  cause  of  ■•^imi.'ies  or  incomplete 
fistula?,  the  external  communication  failing  to  clo.se  from  defect  in  the  healing  power  of 
the  part,  from  some  interference  with  the  reparative  process,  from  the  want  of  a  suffi- 
ciently free  vent  for  the  discharge  of  pus.  from  mu.scular  action  which  forbids  that 
amount  of  rest  which  is  required  for  its  repair,  or.  lastly,  from  the  presence  of  some  for- 
eign body  introduced  from  without,  or  from  dead  bone  or  cretaceous  inflammatory  prod- 
uct from  within. 

The  TREATMENT  of  the  diff"erent  forms  of  fistula?  is  given  in  the  chapters  devoted  to 
the  special  organs  that  are  involved.  In  a  general  way,  however,  it  may  be  asserted  that 
so  long  as  the  cause  of  the  fistula  exists  repair  cannot  go  on  ;  so  that  in  •'  nrivory  Jxstula,'* 
when  stricture  is  the  cause,  the  stricture  must  be  treated  before  the  fistula.  In  "  aiu/V^ 
fistula,  when  the  action  of  the  sphincter  ani  foi-bids  repair,  its  action  must  be  paralyzed. 
In  '•  f^xal"  fistula,  when  obstruction  to  the  bowel  is  present,  the  obstruction  must  be 
removed.  In  ••  salivary "  fistula  the  salivary  duct  must  find  a  natural  outlet  before 
its  unnatural  orifice  can  be  expected  to  close.  When  any  foreign  body,  tooth,  or  dead 
bone  4s  keeping  the  sinus  open,  it  must  be  removed.  When  a  suppurating  cavity  at 
one  end  of  the  fistula  continues  to  discharge,  means  must  be  taken  to  close  it.  When 
the.se  objects  have  been  achieved,  attention  may  be  directed  to  the  fistula  or  sinus  itself; 
and  various  are  the  means  that  can  be  employed  for  their  cure. 

Pressure  in  recent  sinuses,  to  keep  the  parts  in  apposition,  by  means  of  pads,  strap- 
ping, or  bandages,  is  sometimes  of  use.  the  muscles  that  move  the  part  being  kept  thereby 
absolutely  at  rest.  In  stumps  and  after  mammary  abscesses  this  practice  is  very  beneficial. 
Injection  of  some  stimulating  fluid,  such  as  the  preparations  of  iodine  (either  the 
tincture  alone  or  diluted  with  one  or  two  parts  of  water)  will  sometimes  set  up  a  healthy 
action  :  for  the  same  purpose  a  .^eton  has  been  used,  and  of  all  setons  the  small  drainoge- 
tube  is  the  best,  or  a  narrow  coil  of  rolled  gutta-percha.  The  conten/  is  sometimes  of 
great  use.  and  the  galvanic  is  to  be  preferred.  It  can  be  accurately  applied  to  the  exact 
spot,  and  its  heat  maintained  for  any  required  time.  It  is  generally  most  useful  in  small 
fistula-. 

Laying  open  the  sinus  is.  however,  as  a  rule,  the  surest  plan,  dividing  it  from  end 
to  end  and  keeping  the  sides  asunder  to  allow  of  its  healing  from  below.  In  superficial 
sinuses,  where  the  skin  is  undermined,  the  thin  overhanging  portions  should  be  removed; 
and  this  is  best  done  with  narrow  scissors  (Fig.  12).  When  done  with  a  knife,  the  incis- 
ion is  to  be  made  upon  a  grooved  probe  or  director  which  has  been  previously  introduced 

through  the  sinus.     This,  however,  may 
Fig,  12.  often  be  done  to  great  advantage  with 

the  wire  of  the  galvanic  cautery  passed 
tlirough  the  sinus  on  the  grooved  director 
Mr  threaded  in  an  eyed  probe,  the  surgeon 
>ubsequently  making  traction  on  the  two 
ends  of  the  wire,  made  hot  by  contact 
with  the  battery,  and  dividing  the  tissues 
with  a  sawing  motion.  The  division  with 
the  cautery  has  this  advantage — that  the 
Probe-pointed  .Sinus  Scissors.  surface  of  the  sin  US  is  SO  destroyed  that 

it    nuust    granulate.       There    is.    conse- 
quently, less  need  of  careful  dressing ;  and  in  old  sinuses  this  is  a  point  of  importance, 


V  WE  lis   ASH   SOUKS.  73 

fur  their  surt'accs  arc  so  ciilloiis  that  tlicy  rr(|iiiri'  to  lie  scrajicil  (ir  othcrwiso  renclered 
raw  t(»  cxcitt'  granulations  to  Wwxu. 

The  division  of  a  Hstnia  with  a  ligaliirt'  is  now  rarely  iierrornicd.  ahhoiigli  with  one 
of  "  in«lia-rul»l>t'r  "  it  is  i'casiltU-.  In  •  hh-cdcrs  "  it  inifrht  he  caHeil  for.  Itut  in  these  the 
win'  id'  the  ;.;alvanie  cautery  is  |)r(derahh>  wlien  it  can  l»e  obtained. 

Oilatation  <d"  the  fistula  hy  niean.s  of  a  sponge  (tr  ianiinaria  tent  is  often  of  value. 

Plastic  operations  for  tlie  cure  of  fistiil;i'  are  al.so  means  (d"  great  value,  particularly 
of  vaginal  and  rectal  tislMl,*-.      These  will  he  discussed  in  a  future  chapter. 

Constitutional  Treatment  of  Fistula. — Last,  l)ut  not  least,  in  the  treatment 
of  sinuses  and  li-tMl;e.  constitutional  treatment  should  be  emplovcd.  In  the  fistula  fol- 
lowing operations  sucdi  treatment  is,  as  a  rule,  all  that  is  wanted,  and  many  are  the  cases 
in  metro|)olitan  hospitals  of  sinuses  about  stumps,  skin  wounds,  or  mammary  wounds 
that  will  heal  ra]»idly  under  the  influence  of  fresli  air.  good  food,  and  tonic  medicine.  In 
all  cases  these  means  are  most  es.sential,  and  with  them  and  local  treatment  success  i.s 
generally  to  be  attained. 

ULCERS   AND   SORES. 

Ulceration  is  the  result  of  an  inflammatory  process  by  which  a  .sore  or  chasm  i.s 
produced  by  the  molecular  disintegration  of  ti.ssue  the  .seat  of  cellular  infiltration,  the 
nutrition  of  the  tissue  being  so  disturbed  by  what  is  called  the  inflammatory  process  as 
to  allow  the  chemical  or  disintegrating  changes  to  have  their  way. 

A  sore  is  a  chasm,  a  solution  of  continuity,  caused  by  ulceration,  the  result  of 
injury  or  otherwise,  upon  an  external  or  iiiternal  surface  of  the  body. 

When  a  .•'ore  is  being  formed  or  is  spreading  by  the  process  of  ulceration,  an  vher  i.s 
said  to  exist  :    when  the  ulceration  has  ceased,  a  xnrc  remains. 

Varieties  According  to  Progress. — When  an  nicer  spreads  rapidly,  it  is 
termed  •'p/nii/tthtnic ;"  when  it  spreads  by  gangrene.  '•.^t/o^yA/W/;"  and  w^hen  with  this 
gangrene  the  molecular  death  of  the  tissue,  or  ulceration,  is  combined,  '•  s/our/hi/ir/  phage- 
dfena'^  is  said  to  exist.  All  these  processes  are  consequently  different  varieties  of  ulcers, 
and  are  characterized  by  degrees  of  rapidity  of  the  process,  the  simple  ulcer  being  the 
mildest  and  the  sloughing  phagedjisnic  the  most  severe  form. 

Varieties  According  to  Condition  of  Ulcer. — A  healing  or  cicatrizing  sore 

heals  by  ^'  grmut/dfio-n."  and  the  process  is  the  same  as  it  is  in  any  wound  the  result  of 
injury  or  operation.  It  may,  consequently,  assume  many  different  appearances,  and 
these  have  been  considered  under  the  heading  of  diseases  of  granulations,  p.  62.  Sores 
may.  therefore,  be  henlffij/,  in  flamed,  ri-e<(h\  indolent,  s/oiif/hinff  from  excess  rjf  indolence,  or 
irritable — terms  which  are  applied  to  granulating  sores  to  express  their  conditions  at  the 
time,  but  which  have  no  .special  signification  ;  for  these  appearances  fluctuate  according 
to  the  general  condition  of  the  patient  and  the  local  treatment  of  the  sore.  A  sore  may 
also  at  any  time  take  on  the  ulcerative  process  and  spread,  or  may  assume  any  of  the 
other  forms  of  spreading  already  described. 

An  Ulcer  may  have  a  Local  or  a  Constitutional  Cause. — Among  the 

loc(d  causey:  of  ulcers  are  injuries  ])roduced  by  blows,  pressure,  some  chemical  or  irritat- 
ing application,  or  some  skin  eruption  set  up  or  followed  by  inflammation  and  subsequent 
ulceration. 

Amongst  the  constitutional  causes,  exchiding  cancers,  may  be  classed  anything  that 
superinduces  a  low  condition  of  the  vital  powers,  such  as  any  illness,  scrofula,  certain 
habits  of  life,  syphilis,  or  scurvy. 

A  local  ulcer  or  sore  produced  from  local  cau.ses  may.  however,  fail  to  heal  from  some 
constitutional  defect,  and  a  sore  which  has  a  constitutional  origin  may  be  kept  up  by 
local  causes.  Thus,  a  syphilitic  or  cachectic  ulcer  originating  from  a  constitutional  cause 
may  take  on  any  of  the  characters  common  to  the  local  sore. 

There  are,  likewise,  special  ulcers,  such  as  lupus,  rodent  ulcer,  epithelial  or  carcino- 
matous ulcers,  to  which  attention  will  be  drawn  later  on. 

Local  sores,  as  already  stated,  have  a  local  origin — something  exciting  an  inflam- 
mation and  ulceration  in  the  skin  and  a  sore  remaining — the  disease  being  cutaneous 
from  the  first.  The  ulcer  fails  to  repair  either  because  its  position  is  iinfavorable  for  the 
process  to  be  carried  on  or  owing  to  some  local  peculiarit}"  of  the  circulation  of  the  part, 
such  as  varicose  veins,  or  from  some  want  of  care  in  its  local  treatment  or  want  of  power 
in  the  patient. 

Constitutional  sores  have  rarely  a  cutaneous  oriirin.  unless  thev  orisrinate  in  some 


74  ULCERS  AND  SORES. 

ulcerating  skin  eruption,  such  as  ecthyma  or  rupia.  They  almost  always  commence  in 
the  subcutaneous  connective  tissue  as  a  more  or  less  circumscribed  induration,  which 
lasts  a  very  variable  period  and  then  softens  down  ;  the  skin  over  it  inflames,  sloughs, 
and  ulcerates,  to  give  vent  to  a  deeper  slough,  the  sores  or  ulcers  always  being  of  a 
'•  celhi/ai-mf»tbraiious  kind."  These  ulcers  may  have  their  cause  in  an  ordinary  cachexia 
or  in  syphilis,  but  the  cellulo-membranous  ulcer  is  ahcii/s  constitutional  and  requires 
general  more  than  Inad  treatment.  In  syphilis  the  ixlcers  are  the  result  of  broken-down 
subcutaneous  '•  gummata."  The  appearance  of  these  sores  will  depend  much  upon  the 
period  at  which  they  are  seen,  but  from  the  time  when  the  skin  has  broken  and  ulcerated 
the  margins  of  the  opening  in  the  skin  will  appear  thin,  irregular,  and  undermined,  and 
at  the  bottom  of  the  opening  the  slough  will  appear.  When  simple,  the  slough  will 
appear  more  or  less  white,  sometimes  pearly  ;  but  when  syphilitic,  it  will  have  the  aspect 
of  a  piecr  of  icet  icas/deathcr — at  least,  in  the  majority  of  cases.  When  any  of  the 
slough  has  come  away,  the  skin  will  at  first  be  undermined  and  the  margin  of  the  sore 
will  fall  inward,  but  as  the  granulations  rise  from  below  the  skin  will  be  pressed  up. 
When  the  wound  has  cicatrized,  the  sear  will,  however,  almost  always  be  a  depressed, 
and  in  syphilis  a  stained,  one. 

Around  this  sore  several  small  openings  often  coexist,  each  one  having  foi-med  to  give 
exit  to  a  small  slough,  the  margins  of  which  appear  as  if  they  had  been  punched  out. 
These  sores  occur  mostly  about  the  lower  part  of  the  thigh  and  knee,  elbow,  shoulder, 
and  forehead  :  they  are  found,  however,  in  any  part  of  the  body.  The  syphilitic  are 
always  surrounded  by  a  dusk//  kind  of  inflammatoiy  border,  and  are  rarely  painful ;  the 
non-svphilitic  have  a  pinker  blush.  The  washleather  slough  and  dusky  margin  clearly 
indicate  the  syphilitic  sore. 

It  is  by  no  means  uncommon  to  discover  in  such  a  sore  the  specific  character  of  a 
disease  that  had  been  contracted  some  twenty  or  more  years  previously,  and  that  had 
lain  dormant  after  having  manifested  its  presence  by  marked  .symptoms.  Indeed,  it  is 
from  the  occurrence  of  such  sores  as  these  that  the  surgeon  inquires  whether  constitu- 
tional syphilis  is  really  ever  cured — that  is.  eradicated — and  whether  a  man  once  syphil- 
ized,  as  once  vaccinated,  is  not  so  permanently  altered  as  to  show  under  certain  condi- 
tions, with  comparative  certainty,  that  he  is  still  under  the  influence  of  the  poison,  and 
that  other  diseases  must  for  ever  after  be  modified  by  its  existence. 

A  healthy,  healing,  cutaneous  sore  is  known  by  the  small  florid  conical 
granulations  that  cover  its  surface  and  the  healthy  creamy  pus  thrown  oflF  from  it.  •'  In 
granulations  new  substances  are  formed,  as  if  the  earth  was  taken  in  heaps  from  one 
place  and  laid  in  another ;  the  thicker  and  smaJIer  /he  heaps,  the  better  the  granulations" 
(John  Hunter.  MS.  lect..  1787).  The  granulations  are  not  so  vascular  as  to  bleed  or  so 
sensitive  as  to  cause  pain  on  the  slightest  touch.  The  margin  is  natural,  and  where  the 
skin  and  granulations  meet  a  band  of  cicatrizing  tissue  is  to  be  seen,  assuming,  where  in 
union  with  the  skin,  a  whitish  line  with  a  fine  covering  of  epidermis  (Fig.  50  b),  but 
where  in  contact  with  the  granulations  a  more  vascular  appearance  than  at  any  other 
part  of  the  sore,  the  centre  of  the  band  being  covered  with  a  thin  purplish-blue,  semi- 
transparent  film. 

By  the  gradual  and  centripetal  cicatrizing  process  of  the  outer  border  of  the  band 
and  the  gradual  narrowing  of  its  circle,  the  sore  heals. 

Treatment. — The  surgeon's  sole  aim  is  to  guard  against  anything  that  can  interfere 
with  the  progress  of  repair.  The  treatment,  consequently,  is  simple,  a  piece  of  absorb- 
ent lint,  to  protect  the  surface  of  the  sore  from  injury,  covered  either  with  some  anti- 
septic oily  dressing,  such  as  the  terebene  or  carbolic  oil,  eucalyptol  ointment,  or  a  lotion 
of  boracic  acid,  with  the  elevation  and  immobility  of  the  part,  being  all  that  is  required. 
The  surface  of  the  .sore  should  be  cleansed  by  means  of  a  stream  of  tepid  iodine  water 
or  a  wad  of  absorbent  cotton-wool 

When  the  granulations  are  disposed  to  rise  too  high,  dry  lint  may  be  applied,  and  at 
times  a  rub  with  lunar  cau.stic  hastens  recovery.  Small  sores  may  be  allowed  to  scab. 
Rest,  with  elevation  of  the  limb,  is  always  beneficial  in  aiding  repair;  but  should  this  be 
impracticable,  a  good  pure  rubber  bandage  may  be  substituted,  and  a  piece  of  thin  sheet- 
lead  bound  over  the  sore  outside  the  dressing  gives  efiicient  support  and  protection.  In 
removing  the  dressing  care  .«bould  be  taken  not  to  injure  the  band  of  delicate  cicatrizing 
tissue. 

Deviations  from  Typical  Sore. — Accenting  this  description  as  that  of  a  heal- 
ing sore,  deviations  from  this  type  constitute  the  diff"erent  forms  that  have  been  described. 
Thus,  when  the  granulations  assume  a  large,  pale,  elevated,  watery  appearance,  the  sore 


rij'h-jis  AM)  SO/IKS.  76 

is  said  to  ha  "  wcii/c,"  the  granulations  in  jxipular  language  being  "  prouil  flesli,"  the  popu- 
lar word  "proud"  hi'ing  synonymous  with  wiolc.  There  is  power  in  the  sore  to  granu- 
late, but  the  granulations  hav(!  little  power  of  cicatrizing  ;  they  are  ilisposed,  moreover, 
to  slough  on  the  slightest  cause.  These  re(juire  local  stinjulants,  such  as  the  nitrate  of 
silver  in  stick,  sulphate  of  zine  or  copper  lotion,  carliolic  acid  lotion  in  the  proportion  of 
two  grains  to  the  ounce,  or  terebeiic  alone  or  diluted  with  one  or  two  parts  of  olive  oil. 
Dusting  the  surface  with  powdered  alum  or  tannin  is  also  sometimes  benelicial. 

Tlie  linili  should  l>e  e.ifefiilly  ele\  ntcd  or  bamlaged.  ami  t he  general  health  attended  to. 

The  Indolent  and  Callous  Ulcer. — Wlu-n  there  is  still  less  power  in  the  sore, 
no  granulations  I'orm  ;  the  surface  jtuts  on  the  appearance  of  a  piece  of  mucous  mem- 
brane, such  as  that  of  the  pharynx,  the  sore  being  then  called  ''  imlnUnl.''  At  tinu!s  a 
few  weak  granulations  are  lound  at  one  corner  of  its  surface,  but  the  greater  part  has  a 
smooth  and  glassy  aspect,  with  a  thin  and  watery,  but  not  purulent,  secretion.  Where 
the  sore  has  existed  long  the  edges  will  appear  rai.sed  and  indolent,  covered  with  a  layer 
of  epithelium,  and  very  senseless.  It  then  ac((uires  the  term  " 'v//Ay»«,"  a  callous  sore 
being  an  indolent  one  of  long  standing.  This  inchdent  sore  is  alway.s  ready  to  take  on  a 
sloughing  action  on  any  slight  cause,  such  as  some  general  derangement  of  the  health  or 
the  long  assumption  of  the  dependent  position  of  the  limb.  It  is  common,  indeed,  to  find 
the  surface  of  the  indolent  sore  '^  s/tjiu/hiiii/ " — not,  liowever,  from  inflammatory  action, 
h\\t  h\m\  r.clremr  inihth'ii(x  ill  tli.e  (jidiinlatiiifj  forcf.  Under  these  circumstances  the  sur- 
face of  the  sore  becomes  covered  with  a  greenish,  often  fetid,  secretion,  the  granulations 
as  they  form  dying.  When  the  sore  is  large,  this  appearance  is  more  general  toward  its 
centre  or  lowest  part ;  and  as  repair  goes  on  the  sore  may  cicatrize  at  its  edges,  where  the 
granulations  derive  the  full  benefit  of  the  vascular  and  nerve  supply,  while  the  centre  of 
the  sore  still  sloughs.  In  old  people  the  margin  of  the  .sore  may  slough  in  one  part  and 
heal  in  another.  Authors  have  described  this  indolent  sore  in  the  old  as  atuHr.  uher. 
These  sores  are  very  common,  and  are  usually  found  in  the  lower  extremities — often,  too, 
associated  with  varicose  veins;  this  condition  of  veins  has,  however,  little  to  do  with  their 
origin,  although  it  tends  much  to  retard  their  recovery.  These  have  been  described  by 
old  authors  as  vnricosi'  ulcers  simply  from  the  fact  of  the  two  conditions  being  often 
found  together.  Such  are  almost  always  found  in  weak  subjects  with  a  feeble  circula- 
tion. 

Till'  TREAT.MKXT  o/'  flipse  iiidoinif  sonn  consists  in  encouraging  the  venous  circulation 
of  the  i)art  by  its  elevation,  and  by  pressure  where  this  cannot  be  secured  by  rest,  and  by 
local  stiujulants  and  general  tonic  treatment.  For  pressure,  there  is  nothing  equal  in 
value  to  the  pure  rubber  bandage  well  applied,  as  recommended  by  II.  Martin  of  Massa- 
chusetts in  1877  ( 7'/v^n.s-.  of  Ameririin  Med.  Association^.  When  there  is  little  or  no 
action  in  the  sore,  the  application  of  one  or  more  blisters  to  the  surface  is  very  beneficial, 
or  blistering  liquid  may  be  painted  over  its  edges.  When  the  surface  is  sloughing,  half 
an  ounce  of  carbolic  acid  or  six  ounces  of  terebene  to  a  pint  of  olive  oil,  with  or  without 
the  extract  of  opium,  according  to  the  amount  of  pain,  forms  an  excellent  application. 
Where  the  edges  of  the  sore  are  indurated  and  callous,  so  that  the  cicatrization  and  con- 
traction are  almost  impossible,  the  free  scarification  of  the  margin  every  half  inch  is  often 
followed  by  a  rapid  change  for  the  better,  or  two  free  incisions  may  be  made  on  either  side 
of  the  margin  of  the  sore  for  the  same  purpose.  During  this  treatment,  if  the  venous 
circulati(ui  is  assisted  by  raising  the  leg  higher  than  the  hip,  the  utmost  good  may  be 
obtained.  In  private  practice,  when  the  leg  can  be  dressed  daily,  the  ulcer,  with  its  dres.s- 
ing,  and  the  wliole  limb  may  be  covered  with  strapping.  The  strapping,  therefore,  ought 
to  be  good — not  such  thin  material  as  that  spread  on  calico  nor  thick  felt  strapping,  but 
that  spread  on  linen,  such  as  is  used  at  Guy's  Hospital.  The  rubber  bandage  is^  how- 
ever, to  be  preferred  to  the  strapping. 

When  the  sore  is  painful  or  the  patient  has  an  irritable  pul.se.  the  beneficial  effects  of 
opium  twice  a  day  in  a  pill  are  very  marked,  and  quinine,  iron,  nux  vomica,  or  the  vege- 
table bitters  may  be  given,  as  the  wants  of  the  case  indicate.  The  bowels  also  require 
attention,  drachm  doses  of  the  sulphate  of  magnesia,  with  quinine,  being  a  good  aperient. 
When  the  sore  is  unusually  large  and  there  is  little  probability  of  the  whole,  from  loss  of 
skin,  healing,  fresh  centres  of  cntijii-atioii  should  be  inserted  by  transplantation.  In  this 
way  I  have  brought  about  the  cicatrization  of  a  large  sore  of  twenty-four  vears'  stand- 
ing in  three  weeks,  and  many  others  of  smaller  size  in  an  equally  short  period  :  indeed, 
by  this  practice  of  skin-grafting,  I  believe  the  necessity  of  amputation  in  the  more  severe 
forms  of  this  affection  will  be  greatly  diminished,  for.  hitherto,  indolent  ulcers  that  sur- 
round a  limb  have  ever  proved  themselves  incurable,  amputation  being  their  only  remedy. 


76  ULCERS  AND  SORES. 

All  sores  may  inflame  or  become  irritable,  but  there  is  an  injlamed  aore  or  nicer  which 
is  found  in  subjects  with  thin  and  fair  skins  who  are  in  some  way  reduced  in  power  or 
"  out  of  sorts,"  either  from  irregular  living,  overwork,  or  bad  feeding.  It  appears  as  a 
small  superficial,  inflamed,  irritable  sore  with  a  raw-looking  appearance,  an  ash-colored 
slough,  or  thick  secretion  over  its  surface,  and  discharges  a  thin  ichorous  fluid  sometimes 
tinged  with  blood.  The  patient  will  complain  of  its  exces.sive  painfulness,  particularly  at 
night,  and  will  dread  its  being  touched.  It  will  look  red  and  angry,  though  superficial. 
A  blow  or  a  graze  may  have  caused  it,  or  a  local  patch  of  eczematous  inflammation  pre- 
ceded it,  in  which  case  it  may  be  described  as  an  ecznnatous  nicer. 

The  TRE.\TMENT  of  these  sores  is  very  troublesome,  the  skin  being  usually  highly 
sensitive.  They  always  want  soothing,  and  the  best  lotion  is  one  of  diacetate  of  lead 
mixed  with  the  extract  of  opium  ;  but  this  sometimes  irritates,  while  the  lead  or  zinc 
ointment  gives  comfort.  At  other  times  a  cold  bread  poultice  is  the  best  application.  In 
all  cases  the  limb  wants  rest  and  elevation.  In  the  eczematous  sore,  where  the  discharge 
from  the  eruption  round  the  sore  is  profuse,  the  powdered  oxide  of  zinc  and  starch,  in 
equal  proportions,  may  be  used,  or  the  surface  may  be  washed  with  a  solution  of  nitrate 
of  silver  in  the  proportion  of  ten  grains  to  the  ounce.  Occasionally  a  solution  of  the 
extract  of  opium  is  the  best  lotion.  Simple  nutritious  food,  with  a  moderate  allow- 
ance of  stimulants,  should  be  administered,  but  all  high  feeding  is  injurious.  The  general 
health  mostly  requires  tonics  of  a  non-stimulating  kind,  such  as  the  vegetable  bitters  with 
alkalies,  as  the  intestines  are  generally  irritable.  When  the  pain  is  severe,  opiates  and 
sedatives  are  indicated.  In  very  inflamed  ulcers  the  application  of  a  few  leeches  at  some 
distance  from  their  edge  occasionally  gives  relief.     These  sores  are  invariably  obstinate. 

Authors  describe  a  varicose  nicer,  but  does  such  an  ulcer  exist?  Many  indolent  sores 
are  doubtless  associated  with  varicose  veins,  and  are  probably  indolent  on  account  of  this 
association;  but  how  far  they  are  really  caused  by  them  is  a  diff'erent  matter,  for  vari- 
cose veins  and  ulcers  of  all  kinds  are  constantly  met  with  together.  Of  all  ulcers 
entitled  to  the  term  "  varicose,"  the  eczematous  has  probably  the  most  claim  ;  for  cer- 
tainly eczema  of  the  leg  is  a  common  consequence  of  varicose  veins,  and  an  ulcer  the 
result  of  the  eczema. 

Practically,  however,  it  is  well  to  remember  that  when  varicose  veins  exist  v;ifh  an 
ulcer  repair  cannot  go  on  favorably  unless  the  venous  circulation  of  the  limb  be  assisted 
by  position  or  pressure,  and  that  where  these  varicose  veins  are  present  all  ulcers  or 
sores,  if  neglected,  are  disposed  to  become  indolent.  When  an  ulcer  takes  its  origin  from 
an  inflamed  vein,  the  term  is  applicable  in  a  measure,  but  this  ulcer  has  no  special  cha- 
racteristics. 

Sores  that  are  prevented  from  healing  by  varicose  veins  must  be  treated  by  the  ele- 
vated position  of  the  limb  or  by  the  use  of  the  rubber  bandage  or  strapping,  and  in  bad 
cases  by  the  obliteration  of  the  veins.  Without  this  obliteration  the  treatment  will  of 
necessity  fail ;  whereas  with  it  the  sore  may  be  expected  to  heal  with  the  use  of  such 
general  and  local  means  as  its  nature  may  require. 

How  fir  it  is  right  to  heal  an  old  chronic  sore  has  not  yet  been  quite  decided.  Older 
surgeons  declared  it  to  be  inexpedient,  as  cases  were  met  with  in  which  apoplexy  or  some 
other  alarming  condition  supervened.  Modern  surgeons,  however,  are  disposed  to  ques- 
tion the  explanation  of  these  facts,  and  to  look  upon  that  practice  as  beneficial  which 
removes  any  abnormal  condition,  local  or  general.  Still,  it  is  wise,  when  a  patient  has 
been  in  the  habit  of  losing  by  discharge  from  the  surface  of  a  sore  a  certain  amount  of 
material  which  would  otherwise  have  been  used  to  maintain'  the  general  powers,  to  cut 
ofl"  the  supplies  in  another  way,  to  order  more  abstemious  living,  and  to  regulate  the 
bowels  by  some  saline  water,  natural  or  artificial,  as  may  suit  the  stomach. 

Sloughing  and  phagedsenic  sores  are  rarely  seen  except  in  connection  with 
syphilis  or  hospital  gangrene.  In  syphilis  sloughing  is  found  in  the  intemperate  and  ill- 
fed,  and  mostly  in  gin-drinking  pi'ostitutes.  It  attacks  any  surface  that  has  been  made 
sore  either  from  venereal  contact  or  other  causes,  and  it  is  marked  by  the  rapid  way  in 
which  the  process  destroys  tissues,  by  the  foetid  character  of  the  discharge,  the  great 
depression  of  power  which  is  an  invariable  accompaniment,  and  the  constitutional  di.s- 
turbance. 

Opium  in  full  doses  is  required  for  their  tre.\tment,  with  tonics  and  good  nutritious 
food.  When  these  means  do  not  control  the  ulcei-ation,  the  application  of  strong  nitric 
acid  with  a  piece  of  wood  to  the  surface  of  the  sore  is  often  useful ;  sometimes,  too,  the 
local  application  of  iodoform,  iodine,  or  bromine  in  solution  is  of  great  benefit.  Fresh 
air  is  always  indicated,  and  abundance  of  disinfectants,  such  as  Condy's  fluid,  terebene, 


ULCERS  AND  SORES.  77 

or  i'ail>nlic  iicitl  in  sonic  oi'  its  iorms.  Those  sores  arc  mostly  due  to  some  feeble  coristitu- 
tioMiil  ('omlitiou,  and  not  to  a  loi-al  cause,  altliou;;h  at  times  the  action  seems  local,  when 
the  applieation  of  .somc^  j)owerf"ul  escharotic,  such  as  nitric  acid,  is  called  i"or. 

Sir  J.  I'ajrc't  descrilu'S  rnlil,  ulo  rs:  "  They  are  like  small  inflammatory  ulcers  occurring 
spontaneously  in  the  extremities,  especially  at  the  ends  <.>{'  the  fingers  or  toes  or  at  the 
roots  of  the  nails.  In  some  eases  they  are  pnu-eded  l>y  severe  pain  and  small  garigrenou.s 
spots.  They  are  in  many  respects  like  ulcerated  chilblains,  but  they  occur  without  any 
exposure  to  intense  cold  in  patients  whose  feet  and  bands  are  commordy,  «tr  even  habitu- 
ally, but  little  warmer  than  the  atmosphcn;  they  live  in.  Such  patients  arc  among  tln)se 
who  say  they  are  never  warm,  and  tiic  skin  of  their  extremities,  uidess  artificiallv  heated, 
is  to  the  touch  like  the  surface  of  a  cold-blooded  animal.  With  this  defect,  which  is  com- 
mon in  women,  there  is  a  small  feeble  pulse,  a  dull  or  half-livid  tint  in  the  parts  which 
in  healtliy  pcnplc  are  rmldy.  a  weak  digestion,  constipated  bowels,  and  scanty  men- 
struatinii. 

"  The  cure  of  the  ulcers  and  prevention  of  their  recurrence  lie  in  the  remedv  of  these 
defects.  Many  tonic  uiedieines  may  be  useful,  but  the  mo.st  so  is  iron  ;  with  it  purga- 
tives are  generally  neces.sary — ?..</.,  small  doses  of  mercury  and  aloes  or  .sulphate  of  mag- 
nesia. Full  diet,  exercise  in  the  fresh  air,  dry  warm  clothing,  especially  of  the  lower 
half  of  the  body,  and  warm  bathing  are  required ;  dry  applications  or  lotion  of  sulphate 
of  zinc  or  copper  are  the  best  local  means,  and  the  part  must  be  kept  warm  ;  healing  is 
always  tardy  at  a  low  temperature." 

Allied  to  cold  ulcers  are  those  formed  on  fingers  or  other  parts  which  have  been 
deprived  of  their  nerve  supply  by  some  injury. 

Scorbutic  Ulcer. — In  Sir  J.  Paget's  able  article  in  Holmes's  Sijstem  occurs  the 
following  description  of  the  .scorbutic  ulcer  by  Mr.  Busk  :  "Although  scurvy  in  itself 
cannot  be  said  to  be  attended  with  any  peculiar  form  of  ulceration,  ulcers  or  sores  of 
any  kind  already  existing  from  other  causes  assume,  in  consequence  of  this  .scorbutic 
taint,  a  more  or  le.ss  peculiar  character,  and  when  thus  modified  have  been  usually  termed 
*  scorbutic  ulcers.' 

"  Scurvy  essentially  consists  in  an  alteration  in  the  constitution  of  the  blood  which 
leads  to  the  effusion  into  the  various  tissues  of  a  fihrinona  exiulafion,  usually  deeply 
colored,  and  which  has  on  that  account  been  commonly  regarded  as  a  simple  coagulum. 
That  this  effusion,  however,  can  scarcely  be  regarded  in  this  light  is  proved  by  several 
considerations,  but  more  especially  by  the  circumstance  that  it  is  from  the  first  soIi</  and 
capable  of  hecominc/  imperfecth/  organized — that  is  to  say,  it  is  after  a  time  permeated  by 
newly-formed  vascular  channels.  It  is  tlie  presence  of  this  effusion  which  causes  the 
spongy  swelling  of  the  gums,  the  tumefaction  and  induration  of  the  intermuscular  tissue, 
the  so-termed  scorhutir  nodes,  and  which,  when  poured  out  on  the  surface  or  in  the  sub- 
stance of  the  corium,  constitutes  the  vibices  and  petechijfi  so  characteristic  of  the  di.sease. 
It  is  the  effusion,  also,  of  flie  same  sent  ip  fas  fie  material  on  flie  free  siir/ace  of  sores  or  ulcers 
which  gives  them  the  pernliar  aspect  termed  scorhiifiey 

"  Ulcers  of  this  kind  are  distinguished  by  their  livid  color  and  irregular  tumid  border, 
around  which  no  trace  of  cicatrization  is  evident,  whilst  the  surface  of  the  sore  is  covered 
with  'a  spongy,  dark-colored,  strongly  adherent,  foetid  crust,  whose  removal  is  attended 
with  free  bleeding  and  is  followed  by  a  rapid  reproduction  of  the  same  material.  This 
cru.st.  in  bad  cases,  as  remarked  by  Lind,  attains  to  a  '  mon.strous  size,'  and  constitutes 
what  has  been  appropriately  termed  by  sailors  '  bullock's  liver.'  " 

The  Syphilitic  Superficial  Sore. — The  deep  cellulo-membranous  syphilitic 
sore  has  been  already  ilescribed  (page  74).  under  the  heading  of  constitutional  sores,  but 
the  superficial,  cutaneous,  rupial  sypliilitic  sore  deserves  notice  because  it  is  verv  common. 
It  mostly  succeeds  an  ecthyma  or  rupia,  is  mixed  with  the  eruption  in  some  other  stages, 
and  is  simply  an  ulceration  of  the  base  of  a  syphilitic  eruption.  This  goes  on  increasing 
irregularly  in  a  serpiginous  form,  the  sore  healing  in  one  place  and  spreading  in  another, 
but  it  involves  only  the  skin.  The  edges  of  the  .sore — or  sores,  for  they  are  often  numer- 
ous— are  usually  well  defined,  and  frequently  irregular;  the  surface,  too.  is  generally  of 
a  deep  color,  and  when  healing  may  either  scab  or  granulate,  as  any  other  sore.  "They 
are  met  with  at  any  period  after  the  fir.st  constitutional  symptoms  of  syphilis  have  passed 
away,  and  occasionally  at  a  remote  date ;  they  are  always  found  in  a  cachectic  or 
enfeebled  subject  ;  indeed,  it  appears  as  if  want  of  power  allowed  the  disease  to-  manifest 
itself  in  the  new  form. 

The  treatment  of  these  sores,  when  once  they  have  been  recognized,  is  not  usually 
difficult.     Tonics,  with  the  iodide  of  potassium  or  sodium,  in  doses  of  from  three  to  ten 


78  BED-SORES. 

grains,  usually  effect  a  cure — at  least,  for  a  tinu' ;  liquor  cinchontc  and  compound  spirit 
of  ammonia  in  half-drachm  doses  are  also  good  remedies.  In  other  cases  the  mineral 
acids,  ((uinine,  or  iron  is  indicated.  Mercurial  remedies  are  sometimes,  though  rarely, 
necessary  ;  and  of  these  the  perchloride  of  mercury,  in  doses  of  one-sixteenth  of  a  grain 
in  bark,  green  iodide  in  one-grain  doses  in  a  pill,  or  the  mercurial  suppository,  are  the 
best  forms  to  employ. 

Locally,  the  sores  may  be  dressed  with  any  simple  dressing ;  but  when  indolent, 
a  mercurial  lotion,  as  the  black  wash,  is  the  best. 

Lupus,  for  convenience'  sake,  must  be  classed  amongst  the  ulcers.  It  is  met  with 
in  two  forms — the  '■'■lupna  ert/tliemafosiis'^  and  the  ^'  lupus  vulfjaris,'"  the  latter  being  more 
common  in  young  scrofulous  subjects,  and  the  former  in  the  middle-aged.  When  asso- 
ciated with  a  spreading  ulceration,  it  has  been  called  "  fupus  exedfus.'" 

The  "  lupus  erythematosus"  occurs  chiefly  upon  the  face  and  is  symmetrical  ;  each 
patch  has  well-defined  edges  and  a  red.  scaly  surface,  wnth  small  horny  points  upon  it, 
due  to  accumulation  in  the  dilated  mouths  of  sebaceous  ducts.  The  "  lupus  vulgaris" 
has  its  origin  in  a  skin  tubercle,  or  tubercles,  of  a  flat  form,  fleshy  consistence,  and  pink 
shining  appearance ;  and  these  at  times  ulcerate.  This  lupus  ulceration,  when  once 
originated,  progresses  steadily,  destroying  every  tissue  it  attacks,  and  when  it  reaches  the 
nose — its  very  favorite  seat — it  simulates  cancer.  The  surface  of  the  sore  is  sometimes 
free  from  all- signs  of  granulations  and  often  very  irregular,  while  the  edges  are  ragged, 
raised,  and  often  everted.  It  is  painless.  The  tubercles  themselves  feel  spongy,  are 
neither  .so  hard  nor  so  well  defined  as  cancer ;  they  are  composed  of  granulation  tissue. 

These  lupus  ulcers  are  more  commonly  found  on  the  face  than  elsewhere,  and  probably 
next  in  frequency  on  the  female  genitals.  They  are  most  destructive  when  left  alone, 
but  often  very  amenable  to  treatment.  In  young  adult  life  they  are  uiore  common  than 
in  the  old,  and  appear  closely  allied  to  tuberculosis. 

Treatment.— -Although  the  disease  has  probably  a  constitutional  origin  and  requires 
tonic  treatment,  both  by  medicine  and  regimen,  there  is  no  disease  that  derives  more 
benefit  from  local  treatment.  When  the  ulceration  is  superficial  and  the  skin  is  not  deepljr 
infiltrated,  the  local  application  of  cod-liver  oil  on  lint  and  the  covering  up  of  the  part 
with  cotton-wool  to  keep  it  warm  at  times  works  wonders.  But  under  other  circum- 
stances, when  the  skin  is  deeply  involved  and  infiltrated  with  disease,  the  free  removal  of 
the  whole  growth  is  the  most  efficient  treatment;  and  this  may  be  carried  out  by  care- 
fully scraping  the  surface  of  the  growth  or  by  destroying  it  with  the  cautery  or  caustics. 

The  most  successful  method  is  unquestionably  the  scraping,  so  long  as  it  is  done 
boldly  and  effectually,  for  every  particle  of  infiltrating  tissue  must  be  scraped  away  ;  and 
a  blunt  knife  or  a  sharp  spoon  is  the  best  instruTuent  to  use.  After  scraping,  it  is  well 
to  dress  the  wound  with  lint  soaked  in  liquid  carbolic  acid.  If  a  healthy  action  follows 
the  operation,  all  is  well  and  the  parts  will  heal  under  a  dressing  of  cod-liver  oil.  If  any 
signs  of  disease  reappear,  the  sharp  spoon  should  be  at  once  reapplied. 

When  scraping  is  rejected,  the  free  use  of  the  electric  or  gas  cautery  may  be  substi- 
tuted; and,  so  long  as  the  local  disease  is  effectually  destroyed,  the  choice  of  means  is  not 
very  material.  These  means,  however,  have  entirely  set  aside  the  use  of  escharotics.  In 
exceptional  cases  excision  may  be  beneficial. 

BED-SORES. 

In  theory  bed-sores  should  never  occur,  yet  in  practice  they  appear  in  certain  cases 
in  spite  of  the  greatest  care  and  attention.  It  is  well,  however,  for  the  surgeon  to  act 
upon  the  theory,  as  by  so  doing  he  is  stimulated  to  do  everything  in  his  power  to  guard 
against  their  occurrence  ;  and  no  better  illustration  of  the  old  adage,  '•  Prevention  is 
better  than  cure,"  could  be  found  than  in  such  a  case. 

Bed-sores  may  briefly  be  described  as  the  death  of  a  part  from  mechanical  pressure, 
the  parts  involved  in  some  cases  literally  dying  from  being  deprived  of  their  nourishment 
by  prolonged  and  continued  pressure  ;  in  others,  from  some'inflammatory  action  induced 
by  it.  "  ^ 

Bed-sores  may  arise  in  healthy  subjects  who  are  kept  unmoved  for  ten  or  fourteen  days, 
but  in  the  old.  the  fat,  or  very  thin  they  may  occur  at  an  earlier  date,  as  they  do  in  fever 
cases  of  all  kinds,  and  in  spinal  or  partially  paralytic  cases ;  completely  paralyzed  parts 
are  less  prone  to  slough  than  the  partially  paralyzed. 

Dirt  and  moisture,  under  all  circumstances,  accelerate  their  appearance. 

A  bed-sore  may  appear  as  a  simple  abrasion,  a  sloughing  of  the  skin  or  subcutaneous 


MonriFlcATIOS.  79 

tissue,  and  in  severer  cases  the  exposetl  Imiie  may  ilie,  ami  in  the  worst  the  spinal  canal 
may  he  opened. 

Thkat.mknt. — Since,  as  a  rule,  tlicy  are  caused  hy  cuntinual  prcs.siire  on  a  jiart,  they 
may  very  geneniUy  he  averted  hy  some  ehanire  of  the  patient's  position.  The  necessary 
amount  of  movement  nuiy,  as  a  rule,  he  allowed  in  all  medical  and  in  m<jst  surpical  cases, 
but  local  pressure  under  all  circumstances  should  he  periodically  relieved. 

The  skin  of  the  part  pressed  upon  should  he  hardeiu-rl  hy  washing:  it  at  least  twice  in 
the  twentv-four  houis  with  some  camphor  spirit  ami  water,  vincfrar  and  water,  or  nitrous 
ether  and  water,  in  the  proportion  of  one  jiart  to  three.  An  artificial  coveriji;:  of  the 
fle.Kihle  collodion  is  occasionally  of  jrrcat  use. 

When  the  parts  are  about  to  slou<rh.  these  applications,  liowever,  are  useless,  and  noth- 
ing Imt  the  removal  of  pressure  will  suffice.  With  tliis  ol>ject,  well-filled  water  beds  and 
water  (u-  air  cushions  should  lie  employed.  I  have  found  a  mattress  divided  transversely 
into  three  parts  and  a  water  cushion  substituted  for  the  middle  section  of  great  use.  At 
other  times  the  sections  of  the  mattress  may  be  simply  separated  for  a  few  inches  in  the 
line  of  pressure. 

In  spare  patients,  where  the  spinous  processes  of  the  vertebra?  are  prominent,  thin 
slips  of  felt  plaster  placed  vertically  down  the  back  give  great  relief,  and  the  .same  plaster 
applied  to  other  painful  parts  is  of  value;  cu.shions  of  amadou  and  well-adjusted  pads  of 
cotton-wool  or  spongio-piline  are  also  always  of  service. 

When  sloughing  is  present,  a  linseed-and-bread  poultice  with  a  solution  of  carbolic 
acid,  of  iodine.  Condy  s  fluid,  or  charcoal  sprinkled  upon  the  surface  is  the  best  applica- 
tion, though  a  carrot  or  yeast  poultice  occasionally  cleans  the  wound. 

When  the  slough  has  separated,  some  .stimulating  lotion  or  ointment  may  be  required  ; 
and  this  is  best  applied  on  cotton-wool.  The  glycerine  of  boracic  acid  or  a  lotion  of 
chloral,  gr.  x  to  the  ounce,  is  the  best  application. 

In  all  cases  where  patients  have  to  rest  for  a  lengthened  period,  careful  attention 
should  be  paid  to  keep  the  bed  smooth  and  the  sheets  free  from  rucks.  Corded  or 
feather  beds  should  not  be  used.  The  best  is  a  horse-hair  mattress  placed  upon  a 
second  or  spring  bed. 

MORTIFICATION,  TRAUMATIC,  ARTERIAL,  AND  VENOUS. 

The  mortification  of  any  part  of  the  body  signifies  its  death.  When  a  soft  part  is 
"  dying."'  it  is  said  to  be  in  a  state  of  '•  gangrene ;  "  and  when  "  dead,"  in  that  of 
"sphacelus."  The  dead  portion  is  called  a  *•  slough,"  and  the  process  of  separation  the 
act  of  "sloughing."  When  bone  is  dead,  the  term  "  necrosis  '  is  employed,  the  dead 
portion  being  called  the  "sequestrum"  and  the  process  of  its  separation  "  exfoliation." 

The  dead  portion  of  any  tissue  is  thrown  off  from  the  living  by  means  of  ulceration  ; 
and  when  the  slough  has  separated,  the  parts  heal  by  granulation,  as  an  ordinary  wound. 
In  the  "  sloughing  phagedaena  "  the  two  processes  of  ulceration  and  sloughing  are  com- 
bined, the  molecular  death  of  a  part,  or  ulceration,  going  on  with  the  more  general 
destruction  of  gangrene. 

Ca.ses  of  mortification  may  Vte  divided  into  three  main  groups  according  their  causes — 
viz. : 

Traumatic  ;   anaemic,  or  arterial ;  static,  or  venom. 

Trmininfir  gangrene  includes  cases  brought  about  by  external  violence  or  chemical 
action,  the  term  "  direct "  being  applied  to  those  in  which  the  vitality  of  the  part  is 
destroyed  at  once,  and  "  indirect  "  where  the  .same  result  is  brought  about  by  the  inflam- 
matory action  which  follows  an  injury. 

Anaemic  or  arterial  gangrene  includes  cases  in  which  a  part  is  .starved  from  the  obstruc- 
tion of  its  artery,  either  from  operation,  accident,  or  disea.se. 

Static  or  venous  gangrene  includes  those  in  which  .stagnation  of  blood  is  cau.sed  by 
the  mechanical  arrest  of  the  circulation  through  the  veins,  complicated  or  not  with 
secondary  inflammatory  action. 

In  ^h  and  all  of  these  groups  inflammation  plays  directly  or  indirectly  an  important 
part. 

Moist  and  Dry  Gangrene. — When  mortification  takes  place  in  tissues  that  are 
filled  with  Idood.  and  more  particularly  with  inflammatory  fluids,  "moist,  hot,  or  humid 
gangrene  "  is  produced  ;  biit  when  it  take  place  in  parts  in  which  no  such  stasis  exists, 
and  where  death  of  the  tissues  is  the  result  of  a  want  of  arterial  supply,  "  dry.  cold,  or 
chronic  ganirrene  "  is  caused.     These  two  forms,  however,  are  in  a  measure  convertible, 


80  MORTIFICA  TION. 

the  rapidity  of  the  proce.s.s  and  the  amount  of  inflammatory  infiltration  influencing  the 
result. 

Tissues  suiFering  from  defective  nutrition,  either  as  the  result  of  some  want  of  nerve 
supply  or  energy  or  of  extreme  debility  the  consequence  of  severe  illness  or  other  depress- 
ing influence,  are  more  prone  than  others  to  mortify  on  slight  causes. 

Direct  traumatic  gangrene  is  well  exemplified  in  the  destruction  of  skin  from 
the  contact  of  a  corrosive  acid,  such  as  sulphuric  or  nitric,  in  bad  burns  and  "  smashes." 
It  is  also  well  illustrated  in  cases  of  extravasation  of  urine  or  faeces,  and  probably  also  by 
the  action  of  some  animal  poisons. 

Indirect  traumatic  gangrene  is  also  well  seen  in  the  integument  after  the 
application  of  a  blister  to  a  child  or  feeble  patient,  the  blister  being  followed  by  inflam- 
mation of  the  blistered  part  and  its  subsequent  death.  It  is  more  frequently  met  with, 
however,  in  bad  compound  fractures  in  which  the  limb  swells  a  few  days  after  the  acci- 
dent and  the  skin  assumes  a  mottled  and  livid  hue  ;  loose  blisters  or  phlyctenae  of  raised 
cuticle  appear  on  the  surface,  containing  more  or  less  bloodstained  serum,  and  the  tissues 
become  sooner  or  later  cold  and  insensible,  the  temperature  of  the  part  often  falling 
rapidly.  The  fluids  from  the  wound,  likewise,  soon  become  ofl"ensive.  blood-stained,  and 
mixed  with  gas,  and  the  tissues  crepitate  on  pressure  from  its  presence. 

Line  of  Demarcation. — The  gangrene  may  be  limited  or  spreading.  When  the 
action  has  attained  its  limit,  a  defined  vascular  line,  "  the  line  of  demarcation,"  appears 
where  the  living  tissues  come  in  contact  with  the  dead.  In  this  vascular  line  ulceration 
takes  place,  and  if  left  to  take  its  course  leads  to  the  separation  of  the  slough  from  the 
living  tissues.  By  it  soft  parts,  and  even  bone,  may  be  divided,  the  granulations,  as  they 
spring  up  during  the  process  of  repair,  materially  assisting  the  ca.sting  ofl"  of  the  slough. 
AVhen  the  deeper  tissues  of  a  limb  are  thus  afi"ected.  they  rapidly  decompose  and  give  rise 
to  a  horrible  foetor,  the  extent  of  decomposition  depending  much  upon  the  fluids  in  the 
part.  Should  the  limb  be  exposed,  the  integument  will  dry,  become  black,  and  gradually 
wither,  while  the  soft  parts  beneath  will  undergo  decomposition. 

This  process  is  rarely  attended  with  haemorrhage,  the  vessels  becoming  obstructed  by 
the  coagulation  of  their  blood  during  the  sloughing  action.  In  exceptional  cases,  how- 
ever, the  vessels  give  way,  the  more  rapid  the  sloughing  action  in  the  part,  the  greater, 
apparently,  being  the  liability  to  bleed. 

Anaemic  Gangrene. — The  best  examples  of  this  group  are  found  after  the  appli- 
cation of  a  ligature  to  a  large  artery,  such  as  the  femoral,  for  aneurism  or  injury  ;.  after 
the  contusion  or  stretching  of  an  artery  (rA/e  Fig.  134)  or  its  embolic  plugging.  In  all 
these  instances  the  part  dies  by  starvation  from  want  of  blood  ;  and  the  more  sudden  the 
act  by  which  the  supply  is  cut  off",  the  greater  is  the  probability  of  gangrene  being  the 
result.  The  more  gradual  occlusion  of  an  artery,  except  in  the  aged,  is  more  rarely  fol- 
lowed by  such  a  result,  the  collateral  circulation  preventing  it.  In  the  form  of  gangrene 
called  "  senile  "  it  is  very  probable  that  arterial  obstruction,  the  result  of  atheromatous 
arterial  disease  or  of  embolic  plugging  of  the  vessel  from  the  breaking  loose  of  some 
portion  of  the  diseased  arterial  coats,  is  the  immediate  cause  of  the  gangrene ;  but  the 
feebleness  of  old  age,  the  degeneration  of  the  tissues  that  have  been  badly  supplied  with 
arterial  blood,  coupled  often  with  some  slight  local  injury,  are  doubtless  powerful  agents 
in  giving  efi'ect  to  the  process.  One  or  more  of  these  agents  may  be  the  true  cause  of 
the  gangrene,  but  in  the  majority  of  cases  they  are  probably  combined.  When  the  gan- 
grene is  purely  a  dry  withering  or  mummifying  process,  the  cause  is  probably  the  simple 
want  of  blood  supply  ;  but  when  inflammation  coexists,  the  gangrene  will  be  moist,  the 
feebly-nourished  tissues,  either  from  injury  or  otherwise,  becoming  inflamed  from  some 
accidental  cause,  and  ultimately  dying. 

In  the  gangrene  met  with  from  arteritis  or  embolism  in  the  young  or  middle-aged,  the 
dry  form  is  the  usual,  the  parts  becoming  cold,  bloodless,  waxy,  rapidly  withering,  turn- 
ing black,  and  then  mummifying.  When  caused  by  embolism,  the  onset  of  the  gangrene, 
or  rather  the  early  indication  of  the  plugging  of  the  vessel,  is  marked  by  a  sudden  shoot- 
ing or  crampy  pain  down  the  extremity,  this  symptom  being  speedily  followed  by  those 
of  "  arterial  gangrene." 

When  the  occlusion  of  the  vessel  is  gradual,  this  pain  is  not  present  and  the  symp- 
toms of  gangrene  are  more  chronic. 

Gangrene  from  "  cold  "  may  be  the  direct  result  of  want  of  blood  supply,  or  may  be 
indirectly  caused  by  the  inflammation  due  to  excessive  reaction  from  cold  ;  this  latter 
form  is  called  secondary  mortification.  Gangrene  following  the  use  of  the  "  ergot  of 
rye  "  is  dry,  and  follows  precisely  the  same  cour.se  as  when  due  to  arterial  obstruction. 


MnirniKArins.  81 

Static  Gangrene. — Tin-  liot  illu^tiatiuns  lA'  this  varit-ty  of  ^aiifrrcno — which 
results  fruni  i>hgtnirhiiii — are  sct'ii  in  cases  ot"  st laiiLruhitcfl  femoral  hrniia  ;  where  splints 
are  t(i(t  tiirhtly  applieil  ;  after  the  jirol()ii;;ed  employment  of  the  tonrnifjuet  to  cheek 
hii'inorrhaire  ;  in  a  ti;iht  paraphyinosis  ;  in  slou<rhin.i;  of  protrmliriL'  pih's  ;  in  the  {ranjrrene 
of  a  liml)  from  the  pressure  of  an  aneurism  or  tumor  up<ui  the  chief  venous  trunks;  in 
the  sloii^hini;  of  the  leirs,  groins,  or  otlier  parts  of  patients  sufferiufr  from  some  obstruc- 
tive lu'art  disease.  In  all  these  tlie  parts  may  dit:  from  blood  stasis  mechanically  j)ro- 
duced.  thouirh  inflammation  more  or  less  marked,  with  its  products,  has  generally  an 
important    influence  in   j)rodueing  the   result. 

Mortification  is  thus  a  com])ound  process,  and  is  brouL'lit  about  bv  mixcil  cau.ses, 
direct  injury,  want  of  arterial  sup])ly.  and  bhxjd  stasis  irom  a  mechanical  obstruction  to 
the  return  of  the  vcikmis  blood  beiufr  the  three  chief.  At  the  same  time,  in  each  of  tli«; 
three  ela.sses  of  cases  inflammatory  action  has  seccnidarily  an  important  influence.  Feeble- 
ness of  power  from  old  aire,  want  of  nutrition,  or  deficient  nerve  supply  in  a  jtart  at  the 
same  time  renders  a  patient  or  tissue  more  prone  to  the  action  of  tliese  cau.ses.  and  the 
process  more  active. 

The  constitutional  symjitonis  associated  with  jrangrene  vary  witli  its  cau.se,  but  under 
all  circumstances  a  depressed  condition  of  the  onlinary  powers  is  recofrnizable.  In  trau- 
matic inflammation,  durintr  the  stasre  of  excitement,  the  pulse  may  be  rapid  and  the  beat 
.stronj;:  there  may  be  hi^di  fever  and  other  .symptoms  indicative  of  sthenic  action;  but 
when  about  to  terminate  in  gangrene,  all  these  .symptoms  will  be  marked  by  a  sudden 
fall  of  the  temperature  of  the  body — .say  from  104*'  or  1(15°  to  !»9°  F.' 

When  the  mischief  is  extensive  and  the  gangrene  spreads,  what  are  known  as  typhoid 
symptoms  may  supervene.  In  the  more  acute  ca.ses  death  takes  place  very  rapidly,  but 
in  the  chronic  the  constitutional  symptoms  are  negative. 

Trkatmknt. — The  mr^st  important  point  the  surgeon  has  to  bear  in  mind  in  the  gen- 
eral treatment  of  every  form  of  mortification  is  that  the  condition  indicates  a  depressed 
state  of  tlie  sy.stem  ;  consef|uently,  his  eflFfjrts  should  be  directed  toward  maintaining  the 
patients  strength  and  cautiously  building  up  liis  feeble  powers  by  means  of  nutritious 
food,  stimulants,  and  tonics,  allaying  pain,  at  the  same  time,  by  local  and  general  sooth- 
ing remedies,  such  as  opium,  morithia,  or  chloral,  since  nothing  depresses  more  than  pain. 

In  the  local  treatment  of  gangrene  its  cau.se  has  closely  to  be  considered.  To  treat  a 
case  of  gangrene  the  result  of  a  local  injury  as  one  due  to  an  obstruction  of  an  artery 
would  be  clearly  wrong,  and  to  deal  with  an  example  of  this  latter  form  in  the  same 
manner  as  with  another  due  to  blood  stasis  the  result  of  mechanical  obstruction  to  the 
return  of  the  venous  blood  of  a  part  would  be  unscientific.  I  shall,  therefore,  consider 
the  question  of  treatment  as  applied  separately  to  the  three  groups  of  cases  already 
formed. 

Treatment  of  (Urect  traumatic  gangrene,  when  of  a  limifeil  nature,  need  cau.se  but  little 
anxiety.  It  should  be  treated  on  ordinary  principles  of  local  cleanliness,  poultices,  and 
irrigation,  or  the  local  application  of  absorbent  cotton,  with  some  antiseptic  lotion  such 
as  iodine  lotion,  sulphurous  acid.  Condy's  fluid,  carbolic  acid,  or  chloride  of  zinc,  is  all 
that  is  needed.  When  the  slough  has  come  away,  the  surface  is  to  be  treated  as  an  ordi- 
nary sore. 

When  the  gangrene  is  more  extensive  and  involves  possibly  a  portion  of  a  limb,  hut 
yet  define,!,  the  expediency  of  removing  the  dead  part  by  amputation  is  not  to  be  dis- 
puted. No  more  of  it,  however,  .should  be  sacrificed  than  is  absolutely  necessary,  and  to 
ensure  this  object  the  flaps  to  cover  the  end  of  the  stump  may  be  cut  of  any  shape. 
Thus,  in  gangrene  of  the  leg  it  is  better  to  amputate  below  the  knee  with  any  form  of 
flap  that  can  be  made  of  sufficient  size  to  cover  in  the  end  of  the  stump  than  at'the  joint, 
and  it  is  far  better  to  amputate  at  the  joint  than  above  it. 

The  treatment  of  indirect  fraumotir  or  inflammatory  gangrene  is  full  of  difliculties, 
more  particularly  when  .seen  in  a  ca.se  of  compound  fracture,  since  to  remove  a  limb  at 
once,  as  soon  as  the  action  has  declared  itself,  would  be  to  take  away  what  often  might  be 
saved  or  to  do  that  which  will  not  arrest  the  disease  ;  and,  on  the  other  hand,  to  defer  the 
removal  too  often  diminishes  the  prospect  of  recovery,  the  extension  of  the  mischief 
rendering  the  amputation  a  more  formidable  one  or  precluding  the  possibility  of  its  per- 
formance. It  is  xcise,  however,  in  all  cases,  to  amputate  tchen  the  gangrene  is  extending, 
oicing  to  the  ivfiltrafion    info  the  health//  ti.<<.-iues  of  the  decomposing  fluids  from  the  parts. 

In  a  case  of  compound  fracture  which  is  so  bad  as  to  suggest  the  necessity  of  primary 

amputation,  but  in  which  the  surgeon  has  been  desirous,  if  po.ssible.  of  saving  the  limb, 

'  Peck,  St.  Georges  Hospital  ReporU  for  1868. 
t> 


82  MORTTFK  'A  TION. 

the  first  onset  of  an  inflammatory  action  tliat  assumes  a  gangrenous  form  should  he  met 
by  amputation  ;  while  in  a  case  less  severe,  where  the  injured  limb  has  a  good  prospect 
of  being  made  a  useful  one,  an  attack  of  inflammatory  gangrene  need  not  necessarily  lead 
to  its  loss. 

Where  the  gangrene  is  due  to  the  injury,  it  will  probably  be  limited,  and  may  so 
terminate  that  a  good  limb  can  subsequently  be  secured.  Where  it  is  due  to  constitutional, 
and  not  to  local,  causes,  amputation  of  the  limb  will  not  arrest  it;  for  the  gangrenous  action 
will  in  all  probability  attack  the  stump  and  continue  till  it  finds  a  limit  or  destroys  life. 

When  the  gangrene  originates  from  a  local  cause,  amputation  is  clearly  the  best  prac- 
tice ;  but  when  from  a  constitutional  cause,  it  had  better  not  be  entertained  till  the  action 
has  ceased  and  a  limit  to  the  disease  been  formed.  In  military  surgery  there  may  be  many 
reasons  why  this  practice  cannot  be  observed,  for  all  conservative  surgery  or  treatment 
based  on  expectancy  has  to  be  sacrificed  to  the  exigencies  of  the  moment. 

How,  then,  it  may  be  asked,  is  spreading  gangrene  to  be  treated  ?  I  reply.  By  main- 
taining the  part  as  free  as  possible  from  all  foetid  dischai'ges  and  employing  incisions 
when  necessary  to  secure  these  ends,  by  local  cleanliness  and  the  use  of  antiseptic  applioia- 
tions,  and  internally  tonics  and  good  food. 

Under  this  practice,  when  nature  is  strong  enough  to  check  the  progress  of  the  disease, 
a  limit  to  its  extent  will  be  formed  and  the  local  affection  will  be  amenable  to  treatment ; 
but  when  no  limit  takes  place,  death  will  ensue,  which  amputation  would  not  have  arrested. 

When 'amputation  is  deemed  necessary  on  the  arrest  of  the  action,  the  limb  should  be 
removed  as  close  as  possible  above  the  diseased  part.  There  exists  no  necessity  to  saci'i- 
fice  any  tissue,  and  much  less  a  joint,  to  make  an  amputation  neat.  The  only  point  for 
consideration  is  that  the  diseased  tissues  should  be  avoided,  but  beyond  these  no  healthy 
structures  should  be  sacrificed. 

The  Treatment  of  Anirmic  or  Arterial  Gangrene. — The  surgeon's  object  should  be  to 
prevent  its  exten.sion,  and  to  assist,  when  called  upon,  the  separation  of  the  parts. 

To  carry  out  the  first  of  these,  the  mortified  parts  maybe  wrapped  in  some  lint  dipped 
in  simple  or  carbolized  oil ;  and  the  whole  extremity  should  be  raised,  to  encourage  the 
venous  circulation,  and  surrounded  with  cotton-wool,  to  maintain  its  warmth. 

A  liberal  allowance  of  bland  nutritious  food  should  be  given,  aided  with  stimulants 
and  tonics  to  assist  digestion  ;  the  circulation,  too,  should  be  sustained,  though  anything 
like  overstimulating  is  reprehensible.  Opium  also  may  be  given  to  allay  pain,  the  patient 
being  kept  gently  under  its  influence.  Where  small  parts  only  are  implicated  their  sepa- 
ration may  be  left  to  nature,  but  where  hands  or  feet  are  involved  in  the  gangrene  the 
surgeon  should  assist  nature's  processes  by  amputation  above  or  about  the  line  of  demarca- 
tion as  soon  as  indicated. 

AVhen  a  limb  dies  from  embolic  plugging,  occlusion  of  an  artery,  or  from  the  eff'ects 
of  ergot  of  rye,  amputation  may  be  performed  as  soon  as  the  line  of  demarcation  has 
been  indicated — that  is,  provided  the  general  condition  of  the  patient  be  such  as  not  to 
forbid  it.     In  "senile  grangrene"  the  interference  should  be  of  the  mildest  kind. 

Where  ''  sphacelus"  takes  place  after  the  application  of  a  ligature  to  a  large  artery, 
early  amputation  is  sometimes  called  for,  it  being  at  times  wise  to  remove  the  limb  above 
the  line  of  ligature  rather  than  to  wait  for  nature  to  indicate  the  point,  particularly  when 
the  limb  is  fcdematous  from  blood  .stasis  and  infiltrated  with  inflammatory  products,  this 
practice  saving  much  constitutional  disturbance  and  economizing  power.  In  cases,  how- 
ever, in  which  the  gangrene  assumes  the  an;<!mic  form  and  spreads  slowly,  a  line  of 
demarcation  may  be  waited  for,  more  particularly  when  the  constitutional  condition 
of  the  patient  is  good. 

In  the  treatmei)t  of  the  fJiird  group  of  cases.  fJio.se  of  ^^  .<<fafic  ffanc/rene^'  caused  by  the 
mechanical  obstruction  to  the  return  of  blood  from  a  part,  the  first  thing  to  be  done  is  to 
remove  the  cause.  In  hernia  this  is  accomplished  by  dividing  the  stricture  ;  in  paraphy- 
mosis,  by  freeing  the  prepuce ;  and  when  the  result  of  the  application  of  a  tourniquet  or 
splints,  by  their  removal.  By  this  course,  if  the  parts  involved  are  not  irreparably  lost, 
a  recovery  may  take  place  by  natural  processes,  their  venous  circulation  being  aided  by 
position  and  other  means.  When  gangrene,  however,  has  taken  place  in  a  limb,  its  early 
amputation  is  necessary,  it  being  wiser  to  remove  the  dead  part  at  once  before  the  setting 
in  of  secondary  inflammation,  which  may  spread  and  cause  more  loss  of  tissue,  the  point 
of  application  of  the  mechanical  force  fairly  indicating  the  extent  of  mischief. 

In  gangrene  of  a  limb  from  a  ruptured  artery  or  aneurism  the  same  practice  should 
be  resorted  to,  for  similar  reasons,  delay,  under  all  the  circum.stances,  being  unnecessarj 
as  well  as  injurious. 


HosviTM.  i;.{s<:ni':yE.  83 

HOSPITAL   GANGRENE, 

or  sltMiL'liiiiLr  |ili;ii:iilaMi:i.  is  an  iifrcciiun  tli;it  ;iit;nk>  wuiiikUmI  or  iiijiircfl  parts,  and  chiefly 
ill  ovorcntwtU'd,  hadly-vciitilatcd,  or  ill-drained  hospitals.  At  tiiiu-s  it  pn-sciits  itself  as 
if  jroiienitL'il  ill  a  ward  too  closi-ly  lillc([  with  patii-iits  who  have  sup[»uratiii^'  wounds;  at 
others,  as  if  eoiiveyeil  into  a  ward  Ity  the  introduetioii  of  a  sloii<:hiii^  or  f<etid  sore.  Want 
of  eh'aiiliness  in  the  treatment  of  suppurating:  wounds  and  want  of  attention  to  sanitary 
laws  have  undouhtedly  niiich  to  (ht  with  its  propagation,  for  the  di.sease  seems  to  be  eonta- 
irioiis  as  well  as  infectious,  througli  its  discharges.  Its  contagious  character  is  admitted  by 
all,  though  some  dispute  its  infectiousness,  (luthrie,  however,  in  his  (JommnitaritH^riiX&iQii 
the  following  striking  fact  bearing  upon  the  point:  '"  Hurgmans  says  that  hospital  gangrene 
prevailed  in  one  of  the  low  wards  at  Leyden  in  ITi'H,  whilst  the  ward  above  it  was  free. 
The  surgeon  made  an  opening  in  the  ceiling  between  the  two.  in  ctrder  to  ventilate  the 
lower  or  affected  ward,  and  in  thirty  hours  three  patients  who  lay  next  the  opening  were 
attacked  by  the  disease,  which  soon  spread  through  the  whole  ward." 

Tiro  forms  of  the  disease  exist.  In  one  the  gangrene  takes  place  by  small  sloughs 
and  tlu'  ulcerative  action  is  the  more  violent  ;  wounds  attacked  with  it  rajiidly  spread, 
and  skin,  subcutaneous  and  connective  tissues  all  disappear  under  its  action.  lilackadder 
relates  how  a  vesicle  forms  and  ulcerates  and  the  ulceration  ra})idly  spreads,  leaving  a 
sharp  well-defined  edge  to  the  ulcer.  This  form  of  the  affection  Delpech  designated 
"ulcerous,"  and  Boggie  "'phagedaena  gangrenosa." 

In  the  second  form  the  tissues  die  in  masses,  forming  pale,  ash-colored,  pultaceous, 
horribly  offensive  sloughs,  these  sloughs  giving  the  old  term  "  putrid  degeneration"  to 
the  disease.  In  one  epidemic  the  ulcerative  form  will  predominate ;  in  another,  the 
sloughing;  and  at  times  it  appears  as  if  one  form  of  the  disease  would  give  place  to  the 
other.  As  a  rule,  though  not  always,  an  open  wound  .seems  requisite  for  the  disea.se  to 
fix  upon.  In  1849.  when  the  wards  of  Guy's  Hospital  lust  contained  such  ca.ses.  a  con- 
tused part  often  took  on  the  action,  and  the  gangrene  commenced  as  a  vesicle  the  base 
of  which  turned  at  once  into  a  grayish  slough,  which  rapidly  extended.  When  it  attacked 
a  wound,  the  edges  or  surf\ice  would  first  cease  to  secrete,  then  assume  a  gray  color  and 
slough  ;  and  this  action  would  spread,  small  wounds  becoming  large  even  in  twenty-four 
hours.  When  the  slough  had  ceased  to  spread,  ulceration  would  throw  it  off;  and  the 
fietor  of  the  slough,  with  the  (Uhris  of  the  ulcerating  tissues,  formed  a  mass  of  decom- 
posing material  unequalled  in  any  other  affection.  Skin  readily  died  under  the  influence 
of  the  process  on  the  connective  tissue,  and  muscles  became  involved ;  tendons  and  ves- 
sels gave  way  only  in  prolonged  cases,  and  haemorrhage  was  rare. 

The  constitutional  symptoms  of  the  disease  in  the  epidemic  I  have  witnessed  were 
absent  at  the  out.set.  and  there  was  certainly  neither  fever  nor  other  disturbance-  to  indi- 
cate the  approach  of  the  action  ;  yet  when  the  local  disease  had  once  manifested  itself, 
great  depression  became  very  general.  It  was  always  remarked,  however,  that  the  con- 
stitutional .symptoms  were  never  in  proportion  to  the  extent  of  the  local  affection.  When 
strong  subjects  were  attacked,  the  local  mischief  told  but  little  upon  their  powers;  while 
with  feeble  subjects  the  effects  were  more  marked. 

Military  surgeons,  however,  have  related  that  the  con.«titutional  often  preceded  the 
local  symptoms.  Hennaii  states  this  very  clearly,  and  Thompson  of  America  found  a 
like  result  :  while  Blackadder.  Delpech,  Guthrie,  and  Macleod  found  the  local  affection 
took  precedence  in  point  of  time. 

It  would  rather  appear,  from  the  descriptions  given  of  the  epidemic  at  various  times, 
that  the  ulcerative  form  is  more  commonly  preceded  by  constitutional  .symptoms  than  the 
sloughing,  the  sloughing  being,  apparently,  a  local  affection  at  the  first.' 

During  the  late  German  campaign  Professor  Billroth  met  with  a  wound  disease  which 
he  had  not  seen  before,  and  which  he  terms  •  diphtheritic  phlegmon"  or  ••  diphtheritic 
infiltration  ;"  and  he  describes  three  ca.ses  in  which  the  diphtheritic  appearance  occurred 
soon  after  operations  and  was  speedily  followed  by  fatal  collapse.  In  these  the  surface 
of  the  wound  assumed  a  pale-gray  or  white  color,  and  the  entire  muscular  structure 
of  the  part  became  hard  and  stiff  from  an  indurated  infiltration.  The  affection  was  dis- 
tingui.shed  from  gangrene  by  an  absence  of  any  rapid  increa.se  of  the  ulcerative  proce.ss 
or  of  inflammatory  redness  in  the  vicinity,  and  by  the  surface  of  the  wound  exhibiting 
a  lardaceous  gray  or  whiteness,  and  not  the  greasy  pulpiness  of  hos]>ital  gangrene. 
The  broad,  hard  infiltration  so  soon  following  the  operation  might  seem  to  be  due  to 
contagiftn  by  means  of  the  dressings  employed,  but  this  was  scarcely  probable.  In  its 
sporadic  form   it  especially  appears  to  affect  the  subjects  of  septic  or  pyjemic  disease, 


84  ERYSIPELAS. 

and  perhaps  certain  conditions  of  tlie  secretions  inclined  to  coagulation  may  favor  its 
production. 

Treatment. — Abnndwiec  of  fresh  air,  as  maintained  by  a  constant  current  allowed 
to  pass  through  the  ward  or  room,  is  most  essential,  with  isolation,  the  free  use  of  anti- 
septics and  close  attention  to  all  sanitary  measures.  During  the  early  stages  of  the  dis- 
ease irrigation  seems  to  be  the  best  local  treatment,  with  the  removal  of  oil  slutit/Iis  and 
jnitrescent  material  by  carefully  cutting  the  existing  slough  with  scissors  or  scalpel  aided 
by  the  dressing-forceps  and  mopping  the  surface  of  the  wound  with  cotton-wool  or  tow, 
thus  tlioroiufhiij  cl<;a)iniiig  tlu'  whole  surface  of  the  ico»n<L  The  next  aim  is  to  prevent  tlie 
extension  or  return  of  the  sloughing,  by  means  of  local  applications  ;  and  of  these  nitric 
acid  was  formerly  the  chief,  the  acid  being  freely  applied  to  the  diseased  parts  and  care- 
fully introduced  into  every  hollow  and  excavation  into  which  it  could  percolate. 

To  apply  the  acid,  writes  Welbank,  "the  sore  must  be  thoroughly  cleansed  and  all 
its  moisture  absorbed  by  lint  or  tow.  The  surrounding  parts  must  next  be  defended 
with  a  thick  layer  of  ointment ;  then  a  thick  pledget  of  lint,  which  may  be  conveniently 
fastened  to  the  end  of  a  stick,  is  to  be  imbued  with  the  acid,  and  to  be  pressed  steadily 
on  every  part  of  the  diseased  surface  till  the  latter  is  converted  into  a  dry,  firm,  and 
insensible  mass.  The  part  may  then  be  covered  with  simple  dressings  and  cloths  wet 
with  cold  water." 

Dr.  Goldsmith  of  America,  and  others,  have  spoken  very  highly  of  the  value  of  bro- 
mine as  an  application  which  arrests  ulceration  and  turns  sJoug-hs  into  tough  deodorized 
tissues.  It  should  be  applied  fref\y  to  the  whole  surface,  and  its  application  .should  be 
repeated  when  the  sloughing  or  ulceration  spreads.  Iodine,  carbolic  acid,  and  the  oil  of 
turpentine  have  also  been  advocated  ;  and  the  latter,  it  is  said,  has  the  power  to  dissolve 
the  sloughs  and  change  the  action  of  the  disease.  Delpech  and  some  surgeons  speak 
highly  of  the  actual  cautery  ;  and  when  the  benzoline  cautery  is  to  be  had,  it  might  be 
used.  The  object  of  all  these  diiferent  plans  of  treatment  is  to  excite  a  new  action  on 
the  surface  of  the  wound,  and  to  destroy  the  sloughing  tissues  Avhich,  doubtless,  by  mere 
contact,  have  a  power  of  keeping  up  or  propagating  the  disease. 

When  the  sore  is  extensive,  an  anaesthetic  should  be  administered  during  this  local 
treatment.  After  the  cauterization  the  surface  of  the  sore  should  be  dressed  with  car- 
bolic or  terebene  oil ;  whilst  laudanum,  iodine  lotion,  or  bromine  in  solution,  two  drops 
to  the  ounce  of  water,  is  also  beneficial. 

Dr.  Packard  of  Philadelphia  used  powdered  sugar  or  thick  syrup,  sugar  being  a 
hydrate  of  carbon  which  does  not  give  up  its  oxygen.  He  dusted  the  parts  with  the 
sugar  and  covered  the  whole  with  wet  lint.  When  odor  exists,  charcoal  should  be  mixed 
with  the  sugar. 

The  constitutional  treatment  consists  in  abundance  of  light,  nutritious  food,  milk 
being  administered  as  freely  as  it  can  be  taken,  with  sufficient  stimulants  to  maintain  the 
circulatory  system  and  assist  digestion. 

Tonics,  such  as  quinine  and  iron,  are  often  well  borne  in  large  doses,  five  grains  of 
the  former  dissolved  in  half  a  drachm  of  the  tincture  of  the  perchloride  of  iron  being  a 
good  recipe;  or  when  quinine  cannot  be  taken,  the  tincture  of  nux  vomica  in  ten-drop 
doses  may  be  substituted.  Opium  is  an  admirable  drug  when  the  ulcerative  action  is 
present,  but  in  the  sloughing  stage  it  is  not  so  satisfactory.  Chloral  is  probably  a  good 
remedy  for  a  like  purpose. 

ERYSIPELAS. 

Erysipelas  is  a  contagious  and  infectious  specific  disease  due  to  the  presence  of  some 
bJood  poison  that  has  probably  been  introduced  into  the  body  from  without.  It  is  inti- 
nii'.'.-t^'y  allied  with  other  blood  poisons,  such  as  are  found  in  scarlet  or  puerperal  fevers  or 
septicaemia  in  any  of  its  forms  ;  for  these  poisons  seem  to  be  convertible.  It  is  connected 
with  d-.;fects  of  drainage  or  ventilation,  but  is  not  so  much  a  hospital  disease  as  is  gen- 
erally believed,  only  186  cases  having  taken  place  in  Guy's  Hospital  in  the  eight  years 
ending  with  1879  out  of  18,922  surgical  patients  which  were  admitted,  or  less  than  one 
per  cent.  No  less  than  451  cases  were,  however,  admitted  icitli  the  affection,  and  some 
of  those  recorded  as  Iniving  been  transferred  from  one  of  the  wards  simply  passed 
through  it. 

It  manifests  its  presence  in  three  forms — as  a  diffused  cutaneous  inflammation, 
"simple  cutaneous  erysipelas;"  as  a  diff"used  inflammation  of  the  cellular  tissue,  "dif- 
fused cellular  inflammation  ;"  and  as  a  dift'used  inflammation  of  both  skin  and  cellular 
tissue  combined,  "  phlegmonous  erysipelas  ;"  the  latter  two  being  included  in  the  expres- 


ERYSIPELAS. 


85 


sion  'Tellulo-cutaiit'ous."  The  state  of  the  system,  the  temperature  and  hahits  of  the  indi- 
vidiial.  have  iiiucli  to  do  in  (U'terininin<;  the  form  of  the  affection.  When  tlie  disease  follows 
an  injury,  it  is  called  ••  traumatic  ;"'  when  it  occurs  sponlancftusly,  it  is  styled  "  idiopathic." 

The  peculiarity  oi"  erysipelas  lies  in  the  diffu.sed  character  of  the  inflaniniatifm  and  in 
its  atonic  nature.      It  is  Itoth  in/irfinns  ami  nmtitijloiis. 

The  attack  is  occasidually  jireceded  by  some  constitutional  disturhancc.  hut  as  often 
as  not  su(di  has  not  heen  oliserved  ;  the  severity  of  the  <:eneral  symptoms,  moreover,  in 
no  way  hears  any  prttportion  to  that  of  the  local  disease.  Febrile  symjitoms  ushered  in 
by  chilliness  and  /vV/o/-  are  the  most  common,  the  tonj^ue  bein<^  pntbably  foul  and  the 
bnwils  either  constipated  or  relaxed.  As  the  disease  advances  the  fever  runs  hi^di  and 
delirium  of  different  forms  appears  ;  the  pulse  becomes  (juickened  ;  if  full,  it  will  always 
be  compressible,  and  often  irrc<rular  or  intermittent.  Toward  the  close  of  the  disease, 
]>articularly  when  terminatintr  unfavorably,  the  pul.se  will  be  small  and  weak.  The  temper- 
ature at  the  first  onset  of  this  di.sea.se,  as  a  rule,  ri.ses  rajiidly,  and  in  its  decline  falls  as  fast 
(^vidi  tigs.  IM  and  14 ).   When  the  temperature  remains  hiirh,  a  bad  prognosis  should  be  given. 

C.  de  Morgan,  Nunneley,  and  II.  Bird  assert  that  if  the  pulse  rise  in  fre«|uency  after 
the  sixth  or  seventh  day  it  is  a  very  bad  sign.  I  cannot,  however,  endorse  this  observa- 
tion, although,  as  the  end  of  the  first  week  is  about  the  time  that  complications  appear 
if  they  occur  at  all.  it  may  pos.sibly  Vje  correct. 

Frank  has  pointed  out  that  when  a  patient  has  had  febrile  .symptoms  for  sonte  hours 
attended  with  pain,  tenderness,  and  swelling  of  the  lymphatic  glands  of  the  part,  there  is 

Fir;,  l:;.  Fir;.  14. 


BSISBBBSHI 


Thermograph  of  erysipelas  supervenin.:  upou  removal 
of  the  tarsal  bones  after  the  traumatic  temperature  had 
subsided,  showing  rajiid  elevation  of  temperature — 
nearly  5  degrees— at  the  onset  of  the  disease  and  steady 
fall  during  convalescence.    Case  of  H  B.,  set.  32. 


■■■■■■■g 

ESSSlBaBDBDBBHDB 

ThermoLTaph  oi  erysipelas  in  man.  at.  ■_".',  after  re- 
moval (if  parotid  tumor.  Operation  iday  li  fol- 
lowed by  slight  traumatic  fever  (day  2)  anil  steady 
fall  in  temperature.  Klevation  of  temperature 
(day  4i  when  blush  first  became  visible,  and  steady 
rise  for  three  days  during  increase  of  disease, 
with  rapid  fall  on  its  subsidence.  Convalescence 
on  eleventh  da  v. 


no  doubt  that  erysipelas  is  coming  on.  Chomel  held  the  same  view,  and  Campbell  de 
Morgan  relates  "  that  Busk  is  so  convinced  of  the  invariable  occurrence  of  affection  of 
the  glands  before  ery.sipelas  appears  as  to  consider  it  a  pathognomonic  symptom,"  and  he 
believes  that,  although  the  blood  became  affected,  the  actual  primary  seat  of  the  local 
inflammation  was  in  the  absorbent  system.  Sometimes  swelling  and  excessive  tenderness 
of  the  glands  precede  by  many  hours  the  appearance  of  a  blush  on  the  skin.  These 
views  accord  well  with  those  which  Dr.  Bastian  brought  before  the  Pathological  Society 
in  1869,  based  on  the  po.st -mortem  examination  of  a  man  who  died  from  erysipelas  in  a 
state  of  delirium  and  stupor.  In  this  case,  finding  the  small  arteries  and  capillaries  of 
the  brain  plugged  with  embolic  masses  of  white  blood  corpuscles,  he  suggested  this  con- 
dition as  the  cause  of  delirium.  He  stated  "  that  the  blood  change  is  a  general  one,  and 
through  every  part  of  the  body  this  blood  is  carried  with  its  rebellious  white  corpuscles ; 
so  that  we  may  expect  that  in  all  organs  alike  the  same  obliterations  of  small  arteries 
and  capillaries  take  place."  Thus,  when  those  of  the  liver  are  involved  jaundice  may  be 
produced,  and  when  those  of  the  kidney  albuminuria,  these  conditions  being  occasionally 
found  in  erysipelas. 

If  we  accept  Dr.  Bastian's  ob.servations  pathologically,  and  look  to  the  condition  of 
the  white  blood  corpuscles  for  an  explanation  of  many  of  the  phenomena  of  ery.sipelas, 
we  may  fairly  admit  the  inference  from  clinical  observations  respecting  the  absorbent 
system  to  which  Frank  and  Busk  have  called  our  attention,  for  the  glands  of  this  system 
and  the  white  blood  corpuscles  are  generally  recognized  as  having  a  close  relationship. 
These  views  receive  much  confirmation  from  the  pathological  observations  to  be  read  on 
page  87. 

Local  Symptoms. — In  the  simple  form  of  cutaneous  erysipelas  mere  excess  of 
vascularity,  as  indieatcd  by  the  vivid  redness  of  the  part  affected,  is  the  chief  local  symp- 
tom, and  with  this  there  is  a  sensation  of  heat  or  tingling  in  the  part,  and  in  rare  instances 


86  ERYSIPELAS. 

the  formation  of  small  vesications.  Tho  border  of  inflammation  is  invariably  well  defined. 
The  redness,  wliieli  spreads  rapidly,  disappears  on  pressure,  to  return  directly  the  pressure 
is  removed  ;  but  there  will  be  no  pitting  of  the  parts  to  indicate  oedema.  In  a  day  or  two 
these  syniptouis  will  subside  or  disappear,  and  the  cuticle  will  descjuamate. 

In  the  7iiorc  sfvn-c  form  of  cutaneous  erysipelas  the  vascularity  of  the  skin  will  be  as 
intense  as  in  the  simple,  but  it  may  be  more  livid.  It  will,  however,  be  associated  with 
some  perceptible  thickening  of  the  parts,  tfhe  inflamed  tissues  feeling  raised  on  pal])ation. 
Where  much  cellular  tissue  exists,  as  in  the  eyelids  or  scrotum,  oedema  will  rapidly  show 
itself.  Small  or  large  vesicles  may  likewise  form  on  the  surface,  containing  either  a  clear 
serum  or  a  blood-stained  or  sero-purulent  fluid,  the  latter  form  indicating  great  depression. 
In  the  head  or  other  parts  where  the  skin  is  tight  the  feeling  of  tension  is  very  great  and 
the  surface  looks  shining,  the  features  being  altogether  obliterated.  There  is  rarely, 
however,  nmcli    ])aiii. 

Course  and  Duration.— The  disease  runs  its  course  in  al)()ut  ten  days.  j)uring 
the  first  three  or  four  it  spreads,  and,  having  reached  its  height,  declines,  the  redness  and 
swelling  gradually  subsiding  and  the  .skin  des(juainating.  In  some  cases  a  local  suppura- 
tion takes  place,  and  tliis  is  always  to  be  sus])ected  when  any  local  redness  remains  after 
the  subsidence  of  the  inflammation.  In  the  eyelids  and  other  parts  containing  loose 
cellular  tissue  such  a  result  is  common.  In  the  cachectic  subject  the  disease  is  always 
more  (edematous  than  in  the  healthy.  When  it  attacks  a  wound,  the  general  symptoms 
are  the  same,  but  the  local  consist  in  arrest  of  secretion  in  the  part,  then  ulceration,  and 
later  on,  where  union  has  existed,  disunion,  stumps  and  wounds  sometimes  reopening  and 
discharging  a  thin  ichorous  fluid. 

After  the  disease  has  subsided  repair  is  usually  .slow,  but  at  times  it  goes  on  healthily 
to  complete  recovery. 

Pr()(JNO.>>is. — Simple  erysipelas,  unless  in  the  feeble  or  cachectic,  is  rarely  a  disease 
of  much  danger.  In  free-living  subjects,  and  in  others  who  have  l)ad  viscera,  it  is,  how- 
ever, a  dangerous  affection,  lighting  up  latent  disease  that  often  proves  fatal.  When  it 
attacks  the  scalp  after  head  injuries,  it  is  exceptional  to  find  it  followed  by  bad  conse- 
quences. 

Where  the  erysipelas  attacks  the  mucous  lining  of  the  throat,  fauces,  or  larynx,  it 
may,  from  mechanical  causes,  threaten  life. 

In  some  cases  the  disease  will  affect  different  parts  of  the  body  consecutively  or  leave 
one  spot  to  attack  suddenly  another.  Such  cases  usually  indicate  want  of  power,  and 
too  often  are  found  in  those  who  have  some  organic  disease  of  the  kidney  or  other  excre- 
tory org.iii. 

Diffuse  cellular  inflammation  may  clinically  be  looked  upon  as  a  form  of  ery- 
sipelas, the  disease  attacking  primarily  the  cellular  tissue  instead  of  the  skin.  It  is  cha- 
racterized by  the  same  diffused  form  of  inflammation  and  by  the  same  atonic  character. 
It  is,  however,  more  frequently  the  result  of' some  local  injur}',  such  as  a  punctured  or 
dissection  wound,  than  is  the  simple  form,  and  it  is  even  found  in  patients  from  whom  no 
such  history  can  be  obtained.  It  is  generally  as.sociated  with  absorbent  inflammation 
and  glandular  enlargement. 

The  disease  appears  as  a  diffused  swelling  and  induration  of  the  cellular  tissue  of  the 
part  aflected,  the  tissues  feeling  infiltrated  and  brawny  and  the  skin  tense  from  over-dis- 
tension. When  suppuration  or  sloughing  of  the  cellular  tissue  has  taken  ])lace.  fluctua- 
tion or  crepitation  will  be  detected  or  the  parts  may  feel  boggy.  The  skin,  if  not  pre- 
viou.sly  inflamed,  will  now  participate  in  the  disease;  it  will  inflame,  ulcerate,  or  slough, 
to  permit  the  escape  of  the  pent-up  pus  or  sloughing  cellular  tissue.  When  resolution 
takes  place  at  an  early  period  of  this  affection,  the  skin  may  escape  uninjured;  but  such 
a  result  is  rare. 

The  constitutional  symptoms  attending  these  changes  in  the  cellular  tissue  are  always 
those  of  great  depression.  The  febrile  symptoms  will  be  of  the  typhoid  type,  the  pulse 
feeble,  although  rapid  from  the  first,  and  the  disposition  to  sink  very  marked.  Profuse 
sweating  is  an  early  and  constant  s3'mptom.  Delirium  also  is  sometimes  present.  Vis- 
ceral complications  are,  as  a  rule,  the  cause  of  death,  the  connection  between  this  affec- 
tion and  py;\!mia  being  very  close. 

Phlegmonous  erysipelas  is  a  combination  of  the  two  former.  It  is  fiir  more 
serious  than  the  sinqde,  and  as  much  so  as  the  cellular  inflammation.  It  is  characterized 
by  a  dift'used  inflammation  of  the  skin  an<l  cellular  ti.ssue  together,  the  parts  having  a 
strong  disposition  to  suppurate  and  slough.  It  is  commonly  the  result  of  some  punc- 
tured wound  or  injury  involving  the  skin  and  cellular  tissue  beneath,  and  begins  locally 


KRYSII'EI.AS.  87 

as  a  hrawny  infiltriitiim  <>f  the  part,  tin-  skin  prescntiiifr  cryMipolatous  redness  of  a  dusky 
hue,  and  the  houiidary  lietweeii  the  intlaiiied  and  utiinflanied  skin  heirijr  ill-niarki'd  ;  outside 
the  limit  (»t'  the  rechiess  the  skin  feels  unnaturally  Hrni.  and  the  edlular  tissue  beneath  as 
if  infiltrated.  To  the  tinj^er  the  inflamed  ])arts  feel  more  solid  and  pit  on  pressure.  Reso- 
lution is  almost  unknown  as  a  termination  of  the  disea.se,  one  ca.se  differin;r  fr(»ni  another 
oidy  in  the  extent  of  the  destruetion  of  tissue  with  which  it  is  accompanied. 

As  the  di.sea.se  protrres.ses.  and  the  t-ellular  tissue  beneath  the  integument  becomes 
infiltrated  with  inflammatory  pnnlucts,  the  skin  will  be  made  tense  and  cease  in  pit  ;  uni- 
form hanlness  of  the  tissues  will  irive  jdace  to  a  .sen.se  of  fluctuation,  as  of  fluid,  or  to  a 
boiriry.  (juajrsy.  crepitatiuLr  feel  of  slouirhiiii:  cellular  tissue. 

If  the  case  be  left  to  nature,  the  skin  will  V)ecome  thin  and  ulcerate  in  jiarts  or  slough 
in  masses,  to  give  vent  to  the  pent-up  and  sloughing  tissues.  Phlyct;cn;e  will  also 
appear  over  the  dead  portions  of  skin,  as  in  other  forms  of  gangrene  ;  while  the  pus  and 
sloughs  which  escape  are  always  fietid.  In  bad  cases  the  whole  cellular  tissue  of  a  limb, 
with  large  portions  of  integument,  in  this  way  may  die,  bands  of  skin  held  down  by  fascia 
being  left,  which  during  recovery  will  become  the  centres  of  cutification. 

In  the  ordinary  run  of  cases  this  dift'used  infiltration  of  the  cellular  tissue  is  confined 
by  the  fascia  to  the  subcut^meous  ti.ssue.  but  in  .some  instances  the  cellular  tissue  that 
separates  the  muscles  becomes  involved,  when  the  case  assumes  a  far  more  .serious  a.spect; 
for  the  suppuration  is  then  of  a  burrowing  kind,  and  the  sloughing  is  more  exten.sive. 
The  prospect  of  recovery  with  a  useful  muscle  becomes  also  very  slender,  for  muscles 
and  tendons  may  not  <jnly  slough  wholly  or  in  part,  but  on  recovery  taking  place  they 
may  become  .so  closely  bound  together  with  the  other  ti.ssues  that  they  are  u.seless  as 
moving  organs.  From  this  cause,  after  phlegmonous  inflammation  of  the  hand  and  fore- 
arm, a  stiff  and  immovable  extremity  is  often  met  with,  and  the  hand  becomes  a  kind  of  fin. 

The  constitutional  symptoms  associated  with  phlegmonous  erysipelas  vary  con.sider- 
ably,  and  their  .severity  depends  much  upon  the  rapidity  with  which  the  disease  spreads. 
They  are.  however,  in  character  the  same  as  are  found  in  other  forms  of  the  affection, 
though  they  are  probably  more  severe.  The  rigors  are  more  marked,  the  fever  is  higher, 
the  pulse  more  rapid,  and  the  tendency  to  fall  in  power  always  greater.  Thus,  in  the 
suppurative  or  sloughing  .stage  of  the  disease  the  rigors  frequently  recur,  and  cold  sweats 
and  fever  intervene  as  in  an  ague.  When  the  local  affection  is  undergoing  repair,  or,  at 
any  rate,  has  ceased  to  spread,  and  these  "  false  ague-fits  "  persist,  some  internal  or  vis- 
ceral complication  may  be  looked  for ;  the  blood  becomes  poisoned  as  in  septicsemia.  often 
to  the  extent  of  destroying  life. 

The  pathological  appearances  met  with  in  cases  of  death  from  erysipelas 
have  l>een  kindly  drawn  up  fur  nie  liv  Dr.  J.  F.  Goodhart  after  a  careful  analysis  of  the 
post-mortem  records  of  the  hospital.  They  admit  of  being  classified  as  h/col  and  general^ 
the  former  including  all  those  morbid  changes  which  occur  in  the  primary  focus  and  in 
the  surrounding  parts  directly  extending  from  it ;  the  latter,  the  various  alterations  of 
blood  or  tissue  found  in  any  secondary  foci  or  in  the  system  at  large. 

The  local  changes  vary  according  to  the  severity  of  the  disease  and  the  rapidity  with 
which  it  causes  death. 

In  the  slighter  forms,  where  it  has  not  been  the  immediate  cause,  but  has  supervened 
as  an  intercurrent  affection  in  the  course  of  some  other  disease,  it  may  often  happen  that 
no  morbid  appearance  is  visible  po.st-mortem  indicating  erysipelas.  Again,  the  skin  alone 
may  be  affected  either  with  a  mere  faint  purple  discoloration  or  with  slight  oedema,  or  the 
cuticle  may  be  raised  into  bulht  or  separated  more  or  less  around.  In  more  pronounced 
cases,  the  areolar  tissue  beneath  the  skin  and  along  the  tendons  and  intermuscular  septa 
has  numerous  minute  ecchymoses  and  extravasations  of  blood  in  it  and  is  often  soaked 
with  yellow  serum  or  gelatinous  matter,  apparently  produced  by  a  delicate  fibrinous 
coagulum  :  in  the  more  prolonged  or  in  severe  cases  the  serum  is  replaced  by  healthy 
pus.  Ecchymoses  in  the  subcutaneous  areolar  tissue  are  very  common,  even  in  cases 
where  death  has  been   very  rapid  and  no  other  morbid  appearances  are  seen. 

It  is  charact*?ristic  of  the  further  changes  that  there  is  no  tendency  to  the  limitation 
of  the  disease  around  the  primary  focus ;  the  pus  or  serum  leads  to  the  formation  of  no 
abscess  sac,  but  spreads  along  the  subcutaneous  tissues  and  intermuscular  septa,  sometimes 
even  making  a  complete  dissection  of  some  of  the  muscles. 

There  may  or  may  not  be  phlebitis  in  the  parts.  Where  it  exists  the  interior  of  the 
veins  affected  is  discolored  and  filled  with  grunious  chocolate-colored  fluid,  while  the  inner 
surface  of  the  vein-wall  is  rough  from  the  inflammatory  processes  it  has  undergone  and 
the  adhesion  of  small  particles  of  clot.     Where  the  disease  has  existed  some  time  a  tube 


88  ERYSIPELAS. 

of  semi-organized  clot  may  line  the  vein,  and  within  that  -nill  he  found  the  broken-down 
clot,  which  it  is  often  impossible  microscopically  to  distinguish  from  pus. 

It  is  quite  as  common,  however,  to  find  the  vessels  unaffected  as  to  find  them  plugged, 
if  not  more  so.  Pus  may  even  run  along  their  course,  sometimes  apparently  in  their 
adventitia.  or  more  often  immediately  outside  it.  and  still  lead  to  no  clotting.  On  micro- 
scopical examination  in  these  cases  the  pus  is  seen  to  lie  in  smooth-walled  channels  which 
in  all  probability  are  lymphatic  spaces  (^suppurative  lymphangitis). 

Affection  of  Glands. — The  neighboring  lymphatic  glands — >'.  e..  those  in  the  groin 
if  the  di.-La.-e  be  >ituated  in  the  leg,  the  axillary  if  in  the  arm — are  usually  swollen,  red, 
and  ecchymosed  on  section,  and  are  frequently  surrounded  by  the  same  kind  of  serous 
fluid  as  is  found  in  the  immediate  neighborhood  of  the  primarily  diseased  tissue.  The 
tissues  of  all  the  diseased  parts  are  said  to  be  crowded  with  small  vegetable  organisms 
called  "  bacteria.  "  These  constitute  the  local  changes.  It  may  be  as  well  to  add.  j)er- 
haps.  when  erysipelas  affects  the  scalp,  that  a  yellow  color  of  the  vault  of  the  .skull  is 
often  observed,  and  also  that  suppuration  between  the  bone  and  dura  mater  and  suppura- 
tive arachnitis  and  meningitis  are  not  very  unusual  sequences.  About  the  neck  it  may 
be  followed  bv  cedema  glottidis.  and  occasionally  by  pericarditis  or  suppurative  inflam- 
mation of  the  mediastinum. 

The  morbid  appearances  in  the  system  at  large  are  similar  to  those  found  in  septicae- 
mia from  other  cau.ses — viz..  ecchymoses  about  the  pleura  and  pericardium,  a  fluid  and 
sometimes  treacly  state  of  the  blood,  congested  kidneys,  and  a  softened  state  of  the  liver 
and  spleen.  So  soft,  indeed,  is  the  latter  organ  that  were  it  not  for  its  capsule  it  would 
at  times  lo.se  all  shape.  The  blood  has  been  said  to  contain  bacteria,  but  I  have  never 
found  such  during  life,  though  they  are  sometimes  present  when  the  blood  is  examined 
some  hours  after  death.  In  addition  to  these  general  changes,  separate  foci  of  diffuse 
cellulitis  are  found — in  both  fore-arms  and  in  the  calf  of  the  leg.  for  instance,  after  a 
primary  erysipelatous  state  of  the  scrotum  :  and  in  at  least  two  recorded  cases  a  similar 
diffuse  cellulitis  or  myocarditis  has  been  noticed  in  the  muscular  wall  of  the  heart. 
Patients  with  erysipelas  are  also  liable  to  suppurative  peritonitis  and  pleurisy,  which, 
though  commonly  so.  are  not  necessarily  determined  by  the  presence  of  a  neighboring 
wound.  A  subject  of  hernia  or  ovariotomy  at  a  time  when  erysipelas  is  rife  will  be  likely 
enough  to  die  of  suppurative  peritonitis  ;  while  another  who  has  undergone  an  excision 
of  the  breast  may  die  of  a  similar  form  of  pleurisy  without  showing  any  external  evi- 
dence of  erysipelas. 

A  wound,  however,  is  not  necessary.  For  example,  in  a  post-mortem  made  not  long 
since  a  lady  about  sixty  had  been  nursing  a  friend  who  died  of  some  febrile  affection 
called  ••  low  fever."'  Within  a  few  days  she  herself  became  exceedingly  ill.  and  died 
quickly.  The  inspection  revealed  what  had  only  been  evidenced  by  the  faintest  blush  on 
the  skin  during  life — viz..  an  early  suppurative  inflammation  of  the  cellular  tissue  of  the 
right  axilla  and  pectoral  region,  and  pus  on  the  surface  of  both  pleurse  ;  all  this  without 
any  external  wound  whatever. 

As  occasional  causes  of  death  in  erysipelas  may  also  be  mentioned  acute  lobar  pneu- 
monia and  a  diphtheritic  sloughing  of  the  mucous  coat  of  parts  of  the  bowel ;  while,  to 
complete  the  history,  it  must  also  be  said  that  at  times  when  erysipelas  is  present  in  a 
hospital  or  its  neighborhood  not  only  are  cases  of  pyaemia,  with  its  known  manifestations, 
such  as  abscesses  in  the  viscera  and  pus  in  the  joints,  frequent,  but  patients  suffering 
from  chronic  suppuration  become  feverish  and  die  without,  it  may  be.  any  adequate  cause 
appearing  in  the  viscera. 

In  this  description  of  the  pathological  appearances  found  in  erysipelas  no  attempt  is 
made  to  distinguish  between  it  and  cellulitis.  The  morbid  changes  in  both  are  the  same, 
and  it  is  as  impossible  in  the  deadhouse  as  at  the  bedside  to.  separate  the  two. 

Treatment. — The  disease  in  all  its  forms  is  essentially  an  fitonic  one ;  consequently, 
nothing  like  ■•  antiphlogistic  "  remedies  are  to  be  entertained,  and  in  the  simpler  forms 
which  have  a  tendency  to  run  a  definite  course  the  practitioner  has  merely  to  guide  his 
patient  through  the  attack  and  to  ward  off  whatever  might  prove  injurious.  "With  these 
objects,  when  the'  patient's  powers  are  eood  and  no  indications  of  feebleness  manifest 
themselves,  a  mild  aperient  or  purge,  to  clear  out  the  bowels,  with  bland  nutritious  food. 
such  as  milk  and  beef-tea.  is  probably  a  sufiicient  remedial  means,  the  disease  on  the 
third  or  fourth  day  attaining  its  height,  and  then  declining. 

Should  anv  feebleness  or  want  of  power  appear  at  the  beginning  or  during  the  cour.se 
of  the  disease,  tonics  are  indicated ;  and  of  these  iron  seems  the  best.  The  tincture  of 
the  perchloride  in  half-drachm  doses,  or  more  to  an  adult,  frequently  repeated,  with  or 


f.Rysirh'LAs.  89 

witlidiit  ((uiiiiiu'  or  stryliriiii.  acts  at  fiiiics  liki-  a  ••liariii.  and  douhtlcsis  often  cuts  short 
the  disease.  Its  iisi'  was  iiitroduci'(I  to  liritish  siir^reoiis  hy  I'r.  II.  IJeli  of  Kdiiiljur^rh  in 
is.")!,  ahhoiiiili  V(d|ieau  in  ]X[l  had  previously  declared  its  value. 

In  the  earliest  staj^e  of  the  aflet-tion,  when  the  first  |iat<-h  of  intianiniatidn  appears  on 
the  skin  or  around  a  wouimI.  an  emetic  may  at  times  aliruptly  (dn-ck  the  attack. 

When  I'ood  cannot  he  taken,  stimulants  must  he  suhstituted ;  and  it  is  well  to  introduce 
inid  llieni,  and  particularly  int(»  stout,  some  essence  of  meat.  The  form  of  stimulant 
must  depend  upon  circumstances,  but,  as  u  rule,  that  which  the  patient  has  hc.cu  in  the 
hahit  of  takinj;  is  the  iie>t.  When  hraiidy  is  ^iven,  it  slnjuld  be  nii.xed  with  milk  or  efr<rs. 
it  being  always  better  not  to  give  stimulants  alone.  The  amount  nni^t  be  regulated  with 
care,  for  over-e.\citation  of  the  system  is  always  bad. 

Hypnotics  or  sedatives  should  be  used  with  caution,  for  they  are  not  usuallv  bene- 
ficial. Of  these  chloral  seems  less  liable  to  disagree  than  opium  ;  cam[dior  and  henbane 
in  five-grain  do.ses  are  tlntught  well  of  by  some,  while  ammonia  is  as  highly  recommended 
by  others. 

In  jddegnionous  and  cellular  erysipelas  tlie  same  principles  of  practice  are  applicable. 
In  the  suppurative  or  sloughing  stages  it  is  necessary  to  give  abundance  of  good  food  of 
all  kinds,  and  stimulants  in  proportion;  strong  animal  broths  and  milk  are  the  best  forms 
of  diet. 

Lotwi..  Treatment. — The  inflamed  parts  should  always  be  kept  warm  and  raised,  air 
being  e.xcluded  from  the  surface;  consequently,  when  the  head  and  face  are  implicated 
with  simple  erysipelas,  the  old  practice  of  dusting  the  parts  with  flour,  fullers  earth, 
starch,  or  o.xide  of  zinc  is  effective.  Mr.  C.  de  Morgan  used  cotton-wool  in  addition.  Warm 
apjilieations.  however,  are  in  some  cases  the  best,  especially  the  lead  lotion  with  opium. 
Cold  is  always  injurious. 

In  the  face  and  head,  when  the  parts  are  tense  and  j>ainfiil.  relief  is  readily  given  by 
following  the  practice  of  8ir  R.  Dobson  in  puncturing  the  skin  with  a  .series  of  small 
punctures,  oozing  of  blood  or  serum  being  encouraged  l)y  warm  applications. 

In  erysipelas  of  other  parts  the  application  of  the  tincture  of  iodine  is  to  be  recom- 
mended. Mr.  Luke  thouglit  highly  of  the  free  use  of  collodion  applied  over  the  part; 
Mr.  Higginbottom,  of  a  solution  of  nitrate  of  .silver  twenty  grains  to  the  drachm  of 
water ;  others,  of  the  tincture  of  the  perchloride  of  iron.  I  have  employed  at  times  all 
these,  and  prefer  the  tincture  of  iodine  to  any ;  but  none  of  them  have  any  certain  power 
of  arresting  the  progress  of  the  di.sease.  Some  American  surgeons  .speak  strongly  in 
favor  of  the  application  of  a  solution  of  bromine  on  lint  with  oil-silk  over  the  whole,  and 
quite  recently  the  subcutaneous  injection  of  a  solution  of  carbolic  acid  has  been  highly 
spoken  of.      Mr.  Harwell  has  advocated  white  paint. 

The  local  treatment  of  the  cellulo-cutaneous  forms  of  the  disease  must 

be  conducted  on  tlie  same  principles  as  the  simple,  but  as  soon  as  anything  like  tension  of 
the  integument  appears  incisions  should  be  made  deep  enough  to  allow  of  the  escape  of 
the  eff"used  serum  from  the  cellular  tissue  beneath  the  skin,  and  long  enough  to  relieve 
the  tension  of  the  whole.  Some,  and  amongst  them  the  late  Sir  W.  Lawrence,  recom- 
mended the  incision  to  be  free,  so  as  to  extend  the  whole  length  of  the  affected  part. 
Others,  among  whom  I  claim  a  place,  prefer  a  greater  number  of  limited  incisions.  The.se 
limited  incisions  answer  the  same  purpose  as  the  long,  and  are  not  attended  with  so  copi- 
ous a  hicmorrhage  or  with  so  great  a  risk  to  life.  Even  after  these  the  bleeding  is  at 
times  profuse,  but  it  may  generally  be  readily  arrested  by  elevating  the  limb  and  by 
temporary  pressure. 

When  suppuration  and  sloughing  exist,  the  surgeon  must  let  out  matter  as  soon  as 
formed  ;  for  there  is  little  doubt  that  the  disease  is  kept  up  by  its  presence.  The  open- 
ing into  these  abscesses  should  be  free,  and  their  cavities  kept  clean  by  careful  wa.<hing 
out  at  each  dres.sing  with  Condy's  fluid  or  iodine  lotion — a  detail  which  adds  materially 
to  the  comfort  of  the  patient  and  the  well-doing  of  the  case.  De  Morgan  prefers  a  solu- 
tion of  chloride  of  zinc  fifteen  grains  to  the  ounce.  Dressings  with  boracic  acid  lotion 
ten  grains  to  the  ounce,  and  gutta-percha  over  the  wet  lint,  .should  be  applied  to  the  parts, 
and  frefjuently  changed.  Poultices  are  not  so  good,  although  at  times  patients  say  they 
derive  the  most  comfort  from  them.  During  the  period  of  repair  the  surgeon  will  often 
have  to  lay  open  sinuses.  When  the  sloughing  has  been  very  severe,  amputation  may 
be  called  for. 

It  has  ever  to  be  borne  in  mind  that  erysipelas  is  highly  contagious  and  infectious. 
In  hospital  practice,  consecjuently,  every  case,  as  it  arises,  .should  be  separated  from 
others  in  which  wounds  exist  and  transferred  to  a  separate  ward.     All  dressings  as  they 


90  ERYTHEMA. 

leave  the  ward  or  chamber  should  he  burnt  or  disinfected,  and  a  spouiie  shoidd  never  be 
used.  Plenty  of  fre.sh  air  ouuht  ro  be  admitted  into  the  room,  but  no  drautiht,  and  dis- 
infectants should  be  freely  distributed  about.  No  medical  ])ractitioner  under  any  circum- 
stances should  go  direct  from  a  case  of  erysipelas  to  a  midwifery  case  or  to  dre.ss  a  wound 
of  any  sort,  accidental  or  surgical.  If  he  is  obliged  to  attend  a  labor  when  in  charge  of 
a  case  of  erysipelas,  he  should  allow  as  much  time  as  possible  to  intervene  before  doing 
so,  and  then  should  attend  only  after  having  changed  his  clothes  and  carefully  disinfected 
his  hands ;  for  there  is  a  direct  connection  between  erysipelas  and  puerperal  fever. 

ERYTHEMA. 

Erythema  finds  its  place  here,  as  in  its  clinical  features  it  bears  some  resemblance  to, 
and  has  been  mistaken  for,  the  simple  cutaneous  erysipelas.  It  appears  as  a  roseate  or 
more  vivid  injection  of  the  .skin,  of  a  local  or  general  character,  disappearing  on  pressure 
and  accompanied  with  some  slight  degree  of  oedematous  swelling. 

In  its  transitory  form  it  may  be  regarded  as  a  symptom  of  some  bowel  or  intestinal 
irritation  induced  by  irregularity  in  diet  or  other  cause.  In  so-called  bilious  subjects  it 
is  by  no  means  uncommon,  and  a  local  patch  of  redness  on  some  part  of  the  face  or  other 
part  of  the  body  often  indicates  the  approach  of  a  "  bilious  attack."  It  is  found,  also, 
where  organic  disease  of  the  intestines  is  present.  In  other  cases  it  precedes  an  attack 
of  smallpox,  attends  vaccinia,  and  is  common  in  children. 

Hebra  gives  the  term  ^'' Erijthema  fugux^  to  all  these  symptomatic  forms  of  erythema. 

Erythema,  as  a  {/tsea!<e,  more  commonly  attacks  the  extremities  than  the  trunk,  and 
the  dorsal  surfaces  in  preference  to  other  parts.  When  the  eflSiorcscence  appears  in  small 
patches  of  papules  or  tubereules  upon  the  fingers  or  hands,  the  terms  E.  j^nqyulatiim  and 
E.  tHherculatiim  are  respectively  given. 

AVhen  these  patches  assume  the  form  of  a  red  ring,  the  term  E.  annulare  is  applied  to 
it.  When  a  second  ring  forms  round  the  first  before  it  has  passed  away,  or  when  it  is 
represented  by  a  small  spot,  the  E.  iris  is  formed ;  and  where  many  such  circles  or  half 
circles  appear  together  and  touch  or  coalesce  and  spread,  the  E.  circinatnm  and  E. 
gyratmn  are  respectively  present.  Wilson  mentions  a  case  in  which  the  E.  ijyratnm 
covered  the  whole  body  ;  but  all  these  different  forms  of  erythema  must  be  regarded  ag 
different  stages  of  the  same  disease.  Hebra  says,  ''  It  will  depend  on  the  period  at  which 
the  patient  comes  under  medical  observation  whether  the  case  shall  be  diagnosed  as  E. 
jwptilatum  or  E.  gyrat}im.'"  He  gives  one  term  to  the  whole,  E.  mnltiforme.  As  the 
disease  subsides  a  slight  desquamation  follows,  and  then  some  small  deposit  of  pigment. 
Mr.  Morrant  Baker'  describes  an  Erythema  serpens  which  follows  a  slight,  probably 
poisoned  abrasion  and  spreads  in  a  circular  manner,  leaving  the  injured  part  well.  It 
generally  occurs  in  the  hand. 

Treatment. — All  these  forms  run  a  definite  course  and  have  a  tendency  to  get  well, 
lasting  from  one  to  three  or  four  weeks.  They  require  for  treatment  little  else  than  a 
well-selected  diet  and  attention  to  the  bowels. 

Erythema  occurs  at  times  during  the  secondary  stage  of  cholera. 

The  erythema  that  precedes  or  accompanies  the  progress  of  elephantiasis  is  worthy  of 
notice. 

Erythema  nodosum  is  a  more  definite  aff'ection  ;  it  is  found  in  both  sexes,  but  more 
commonly  in  the  female  ;  it  is  also  usually  seen  upon  the  legs,  but  not  rarely  upon  the 
arms,  as  well  as  other  parts  of  the  body.  It  shows  itself  in  rai.sed  and  tender  oval  patches 
of  a  red  color  and  of  very  variable  size,  some  being  as  large  as  a  .sixpence,  others  as  of  an 
orange  ;  these  patches  at  times  join.  At  first  they  are  of  a  bright-red  color,  but  as  they 
die  away  they  become  of  a  livid  hue  and  appear  very  like  bruises;  like  them,  also,  they 
lastly  assume  a  yellow  tint.  The  cuticle  always  desquamates.  When  the  disease  is 
limited,  there  may  be  no  constitutional  disturbance,  although  occasionally  some  febrile 
symptoms  appear ;  and  there  is  usually  some  evidence  of  derangement  of  the  digestive 
organs,  with  a  foul  tongue.  As  often  as  not,  however,  the  local  disease  is  the  first  symp- 
tom that  attracts  attention.  The  eruption  is  often  symmetrical.  When  it  appears  over 
the  tibia  and  the  skin  is  very  red  and  painful,  it  is  often  mistaken  for  some  more  serious 
affection,  such  as  perio.stitis  ;  but  the  absence  of  the  severe  conf5titutional  disturbance 
which  commonly  attends  this  aff'ection  ought  to  prevent  such  an  error.  The  history  of 
the  case  is  enough  to  distinguish  it  from  a  bruise  ;  and  the  diff"erent  centres  of  redness  or 
congestion,  from  erysipelas. 

1  St.  Barthol.  Hoi^p.  Rep.,  vol.  ix. 


o.v   TRM'MATir  i'/:\i:i:.  Si:rTI<'.KMl.\.   .\SI>  rV.KMIA.  91 

Its  TiiKAiMKNT  is  siiuiilr  Saline  jiurj^ativcs,  tonics,  ami  a  can'rully  rc^rulatcd  diet  are, 
as  a  riili".  .siiniricnt  in  a  L:iii.ral  way,  and  the  ajijiliiatioii  nf  a  Ifa<l  lotion  to  tiie  inflaini'd 
part,  with  i-lcvatioii  of  the  limlis.  is  trtnicraliy  all  tlir  jcical  tnainnMit  tliat  is  rfi|uin'd  ; 
l)iit  in  cxfciilional  cases  warm  rnuieiilatiMiis,  with  ur  witlmut  poppy  decoction.  <:ive 
LM'oatcr  coiiirorl. 

ON  .TRAUMATIC   FEVER,  SEPTICEMIA,  AND  PYEMIA. 

Inliainniatory  I'cvcr,  suri^ical,  suppurative,  or  traumatic  fcvijr,  scpticjcniia,  icliora-niia, 
puerperal  fever,  and  pyitMuia.  may  all  he  considered  as  so  many  diljerent  names  for  and 
manifestations  of  one  condition — viz.,  hlDixI-jKiiaoiiinij. 

In  inflammatory  and  surtiit-al  fever '•  the  returniiiir  fluids  of  the  inflamed  i)art.  its 
venous  Idood,  and  its  lymph  are  the  agents  of  general  infection"  {.Simon;,  the  poisoninj^ 
beinu;  '•  due  to  the  introduction  into  the  torrent  of  the  circulation  of  toxic  substances  i)ro- 
duced  by  the  oruanism  itself"  (IMaisonneuve),  the  poison  beiiiL:  proljably  derive<l  from 
</isiiifri/rii/t(/  /issiiia  (Hid  i/eii<r(iff<f /ruin  iri'fhiii  the  hoili/. 

Tn  septicemia,  ichor;omia,  puerperal  fever,  and  ])yiemia  the  absorption  u\'  jmtrlil  inflam- 
matorv  products  or  of  pus  or  jjus-formin*;  material,  or  of  some  other  ])oison,  whether  from 
ft  woMuded  i)art  or  not,  is  the  undoubted  cause  of  the  di.sea.se,  //"'  poinDii  bi-imj  tohni  into 
'he  Ii'kIi/  either  by  the  veins  or  by  the  ab.sorbents.//-o»)  irithont.  Traumatic  or  surgical 
f'ever  mav,  however,  pass  into  septicjvmia  and  this  intopyajmia.  the  first  being  the  mildest 
i^'orm  of  blood-poisoning,  the  last  the  most  severe.  Surgical  fever  generally  ends  in  recov- 
ery ;  pyjvmia,  after  the  formation  of  secondary  absces.ses.  either  in  the  viscera,  joints,  or 
connective  tissue,  in  death. 

Symptoms  of  Blood-Poisoning. — One  and  all  are  ushered  in  by  very  similar 
general  symptoms,  and  an  outline  of  those  met  with  in  a  typical  example  of  inflammat<jry 
fever  wili  be  found  on  page  G5,  "  but  practically  the  affection  shows  numberle.ss  grades 
and  differences  and  complications.  First,  there  are  wide  differences  of  degree  and  cha- 
racter ;  for  in  proportion  as  the  local  process  is  less  acute  and  less  extensive  there  is  less 
attendant  febrility,  and  in  proportion  as  the  local  process  has  to  invade  fewer  successive 
strata  of  texture* the  fever  is  of  shorter  course.  ()n  the  one  hand,  it  may  be  so  slight  as 
readily  to  escape  notice,  and  may  end  within  a  few  hours  of  its  commencement ;  on  the 
other  hand,  it  may  last  in  full  force  during  many  successive  days,  and  may  be  so  severe 
as  to  shake  the  patient's  life  to  its  foundation  :  and  besides  these  differences  there  are 
varieties  of  result,  sometimes  from  complicative  local  conditions,  sometimes  from  peculiar 
susceptibilities  of  the  patient.  If  the  wound  become  the  seat  of  some  large  textural  dis- 
organization, with  consequent  .soakage  of  putrefying  material,  more  marked  signs  of  hlood 
pollution  may  be  expected  to  mix  with  or  supersede  tho.se  of  common  inflammatory  fever. 
The  patient's  general  state  will  then  incline  to  be  one  of  depression  and  apathy  ;  his 
tongue  will  be  more  than  commonly  foul,  and  foetid  diarrhoea  will  probably  exist;  or  if, 
perchance,  during  the  local  process  it  happen  (as  is  especially  apt  to  be  the  case  where 
cancellous  bone-structure  is  affected)  that  pus  pa.s.ses  up  a  vein  into  the  general  stream 
of  blood,  the  patient's  improvement  is  abruptly  cut  short  by  the  s^evere  rccnrrnit  rl(/ors 
and  sia'dfiiii/  of  pi/tn'iitia,  accompanied  by  local  signs  of  secondary  suppuration  in  parts  to 
which  the  pus  is  conveyed"  (Simon). 

Confirmed  blood-poisoning,  therefore,  is  characterized  not  only  by  all  the  .symptoms 
of  inflammatory  fever,  but  by  acvere  rii/orx  breaking  in  upon  the  febrile  symptoms,  by 
siiddtn  and  mnrkrd  variations  of  temperature  (vide  Fig.  15),  hi/  pro/me  anyats  and  great 
depression  of  tlw  patient's  powers ;  and  when  these  symptoms  occur  in  the  course  of  an 
attack  of  inflammatory  fever,  severe  blood-poi.soning  is  certainly  indicated,  the  gravity 
of  the  attack  being  measured  by  the  inten.sity  of  the  symptoms.  We  generally  meet, 
moreover,  in  pyaiinia  with  local  signs  of  inflammation  of  some  internal  organ  or  external 
part  of  the  body  ;  and  this  inflammation  runs  on  to  the  formation  of  metastatic  or  second- 
ary abscesses,  as  they  are  called.  When  an  internal  organ  is  involved  in  this  disea.se.  the 
result,  as  a  rule,  is  fatal.  When  suppuration  attacks  the  integuments  or  extremities, 
although  it  may  be  severe,  there  is  alw^ays  some  hope  of  recovery.  It  is  an  interesting 
clinical  fact  that  these  two  different  forms  are  rarely  met  with  in  the  same  subject.  They 
may  for  clearness  be  .separately  called  internal  and  external  py:vmia.  or  acute  or  chronic, 
pyaemia,  when  involving  internal  parts,  being  generally  rapid  in  its  course  and  fatal,  and 
when  attacking  external  parts  it  is  as  a  rule  chrojiic  ;  at  times,  however,  the  latter  may 
supervene  upon  the  former  variety. 

In  many  cases  of  pyaemia  a  peculiar  sweet  hay-like  odor  of  the  breath  is  undoubtedly 


92 


ox  TRAUMATIC  FEVER,   SEPTICEMIA,   AND   PYEMIA. 


present.     Some  authors — and  Braidwood  is  amongst  them — look  upon  this  symptom  as 
pathognomonic. 

Traumatic  fever,  when  it  occurs,  generally  makes  its  ap|)earance  from  the  second 
to  the  ninth  day  after  an  accident  or  operation  and  seldom  lasts  over  a  week.  Jn  a  simple 
case  it  may  subside  after  twenty-four  hours,  and  in  a  severe  one  it  may  continue  I'or  a 
week.  When  a  relapse  or  a  second  sudden  rise  of  temperature  takes  place,  grave  mischief 
may  be  anticipated,  as  some  local  internal  or  external  inflammation.  Billroth  has  described 
this  second  attack  of  fever  as  •'secondary  fever."  When  it  runs  on  for  a  more'lengthened 
period  than  a  week,  severe  complications  are  sure  to  exist  to  keep  up  the  symptoms. 
During  its  coitrse  the  temperature  of  the  body,  naturally  \^'S'.'a°  F.,  may  rise  suddenly  5° 
or  G°  F.,  and  in  ordinary  cases  its  fall  is,  as  a  rule,  gradual ;  while  with  its  fall  deferves- 
cence takes  place.  Should  the  fall  be  sudden,  a  general  breakdown  of  the  powers  of  the 
patient  is  indicated ;  and  under  these  circumstances  sloughing  of  the  wound  may  be 
expected.  The  rise  of  temperature  is  generally  accompanied  by  an  arrest  of  secretion  or 
some  change  of  action  in  the  wound,  but  the  fall  of  temperature  indicates  the  oncoming 
of  suppuration. 

These  points  are  well  seen  in  the  following  thermographs,  figs.  15,  16,  17,  18,  and  19. 
It  is,  however,  important  to  know  that   traumatic  fever  is  by  no  means  a  necessary 

consequence    of    an    injury    or 
Fig.  15.  operation,  however   severe,  that 

it  may  follow  a  trivial  or  fail  to 
follow  a  severe  injury,  and  that 
it  is  quite  impossible  to  predict 
its  occurrence  under  any  cir- 
cumstances. After  a  large  num- 
ber of  capital  operations  it  is 
entirely  absent — I  should  sa}' 
after  one-third  ;  and  since  the 
practice  of  the  torsion  of  ar- 
teries has  been  adopted,  and 
wounds  have  consequently  been 
freed  from  the  presence  of  such  foreign  bodies  as  ligatures,  the  number  of  eases  in  which 
it  is  absent  has  decidedly  increased. 

Fig.  16.  Fig  17.  Fig.  IS. 


DAY    OF        1  2, 

DISEASE    M    E      M     £ 


lUSBjifazni 


BHBBitBat^ngBBBi 


rB!KH9tH3BroiBSBEII 


14S;eo5o;5a  45158  56:72    - 


Therniograiih  of  acute  ostitis  of  ilie  tiliia  in  .1  buy,  a-t.  ir,,  followiriL.'  a 
Mow  ;"aclniitted  into  GuyV  ou  ih'-  luuiitenth  day  »ith  iiya?niia,  which 
destroyed  life  nine  dayslater.  The  table  well  shows  the  fluctuation  of 
temperature  which  is  found  in  jiya-niia,  with  the  night  and  morning 
variations. 


BMHH 


Thermografih  of  traumatic  fe- 
rer,  rise  for  three  days,  sud- 
den fall,  after  amputation  at 
hip-joint,  ill  a  boy,  a;t.  9,  ter- 
minating in  recovery. 


Thermograph  of  traumatic  fe- 
ver, sudden  rise  and  steady 
fall  after  amputation  of  the 
leg  for  disease  of  foot  in 
man,  set.  52,  terminating  In 
recovery. 


Thermograph  of  traumatic  lever  after  opera- 
tion for  ruptured  perina-um.  Kever  at  its 
height  on  fifth  .lay,  when  quill  sutures 
were  removed,  after  which  there  was  a 
sudden  fall  and  a  .steady  convalescence. 
Patient  set.  45. 


Fk;.  10 


Arrest  of  Secretion.— When  blood-poisoning  attacks  a  patient  the  subject  of  a 
wound,  whether  caused   by  djieration   or  injury,  it  is  generally  to  be  observed  that  the 

secretion  of  the  wound  becomes  sanious.  se- 
rous, or  foetid  :  probably  it  will  be  arrested, 
and  the  surface  will  become  glazed  or  glassy, 
or  perchance  assume  a  .sloughing  action.  The 
integument  around  the  wound  will  often  have 
an  erythematous  blush,  or  acquire  a  peculiar 
leaden,  dusky  appearance,  which  is  somewhat 
tvpieal.  T'liion.  if  progressing,  will  cease,  or 
disunion  may  result.  When  any  internal  or- 
gan is  implicated,  special  symptoms  indicative 
of  disturbance  of  its  functions  will  be  pres- 
ent. When  the  brain  is  involved,  there  will 
be  sleeplessness  or  delirium  of  a  low  muttering  kind  or  ''relapsing  unconsc^v^!sness  — 


Thermograph  of  traumatic  fever  after  ovariotomy  in  a 
woman,  aet.  4;i,  ending  in  recovery.  Temperature 
never  rose  above  lu(i. 


/^l77/o/,o^7r.|/,  cDynfTi'tss  fr')M  i'Y.kmia  rnrsi)  .\rr/:n  dkath.    i>3 


III    ran;  cases 


iiiiciiiisciousness   (Vnin  wliidi    tin-   ]i;iti(iit    i;iii  lie   r<>u>cc|   only  tu   ri-l:i|i> 
ariiti'  doliriiiin   and  mania  nccnr. 

Wlu'ii  tln'  I's/iiitifnri/  niyniis  aii'  iiivulvcil — ami  it  may  ln"  statfil  that  tlicy  arc  so  far 
mnn-  fVi'«nii'iitlv  tliau  any  other — dittiiMilty  of  h|•(•athillu^  with  a  har.-h  dry  coii;;h.  and 
in'rhaiis  viscid  Idood-staiiiiMl  s|mtum.  art'  the  ]iromiiiiMit  sym|ttoms  ;  occasionally  pliMiritic 
pains  arc  present,  or  symptoms  of  liromdiitis,  with  ^reat  dysjiiKea. 

When  the  nliilininiiiil  riscrrn  are  affected,  nausea  or  sickness  and  proru>e  diarrhuu'a 
are  j)rominent  symptoms  ;  the  latter  in  some  cases  apparently  <-arries  rjff  the  poison. 
When  anvthiiiL;  like  sallowness  of  the  skin  or  jaundice  appears,  liepatic;  ahscess  should  he 
fjusjiectcd  .  and  under  tlu'se  circumstances  there  will  <d"ten  he  pain  in  the  rejrion  of  the 
liver.  At  the  same  time,  the  reader  must  rememher  that  a  sli<rht  de-rree  of  jaundice  is 
often  pre.sent  without  hepatic  suppuration.  The  urine  is  rarely  altered  either  in  (diarac- 
ter  or  in  (juantity.  although  at  times  it  is  scanty  and  dark-colored.  When  .seven;  or  dull 
pains  are  experienced  in  a  joint,  suppuration  should  he  suspected  ;  and  anythinfr  like 
so-called  rheumatic  ])ains  occurring  in  a  patient  with  py;emia  hecomes  a  source  of  sus- 
picion :  •■  rheumatic  '  pains  in  hlood-poisonintr  too  often  mean  joint  or  ))one  miscliief  of  a 
suppurative  kind.  It  is  also  remarkahle  how  slij^ht  the  sym])toms  often  are  in  these 
cases  when  severe  local  disease  exists.  This  fact  demands  that  the  surjreon  should  ever 
he  on  the  watch  to  detect  anything;  like  local  chaii,u;es.  inasmuch  as  it  is  a  pathological 
truth  that  there  is  no  organ  or  ti.ssue  of  the  hody  in  which  sujipurative  disease  may  not 
take  jilace  in  a  case  of  hlood-poisoning  or  pyaMuia  ;  and  it  is  certainly  true  that  the  exist- 
ence of  severe  local  disease  is  too  often  only  first  discovered  on  the  posf-morf'iii  tahle. 

What,  then,  it  may  he  asked,  are  the  pdthiiliiijiail  ruiuh'tioii^  found  after  death  in  a 
case  of  hlood-poisoning  or  py:emia,  using  this  word  in  a  general  sense  ? 


Analysis  of  203  F.at.\l  C.\ses  of  Py.emia. 


Nature  of  .\ccideDt  or  Disease. 


jCompoiind  fracture 

|Araputatioii    after    compound 
!     fracture 

Amputation  for  disease 

(Injury  to  scalp  and  skull 

I  Inflammation     and     suppura- 

j     tion  of  soft  parts 

'Disease  of  urinary  organs 

Disease  of  hones  and  joints 

Operations  on  soft  parts -t 

Carbuncle 6 

Burns ,     5 


28 


Total.. 


Eg 

a 

is 

i 
<3 

1 

< 

26 

23 

1142-3 

3i< 
29 
11 

34 
24 
11 

1  «■ 

33 

30 

9o-. 

f3.1- 
•'lOO- 


203 

186 

78 

or 
91.fi 

or 

.38.4 

per 
cent. 

per 
cent. 

I  —  I 

34.61 

.39.4 
20.6! 
63.6 


Spleen. 


Brain.     \     Heart.         Joint-<i.      Cell-tissae- 


S3  I 


S  I 


11..5I     1  I    3.81 


6     15.7 
2  :    6.9 


6.9 
45.4 


8 

24.2 

8 
10 

6 

21.4 

8 

1 

20. 

1 

3 

50. 

2 

"522" 

277 

"3^ 

24.2 
4.5.4 

28.5 

20. 

33.3 


5     15.1 


4     14.2 
1   i20. 


17.7;  19       9.3 


6. 
45 


.1    4  I  15.3;     3  1 11.5 


5 

1 

4 

I 

16.6      2 


15.1 

4.5 
14.2 
20. 
.33.3 


4  10.5 

2  6.9 

1  9. 

8  24.2 

6  21.4 


3  7.8 

4  1.3.8 
2  18.1  j 

5  ■  15.1 

1  4  5' 

2  T.l 
1  20.  i 


6.41  25»  I  12.3,  21     10.3 


•  In  which  the  lungs  were  alone  involved.    The  small  figures  show  the  percentages.  -  The  liver  was  involved, 

alone  in  two  cases  only ;  in  all  others  the  lungs  were  aflfected  as  well.  ^  Sterno-clavicular  in  eight.  I 


The  analysis  (shown  in  the  form  of  a  tahle,  ahove)  of  two  liundred  and  three  fatal 
eases,  wliich  I  have  collected  from  the  records  of  Guy  s  Ho.spital  with  the  sanction  of  my 
colleagues,  Drs.  Wiiks  and  Moxon.  ])y  whom  all  the  examinations  were  made,  will  answer 
this  question. 


Pathological  Conditions  from  Pyemia  found  after  Death. 

The  Lungs. — The  most  prominent  fact  indicated  by  this  table  has  reference  to  the 
lungs,  for  it  proves  that  in  the  larger  proportion  of  fatal  cases  of  blood-poisoning  the.se 
organs  are  implicated,  and,  further,  that  in  many  they  are  the  only  parts  involved.  Lung 
mischief  was  found  one  hundred  and  eighty-seven  times  in  two  hundred  and  three  ca.ses ; 
while  in  seventy-eight,  cases,  or  thirty-eight  in  every  hundred,  the  lungs  were  the  only 
organs  affected.  Lohnlnr pneumonia  is  the  form  in  which  the  di.sease  is  generally  found; 
and  when  even  a  lobar  pneumonia  is  present,  it  can  usually  be  made  out  to  have  origi- 
nated in  lobules  and  to  have  spread  from  them  as  centres.  This  lobular  pneumonia,  like 
the  lobar  form,  is  also  generally  seen  in  the  Jmrer  hUs.  and  not  at  the  apices,  and  nearer 
the  surface  than  the  central  parts.  The  earliest  indication  of  disease  is  a  lobular  pneu- 
monia, and  ••  subsequently,"  says  Wilks,  '•  these  congested  spots  are   found   to   contain 


94      PATHOLOGICAL   CONDITIOyS  FROM  PWEMLi   FOUND  AFTER   DEATH. 

iiiflainniatdry  products  ;  and  tlni.s  we  have  red  hepatization,  suppuration,  or  sloughing," 
all  these  stages  of  inflammation  being  visible  in  individual  masses.  Associated  with  this 
lobular  pneumonia  some  icrlii/niosis  of  the  surface  of  the  lung  will  generally  be  found — a 
purpuric  condition,  in  fact — strongly  suggestive  of  blood-poisoning.  Pleurisy,  moreover, 
generally  exists,  the  fact  being  accounted  for  by  the  superficial  position  of  the  lobular 
pneumonia. 

The  Liver,  like  the  lungs,  is  also  attacked  in  its  lobules,  which  may  be  either  con- 
gested, inflamed,  suppurating,  or  sloughing.  At  times  it  is  filled  with  small  abscesses. 
When  these  approach  the  surface  of  the  liver,  they  ma}'  burst  and  give  rise  to  a  general 
peritonitis.  The  liver  Avas  involved  in  this  aflection  twenty-seven  times  in  every  hundred 
cases,  and  almost  always  in  association  with  disease  in  the  lungs.  Thus,  out  of  fifty-five 
case  in  which  the  liver  was  aff'ected.  in  only  two  were  the  lungs  uninvolved.  It  would 
appear,  likewise,  from  the  table  that  the  liver  is  more  frequently  the  seat  of  pytemic 
suppuration  after  injuries  to  the  head  than  after  any  other  aff"ection,  and  that  it  is  rarely 
found  involved  after  disease  of  the  urinary  organs  and  burns. 

The  Kidneys. — When  these  organs  are  aff'ected,  they  are  so  in  a  similar  manner  to 
the  lungs  and  liver,  and  present  small  isolated  points  of  suppuration  surrounded  by  a 
zone  of  congestion  either  on  their  surface  or  in  their  cortical  structure.  They  are  not. 
however,  aff'ected  so  frequently  as  are  the  two  former  organs — not  oftener,  indeed,  than 
in  seventeen  cases  out  of  every  hundred,  and  then  mostly  after  disease  of  the  urinary 
organs,  or  suppurative  disease  of  the  cellular  tissue,  particularly  of  that  surrounding  the 
shafts  of  bones. 

In  the  Spleen  abscesses  are  often  present,  and  in  the  Brain.  Heart,  Prostate.  Tes- 
tis. Tongue,  Thyroid  Gland,  and.  in  fact,  in  any  portion  of  the  body,  they  may  be  met 
with.  In  the  cellular  tissue  of  the  trunk  and  extremities,  as  the  joints,  suppuration  is 
very  common. 

When  inflammation  attacks  such  serous  membranes  as  the  pleura  and  peritoneum, 
there  is  good  reason  to  believe  that  it  is  generally  due  to  the  extension  of  disease  from 
the  lung,  liver,  or  spleen.  In  the  case  of  the  synovial  membrane  of  the  joints  no  such 
extension  can  be  made  out.  The  sterno-clavicular  articulation  is  more  frequently  involved 
than  any  other,  for  I  find  that  out  of  twenty-five  instances  in  which  joint  complication 
existed  this  was  involved  in  eight.  Any  joint  may,  however,  be  aff'ected.  In  some  ca.'^es 
the  articulation  is  only  filled  with  an  increase  of  synovia;  in  others  the  contents  are  puri- 
form,  sometimes  purulent.  At  times  the  pus  in  the  joint  appears  to  be  so  slightly  irritat- 
ing that  the  cartilage  and  the  synovial  membrane  are  uninjured  by  its  presence,  whilst  at 
others  it  is  so  destructive  as  to  produce  complete  disorganization,  the  bones  forming  the 
joint  being  under  these  circumstances  exposed,  and  at  times  necrotic.  When  these 
changes  occur,  they  are  probably  sometimes  due  to  acute  articular  ostitis. 

The  skin  has  occasionally  a  vesicular  or  pustular  erupfiou  upon  it.  and  too  frequently 
purpuric  spot.^  or  patches  are  present,  which  at  times  lead  on  to  mortification  ;  and  in  con- 
nection with  this  subject  •'  we  may  mention  another  evidence  of  the  blood  disease  in  the 
rapid  decomposition  of  the  bodies  and  the  'marking  of  the  veins  on  the  surface.  Thus, 
before  the  body  is  scarcely  cold  there  may  sometimes  be  seen  the  blue  and  red  coursing 
of  the  veins  and  the  coloring  which  has  exuded  from  them  into  the  tissues"  (Wilks). 

Lastly,  it  is  to  be  noted  that  it  is  exceptional  to  meet  with  any  evidence  of  phlehith, 
general  or  local ;  and  this  leads  me  to  consider,  although  briefly,  the  now  already  aban- 
doned and  untenable  theory  that  phlebitis,  or  inflammation  of  a  vein,  is  the  invariable 
cause  of  pyaemia. 

The  most  telling  evidence  against  the  theory  i.>;  the  one  just  mentioned — that  it  is  only 
in  exceptional  cases  of  pysemia  that  any  evidence  can  be  found  of  phlebitis;  and  the  sec- 
ond is  almost  equally  strong,  becatise,  "  so  far  from  phlebitis  being  a  cause  of  pya?mia.  it 
is  remarkable  how  often  the  former  occurs  without  any  contamination-  of  the  blood  what- 
ever— that  is.  if  we  can  call  that  phlebitis  where  we  find  a  vein  and  its  branches  quite 
closed  by  coagulum  or  adherent  fibrin"  (Wilks).  Moreover,  "it  is  a  (juestion  whether, 
in  those  cases  in  which  the  veins  are  plugged  or  inflamed,  thrombosis  and  phlebitis  are 
not  the  local  and  pyaemia  the  general  eff'ect  of  the  same  cause  '"  (8avory) — that  is,  blood 
infection.     With  these  views  I  cordially  agree. 

That  blood-poisoning  may  take  place  through  veins  is  certain,  although,  as  I  have 
already  shown,  inflammation  of  their  coats  does  not  necessarily  lead  to  it ;  neither  is  it 
probable  that  the  absorption  of  pus,  as  pus,  is  the  usual  cause,  for.  Avhen  pus  mixes  with 
blood  coagulation  is  produced,  and  thus  its  circulation  is  prevented.  There  seems,  how- 
ever, good  reason  to  believe  that  the  fluid  portion  of  pus  or  of  some  decomposing  inflam- 


IWTIlOlJxncM.    COM'lTloSX  Fi:<)M   I'V.KMfA    inI'M)   AFTKlt   DKATII.      05 

matnrv  product  iiiav  lie  takfti  ii|>  l»y  tlic  veins  iiml  rarriftl  into  the  system,  and  thus 
fiiusi-  |iv;i'iu:;t.  The  jmi.-nn  niav  l>o  iuipnrted  intn  the  <.'eneral  cireuhition  thri»uj:h  either 
a  sn)all  nr  hirL'e  vein  when  involved  in  a  supituratinfr  or  sh»u<rhin<r  tissue;  this  is  a  tVe- 
<(Ui'iit  occiir'-'-nic  whin  the  vein  is  connecteil  with  an  infianied  or  divich-d  hone. 

Theory  of  PyaBmia. — It  may  he  fairly  inferred  that  the  iiiihh  r  /miiis  of  hluml- 
poisii/n'iiif,  sueh  as  trauniatie  fever,  are  caused  hy  tin*  circulation  of  morhid  elejjients  in 
tlie  hlood,  which  are  L'enerated  either  within  the  Itofly  or  imported  into  it  from  without, 
and  that  these  morhid  elements  are  at  times  carried  off,  .sometimes  hy  th(!  lunps  and  at 
other  times  l)v  the  intestines;  that  the  niorr  srrcre  /'unim  '>/'  />f'tii(/-jtoisi>iiiii(/,  as  pyjcmia, 
are  caused  1)V  emholism.  thromhosis.  or  hlood  extravasation,  due  tr»  the  aihnixturc  witli 
the  Vdood  of  some  morhid  fluid  ;  and  tliat  this  morhid  material  ori<rinates  the  chancres 
wliich  frive  rise  to  the  secondary  or  metastatic  ab.sceH.se.s  with  which  sur<reons  and  pathol- 
oirists  are  sc  f^imiliar.  This  view  receives  much  support  from  the  fact  that  disintegrating 
fihrin  may  he  carried  from  the  heart  through  tlie  arterial  system  into  the  smaller  vessels 
of  the  pari'nehvmatous  organs,  and  give  rise  not  only  to  constitutional  symptoms  much 
akin  to  those  which  have  heen  described  as  being  present  in  pya;mia,  but  to  analogous 
pathological  contlitions.  This  condition  is  spoken  (»f  as  arterial  pyaemia.  Thus,  in  the 
more  cctmmou  form  of  pyjemia  abscesses  form  in  the  viscera  or  in  other  parts,  and  iti 
"arterial  py;tmia"  lobular  fibrincms  changes  occur.  Tn  the  former  case  secondary 
abscesses  are  found  after  death  ;  in  the  latter,  secondary  fiV)rinous  deposits.  It  .seems 
probable,  also,  that  at  times  these  fibrinous  deposits  may  break  down  and  give  rise  to 
abscesses. 

This  arterial  pyjvmia  is  met  with  after  ulcerative  and  rheumatic  endocarditis  ;  it  is. 
doubtless,  the  cause  of  the  .so-called  rheumatic  pains  that  follow  .scarlet  fever,  and  in  rarer 
instances  it  gives  rise  to  the  embolic  plugging  of  some  large  vessel,  which  may  be  fol- 
lowed by  gangrene  or  by  the  formation  of  an  aneurism.  On  two  occasions  I  have  had  to 
remove  a  leg  for  gangrene  from  embolism  of  the  femoral  artery  after  scarlet  fever.  I 
have  also  seen  cases  of  aneurism  which  have  probably  been  due  to  the  same  cause.' 

Arterial  pva'mia  is  not  necessarily  fatal.  Mild  attacks  come  and  gr).  says  Wilks. ''the 
proof  being  found  eventually  in  the  cicatrices  and  remnants  of  deposits  met  with  in  the 
organs  of  the  bodies  of  those  who  have  died  with  heart  disease.'  The  mild  forms  manifest 
themselves  by  pyrexia,  prostration,  and  pains  in  the  joints. 

Hence,  when  a  patient  dies  rapidly  from  blood-poisoning,  the  only  ])ath(dogical  change 
found  in  the  tissues  mav  be  some  lobular  congestion  of  the  lung,  indicating  the  first  stage 
of  pneumonia  ;  when  life  has  lasted  lonirer  red  or  gray  hepatization  may  be  present,  and 
in  a  later  stage  suppuration,  these  different  conditions  depending  upon  the  intensity  of 
the  disease  and  its  duration.  '•  The  first  stage  of  the  morbid  condition  which  is  produced 
in  the  viscera  is  a  coagulation  in  the  vessels,  and  the  last  stage  is  a  suppuration"  C  Wilks). 

In  feeble  patients  who  have  no  resistine:  power  against  disease  it  is  possible  that  even 
these  pathological  conditions  may  not  be  found,  life  being,  as  it  were,  suddenly  destroyed 
in  the  first  onset  of  the  blood-poisoning.  Under  these  circumstances  no  definite  post- 
mortem appearances  would  be  seen,  beyond,  perhaps,  a  general  softening  of  the  viscera 
or  some  pur|iuric  conditioi!. 

Duration  of  the  Disease. — There  seems  reason  to  believe  that  a  patient  may 
die  in  two  or  three  days  after  the  first  appearance  of  the  .symptoms,  and.  as  a  rule,  bad 
cases  terminate  during  the  second  week.  Others  go  on  for  six  or  seven  weeks.  The 
longer  a  patient  lives,  the  greater  the  hopes  of  a  successful  issue. 

Prognosis. — In  every  ca.se  of  blood-poisoning  great  cause  for  anxiety  exists,  it  being 
impossible  to  foretell  its  course  or  its  end.  In  one  case  a  small  dose  of  the  poison  will 
prove  fatal,  while  in  another  a  full  dose  will  be  thrown  oflT.  The  violence  of  the  attack 
does  not  depend  upon  the  severity  or  size  of  the  wound,  for  a  trifling  wound  is  at  times 
followed  by  urgent  symptoms,  while  a  severe  local  injury  may  be  followed  by  but  few. 
if  any.  complications.  Indeed,  some  of  the  severest  cases  of  blood-poisoning  are  found 
in  tho.se  in  whom  there  is  no  wound. 

A  robust  per.son.  doubtless,  has  a  better  chance  of  recovery  than  a  feeble,  and  an 
abstemious  one  than  a  drunkard.  Where  disea.eed  viscera  exist,  particularly  diseased 
kidneys,  the  prospects  of  recovery  are  small  indeed,  the  capabilities  of  a  patient  to  resi.«t 
any  di.seased  action  under  these  circumstances  being  slight  in  the  extreme.  A  single 
attack  of  traumatic  fever  may  pass  off"  without  trouble,  but  a  relapse  or  a  second  attack 
alwavs  indicates  serious  mischief.  Rigors  rarely  occur  without  suggesting  the  presence 
of  .some  secondary  deposit  or  local   inflammation.     One  rigor  may  pass  off"  and  leave  no 

'  Vide  Pnih.  Soc.  Trans.,  1877. 


96      PATHOLOGICAL   COXDITIOXS  FROM  PY.KMIA    FOl'SD   AFTER   DEATH. 

trace  of  harm  behind,  but  a  succession  of  them  is  associated  too  frequently  with  the 
gravest  local  complications,  such  as  secondary  metastatic  abscesses.  These  abscesses, 
also,  when  they  occur  outside  any  of  the  three  great  cavities  of  the  body,  are  less  danger- 
ous than  when  they  occur  in  the  viscera.  Acute  pyasmia  is  always  accompanied  with 
great  danger ;  when  the  disease  is  chronic,  there  is  always  more  hope. 

The  occurrence  of  pya-mia  in  different  surgical  affections  is  well  shown  in  the  follow- 
ing analysis  of  cases : 

Of  217  consecutive  cases  of  pyaemia.  68.  or  31.3  per  cent.,  were  after  compound  frac- 
tures, of  which  24.  or  11  per.  cent.,  were  not  amputated,  and  44,  or  20.2  per  cent.,  were 
amputated :  2t).  or  12  per  cent.,  were  after  amputation  for  disease ;  28.  or  12.9  per  cent., 
were  after  other  operations  :  21,  or  9.6  per  cent.,  were  after  injury  of  soft  parts  without 
operation;  60.  or  27.6  per  cent.,  were  after  disease  without  operation:  12.  or  5.5  per 
cent.,  were  idiopathic ;  2.9  per  cent.,  puerperal. 

Statistics  of  Co.mpound  Fracture. 

Out  of  790  cases.  192  died,  or  24  per  cent.  :  68,  or  8.6  per  cent.,  of  pyemia. 

Of  184  ca.ses  treated  by  amputation,  89  died,  or  47.7  per  cent. ;  44,  or  23.9  per  cent., 
of  pyaemia. 

Of  606  treated  witliout  amputation.  lOo  died  :  or  17  per  cent.  :  24.  or  3.9  per  cent., 
of  pyaemia. 

Out  of  324  cases  of  amputation  of  thigh,  leg.  arm.  and  fire-arm  for  disease.  126  died, 
or  38.8  per  cent. ;  26.  or  8  per  cent.,  of  pya?mia. 

Pyaemia  is  thus  seen  to  be  three  times  as  fatal  after  amputatinn  fa-  comji'iund  frac- 
ture as  for  disease. 

Out  of  29,434  surgical  ca.ses  admitted  into  Guy's  during  ten  years,  there  were  1749 
deaths,  or  5.9  per  cent.  ;  203  of  these,  or  11.6  per  cent,  of  the  fatal  cases,  were  from 
pyaemia,  about   1   in  9  of  the  deaths  arising  from  this  cause. 

But  of  the  whole  number  of  cases  treated.  pva?nna  was  fsital  in  1  ease  out  of  145. 

Statistics  of  last  Five  Years.  EXDiMi  with  1882. 

During  these  years  a  better  result  than  the  above  can  be  recorded  :  and  out  of  14,951 
surgical  ca.ses.  of  which  847  eases,  or  5.6  per  cent.,  died,  only  42.  or  5  per  cent,  of  the 
fatal  eases,  died  from  pyaemia,  the  general  mortality  of  pyaemia  in  the  last  five  years 
having  fallen  from  1  in  every  145  cases  treated  to  1  in  every  356. 

In  the  compound  /racturfn.  also,  a  like  improvement  is  indicated  by  the  fact  that  of 
the  213  cases  treated  32.  or  15  per  cent.,  died,  and  only  4  of  these  from  pya?mia. 

Of  120  cases  treated  conservatively.  9  cases,  or  7.5  per  cent.,  died.  1  from  pya?mia. 

Of  93  cases  treated  by  amputation.  23  cases,  or  24.7  per  cent.,  died.  3  fmni  ])ya?mia. 

Out  of  11  double  amputations.  5  recovered. 

But  is  pt/semia  a  ho><pif'fl  disease?  Does  it  arise  from  causes  that  are  generated  in  a 
hospital,  or  is  it  met  with  more  frequently  in  a  hospital  because  the  class  of  cases  in 
which  it  is  most  prone  to  occur  are  there  treated  ?     Is  it  found  in  private  practice  ? 

As  an  answer  to  the  last  question  it  is  only  neces.sary  for  me  to  refer  to  Mr.  Prescott 
Hewett's  presidential  address  at  the  Clinical  Society  in  1874,  in  which  he  gave  the  par- 
ticulars of  twenty-three  examples  of  pvf^mia  occurring  in  private  practice  and  in  six 
only  after  operations,  four  of  which  were  very  trivial. 

Sixteen  of  the.se  were  in  town  and  seven  in  the  country,  and  all  were  placed  under 
most  favorable  circum.stances. 

We  know,  moreover,  that  some  of  the  worst  cases  of  pyaemia  that  are  seen  in  the 
London  hospitals — and  I  can  answer  for  Guy's — are  admitted  with  the  infection. 

Under  these  circumstances  it  may  confidently  be  asserted  that  what  is  known  as  pyae- 
mia is  hot  peculiarly  a  hospital  disease,  and  that  it  probably  occurs  after  surgical  injuries 
and  operations  as  frequently  in  private  as  in  hospital  practice.  It  is  true  that  pyjemia 
often  takes  its  origin  in  hospitals,  but  equally  true  is  it  that  it  does  so  because  the  class 
of  cases  in  which  the  affection  is  the  most  prone  to  occur  are  there  to  be  found. 

Blood-poisoning  may  occur  anywhere,  in  hospitals  or  in  private  houses  :  but  it  is 
unfair  and  unscientific  to  attribute  it  without  reason  or  evidence  to  what  has  been  so 
wronofully  described  as  ••hospitalism.  ' 

Treatment. — An  unlimited  supply  of  fresh  air.  .simple  nutritious  food,  and  where  a 
wound  or  suppuration  exists  the  most  thorough  cleanliness,  are  the  main  points  of  prac- 


PATiinij)ai('M.  (osDirrnxs  from  pv.kmia  roiwn  .\rn:i:  in:.\rii.    97 

ticc  tu  111'  ai  tciidol  Id  in  the  i  real  iiiciil  of  every  fuse  of  traiiiiiiitie  fever  nr  jivii'iiiiu.  ('itrn- 
pared  with  tlie.si',  all  ntlur  imaiis  are  (if  secomlary  iinportaiiee. 

As  the  disease  is  due  tn  a  Iduod-poisoii  oftcsii  taken  into  tlie  txxly  froiii  witlioiit.  it  is 
tlie  siirueoii's  duty  to  sec  that  tlic  patient's  rooin  is  well  ventilated,  that  it  is  neither  too 
hot  nor  too  eold — as  lioih  extremes  arc  powcrlnl  deprcjssants — that  the  air  cireulatin<^ 
throiitrh  it  is  free.  IVesli,  and  frairrant,  that  the  room  is  iVefpiently  purified  hy  eleansinj^ 
antl  disinfectants,  larui'  dishes  of  any  disinfeetinj;  fluid  and  cdoths  .saturated  with  the 
fame  heinu  distributed  ahout  ;  s(did  iodine  exposed  in  a  jtlate  to  the  air  i.s  a  good  disiri- 
teetant.  and  more  persistent  than  some  others.  Care  must  be  taken  that  no  poison  from 
a  drain  or  el<»set  rea<diesthe  room,  and  that  all  excretions  are  disinfected  at  once — ituh-ed, 
passed  directly  into  vessels  containinjx  disinfeetint:'  fluid,  such  as  Condy's,  carbolic  acid, 
chloride  of  lime,  or  chloralum.  The  wound  should  be  kept  clciui^  and  care  should  be 
taken  that  all  discharjics  are  allowed  a  free  escape.  I)ressin;.i:s,  when  employed  to  a  sup- 
purating; or  shtuiihinii  wound,  should  be  saturated  with  disinfectinfr  lotions  and  changed 
every  three  or  four  hours.  When  possible,  foul  wounds  should  be  irrigated,  a  stream  of 
warm  water  containing  a  disinfectant  being  allowed  to  run  over  the  surface.  I  know  of 
no  means  so  valuable  for  keeping  a  wound  clean  as  thi.s.  When  sloughing  of  the  part  i.s 
present,  charcoal  poultices  are  at  times  beneficial.  Sponges  should  never  be  employed 
where  pus  exists,  but  tow  or  cotton-wool,  more  particularly  the  ab.sorbing  cotton-wool. 
Poultices,  when  employed,  may  be  put  on  tow  or  oakum,  both  of  which  materials,  through 
the  tar  they  contain,  being  disinfectants. 

In  simple  iinconipliaifcd  tntnmaiic  fever,  when  it  stops  within  tlu;  ordinary  bounds  and 
neither  runs  on  n(»r  returns  in  any  severity,  no  special  treatment  is  called  for.  Should 
restlessness  or  mu(-h  pain  exist,  a  sedative  dose  of  chloral,  opium,  or  morphia  may  be 
given,  either  by  the  mouth,  rectum,  or  skin  ;  and  beyond  this  nothing  is  needed.  In 
more  confirmed  cases  of  suppurative  fever,  when  systemic  infection  is  declared,  the  vital 
energies  of  the  patient  must  be  maintained  or  stimulated,  and  everything  that  tends  to 
lower  must  be  warded  off;  thus,  the  administration  of  tonic  medicine  becomes  a  necessity, 
the  preparations  t)f  (juinine  being  the  best,  but  strychnine  and  iron  are  likewise  of  great 
use.  From  ten  to  twenty  grains  of  quinine  given  at  the  first  onset  of  pyncmia  and 
repeated  every  three  or  four  hours  help  defervescence.'  Stimulants  must  be  administered 
with  caution  and  their  amount  regulated  by  the  wants  of  the  individual  case.  When  the 
patient's  habits  have  been  free,  alcohol  in  one  of  its  forms  will  be  required,  even  in  large 
((uantities ;  whereas  to  an  abstemious  person  a  very  moderate  dose  will  be  sufficient. 
The  form  t)f  stimulant  to  which  the  patient  has  been  accustomed  is  apparently  the  best. 

The  diet  should  be  as  nutritious  as  possible,  but  its  nature  must  depend  upon  the 
assimilative  powers  of  the  stomach.  Where  milk  agrees  no  better  drink  can  be  given, 
either  alone  or  mixed  with  eggs  or  some  spirit;  cream  may  be  added  at  times,  or  the  con- 
centrated Swiss  milk  ;  animal  broths  may  likewise  be  freely  used.  When  meat  can  be 
digested,  it  may  be  given,  although  sparingly.  When  a  patient  refuses  food,  Liebig's 
extract  of  meat  or  Darby's  fluid  meat  may  be  mixed  with  the  beer  or  wine  without  his 
knowledge.  When  the  stomach  rejects  nourishment,  it  must  be  given  by  the  rectum,  a 
two-  or  three-ounce  enema  of  beef-tea  and  egg  being  administered  every  four  or  six  hours. 
Ice  may  always  be  allowed  in  small  quantities,  as  it  gives  comfort.  When  the  nervous 
system  is  disturbed  from  want  of  sleep  or  otherwise,  opium  may  be  given,  small  doses 
frefjuently  repeated  being  better  than  large.  WHiere  enemata  are  used,  laudanum  may  be 
mixed  with  them. 

Should  diarrhoea  exist,  it  must  not  be  checked  too  suddenly,  for  in  some  cases  of 
blood-poisoning  it  appears  to  have  an  eliminative  tendency  ;  it  should  be  stopped  only 
when  telling  on  the  patient's  powers.  To  give  remedies,  however,  with  the  view  of  elim- 
inating the  poison  by  the  bowel  is  a  rash  practice  and  cannot  be  recommended.  The  sul- 
phites and  chlorides,  which  have  been  highly  praised,  do  not  a])pear.  in  any  of  their  forms, 
to  have  any  power  to  neutralize  the  poison  in  the  blood.  The  alkaline  salts  have  like- 
wise been  .strongly  recommended  "to  promote  the  changing  and  eliminating  of  the  prod- 
ucts of  the  retrograde  metamorphosis  of  the  tissues  "  (Savory),  of  which  the  carbonate 
of  ammonia  is  probably  the  best,  either  given  alone  or  with  the  liquid  extract  of  bark. 

When  secondary  abscesses  have  formed  in  the  cellular  tissue  and  between  the  muscles, 
they  should  be  opened  ;  but  great  caution  mu.st  be  ob.served  in  dealing  with  inflamed 
joints.  When  the  presence  of  pus  can  be  clearly  made  out,  it  should  be  evacuated  by  a 
free  incision  into  the  joint  and  care  taken  that  it  does  not  reaccumulate  ;  to  prevent  this, 
a  drainage-tube  should  be  introduced  into  the  cavity  and  the  joint  daily  freely  washed 

'  Goodheart,  Guy's  Ho.<p.Rep.,  1870. 


98  HECTIC  FEVER. 

out  with  a  stream  of  warm  water  colored  with  Condy's  or  some  other  disinfecting  fluid, 
such  as  carbolic  acid  one  part  in  forty,  or  iodine  water  composed  of  one  drachm  of  the 
tincture  of  iodine  to  a  pint  of  water.  Soothing  applications  should  at  the  same  time  be 
employed,  poppy  fomentations  being  probably  the  best. 

When  acute  blood-poisoning  has  set  in,  it  is  almost  needless  to  say  that  amputation 
of  a  diseased  limb  has  n6  influence  in  checking  the  disease,  nor  has  the  application  of 
caustics  or  cauteries  to  a  wound ;  indeed,  no  local  treatment  is  known  by  which  the  for- 
mation of  secondary  abscesses  can  be  prevented.  In  chronic  pyaemia,  however,  amputa- 
tion is  often  of  essential  service. 

How  far  blood-poisoning  can  be  prevented  i^*  another  question,  and,  as  it 
is  an  important  one,  it  may  be  consi(h'red  here. 

As  to  the  exciting  cause  of  the  disease  nothing  is  known.  It  attacks  the  healthy  as 
well  as  the  cachectic,  those  surrounded  by  perfect  hygienic  influences  as  well  as  those 
subjected  to  the  most  unfavorable,  and  it  is  found  in  private  as  well  as  in  public  practice. 
It  is  true  that  the  cachectic  and  those  who  are  subjected  to  close  and  unhealthy  atmo- 
spheres are  the  more  prone  to  its  attack,  and  that  overcrowding  in  small  wards,  bad  ven- 
tilation, bad  drainage,  and  bad  feeding,  with  every  other  depressing  influence,  have  an 
injurious  tendency.  It  becomes  the  surgeon's  duty,  therefore,  to  ward  off",  as  far  as  he 
can,  all  such  influences.  In  cases  for  operation,  when  time  is  allowed  for  preparation,  the 
general  condition  of  the  patient  should  be  investigated ;  care  should  be  taken  that  the 
excretory  glands  are  performing  their  functions,  and  if  not  they  should,  if  possible,  be  at 
once  corrected.  The  feeble  must  be  strengthened  by  tonics  and  good  nutritious  food, 
and  the  supply  of  stimulants  should  be  regulated  in  all.  The  intemperate  man  should 
be  brought  to  see  the  necessity  for  moderation,  and  to  know  that  life  cannot  long  be  sus- 
tained by  drink  alone  ;  he  must  learn,  also,  that  stimulants  are  chiefly  of  value  in  assist- 
ing digestion  and  the  assimilation  of  nutritious  food.  The  vn'ne  under  all  circumstances 
should  he  exdmmed  for  albumen  ;  for,  although  its  presence  would  not  deter  the  surgeon 
from  performing  an  operation  of  necessity  to  save  life,  it  would  aff'ect  his  prognosis,  and 
would  most  certainly  influence  his  decision  in  an  operation  of  expediency.  All  patients 
after  operation  .should  be  kept  in  absolute  repose,  the  wounds  kept  clean  and  lightly 
dressed.  Everything  that  tends  to  procure  rapid  union  must  be  considered  good,  and 
all  that  induces  or  keeps  up  suppuration  bad.  Blood-poisoning  and  suppuration,  whether 
with  or  without  a  wound,  have  a  close  connection.  No  one  who  has  been  in  contact  with 
any  infectious  disorder,  such  as  erysipelas  or  scarlet  fever,  should  be  allowed  to  come  near 
the  patient ;  for  there  can  be  no  doubt  that  there  is  subtle  connection  between  these 
poisons  and  pyaemia.  And,  lastly,  every  cheering  influence  should  be  brought  to  bear 
on  the  mind  of  the  patient,  as  well  as  on  his  surroundings  ;  for  among  the  agents  predis- 
posing to  blood-poisoning  mental  anxieties  and  depressing  emotions  should  doubtless  be 
reckoned. 

HECTIC  FEVER. 

There  can  be  little  doubt  that  surgeons  of  former  times  included  under  the  above 
heading  many  cases  of  what  we  now  call  septicaMnia,  pyajmia,  or  blood-poisoning ;  and 
even  at  the  present  time  it  is  an  open  point  as  to  how  far  the  symptoms  which  denote 
hectic  fever  are  due  to  the  absorption  of  some  foreign  element  into  the  blood. 

That  hectic  fever  is  never  found  except  in  those  who  are  the  victims  of  destructive 
organic  changes,  chiefly  of  a  suppurative  nature,  is  an  esta1)lished  fact,  and  it  is  in  such, 
also,  that  confirmed  blood-poisoning  generally  occurs.  The  physician  meets  with  this 
condition  in  pneumonia,  phthisis,  empyema,  abscess  in  the  liver,  kidneys,  or  ovary  ;  the 
surgeon,  in  suppurative  diseases  of  joints  and  bones,  in  spinal  disease,  compound  frac- 
tures, diff"used  suppurations,  etc.  The  characteristic  symptoms  are  of  a  remittent  cha- 
racter and  usually  appear  at  least  once  daily,  generally  toward  evening,  but  they  may 
occur  more  frequently.     They  are  not  unlike  those  of  ague. 

A  paroxysm  of  hectic  may  be  said  to  commence  with  fever,  of  more  or  less  intensity  ; 
the  skin  will  be  hot  and  dry,  the  pulse  rapid  and  feeble.  The  face,  too,  will  be  flushed  in 
a  single  patch,  and  the  palms  of  the  hands  and  the  soles  of  the  feet  hot  and  burning. 
The  tongue  during  the  paroxysm  may  be  dry  and  great  thirst  will  be  present.  There  will, 
however,  be  no  brain  symptoms,  no  clouding  of  the  intellect,  no  delirium.  The  febrile 
condition  may  be  preceded  by  shivering  or  chilliness,  but  such  symptoms  are  unusual  and 
are  always  followed  by  a  profuse  and  exhansfive  sweat.  This  sweating  is,  indeed,  pecu- 
liar to  tlie  aff"ection  ;  for  it  bears  no  proportion  to  the  febrile  symptoms  that  preceded  it. 
At  the  commencement  of  the  disease  the  febrility  may  be  so  slight  as  hardly  to  be  noticed, 


iirji'ir  F/:v /■:/:.  99 

aiitl  yet  tlif  |tatit'?it,  mi  laHiii;:  •'>  >li'f|i  ami  awakciiiriL'.  will  \n'  ItatlK^d  in  jicrs|iiiaf ion. 
Wlu'ii  tin-  iliscast'  is  at  its  lu'ijxlit,  the  fold,  IidI,  and  sweating;  stap-s  iiiav  I"'  casilv  seen; 
but  when  it  dfclincs,  tlic  fcUrilf  syniptonis  will  ]n'  cdnstant,  altIioii<;li  a}.';.'ruvat<'d  toward 
iii^ht,  while  till'  MiurniiiLr  "  <"ollii|iiativc' '  swi-ats  grudually  beconic  more  iirol'iisc  as  lite; 
ebbs  away. 

In  till'  I'aily  stau^-s  of  this  disease,  hrliDiu  the  paroxysms,  there  may  be  no  fever. 
The  tonjriu".  dry  durini^  the  attaek,  will  }»e  moist  and  elcan,  l)Ut  toward  the  close  bt;eom(!S 
morbidly  red,  smooth,  and  son;,  with  ajdithous  uleeration.  The  appetite  an<l  digestive 
or<;ans  are  rarely  much  afioeted  ;  indeed,  they  are  little  altered  till  the  "general  powers 
are  failiii<r  rapidly.  The  skin,  at  first  supple  and  moi.st  between  tlie  attack.s,  beeomes,  as 
the  di.sease  |)roi;rosscs,  harsh,  dry,  and  covered  with  branny  .scales.  The  urine,  alway.s 
scanty  and  hitrh-colored,  i.s  more  .so  toward  tlie  close  of  the  disea.se.  Tlrc  bowels  are  .some- 
times consti|)ated,  but  more  fre((ucntly  loose.  Throughout  the  disca.se,  however,  the 
mental  faculties  remain  unimpaired,  even  when  the  bodily  powers  are  reduced  to  a 
minimum.  l)urin<;-  the  whole  disease  .sleep  is  usually  obtained  between  the  attacks. 
Death   always  ensues  from  exhaustion,  which   bed-sores  tf»o  fre(juently  ajrfjravate. 

TKK.VTMKN'r. — The  removal  of  the  cause  of  the  disease  is  the  only  means  by  which 
a  cure  can  be  effected.  As  the  affection  is  one  purely  of  exhaustiini,  the  object  must 
be  to  maintain  the  streiiirth  of  the  patient  in  every  way  })y  the  administration  of  abun- 
ilance  of  simple  nutritious  food,  with  stimulants  carefully  adjusted  to  the  special  wants  of 
the  case.  The  former  should  be  given  at  certain  short  intervals  in  small  (juantities.  and 
the  latter  in  sufficient  ([uantitics  to  aid  digestion. 

Tonic  medicine  .should  always  be  given,  quinine  probably  being  the  be.st,  as  this  drug 
has,  doubtless,  a  power  in  checking  febrile  action,  in  keeping  down  tlie  temperature  of  the 
body,  and  in  preventing  sweats.  It  should  be  given  in  a  full  dose,  five  grains  in  the 
.solid  form,  before  the  paroxysm.  Iron  and  strychnine  are  also  valuable  drugs,  and 
the  extract  of  belladonna  in  doses  of  half  a  grain  or  more  combined  with  the 
tonic  is  of  great  value.  Diarrhoea,  when  pre.sent,  should  be  checked  by  astringents, 
but  opium  should  be  sparingly  employed,  except  to  relieve  pain. 

With  respect  to  the  removal  of  the  cause  of  the  disease  by  operation  when  such 
is  possible  there  can  be  no  difference  of  opinion  among  surgeons,  for  hectic  is  a  proof 
that  nature's  reparative  powers  have  been  found  wanting  in  their  efforts  to  cure  the  local 
affection  ;  and  under  these  circumstances  the  surgeon's  duty  doubtless  lies  in  operative 
interference.  If  the  disease  can  be  removed,  this  should  be  done,  and  delay  is  almost 
criminal.  Let  the  source  of  irritation  or  weakness  be  removed,  and  it  is  wonderful  how 
rapidly  the  most  feeble  subject  may  rally  after  the  operation.  If  the  viscera  are  sound, 
good  hopes  of  a  recovery  may  be  entertained  under  apparently  the  most  adverse  condi- 
tions ;  but  if  the  kidneys  are  diseased,  the  prospects  of  recovery  are  feeble. 

MoxoN-,  Guy's  Hoxp.  Repo)t'<,  1871.— Wilk.s,  Gmi/'.s-  Hosp.  Reports  for  1861  and  1870.— Lee,  "On 
Phlebitis,"  Practical  Patholor/y. — Paget  and  Savory,  St.  Bart.  Repitrt.%  vols.  i.  and  ii.,  1865-6. — 
VlKCHOw,  Cellular  Patholoqy. — Pick,  St.  Georcfe'n  Hoxp.  Reports,  vol.  iii.— BiLI.ROTH,  Dr.  Th., 
Archiv.  fiir  Klh>.  Chirurgie  (Lansjenbeck's),  b.  ii.,  vi.,  viii.,  ix. — Bristowk,  Trans.  Path.  Sloe.  Loud.,  vol. 
xiii.,  Reynold's  System  of  Medicine. — Roser,  Sydenhnni  Soc.  Year-Book,  1863,  p.  192. — Prof.  O. 
Weber,  Berl.  Klin.  \Vochen<rhr.,  1864,  Year-Bonk;  1864,  p.  227.— Gibson,  Brit,  and  For.  Med.  Chir. 
Rev.,  January,  1866. — Cai.i.esdkr,  Holmes's  Syst.  of  Surr/.,  second  edition,  vol.  i. — Sedillot,  On 
Pyiemia,  1849. — Arnott,  Med-Chir.  Trans.,  vol.  xv.— Braidwood,  On  Pyemia,  1865. — Gresinger, 
On  Leukamia  and  Pywmia,  discussion  at  Clin.  Soc,  1874. 


100  POISONED    WOUNDS. 


CHAPTER   II. 
ON    ANIMAL    POISONS. 

POISONED  WOUNDS. 

Dissection  "Wounds. — These  are  of  frequent  occurrence,  although  it  is  excep- 
tional to  find  them  followed  by  any  seriously  ill  eftects.  In  common  with  all  wounds, 
they  may  be  attended  with  absorbent  inflammation,  inflammation  of  the  cellular  tissue, 
suppuration,  septicajmia,  or  pyaemia;  and  feeble  or  cachectic  subjects  are  more  liable  to 
these  consequences  than  the  strong  and  steady.  In  exceptional  instances,  however, 
diff'erent  results  follow,  and  two  forms  of  the  affection  may  be  recognized — the'  mild 
and  the  acute. 

"The  symptoms  in  the  ^  niil<1'  form  partake,"  says  Poland,  "more  or  less  of  the  ordi- 
nary character  of  non-specific  inflammation  and  scarcely  present  any  noticeable  character- 
istic signs.  Thus,  the  local  appearances  consist  in  the  puncture  assuming  a  defined  red 
aspect,  which  soon  becomes  pustular;  this  bursts,  and  ends  in  an  unhealthy  suppuration; 
there  is  surrounding  erythema  of  an  erratic  form  and  inflammation  and  pain  extending 
along  the  fore-arm  and  arm  to  the  axilla,  ending  in  the  enlargement  and  suppuration  of 
the  glands.  The  constitutional  effects  consist  in  febrile  disturbance,  loss  of  appetite, 
diarrhoea,  fetid  eructations,  etc.  The  prognosis  and  termination  are  favorable,  and  the 
treatment  required  is  to  be  based  upon  general  principles." 

The  symptoms  of  the  " acute  ^  or  severe  forms  are  those  of  a  truly  specific  disease; 
the  local  signs  commence  by  the  appearance  of  a  small  circular  or  oval  vesicle  over  the 
seat  of  puncture,  which  soon  becomes  turbid,  milky,  and  pustular  and  not  unfrequently 
has  a  defined  margin  resembling  somewhat  that  of  smallpox.  This  is  generally  unattended 
with  pain,  but  the  patient  often  complains  of  intense  pain  in  the  shoulder  and  about  the 
axilla,  which  shoots  down  the  chest.  The  glands  in  the  axilla  are  early  affected  and  seem 
to  act  as  barriers  to  the  further  progress  of  the  poison  ;  they  become  enlarged  and  the 
surrounding  cellular  tissue  is  implicated,  with  serous  effusion  ;  there  is  erythema  and 
puffy  swelling ;  these  extend  to  the  subscapular  and  pectoral  regions,  spreading  down 
the  side  of  the  chest,  yielding  to  pressure,  and  imparting  a  peculiar  spongy  feel.  There 
is,  besides,  an  oedematous  and  doughy  condition  of  the  arm  and  fore-arm,  owing  to  serous 
exudation  into  the  cellular  tissue,  which  seldom,  if  ever,  passes  into  suppuration." 

"  The  coTistitutional  symptoms  are  at  fir.st  those  of  strong  excitement,  but  these  are 
soon  followed  by  those  of  extreme  depression  of  spirits  and  much  suffering.  Rigors, 
headache,  prostration  of  strength,  vomiting,  etc.,  supervene ;  and,  lastly,  all  the  symp- 
toms of  low  typhoid  fever  rapidly  set  in." 

In  some  cases  the  absorbent  glands  are  not  involved,  and  death  may  occur  from  pros- 
tration in  the  early  stage  of  the  disease;  in  others,  suppuration  and  pyaemia  may  appear; 
while  in  a  third,  extensive  and  diffused  .sloughing  of  the  skin  may  ensue;  all  these  points 
being  materially  inflaenced  by  the  power  of  the  patient  to  throw  off  morbific  influences. 

The  PROGNOSIS  in  these  acute  cases  must  be  unfavorable.  Travers  calculated  that 
one  in  seven  recovers :  probably  this  is  rather  in  excess  of  experience  ;  but  if  the  patient 
does  not  sink  during  the  violence  of  the  attack,  his  powers  will  be  tried  to  the  utmost  by 
the  protracted  suppuration. 

The  inoculation  from  a  recently-dead  body  is  more  serious  than  that  from  an  old  sub- 
ject of  the  dissecting-room,  and  bodies  that  have  been  preserved  by  chloride  of  zinc  are 
less  noxious  than  others.  The  fluids  from  a  patient  who  has  died  from  glanders,  perito- 
nitis, and  scarlet  or  puerperal  fever  are  far  more  dangerous  than  all  others.  Indeed, 
there  is  reason  to  believe  that  the  contact  with  such  fluids  is  capable  of  giving  rise  to  the 
disease  without  any  local  wound  or  abrasion. 

Treatment. — To  keep  the  patient  alive  and  to  treat  local  symptoms  as  they  arise  on 
general  principles  are  the  usual  methods  now  pursued. 

A  student  when  he  pricks  his  finger  should  at  once  clean  and  suck  the  wound,  arrest- 
ing at  the  same  time  the  circulation  of  blood  through  it  for  at  least  a  minute  by  pressure 
applied  with  the  opposite  hand  on  its  cardiac  side.  The  part  may  then  be  closed  over,  a 
piece  of  ijutta-percha  skin  made  adherent  with  chloroform  being  an  admirable  application. 
AVhen  the  wound  is   free   and  the  poison  is  from  a  recent  puerperal  ca.se,  some   cau.stic, 


.I.V.17'0,1//r.l/.    (II!    I'.iriKU.nt.'fCAL    'I'l'llKlir'fJ-:. 


I(»l 


PUfli  as  iho  nitrate  of  silver,  eliliniile  lA'  /.inc.  nr  even  nit  lie  iieid.  may  be  applied.  The 
first  two  are  pioi)alilv  tin-  hest.  W'lieii  aiiv  inlianiniation  appears,  a  p<nilti(:e  .should  he 
applied  and  tlu'  hand  raised  ahove  the  shoulder;  and  if  therti  should  he  any  teii.sion  of 
the  part,  it  is  to  he  at  onee  relieved  hy  an  incision. 

Ahsorheiit  or  eelliihir  inflainuiatioti  should  he  treated  hy  fomentations  or  the  applica- 
tion of  the  e.vtraet  of  hellaihinna  ruhhecl  down  with  j:lycerin  to  the  infiamed  part.  Some 
surgeon.s  have  faith  in  the  local  application  of  nitrate  of  silver,  iodine,  or  the  solution  of 
the  perehlorith;  oi"  iron  as  a  means  of  arrestiiif^  its  proL^ress.  The  f^lands,  wht;ii  etilarjred, 
should  he  IVeely  hathed  with  hot  water  and  hot  fomcntation.s  constantly  appli(Mi.  'I'he 
earliest  indications  of  suppuration  ouj;ht  to  he  looked  for,  in  order  that  pus  may  he  at 
once  evaeuateil.  Slouj^hs  ant  to  he  removed  hy  moderate  incisicjiis.  Tonics  should  he 
<;iven  from  tiie  first — iron  when  it  can  he  home  with  or  without  <(uinine  in  full  doses, 
ammonia  and  hark  when  ((uiiiiue  and  iron  are  inapplicable.  Nutritious  food  (JUf^ht  to  be 
given  in  abundance,  milk  being  the  best  drink;  stimulants,  too,  when  needed,  but  alway.s 
with  caution.  Country  air,  as  soon  as  it  can  be  enjoyed,  is  the  great  aid  upon  which  reli- 
ance may  be  placed  for  recovery. 


r 


Anatomical  or  Pathological  Tubercle. 

This  is  a  chronic  skin   aflFection  which  is  to  be  met  with  on  the  hands  of  those  con- 
stantly engaged  in  making  ])Ost-mortem  examinations.      Dr.  Wilks,'  when  describing  some 
models  of  the  affection  that  are  to  be  seen   in   Guy's  museum 
(Fig.  20),  called  it  ''  verruca  necrogcnlcay     In  its  earlier  stages  Fig.  20. 

it  is  not  unlike  epithelial  cancer.    "  It  commences  without  any  evi- 
dent breach  of  surface,  the  parts  affected  being  not  those  liable  to 
pustules,  as  the  back  of  the  hand  or  \vrist,  but  the  knuckles  and 
joints  of  the  fingers.     If  the  disease  should  begin  with  a  pu.?- 
tule,  the  pustule  bursts,  but  instead  of  healing  a  thickening  of 
the  cuticle  takes  place  around  it ;  and  as  from  time  to  time  a 
little  fresh  suppuration  occurs,  so  the  thickening  and  induration 
increase.     Geiu-rally,  however,  these  changes  go  on  slowly  with-      _ 
out  any  preliminary  vesication.      A  warty  thickening  of  the  epi-  '7^. 
theliuni  takes  place,  which  in  course  of  time  becomes  of  a  dark   \J: 
color,  until  a  kind  of  iehthyotic  condition  is  produced." 

The  disease  is  local  and  unattended  by  constitutional  symp- 
toms. The  repeated  application  of  the  strong  tincture  of  iodine, 
acid  nitrate  of  mercury,  nitric  acid,  or,  what  is  better,  the  benzo- 
line-gas  cautery,  will  effect  a  cure. 

Insect-stings  in  England  are  not  very  severe,  and  unless 
inflicted  in  large  numbers  are  rarely  brought  under  the 
notice  of  the  surgeon.  Slight  fever  and  constitutional  disturb- 
ance may  follow  them  in  children  who  are  susceptible  to  exter- 
nal influences,  whilst  local  swelling,  heat,  and  redness  are  very 
marked  in  others.  Should  a  wasp  or  bee  accidentally  be  taken  into  the  mouth  with  fruit, 
and  the  base  of  the  tongue,  pharynx,  or  larynx  stung,  serious  symptoms  may  ari.se  from 
oedema  and  swelling  of  the  parts  impeding  respiration.  When  this  accident  happens, 
scarifications  should  be  employed  with  fomentation  ;  but  if  life  be  threatened,  the  wind- 
pipe must  be  opened. 

When  the  tongue  or  other  accessi])le  part  is  affected,  the  sting  .should  be  removed,  if 
possible,  with  a  pair  of  fine  forceps,  and  thus  much  pain  is  saved.  Where  this  cannot 
be  done  a  drop  of  either  liquor  ammonic'V,  sal  volatile,  or  oil  of  lavender  applied  to  the 
part  generally  gives  relief.  The  parts  should  also  be  protected  from  the  air  by  collodion, 
flour,  chalk,  or  strapping. 

For  mosquito-bites  Dr.  J.  Stevenson  of  Ceylon  advises  (Edin.  Mmifh.  Jourii..  Feb- 
ruary, 1882)  the  use  of  a  moist  cake  of  soap,  the  thin  lather  from  the  cake  being  allowed 
to  dry  upon  the  bitten  part.  All  pain  and  itching,  he  states,  disappears  within  ten  min- 
utes of  this  application. 

The  bite  of  the  scorpion,  the  tarantula,  and  other  tropical  insects  is,  however,  more 
troublesome,  and  is  often  followed  by  nervous  depression,  vomiting,  and  local  pain.  In 
South  America  the  mosquito-bite  is  at  times  attended  with  severe  local  inflammation, 
and  sometimes  with  ulceration.     In  Africa  and  Asia  the  scorpion,  which  is  from  six  to 

'  Guy's  Bep.,  1SG2. 


\mtoniit  il  lubcrcle 
(Model  Guy's  Mus.  I9:J*o.) 


102  ANATO^^CAL   OR   PATHOLOGICAL    TUBERCLE. 

ten  inches  long,  is  so  venomous  as  to  cause  by  its  bite,  at  times,  loss  of  life.  Olive  oil  is 
the  usual  application  for  the  wound,  but  liquor  ammoni?e  is  probably  better.  Brandy  and 
ammf)nia  should  be  given  internally  when  great  depression  exists. 

The  bite  of  the  spider  is  very  .similar  in  its  eifects  to  that  of  the  scorpion,  though  the 
wonderful  stories  as  to  its  poisonous  qualities  are  now  regarded  as  fabulous. 

Serpent-bites  are  often  serious,  and  at  times  fatal,  the  poison  being  squeezed  into 
the  ti.-MU'  in  the  act  of  biting  from  a  special  apparatus  situated  at  the  base  of  the  upper 
fangs.  In  England  the  viper  is  the  only  poisonous  reptile,  and,  although  some  local  and 
constitutional  disturbance  may  follow  its  bite,  a  fatal  result  rarely  ensues. 

The  cobra  i/icapeUo,  raltlemuike.  ichipcord  make,  and  jihoorsasv a ke  are  the  most  venomous. 

In  some  cases  the  poison  seems  to  spend  its  eifects  upon  the  nervous  system,  killing 
by  convulsions  or  coma  ;  in  others,  its  local  effects  are  the  more  important. 

Dr.  S.  Weir  Mitchell  of  Philadelphia,  who  has  carefully  studied  the  effects  of  poison 
by  the  rattlesnake,  states  that  the  bite  is  sometimes  followed  by  pain  of  a  pricking  or 
burning  character,  which  gradually  becomes  more  intense,  also  by  bleeding,  swelling, 
and  discoloration  of  the  injured  part  and  tissues  around,  these  symptoms  depending  upon 
the  effusion  of  blood  into  the  cellular  tissue.  The  wounded  e.xtremity  becomes  larger 
and  the  pain  greater,  the  skin  assuming  a  mottled  marbly  a.spect.  As  secondary  effects 
inflammation  and  disorganization  of  the  tissues  occur;  the  inflammation  assumes  more 
the  character  of  the  phlegmonous  erysipelas  and  is  associated  with  glandular  enlargement 
and  suppuration,  followed  by  gangrene  as  a  common  consequence. 

Great  depression  of  the  nervous  system  and  general  prostration  are  the  most  promi- 
nent constitutional  symptoms,  with  profuse  cold  sweats,  vomiting,  dyspnoea,  and  diarrhoea, 
and  jaundice  often  precedes  death. 

When  the  dose  of  the  poison  is  large  or  the  susceptibilities  of  the  patient  acute, 
death  mav  take  place  at  once  from  general  prostr^ition  and  local  stagnation  of  blood  in 
the  wounded  extremity.  In  the  case  of  a  keeper  of  the  London  Zoological  Gardens  who 
was  bitten  in  the  nose  by  a  cobra  death  took  place  in  little  more  than  an  hour  after  the 
infliction  of  the  wound,  and  half  an  hour  only  had  elapsed  when  he  was  apparently  dying, 
being  unable  to  speak,  swallow,  or  support  himself;  the  pupils  became  dilated,  the  face 
livid,  the  heart's  action  feeble,  and  he  was  scarcely  conscious. 

Mitchell  has  recorded  a  case  which  proved  fatal  in  five  and  a  half  hours.  Of  others, 
one  died  comatose,  another  with  dyspnoea  and  dysphagia,  a  third  felt  sleepy  and  died 
without  agony. 

On  the  other  hand,  patients  at  times  recover  suddenly  even  when  the  symptoms  have 
been  severe,  as  if  the  poison  had  suddenly  lost  its  power.  More  commonly,  however, 
death  ensues;  and  when  recovery  follows,  it  is  only  after  severe  local  suppuration  and 
sloughing,  leaving  a  maimed  and  useless  limb. 

After  death  Mitchell  found  ecehymoses  in  the  thoracic  and  abdominal  viscera,  pur- 
puric in  their  nature  and  clearly  caused  by  a  want  of  normal  coagulating  power  in  the 
blood ;  this  altered  condition  of  the  blood,  indeed,  is  the  most  common  effect  of  snake- 
poisons,  and  it  is  stated  in  some  cases  to  last  through  life.  Hence,  in  bites  from  the 
Indian  phoorsa  snake  there  is  said  to  be  a  hfemorrhagic  tendency  during  life.  After 
death  Mitchell  could  never  detect  the  least  alteration  in  the  blood  cells  in  acute  ca.ses, 
but  in  exceptional  examples  of  chronic  poisoning  he  found  a  few  globules  indented.  In 
chronic  cases,  also,  where  there  has  been  time  for  the  poison  to  act  upon  the  blood,  the  want 
of  coagulating  power  in  the  blood  is  very  constant,  and  putrefactive  changes  rapidly  follow. 

Dr.  Halford  of  Melbourne  .says  he  always  found  the  blood  after  death  dark  and  fluid. 
It  also  contained  germinal  nucleated  cells,  which  he  regards  as  molecules  of  living  for- 
eign matter  thrown  into  the  blood  from  the  venom  ;  and  he  accounts  for  the  asphyxia 
and  death  by  the  increase  and  multiplication  of  these  molecules,  which  take  place  at  the 
expense  of  the  oxygen  normally  wanted  in  inspiration. 

Sir  J.  Fayrer  tells  us,  however,  that  he  has  never  been  able  to  detect  these  changes 
in  the  blood,  although  the  poison  affects  the  blood  primarily  and  the  nervous  centres  indi- 
rectlv  through  it.' 

Treatment  should  be  most  energetic  ;  otherwise,  the  depressing  influence  of  the 
poi.son  will  soon  paralyze  all  action,  a  few  .seconds  often  being  enough  for  the  absorption 
of  the  poison. 

Lorally.  the  aim  should  be  to  arrest  the  absorption  of  the  poison  by  fastening  a  liga- 
ture firmly  on  the  cardiac  side  of  the  wound,  by  excising  the  wounded  part,  and  by  the 
application  of  nitric  acid,  carbolic  acid,  or  the  nitrate  of  silver. 

1  Inflifin  Avtm/.i  of  Med.  Science,  1870. 


BITES  OF  DISEASED  AMMALS.  103 

Fayrer  records  that  the  natives  of  Imlia  ajiply  a  lifrature  not  only  just  aliovc  the  bite, 
but  at  several  plaees  on  the  limit  at  intervals  of  some  in<-hes  ;  they  then  j.laee  a  reil-hot 
coal  upon  the  wounded  part.  The  daiiL'er  and  diflienlty  lie  in  not  applying'  the  litratnre 
quieklv  eiiou^di.  The  litratnre  must  also  be  tiirhteiied  to  the  utmost,  till  the  eireulation 
is  entirely  arrested  and  the  part  is  livid  with  retaine<l  blood.  The  punctures  slmuld  then 
be  searitied,  to  allow  the  blood  to  tlnw  freely,  and  the  cautery  or  caustics  afterward  be 
applied. 

('onstidttioiKiffi/,  the  best  treatment  lies  in  the  administration  of  ammonia  and  stimu- 
lants in  sufficient  (piantities  to  maintain  the  action  of  the  nervous  and  circulatory  sys- 
tems, and  thus  to  keep  tlie  patient  alive  while  the  poison  is  being  worked  oft'  or  becomes 
exhausted ;  for  the  man  who  is  dying  from  snake-bites  is  perishing  from  rapid  oxhau.stion 
of  nerve  force.  Any  other  measure  that  can  rouse  and  stimulate  the  failing  nervous 
energy  may  also  be  emjdoyed. 

Fowler's  solutinii  in  full  doses  every  half  hour  for  four  hours  is  said  to  have  been 
useful.  Iodine  has  also  been  advocated,  and  olive  oil  internally  in  full  doses  has  Vjeen 
hiirhlv  praised.  In  countries  where  poisonous  snakes  abound  difierent  roots  have  theii 
reputation,  such  as  the  guaco.  the  sacra;  vit;e  ancora.  radi.x  corinese,  decoction  of  Virginia 
snake-root,  etc.,  etc. ;  but  Fayrer,  after  repeated  exiieriments,  believes  them  to  be  utterly 
useless. 

Halford  has  inferred  from  his  exi>erimeiits  that  the  injection  of  twenty  to  thirty  drops 
of  a  solution  of  one  part  of  strong  liquor  ammonite  to  three  parts  by  measure  of  water 
into  one  of  the  veins  of  the  wounded  limb,  accompanied  by  the  local  application  of  li(|uor 
ammoni;\>  to  the  part,  is  a  specific ;  but  Fayrer,  who  has  tried  the  practice,  has  failed  to 
find  the  success  looked  for.  Mitchell  advises  ligature  of  the  cardiac  side  of  the  wound, 
or  excision,  amputation,  or  destruction  by  cautery  or  escharotics  of  the  poisoned  part, 
and  even  sucfion  of  the  wound  immediately  after  the  bite,  as  the  poison  has  no  influence 
in  the  stomach.  lie  thinks  well,  also,  of  the  injection  into  the  wound  of  iodine  or  ammo- 
nia, and  savs  the  natives  believe  the  local  application  of  olive  oil  to  be  the  best.  M.  de 
Lacerda  communicated  in  1SS2  to  the  Paris  Academy  a  note  in  which  he  asserts  that  a 
one-per-cent.  filtered  solution  of  the  permanganate  of  potash  injected  beneath  the  skin  or 
into  the  veins  counteracts  very  eff'ectively  the  poison  of  snakes.  "With  this  local  treat- 
ment the  patient  is  to  be  kept  up  by  hope,  the  action  of  the  heart  sustained  by  stimulants 
quite  irrespective  of  quantity,  and  the  general  powers  maintained  by  nutritious  food.  By 
these  means.  '•  if  the  person  be  not  thoroughly  poisoned,  we  may  help  him  to  recover.  If 
he  be  badly  bitten  by  one  of  the  more  deadly  snakes,  we  can  do  no  more  "  (Fayrer). 

Bites  of  Diseased  Animals. 

Hydrophobia,  meaning  the  '•  dread  of  water  " — which  is  more  correctly  termed 
"rahies' — is  a  disease  contracted  from  the  bite  of  a  rabid  animal  through  its  saliva  or 
mucus.     It  appears  at  all  seasons  of  the  j'ear,  and  is,  as  a  rule,  fatal. 

It  is  more  common  in  temperate  regions  of  the  world  than  in  the  torrid  and  frigid 
zones.     It  is  unknown  in  Australia,  New  Zealand.  Greenland,  and  Kamschatka. 

Blaine  and  Youatt  affirm  that  in  animals  rabies  is  entirely  due  to  a  trauTnatie  action — 
viz..  the  bite  of  some  rabid  creature  inflicted  on  another  previously  free  from  the  disease. 
Fleming,  the  most  recent  authority,  tells  us.  however,  that  the  virus  of  rabies  may  under 
certain  favorable  conditions  be  generated  directly  without  the  intervention  of  any  infect- 
ing medium,  although  at  present  we  are  in  complete  ignorance  of  the  conditions  on  which 
its  spontaneous  production  depends.  All  animals  bitten  do  not  contract  the  disease,  as 
is  proved  by  Renault  of  Alfort.  who  cau.sed  dogs,  horses,  etc.,  to  be  bitten  several  times, 
and  even  inoculated  them,  when,  out  of  99  cases.  67  contracted  the  malady,  and  32,  or 
one-third,  escaped.  Fleming  calculates  that  30  or  40  per  cent,  of  people  who  are  bitten 
by  mad  animals  go  mad. 

In  the  d"g  there  are  three  well-marked  stages  of  the  complaint.  The  prut  is  the  mel- 
ancholic, characterized  by  melancholy,  depression,  sullenness.  and  fidgetiness;  the  second, 
the  /itn'iiHS.  by  excitement  or  rabid  fury  ;  and  the  A/s^  the  paralytic,  by  general  muscular 
debility  and  actual  parah/aix. 

'•  The  dog.''  writes  Trousseau.  '■  looks  ill  and  sullen  after  a  period  of  incubation  of  a 
very  variable  length  :  he  is  constantly  agitated,  turning  round  and  round  inside  his  ken- 
nel, or  roaming  about  if  he  is  at  large.  His  eyes,  when  turned  on  his  master,  have  a 
strange  look  in  them  expressive  of  sadness  as  well  as  of  distrust.  His  attitude  is  sus- 
picious and  indicates  that  he  is  not  well :  by  his  wandering  '  he  seems  to  be  seeking'  for 


104  BITES  OF  DISEASED  AXLMALS. 

a  remedy.  He  is  not  to  be  trusted  :  if  he  obeys  at  all.  he  does  it  slowly  ;  if  you  chastise 
him,  he  may  in  spite  of  himself  inflict  a  fatal  bite."'  ''His  agitation  increases:  if  in  a 
room,  he  runs  about  looking  under  the  furniture,  tearing  the  curtains  and  carpets,  some- 
times flying  at  the  walls,  at  others  jumping  as  if  to  catch  flies;  the  next  moment  he 
stops,  stretches  his  neck,  and  seems  to  listen  at  a  distant  noise.  He  probably  then  has 
hallucinations  of  sight  and  hearing."' 

■  This  delirium.'  says  Youatt,  ••  may  still  be  dispersed  by  the  magical  influence  of  his 
master's  voice ;  all  these  dreadful  objects  may  vanish,  and  the  creature  creeps  to  his 
master  with  the  expression  of  attachment  peculiar  to  him.  " 

"  There  follows  then  an  interval  of  calm  :  he  slowly  closes  his  eyes,  hangs  down  his 
head,  his  fore-legs  seem  to  give  way  beneath  him.  and  he  looks  on  the  point  of  dropping. 
Suddenly,  however,  he  gets  up  again  ;  fresh  phantoms  rise  before  him  ;  he  looks  around 
him  with  a  savage  expression,  and  rushes  against  an  enemy  which  only  exists  in  his 
imagination.  By  this  time  the  animals  bark  is  hoarse  and  mufiled  ;  loud  at  first,  it 
gradually  fails  in  force  and  intensity  and  becomes  weaker  and  weaker.  In  some  cases 
the  power  of  barking  is  completely  lost ;  the  dog  is  dumb,  and  his  tongue  hangs  out 
through  his  half-opened  jaws,  from  which  dribbles  a  fi'othy  saliva.  Sometimes  his  mouth 
is  perfectly  dry  and  he  cannot  swallow,  although  in  the  majority  of  cases  he  can  still  eat 
and  drink.  When  he  cannot  drink,  he  will  appear  to  lap  fluids  with  great  rapidity ;  but 
on  looking  closely  it  will  be  seen  that  he  merely  bites  the  water.  He  can  still,  in  some 
cases,  swallow  solids,  and  he  may  then  swallow  anything  that  is  within  hi.>  reach — bits 
of  wood,  pieces  of  earth,  straw,  etc." 

'•  Toward  the  close  of  the  second  .stage  of  rabid  fury  the  dog  often  breaks  his  chain  and 
runs  away  ;  he  wanders  about  the  fields,  being  seized  from  time  to  time  with  paroxysms  of 
fury,  and  then  he  stops,  from  fatigue,  as  it  were,  and  remains  hours  in  a  somnolent  state.  He 
generally  dies  in  a  ditch  or  retired  corner,  apparentlv  from  hunger,  thirst,  and  fatigue." 

Veterinary  surgeons  do  not  say  that  he  dies  from  asphyxia  brought  on  bj'  spasm  of 
the  pectoral  muscles  or  by  convulsions.  The  disease  runs  its  course  in  from  five  to  eight 
days,  and  it  is  the  same  in  the  dog.  cat.  horse,  and  wolf,  from  any  of  which  man  may 
become  inoculated. 

In  man  the  disease  may  show  itself  at  any  period  from  six  weeks  to  a  year  after 
the  inoculation,  although  Fleming  and  Bouley  assert  that  the  incubatory  period  in  man 
varies  from  one  to  two  months,  and  that  after  the  third  month  the  chances  of  immunity 
are  great.  Thamhayn  (Schmidt's  Jahrhuch..  1859).  in  an  analysis  of  220  cases,  showed 
that  in  49  the  symptoms  appeared  within  a  month,  in  98  during  the  second,  in  29  during 
the  third,  and  in  2G  during  the  fourth,  month.  16  of  the  remaining  cases  showing  them- 
selves within  twenty-six  months,  two  cases  only  maturing  at  a  period  of  four  and  five 
and  a  half  years  respectivel}'.  But  these  cases  are  always  doubtful,  and  are  probably 
examples  of  hysterical  or  vervovs  hi/dropliohia.  Fleming,^  however,  records  some  strik- 
ing cases  which  seem  to  show  that  the  latent  disease  may  be  induced  or  brought  into 
activity  by  mental  agitation. 

The  disease  may  attack  the  infant  at  the  breast  or  the  aged,  the  male  or  the  female, 
and  during  the  incubative  stage  no  disturbance  of  the  general  health  is  usually  observed. 
Van  Swieten  has  pointed  out  that  during  this  period  such  a  disease  as  variola  may  run 
its  course  without  any  modification,  two  poisons  thus  coexisting  in  the  same  frame. 

After  the  incubative  stage  has  passed  the  Jirst  si/mptom  usually  displayed  is  that  of 
sadness,  the  victim  either  not  suspecting  his  complaint  or  carefully  avoiding  mentioning 
the  circumstance.  His  sleep  is  disturbed  :  he  is  fidgety,  sighs  deeply,  and  avoids  society  ; 
he  is  troubled  by  noise  or  is  very  irritable  and  ill-tempered.  The  second  stcK/e  will  be 
marked  by  an  aggravation  of  all  these  symptoms,  but  there  will  be  in  addition  pain  in 
the  region  of  the  heart  with  some  irregularity  of  the  pulse ;  rigors  will  soon  appear, 
which,  says  Trousseau,  •'  are  true  convulsions  of  all  the  muscles  of  the  body  ;"  and,  lastly, 
the  characteristic  symptom  of  dread  of  water — not  as  fluid,  however,  but  as  connected 
with  the  diflicultv  of  drinking.  The  sight  of  water  is  frequenth-  sufiicient  to  bring  on 
shuddering,  vet  it  is  when  the  patient  carries  water  to  his  lips  that  he  is  seized  with  the 
typical  terrors.  A  rabid  man  is  always  rational  and  tries  to  drink,  but  the  attempt 
excites  terror  and  the  expression  of  his  inability.  His  eyes  become  fixed,  his  features 
contracted,  and  his  countenance  expressive  of  the  deepest  anxiety  ;  his  limbs  shake  and 
the  whole  body  shivers.  The  paroxysm  lasts  a  few  seconds,  then  subsides,  but  only  to 
be  renewed  on  the  slightest  breath  of  air  touching  his  body  ;  for  hi/persesthesia  is  one  of 
the  most  marked  symptoms  of  the  aff"ection. 

'  Rabies  and  Hydrophobia,  1872. 


nrn:s  of  1)Iskasi:i>  AsnrALS.  105 

Diiriiig  tho  faliii.  nausea,  or  even  vuniitinir.  may  appear,  ami  priapism  is  often  a  most 
distressiiifj  symptom.  Sudden  terror  of  an  unknown  kind  haunts  the  mind  and  iriiafrinary 
.•allinj;  of  fiends  often  e.\i.sts.  Dr.  Ber«rerons  records  a  case  in  which  the  patient  heard 
the  iin<;in^'  of  bells  and  .saw  mice  run  about  over  his  bed. 

In  the  tliiril  nmf  /nsf  sliujr  the  hin;rinjr  tor  drink  becomes  intense,  with  an  increasing 
ina]>ilitv  to  take  it  ;  the  voice  becomes  hoarse  and  tlie  mouth  full  of  a  frothy  fluid.  The 
patient  tries  to  get  rid  of  this  by  sjiitting.  and  then  becomes  frightened  at  its  results.  In 
some  ca.ses  he  fears  that  by  contact  this  fluid  may  pro|»agate  the  'lise'ase.  Convulsive 
seizures  increase  in  fre(|uency  and  intensity,  the  spasm  of  the  respirat(jry  muscles  threat- 
eniuL'^  life  ,   at  last  a  fatal  spasm  takes  place,  and  death  by  asphyxia  ensues. 

Cause  of  Death. — In  the  dog  death  results  from  jiaralysis  ;  in  man  it  is  due 
generallv  to  asplivxia,  ami  in  exceptional  cases  to  exhaustion. 

Duration  of  Disease. — This  painful  affection  rarely  lasts  longer  than  four  days, 
though  it  has  been  fatal  in  sixteen  hours  and  has  lasted  as  long  as  two  or  three  weeks. 
Thamhayn  shows  that  5tj  out  of  20:^  cases  died  within  forty-two  hours,  73  in  forty-eight 
hours,  88  between  the  second  and  third  days,  19  between  the  third  and  fourth  days,  7  in 
five.  5  in  six,  and  4  in  seven  days. 

The  seat  of  wound  or  cicatrix  rarely  shows  anything  unusual.  In  three  or  four  ca-ses 
out  of  a  hundred  it  may  be  slightly  painful,  irritable,  and  inflamed,  or  the  seat  of  a 
neuralgic  pain,  which  in  some  instances  is  very  severe  and  of  the  nature  of  '•  aura,"  as  in 
epilepsy. 

DiAGNOSi.s. — Taken  as  a  whole,  there  is  no  disea.se  like  hydrophobia.  In  a  certain 
sense  it  resembles  tetanus,  yet  the  two.  in  their  general  features,  are  unlike.  They  may, 
however,  occur  together,  and  so  good  an  observer  as  Dr.  J.  W.  Ogle  has  published  a  ca.se 
of  combined  tetanus  and  hydrophobia  in  the  Briti.<}i  and  Foreign  Medico- Chir.  Reviev:.  1868. 

What  Trousseau  has  called  nervous  hydrophobia — that  is.  true  dy.sphagia  brought  on 
by  a  dread  of  rabies — may,  however,  be  mistaken  for  it ;  '•  but  the  sudden  invasion  of 
this  complaint,  generally  coming  on  through  the  person  recalling  to  mind  or  hearing  the 
relation  of  a  case  of  true  hydrophobia,  and  the  duration  of  the  dysphagia  over  the  period 
of  four  days  are  amply  sufficient  to  characterize  the  complaint  and  to  enable  the  prac- 
titioner to  persuade  the  patient  that  he  is  suff'ering  from  mere  nervous  .symptoms  which 
will  vani.-ih  as  soon  as  he  ceases  to  fear.  Besides,  in  nervous  hydrophobia  there  is  dys- 
phagia only,  but  no  general  convulsions,  the  spasm  aff"ecting  the  pharynx  alone,  while  the 
breathing  goes  on  with  regularity." 

In  the  very  early  period  of  the  disease,  during  its  incubation.  Drs.  Marochetti, 
Magistel.  Xanthos.  and  others,  have  called  attention  to  the  presence  of  pustules  or 
vesicles  near  the  fra^num  of  the  tongue,  known  in  Greece  as  ^y.<s?*;  and  they  assert  that 
if  these  lyssi  are  cauterized  all  manifestations  of  disease  can  be  prevented.  Should  these 
observations  be  confirmed,  a  valuable  means  of  diagnosis  as  well  as  of  treatment  in  the 
very  earliest  .stage  of  the  disease  will  have  been  found.  These  lyssi  are  said  to  show 
themselves  at  an  earlier  period  in  proportion  to  the  amount  of  poi.son  deposited  in  the 
wound.  Marochetti  made  early  incisions  through  the  vesicles,  and  then  cauterized  the 
surface  with  a  red-hot  iron,  with,  he  states,  invariable  success. 

Pathology. — There  are  no  patliological  lesions  peculiar  to  hydrophobia — at  least, 
none  such  have  as  yet  been  described.  Mr.  Durham,  in  a  case  that  occurred  at  Ouy's  in 
1865,  carefully  examined  the  cord,  prepared  after  Dr.  L.  Clarke's  method,  and  found 
extreme  congestion  of  the  gray  matter  of  the  cord  and  numerous  minute  patches  of 
extravasated  blood  in  diff"erent  sections.  More  recently  Dr.  Benedikt  of  A'ienna  has  made 
out  that  in  dogs  '•  the  pathological  process  in  this  disease  consists  in  acute  exudative 
inflammation,  with  hyaloid  degeneration,  which  doubtless  arises  from  the  exudative  infil- 
tration of  the  connective  ti.ssue  of  the  brain"  (^Wiener  Medh.  Pre^sp.  June.  1874:  London 
Med.  Rer..  September  .30.  1874). 

Treatment. — In  all  ca.ses  of  bites  from  dogs  or  animals  in  which  the  faintest  sus- 
picion of  rabies  exists  free  cauterization  with  lunar  caustic  should  be  performed.  Youatt 
states  that  he  adopted  this  practice  in  upward  of  four  hundred  cases,  and  four  times  on 
himself,  with  complete  success,  and  that  in  all  these  there  was  no  doubt  as  to  the  dog 
being  mad.  With  such  a  result  no  other  caustic  need  be  used  :  when  this  is  not  at  hand, 
any  acid,  caustic  alkali,  or  cautery  will  suffice.  When  the  escharotic  cannot  be  obtained, 
the  part  may  be  exci-sed.  a  ligature  being  fiistened  beforehand  on  the  cardiac  side  of  the 
wound.     Some  surgeons  advise  amputation. 

Mental  stimulants,  in  the  way  of  in.spiring  hope  and  removing  fear,  must  be  freely- 
administered,  and  such  general  treatment  as  may  be  needed.     No  drug  has  yet  been 


106  GLANDERS. 

found  that  lias  the  least  influence  on  the  disease,  either  in  preventing  or  eur'ng  it.  Dr. 
Marochefti's  treatment  of  the  lyssi  is  the  only  one  that  can  claim  any  degree  of  success. 
How  far  the  constant  administration  of  chloroform  would  influence  the  disease  is  a  ques- 
tion that  has  yet  to  be  put  to  the  proof.  To  prevent  asphyxia  from  taking  place,  trache- 
otomy, as  suggested  by  Dr.  jNIarshall  Hall,  is  a  justiiiable  measure,  the  operation  being 
based  on  a  good  theory,  although  it  has  never  been  performed  on  the  human  subject. 
By  it  the  immediate  risk  of  death  from  asphyxia  would  be  rendered  impossible  and  time 
given  for  remedies  to  act  or  for  the  disease  to  run  its  course.  It  seems  that  six  or  seven 
days  is  the  utmost  period  for  the  disease  to  be  in  existence.  If  life  can  be  prolonged 
thus  far,  the  hope  of  a  good  result  may  be  entertained.  Anything  that  can  tend  to  pre- 
vent death  and  keep  the  patient  alive  is  useful.  Tracheotomy  is  one  of  these  means  and 
deserves  trial,  wine  and  food  being  valuable  adjuvants. 

When  a  dog  is  known  to  be  ipad,  it  ought  to  be  destroyed  ;  but  when  any  one  has 
been  bitten  by  an  animal  in  which  there  is  a  suspicion,  but  no  evidence,  of  madness,  it 
should  be  kept,  although  apart  from  others  and  guarded,  as  time  will  prove  the  truth  of 
its  condition  and  do  away  with  the  morbid  fear  of  '•  rabies  "  that  may  have  been  excited 
by  the  injury. 

Glanders. 

This  is  a  specific  disease  given  to  man  by  inoculation  from  the  horse.  Dr.  Elliotson 
first  recognized  its  true  nature,  and  described  it  under  the  term  "  Equina."  It  shows 
itself  in  two  forms.  In  one  the  disease  attacks  the  mucous  membrane  of  the  nose  and 
the  neighboring  glands,  and  is  then  termed  '■'■  glaiulcrs ;"  in  the  other  it  affects  the  lym- 
phatics of  the  body  generally,  giving  rise  to  tumors  or  a  knotty  condition  of  the  sub- 
cutaneous glands  called  '■•farct/  hiich,''  and  is  therefore  called  "farci/." 

In  man  these  two  forms  are  generally  found  together. 

Symptoms. — There  is  .said  to  be  a  stage  of  incubation  varying  from  two  to  fifteen 
days  from  the  inoculation,  after  which  febrile  symptoms  with  excitement  appear,  followed 
by  the  specific  eruption.  The  pains  in  the  limbs  accompanying  the  febrile  condition  are 
generally  associated  with  tenderness  wherever  glands  exist,  and  on  examination  some 
enlargement  of  these  glands  will  be  found.  The  eruption  is  very  characteristic,  being 
made  up  of  a  crop  of  vesicles,  which  become  pustular  and  are  very  hard,  resembling 
those  of  variola  more  than  anything  else.  They  are  arranged  in  groups  with  inflamed 
bases,  the  face,  neck,  and  abdomen  being,  as  a  rule,  more  covered  than  the  extremities  ; 
when  close  together,  they  become  confluent.  These  pustules,  with  their  indurated  bases, 
then  soften  down,  leaving  ulcerated  excavated  surfaces.  They  affect  the  mucous  lining 
of  the  nose,  giving  rise  to  the  discharge.  Virchow  says  that  "  these  so-called  pustules 
are  really  due  to  the  presence  of  a  tenacious  deposit  in  the  corium  of  the  skin,  which  has 
much  resemblance  to  tubercle  and  microscopically  is  made  up  of  an  amorphous  granular 
appearance  mixed  with  cell  elements,  cell  growths,  and  fat  globules."  This  opinion  is 
supported  by  the  clinical  fact  that  tubercles  in  farcy  are  often  found  in  subcutaneous 
tissue,  appearing  as  hard  circumscribed  blind  boils  or  more  or  less  diffused  swellings. 
These  soften  down  and  give  rise  to  extensive  sloughing  of  the  skin  and  surrounding  parts, 
and  are  rarely  absorbed.  During  the  progress  of  the  disease  soft  tumors  not  unlike 
pyaemic  cutaneous  abscesses  appear  about  the  body,  and  sometimes  attack  deeper  parts. 
In  the  more  advanced  stages  of  the  disease  these  tubercles  or  so-called  pustules  attack 
the  larynx  and  the  whole  respiratory  tract,  and  more  particularly'  the  lungs,  and  give  rise 
to  Virchow's  pneumonia  of  glanders — an  affection  which  consists  of  a  seiies  of  tubercles 
beneath  the  pleura  covering  the  lungs  and  surrounded  by  lobular  pneumonic  inflamma- 
tion, as  in  pyremia.  These  tubercles  are  said  to  have  been  found  in  the  testicles,  kidneys, 
pancreas,  and  joints.  When  they  attack  the  nose — which  they  usually  do  at  an  early 
period,  and  often  before  they  appear  in  other  parts — the  secretion  from  the  nose  is  at  first 
catarrhal,  thin,  and  clear;  subsequently  it  becomes  thick,  tenacious,  and  puriform,  and  is 
often  mixed  with  blood ;  but  in  man}^  cases  it  is  altogether  absent  or  not  noticed  till  a 
later  period  of  the  disease.  The  face  and  head  often  swell  from  oedema  and  present  a 
puffy,  erysipelatous,  shining  surface ;  the  conjunctiva  also  exudes  a  thick  fluid,  gluing  the 
eyelids.  The  tonsils  are  frequently  involved  and  often  suppurate.  As  the  disease  pro- 
gresses the  swellings  and  discharge  increase,  the  inflammation  around  spreads  and  becomes 
gangrenous,  bullae  appear  on  the  skin,  the  constitutional  symptoms  become  typhoid,  a  low 
delirium  sets  in  not  unlike  that  from  pyj^emia,  and  death  ensues  from  coma  and  exhaus- 
tion. When  the  glands  and  absorbents  are  involved,  as  in  the  farcy  form,  suppuration 
and  sloughing  are  superadded  to  those  already  laid  down. 


(;r.\M>i:iis.  107 

The  I'HOiiNOSis  of  filaiiiliTs  is  most  uiii;ivoral)lo,  situ'O  rocnvory  only  takos  plafc  in  the 
mikU'st  cases  of  poisoninj;.  The  disease  in  its  aeutest  H{ii<nt  has  run  its  course  in  three 
days,  and  may  j)rove  fatal  in  a  week,  hut  in  jicnerai  it  lasts  for  three  or  four  weeks,  and 
in  very  chronic  eases  life  luis  been  j)rolonged  for  months.  In  chronic  "  farcy  "  slough- 
in<;  glands  may  leave  large  sores,  which  remain  o]m'm  lur  a  long  time;  occasionally  such 
dironic  cases  end  liy  an  attack  of  acute  disease. 

The  ])ost-mortem  appearances  have  been  well  descrihcil  in  rnhmd  s  article,  Holmes's 
S//st(iii,  third  edition,  vol.  i.,  in  two  recent  cases,  in  both  of  wliicii  there  was  an  al)sence 
of  nasal  discharge.  One  was  l)i(;kinson's  ca.se,  and  the  other  I'oland's.  The  first-men- 
tioned subject  died  on  the  twenty-first  day.  The  Idood  was  found  fluid,  the  mu.scles  soft 
an<l  rotten,  the  cervical  and  left  parotid  glands  suppurating,  the  lower  part  of  the  right 
Innti'  solid  witli  urav  lie|)atization,  its  tissues  completely  broken  down  and  infiltrated  with 
jmruleiit  fluid,  and  tlie  left  lung  studded  with  numerous  slate-colored  patches  of  the  size 
of  hazel-nuts. 

The  second  patient  died  on  the  tliirtecntli  day.  There  was  no  affection  of  the  lym- 
phatic glaiuls,  but  suppuration  had  taken  place  in  the  muscles  of  both  calves  of  the  legs, 
accompanied  by  local  abscesses  in  other  parts  of  the  body,  chiefly  in  the  muscles ;  the 
joints  were  free  from  suppuration  ;  there  were  recent  patches  of  lymph  on  the  pleura 
and  lobular  pneumonia  in  the  base  of  the  upper  lobe  of  the  right  lung,  which  was  in  a 
state  of  gray  hepatization  ;  throughout  the  lower  lobes  of  both  lungs  were  smaller  hepa- 
tized  masses ;  the  liver  was  free  from  disease. 

Billroth  lays  great  stress  on  the  presence  of  haemorrhagic  ab.sces.ses  in  the  muscles  as 
being  characteristie  of  the  pyjiemia  of  glanders. 

Mode  of  Inoculation. — In  man  the  poison  is  generally  communicated  through 
the  nasal  discharge  from  the  horse  or  by  the  discharge  from  farcy  swellings.  Where  the 
inoculation  takes  place  from  the  latter  the  disease  in  man  is  more  of  the  character  of 
farev.  It  can  be  communicated  from  man  to  man.  The  poison,  to  be  absorbed,  must  be 
applied,  as  a  rule,  to  a  wound  or  delicate  membrane;  yet  cases  are  on  record  where  the 
disease  has  been  set  up  by  wiping  the  face  with  unclean  hands  or  cloths. 

Youatt  states  that  the  disease  is  not  one-tenth  part  so  common  as  it  was,  and,  '•  gen- 
erally speaking,  it  is  only  found  as  a  frequent  and  prevalent  disease  where  neglect  and 
filth  and  want  of  ventilation  exist." 

Ghuulcrs,  writes  Dr.  G.  Milroy  (Trnns.  Epidem.  Sue,  vol.  i.),  is  "a  general -a^  well  as 
a  propdijable  disease;  it  is  extremely  apt  in  some  seasons  to  develop  itself  in  foul,  unven- 
tilated  stables."  Its  development  may,  however,  be  controlled,  even  to  absolute  preven- 
tion, by  the  observance  of  simple  sanitary  rules. 

Treatment. — To  keep  the  machinery  of  life  going  and  to  treat  symptoms  upon  ordi- 
nary surgical  principles  seems  to  be  the  best  mode  of  practice,  for  there  is  no  drug  which 
has  any  influence  on  the  disease.  Abundance  of  fresh  air  should  be  provided,  with  good 
^ut  not  too  stimulating  food,  accompanied  by  tonics,  such  as  quinine  and  iron.  Pain 
should  be  soothed  by  sedatives.  When  the  nose  is  a  source  of  trouble,  it  should  be  kept 
clean  by  washing  and  by  a  stream  of  water  passed  through  the  nostril,  and  rendered  anti- 
septic by  iodine,  carbolic  acid,  Condy's  fluid,  or  creosote,  nitrate-of-silver  solution,  tannic 
acid,  and  other  more  stimulating  substances  being  at  times  valuable.  Where  the  throat 
is  affected  it  should  be  sponged  with  some  nitro-muriatic  acid  lotion,  and  a  gargle  of 
chlorate  of  potash  should  be  used. 

Abscesses  and  softened  tubercles  should  be  opened  early  and  freely,  poultices,  or 
fomentations  being  applied  to  the  parts.  Perfect  cleanliness  should,  of  course,  be  ob- 
served. 

Glanders  in  the  Horse,  as  Mr.  Youatt  tells  us  in  his  book  on  that  animal,  is 
chiefly  to  be  recognized  by  the  persistent  (Hschargr  from  the  nostril  and  the  singular 
Itardnesii  of  the  submaxillary  glands,  Avhich  become  adherent  to  the  bone  from  the  effusion 
of  inflammatory  lymph  around  them.  These  glands  are  not  very  large  except  at  the 
commencement  of  the  disease  ;  neither  are  they  hot  or  tender. 

When  any  doubt  exists  as  to  the  nature  of  the  disease,  a  condemned  horse  or  ass 
should  be  inoculated  with  the  nasal  secretion  of  tlie  suspected  animal ;  and  if  the  disease 
be  genuine,  it  will  be  reproduced  in  a  few  days. 

Equina  mitis  is  a  local  pustular  disease  affecting  the  hands  and  body  of  those  who 
dress  the  heels  of  horses  affected  with  what  Jenner  has  described  as  the  "grease.''  It 
consists  of  an  inflammation  and  swelling  of  the  heels  of  the  horse,  attended  with  the  dis- 
charge of  a  thin  acrid  matter  therefrom.  It  is  not  unlike  ecthyma  or  vaccinia,  but  more 
angry  ;  the  pustules  are  about  the  size  of  a  sixpence  ;   they  suppurate  on  the  third  day, 


108 


MALIGNA^'T  PUSTULE,    OB   CHARBON. 


dry  up  about  the  tenth  or  twelfth,  and  form  scabs  which  leave  cicatrices, 
runs  its  course,  and  is  to  be  managed  by  rest  and  cleanliness. 


The  disease 


Malignant  Pustule,  or  Charbon. 

This  disease  has  been  more  common  in  recent  years  than  it  was  formerly,  and  I  have 
seen  at  least  a  dozen  of  the  seventeen  cases  that  have  been  treated  at  Guy's  Hospital 
dui-ing  the  last  ten  years.  My  colleague  Mr.  Davies-Colley  has  given  an  excellent  account 
of  it,  and  M.  Bourgeois'  has  fully  described  it  in  a  work  entitled  La  Pmfiile  Mallgne  et 
(Edeme  Malin  (Paris,  1860). 

The  disease  is  doubtless  due  to  a  distinct  poison  communicated  to  man  by  direct  con- 
tact with  the  body  of,  or  with  any  material  that  has  been  in  contact  with,  a  diseased 
animal.  At  Bradford,  where  there  was  an  outbreak  of  it  in  1880,  it  was  termed  "  wool- 
sorter's  disease."  At  Guy's  it  is  found  to  occur  amongst  those  who  work  amongst  hides 
in  the  neighboring  tanyards.  It  is  found  chiefly  on  the  exposed  parts  of  man,  such  as 
the  hands,  fore-arm,  neck,  and  face.  It  begins  as  a  small  red  inflamed  and  itching  spot, 
which  in  twelve  or  fifteen  lioura  vesiculates,  the  skin  beneath  the  vesicle  appearing  as  a 
dry  brown  or  black  slough.  In  the  course  of  the  second  day  another  crop  of  vesicles 
appear  around  the  original  seat  of  the  disease,  which  run  the  same  course.  About  this 
time  the  seat  of  the  original  disease  becomes  more  swollen,  appearing  as  a  defined  lump 
("  bouton"),  the  parts  around  being  oedematous,  and  the  whole  subsequently  sloughing. 
"  The  raised  indurated  area  with  its  central  blackish  depression  surrounded  by  small  ves- 
icles can  hardly  be  mistaken  for  any  other  affection."  In  this  stage  of  the  disease  there 
is  little  pain;  the  slough  is  always  dry,  and  there  is  no  pus;  the  .sloughing  spreads  fi'om 
the  skin  down  to  the  subcutaneous  tissue  instead  of,  as  in  carbuncle,  from  the  latter  to 
the  former. 

This  disease  is  usually  rapid  in  its  progress,  four  to  nine  days  seeing  its  end.  It  is 
ushered  in  with  rigors,  followed  by  vomiting  and  greaf  depression  ;  often  cold  sweats  and 

delirium  occur,  and  the  patient  dies  from  the  de- 
pressing influence  of  the  animal  poison  before  its 
local  effects  have  had  time  to  Avork.  In  young 
subjects  the  prospects  of  recovery  are  greater  than 
in  the  old  ;  and  when  the  hands  are  involved,  the 
chance  is  better  than  when  the  head  is  affected. 

By  the  microscope  straight  or  slightly  curved 
bacilli  are  found  in  abundance  along  the  sheaths 
of  the  hair  follicles  and  about  the  border  of  the 
eschar  (Fig.  21).  They  are  likewise  found  in  the 
blood  as  w.ell  as  in  the  secretions  of  the  body.  In 
the  viscera  they  are  the  causes  of  local  sloughs 
from   embolic  capillary  plugging. 

Treatment. — The  disease,  being  at  its  origin 
local,  should  be  locally  treated ;  and  there  can 
be  no  doubt  that  the  excision  of  the  inflamed  and 
vesiculated  area  is  the  best  practice  to  adopt  even 
in  advanced  cases.  By  this  method  thirteen  out 
of  the  fifteen  cases  in  which  it  was  carried  out  at 
Guy's  were  cured,  although  in  twelve  the  inflam- 
mation had  spread  to  the  surrounding  parts  or  had  involved  the  lymphatic  glands,  and  the 
constitutional  symptoms  were  more  or  less  severe.  In  less  severe  cases  the  destruction 
of  the  local  disease  by  the  thermo-cautery  may  be  resorted  to,  or  caustic,  such  as  the 
potassa  fusa,  as  advocated  by  Bourgeois,  or  carbolic  acid,  may  be  substituted. 
Tonics  and  diffusible  stimulants  are  always  of  use. 


Fig.  21. 


Bacilli  from  Charbon.   (Drawn  hy  Dr.  F.  C.  Turner.) 
Vide  Mr.  Davies-Colley's  paper. 


SYPHILIS. 

Syphilis  is  a  constitutional  disease  the  result  of  a  specific  animal  poison  introduced 
from  without.  Like  other  specific  animal  poisons,  it  is,  as  a  rule,  propagated  by  some 
local  inoculation  ;  but,  unlike  all  others,  it  has,  by  its  subtle  influence  through  the 
>3arents,  the  power  of  affecting  the  unborn  foetus  and  the  newly-born  child.  No  other 
blood  poison  appears  to  possess  this  power — at  any  rate,  to  the  same  degree ;  and  it  is 
1  Vide  Med.-Chir.  Trans.,  vol.  Ixv.,  1882. 


sy  nil  LIS.  ]()0 

Well  In  hear  tilis  iiii|Hiii:iiit  |i()iiit  of  (litrri'ciicf  in  iiiiii<I.  for  in  all  other  rosixM-ts  tlicrc  is  a 
stroiiLi-  aiialoLiy  lictwccii  all. 

Till'  poison,  oiii'f  iiilroiluccil  into  llic  system  either  liv  inlieritance  ( in/irn'/it/  .■<i/n/,i/is\ 
or  hy  sonic  hn-al  iiiocnhitioii  {iic<juir((/  si/ii/u'/is),  iiiaiiit'ests  its  presenile  in  its  own  peculiar 
way  liy  the  a]>pcarancc  oi"  a  s(»iucwliat  irrc<:ular  althou<rli  cliaractcristic  chain  of  svinp- 
toins.  Tlie^e  arc  uncertain  in  the  jicriod  fil"  their  nianircstation  after  tlie  inoculation,  in 
the  orilei'  of  their  appearance,  and  in  their  form  and  clhicts  ;  yet  tliey  possess  their  own 
sjtecial  fcaturi's.  They  arc  /orv// and  yr/^r/v//.  They  run  tlieir  course,  yet  ilo  not  elimi- 
nate tlie  poison.  They  may  disappear  for  a  time,  to  reappear  in  some  other  lorm.  'J'lie 
poison  may  lie  dormant  for  years,  atid  in  healtliy  suhjeets  show  no  si{;ns  of  its  presence 
till  some  weakening  infltience  has  depressed  the  powers  of  its  victim  and  given  ri.sc  to  a 
local  affection  in  wliicli  the  practised  eye  will  read  witli  more  or  less  certainty  the  mod- 
ifying influence  of  an  antecedent  sypliilitic  affection.  The  poison  has  been  .scotched  for 
a  time  only.  ]>ut  not  killed,  and  in  the  weakness  of  its  possessor  has  reas.serted  its  power. 
No  other  animal  poi.son  a])])ears  to  have  such  tenacity  of  existence.  Others  produce 
tlieir  specific  effects  in  a  definite  way  and  in  a  regular  series  of  symptoms  and  are  either 
eliminated  or  destroy  life  ;  they  cease  to  act  and  become  innocuous  after  having  run  their 
course,  their  power  for  harm  being  exhausted.  The  ])oison  of  syphilis,  however,  is  so 
subtle  that  it  is  tolerably  certain  mo.st  of  the  secretions  of  a  sypliilitic  subject  are  cap- 
able of  producing  the  same  disease  in  another,  clinical  experience  having  dis}»roved  Hun- 
ter's opinion  that  syphilis  could  only  be  propagated  })y  the  secretion  of  a  primary  .sore, 
and  Kicords  pro])ositioii  that  "chancre  at  the  period  of  progress  is  the  on///  source  of  the 
syphilitic  virus.'"  Indeed,  it  may  fairly  be  asserted  that  a  healthy  woman,  marrying  a 
man  who  has  had  syphilis,  but  in  whom  all  symptoms  have  long  disappeared,  may  give 
birth  prematurely  to  a  dead  f(ptus,  to  a  stillborn  child,  or  to  an  infant  that  will,  cither  at 
its  birth  or  within  a  few  weeks  subsequently,  show  symptoms  of  syphilis,  all  the.se  results 
being  the  effects  of  syphilis  transferred  from  the  father.  On  the  other  hand,  no  such 
result  may  ensue.  Maternal  heredity  has  a  stronger  influence  than  paternal.  When 
both  parents  are  syphilitic,  the  chances  of  a  foetus  being  affected  are  grcatlv  enhanced. 
'■  The  semen  of  a  diseased  man  depo.sited  in  the  vagina  of  a  healthy  woman  will,  by  being 
absorbed  and  without  the  intervention  of  pregnancy,  contaminate  that  woman  with  the 
secondary  (constitutional)  form  of  the  disease,  and  that  without  the  presence  of  a  chan- 
cre or  any  open  sore  cither  on  the  man  or  the  woman  "  (Dr.  Porter,  l)iib.  Jourri.  of  Mefl. 
Science,  1857). 

A  healthy  woman  nu^rrying  a  man  Avho  has  had  .syphilis,  but  who  has  lost  all  symp- 
toms of  it,  may — not  must — acquire  syphilis  either  through  the  medium  of  a  blighted 
ovum  or  a  series  more  or  less  prolonged  of  stillborn  children,  or  through  the  medium  of 
the  utero-plaeental  circulation. 

A  healthy  woman  giving  suck  to  -a  child  the  subject  of  hereditary  syphilis  may 
acquire  the  disease  through  some  fissure  of  the  nipple,  the  di.sease  locally  and  con- 
stitutionally manifesting  its  presence  with  all  the  intensity  of  a  primary  inocula- 
tion. 

Again,  the  secretion  of  any  true  syphilitic  sore,  chancre,  or  mucous  tubercle,  whether 
of  the  mouth,  nose,  anus,  vulva,  or  penis,  is  capable  of  transferring  the  disease ;  and  the 
syphilitic  poison  may  probably  be  simply  absorbed  by  the  vessels  of  a  part  {  ph/jsviloqknl 
nhs^orptioii)  without  giving  rise  to  any  local  aft'ection.  Hunter  believed  this,  and  Lane, 
Marston.  and  Lee  have  published  observations  that  tend  to  support  the  theory. 

"  It  should  never  be  forgotten  that  it  is  the  virus  which  infects  the  system,  and  that 
the  sore  is  the  mere  local  lesion,  and  not  a  neces.sary  antecedent  to  infection  "  {Committee 
on  Si/philis,  p.  8).  '•  It  is  impossible  to  predicate  with  ab.solute  certainty  of  any  given 
sore  that  it  will  or  will  not  be  followed  by  con.stitutional  infection  "  (J.  Lane). 

It  should  never  be  forgotten  that  the  poison  of  syphilis,  however  introduced  into  the 
system — whether  inherited  or  acquired  from  primary  sores  or  from  the  secretions  of  a 
syphilitic  subject — is  the  same,  and  manifests  its  presence  in  much  the  same  way. 

It  may  be  difficult  in  individual  cases  to  make  out  the  direct  source  of  the  contagion  ; 
but  if  we  recognize  the  fact  that  the  virus,  however  diluted  in  one  subject,  may,  when 
introduced  into  another,  behave  as  if  it  had  been  taken  from  a  spreading  primary  chan- 
cre, the  explanation  of  most  clinical  facts  becomes  easy. 

Syphilis  is  an  animal  and  a  human  poison  ;  it  is  capable  of  propagation  by  any  form 
of  inoculation  from  the  secretion  of  any  syphilitic  to  a  virgin  subject  in  all  its  intensity  ; 
it  may  likewise  be  inherited.  Nothing  is  known  of  its  nature,  although  its  effects  are 
sufficiently  familiar 


110  ACQUIRED  SYPHILIS. 

How,  then,  it  may  be  asked,  is  syphilis  to  be  recognized?  Is  it  to  be  recognized  in 
its  primary  inoculation,  or  is  it  only  to  be  known  by  its  constitutional  symptoms? 

It  has  been  already  stated  that  most  authorities  ai"e  agreed  upon  the  fact  that  there 
is  no  form  of  local  sore  or  chancre  that  can  be  said  with  certainty  to  be  the  result  of 
the  local  inoculation  of  syphilis.  In  the  cartilaginous  indurated  sore  with  enlarged 
indurated  glands  there  is  every  probability  of  syphilis  manifesting  its  presence,  and  in 
the  multiple,  suppurating,  non-indurated  chancre  there  is  every  probability  of  no  such 
symptoms  appearing.  But  in  the  first  form  such  svmptoms  may  not.  and  in  the  second 
they  may,  appear ;  consequently,  as  a  law  this  distinction  becomes  of  little  value. 
Indeed,  syphilis  as  a  disease  can  only  be  known  by  the  manifestations  of  its  consti- 
tutional symptoms,  and  not  by  the  inoculation,  in  the  same  way  as  smallpox,  when 
propagated  by  inoculation,  is  only  to  be  recognized  by  the  eruption,  and  not  by  the  local 
appearances  resulting  from  inoculation. 

Acquired  Syphilis. 

Cause. — Acquired  syphilis  is  contracted  through  inoculation  from  a  chancre,  from  a 
syphilitic  mucous  tubercle,  condyloma,  or  other  syphilitic  sore,  or  from  the  secretions  of 
a  syphilitic  subject,  the  secretion  of  one  form  of  syphilitic  sore  from  one  subject  being 
capable  of  producing  a  chancre  of  another  form  in  another  subject. 

Drs.  Maury  and  Dulles'  have  traced  it  to  a  '' tattooer  "  Avith  mucous  patches  using 
his  saliva  to  moisten  the  coloring-matter  employed  in  his  work. 

Mr.  John  Morgan  of  Dublin,  by  experiments,  has  been  led  to  belie>e  that  ■•  the  dis- 
charge of  a  syphilitic  female  produces  on  !<ijpliiUtics  the  sore  identical  with  that  produced 
from  the  soft  sore  or  chancre." 

After  inoculation,  a  certain  time,  which  varies  from  six  to  twelve  weeks,  usually 
elapses  before  the  poison  manifests  its  presence.  In  exceptional  cases  the  symptoms  of 
syphilis  may  appear  within  the  month  or  fail  to  appear  for  four  or  more  months,  but 
every  week  that  passes  after  the  third  month  without  their  manifestation  lessens  the 
likelihood  of  their  appearance  ;  and  when  six  months  have  elapsed  without  syphilitic 
symptoms  showing  themselves,  the  probabilities  of  their  doing  so  are  very  slight. 

The  diiferent  forms  of  syphilitic  inoculation  will  be  considered  under  the  head  of 
'■'■  Chancre.' 

Dismissing,  therefore,  the  consideration  of  the  character  of  the  sore  to  which  the 
poison  of  syphilis  usually  gives  rise  with  the  simple  reminder  that  there  is  positively  no 
specific  sore,  the  constitutional  symptoms  of  syphilis  now  claim  attention  :  and  the  vari- 
ety of  forms  they  assume  is  very  striking.  They  usually  show  themselves  primarily 
upon  the  skin  in  the  form  of  an  eruption,  or  upon  the  mucous  membrane  of  the  aliment- 
ary canal,  as  indicated  by  sore  tongue  and  throat,  while  some  amount  of  fever  and  con- 
stitutional disturbance  at  times  precedes  their  appearance.  This  "syphilitic  fever''  varies 
according  to  the  nervous  susceptibilities  of  the  patient. 

The  skin  eruption  may  be  only  a  ro.se  rash,  roseola,  giving  rise  to  a  mottling  of  the 
skin  or  to  a  more  lasting  staining.  It  may  assume  the  papular  form,  lichen  ;  the  pustular, 
ecthyma  ;  the  vesicular,  nipia  ;  the  tubercular,  ulcerating  or  non-ulcerating,  or  the  scaly, 
lepra  or  j)!!orta.v'x.  Bullae  are  rare  except  in  hereditary  disease  ;  when  present,  they  indi- 
cate a  cachectic  condition. 

The  mildest  form  of  roseola  may  last  but  a  few  days  and  disappear,  or  leave  a  dusky 
coppery  stain  behind  of  some  durability. 

The  l^'ch/'ji  will  soon  show  the  copper  tint,  and  as  it  flattens  may  become  a  tubercle, 
and  this  a  scale,  the  skin,  after  the  desquamation  of  the  scale,  showing  much  the  same 
as  the  macula  of  the  rose  eruption. 

When  the  eruption  is  tubercular  at  the  first,  the  same  series  of  changes  will  be  seen, 
the  raised,  indurated,  or  spongy  tubercle  as  it  withers  usually  showing  a  scale  upon  its 
surface  and  then  flattening  down  to  a  macula. 

The  lepra  and  p.-toriasis  appear  as  inflamed  patches  more  or  less  extensive,  as  in  the 
non-specific  forms,  the  epithelial  scales  varying  in  thickness  and  the  fissures  in  depth. 
The  psoriasis  commonly  appears  on  the  palms  of  the  hands  and  the  soles  of  the  feet. 

All  these  eruptions  have  a  copper-colored  tint,  more  particularly  after  their  first 
appearances  have  faded.  But  what  is  still  more  characteristic  is  the  fact  that  upon  the 
same  subject  several  forms  of  eruption  are  often  found  together,  the  macula,  papule,  pus- 
tule, tubercle,  and  scale  passing  one  into  another. 

^American  Journal  of  Med.  Sci..  January,  1878. 


ACQUIRKI)  SY  I'll  I  LIS.  Ill 

What  determines  tlie  form  of  tlie  eruption  at  its  first  appearance  is  not  known.  Why 
syphilis  in  one  man  should  manifest  its  pre>ence  hy  an  eruption  of  macuUc,  in  another  by 
a  pa|)ular  or  sealy  eru])tion,  and  in  a  third  hy  a  j)ustular,  tuhereular,  or  ulcerative  form, 
is  not  known  The  theory  propounded  by  Carmichael — that  each  sort  of  eruption  has 
its  own  form  of  local  sore  or  inoculation — was  injrenious,  but  is  not  suj)ported  by  facts; 
and  the  generally-received  o|iinioii  is  that  the  peculiarity  or  power  of  the  infected  patient 
has  more  to  tlo  with  these  phenomena  than  the  nature  of  the  jioison  itself.  The  pustular 
an<l  vesicular  eruptions  are  more  prone  to  appear  in  cachectic  than  in  the  robust  subjects, 
and  an  ulcerative  action  is  more  likely  to  accoinpany — or,  rather,  to  follow — their  appear- 
ance ;  the  l»ase  of  the  |>ustule  or  of  the  vesicle,  and  at  times  the  substance  of  the  tuber- 
cle, break  down  ami  L'ive  rise  to  a  troublesonui  and  spreading  ulcer. 

Affections  of  the  Mucous  Membrane. — As  the  onttinh  skin  in  syphilitic 

subjects  is  attaiki'd  bv  eruptions,  sinipk-  and  ulcerative,  .so  the  iiisldt  skin  or  7ni(co)is  mem- 
hniiu's  is  etpially  involved.  "  Every  form  of  syphilitic  affection  of  the  skin,"  writes  Lee, 
"has  its  counterpart  in  the  mucous  membrane;  but  the  appearances  will  bo  modified  by 
the  comparative  thinness  of  the  structure,  by  the  absence  of  cuticle,  and  by  the  little 
dispo.sition  these  parts  have  to  take  on  tlie  adhesive  inflammation."  The  mucous  tuber- 
cle is  the  more  common  form,  and  is  found  in  the  organs  of  generation,  tongue,  mouth, 
lips,  nose,  palate,  throat,  rectum,  and  anus,  and  occasionally  in  other  parts  of  the  aliment- 
ary canal.  It  is  known  also  in  the  laryn.x.  At  times  these  tubercles  break  down  and 
ulcerate,  giving  rise  to  irregular  excavated  sores. 

Moist  tubercles  may  appear  in  syphilitic  subjects  at  any  part  of  the  body  where  two  skin 
surfaces  are  in  contact,  associated  with  moisture.  When  they  are  found  between  the  toes, 
they  arc  known  as  rfui'/nih's ;  and  when  about  the  orifice  of  a  mucous  passage^ias  a  condyloma. 

Syphilitic  sore  throat  may  a])pear  as  a  mere  mucous  patch  upoh  the  surface  of 
the  mucous  membrane,  or  at  times  as  an  ulceration  of  this  patch,  while  at  others  it  shows 
itself  as  a  distinct  affection,  the  throat  becoming  swollen  and  of  a  livid  color  and  rapidly 
passing  into  ulceration.  These  ulcers  may  attack  the  soft  palate,  pillars  of  the  fauces, 
tonsils,  or  pharynx,  and  present  every  kind  of  appearance,  shape,  and  character.  They 
may  be  serpiginous  like  the  trail  of  a  snake,  horseshoe  shaped  or  circular,  superficial  or 
excavated  with  sharp  edges,  inflamed,  sloughing,  or  indolent.  By  themselves  they  are 
not  typical  of  syphilis,  however  suspicious,  and  other  concomitant  symptoms  are  refjuired 
to  determine  the  diagnosis.  The  mucous  patch  is  the  most  characteristic.  Xo  ulceration 
is  typical,  although  the  sharply-cut  excavated  ulcer  is  the  most  unmistakable.  In  hered- 
itary syphilis  this  form  of  excavated  ulcer  is  rare,  though  I  have  seen  the  perforating 
ulcer  of  the  soft  palate  in  an  infected  infant  a  month  old. 

Syphilitic  disease  of  the  tongue  is  a  very  troublesome  affection  and  manifests 
itself  in  a  variety  of  ways ;  it  appears  more  commonly  in  the  form  of  aphthous  and 
mucous  patches,  ulcerating  or  otherwise,  but  not  unfref|ucntly  the  whole  thickness  of  the 
organ  is  infiltrated  with  the  gummatous  syphilitic  material,  either  as  an  isolated  nodule 
or  as  a  general  infiltration.  When  this  nodule  has  softened  down  and  suppurated,  a  deep 
excavated  sore  or  fissure  may  be  left,  not  unlike  that  of  cancer;  and  when  this  sloughs 
or  is  of  a  chronic  nature,  the  diagnosis  becomes  still  more  obscure.  In  cancer,  however, 
there  is  probably  a  more  marked  local  induration  than  in  syphilis,  and  rarely  a  sharp, 
well-defined  edge.     The  history  of  the  case  is,  too,  very  different  (n't/r  Chapter  XII.). 

The  mucous  lining  of  the  mouth,  lips,  nose,  etc.,  is  also  equally  liable  to  syphilitic 
disease,  either  in  the  shape  of  aphthous  and  mucous  patches  or  of  ulceration  not  unlike 
that  found  on  the  throat  or  tongue  ;  indeed,  the  di.sease  of  one  part  of  the  mucous  mem- 
brane is  the  same  as  that  of  others,  the  local  appearances  and  symptoms  being  modified 
only  by  the  peculiarities  of  the  part. 

In  ulceration  of  the  rectum  syphilis  bears  an  important  part,  and  as  a  cause  of  stric- 
ture it  is  not  rare.  When  present,  the  disease  usually  spreads  upward  from  the  anus, 
the  bowel  being  in  .some  cases  superficially,  in  others  deeply,  infiltrated  and  ulcerated. 
This  form  of  disease  is  more  common  in  women  than  in  men  (vi<fe  Chapter  X\'I.). 

Syphilitic  disease  of  the  periosteum  shows  it.self  in  the  form  of  nodes,  and 
rarely  as  a  single  node.  If  the  tibia  be  involved,  several  swellings  exist ;  and  the  same 
occurs  in  other  bones,  particularly  the  cranium.  The  swelling  is  merely  an  efiusion  of 
the  gummy  material  beneath  the  periosteuiu.  When  the  bones  are  attacked,  the  disease 
is  mostly  chronic  and  too  often  ends  in  the  death  of  the  part — /'.  «?..  in  necrosis. 

Symptom.s. — In  disease  of  the  periosteum  extreme  tenderness  and  pain  with  local 
swelling  are  the  chief  symptoms.  When  the  bones  are  implicated,  the  pain  is  of  a  con- 
stant aching  character,  and  this  is  always  aggravated  toward  night ;  but  there  is  neither 


112 


A  CQ  riRED  S  YPHIL  IS. 


Fig.  22. 


^Syfihilitic    [^ 
de/iosit 


such  swelling  nor  so  much  tenderness  as  there  is  in  the  periosteal  aflfi'Ction.     Tn  disease 
of  the  bones  of  the  skull  the  dura  mater  and  brain  may  become  secondarily  afi'cctcd. 

It  must  not  be  thought,  however,  that  syphilis  and  its  effects  are  confined  to  those 
parts  of  the  body  that  come  under  the  immediate  notice  of  the  surgeon.  It  is  hardly 
probable  that  both  ends  of  the  alimentary  canal  should  show  evidence  of  the  affection 
without  some  part  of  its  intermediate  twenty-five  feet  being  implicated,  or  without  some 
of  the  compound  glands  that  are  as.sociated  with  it  being  involved.  The  pathologist 
knows  this  to  be  the  case,  and  recent  research  has  confirmed  Wilkss  observation  {(luys 
Rf'ports,  I8O0)  that  "  the  extent  of  the  influence  of  syphilis  is  only  commensurate  with 
the  tissues  of  the  body,"  and  that  '•  there  appears  to  be  scarcely  a  tissue  which  may  not 
be  affected,  and  always  in  one  particular  and  characteristic  manner.  The  internal 
organs  may  be  affected  equally  with  the  external — not  only  the  cranium,  but  the  brain 
within  it,  or  the  nerves;  not  only  the  muscles  of  the  limbs  and  tongue,  but  the  heart; 
not  only  the  pharynx,  but  the  cesophagus  ;  not  only  the  larynx,  but  the  trachea,  bronchi, 
and  lungs,  also  the  liver,  spleen,  and  other  viscera." 

"The  peculiar  effect  of  syphilis  on  the  system,"  says  the  same  writer, 

"shows  itself  in  a  disposition  to  the  effusion  of  a  low  form  of  lymph  or  fibro-plastic 
material  in  nearly  every  tissue  of  the  body,  occasionally  modified  in 
character  to  a  slight  extent  by  the  organ  in  which  it  occurs.  In 
solid  organs  or  in  the  interior  of  the  tissues  there  is  found  a  more 
or  less  circumscribed  deposition  of  an  albumino-fibrous  material, 
whilst  on  the  surface  of  the  bod}'  a  similar  material  may  constitute 
merely  the  base  and  border  of  an  ulcer."'  In  the  testicle  this  is 
well  seen  (Fig.  22). 

Pathology  of  Syphilis. — In  these  observations  the  whole 
patlinlogv  of  syphilis  is  included  ;  for,  whether  syphilis  involve 
skin,  mucous  membrane,  connective  tissue,  muscle,  bone,  perios- 
teum, or  a  viscus,  the  same  exudation  exists,  either  as  an  exudation 
and  induration  or  as  an  exudation  breaking  up  with  ulceration. 

This  exudation  is  the  same  in  all  stages  of  syphilis,  in  all  tissues, 
in  hereditary  as  well  as  in  acquired  syphilis.  When  the  exudation  is 
reabsorbed,  a  recovery  is  said  to  have  taken  place  ;  when  it  breaks 
down,  suppuration  ensues.  When  it  attacks  the  external  tissues, 
"  secondary  symptoms"  are  said  to  exist ;  when  the  internal  viscera 
or  the  bones  are  affected,  the  .symptoms  are  called  tertiary. 

Affection  of  Bones  and  Larynx. — In  cachectic  and 

feeble  subjects,  where  visceral  mischief  has  a  tendency  to  appear, 
syphilitic  disease  of  the  organ  may  occur.  The  bones,  if  affected, 
are  liable  to  become  necrosed ;  the  larynx,  to  ulcerate ;  and  the 
skin,  when  affected,  to  suppurate  as  well  as  ulcerate.  In  fact, 
syphilitic  disease  in  the  feeble  and  cachectic  is  as  liable  to  be  associated  with  disorgan- 
izing changes  as  any  inflammatory  or  other  affection.  The  longer  the  disease  has  existed, 
the  "greater,  also,  is  the  probability  that  the  viscera  and  the  tissues  of  the  body  generally 
will  be  involved.  But  in  all  other  respects  the  effects  of  syphilis  are  the  same.  The 
virus,  as  it  affects  the  body  in  all  its  different  ways,  is  the  same  ;  at  all  times  it  is  the 
same  ;  the  so-called  secnKhtn/  and  fertian/  syphilis  are  the  same,  for  these  terms  have  no 
definite  signification.  They  have,  I  believe,  tended  to  confuse  rather  than  clear  the  sub- 
ject, and  were  framed  when  the  pathology  of  the  disease  was  but  little  known.  Syphilis 
is  clinically  known  by  certain  constitutional  symptoms,  and  pathologically  by  certain 
morbid  conditions.  It  may  manifest  its  presence  in  different  subjects  in  different  ways, 
involving  now  one  tissue,  then  another,  with  no  apparent  law  regulating  its  action.  In 
one  patient  a  tissue  may  be  involved  early ;  in  another,  late ;  but  the  node  on  a  bone,  the 
nodule  of  lymph  on  the  iris,  the  indurated  gummy  tumor  in  the  connective  tissue  or  in  a 
muscle,  the  puckered  nodule  of  fibrous  tissue  beneath  the  peritoneal  covering  of  the  liver, 
the  mass  of  fibre  tissue  poured  out  in  a  syphilitic  testicle,  are  all  alike.  These  differ  only 
in  their  symptoms  and  effects  according  to  their  position,  yet  whether  they  occur  soon  or 
late  after  the  primary  inoculation  is  a  matter  of  no  clinical  importance. 

'•  While  syphilis  is  thus  unsparingly  general  in  its  attacks  upon  organs,  yet  it  plays 
over  much  the  same  series  of  organs  as  other  diseases  ;  vulnerable  or  much-abused  organs 
which  suffer  disproportionately  from  common  causes  of  disease  suffer  also  in  much  the 
same  proportion  from  syphilis,  while  the  thyroid,  spleen,  capsules,  deep-seated  bones,  and, 
indeed,  generally  those'parts  which  are  not  obnoxious  to  other  'common'  diseases,  escape 


Hall  a  Testicle  intiltrated 
with  Svphiliiic  Deposit. 
(2:«1S8."  Prep.  Guy's  Hos. 
Mus.) 


AC(,>rini:/)  svrimjs.  nr> 

also  ill  syphilis"  (Mox«»n.  Mr,/,  '/'inns,  .Iiuif  -\.  1S71  j.  In  fjict,  hcyond  tho  Ii»cal  inoc- 
ulation, syphilis  fixi-s  upon,  or  rather  attacks,  an  orjran  much  as  any  other  disease,  pos- 
sossiiii;  no  lipeeial  jiredileetion  for  one  or^'aii  or  tissue;  in  preferenee  to  another,  the  so- 
called  secondary  and  tirliary  afrcctions  havinL'  no  real  dinen-ricc  save  ordy  in  the  surgeon's 
mind. 

'rKKATMKNT. — There  is  no  remedy  in  the  i'harmacopu'ia  that  can  he  relied  upon  as  a 
specific  tor  syphilis,  althoUL'h  there  are  many  that  have  a  very  Itenefieial  iiiHuence  in  aid- 
ing the  disappearance  of  the  symptoms;  they  can,  however,  do  no  more.  It  is,  indeed,  a 
(juestion  whether  the  disease  is  really  ever  cured — whether  a  person  once  under  the  influ- 
ence of  syphilis  is  not  really  like  one  hroujrht  under  the  influem;e  of  vaccinia;  which 
means  that  his  hody  has  heeii  so  affected  hy  the  poison  as  to  he  influenced  by  it  for  life. 
After  successful  vaccination  a  .^second  inoculation  rarely  takes  as  it  does  in  a  virgin  sub- 
ject, and  after  true  syphilis  a  second  attack  rarely  if  ever  ensues,  Porter's  law  being 
tolerably  proved — "  that  the  influence  of  syphilis  never  returns  upon  itself  or  recontam- 
inates  the  source  from  which  it  had  been  derived"  (JJuhfin  Quart.,  1857).  Ilicord,  Lee, 
and  others  have  proved  that  the  .soft  or  non-infecting  chancre  is  the  oidy  one  that  can  be 
inoculated  with  success  on  the  same  subject.  It  is  true  that  in  a  large  number  of  cases 
syphilis  appears  to  be  cured,  that  the  symptoms  disapjiear,  and  that  the  health  of  the 
patient  is  re-established  ;  yet  it  is  ecjually  true  that  in  such  ca.ses,  after  the  lapse  of  years 
— it  may  be,  even  after  a  (|uartcr  of  a  century — the  existence  of  former  syphilis  is 'again 
recognized  if  the  health  of  the  patient  is  lowered.  So  long  as  the  powers  of  the  subject 
who  had  syphilis  remain  good,  no  evidence  existed  of  its  presence  ;  but  when  these  failed, 
the  ]toison  reasserted  its  claim  to  recognition.  It  must,  however,  be  stated  with  consid- 
erable confidence  that  nature,  unassisted  by  art,  seems  incapable  of  eliminating  the  dis- 
ease or  of  arresting  its  progress. 

On  Ui<e  of  MercKiy. — In  former  times  it  was  thought  that  in  mercury  the  surgeon 
possessed  a  specific  against  the  disease  ;  and  when  all  chancres  were  looked  upon  as  syph- 
ilitic and  mercury  was  administered,  a  large  proportion  of  supposed  cures  were  recorded, 
no  constitutional  .symptoms  showing  themselves. 

In  modern  times,  however,  when  it  is  known  that  at  least  three  out  of  every  four 
cases  of  chancres  of  the  penis  are  local  venereal  affections  and  not  syphilitic,  the  real 
success  of  the  mercurial  plan  is  acknowledged  to  be  less  extensive  than  was  supposed, 
although  in  .syphilis — that  is,  when  the  constitutional  evidence  of  the  disease  is  present 
— the  power  of  mercury  in  getting  rid  of  the  symptoms  is  indisputable. 

In  strong  and  healthy  subjects,  therefore,  when  syphilis  is  present  either  in  the  form 
i>f  skin  eruption,  sore  throat,  or  other  affection  of  the  mucous  membrane  of  the  intestinal 
or  respiratory  tract,  mercury  is  beneficial.  The  best  mode  of  using  it  is  generally  sup- 
posed to  be  by  inunction — /.  e.,  the  rubbing  of  mercurial  ointment  about  the  size  of  a 
nut,  or,  what  is  better,  of  the  oleate  of  mercury,  ten-per-cent.  strength,  the  size  of  a  pea, 
into  the  axilla  twice  a  day  till  the  gums  are  touched,  and  after  then  only  once  a  day.  Dr. 
B.  G.  Babington  recommended  the  inunction  in  adults  to  the  soles  of  the  feet,  the  rubbing 
in  being  performed  by  the  action  of  walking.  The  internal  administration  in  bark  of  the 
bichloride  of  mercury  in  doses  of  one-sixteenth  of  a  grain  three  times  a  day  is  a  good 
form  of  administration,  as  is  also  the  green  iodide  of  mercury  in  grain  doses  twice  a  day, 
with  Dover's  pill.  Some  surgeons  still  use  the  blue  pill  with  opium.  During  the  last 
eight  or  ten  years  I  have  been  using  the  mercurial  suppository  twice  a  day,  and  have 
been  greatly  satisfied  with  its  action  ;  the  drug  acts  as  well  thus  as  by  the  mouth  and  in 
no  way  interferes  with  digestion  or  the  functions  of  the  abdominal  viscera.  Indeed.  I 
am  disposed  to  think  it  by  far  the  best  mode  of  administering  mercury  ;  I  know  of  no 
objection  to  its  use.     Next  to  this  plan,  the  calomel  vapor  bath  is  the  best. 

The  most  convenient  calomel  vapor  bath,  writes  Lee,'  is  one  which  was  made  at  my 
request  by  Mr.  Blai-se.  In  this  apparatus  the  lamp  which  sublimes  the  calomel  boils  the 
water  at  the  .same  time.  In  the  centre  of  the  top,  immediately  over  the  wick  of  the 
lamp,  is  a  small  separate  circular  tin  plate,  on  which  the  calomel  is  placed  ;  around  this 
is  a  circular  depression,  which  may  be  filled  one-third  with  boiling  water,  the  apparatus 
being  placed  on  the  ground  and  the  lamp  lighted.  The  patient  then  sits  over  it  with  an 
American  cloth  cloak  or  mackinto.^h  fastened  round  his  neck.  He  thus  becomes  sur- 
rounded with  calomel  vapor,  which  he  is  generally  directed  to  inhale  for  two  or  three 
separate  minutes  during  each  bath.  In  doing  this  the  patient  should  not  put  his  head 
under  the  cloak,  but  simply  allow  some  of  the  vapor  to  escape  from  the  upper  part  and 
breathe  it  mixed  with  a  large  proportion  of  common  air.  At  the  expiration  of  a  quarter 
'  Holmes's  Surgery,  third  edition,  vol.  iii. 


114  ACQUIRED  SYPHILIS. 

of  an  hour  or  twenty  minutes  the  calomel  is  volatilized  and  the  water  will  have  boiled 
away,  a  portion  of  the  calomel  being  deposited  on  the  patient's  body.  The  patient  may 
then  gradually  unfasten  his  dress  and  put  on  his  nightgown,  but  must  not  wJ[)e  his  skin. 
If  he  prefers  it,  he  may  go  to  bed  in  the  cloak  and  wear  it.  The  bath  ought  to  be  used 
every  night,  and  five  or  ten  grains  of  calomel  is  the  quantity  that  should  be  evaporated. 

Bricheteau,  Lewin,  and  Sigmond  have  employed  the  hypodermic  injection  of  mercury 
with  some  success,  throwing  in  fifteen  minims  of  a  solution  of  corrosive  sublimate,  four 
grains  to  the  ounce  of  water. 

Iodide  of  Fofaamnn. — For  feeble  cachectic  subjects,  however,  mercury  is  ill  adapted, 
and  for  such  the  iodide  of  potassiiim  in  five-grain  doses,  gradually  raised  to  ten,  or  more, 
will  do  all  that  is  needful.  In  London  practice  it  is  generally  required  to  be  combined 
with  some  tonic,  such  as  bark,  quinine,  or  iodide  of  iron.  The  combined  use  of  mercury 
and  i(jdide  of  potassium  will  occasionally  be  of  great  value. 

When  the  mucous  tracts  are  involved,  the  addition  of  some  alkali,  such  as  the  bicar- 
bonate of  potash,  in  ten-grain  doses,  to  the  iodide  is  advisable.  The  addition  of  the 
compound  spirit  of  ammonia  to  the  bark  mixture  is  also  useful. 

When  the  symptoms  begin  to  yield,  the  ti'eatment  must  be  continued ;  inc^eed,  the 
effects  of  the  drugs,  whatever  they  may  be,  should  be  kept  up  for  at  least  six  months 
after  the  disappearance  of  all  symptoms,  otherwise  a  relapse  will  ensue. 

Comparison  of  Mercury  and  Iodide. — Comparing  the  effects  of  the  two  drugs  together, 
it  may  be  asserted  that  the  mercurial  plan  of  treatment  is  more  applicable  to  the  early 
than  the  late  symptoms  of  syphilis ;  that  in  cases  of  relapses  or  of  late  syphilis  the 
iodide  of  potassium  is  preferable,  although  under  both  circumstances,  in  exceptional 
cases,  one  plan  of  treatment  will  succeed  whei'e  another  fails.  When  iodide  of  potassium 
cannot  be  tolerated,  iodide  of  sodium  may  be  substituted. 

Ij!('f, — During  the  course  of  syjihilis  the  patient  should  live  on  simple,  nutritious, 
but  non-stimulating,  diet.  Wine  and  beer  should  be  given  in  moderate  proportions,  spirits 
never  allowed,  and  smoking,  as  a  rule,  should  be  interdicted. 

When  mercury  is  being  employed,  the  skin  should  be  kept  warm  and  the  feet  dry,  all 
sudden  chills  being  bad.  When  suppuraticm  or  ulceration  exists  in  any  form  of  syphilis, 
mercury  is  rarely  applicable ;  iodide  of  potas.sium  combined  with  tonics  is  then  the  best 
drug,  with  or  without  opium.  Sarsaparilla  has  no  specific  influence  in  syphilis ;  it  is  a 
pleasant  vehicle,  but  nothing  more.  Opium  combined  with  other  drugs  is  at  times  of 
great  value  ;  with  mercury  it  is  invaluable.  It  may  be  given  in  small  doses  whenever 
the  nervous  .system  has  been  overwrought  and  there  is  great  irritability  of  pulse. 

The  syphilitic  affections  of  the  mouth,  tonsils,  throat,  tongue,  etc., 

are  expedited  in  their  disappearance  by  the  local  apjilicatiou  (if  nitrate  of  silver,  chromic 
acid,  gr.  v  to  x  to  the  ounce,  chlorate  of  potash,  boracic  acid,  or  borax  gargle  ;  constitu- 
tional treatment  should  be  simultaneously  employed. 

The  mucous  tubercles  of  the  genitals  and  other  parts  are  most  successfully  treated 
by  the  local  application  of  calomel,  which  should  be  dusted  over  the  diseased  surfaces 
through  a  muslin  bag.  A  good  rub  with  nitrate  of  silver  at  times  expedites  the  cure. 
The  parts  should  be  kept  well  dry. 

Condylomata  are  not  so  amenable  to  the  calomel  treatment  as  the  moist  tubercles; 
they  may,  however,  be  successfully  treated  by  the  local  application  of  the  chromic-acid 
solution,  nitrate  of  .silver,  or  sulphate  of  copper,  by  a  lotion  of  bichloride  of  mercury 
gr.  ij  to  the  ounce  of  water,  or  of  black  wash.  When  the  growths  are  very  fle-shy,  excision 
is  the  best  practice. 

In  ulceration  of  the  throat  iodide  of  potassium,  in  doses  varying  from  six  to 
fifteen  grains  three  times  a  day.  is  of  great  value,  with  the  local  application  of  the  nitrate 
of  silver  in  stick  or  strong  solution  ;  a  gargle  of  alum,  chlorate  of  potash,  or  borax,  a 
drachm  to  a  pint  of  water,  is  also  good. 

In  laryngeal  disease  the  iodide  must  also  be  given  quite  as  freely  ;  and  when 
ulceration  has  commenced  and  seems  to  be  unaffected  by  general  treatment,  tracheotomy 
claims  serious  consideration,  because,  unless  the  larynx  can  be  kept  quiet,  repair  will  not 
■go  on,  and  so  long  as  ulcerative  disease  is  present  a  sudden  spasm  of  the  glottis  may 
occur  and  render  imminent  the  death  of  the  patient.  The  operation  should,  however, 
only  be  undertaken  when  the  disease  is  steadily  progressing  in  spite  of  treatment,  and  if 
it  is  clear  that  the  larynx  will  be  destroyed  as  a  vocal  as  well  as  a  respiratory  organ  unless 
some  steps  be  taken  to  stop  its  progress.  Of  these  steps  there  are  none  equal  to  trache- 
otomy, for  all  surgeons  are  familiar  with  the  fact  that  even  under  the  most  extreme  con- 
ditions of  disease  repair  goes  on  in  the  larynx  directly  the  tracheal  tube  has  been  intro- 


HEREDirMlY  SYPHILIS.  115 

duced,  and  physiological  rest  is  given  t<j  the  organ  {viih'  paper  by  author,  Clin.  S'jc. 
Trans.,  18G8). 

In  the  (jummy  tumors  of  the  tongue,  muscles,  and  cellular  tissue  large  doses  of  the 
iodide  with  tonics  are  as  heneficial  as  they  are  in  the  pfriostraf  affections  of  syphilis. 

TnnfnHiif  nf  Inlirnnl  Si/ji/iiii.-<. — There  is  rea>on.  however,  to  ht-iieve  that  in  the  vis- 
ceral as  well  as  in  other  diseases  which  may  he  looked  upon  as  the  se«|ueUe  of  syphilis, 
or  as  the  result  of  the  cachexia  caused  by  the  disease  and  the  remedies  emph^yed  fur  its 
reniiival.  ioilidf  of  jtotassium  alone  has  little  influence.  J>r.  Wilks  has  shown  how  the 
lardaceous  and  wa.xy  diseases  of  organs  are  found  after  .syphilis,  and  every  one  knows  how 
little  amenable  to  treatment  these  affections  are.  Dr.  Dickinson  has.  however,  done  some- 
thing to  prove  that  they  are  due  to  a  want  of  alkalinity  in  the  blood,  and  are  to  be  pre- 
vented, and  in  a  manner  cured,  by  the  medical  use  of  alkalies.  With  the  same  view  a 
non-nitrogeni>us  diet  should  be  allowed. 

During  the  later  period  of  the  disease,  when  the  gummous  depositions  take  place, 
whether  it  be  visceral,  osseous,  glandular,  or  otherwise,  iodide  of  pota-ssium  in  full  doses 
is  of  great  value.  In  the  sequelje,  in  waxy  or  lardaceous  disea.se.  it  is  of  little  u.se.  alka- 
lies with  tonics  being  then  apparently  the  best.  Upon  this  knowledge  it  is  probable  that 
the  late  Mr.  Aston  Key  based  his  advocacy  of  lime  water  and  the  infusion  of  sarsaparilla 
in  the  syphilitic  cachexia. 

Hereditary  Syphilis. 

That  syphilis  is  capable  of  being  propagated  by  hereditary  transmission  is  a  clinical 
fact  generally  recognized,  constituting  the  main  distinction  between  syphilis  and  all  other 
animal  poisons.  To  what  an  extent  this  influence  spreads  is  still  a  debatable  question. 
According  to  some  observers,  instead  of  diminishing,  the  radius  of  its  action  appears  to 
be  yearly  increasing. 

That  the  child  of  a  parent  who  has  had  syphilis  moT/ — not  /»?/.«/ — inherit  the  disease 
is  generally  acknowledged,  and  when  both  parents  have  been  affeetefj  the  probabilities  of 
its  transmi.ssion  are.  doubtless,  increased ;  but  data  are  still  wanting  to  determine  under 
what  circumstances  the  offspring  of  such  parent  or  parents  is  likely  to  be  born  healthy. 

There  is,  however,  some  reason  to  believe  that  when  the  mother  is  at  fault  the  early 
conceptions  are  more  likely  to  be  blighted  and  the  later  come  to  maturity  ;  whilst  when 
the  father  is  at  fault  the  first  conceptions  .show  few.  if  any.  signs  of  the  affection,  the 
symptoms  becoming  more  marked  in  each  succeeding  one,  till  at  last  the  ovum  becomes 
blighted  and  the  wife  constitutionally  affected. 

The  probabilities  of  the  child  being  affected,  as  well  as  the  degree  of  the  affection, 
turn,  likewise,  much  upon  the  period  of  time  which  has  elapsed  between  the  disappear- 
ance of  the  con.stitutional  symptoms  in  the  parent  and  the  date  of  marriage. 

Daily  experience  proves,  however,  that  a  man  who  has  had  syphilis  and  lost  all  traces 
of  it  under  treatment,  who  enjoys  good  health  and  marries  a  healthy  wife,  maybe  blessed 
with  healthy  children  in  whom  no  traces  of  .syphilis  can  be  found :  but  the  .same  experi- 
ence also  indicates  that  these  subjects,  marrying  in  a  less  vigorous  condition  or  lapsing 
into  bad  health,  may  give  rise  to  diseased  offspring. 

A  certain  number  of  children  succumb  in  their  mother's  womb  to  syphilis  solely 
because  they  are  already  affected  with  the  disease.  At  other  times  the  children  come 
into  the  world  with  lesions  unmistakably  .syphilitic :  while  in  the  great  majority  of  cases 
the  child  who  inherits  .syphilis  has  at  first  the  appearance  of  health  and  some  weeks  after 
birth  presents  signs  which  betray  the  evil  transmitted  to  it  from  its  parents,  it  being  usu- 
ally from  the  first  to  the  third  month  of  extra-uterine  life  that  .syphilis  manifests  itself  in 
the  new-born  child.  Cullerier  cives  a  vear  as  the  latest  time  for  the  disease  to  show 
itself. 

With  respect  to  the  symptoms  of  hereditary  .syphilis,  it  may  be  well  to  a.ssert  at  the 
beginning  that,  with  the  exception  of  the  primary  inoculation,  they  are  much  the  same 
as  those  of  the  acquired  disease.  Affections  of  the  skin  are  found  a-s-sociated  with  those 
of  the  mucous  memVjranes,  bones,  or  viscera,  and  these  manifest  themselves  in  no  definite 
order. 

At  birth  the  child  may  be  plump  and  fat.  and  for  some  days  appear  healthy  in  every 
respect.  After  the  lapse  of  a  few  days  some  difficulty  in  breathina  will  probably  appear, 
with  symptoms  of  cold  in  the  head,  these  so-called  "  snvjffes '"  being  always  suspicious. 
At  this  time,  if  the  skm  be  carefully  examined,  more  particularly  about  the  buttocks  and 
feet,  some  eruption  will  be  seen.  This  may  be  simply  a  staining  of  the  skin  or  a  more 
definite  papular,  vesicular,  or  pustular  rash :  it  may  be  associated  with  some  affection  of 


116 


HEREDITARY  SYPHILIS. 


Fig.  23. 


the  internal  skin  or  mucous  nK'nil)raiie,  mucous  patches  or  condylomata  showing  them- 
selves at  the  anus,  about  the  mouth  or  within  it,  around  the  nose  or  other  parts.  The 
seat  of  the  eruption  is  greatly  determined  by  the  degree  of  cleanliness  observed,  the  irri- 
tation of  dirt  and  moisture  in  any  locality  in  syphilitic  children  being  followed  by  condy- 
lomata or  mucous  patches. 

The  orifices  of  the  nose,  mouth,  and  anus  are  at  times  fissured  in  a  very  marked  man- 
ner, and  occasionally  leave  traces  of  the  disease  which  can  never  be  mistaken  even  years 
afterward.  In  the  annexed  drawing  these  alterations  about  the  face  are  most  typically 
shown  (Fig.  23). 

When  the  disease  is  allowed  to  run  its  course,  the  child's  general  condition  suffers; 
it  becomes  emaciated  and  puny,  the  digestive  organs  become  deranged  and  refuse  to 
assimilate  food,  however  good,  while  vomiting  and  diarrhcea  are  common  consequences. 
Evidence  of  starvation  soon  appears ;  the  skin  becomes  baggy  and  of  a  peculiar  dusky 
hue;  when  not  covered  or  scarred  with  eruptions,  it  may  have  a  jaundiced  appearance; 
and  the  child  will  pr(»})ably  die  from  what  is  called  marasmus,  which  means  wasting  from 
starvation. 

When  the  disease  does  not  run  so  rapid  a  course,  other  symptoms  show  themselves. 
It  may  be  in  the  skin,  bones,  eye,  ear,  or  viscera. 

In  the  akin,  subcutaneous  or  submucous  tissues  the  disease  may  appear  in  the  form 
of  ijummi/  swclfi)if^.s  or  tumors,  which  may  break  up  and  give  rise  to  irregular  excavated 
cellulo-membranous  abscesses.     In   the  bonrs  the  disease  may  show  itself  as  nodes,  the 

humerus  appearing  to  be  the  bone  most  commonly  affected, 
though  I  have  seen  several  instances  in  which  the  bones  of  ■ 
the  .skull  were  frightfully  involved. 

In  the  eye  the  symptoms  are  well  known  ;  interstitial 
keratitis,  a  form  of  disease,  according  to  Hutchinson,  which 
is  peculiar  to  hereditary  syphilis,  generally  shows  itself 
between  the  ages  of  eight  and  fifteen  years.  It  appears  as 
a  iliflf'used  haziness  of  the  centre  of  the  cornea,  unattended 
with  ulceration ;  this  haziness  begins  in  independent 
patches,  which  subse((uently  coalesce,  the  cornea  at  a  later 
date  appearing  like  ground  glass.  The  affection  is  attended 
with  photophobic  pain  about  the  orbit  and  the  sclerotic 
injection.  It  generally  involves  both  eyes  seriatim.  Under 
treatment  the  disease  may  be  arrested ;  but  when  it  is 
severe,  patches  of  haziness  renuiin  which  interfere  with 
vision  and  at  times  cause  complete  blindness  (Fig.  23). 

Iritis  is  another  complication,  though  a  rare  one.  as  is 
choroiditis,  and  also  amaurosis. 
Deafness  is  not  unfrequent.  the  hearing  failing  without   any  external  disease,  such  as 
otorrhoea.     In  most  cases  both  ears  are  affected. 

Hydroceplialus  and  syphilis  are  also  allied.  Sj/philitic  disease  of  the  testicles  is  also 
to  be  met  with.  I  have  seen  several  cases  of  this  nature,  and  the  most  marked  was  in  a 
boy  four  months  old,  the  third  child  of  syphilitic  parents,  who  had  snuffles  and  mucous 
patches  on  the  lips.  I]ach  of  the  testicles  was  an  inch  and  a  half  long  and  very  hard. 
The  disease  was  cured  by  mercurial  treatment. 

There  is  reason  to  believe,  moreover,  that  in  hereditary  as  in  acquired  syphilis  every 
organ  of  the  body,  in  different  cases,  may  be  found  diseased,  the  viscera  of  the  cranium, 
thorax,  and  abdomen,  with  the  glands  generally,  as  well  as  the  skin,  mucous  membrane, 
mu.scles,  nerves,  and  bones. 

It  is  difficult  to  decide  how  far  the  syphilitic  poison  follows  the  subjects  who  inherit 
it.  It  is  no  uncommon  event  to  find  a  child  entirely  free  from  all  evidence  of  constitu- 
tional syphilis  born  of  parents  who  had  previously  given,  and  may  subsequently  give, 
birth  to  stillborn  or  diseased  offspring.  A  healthy  child  may  stand  alone  in  a  long  series 
of  conceptions  as  a  living  proof  of  the  power  of  life  even  over  such  a  poison  as  syphilis. 
I  have  also  before  me  the  notes  of  an  instance  of  twins  born  of  syphilitic  parents  ; 
one  passed  through  all  the  series  of  complaints  common  to  hereditary  syphilis,  while  the 
other  escaped  altogether — that  is,  at  the  end  of  a  year  and  a  half  no  symptoms  had 
appeared. 

I  have  the  notes  of  another  case  of  twins,  born  under  like  circumstances,  in  which  the 
symptoms  appeared  in  one  at  the  end  of  a  month,  and  in  the  other  in  the  fourth  month. 
Such  cases  as  these  would  appear  to  show  that  the  manifestation  or  non-manifestation 


Hereditary  Syphilis.   {Frmu  life.) 


iii:i:i:i)irMiY  syriiius. 


117 


Fig.  25. 


^^^y 


Syphilitic  Teeth. 


llealthv  Teeth. 


(it"  till-  .syiii|itniiis  ul'  licrnlilary  .syi>liili.s  (Ii'|m-ih1.^  inurh  ii|>(iri  tin'  |)cr.s(iii;il  power  nl"  the  cliilil 
who  iiilicrit.s  it,  :i  strong  cliild  throwiiiix  oil'  or  fliiiiiniitiiitr  tln'  poLsoii.  wliilc  tin;  WL-ak  falls 
uiaK-r  its  iiiHiifiicc.  .sine*'  in  tlio  case;  of"  the  twiii.s  altovt-  iiii'iilioiird  tiiere  can  he  no  niicstioti 
as  to  the  simiiaril y  of"  tin-  foiidilions  uinh-r  which  llicy  wurc  |ilacLMl.  In  hcn-ditary  sv|iliilis 
this  conclusion  is  fomnlcd  u)ion  slroni;  cvidcnct;,  ami  in  the  acijuin^d  it  is  at  least  prohahlc. 

Affections  of  the  Teeth. — .Vmonirst  tin;  evidences  of"  li(;reditary  syphilis  estalt- 
lislicil  l>y  .Mr.  1 1  iiicliinsori  tlitic  are  often  pr(;sent  in  the  permanent  teeth  iinportatit  indi- 
cations— .so  important,  indeed,  that  when  jiresent  the  existence  of  hereditary  syphilis 
nniy  with  .some  confidence  he  pronounce*].  They,  however,  exist  oidy  in  exceptional 
instances  of  hereditary  syphilis.  ''  The  centnil  iijtjtir  incisorn  of  the,  mrond  xrt  arc  the  tpM 
teeth;"  these  are  usually  short  and  narrow,  with  a  hroad  vertical  notch  in  the  edges,  and 
their  corners  rounded  of}'  (Fifr.  24).  Horizontal 
notches  have  nothinii;  to  do  with   syjihilis. 

"  Next  in  value  to  the  malformation  of  the  teeth," 
writes  Hutchinson,  ''are  the  state  of  the  patients 
skin,  the  formation  of  hi.s  nose,  and  the  contour  of 
his  forehead  ;  the  skin  is  ahmjst  always  tliick,  pasty, 
and  opa(iue.  It  also  shows  little  pits  and  .scars,  the 
relics  of  a  t'ormer  erujition,  and  at  the  angles  of  tlie 
mouth  are  radiating  linear  scars  running  out  into  the 
elieeks.  The  bridge  of  the  nose  is  almost  always 
hroader  than  usual,  and  low  ;  often  it  i.s  remarkahly 
sunk  and  expanded.  The  forehead  is  u.sually  large 
and  protuberant  in  the  regions  of  the  frontal  emi- 
nences ;  often  there  is  a  well-marked  broad  depression  a  little  above  the  eyebrows.  The 
hair  is  usually  dry  and  thin,  and  now  and  then  the  nails  are  broken  and  splitting  into 
layers.  Interstitial  keratitis  is  pathognomonic  of  inherited  taint;  and  when  coincident 
with   the  syphilitic  type  of  the  teeth,  the  diagnosis  is  beyond  a  doubt." 

In  Fig.  2o  every  point  in  this  description  is  illustrated  except  with  reference  to  the 
teeth,  which  were  unusually  good. 

There  is,  however,  good  reason  to  believe  that  the  children  of  .syphilitic  parents  mm/ 
be  affected  by  the  poison  in  a  way  wdiich  cannot  be  classed  amongst  any  of  the  ordinary 
forms  of  hereditary  .syphilis  as  described. 

Treat:vient. — To  help  the  disappearance  of  the  symptoms  of  hereditary  syphilis 
remedies  are  of  great  value,  and  in  an  infant  showing  evidence  of  any  constitutional 
power  the  prospects  of  a  recovery  are  very  good.  When  the  child  is  being  suckled, 
whether  the  mother  shows  or  not,  I  have  for  many  years  administered  my  remedies 
through  the  mother,  giving  her  from  six  to  ten  or  sixteen  grains  of  iodide  of  potassium 
with  quinine,  or  other  tonic  mixture,  three  times  a  day,  half  an  hour  before  the  child  is 
put  to  the  breast ;  and  I  have  been  much  impressed  with  the  excellent  results  of  the 
practice.  When  this  process  acts  slowly,  I  give  the  child  in  addition  a  grain  of  gray 
powder,  with  three  or  four  grains  of  dried  soda  every  night. 

Before  this  I  administered  the  gray  powder  and  soda  twice  a  day.  or  rubbed  in  about 
ten  grains  of  blue  ointment  every  night  on  the  soles  of  the  child's  feet,  the  abdomen,  or 
the  axilla,  but  I  much  prefer  the  practice  previously  laid  down.  In  young  infants  the 
mercurial  ointment  may  be  put  on  the  belly-band  and  thus  rubbed  in.  As  the  snuffles 
disappear  the  eruption  and  mucous  tubercles  fade,  and  the  child  begins  to  fatten  and  show 
signs  of  progress.  The  treatment  should  be  kept  up  for  at  least  a  month  after  the  disap- 
pearance of  all  sympt(jms. 

The  chlorate-of-potash  treatment  in  some  instances  is  doubtless  attended  with  no 
unfavorable  result,  strong  infants  with  care  and  nursing  battling  through  the  disease,  and 
possibly  eliminating  it.  But  the  weaker  die  when  through  more  active  measures  they 
might  probably  have  been  saved.  Many  apparently  hopeless  victims  of  hereditary  syphilis 
become  under  treatment  .strong  and  healthy  infants. 

A  child  with  hereditary  syphilis  should  under  no  circumstances  be  suckled  by  any 
other  than  the  mother,  for  many  a  healthy  wet-nurse  has  been  inoculated  by  such  a  crim- 
inal practice.  When  the  mother  cannot  attend  to  the  child,  it  should  be  brought  up  by 
hand. 

Serpiginous  Ulceration. 

This  is  a  rare  and  somewhat  singular  form  of  venereal  disease.  It  would  seem  to  be 
more  closely  connected  with  the  local  suppurating  non  syphilitic  sore  than  the  syphilitic, 


118  SERPIGINOUS  ULCERATION. 

for  it  is  rarely  if  ever  associated  with  constitutional  syphilis.  It  usually  appears  in  the 
groin  or  thigh  after  a  suppurating  bubo  the  result  of  a  suppurating  non-syphilitic  chancre, 
the  opening  in  the  groin  spreading  in  crcscentic  patches  of  ulceration,  one  part  of  the  sore 
increasing  while  a  second  is  healing;  when  the  cicatrix  forms,  it  presents  a  smooth  glazed 
appearance.  This  ulceration  is  most  obstinate ;  indeed,  medicine  appears  to  have  little 
or  no  influence  on  its  progress,  and  it  may  so  spread  as  to  extend  over  the  thighs  and 
lower  part  of  the  abdomen  and  continue  at  intervals  for  years,  but  wearing  itself  out  at 
last.  I  have  seen  one  case  in  which  it  spread  as  high  as  the  umbilicus  and  as  low  as  the 
knee.  The  disease  at  one  time  promises  to  heal,  and  then  spreads  without  any  clear 
cau.se.  It  is  often  found,  too.  in  apparently  healthy  subjects,  and  appears  to  follow  some 
course  of  its  own  that  is  not  yet  understood.  It  should  be  added  that  this  sore  is  capable 
of  being  inoculated  u{i()n  the  .same  subject,  the  point  of  inoculation  taking  on  the  same 
action. 

Treatment. — Mercury  and  iodide  of  potassium  appear  to  have  little  or  no  influence 
on  this  malady  ;  and  if  the  view  indicated  by  its  cour.se  be  correct — that  the  disease  is 
not  syphilitic — such  a  result  is  only  what  should  be  expected.  The  local  treatment  of 
the  sore  seems  to  be  the  most  important,  and  the  best  practice  con.sists  in  the  local  applica- 
tion of  some  strong  caustic,  such  as  nitric  acid,  carbolic  acid,  or  the  cautery,  either  gal- 
vanic or  actual,  the  patient  being  under  the  influence  of  .some  anaesthetic.  The  local 
application  of  iodoform  or  of  resorcine  in  solution  fifteen  grains  to  the  ounce  of  distilled 
water  should  also  be  tried.  Opium  in  moderate  doses  is  of  use,  and  so  also  are  tonics ; 
but  in  a  general  way  the  subjects  of  this  affection  are  in  good  health.  In  several 
instances  I  have  found  a  sea-voyage  of  more  value  than  any  other  treatment.  In  three 
cases  the  .sore  rapidly  healed  after  the  operation  of  .skin-grafting  had  been  performed. 

When  maij  a  man  icho  has  had  syphilid  marry?  is  a  question  which  is  often  asked; 
and  to  answer  it  with  any  degree  of  confidence  is  no  easy  task,  assuming,  as  I  do,  that 
the  opinions  laid  down  in  these  pages  are  correct — that  a  man  who  has  once  had  syphilis 
can  never  be  pronounced  free  from  its  influence,  and  that  the  poison,  once  in  the  body, 
may  reveal  its  presence  a  quarter  of  a  century  after  all  external  evidence  of  its  existence 
in  the  form  of  local  di.sease  has  disappeared. 

A  man  who  has  had  .syphilis  may,  therefore,  when  he  marries  so  aff"ect  the  ovum  of 
his  wife  as  to  cause  its  death  or  produce  some  evidence  of  disease  or  feebleness  ;  or  if  the 
wife  be  healthy  and  he  himself  in  good  condition  and  free  from  evidence  of  the  disease 
at  the  time  of  conception,  the  offspring  may  escape  altogether  and  appear  as  healthy  as 
that  of  other  uninfected  parents.  Indeed,  it  would  appear  that  if  a  man  marries  when  in 
robust  or  good  health  a  year  after  all  evidence  of  the  disease  has  vanished,  he  may  be 
the  father  of  a  healthy  child  ;  but  if  his  general  condition  fails  and  he  becomes  cachectic, 
the  poison  may  reassert  its  influence  and  manifest  its  presence  by  some  feeble,  or  even 
disea.sed.  condition  of  the  subsequent  offspring. 

When  the  mother  is  affected  with  the  disease,  the  same  risks  are  run. 

Every  parent  who  has  had  syphilis  runs  the  risk  of  giving  birth  to  feeble  or  diseased 
off"spring ;  these  risks  are  diminished  by  the  general  vigor  of  the  parents,  and  increased 
by  dimini.shed  power.  No  man  should  marry  so  long  as  the  .slightest  taint  of  the  disease 
manifests  its  presence  ;  but  if  in  good  health  and  free  from  all  evidence  of  its  presence 
for  a  year,  marriage  may  be  contracted.  To  ask  for  a  longer  delay  when  such  a  step  is 
contemplated  is  unfair  and  unnecessary ;  a  risk  must  be  run,  and  the  lapse  of  a  longer 
period  will  not  lessen  it. 

Inoculation  and   Syphilization. 

Ricord  was  the  first  surgeon  who  employed  inoculation  f(ir  diagnostic  purposes  in 
venereal  affections,  and  through  his  experiments  he  was  led  to  the  conclusion  that  "  a 
chancre  at  the  period  of  progress  is  the  only  source  of  the  syphilitic  virus."  As  a  test 
of  the  simple  suppurating  sore  it  may  now  be  employed,  for  a  second  sore  can  readily  be 
obtained  by  inoculating  a  patient  from  the  pus  of  his  own  primary  one.  Indeed,  this 
process  of  auto-inoculation  may  be  continued  for  a  long  series,  but  only  with  any  effect 
from  the  suppurating  sore.  In  the  .syphilitic  sore  no  inoculation  will  take,  and  in  the 
inoculation  of  common  pus  no  reaction  occurs,  or  next  to  none,  a  simple  pustule  probablv 
alone  appearing. 

From  these  clinical  facts  it  would  appear  that  common  pus,  the  pus  from  a  suppurat- 
ing non-syphilitic  sore,  and  that  from  a  syphilitic  one  are  very  distinct,  including  under 
the  term  '•  .syphilitic  "'  any  sore  that  is  followed  by  .syphilis. 


VAccfxo-svi'nfijs.  119 

Hv  iiinculaiiitii.  tlicrcturi',  :i  siiru'i'iiii  may  fairly  (Irtrriiiiiie  tlic  fact  as  to  tlic  nature 
of  u  chancre,  and  under  Minie  cirennistances  tlie  evidence  <)l)lained  \i\  tlie  practice  mav 
be  valnalde. 

Syphilization  nri<:iiiated  in  1st  J  throii^di  sunie  exjierinients  of  M.  Auzias  Turenne 
U|>iin  aninial>  In  iunciilate  them  with  syphilis,  and  in  these  lu;  i'ound  that  after  a  number 
of  inoeuhitions  they  Iteeame  ])r<iof  aj;ainst  tin-  syphilitic  virus.  It  was  followed  up  l)v 
M.  Sperino  of  Turin  and  i-xtoiisively  (jmjiloycd  by  J'rofcssors  Moeck.  I''aye.  and  Kidenkap 
at  Christiania,  several  hundred  eases  havintr  been  treated  upon  the  principle,  the  object 
beinir  '"  to   cure  syphilis.' 

The  theory,  as  expressed  by  l^ieek,  "  that  tlio  syphilitic  virus  by  continued  inocula- 
tion annihilates  itself,"  was  practically  carried  out  by  inoculating  a  patient  the  .subject 
of  syjdiilis  with  fresh  matter  from  any  active  venereal  sore  of  any  kind  till  the  inocula- 
tions failed  to  take.  The  inoculations  were  repeated  every  three  or  four  days,  first  on 
the  body,  then  on  the  extremities.  When  inoculation  is  no  loiifrer  possible,  "  the  treat- 
ment is  finished  and  the  ]>atient  has  recovered  bis  health." 

Boeck  never  iMMctised  syphilization  until  the  constitutional  symptoms  appeared;  for, 
says  he,  "  I  cannot  double  a  malady  already  j)resent,  so  I  am  f|uite  certain  not  to  do  harm 
to  the  patient."  Syphilization  is  not  used  with  e((inil  success  aL-^aitist  all  cases  of  syphilis. 
"  In  those  that  have  not  been  treateil  with  mercury  the  ]irn<iress  of  syphilization  will  be 
retrular;  the  .syphilitic  pheiionieiia  will  vanish  away,  immunity  will  take  place  eventuall}', 
and  recovery  be  attained  with  certainty.  In  those  who  have  taken  mercury  syphiliza- 
tion is  not  so  certainly  useful  ;  it  ouj^ht  to  be  tried.  It  does  often  cure  syjihilis  entirely, 
and  at  least  does  good."  These  are  Boeck's  conclusions,  but  I  need  hardly  add  they  are 
not  those  of  British  surseons.  The  practice  has  been  mentioned  and  briefly  described, 
but  not  to  be  recommended.  It  has  no  single  advantage,  and  is  certainly  loathsome. 
"\Ve  are  decidedly  of  opinion,  write  Lane  and  Ga.scoyen  in  an  able  article  on  the  subject, 
that  "syphilization  is  not  a  treatment  which  can  be  recommended  for  adoption.  We  con- 
sider that,  even  if  it  could  be  admitted'  to  possess  all  the  advantages  claimed  for  it  by  its 
advocates,  its  superiority  over  other  modes  of  treatment,  or  in  many  instances  over  no 
treatment  at  all,  would  not  sufficiently  compensate  for  its  tediousness,  its  painfulness,  and 
the  life-long  marking  which  it  entails  upon  the  jnitient  "  (Med.  Chir.  Trans.,  vol.  i.). 

Vaccino-Syphilis. 

That  sypliilis  may  be  transferred  by  means  of  vaccination  is  a  fact  which  must  be 
honestly  recognized,  although  where  it  has  occurred  it  seems  more  than  probable  that 
something  more  than  the  unmixed  lymph  of  the  genuine  vaccine  vesicle  had  been 
employed,  such  as  the  blood  of  the  vaccinfer  ;  for  no  one  can  now  well  dispute  the  po.ssi- 
bility  of  inoculating  syphilis  when  the  blood  of  a  syphilitic  vaccinifer  is  transferred  with 
the  vaccine  matter  to  a  non-syphilitic  subject.  "Whether  it  be  possible  to  transfer  syphi- 
lis through  unmixed  vaccine  lymph  is  still  an  open  (|uestion.  In  this  country  such  a 
misfortune  as  a  sypliilitic  inoculation  through  vaccination  has  been  happily  rare,  and  only 
in  recent  days  has  the  attention  of  the  great  body  of  the  profession  l)een  directed  to  the 
subject.  In  Mr.  Hutchinson's  paper  and  in  the  report  of  the-  Royal  Med.  and  Chir. 
Society  for  1871  there  will  be  ftumd  sufficient  material  to  prove  the  truth  of  wlrat  has 
been  written,  and  in  Dr.  Seaton's  Ihtndhodk  on  Vaccination  and  in  Dr.  Ballard's  work  all 
that  is  known  on  the  sul>ject  mav  l>e  ascertained. 

Instructions  for  Vaccinators. — Vaccinate  only  subjects  who  are  in  good 
health.  Ascertain  that  there  is  not  any  febrile  state,  nor  any  irritation  of  the  bowels, 
nor  any  unhealthy  state  of  the  skin,  especially  no  chafing  or  eczema  behind  the  ears  or  in 
the  groin  or  ehsewhere  in  folds  of  skin.  Do  not  vaccinate  in  cases  where  there  has  been 
recent  exposure  to  the  infection  of  measles  or  scarlatina,  nor  where  erysipelas  is  prevailing. 

Lymph  is  to  be  used  according  to  the  following  instructions : 

1.  In  proceeding  to  use  a  charged  capillary  tube,  snip  off  its  two  ends;  then  from  one 
end  of  the  tube  blow  the  lymph  through  the  opposite  end  upon  the  arm  of  one  of  the 
infiints,  over  the  place  where  the  operation  is  to  be  performed,  having  had  previou.sly  two 
or  three  other  infants'  arms  prepared  for  vaccination.  The  lancet  is  then  to  be  loaded 
from  the  drop  and  inserted  into  the  arms  of  the  children  prepared  to  receive  it.  but 
enough  is  to  be  left  upon  the  original  arm  to  vaccinate  that  child.  L^nless  the  tube  be 
very  copiously  charged,  not  more  than  two  children  are  to  be  vaccinated  from  it.  The 
insertion  should  ])e  made  in  four  spots,  as  hereinafter  directed. 

2.  In  operating  with  a  charged  ivory  point  use  no  wafer  to  so/ten  the  li/mph.     In  this 


120  TUMORS. 

mode  of  vaccinating  the  operator  shouUl  make  a  few  scratches  just  fhrovgh  the  cuticle, 
only  sufficiently  deep  to  tlomp  the  surface  with  hJood.  These  scratches  should  he  mode 
■in  four  qjots.  each  covering  a  surface,  at  nearly  one  inch  apart.  The  scratches  may  be 
abrasions  of  the  cuticle  by  fine  parallel  lines  or  by  further  cross-.scratch.  The  operation 
may  be  performed  on  both  arms  when  the  surface  available  or  the  po.sition  usually  selected 
is  of  limited  extent.  The  operator  should  proceed  with  caution  and  take  time.  On  no 
account  should  incisions  be  made  and  the  point  of  the  ivory  inserted  into  them,  and  it 
should  be  borne  in  mind  that  the  vaccine  virus  ought  not  to  reach  the  subcutaneous  cel- 
lular tissue.  The  child  should  be  kept  under  observation  till  the  spots  are  perfectly 
dry,  and   orders   Lnven    that   the  arms   mmt  not  he  v:ashed. 

'i.  Selection  of  Lymph. — Never  either  use  or  furnish  lymph  which  has  in  it  any, 
even  the  slightest,  admixture  of  blood.  In  storing  lymph  be  careful  to  keep  separate  the 
charges  obtained  from  different  subjects,  and  to  affix  to  each  set  of  charges  the  name,  or 
the  number  in  your  register,  of  the  subject  from  whom  the  lymph  was  derived. 

4.  Never  take  lymph  from  cases  of  revaccination.  Take  lymph  only  from  subjects 
who  are  in  good  health  and.  as  far  as  you  can  ascertain,  of  healthy  parentage,  preferring 
children  whose  families  are  known  to  you  and  who  have  elder  brothers  or  sisters  of 
undoubted  healthiness.  Always  carefully  examine  the  subject  as  to  any  existing  skin 
disease,  and  especially  as  to  any  signs  of  hereditary  syphilis.  Take  lymph  only  from 
well-characterized,  uninjured  vesicles.  Take  it  (as  may  be  done  in  allregular  ca.ses  on 
the  day  week  after  vaccination)  at  the  stage  when  the  vesicles  are  fully  formed  and 
plump,  but  when  there  is  no  perceptible  commencement  of  areola.  Open  the  vesicles 
with  scrupulous  care,  to  avoid  drawing  blood.  Take  no  lymph  which  as  it  issues  from 
the  ve-sicle  is  not  perfectly  clear  and  tran.sparent  or  is  at  all  thin  or  watery.  Do  not, 
under  ordinary  circumstances,  take  more  lymph  from  a  vesicle  than  will  suffice  for  the 
immediate  vaccination  of  five  subjects,  or  for  the  charging  of  seven  ivory  points,  or  for 
the  filling  of  three  capillary  tubes ;  and  from  larger  or  smaller  vesicles  take  only  in  like 
proportion  to  their  size.  Never  squeeze  or  drain  any  vesicle.  Be  careful  never  to  tran.s- 
fer  blood  from  the  subject  you  vaccinate  to  the  subject  from  whom  you  take  lymph. 

5.  Keep  in  good  condition  the  lancets  or  other  instruments  which  you  use  for  vacci- 
nating, and  do  not  u.se  them  for  other  surgical  operations.  When  you  vaccinate,  have 
water  and  a  napkin  at  your  side,  with  which  invariably  cleanse  your  instrument  after  one 
operation  before  proceeding  to  another. 

With  these  precautions  vaccination  may  be  regarded  as  a  perfectly  safe  operation ; 
without  them  the  risks  of  syphilitic  inoculation,  although  slight,  exist.'  They  tell,  how- 
ever, but  little  against  the  enormous  advantages  of  vaccination. 

Lee,  Holmeii's  System,  third  edition,  vol.  ili.— Marston,  Med-Chir.  Trans:.,  vols.  xlv..  xlvi. — Laxc 
AND  Gascoyex,  Med.-Chir.  Tram.,  vol.  1.— Bf-MSTEAD,  Edit,  of  ddlerier,  Pliiladelphia.  1868.— Por- 
ter, Dublin  Quart.,  1857. — Lanx-ereaux,  Oji  Syphilid,  Xew  Svd.  Soc. — Wallace,  On  Venereal. — 
Carmichael.  On  Venereal. — HuTcmxsox,  Syphilitic  Dliea.^es  aj  Eye  and  Teeth. — Report  of  Committee 
an  Venereal  Diseases,  1868.— TuREXKE,  Academie  des  Sciences,  1850.— Boeck,  Edin.  Med.  Jour., 
lSo8.— Dublin  Journal,  1857. 


CHAPTER    III. 


TUMORS. 

I.\  the  prepathological  period,  before  the  minute  anatomy  of  healthy  and  diseased 
tissues  was  understood  and  the  microscope  had  rendered  intelligible  subjects  that  still 
rested  in  darkness,  tumor.^  had  from  neces.sity  been  .studied  simply  in  their  clinical  aspects, 
and  surgeons,  in  their  attempts  to  classify  them,  were  guided  .solely  by  the  mo.st  obvious 
characteristics  of  the  growths  and  by  their  real  or  fancied  resemblance  to  the  natural 
tissues  of  the  body.  As  time  advanced  more  ambitious  attempts  at  classification  were 
made,  and  the  most  important  work  was  that  of  Ahernethy.  who  at  the  beginning  of  this 
century  puVjlished  his  Atttnipt  to  form  a  Classification  of  Tumors  according  to  their  Ana- 
tomical Structures.  In  that  able  production  he  asserted  "  that  the  structure  of  a  tumor 
is  sometimes  like  that  of  the  part  near  which  it  grows,  and  sometimes  unlike ;  that  in 
many  cases  the  nature  of  the  tumor  depends  on  its  own  action  and  organization  and 
merely  receives  nourishment  from  the  surrounding  parts.'"     He  thus  gave  expression  to 


patlii)loj^ic!il  tnitlis  r)f  tlio  <i;reate.st  iniportaiKM!  ami  that  still  remain  iiironlrovcrtiliji'.  'I'lio 
next  roal  advanco  was  duo  to  Hicliat,  who  rcco^^nizcd  thti  essential  ditterence  hetweeii 
tumors  and  the  parasitic  nature  of  the  eysticereus  and  eehinoeoeeus,  althoujrh  by  his  fol- 
lowers this  parasitic  notion  was  carricMl  out  far  too  fully,  for  they  looked  upon  caneer  as 
the  prixluet  of  a  parasitic  t;;rowlh  ol'  ciitdZMu.  It  was  left,  however,  to  Ijohstein  of  Stras- 
bourg; to  emliody  Hieliats  idea  ami  to  j^ive  it  full  expression,  which  he  «lid  hy  namiii;; 
tho.se  tumors  /iniiiniip/ns/ii-  which  W(>re  similar  in  structure  to  the  natural  eonstitucMits  of 
the  body,  and  tho.so  /ted roj)/iisfic  which  were  composed  id"  products  whi(di  ilifler  frr)m  the 
normal  tissues.  Since  that  time  countless  workers  havt;  becMi  examining  tumors  and 
attem|itinii-  to  classify  them,  one  of  the  most  prominent  bein<^  Lebert,  and  to  him  must 
fairly  l>e  attributetl  the  credit  of  assij;iiin^  specific  elements  to  specific  tumors,  eacdi  tumor 
havinir,  in  his  opinion,  a  definite  structure  ;  cancer  was  to  be  known  by  the  caudate  fusi- 
form cells  that  even  now  are  looked  upon  by  s(uno  as  typical  of  the  di.sease.  This  notion 
of  specific  elements  was  very  feasible.  f(jr  it  simplified  knowled<re  and  induced  men  to 
think  they  had  a  ready  means  of  deciding  upon  the  nature  of  any  new  growth  ;  and  had 
it  not  been  for  \'irchow,  it  is  probable  the  theory  would  have  long  held  its  ground.  In 
this  learned  pathologist,  however,  it  found  an  opjionent  of  consun»mate  power;  and,  as 
his  reasons  for  disl)elioving  it  are  the  groundwork  of  his  great  book  on  (Jillidar  Palholoijij 
and  TiiDiors,  it  is  well  to  have  them  in  his  own  words  : 

"  In  (Jermany  the  doctrine  of  specific  elements  has  from  the  first  made  few  j)roselytes, 
and  now  it  is  entirely  abandoned.  From  the  commencement  of  my  career  I  have  been 
compelled  to  combat  this  error,  ami  I  believe  that  at  the  present  moment  we  are  in  a 
position  to  demonstrate  in  every  direction  that  there  do  not  exist  in  tumors  true  specific 
elements  which  have  no  analogy  with  the  normal  tissues.  It  is  enough  for  that  to 
remember  that  the  tumor,  however  parasitic  it  may  appear  to  be,  is  <i/wa>/s  a  part  of  the 
hod !i  from  idilch  it  spriinj^,  and  that  it  is  not  develoj)ed  in  an  isolated  manner  at  the 
expense  of  some  juice,  at  some  one  place  in  the  body,  by  the  inherent  force  of  this  pro- 
ductive juice.  To  admit  such  a  mode  of  development  dc  voro  was  possible  at  a  time 
when  it  was  also  believed  that  entozoa  were  spontaneously  developed  in  the  body  at  the 
expense  of  a  liquid  or  an  excretion,  by  equivocal  generation,  when  no  idea  had  been  as 
yet  formed  as  to  how  a  cy.sticercus  arrived  in  the  abdomen  and  there  was  able  to  develop 
itself  and  grow.  There  was  no  other  opinion  which  medical  men  could  then  form  save 
that  entozoa  sprung  from  aninuil  substances,  either  from  the  tissues  themselves  or  from 
the  intestinal  mucus  (^mbxrnt).  In  the  present  day,  when  it  is  known  that  entozoa 
always  penetrate  into  the  body  from  without — by  a  way  often,  it  is  true,  extraordinary, 
yet  always  natural — this  analogy  can  no  longer  be  invoked.  This  is  still  more  evident 
since  we  have  come  to  know  that  in  a  free  exudation  there  is  no  new  element  produced 
— that,  furthermore,  the  elements  of  the  body  itself  have  a  legitimate  origin  from  father 
and  mother  (or,  to  speak  more  correctly,  from  father  or  from  n)other,  for  it  is  a  case  of 
parthenogenesis)  ;  so  that  we  must  completely  abandon  the  idea  that  a  tumor  can  develop 
itself  in  the  body  as  an  independent  being.  It  is  a  part  of  the  bodij ;  it  is  not  merely 
contiguous  to  it,  but  proceeds  from  it  and  is  subject  to  its  laws.  The  laws  of  the  body 
govern  also  the  tumor.  This  is  the  reason  why  it  is  not  an  object  of  natural  history  that 
one  can  regard  as  foreign  from  the  elements  of  the  body  ;  it  is,  on  the  contrary,  to  be 

looked  upon  as  embraced  within  its  limits Hair  may  make  its  appearance  and 

grow  at  a  place  where  we  do  not  expect  to  meet  with  hair,  but  no  one  will  fancy  or 
believe  that  feathers  will  grow  in  the  human  body.  As  a  matter  of  fact,  there  are 
tumors  in  man  which  contain  hair,  and  in  cutting  up  geese  tumors  are  sometimes  found 
containing  feathers  ;  but  if  ever  a  man  engendered  a  tumor  with  feathers  or  a  g(jose  one 
with  hair,  this  would  be  a  production  sui.  generis^  because  the  thing  produced  would  devi- 
ate from  the  type  inherent  to  the  individual. 

"  The  type  which  in  (je)iir(d  i/overns  the  devlopnirnt  and  formation  of  the  organism  gov- 
erns equally  the  development  and  formation  of  its  tumors. 

"  There  does  not  exist  a  new,  different,  independent  type. 

"  What  is  established  by  logic  in  this  matter  results  also  from  the  direct  observations 
of  tumors  themselves.  This  is  why  I  deny  that  there  is  any  heterology  in  the  sen.se  in 
which  it  has  been  maintained  since  Bichat's  time,  or  such  as  was  suppo.sed  even  before 
then — that  is  to  say,  that  a  tumor  could  develop  it.self  and  exist  in  the  body  in  accord- 
ance with  some  quite  new  plan,  some  new  law.  I  go  farther:  each  .species  of  tumor, 
whatever  it  may  be,  answers  in  its  important  parts  to  the  elements  of  the  body  the  type 
of  which  is  known,  and  the  capital  difference  amongst  divers  tumors  resides  in  this — that 
tissues  normal  in  themselves  appear  under  tlie  form  of  a  tumor,  sometimes  in   regions 


122  TUMORS. 

where  this  tissue  normally  exists,  sometimes  in  places  where  it  does  not  exist  in  the 
normal  state  of  things.  In  the  first  case  I  speak  of  it  as  homology ;  in  the  second, 
as  hetfroloiiij. 

''  Wherever  a  normal  tissue  appears  at  a  point  which  already  contains  some  similar 
tissue,  then  as  a  consecfuence  the  new  tissue  is  identical  with  the  old.  so  that  the  type  of 
the  new  production  answers  to  the  type  of  the  pre-existing  tissue ;  in  this  case  the  new 
tissue,  the  tumor,  is  homologous.  When,  on  the  contrary,  the  new  type  does  not  corre- 
spond with  the  old  one,  when  it  deviates  from  the  pre-existing  type  or  that  which  is  the 
original  and  normal  one  of  the  region,  then  there  is  heterology.  But  this  latter  has  like- 
wise its  analogue  in  the  body,  only  in  another  part  of  the  body  from  that  in  which  the 
tumor  is  situated. 

"We  cannot,  in  my  opinion,  distinguish  tumors  according  to  the  tissues  in  such  a 
fashion  that  tumors  containing  certain  tissues  are  to  be  regarded  as  homoeoplastic,  whilst 
those  containing  certain  others  are  to  be  set  down  as  heteroplastic  ;  cjuite  the  contrary, 
the  same  kuid  of  tumor  may  he,  under  certain  circumstances,  Jiomologons,  and  under  other 
circumstances  heterohgous^.  The  same  sort  of  tumor  may  at  one  time  appear  at  a  point 
where  it  is  merely  the  expression  of  an  excessive  development  of  the  tissue  normally 
exi.sting  at  this  point,  at  another  time  at  a  place  where  this  tissue  is  not  in  existence  and 
where  its  development  is  abnormal  and  strictly  pathological  Let  us  take  an  example. 
A  tumor  may  be  formed  of  cartilage.  The  cartilaginous  tumor  is  homologous,  not 
because  it  is  formed  of  cartilage,  but  only  if  it  springs  from  cartilage,  if  in  this  place 
there  is  cartilage  already.  Thus,  a  costal  cartilage  may  be  the  point  of  origin  of  an 
enormous  cartilaginous  tumor ;  this  is  homology.  But  it  is  also  possible  for  a  cartilagi- 
nous tumor  to  be  developed  in  the  testis,  which  contains  no  cartilage,  where  this  tissue 
should  not  be  met  with :  here  the  same  product  constitutes  an  heterology." 

"  Homology  "  and  "  heterology  "  have,  therefore,  very  different  meanings  as  used  by 
Yirchow  and  other  writers.  In  Virchow's  language  a  tumor  is  hornologous  when  it  cor- 
responds in  structure  with  the  tissue  in  v:hich  it  grows,  and  heterologous  when  it  deviates 
from  that  structure.  A  tumor  that  is  homologous  in  one  position  may  be  heterologous 
in  another.  On  the  other  hand,  in  the  French  and  other  schools  a  tumor  is  homeAogous 
when  built  up  of  elements  naturally  existing  in  some  tissue  of  the  body,  heterrjlogous 
when  composed  of  elements  that  deviate  from  the  natural  structures,  these  definitions 
having  nothing  whatever  to  do  with  the  position  of  the  tumor.  In  Virchow's  language 
the  terms  are  relative  ;  in  that  of  other  pathologists  they  have  a  definite  clinical  meaning 
of  no  slight  importance,  for  homology  means  innocence  and  heterology  malignancy  in  a 
tumor.  Yirchow,  however,  admits  that  his  heterologous  tumors  are  suspicious,  although 
every  heterologous  tumor  is  not  of  a  malignant  nature.  "  There  are  a  great  many  such 
tumors  borne  without  any  ill  consecjuences,  and  whose  properties  are  quite  similar  to 
those  of  which  the  nature  is  benign.  Malignancy  follows  a  certain  scale  among  heterol- 
ogous tumors,  from  species  to  species ;  and  we  are  able  to  show  how  it  is  manifested 
more  and  more  strongly,  for  the  most  part  following  two  directions.  In  the  first  place, 
heterology  is  distinguished  according  to  the  degree  which  it  attains.  The  tissues  of  con- 
nective substance  have  a  much  nearer  relationship  existing  among  themselves  than  they 
have  with  epithelial  tissues  or  with  the  specific  animal  tis.sues.  When,  therefore,  a  car- 
tilaginous or  bony  tumor  is  developed  in  connective  tissue,  or  even  a  mucous  tumor  in 
adipose  tissue,  that  is  not  nearly  so  heterologous  as  when  an  epidermoid  tumor  is  formed 
in  connective  tissue  or  a  tumor  of  cylindrical  epithelium  in  a  lymphatic  gland.  A  carti- 
laginous tumor  which  is  developed  in  connective  tissue  or  in  the  tissue  of  bone  is  indeed 
heterologous,  but  it  is  not  so  to  the  same  degree  as  an  epithelial  tumor  or  a  muscular 
tumor  would  be  in  the  same  place.  But  a  still  more  important  circumstance  is  this — 
that  tumors  engender  certain  liquid  substances  which  we  speak  of  under  the  name  of 
'juice.'     This  is  the  humor  or  juice  of  the  tumor,  of  which  much  has  been  said." 

'•  This  parenchymatous  juice  is  sometimes  related  to  the  cells,  sometimes  to  the  inter- 
cellular substance  ;  and,  accordingly,  it  appears  under  the  form  of  fluid,  either  intracellu- 
lar or  intercellular,  contained  in  the  cells  or  interposed  among  them  in  a  liquid  state  like 
serosity.  Whenever  a  tumor  contains  much  juice,  it  gives  evidence  of  more  troublesome 
qualities  and  it  possesses  to  a  high  degree  the  property  of  infection.  A  dry  tumor  of 
the  epidermoid  kind  is  by  far  less  dangerous  than  a  moist  one ;  a  soft  cancer  is  much 
more  to  be  dreaded  than  a  hard  one. 

"  The  more  a  tumor  is  poor  in  vessels,  the  less  it  will  extend  its  infecting  action 
beyond  the  neighboring  parts  ;  but  the  more  it  is  rich  in  blood  vessels  and  lymphatics, 
the  more  it  is  traversed  by  the  blood  and  lymph,  the  more  the  parenchymatous  juices 


rcMons.  J  23 

arc  in  t'diitact  witli  tln'  lilinnl.  sd  iinidi  the  iiiun,'  is  the  iiifcctinii  likely  t<i  liccoinc 
gciiorai. 

"I  give  llins  an  iiilcr|ir('taliiiii  nf  Tacts,  Imt  it  is  in  accnrd  with  (iliscrvatinn.  'I'lie 
dciireo  of  cnutaLiiousnfss  nf  timiurs  increases  in  |)r(i|nirti(in  as  tliey  hecnine  more  rich  in 
vessels,  and  that  ahtngsich^  the  vessels  tiiey  contain  an  alMindance  of  li(|i)id  materials. 
Every  soft  succulent  tumor  is  sus|)icious,  and  that  just  in  |iro|)ortion  as  it  contains  many 
vessels  and  eidis.  The  more  the  juice  is  intercellular  and  in  contact  with  the  vascular 
stronni  td'  connective  tissue,  the  nnuv  the  mali;_'nant  properties  which  are  manifested  l»y 
an  ever-new  t'xcitation  t(t  the  progressive  jyroduelion  oi'  the  tumor. 

"  I  ought,  iiuleed,  to  speak  more  at  length  as  to  the  nature  of  these  juices,  hut,  in 
trutli.  I  do  not  know  wliat  to  say  upon  the  subject.  The  results  which  chemists  have 
arrived  at  on  this  suliject  have  no  kind  of  value.  Here  the  field  is  o|)en  to  in(|uirir)g  and 
progressive  sjiirits,  and  I  hope  that  hereafter  researches  will  he  undertaken  in  this  direc- 
t'utu,  and  that  they  may  be  crowned  with  success." 

But,  as  this  is  not  a  work  on  pathology,  I  cannot  allow  myself  to  enter  further  into 
tliese  speculations,  and  must  refer  the  reader  to  Virchow's  masterly  work  on  Celfuldr 
P(if/i(tfof/i/  (iiid  fill  Tumors  for  a  fuller  elucidation  of  the  .subject. 

In  the  .se(|uel  I  shall  regard  tumors  in  their  clinical  aspect  alone,  giving  their  anatomi- 
cal characters  only  so  far  as  they  illustrate  the  practical  aspects  of  the  subject.  All 
speculative  ])athologieal  doctrines  will  be  set  aside  as  tending  to  confuse  rather  than  to 
elucidate  clinical  phenomena  until  the  day  wlieii  pathological  science  shall  have  so  far 
advanced  as  to  allow  of  an  anatomical  classification  of  tumors  being  made  that  will  fully 
dovetail  in  with  that  founded  on  clinical  observation.  The  microscopical  anatomv  of 
tumiu's  has  been  furnished  by  the  pen  of  my  friend  and  colleague  Dr.  Mo.xon. 

I  ]iropose  to  lay  down  here  some  few  pathological  points  which  have  an  important 
clinical  bearing,  and  which  tend  to  illustrate  the  subject  of  the  diagnosis  of  tumors. 

A  tumor  mai/  be  defined  to  he  a  nciv  growth,  eijstic  or  solid,  uiJUtrntliicf.  separate  from 
or  coiduiuonx  with  normal  tisKites.  It  is  an  addition  to  natnral  jtarfs,  and  it  manifests  its 
independent  existence  hy  its  disposition  to  grow  irrespective  of  the  part  in  ichich  it  is  j^laced. 

All  tumors,  with  the  exception  of  the  hj/datid,  are  vinde  up  of  one  or  viore  of  the  natural 
elementary  tissues  (f  the  body  in  a  rudimental  or  inorhid  state,  and  in  no  single  example  has 
any  extraneous  or  neio  element  ever  been  detected. 

A  mere  increase  or  overgrowth  of  natural  parts  is  a  hypertrophy.  Just  as  the  natu- 
ral body  is  built  up  of  cells  and  fibres  in  one  or  other  of  their  different  forms,  so  tumors 
are  made  up  of  like  elements,  although,  it  may  be,  of  unecjual  proportions.  Tumors, 
like  the  natural  tissues,  differ,  therefore,  anatomically  according  to  the  nature  of  the  ele- 
mentary structure  of  which  they  are  composed  ;  and  this  again  appears  to  be  materially 
determined  by  the  part  of  the  body  in  which  they  are  developed. 

From  this,  therefore,  a  second  leading  principle  may  be  fairly  deduced — viz.,  tliat  all 
tumors  partake  of  the  nature  of  the  part  in  ivhich  they  are  developed  <uid  are  more  or  less 
made  up  of  the  elements  which  natur(tlly  enter  info  its  formation. 

Hence  a  tumor  developed  in  the  stroma  of  a  fibrous  structure  will  probably  be  fibrous; 
if  connected  with  bone,  more  or  less  osseous ;  and  if  situated  in  a  gland,  it  will  in  all 
probability  partake  of  the  gland  structure.  But  new  growths  never  assume  the  compli- 
cated structure  of  a  fully-developed  gland:  they  only  in  a  degree  simulate  it.  Wilks  well 
expresses  it  when  he  says  that  "  the  great  difference  between  physiological  and  pathologi- 
cal formations  appears  to  be  that  nearly  all  new  growths  are  of  the  simplest  composition, 
not  putting  on  the  form  of  the  complex  organs  near  which  they  may  be  placed,  but  con- 
sisting principally  of  cells  and  fibres."  The  cells  and  nuclei  of  a  part,  instead  of  develop- 
ing into  normal  tissues,  err  in  their  course,  multiplying  and  possibly  growing,  and, 
'•  whilst  conforming  generally  with  the  part  in  which  they  are  placed  in  minute  structure 
and  composition,  yet  they  more  and  more  widely  deviate  I'rom  it  in  shape  and  size  "  (Paget). 

The  practical  bearing  of  these  pathological  principles  is  by  no  means  unimportant, 
because  to  the  surgeon  who  has  once  recognized  the  true  position  of  a  tumor  there  is  a 
certain  amount  of  probability  as  to  its  nature  which  will  at  once  suggest  itself  to  his 
mind.  If  the  tumor  is  situated  in  the  skin  or  subcutaneous  tissue,  a  strong  probability 
exists  that  it  will  be  composed  of  some  one  or  other  of  the  structures  of  the  tissue  ;  thus 
it  may  be  the  sebaceous  tumor,  which  is  rarely  found  in  any  other  position,  or  the  fatty, 
for  these  two  materials  enter  largely  into  cutaneous  structures:  or  it  may  be  one  of  the 
fibrous  or  fibro-cellular  nature,  fibre-tissue  existing  abundantly  also  in  these  parts.  Should 
the  tumor  be  located  between  the  muscles  of  a  part,  the  tumor  will  proV»ably  be  composed 
of  connective-tissue  elements  in  the  form  of  a  sarcoma  or  myxoma.      Should  bone,  again, 


124  TUMORS. 

be  the  seat  of  the  disease,  some  one  of  the  elements  of  bone  will  to  a  certainty  enter 
into  its  formation,  the  probability  of  its  being  an  enchondroma,  an  osseous,  or  a  myeloid 
tumor  naturally  presenting  itself  to  the  mind.  And,  lastly,  should  a  tumor  be  present  in 
a  gland,  such  as  the  breast  or  prostate,  the  probability  of  its  being  an  adenoid  or  glandu- 
lar tumor  cannot  be  overlooked  ;  for  pathologi.sts  now  all  recognize  the  fact  of  the  close 
resemblance  of  tumors  so  situated  to  the  natural  gland  structure.  Even  in  malignant 
tumors,  if  modern  recorders  are  to  be  relied  upon,  the  same  principle  holds  good;  for  car- 
cinoma is  now  generally  recognized  to  be  an  epithelial  growth,  and  only  occurs  primarily 
where  true  epithelium  already  exists.  Secondary  growths  can  only  be  produced  by  the 
direct  propagation  of  the  epithelial  cells,  which  may  be  transported  from  their  primary 
seat  either  through  the  lymph  vessels  or  as  embola  are  carried  through  the  blood  ves.sels 
to  a  suitable  place,  where  they  develop  like  the  germs  of  entozoa. 

Tumors  are  eiflLcr  simple  or  cancerous,  innoceut  or  mjjtigniint.  the  simple  or  innocent 
approaching  in  their  nature  to  the  more  completehj  devehiped  natural  structures  of  the  hoily, 
even  to  the  perfect  gland  alar,  and  the  malignant  or  cancerous  simulating  the  more  elementary 
or  embryonic.  As  the  normal  tissues  were  formed  from,  a  simple  cell,  and  in  tJteir  higher 
grades  are  but  a  development  of  that  cell  or  those  cells,  so  the  sarcomatous  and  cancerous  ele- 
ment c(msists  in  a  persistence  of  the  simple  cell  type  or  that  of  the  undeveloped  embryonic 
nucleus.  The  group  of  cases  called  "  7'ecurreut"  must  be  placed  in  an  intei-med iate  jiosition  ; 
for,  while  in  their  earlier  stages  they  tend  to  build  up  embryonic  tissue,  this  subsequently 
becomes  lost  in  cell  proliferation. 

In  proportion,  therefore,  to  the  amount  of  the  embryonic  cell  element  in  a  tumor  its 
cancerous  tendency  may  be  determined ;  and  the  greater  the  proportion  of  the  fibrous  or 
well-developed  structure,  the  greater  the  probability  of  its  nature  being  innocent  or 
simple.  The  more  a  tumor  simulates  the  natural  structure  of  a  tissue  or  gland,  the 
greater  the  probability  of  its  being  innocent ;  the  more  a  tumor  simulates  the  undevel- 
oped cell  structure,  the  greater  the  certainty  of  its  being  cancerous ;  malignancy  appear- 
ing to  diminish  in  proportion  as  the  cells  become  more  fully  developed.  As.  moreover, 
it  is  in  the  nucleus  of  a  cell  that  the  active  principle  of  its  growth  is  to  be  sought,  so  it 
is  clear  that  the  more  the  tumor  is  composed  of  nuclei,  the  more  malignant  is  its  nature ; 
and  the  better  the  formation  of  the  cell  wall,  the  less  malignant  is  the  growth. 

The  nearer  a  new  growth  approaches,  both  in  its  elements  and  in  the  ai'rangements 
of  its  elements  or  structure,  to  the  complex  organs  of  the  body,  the  greater  are  the  prob- 
abilities of  its  being  innocent,  new  growths  under  no  circumstances  erjualling  the  perfec- 
tion of  a  true  gland  tissue. 

Simple  tumors  separate  tissues  in  their  groicth,  but  never  infiltrate  ;  cancerous,  as  a  rule, 
infiltrate  and  rarely  separate.  No  more  important  practical  point  than  the  above  can  be 
adduced  to  aid  the  surgeon  in  his  diagnosis  of  a  tumor.  A  simple  or  innocent  tumor, 
however  long  it  may  be  in  growing  or  large  a  size  it  may  attain,  will  never  do  more  than 
separate  the  parts  between  and  beneath  which  it  may  be  developed.  The  bones  may  be 
absorbed  by  its  pressure,  but  they  will  never  be  infiltrated,  and  the  skin  may  be  so 
stretched  and  attenuated  by  its  distension  as  to  ulcerate  or  burst,  but  it  can  never  be 
infiltrated  with  the  elements  of  the  tumor.  This  fact  is  well  exemplified  by  a  close 
examination  of  the  margin  of  a  cutaneous  opening  the  result  of  overdistension,  for  it 
will  appear  as  if  cleanly  cut,  or  rather  punched,  at  its  edges,  and  never  thickened  or  dis- 
eased. An  intra-cystic  growth  may  project  from  it  as  a  fungus  and  put  on  many  of 
the  appearances  of  a  cancerous  tumor,  yet  the  margin  of  the  opening  will  be  free,  and 
not  infiltrated.  In  the  cystic  tumors  of  the  breast  this  clinical  fact  is  easily  perceiv- 
able. 

Simple  tumors,  by  expanding  parts,  cause  the  cellular  tissue  around  to  become  con- 
densed and  to  form  a  capsule';  consequently,  most  of  the  innocent  tumors  are  encap.suled 
more  or  less  completely.  With  the  majority  of  cancerous  tumors,  however,  a  very  differ- 
ent condition  has  to  be  described ;  for  a  cancer  has  the  peculiar  property  of  freely  infil- 
trating all  the  tissues  upon  which  it  presses,  at  its  base,  round  its  borders,  and  upon  its 
cutaneous  aspect.  As  the  tumor  approaches  the  surface  the  integument  first  appears  to 
be  drawn  down  to  it,  and  afterward  seems  as  though  glued  to  its  surface.  At  a  later 
stage  the  skin  becomes  infiltrated  with  cancerous  elements,  feeling  to  the  finger  firm, 
fibrous,  or  tuberculated  ;  and  when  ulceration  has  commenced,  the  edges  of  the  .skin 
are  palpably  indurated,  thickened,  and  infiltrated  with  cancerous  products.  The  con- 
trast between  the.se  different  conditions  of  integument  in  the  two  classes  of  tumors  is 
most  marked  and  very  important,  forming  a  very  valuable  means  of  diagnosis  in  the 
extreme  stage  of  simple  or  malignant  tumors. 


TUMORS.  llio 

Diagnosis  of  Simple  and  Cancerous  Tumors.— Simpfr  <>,■  !,n,ur,„t  hinnns 

affovl  lln  jxilitnt  sol'li/  //iminj/i  tin  ir  load  iiijlin mi .  Tlni^  i/k/io  hi/  lh<  ir  oicii  iiihcn  nt  jn'Of'- 
trtiis,  imsjircfire  i>f  lliv  (jnnvlh  of  l}ie  parts  in  which  tht//  art-  jtlitcctl,  h<ive  little  (lispositiuit 
tn  sft/t'ii  <lfiuii  nr  iilct r<it<\,  mid  no  teiiilcnri/  tu  iiiidtijtliiiitiini  in  ot/ur  tissnis  or  to  iiivolv  tin; 
(disorhcnts  with  irhirh  thri/  iirr  coiuiictnl.  Molii/nuiit  tumors  not  oiili/  offcct  tin-  jxtticnt 
throiit/h  thfir  lonil  tiijlnnnr^  hut  hiirc  a  initrvclloiis  trndiiiri/  to  innltijiliiittion  in  nni/  port  of 
tht  hod  I/.  Tliroiiijli  thi  li/infdi<itir  si/stcin  thiy  involve  tlir  f/ltinds  of  tin:  port  itith  vhich  tlnif 
are  coiincctrd^  irhilc  throinjh  the  vasnilur  si/stt m  tiny  sprrnd  to  otlur  jnirtx.  Tin  ly  an  prone, 
alxo,  to  dei/ein  rate  and  iilerrate. 

Wlifii  simple  tuinors  ari'  iimltiiilc.  they  invariably  arc  found  in  the  sanio  tissue  ;  when 
maliuiiaiit  tumors  arc  multipK',  they  are  mostly  found  in  different  tissues.  'J'lius, 
amonjist  the  innoeent  i^rowths  multiple  fatty  tumors  of  tin;  skin  are  not  uncommon  ;  mul- 
tiple fibromata  of  the  uterus  are  often  seen  ;  multiple  glandular  tumors  of  the  breast  are 
met  with,  inv(dving  one  or  both  organs;  and  there  are  records  of  multiple  fibroplastic  or 
myxomatous  tumors.  It  is  not  seldom  that  multiple  enchondromatous  tumors  and  exos- 
toses are  seen,  but  in  all  these  instances  the  tumors  occupy  one  tissue. 

In  the  malignant  and  cancerous  multiple  tumors  no  such  description  can  be  given, 
for  they  spread  in  ever-widening  circles  from  the  parent  tumor,  the  cell  elements  spread- 
ing locally  in  connective  tissue  as  freely  as  the  floating  blood  cells  move  through  the 
walls  of  the  blood  passages,  as  a  colloid  is  penetrated  by  a  crystalloid,  wandering  about 
in  what  are  called  solid  tissues.  They  follow  the  course  of  the  lymphatics  and  affect  the 
glands,  and  at  times  seem  to  follow  the  course  of  the  venous  circulation.  Tliey  recur  by 
continuity  of  tissue  as  from  constitutional  reproduction,  and  Mr.  Moore,  in  his  work  on 
Rodent  Cancer,  has  referred  to  a  case  of  Mr.  de  Morgan's  in  which  from  a  cancerous 
tumor  within  the  skull  some  detached  fragments  which  had  sunk  in  the  fluid  of  the 
arachnoid  adhered  to  the  spinal  cord  and  grew.  They  spare  no  ti.ssue  or  organ,  but 
invade  one  and  all,  without  order  or  law,  in  their  destructive  objectless  growth. 

Recurrent  or  Intermediate   Tumors. — All    tumors   cannot,  however,  be 

divided  into  the  innocent  and  the  nudignant,  for  there  are  some  of  an  intermediate  kind 
which  in  structure  approach  the  innocent,  but  in  habit  the  cancerous,  as  they  recur  after 
removal.  They  have  consequently  been  called  recurrent  tumors;  but,  as  the  habit  of 
recurrence  is  not  the  only  point  in  which  they  approach  the  cancerous  tumors,  it  is  bet- 
ter, perhaps,  to  term  them  xenii-malir/nduf. 

I  proposi'.  tlicrefon'.  to  describe  tumors  under  the  following  headings: 

A.  Innocent  Tumors,  or  those  composed  of  the  normal  adult  tissues.  This  .sec- 
tion includes  Lipoma,  Fibroma,  Chondroma,  Osteoma,  Adenoma,  Papilloma,  Neuroma, 
Angioma,  and  Lymphoma. 

B.  Semi-Malignant,  or  those  composed  of  embryonic  connective  tissues,  includ- 
ing the  Sarcoma  and  Myxoma.  They  form  a  class  of  tumors  which  in  a  measure  belong 
to  the  one  that  precedes  it  as  well  as  to  the  one  that  follows  it,  since  it  includes  cases, 
such  as  some  of  the  myxoniata  and  sarcomata,  that  are  very  little  malignant,  and  like- 
wise some  sarcomata  that  are  very  much  so.  Nor  is  that  all,  for  it  occasionally  happens 
that  some  innoeent  tumors  become  malignant,  and  lymphomas  which  are  classed  as  inno- 
cent are  sometimes  quite  the  reverse. 

C.  Malignant,  or  those  compo.sed  for  the  most  part  of  epithelial  structures,  includ- 
ing Epitlielial  and  Hard  and  Soft  Colloid  Cancers  and  Rodent  Ulcers. 

I>-  Granulation  Tumors,  or  those  composed  of  granulation  tissue,  including 
Follicular.  Keloid,  (.iuuiuiala,  etc. 

E.  Cysts. 

A.  Innocent  Tumors, 

Or  those  compo.sed  of  the  normal  adult  tissue,  vary  with  the  tissues.  They  are  innocent 
or  benignant  in  that  they  do  not,  like  cancers,  infiltrate  the  parts  in  which  they  grow,  but 
rather  separate  them,  and  are  a  source  of  trouble  more  from  mechanical  than  other 
causes.  When  they  interfere  with  life,  they  do  so  generally  from  pressure  on  important 
parts.  They  may  stretch  skin  even  to  its  rupture,  but  the  margin  of  the  skin-opening 
will  be  uninvolved  in  disease.     In  cystic  breast  tumors  this  is  well  seen. 

1.  Lipomata,  Fatty  Tumors,  otherwise  called  "  steatomata,"  are  very  common. 
They  are  fmiiiil  wherever  fat  exists  naturally  in  the  body;  and  as  this  nuiterial  is  more 
especially  deposited  in  the  integument,  it  is  in  and  beneath  this  that  fatty  tumors  are 
most  frequently  met  with.  They  occur  at  all  periods  of  life  from  infancy  to  old  age.  and 
are  even  eontrenital.      Thev  attack  the  male  .sex  as  well  as  the  female,  but  tliev  are  three 


J  26 


TUMORS. 


Fattv  Tumor  of  Thiriy-Seven  Years'  Growth  on  Arm  of  AVoman 
set.  C9. 


times  as  common  in  the  latter.  They  are  generally  .single,  but  occasionally  multiple. 
I  have  seen  a  ca.se  in  which  the  whole  integument  was  studded  with  them,  and  under 
these  circumstances  they  are  usually  small.  It  is  impossible  to  a.ssign  any  valid  cause 
for  their  development,  hereditary  and  accidental  influences  having  doubtful  effects. 
They  are  troublesome  only  from  their  position  and  the  deformity  they  occasion  (Fig.  26), 

and   are   at   times   the   seat   of    pain, 
Fig.  26.  though    such    a    .symptom    must    be 

looked  upon   as    an   accident    due    to 
their  position. 

The.se  tumors  are.  as  a  rule.  "  en- 
capsuled."  although  in  rare  cases 
they  ai'e  "  continuous  "  or  "  diffused." 
This  latter  variety  differs  only  from 
the  former  in  that  they  are  made  up 
of  smaller  globules  of  fat  and  are 
more  dense,  while  they  are  more  com- 
mon about  the  nape  of  the  neck  and 
face  than  the  encapsuled  variety 
(Fig.  27) ;  the  large  double  chin  is  an 
example  of  the  continuous  lipoma, 
and  congenital  lipomata  are  generally 
of  this  nature.  The  encysted  lipo- 
mata are  most  common  on  the 
.shoulder,  thigh,  and  trunk  ;  some  are 
deep-seated,  as  between  the  muscles 
of  the  limbs  or  within  the  abdomen  or  scrotum.  Fatty  tuniors  at  times  shift  their  posi- 
tion— that  is.  they  drop  downward  ;  .'^everal  such  ca.ses  have  passed  under  my  notice  in 
which  the  tumor  has  travelled  some  distance.  Such  an  occurrence  is  peculiar  to  this 
form  of  tumor  and  suffices  to  fix  its  nature. 

The  DiAGNO.sis  is  not  usually  difficult.  If  subcutaneous,  these  tumors  are  '' lobu- 
that  is.  are  defined  by  a  distinct  boundary,  their  cy.st-wall  being 
formed  by  the  condensed  fibro-cellular  tissue  in  which  they 
are  developed.  To  the  hand  of  the  examiner  the  tumor  will 
feel  more  or  le.ss  firm  and  made  up  of  lobes ;  when  frozen  by 
the  application  of  ice,  it  becomes  harder.  To  the  eye  the 
tumor  will,  on  raising  it  from  its  ba.se  and  distending  the 
skin,  appear  dimpled,  and  in  parts  the  skin  will  be  quite 
drawn  inward  toward  the  new  growth.  If  the  tumor  be 
deep,  a  doubt  may  be  felt ;  but  practically  the  question  is 
not  of  great  moment,  for  it  only  refers  to  the  nature  of  a 
.simple  growth,  and  not  to  its  treatment. 

Treat.ment. — When  no  neces.sity  exists  for  their 
removal,  tumors  .should  be  left  alone.  When  large  and 
unsightly,  cumbersome  or  growing,  they  should  be  removed 
by  excision  or  enucleation.  A  single  incision  through  the 
centre  of  the  growth  is  the  Vjcst  and  most  expeditious 
method  for  turning  the  cyst  out  of  its  bed,  which  can  be  done  readily  by  the  finger. 
Where  the  growth  is  pendulous  the  whole  .should  be  cut  off.  leaving  enough  skin  to  cover 
the  wound.  After  the  operation  the  edges  of  the  wound  .should  be  brought  together  by* 
sutures  and  strapping  and  supported  by  steady  pressure :  rapid  union  usualh-  follows. 
Fatty  tumors,  when  removed,  very  rarely  return.  Curling  has  recorded  a  ca-^e,  how- 
ever, in  which  a  recurrence. took  place,  but  .so  much  connective  tissue  was  present  in 
that  example  as  almost  to  remove  it  from  the  class  of  lipoma  (Path.  Tram.,  vol.  xviii., 
1867).  I  have  also  removed  from  the  buttock  of  a  lady  a  lipoma  of  two  years'  growth 
the  size  of  a  fist,  having  removed  from  the  same  part  a  like  tumor  twelve  years  previ- 
ously. 

The  "  continuous  "  fatty  tumor  should  never  be  removed  unless  under  very  urgent 
circumstances.  The  operation  is  comparativelv  formidable,  so  much  dissection  being 
required.      In  oliiMren.  however,  the.se  tumors  mav  be  dealt  with. 

2.  Fibromata  are  tumors  composed  of  "  hard  "  or  ••  soft  "  fibrous  tissue,  the  .soft 
being  composed  of  masses  of  "  connective  "  and  the  hard  of  "  fiVjrous  "  or  closely-packed 
connective-tissue  elements.     The  "  soft "'  kind  are  found  as  outirrowths  from  the  subcu- 


lated  "  and  '■  encvsted 


Fig. 


Ditfused  Lipoma  of  Neck. 


taneous  tissuo,  ami  frer|uently  in  tl»c  f'fiiialc  external  f^iMiihil  orfjans ;  they  are  known  as 
"  fibro-celliilar  <;rn\vths."  Tliey  are  nu-t  witli  also  in  tin-  lower  extremities  under  tlie 
form  ot"  "  molusciim  tihrosum  "  (rn/e  Kij;.  liS). 

Some  eontain  much  fat,  and  thus  a|)|)roa('h   tlie   li|Miniata.      These  tumors  are  mostly 
outgrowths,  and  appear    as    the  softer  polypi  and    eulaneous    pendulous    tumors.     The 
polypi  of  the  nose  are  the  hest   specimens  of  the   looser   kind  of 
irrowths,  as  in  eonsisteiiee  they  vary  from   a  watery  pellnci<l   pen-  ^■'"-  -'^• 

dulous  out<rrowth  to  a  firm,  more  compact,  and  fihrous  tissue. 
They  are,  however,  always  ectvered  with  mucous  mem))rane  with 
its  ciliated  epithelium.  Tin;  softer  tumors  ol"  the  antrum  are  also 
of  the  saint'  nature,  as  are  the  mucous  polypi  of  the  uterus,  blad- 
der, and  ri'ctum.  in  the  rectum  the  tumor  is  intimately  mixed 
with  the  irlandular  elements  (jf  the  pail.  .Vmonj^st  the  outtrrowths 
of  the  intcL^ument  those  of  the  mah'  and  female  tjenital  orpins  are 
the  commonest.  The  tropical  elephantiasis  scroti  is  ol'this  elass. 
The  pedunculated  outgrowths  of  the  skin  are  also  of  the  sam<' 
kind. 

Deep-seated  tumors  of  this  nature  are  very  rare.  They  do 
oceur,  however,  in  the  connective  tissue  of  the  body,  the  inter- 
mu.seular  spaces  of  the  thiuh  and  arm  being  the  commonest  .seat. 
They  nri'  (t/irai/s  surroiaideil  by  a  atpsidr^  and  when  not  confined 
by  unyielding  parts  are  more  or  less  ovoid  ;  at  times  they  are 
lobed.     They  possess  a  smooth  outline  as  well  as  an  elastic  feel  ;  <'»\«,  of  Moluscum  Fibrosum. 

f.  ,,     *    '  f..         ,  .     1  1       1       •         .,        •  ,  1'  a    ■  1        rpu  '-^''■-  I>avies-Colley's  ease.) 

some  ot  the  softer  kinds,  mdeetl,  give  tlie  idea  of   tfiud.      Ihcy 

are  tumors  of  adult  life,  being  rarely  met  with  in  children.  They  increase  in  size  with 
variable  rapidity,  the  amount  of  fluid  they  contain  materially  affecting  this  feature.  The 
pendulous  outgrowths,  mucous  or  cutaneous,  at  times  swell  out  and  at  others  contract, 
while  those  of  the  skin  appear  shrivelled  and  loosely  encapsuled.  Those  of  the  genital 
organs  may  attain  a  very  large  size,  some  which  are  on  record  having  weighed  as  much 
as  forty  pounds.  At  times  these  tumors  inflame,  slough,  or  ulcerate  in  an  indolent,  but 
in  no  way  a  typical,  manner. 

The  "firmer"  kind  are  met  with  in  many  shapes.  They  are  always  solid,  and  mostly 
encapsuled.  When,  as  in  the  uterus,  mixed  with  the  non-striped  mu.scular  fibre,  the 
growth  is  known  as  ^-  frbro-mnsrultir"  or  as  a  ^'■myomtt'"  (Virchow's  term).  When  as.so- 
ciated  with  cysts,  it  is  called  ^' Jibro-cijatic-/'  and  when  with  calcareous  matter,  '•  Jibro- 
cnlcanousy  These  varieties  are  found  chiefly  in  the  uterus.  Fibrous  outgrowths,  or 
pnb/pi  are  commonly  met  with  in  the  uterus,  nose,  pharynx,  and  rectum.  They  have 
been  found  in  the  intestine  and  other  parts.  Fibrous  tumors  are  found  likewise  in  the 
uterus  and  prostate,  and  oramonnlhj  in  connection  with  the  bones  and  periosteum,  in  the 
latter  as  an  epulis.  In  tho.se  about  the  bones  the  elements  of  bone  or  cartilage  are  usu- 
ally found. 

The  fibrous  outgrowths  have  no  capsule,  but  are  continuous  with  the 

tissue  from  which  they  spring,  and  are  made  up  of  fibre  tissue  more  or  less  closely  packed 
and  arranged  in  bundles  or  in  concentric  circles ;  they  are  but  feebly  va.scular.  Those 
of  the  uterus  are  the  most  typical  (Fig.  20). 

Fibrous  tumors  are  always  encapsuled  and  have  a  tendency  to  assume 
an  ovoid  or  globular  form  when  not  confined  ;  but  when  eompres.sed  or  bound  down  by 
surrounding  ]»arts,  they  take  an  irregular  lobular  .shape.  In  structure  they  are  very  simi- 
'lar  to  the  outgrowths. 

Fibrous  tumors  are  firm,  and  occasionally  most  unyielding.  They  are  slow  in  their 
increase  and  give  pain  only  from  their  po.sition.  When  bound  down  by  a  dense  fa.scia  or 
situated  near  a  nerve,  they  cau.se  much  distress.  They  only  interfere  w-ith  life  or  comfort 
mechanically.  They  are  usually  single,  except  in  the  uterus  and  when  in  connection 
with  the  nerves.  As  they  come  under  the  notice  of  the  surgeon,  those  connected  with 
the  periosteum  or  bones,  called  jvrlostcal  sorconui.  are  the  most  common,  and  of  all  the 
bones  the  jaws  are  the  most  frequently  affected  by  them.  They  are  chiefly  periosteal 
and  appear  as  outgrowths  {vuk  chapter  on  '•  Tumors  of  Bone  ").  They  are  found  in  the 
pharynx,  on  the  lobule  of  the  ear.  and  on  the  nerves  as  "  neuromata." 

The  subcutaneous  fibrous  tumor  is  a  hard  movable  tumor  beneath  the  skin. 
It  is  usually  small  ;  but  when  of  a  less  dense  kind  and  more  nearly  approaching  the  fibro- 
cellular  tumor,  it  may  attain  a  large  size.  Under  these  circumstances  the  skin  will 
become  part  of  the  tumor:  it  will  then   often  ulcerate  and  allow  the  growth  to  protrude 


128 


TUMORS. 


Fig.  29. 


through  the  opening  and  ulcerate,  or  even  slough,  and  thus  these  tumors  sometimes  bleed 
freely.     At  times  fibrous  tumors  seem  to  grow  from  the  deep  fascia. 

Treatment  op  Fibrous  Tumors. — Excision  is  the  only  treatment  which  offers  any 
prospect  of  success ;  and  when  these  fibrous  tumors  are  removed,  a  recurrence  is  rarely 

met  with.      The  fibro-niuseular,  fibro-cystic,  and  fibro- 
calcareous  tumors  are  mostly  uterine. 

3.  Chondromata,  or  cartilaginous  tu- 
mors, iire  most  commonly  met  with  in  connection 
with  bone,  but  they  are  found  in  the  parotid  or  sub- 
maxillary regions,  the  soft  parts,  as  the  testicles,  inter- 
muscular septa,  and  other  parts. 

They  appear,  as  a  rule,  in  young  subjects,  in  people 
under  middle  age,  and  are  far  more  common,  accord- 
ing to  my  own  notes,  in  the  female  than  in  the  male. 
They  are  usually  slow  in  growth,  the  majority  having 
existed  years  before  the  patient  seeks  advice.  The 
instances  of  tumors  of  rapid  growth  on  record  arc  rare. 
These  tumors,  when  not  outgrowths,  are  always  encysted 
and  have  a  smooth,  tense,  and  elastic  feel.  In  some 
examples  they  are  uniform  and  even,  in  others  bossy 
and  nodulated ;  they  rarely  cause  pain,  and  produce 
anxiety  simply  from  their  po.sition  and  size.  Tho.se  in 
the  parotid  or  submaxillar}'  region  appear  to  grow  su- 
perficially and  to  be  movable,  but  they  often  dip  down 
deeply  into  the  tis.sues,  and  considerable  care  is  required 
in  their  removal.  In  a  case  treated  by  my  colleague, 
Mr.  Durham,  the  tumor  appeared  more  as  a  pharyngeal 
than  as  a  parotid  growth.  As  often  as  not  they  are 
very  adherent  to  the  surrounding  parts.  These  simple 
parotid  tumors  rarely  involve  the  facial  nerve  or  cause 
When   the   cartilaginous  tumors  grow  tcifhiu  bones,  they 


Fibrous  Tumor. 
(Prawing  307"-,  CJuy's  Hosp.  Mus.) 


C^^***'*^^''**,,^^ 


paralysis,  as  do  the  cancerous, 
expand  them  into  a  thin  shell. 

Cartilaginous  tumors  are  usually  innocent,  and  consequently  only  separate  the  parts 

between  which  they  are  developed.     They  never 
Fig.  30  involve  the  integument  by  infiltration,  but  only 

(fi  71-^ — ^__  Stretch  it ;  in  exceptional   instances  they  excite 

■^^,J^~"'~>--,.,_^  inflammation  and  ulceration  in  the  skin,  with  sub- 

^^Nisiijj^s^^^^  sequent  perforation  ;  they  do  not  affect  the  sys- 
tem through  the  glands,  although  it  must  be 
added  that  rare  examples  are  on  record  in  which 
cartilaginous  tumors  have  returned  and  affected 
the  lymphatic  system  like  a  cancer.  Sir  J.  Paget 
has  recorded  such  an  instance  in  the  Mcd.-Clu'r. 
TnaiK.,  1855,  and  De  Morgan  in  the  Path.  Trans., 

vol.   XX. 

The  section  of  a  cartilaginous  tumor  is  fairly 
characteristic  (Fig.  30).  It  cuts  cri.sply  and  pre- 
sents a  smooth  surface ;  it  may  appear  of  one  mass  or  made  up  of  many  lobules.  In 
some  ca.ses  the  consistence  of  the  tumor  is  close  and  is  composed  of  translucent  or  bluish 
masses  of  fcetal  cartilage,  as  is  best  seen  in  the  periosteal  forms.  In  others  it  is  loose  and 
granular,  as  in  those  expanding  the  bones.  In  many  of  them  fibrous  or  glandulnr  tissue 
is  intimately  mixed  with  the  structure  of  the  tumor,  the  parotid  tumor  affording  the  best 
type  of  this  kind.  In  the  cartilaginous  tumors  of  bone,  bone  elements  are  always  pres- 
ent;  in  those  of  periosteum,  fibrous  elements;  and  where  glands  are  involved,  glandular 
.structure.  When  cartilaginous  tumors  .soften  down,  cysts  are  found,  usually  containing 
a  dirty  brown  serous  fluid,  or  simply  filled  witli  broken-down  tissue  and  pus  or  with  a 
more  tenacious  synovial  kind  of  fluid. 

Microscopically,  cartilaginous  tumors  present  diverse  forms,  simple  fcetal  cartilage  cells, 
embedded  in  some  cases  in  a  hyaline  or  in  a  granular  matrix,  in  others  in  a  fibrous  or 
glandular  stroma,  or  even  both  in  different  parts  of  the  same  growth.  The  most  typical 
form  is  that  in  which  the  cartilage  cells  are  grouped  together  in  masses  surrounded  by 
fibre  tissue.    From  this  type  great  deviations  occur,  the  cells  being  more  or  less  scattered 


Section  of  an  Enchondromatous  Tumor 
e.xpanding  Metacarpal  Bone. 


TCMOIIS. 


120 


hctwcen  the  Bhros.  In  some  instances  the  nuclei  of  the  cells  are  free  and  hunierr)iis,  in 
others  they  are  tilled  with  granules  or  oil-globules,  ajiparently  degeneralinfj.  Occasionally 
the  eartilaj»'e  cells  are  developing  and  take  on  the  mature  form  of  hone  cells  (Fig.  40). 

TuK.\TMKNT. — The  removal  of  the  cartijaginous  growth  is  the  oidy  efficient  treatment, 
but  the  practice  must  be  determined  by  the  position  of  the  growth  and  all  the  other 
points  with  which  the  tumor  is  clinically  surrounded.  When  removed,  a  return  rarely 
takes  place.  Ca.><es,  however,  are  on  record  (the  (iuy's  museum  containing  a  few;  in 
which  a  return  t-nsued  after  a  second  or  third  excision;  but  such  instances  are  exceptional. 

The  cartila<_'ini>us  tumors  of  bone  will  be  considered  under  the  head  of  '•  Diseases  of 
Bone.' 

4.  Osteomata,  or  osseous  tumors,  naturally  come  to  be  dealt  with  after  the 
cartilairinous.  for  the  two  elements  arc  usually  conibincd  ;  and  as  in  the  enchondromata 
traces  of  bone  may  be  found,  so  in  the  os.seous  tumors  traces  of  cartilage  may  exist 
(Fig.  40). 

These  are  found  in  several  forms,  as  exostoses  or  bony  outgrowths,  as  ivory  or  perios- 
teal exostosis,  and  as  tumors  of  bone.  The  ivory  growth  is  peculiar  to  the  bones  of  the 
skull. 

The  cancellous  exostosis  is  almo.st  always  developed  through  cartilage  and  made  up 
of  tissue  precisely  similar  to  the  cancellous  tissue  of  bone.  In  some  cases  it  is  covered 
with  a  thin  casing  of  compact  bone,  like  the  cartilaginous  tumor  growing  within  a  bone, 
but  in  most  it  is  covered  with  a  layer  of  cartilage,  by  the  ossification  of  which  it  grows. 
A  diagram  illustrating  these  points  will  be  found  in  the  chapter  dealing  with  exostosis, 
and  the  clinical  aspect  of  the  subject  will  be  again  considered  in  the  chapter  on  "  Tumors 
of  Bone."' 

5.  Adenomata,  glandular  or  adenoid  tumors,  are  new  growths  simu- 
lating more  or  It-.-s  perfectly  the  gland  structure  in  the  neighborhood  of  which  they  grow, 
and  are  not  hypertrophies  of  the  gland,  but  distinct  tumors.  In  the  breast  the  usual 
innocent  tumor  of  the  organ  is  of  this  nature,  and  is  called  adenocele ;  but  it  is  also 
found  in  the  prostate,  uterus,  lips,  tonsil,  thyroid,  and  integument.  Fig.  41  represents 
admirably  the  microscopical  features  of  the  adenomata  as  a  cla.ss,  and  Fig.  31  the  appear- 
ance of  such  a  tumor  in  section,  some  parts  being  solid  and  others  composed  of  pendulous 
intra-cystic  growths. 

Thev  are  generally  growths  of  young  life,  and  are  found  during  the  active  period  of 
a  gland's  existence.  They  are  always  encapsuled.  and  can  usually  be  turned  out  of  their 
bed  with  ease  on  dividing  the  capsule.  They  generally  assume  a  rounded  or  ovoid 
shape,  and  are  distinctly  movable  beneath  the  integument  which  is  not  involved.  '•  On 
section,"  says  Paget,  "  they  commonly  appear  lobed  or  intersected  with  partitions  of  con- 
nective tissue  and  are  pale,  grayish  or  yellowish-white,  in  some  specimens  looking  trans- 
lucent and  glistening;  in  others,  opaque  :  in  nearly  all.  acinous  or  glandular.  To  the 
touch,  some,  especially  the  white  and  more  opaque,  are  firm,  tenacious,  and  elastic  ;  others, 
especially  the  yellow  and  more  glistening,  are  softish,  brittle,  slippery,  and  succulent,  with 
fluid-like  serum  or  synovia.  Not  rarely  cysts  are  embedded  in  the  solid  growth,  and  these 
are  filled  with  serous  or  other  fluids  like  tho.se  which  are  found  in  the  barren  cy.sts  of  the 
mammary  gland  itself.  In  the  labial  and  parotid  glandular  tumors  portions  of  cartilage 
or  bone  may  be  mixed  with  the  glandular  structure,  and  sometimes,  chiefly  in  the  mamma, 
the  glandular  tumors  appear  as  if 

formed  wholly  or  in  part  of  clusters  Fig.  31. 

of  small  sessile  or  pendulous 
growths,  which  fill  cysts  or  parti- 
tioned spaces ;  thus  they  indicate 
their  relation  to  the  proliferous  cy.sts 
and  suggest  that  they  originated  in 
such  cysts.  The  textures  around 
the  tumor  are  usually  quite  healthy, 
altered  only  by  displacement."  These 
glandular  tumors  are  often  single, 
but  at  times  multiple.  Thus,  in  the 
breast  they  may  be  many  and  so 
loosely  encapsuled  as  to  move  about 
as  in  a  bag :  in  the  lips  they  are 
commonly  numerous  :  while  lymph- 
atic glandular  tumors  are  almost  always  multiple.    They  grow  with  very  variable  rapidity 


Adeno- 


:u>trarinc  the  Pathological  Appearances 
.-■1"  AdeDoid  Tumors. 


130  TUMORS. 

— at  times  more  slowly,  at  others  with  great  rapidity.  They  require  removal  simply  from 
the  inconvenience  caused  by  their  mechanical  jiressure. 

Treatment. — To  remove  them  it  is  only  necessary  to  divide  their  capsule  and  the 
soft  parts  covering  them  in  and  to  enucleate  them.  This  need  not,  however,  be  done 
under  all  circumstances,  for  these  glandular  tumors  not  only  cease  to  grow,  but  at  times 
disappear  ;  thus  operative  interference  should  only  be  entertained  when  the  growths  are 
large  or  increasing  or  very  painful.  jMedicine  does  not  appear  to  have  any  influence  in 
checking  their  growth. 

The  glandular  tumors  of  special  regions  will  receive  iintice  in  the  different  chapters 
devoted  to  their  coiisidcratioii. 

PapilloiTiata  are  found  in  the  outside  or  inside  skin  and  in  the  mucous  membrane, 
while  instances  are  on  record  where  they  were  found  on  serous  meniln-anes.  On  the  skin 
they  occur  as  warts,  cauliflower  or  sessile,  and  as  condylomata.  .Some  of  the  horny  skin- 
growths  arc  of  this  nature.  On  the  mucous  membrane  they  occur  on  the  lips,  larynx, 
hard  and  soft  palate,  tongue,  and  rectum,  and  as  villous  growths  in  the  bladder  and  rec- 
tum. They  seem  to  be  a  mere  delicate  outgTowth  of  subcutaneous  or  submucous  tissue, 
with  their  natural  epithelial  covering,  at  times  involving  the  gland  structure  of  the  part. 
They  are  usually  innocent. 

Neuromata,  or  fibrous  tumors  developed  in  and  about  a  nerve,  will  be  considered  in 
a  later  cliai)tcr,  as  will  the  angiomata  in  chapter  on  the  "  Diseases  of  the  Vascular  System." 

Lymphoma  is  a  disease  of  the  lymphatic  glands  which  is  at  times  local,  at  others 
general.  When  local  it  has,  as  a  rule,  local  causes ;  when  general,  constitutional  and  is 
associated  with  leuca3mia  or  leucocythiiemia. 

The  glands  are,  as  a  rule,  movable  in  the  surrounding  parts,  and  can  be  shelled  out. 
In  exceptional  cases  they  are  matted  together,  as  in  cancer,  and,  like  it,  are  also  dis- 
seminated as  secondary,  growths.     (For  "  Histology  "  viiJc  Fig.  42.) 

B.  Semi-Malignant  Tumors. 

1,  Sarcoma. — The  semi-maligmmt  tumors,  or  those  composed  of  embryonic  con- 
nective-tissue elements,  include  what  are  known  as  the  '-sarcomata"  and  "  myxomata," 
and  these  clinically  present  a  vast  variety  of  shapes  and  types.  They  approach  the  sim- 
ple growths  in  that  they  do  not  infiltrate  tissues,  but  separate  them ;  and  they  approach 
the  malignant  in  that  they  are  prone  to  recur  after  removal,  and  that  on  each  recurrence 
they  come  nearer  the  characters  of  the  cancer. 

To  the  naked  eye  they  are  succulent,  with  every  degree  of  solidity,  but  a  section  does 
not  give  milky  juice  on  scraping,  and  it  never  presents  the  concavity  like  a  cancer. 

in  some  cases,  where  recurrence  has  taken  place,  the  second  tunnn-,  doubtless,  has  been 
simply  the  external  manifestation  of  a  small  growth  which  existed  when  the  original 
tumor  was  removed,  or  the  increased  growth  of  a  portion  of  diseased  tissue  that  was 
unconsciously  left.  On  two  occasions  when  removing  a  mammary  adenoma  I  have  exposed 
a  minute  growth  of  a  similar  structure  by  the  incision  made  through  a  portion  of  the 
healthy  mammary  gland  to  reach  the  principal  growth.  In  both  these  cases,  had  the 
small  tumor  been  left,  a  recurrence  would  have  been  recorded.  In  cases  of  recurrent 
fatty  tumor  or  of  the  soft  fibroma  it  is  highly  probable  that  a  small  portion  of  the  tissue 
was  left.  On  one  occasion,  when  I  was  enucleating  one  of  these,  of  several  years'  growth, 
from  beneath  the  fascia  covering  the  scapula,  I  discovered  two  smaller  growths  which 
might  have  been  overlooked  and  would  certainly  have  grown.  f]ach  tumor  as  it  recurs 
generally  becomes  less  solid,  more  succulent,  and  more  rapid  in  its  growth.  With  each 
recurrence  the  cell  elements  increase  in  proportion  and  in  all  ways  ;  "  later  formed  tumors 
assume  more  of  the  character  of  malignancy  than  the  earlier."  All  these  sarcomatous 
tumors  are  composed  of  round,  elongated,  oat-shaped,  caudate,  nucleated  cells  like  those 
found  in  granulation  and  embryonic  connective  tissue  (vide  Fig.  43). 

It  must  be  observed  that  these  tumors,  as  a  rule,  attack  the  young  and  healthy. 
They  grow  from  a  fascia  or  aponeurosis,  are  of  slow  growth,  particularly  at  first,  and 
destroy  life  only  after  many  years  and  from  local  causes.  They  return  either  in  the  spot 
from  which  they  originally  sprang  or  from  its  immediate  neighborhood.  They  simply 
aff"ect  the  part  mechanically  by  separating  and  surrounding  tissues,  but  never  by  infiltrat- 
ing them.'  The  skin  is  stretched  over  the  tumor,  but  never  involved  in  it;  and  if 
destroyed,  it  is  by  ulceration  from  overdistension,  while  the  absorbent  glands  are  never 
secondarily  involved,  even  in  extreme  conditions.  Such  tumors  are  to  the  hand  more  or 
less  fibrous  and  lobulated,  their  fibrous  feel  being  much  influenced  by  their  rapidity  of 


77  -MORS. 


131 


Fui.  ■:± 


Sarcoma  of  Bone. 


(I'rep.  <iuy's  Mus.) 


•growth.  WhiM  cut  into,  they  present  a  more  or  less  compact  surface,  a  clear  serous  fluid 
iiitiitratiii;:  its  incslics  ;  while  even  tlie  finest  microscopical  section  will  be  found  toufrh  and 
tenacious  and  incapaldc  id"  hcin^  pressed  into  a  ditHueiit  mass.  I'nder  the  micn^scope 
thi'V  present  an  excess  of  nucleated  cells  and  nueleateil  fihres,  these,  again,  ."-liowinL'  their 
tendeiicv  toward  the  characters  ol"  the  malii;nant  irrowth. 

When  a  sarcomatous  tumor  spriuL's  from  jx-riostcum.  it  is  often  separateil  into  x-otions 
]>V  hands  of  lihres;  and  when  it  oriixinatcs  in  hone,  it 
mav  he  similarly  divided  hy  thin  plates  or  outgrowths 
of  ossific  matter,  these  plates  or  laminn;  heini:  some- 
times distinctly  seiiarate.  at  others  so  closely  packeil 
toircther  as  to  form  .somethinjr  like  a  skeleton  tunnjr 
(Fig.  ^^2),  the  sarcomatous  elements  clothing  the  bony 
outgrowths  or  surrounding  and  covering  them  in.  For 
diagnostic  purposes  the  detection  of  the.se  bony  plates 
is  of  great  value. 

The  treatment  of  recurrent  tumors  need  Tiot  differ 
from  that  of  the  inimceirt.  for  as  long  as  the  disease  is 
local  there  is  a  reas((nahle  hope  that  it  will  at  last  cea.se 
to  recur  after  reinnval. 

Myeloid   or  giant-celled   sarcomatous 

tumors  are  as  primary  growths  generally  I'ound 
associated  with  bone,  either  growing  from  the  bone,  as 
in  "  epulis."  or  more  comnioidy  in  the  bone,  and  when 
in  this  position  usually  in  its  articular  end.  The  term 
was  given  to  the  class  by  Paget  on  account  of  the  like- 
ness between  its  cells  and  tho.se  of  fuctal  marrow. 
Lebert  called  them  "  fibro-plastic,''  and  Virchow  ••  giant- 
celled  sarcoma."' 

When  these  tumors  are  periosteal,  they  have  the  clinical  features  of  a  fibrous  growth ; 
Avhen  within  the  bone,  they  appear  as  chronic  expansions  of  the  articular  extremity  or 
shaft.  When  large  and  so  expanded  as  to  have  burst  through  their  osseous  case,  they 
appear  cystic  and  semi-fluctuating,  even  to  the  extent  of  being  pulsatile.  They  are  usu- 
ally slow  in  their  progress,  and  often  painless ;  and  it  is  fair  to  supjiose  that  many  of  the 
cases  of  cystic  expansion  of  the  articular  extremity  of  a  bone  are  due  to  myeloid  disease. 
The  disease  is  one  of  youth  and  young  adult  life,  and  the  growth  is  usually  single.  It  is 
not  connected  with  any  cachexia  or  glandular  enlargement,  as  happens  with  cancer ;  and 
when  removed,  it  rarely  returns.  Instances  of  recurrence,  however,  have  occurred,  and 
I  have  seen  one.     Sir  J.  Paget  has  recorded  others. 

A  myeloid  tumor  presents  in  section  a  peculiar  appearance.  It  may  be  solid  or  cys- 
tic in  variable  degrees;  osseous  matter,  fibrous  matter,  or  fluid  may  exi.st  in  different  pro- 
portions ;  yet  in  every  specimen  the  cut  surface  will  present  blotches  of  a  pomegranate 
crimson  or  of  a  darker  blood  color,  these  tints  mingling  more  or  less  regularly  with  tho.se 
of  the  other  tissues. 

Under  the  microscope  the  characteristic  polynucleated  cells  are  seen  ;  the.se  are  large, 
round,  or  irregular  cells  containing  manv — even  ten  or  more — oval,  well-defined  nucleated 
nuclei  floating  in  a  clear  or  granular  substance.  They  are  found  in  masses  or  distributed 
throughout  the  tumor  between  the  bundles  of  fibre  tissue.  They  are  diagnostic  of  mye- 
loid disease.  With  these  cells  Lebert's  caudate  or  spindle-shaped  cells  are  also  found 
{cH/r  Fig.  4:-I). 

Melanotic  sarcoma  is  essentially  a  tumor  containing  pigment,  having  its  origin  in 
a  natural  tissue,  as  in  the  choroid  of  the  eye  or  in  a  mole  in  which  pigment  exists;  but 
what  it  is  that  determines  the  development  of  the.se  growths  in  tissues  that  have  had  a 
lifelong  exi-stence  remains  to  be  explained.  The  black  sarcomata  have,  however,  one 
peculiarity,  and  that  is  in  their  tendency  to  multiplicit}-.  In  this  thev'  are  often  mo.st 
remarkable :  the  skin  and  subcutaneous  tissues  at  times  become  studded  with  melanoid 
growths  of  all  sizes  and  shades  and  colors.  Fig.  o3  is  taken  from  a  woman  over  who.se 
whole  body  melanotic  cancerous  tumors  were  distributed,  the  disease  having  originated 
in  a  mole  which  I  had  previously  excLsed. 

Pathology. — If  it  were  necessary  to  adduce  a  forcible  illustration  of  the  fact  that  a 
tumor  when  first  developed  in  a  part  partakes,  iji  a  measure,  of  the  nature  aiul  peculiarities 
of  that  part,  and  even  when  repeating  itself  in  the  lymjihatic  glands  and  internal  organs 
still   preserves  the  characters  which  it  originally  ac(|uired  from   the  seat  of  its  primary 


332 


TUMORS. 


Melanotic  Sarcoma.    (  From  Model,  Guy's  >rus.) 


development,  no  better  could  be  adduced  than  that  derived  from  the  natural  history  of 
primary  and  secondary  melanotic  growths;  for  a  melanotic  sarcoma  always  grows  from  a 
part  which  naturally  contains  pigment,  and  a  mole  is  unquestioriaVjly  its  commonest  seat, 

while  pigment  in  some  of  its 
forms  is  almost  always  to  be 
met  with  in  all  its  secondary 
growths.  It  may  be.  perhaps, 
that  the  secondary  glandular 
enlargements  in  their  rapidity 
of  growth  out.strip  the  tumor 
from  which  they  originally  ini- 
liibed  their  peculiar  nature ; 
nevertheless,  their  true  cha- 
racter is  maintained  and  pre- 
served to  the  end.  This  sar- 
coma, as  a  rule,  is  of  the  soft 
form  and  runs  a  very  rapid 
course,  an  extreme  example  of  melanotic  sarcoma,  indeed,  presenting  all  the  worst  features 
of  a  cancer.  In  rare  examples  of  this  disease  the  melanotic  pigment  may  be  found  in 
the  urine  (Fagge,  Path.  Soc.  Trans.,  1876).  It  has,  however,  peculiarities  of  its  own,  to 
which  attention  will  be  subsequently  directed. 

The  oxfeo  sarcoma  and  chondro  sarcoma  will  receive  attention  in  the  chapter  devoted 
to  the  tumors  of  bone  (Chapter  XXXII.).  They  are  all  probably  only  modifications  of. 
the  medullary  cancer  affecting  bone,  although  it  may  be  mentioned  that  exceptional  eases 
are  on  record  wliere  an  osteoid  cancer  originated  in  some  intermuscular  interspaces. 

2.  Myxoma. — These  tumors  are  very  like  the  soft  fibromata  and  certain  fatty 
tumors.  They  are  encapsuled,  very  soft  and  succulent,  and  exude  a  peculiar  mucous 
juice.  They  are  most  common  in  the  subcutaneous  or  mucous  tissue,  but  are  found 
everywhere.  They  are  seen  as  parotid  growths,  and  often  mixed  with  fibrous  or  cartilag- 
inous elements.  They  are  doubtless  often  mistaken  for  colloid  cancer.  In  the  typical 
mijxoma  the  tumor  is  less  firm  but  more  elastic  than  the  sarcoma  ;  its  nature  is  far  less 
homogeneous  and  presents  less  well-marked  interlacing  fasciculi  of  connective  tissue,  and 
from  the  meshes  of  this  tissue  will  flow  a  variable  stream  of  clear,  translucent,  viscid 
mucus.  The  fibres  of  the  connective  tissue  are  visible  under  the  microscope,  but  in 
smaller  bundles  and  more  drawn  out.  Abundance  of  cells,  also  rounded,  elongated, 
branching,  and  even  anastomosing,  together  with  nuclei,  will  be  found  to  fill  the  cavities 
formed  by  the  confused  network  of  delicate  fibres  of  which  the  tumor  is  composed.  In 
the  structure  of  the  myxomata  fat  often  forms  an  important  element;  glandular  elements 
may  also  be  found,  their  presence  being  determined  by  the  position  of  the  growth  and 
the  propinquity  of  a  gland.  Bone  or  cartilaginous  elements  are  at  times  mixed  with  the 
others  (Fig.  44). 

Mi/.romnta  are  not  rare  about  the  angle  of  the  jaw,  nose^  breast,  and  abdomen.  They 
are  met  with  also  in  the  extremities  and  in  the  eye,  as  well  as  in  the  delicate  connective 
tissue  of  the  nervous  system,  particularly  of  the  brain,  and  also  of  the  nerves.  When 
attacking  the  brain  and  nerves,  such  growths  are  commonly  found  in  the  young.  Vir- 
chow  has  named  them  fjliamaUi.  (Fig.  43),  the  cells  being  of  a  small  round  or  pointed 
form,  embedded  in  granules,  and  held  together  by  delicate  fibres.  In  some  cases  the 
fibre  element  approaches  the  firmer  kind  of  fibro-cellular  tumors  (Fig.  43). 

Treatment. — Excision  is  the  only  practice  that  can  be  followed,  although  this  opera- 
tion need  not  be  performed  when  the  tumor  is  small  and  not  progressing,  especially  when 
it  occurs  in  aged  people.  Good  success  usually  attends  the  practice.  In  the  firmer 
varieties  of  myxomata  a  return  of  the  tumor  is  not  to  be  expected,  but  in  the  softer, 
where  cell  elements  predominate,  the  risks  of  a  return  are  great. 


C.  Cancerous  Tumors. 

What  is  a  cancerous  tumor  ?  Of  what  is  it  composed  ?  and.  How  can  it  be  recognized? 
are  questions  which  the  student  is  constantly  asking ;  and  few  are  more  difficult  to  answer 
with  accuracy  or  precision. 

Pathologically,  a  cancerous  tumor  is  compo.sed  of  cells  which  more  or  less  conform  to 
an  epitlictiiil  type,  but  the  student  must  be  prepared  in  all — at  any  rate,  rapidly  growing 
— tumors  to  find  a  great  variety  of  cell   forms ;  and  it  may  with  truth  be  said  that  the 


CANCEROirs  TV  MORS.  1;};J 

iiuire  tlie  ci'll  elements  prodnniiiiutc  in  u  i:r(»\vlli.  ami  the  inmc  tliey  apiintadi  an  epithelial 
type,  the  <jjreater  is  the  prohahility  nl"  its  licin<i  malignant,  and  iheiefore  eaneerous,  fur 
the  soft  caneers,  which  an-  lUKlunhtcdly  tlit;  ninst  viruh'iit,  are  niadi,'  up  almost  entirely 
of  cells  and  nuclei,  oidv  en<iui:ii  liKrc  tissue  existiiii:  t<i  himl  ami  hold  these  cells  ti»'_'ether 

It  has  heeii  already  shown  how  the  sarcomatous  tumor  approaches  the  malijinant  in 
some  of  its  features;  ami  it  must  have  heen  id)served  that  these,  which  form  the  inter- 
nieiliate  links  hetween  the  innocent  and  nialiL,Miant,  structurally  apju-oaeh  the  latter  in 
liaviuL^  more  of  the  cell  elements  in  their  eo.uposition.  The  recurrent  tumors  exist  as 
proofs  of  this. 

Hut  these  jmints  touch  only  the  anatoniv,  and  not  the  symptoms,  of  those  ^Towths  ; 
tlii'V  do  not  assist  the  surgeon  to  ascertain  before  its  removal  whether  the  tumor  he  a  caii- 
eer  m-  unt. 

Symptoms. — What,  then,  are  the  external  and  jreneral  symptoms  by  which  this 
point  can  be  determined?  And  hero  it  niu.st  be  premised  that  in  makin<r  a  diagnosis  the 
history  and  the  proj^ress  of  the  disease  are  at  least  as  important  as  the  physical  characters 
of  the  tumor. 

If  a  tumor  be  found  iiifillriifiiiij  llir  fisKurs  in  which  it  is  placed,  there  can  be  little  if 
any  doubt  as  to  its  bcinj^  a  cancer  ;  for  no  innocent  LM"owth  iiitiltrates  tissues:  it  oidy  sep- 
arates them. 

.\  cancerous  tumor,  however,  does  not  always  infiltrate  a  part,  althoiicrh  an  infiltratins 
tumor  is  almost  always  a  cancerous  one;  for  it  may  appear  as  a  distinct  and  isolated 
LM'owth.  being  then,  in  surgical  language,  described  as  tuberous.  What,  therefore,  are  the 
symptoms  by  which  a  tuberous  cancer  may  be  known  ?  What  peculiarities  has  the  tumor 
itself  by  which  its  nature  may  be  recognized?  Unfortunately,  a  negative  answer  must 
be  given  to  this  (juestion  ;  for  although  it  may  not  be  unfair  to  suspect  the  presence  of  a 
cancer  when  the  tumor  does  not  present  any  of  the  special  appearances  or  symptoms 
which  commonly  characterize  the  innocent  growths,  it  can  only  be  a  su.spicion,  as  many 
innocent  tumors  are  often  deficient  in  the  special  symptoms  which  when  present  readily 
attest  their  true  nature. 

A  subcutaneous  tumor  unconnected  with  the  integument,  with  an  irregular  bossy  out- 
line, and  of  a  firm,  fil)rous  feel  Avill,  in  all  probability,  be  of  a  simple  nature,  for  these  are 
not  the  characters  of  a  malignant  tumor;  but  another  with  a  smooth  uniform  external 
.surface  may  be  cither  a  sim])le  or  malignant  growth.  If,  however,  any  adhesion  or  draw- 
ing in  of  the  integument  to  the  surface  of  the  growth  can  be  detected,  or  any  immobilitv 
of  the  tumor  upon  the  parts  beneath,  the  suspicion  of  its  being  a  cancer  may  be  enter- 
tained ;  for  the  surgeon  should  ever  remember  the  tendency  which  the  maliirnant  tumor 
possesses  to  involve  by  infiltration  the  tissues  in  its  neighborhooil,  and  that  this  tendency 
does  not  belong  to  the  innocent  growths. 

I  proceed  further  to  direct  attention  to  another  .symptom  which,  if  present,  is  most 
characteristic  of  cancer  ;  and  it  is  a  .secondary  glandular,  lymphatic  enlargement.  If  this 
.symptom  appears,  the  probabilities  of  a  tumor  being  cancerous  become  very  strong,  as  inno- 
cent and  mm-malignant  tumors  are  rarely,  if  ever,  attended  with  enlarged  lymphatic  glands. 

A  distinct  and  i.solated  tumor,  therefore,  which  does  not  possess  any  of  the  special 
characters  of  a  simple  growth,  which  is  attended  with  some  evidence  of  secondary  affec- 
tion or  infiltration  of  the  parts,  and  with  which  an  enlargement  of  the  lymphatic  glands 
in  its  neighborhood  exi.sts,  may  safely  be  regarded  as  cancennis.  It  is,  however,  only  in 
the  early  stages  of  the  development  of  a  tumor  that  a  difficulty  in  diagnosis  is  usually 
felt,  because,  as  a  rule,  in  the  long-standing  and  well-developed  growth  the  diagnosis  is 
not  difficult. 

The  soft  and  so-called  medullary  cancer  is  the  form  which  is  usually  met  with  during 
young  life.  It  generally  makes  its  appearance  suddenly,  and  often  after  the  receipt  of 
soJiie  blow  or  injury.  It  grows,  too,  very  rapidly,  presenting  a  surface  which,  as  a  rule, 
is  .smooth  and  uniform  or  of  a  semi-solid  and  fluctuating  feel,  and  with  large  full  veins 
wandering  across.  It  is  recognized  by  its  sudden  appearance,  rapid  growth,  and  uniform 
surface — points  very  different  from  those  which  simjtle  tumors  present,  innocent  growths 
being  generally  slow  in  their  development  and  more  marked  in  their  outline.  The  cases 
of  medullary  or  soft  cancer  run  their  course  very  rapidly,  and  destroy  life  within  a  very 
short  period  of  their  development. 

Hard  caneers  are  the  affections  of  middle  age  and  adult  life.  They  grow  more  rapidly 
than  the  innocent  growths,  often  not  requiring  more  than  a  few  months  to  establish  their 
true  nature  ;  they  seldom  put  on  the  external  ap])earances  of  a  simple  tumor,  and  never 


134  aiycEROus  tumors. 

• 

exist  long  without  assuming  features  which  are  more  specially  characteristic  of  cancer, 
the  implication  of  neighboring  tissues  and  secondary  glanduhir  enlargements  being  the 
chief  features. 

Summary. — A  amceroits  tumor  has,  therefore,  four  characteristics: 

1.  It  infiltrates  the  tissue  it  attacks  and  spreads  by  infiltrating  neighboring  structures. 

2.  It  spreads  to  the  lymphatic  glands  of  the  neighborhood  through  the  absorbents. 

3.  It  affects  the  body  generally  through  the  vascular  system,  thus  giving  rise  to  sec- 
ondary deposits — that  is  to  say,  to  the  development  of  similar  growths  in  the  viscera  or 
remote  parts,  the  lungs  and  liver  being  particularly  prone  to  its  attack. 

4.  It  is  lial)le  to  recui-  after  removal. 

Cancerous  Tumors  have  been  variously  described  by  authors.  In  these  pages 
they  will  be  treated  of  as  the  hard,  or  scirrhus  ;  the  aoft.  or  encephaloid  ;  the  epithelial  ; 
the  colloid  and  hone  cancers,  or  osteoid. 

All  have,  however,  the  four  special  peculiarities  that  have  been  already  described  as 
characterizing  the  disease. 

Hard  or  scirrhous  cancer  is  the  most  common  ;  it  is  the  hard  or  fibrous  species 
denominated  •'  carcinoma  fibrosum."  It  is  the  usual  form  found  in  the  fenude  breast, 
and  is  seen  in  the  testicle,  tonsil,  skin,  bone,  eye,  rectum,  or  any  tissue.  When  attacking 
a  tissue  either  by  infiltration  (the  most  usual  method)  or  deposition,  it  gradually 
encroaches  upon  the  tissue  ;  and  when  this  is  soft,  it  causes  its  contraction,  as  in  the 
breast.  The  disease  spreads  outward,  and  soon  takes  possession  of  neighboring  struc- 
tures by  infiltrating  them.  In  this  way  it  becomes  gradually  less  movable,  and  at  last 
fixed.  No  structures  resist  its  influence,  fat,  skin,  mu.scles,  and  bones  becoming  filled 
with  cancerous  elements  as  the  disease  progresses.  It  is  said  "to  increase  most  on  the 
side  of  the  chief  arterial  supply,  and  in  that  toward  which  by  lymphatics  and  veins  its 
constituent  fluids  most  easily  filter"  (Moore). 

Thus  the  lymphatic  glands  become  enlarged,  and  these  in  their  turn  may  press  upon 
nerves,  causing  pain,  or  upon  veins,  producing  oedema.  But  cancers  have  not  the  power 
of  living  like  innocent  tumors :  they  are  apt  to  degenerate  and  die ;  and  thus,  after  a 
time,  a  cancerous  tumor  may  soften  down  in  its  centre  and  burst  or  die  as  a  whole  and 
slough  out,  or  its  surface  may  ulcerate.  But,  whatever  happens,  the  disease  spreads  in 
the  neighboring  parts;  indeed,  after  the  sloughing  of  a  cancerous  tumor,  this  spreading 
action  in  the  bed  from  which  it  has  been  enucleated  seems  to  be  more  rapid.  Thus,  the 
death  of  one  part  of  a  tumor  is  seen  with  the  rapid  increase  of  another  part,  and  in  tliis 
manner  the  disease  goes  on  encroaching  upon  and  infiltrating  and  destroying  all  tissues  in 
their  turn,  causing  death  either  by  exhaustion,  hemorrhage,  or  some  internal  complication. 

In  some  instances  of  cancer  the  integument  over  or  about  the  tumor,  before  ulcera- 
tion occurs,  becomes  infiltrated  with  small  shot-like  tubercles  ;  such  a  tubercle  in  its  early 
stage  feels  to  the  finger  like  a  foreign  body  introduced  into  the  cutis,  and  as  this  grows  it 
appears  as  a  distinct  skin  tubercle.  No  clinical  .symptom  is  more  characteristic  of  cancer 
than  the  presence  of  these  skin  tubercles. 

In  other  instances  the  whole  integument  becomes  o^dematous  and  brawny — in  fact, 
infiltrated  with  cancerous  elements — this  state  betokening  the  most  rapid  form  of  cancer. 
This  brawny  condition  of  integument  commonly  follows  venous  obstruction  from  glandu- 
lar enlargement,  but  at  times  it  takes  place  before  any  such  complication.  In  rarer  cases 
the  cancer  withers,  "  atrophic  cancer,"  the  disease  slowly  progressing  t(»  a  point  and  then 
disappearing  by  a  gradual  process.  Thus,  cancerous  tuloercles  will  appear  and  disappear; 
cancerous  nodules  will  form  and  fall  off"  by  the  contraction  of  their  own  fibres.  In  this 
way  cancer  may  become  cured  or  so  stationary  as  not  to  interfere  with  life.  I  have  had 
a  case  under  observation  in  which  the  disease  existed  for  twenty-three  years  and  seemed 
still  local.  I  have  recorded  another,  in  which  the  disease  lasted  twelve  years,  appearing 
and  crumbling  away  at  times  during  that  period  almost  to  a  perfect  cure.  Cancers  dis- 
play a  very  variable  degree  of  growing  or  existing  power,  and  there  does  not  seem  to  be  any 
condition  of  the  patient  or  of  the  tumor  which  either  favors  or  disfavors  these  properties. 
Some  have  an  apparent  vigor  of  increase  that  is  remarkable,  whilst  others  show  no 
such  tendency.  In  many  ca.ses  a  tumor  that  has  been  (juiescent  for  a  long  period  will 
suddenly  increase  actively. 

The  same  thing  may  be  said  as  regards  the  cancerous  vlccr.  In  the  atrophic  form 
this  may  be  merely  a  superficial  loss  of  substance  on  the  surface  of  the  tumor,  which 
may  be  covered  with  a  scab  or  present  a  glazed  or  a  very  slightly  discharging  surface. 
In  other  cases  the  ulcer  will  show  an  irregular  surface  with  an  elevated  everted  edge 
infiltrated  with  new  tissue  (Fig.  ?A). 


CA  AV  •I:r O  I  'V   TIJMOIIS.  1 35 

When  a  (.-avity  exists,  fdniu'd  liy  tlit-  sdl'tciiiri;;  <l<»\vii  of  tlie  centre  of  the  tumor  or 
the  I'liiulcatidii  ui' lU-ad  tissiu',  the  irrt'j:iihir  outline  of  the  eavity,the  i'etid  seuii-puruh-rit 
siiiiious  (liseharire,  as  well  as  the  rajrjred  ami  inliltialed  ed;.M'  of  tiie  wound,  are  eliaraeter- 
istic  signs  of  its  cancerous  nature. 

In  such  cases  a  cachexia  heconies  visible,  a  pale,  hloodless,  ha<.'<rar<l  look  of  sorrow 
and  surterinir.  hnuiirht  on  hy  jiaiu,  sleeplessness,  and  exiiaiisting  discharges. 

Pain  ill  the  development  of  a  cancer  is  a  very  variable  .symptom.  In  primary 
growths  it  is  rarely  severe  unless  .some  tierve  trunk  he  jtressed  u|ton  (»r  the  tumor  is 
bound  down  by  a  tense  fascia  or  is  developed  within  a  bone.  I'ndcr  all  th(;s(!  circum- 
stances the  pain  is  constant,  of  an  "aching  or  of  a  so-called  rheumatic  kind.  '  In  others 
it  is  usuallv  eomjiared  to  an  occasional  dart  (if  pain  through  the  part. 

As  a  sign  of  si'condary  deposits  pain,  however,  is  a  valuable  .symptom,  neuralgic  pain 
following  the  course  of  a  nerve  being  enough  to  excite  fear  of  some  deep-seated  .secondary 
growth.      Than  this  no  nmre  valuable  or  reliable  clinical  symptom  exists. 

The  srrfinii  of  a  scirrhous  cancer  is  genejally  attended  with  a  grating  sensation,  the 
parts  cutting  crisjily;  it  presents  a  concave  mirjace,  and  yields,  on  scraping,  a  milky  juice. 
The  tumor  has  no  defined  margin,  the  diseased  and  healthy  tissues,  as  it  were,  dipping 
into  each  other.  The  surface  of  the  cut  portion  iiuiy  be  vascular  or  bloodless,  and  has  a 
bluish-gray  or  streaked  yellow  aspect,  according  to  the  amount  of  cell  or  fibre  elements 
entering  into  its  formation  or  to  its  progress  toward  degeneration,  the  yellow  spots  being 
indicative  of  degeneration.  Occasionally  cysts,  or  rather  cavities,  contaiijing  .serum, 
blood,  or  broken-down  tissues,  are  found  in  the  tumor,  and  at  others  creaujy,  saponified 
masses  of  degenerated  tissues. 

The  microscopical  appearances  of  carcinomata  are  well  .shown  in  Fig.  45. 
Medullary  cancer,  like  the  .scirrhous,  is  either  in/iltnitliKj  or  fiiheroiis,  and  pos- 
sesses in  a  marked  degree  all  the  cancerous  peculiarities.  It  is  doubtless  only  a  form  of 
cancer,  and  not  distinct  from  the  scirrhous  varieties,  becau.se  both  often  coexist,  and  the 
irrowths  which  are  secondary  to  the  hardest  primary  cancer  are  generally  the  soft  variety. 
>Iedullary  cancer  is,  however,  the  special  form  that  appears  as  a  congenital  tumor  and 
which  attacks  children  and  young  adults,  and  may  be  called  ''  the  cancer  of  young  life." 
These  growths  form  very  rapidly  and  run  their  course  far  more  quickly  than  the  harder 
kind.  They  increase  so  tast  that  they  push  away  the  tissues  with  which  they  are  sur- 
rounded more  like  the  innocent  tumors  which  separate  them  ;  their  capsules  prevent  that 
general  infiltration  of  the  parts  which  is  observed  in  the  infiltrating  form.  It  is  found, 
although  rarely,  in  the  breast,  yet  more  frequently  in  the  intercellular  tissue  and  about 
the  periosteum  and  bones.  It  is  the  usual  form  attacking  the  eye.  uterus,  tonsil,  testis, 
and  ovary,  the  bones  and  cavities  of  the  head  and  face  appearing  peculiarly  liable  to  its 
inroads. 

These  sid't  cancers  usually  appear  as  deep-seated  swellings,  and  when  not  bound  down 
by  fascia  or  connected  with  bone  are  rarely  painful ;  but  when  so  situated,  a  gnawing  pain 
or  ache  is  a  frequent  concomitant.  As  they  progress  and  become  more  visible  they  may 
present  either  a  nodular  lobulated  or  a  .smooth  and  uniform  aspect,  but  in  either  case  the 
integument  covering  in  the  growth  will  be  traversed  by  many  very  large  and  dilated 
veins ;  while  in  .some  instances  the  growth  has  a  blui.sh  congested  aspect,  as  if  filled  with 
venous  blood.  These  tumors  are  often  so  vascular  as  to  pulsate,  and  thus  simulate  an 
aneurism.  Such  a  symptom,  however,  is  mo.stly  observed  in  those  connected  with  bone. 
To  the  touch  the  swelling  feels  soft  and  fluctuating,  often  giving  the  idea  of  fluid ; 
and  should  the  surgeon,  to  satisfy  himself  upon  this  point,  puncture  the  tumor  with  an 
cxploring-needle.  blood  will  freely  escape,  and  with  it  .some  creamy  tissue,  which  under 
the  microscope  will  be  seen  to  be  made  up  of  cells  and  nuclei. 

When  these  soft  cancers  have  burst  through  their  fascial  envelopes,  they  grow  more 
rapidly  ;  and  when  they  have  made  their  way  through  the  skin.  they,  as  it  were,  pulp  out, 
and  project  much  as  a  liernia  cerebri  does  after  ctjmpouiid  fracture  of  the  skull.  The  .«oft 
succulent  granulations  and  blood-infiltrated  tissues  that  project  suggested  to  Mr.  Hay  of 
Leeds  the  term  ■•  fungus  haematodes."  AVhen  a  soft  cancer  is  filled  with  blood,  it  is  kncjwn 
as  a  "  h;«matoid  variety."' 

When  they  appear  in  the  parotid  region,  they  usually,  if  not  always,  pi'oduce  paraly- 
sis of  the  facial  nerve — a  clinical  symptom,  I  think  I  may  say,  never  found  in  the  ordinary 
innocent  parotid  tumor;  so  that  when  present  this  symptom  is  of  value.  As  a  rule,  how- 
ever, this  soft  cancer  surrounds  nerves  and  vessels  without  materially  pressing  upon  them, 
large  vessels  and  nerves  being  often  found  passing  completely  through  their  substance. 
The  section  of  a  soft  differs  from  that  of  a  hard  cancer  as  the  '•  infiltrating  "  differs 


136 


EPITHELIAL   CAyCER. 


from  the  '•  tuberous  "  (compare  Y\<z<.  440  and  447;.  and  differs  also  very  materially  in 
itself  at  different  times.  It  ma}-  be  firm  or  nearly  fluid,  white  and  creamy,  or  red 
and  blood  .stained.  It  may  be  soft'  from  inflammatory  action  or  degenerating  from  natu- 
ral decay. 

Under  all  circum.stanees.  however,  it  will  be  divided  into  lobules.  fiVjrous  septa  or 
fibrous  envelopes  separating  these  lobules  from  one  another  as  the  fibrous  capsule  of  the 
parent  growth  separated  it  from  the  other  tissues. 

The  material  composing  the.se  cancers,  says  Paget.  "  is  a  peculiar,  .soft,  close-textured 
sub.stance  having  very  little  toughness.  ea.sily  crushed  and  .spread  out  by  compression  with 
the  fingers.  It  is  very  often  truly  brainlike,  most  like  foetal  brain,  or  like  adult  brain, 
partially  decomposed  or  cru.shed.  Many  .specimens  are.  however,  much  .softer  than  brain, 
and  many,  though  of  nearly  the  con.tistence  of  brain,  are  unlike  it.  being  grumous.  pulpy, 
shreddy,  or  spongy,  like  a  placenta  with  fine  soft  filaments.  Ver}-  few  have  a  distinct 
appearance  of  fibrous  or  other  regular  structure." 

These  tumors,  when  pressed  or  scraped,  yield  abundant  '•  cancer  juice ;"'  and  such 
juice  is  generally  diffusible  in  water.  No  better  rough  test,  says  Paget,  exi.sts  for  the 
diagnosis  of  medullary  cancer  than  this.  The  .stroma  of  this  cancer  element  is  filament- 
ous and  more  or  less  condensed  ;  it  is  also  generally  very  vascular.  The  cell  element 
always  predominates,  but  the  cells  in  no  way  differ  in  character  from  those  found  in  the 
fibrous  or  .scirrhous  form.  They  are.  however,  le.ss  closely  packed  together,  and  seem  to 
be  su.spended  in  the  juices  of  the  trrowth  or  enclosed  within  its  delicate  connective  tissue 
(Fig.  45  . 

Epithelioma  and  epithelial  cancer  are  terms  given  to  a  form  of  cutaneous 
cancer  frijin  its  similarity  in  structure  to  the  epithelial  elements  of  the  natural  skin,  these 
elements  assuming  in  some  cases,  as  in  the  cancers  of  the  face,  the  smaller  type  of  the 
epithelial  elements,  and  in  others,  as  in  the  lip.  the  larger. 

In  one  case  the  disease  may  appear  as  a  superficial  thickening  of  the  part  affected, 
and  in  another  as  a  nodular  or  warty  growth.  All  these  growths,  however,  have  a  tend- 
ency to  break  down  ;  and  this  tendency  varies  in  each  case.  In  some  it  is  very  .slight, 
whilst  in  others  it  is  so  rapid  that  the  degenerative  changes  keep  such  even  pace  with  the 
formative  that  the  disease  assumes  from  its  very  origin  the  appearance  of  an  ulcer,  when 
it  is  known  as  the  -rodent  ulcer"  (Fig.  35).  In  the  chain  of  malignancy  epithelial  can- 
cers are  linked  to  the  recurrent  tumors,  for  thev  have  both  a  tendency  to  return  in  a  part 
after  their  removal  and  to  affect  the  sy.stem  through  the  lymphatics ;  while  in  exceptional 
instances  they  may  be  found  in  the  internal  organs. 

These  tumors  affect  the  .skin  or  mucous  membrane,  and  never  originate  in  any  other 
tissue.     They  possess  this  feature  also  in  common  with  the  more  malignant  cancers,  in 

that  they  have  a  constant  tendency  to  infiltrate  the  parts 
with  which  they  come  in  contact,  and  do  not,  as  innocent 
tumors,  simply  separate  them.  They  are  the  common  forms 
of  cancer  found  in  the  lip.  tongue,  oesophagus,  rectum,  scro- 
tum, penis,  clitoris,  os  uteri,  vulva,  etc..  and  may  be  described 
as  the  cancer  of  the  skin,  while  in  sweeps  it  is  known  as  the 
'•  chimney-sweep's  cancer."  Epithelial  cancer  is  essentially 
an  infiltrating  disease  :  it  is  not.  as  the  sebaceous,  fatty,  fibro- 
cellular.  or  fibrous  tumor,  a  distinct  growth  developed  in  the 
tissues  and  separating  them,  but  it  is  from  its  very  begin- 
ning an  iiijiHration.  It  begins,  as  a  rule,  in  a  wart  or  tuber- 
cle, which  grows  ;  it  may  fungate,  crack,  fissure,  or  ulcerate; 
and  when  this  latter  stage  has  been  arrived  at.  its  true  cha- 
racter will  at  once  be  observed  by  the  careful  examiner,  as 
the  integument  forming  its  base  and  margin  will  be  evidently 
infiltrated  with  the  cancerous  material,  presenting  the  well- 
known  raised,  indurated,  and  everted  edges  (Fig.  34). 
These  appearances  form  a  marked  contrast  to  the  con- 
dition of  integument  which  is  met  with  where  an  innocent  growth  has  ulcerated  through 
or  ruptured  by  overdistension  its  cutaneous  covering. 

As  a  local  disea.se  epithelioma  may  progress  slowly  for  years  and  cause  little  pain, 
inconvenience,  or  injurious  effects,  and  five.  six.  eight,  or  even  fifteen,  years  have  elap.sed 
in  some  of  the  cases  that  have  been  under  my  notice  before  advice  was  sought :  it  may. 
moreover,  continue  for  many  years  before  it  affects  a  patient  in  other  ways  than  as  a 
local  disease.     On  the  other  hand,  when  it  once  begins  to  spread,  it  may  do  .so  rapidly  ; 


Fig.  34. 


Cancer  of  Stump  of  Two  Years' 
Standing.  (From  a  man  at.  .58.^ 


CA ycERors  ti 'mors. 


VM 


ami  after  rcninval  it  iiiav  return  at  miee.  nut oiily  in  tlie  part,  Init  in  tlie  lynipliutios  of 
tlie  district,  and  even  in  the  internal  i>rt;ans.  W  Inn  it  spreails  lueally,  it  may  us  a  eaiioer 
inliltrate  and  invade  every  tissue  \vlii(di  it  reaidies.  I  liav*;  .seen  it  more  than  once  origi- 
nate in  skin  and  end  in  a  total  destruction  (d'a  hone  (ridr  (/iii/s  I/osj).  Jie/).,  1.S75). 

Ispithelial  cancer  is  made  up  (d'  c(  lis  whicdi  difler  luit  littlt;  Irorii  those  of  ordinary 
epitludium,  tliouuh  they  are  grouped  very  ditVerently  ;  they  iidiltrate  tlic  tissues  in  which 
thev  an;  |)laeed  or  are  cdustered  toirt'thi-r  in  masses,  tlu'se  masses  heiiij;  deseril)ed  as 
"  ue.sts"  (Fii;.  d;')). 

The  surface  (d'  an  cpitludial  cancer  lu.ay  he  dry  ami  warty  or  ulceratin;^  ;  when  uieer- 
atiuLi,  it  will  he,  like  all  cancerous  sores,  irrejxular.  and  will  <lischar<;e  a  thin  or  a  creamy 
Huiil.  The  ed^e  will  always  he  thick  and  elevated,  like  a  wall  <jf  new  ti.s.stic  huilt  up 
between  tho  healthy  and  disea.sed  structures  ( Fig.  84).  When  the  di.sea.se  spreads,  it 
will  invade  and  infiltrate  every  ti.ssue,  forming  deep  excavated  sores.  It  may  involve 
the  lymphatic  glands,  like  any  other  cancer;  and  these  glaiuls  may  soften  down  and 
give  ri.se  to  a  cancerous  abscess  or  an  open  sore.  It  usually  destroys  life  from  local 
causes,  and  not  from  secondary  infiltration  of  the  viscera,  such  a  consequence  being 
<|iiitf   exce|itional. 

Ti{i:at.mk.\t  oi'  Im'I  riiKi.i.vL  Cancer. — These  cancers  should  always  be  removed; 
and  the  sooner  this  is  accomplished,  the  better  the  prospects  of  a  cure  or  of  a  long 
reprieve,  for  if  any  cancer  has  a  local  origin  the  epithelial  has,  and  if  it  be  removed 
before  any  glandular  eidargement  has  taken  place  the  prospects  of  a  good  result  are 
great.  Sibley  (Mn/.-('hir.  Tran^.^  vol.  xliii.)  made  out  from  the  Middlesex  Hospital 
records  that  e])ithelial  cancers,  on  the  average,  destroyed  life  in  fifty-thret;  months,  while 
scirrhous  lasted  but  thirty-two.  When  removed  by  the  knife,  care  should  be  taken  to 
cut  well  free  of  the  disease;  for  it  is  not  unusual  in  this,  as  in  all  cancers,  to  find  the 
tissues  around  the  tumor  sparsely  infiltrated  with  cancerous  elements  which  if  left  would 
cause  a  return  of  the  tumor.     The  same  advice  is  a])plicable  when  caustics  are  employed. 

In  many  examples  of  this  form  of  the  disease  the  removal  by  the  galvanic  cautery  is 
])y  far  the  i)est  method  of  treatment  we  pos.sess,  either  as  a  cautery  applied  to  the  surface 
or  as  a  wire  ecraseur  applied  around  the  base. 

Rodent  ulcers  arc  forms  of  epithelial  cancers.  Dr.  J.  C.  Warren  of  Boston, 
T^iited  States,  in  an  able  essay  upon  this  disease,  asserts  that  the  cells  of  the  rodent 
ulcer  differ  from  tliose  found  in  the  epithelial  by  be- 
ing smaller.  They  are  local  cancerous  affections  and 
expend  their  force  in  destroying  every  tissue  attacked, 
but  tbey  do  not  s^pread  by  means  of  the  lymphatics  or 
by  secondary  growths.  They  usually  begin  on  some 
part  of  the  face,  head,  or  other  locality  as  a  dry  wart, 
which  after  it  has  shed  many  skins  begins  to  ulcerate. 
The  ulcer  then  spreads  slowly  and  regularly,  with  a 
border  of  new  tissue  as  a  wall,  to  separate  it  from  the 
healthy  parts;  outside  the  border  'the  parts  are  soft 
and  natural,  inside  they  are  generally  smooth,  as  an 
indolent  sore,  devoid  of  granulations,  and  glazed 
(Fig.  35).  There  is  little  discharge  from  these  sores 
"when  superficial  ;  but  when  they  are  extensive  and 
have  dipped  down  deeply  into  other  tissues,  this  is 
not  the  case ;  and  when  they  inflame,  they  discharge 
a  fetid  ichorous  pus.  Thev  .seem  to  attack  healthy 
as  well  as  feeble  subjects,  and  have  little  efliect  upon 
the  general  health  until  they  touch  vital  parts. 
They  appear  after  middle  age  and  are  of  extreniely 
slow  growth  ;  they  are  to  be  treated  locally  by  their 
destruction,  cautery,  escharotics,  or  scalpel  being 
u.sed,  as  seems  most  applicable.  In  local  sores  the 
knife,  when  it  can  be  u.sed,  is  probably  the  best 
instrument,  but  in  others  the  galvanic  cautery  is 
unrivalled.  In  lieu  of  this  the  benzoline  cautery 
may  be  u.sed,  and  next  to  this  escharotics;  "the 
caustic  burns  through  the  entire  depth  of  the  solid 
disease,  and  upon  the  casting  of  the  subsc(|uent 
slough   cicatrization   is    rapidly  completed"   (Moore) 


Fig.  35. 


V 


/\. 


/>^v 


3^^ 


/ 


\ 


/ 


Rodent  Caiicer  of  the  Face.  (From  an  origi- 
nal diawinj;  of'.sir  Charles  Hell's,  contained 
in  the  niiiseiini  nf  the  Middlesex  Hospital, 
and  recojinized  hy  Messrs.  Shaw  and  f'anip- 
hell  <ie  .Moiu'an.  '  It  was  intnidiiced  to  my 
notice  liy  my  friend  Mr.  Henry  Morris  of 
the  .Middlesex  Hospital,  and  kindly  placed 
at  my  disposal  hy  the  museuui  committee 
of  that  institution.) 


Chloride   of   zinc,   potassa   fusa, 


138 


THE  CAUSES  OF  CANCER. 


Fig.  3(1. 


Vienna  paste,  or  acid  nitrate  mercury  may  be  applied  ;  the  zinc,  rubbed  down  in  a  warm 

mortar  with  equal  parts  of  fresh  plaster  of  Paris,  is  probably  the  best,  because  it  destroys 

and  dries  the  tissues. 

Colloid,  cancer  is   hardly  recognized  as  a  special  disease,  for  the   term  "  colloid  " 

is  applied  to  tumors  made  up  of  intercellular  spaces  of  variable  sizes  filled  with  a  clear 

glairy  fluid  like  glue,  which  contains  abun- 
dance of  granules  and  large  nucleated  cells 
(Fig.  45).  The  clinical  history  of  some  of 
these  growths  is  that  of  an  innocent  tumor, 
whilst  in  others  it  is  that  of  a  cancerous 
nature.  Colloid  tumors  are  found  in  the 
breast,  parotid  region,  ovary,  rectum,  and 
intestinal  canal,  it  being  known  in  this  last 
region  as  the  alveolar  or  gelatiniform  can- 
cer. Their  true  nature  is  not  yet  fully  under- 
stood. 

In  the  case  Fig.  36  the  patient  was  sixty- 
five  years  of  age  and  the  disease  had  been 
growing  for  two  years.  The  tumor  occupied 
the  outer  portion  of  the  gland  and  had  burst 
the  skin  covering  it  in.  The  colloid  growth 
projected  through  the  opening,  the  margins 
of  which,  however,  were  not  infiltrated  with 
disease.  There  were  no  enlarged  axillary 
glands.  This  patient  was  eight  years  subse- 
quently readmitted  into  Guy's  under  my 
care,  in  jMay,  1881,  when  she  was  seventy- 
three,  with  a  true  carcinomatous  affection  of 
the  nipple  of  the  opposite  breast  which  had 
been  recognized  for  six  munths.  The  nipple 
was  retracted  and  involved  in  an  indurated 
mass  of  disease  about  the  size  of  a  walnut. 
The  lymphatic  glands  were  healthy,  as  was 
the  scar  of  the  old  operation. 

Villous  growths  niay  be  cancerous  as 
well  as  benign.  When  made  up  of  cell 
elements,  their  cancerous  nature  is  to  be 
suspected ;  but  the  fact  is  only  to  be  dis- 
cerned by  the  clinical  career.  The  nature 
of  villous  and  colloid  disease  has  been  very 
ably  discussed  by  Mr.  Sibley  in  the  31(d.- 
and  Path.  Trans.,  vols,  vii.,  viii.,  and  ix. 


Case  of  ("oUoid  Tumor  of  the  Kreast  discharsiins  Exter- 
nally, in  a  Woman  let.  65,  with  Section  of  the  same. 


Chi'r.   Trans.,  vol.  xxxix. 


The  Cau.ses  of  Cancer. 

These  are  most  obscure,  but  the  most  constant  cause  is,  without  doubt,  persistent  local 
irritation.  Local  injur?/  also  appears  to  have  a  very  marked  influence  in  determining  the 
seat  of  a  cancer;  many  cases  supporting  this  view  have  fallen  under  my  observation,  and 
one  of  such  occurred  to  me  recently  in  the  case  of  a  boy  aet.  18,  who,  after  an  injury  to 
his  right  spermatic  cord,  in  a  few  weeks  became  the  subject  of  a  pelvic  tumor,  which 
rapidly  grew,  and  eventually  destroyed  life  by  obstructing  the  rectum  as  well  as  the 
ureters.  After  death  the  tumor  was  found  to  have  been  cancerous,  having  originated 
apparently  in  the  right  or  injured  cord,  spreading  downward  along  the  vas  deferens  to  the 
base  of  the  bladder,  and  subsequentl}^  ascending  from  the  pelvis,  above  the  level  of  the 
umbilicus. 

Heredlfari/  inflnrncc  has  always  been  considered  as  a  very  decided  cause  ;  still,  in  how 
small  a  proportion  of  cases  can  any  such  be  found  !  Sir  J.  Paget  traced  it  in  one  out  of 
every  three ;  Mr.  Sibley,  in  one  out  of  every  nine ;  and  in  222  consecutive  cases  of  my 
own  it  was  ti-aceable  only  in  one  out  of  every  ten  instances.  In  many  other  affections, 
even  the  most  innocent,  as  large  a  proportion  might  be  found.  In  fatty  tumors  and  in 
deformities  all  surgeons  recognize  the  frequency  of  an  hereditary  history.  Indeed,  look- 
ing at  cancer  as  one  of  many  diseases,  there  is  no  reason  for  regarding  it  as  more  heredi- 


TRKATMEST  OF  ('ASi'ER.  1  :i9 

tiirv  tliiiii  uiiv  nilicr;  :iim1  1  iiiii  iii<liiMil  to  ai;ro(>  with  Mr.  do  Mnrpran  when  he  said  "  that 
Jill  that  cniihl  he  said  with  rf<iartl  to  tlu;  coiistitutioual  nature  of  cancur  aftplied  cr|ually 
to  the  constitutional  nature  of  any,  the  smallest,  ;,n-o\vth  that  can  ho  found  in  the  hody." 

The  death-rate  of  eaneer.  aeeiU'din^'  to  the  re<:istrar-;reneiars  report,  is  one  in  "JilSiJ 
ca.ses,  hut — and  iVoni  the  same  authority — eaneer  is  heeomt!  more  eominoti.  Mr.  W  .  II. 
(Vipps  shows  in  a  paper  in  the  Si.  Har/h  Ifnsp.  Rip.,  1H7H,  that  the  death-rate  from  ean- 
eer in  the  community  in  suhjects  over  L!(>  is  ahout  one  in  every  liK.l  cases. 

Strikinir  examples  of  the  hereditary  nature  of  canc(;r  are  met  with  in  practice,  hut 
they  are  not  more  strikinjj;  than,  if  so  much  so  as,  the  hereditarines.s  of  ;rrowthsof  a  sim- 
ple kind.  Sir  J.  l*airet  has  pointed  out,  however,  that  when  a  local  disea.se  or  deformity 
is  inherited,  it  passes  from  pro^'cnitor  toort"s]»rin^  in  the  same  tissue,  if  not  in  exactly  the 
same  place;  whereas,  when  a  cancer  is  hereditary,  it  may  hreak  out  anywhere.  "The 
cancer  of  the  hreast  in  the  parent  is  marked  as  cancer  of  the  lip  in  tin;  oflsprin<;  ;  the 
cancer  of  the  cheek  in  the  parent  becomes  cancer  of  the  bone  in  the  chihl.  Tliere  is  in 
these  cases  absolutely  no  relation  at  all  of  place  or  texture." 

Cancer  is  a  di.sease  of  adult  life,  although  it  may  attack  a  f<jctus  in  utero  or  an  infant 
.soon  after  birth  ((lui/a  IIosp.  Rep.,  1875).  In  a  general  way,  it  is  most  prone  to  attack 
an  organ  that  has  passed  through  the  active  period  of  its  existence  and  is  degenerating, 
as  in  the  breast  or  uterus.  Sir  J.  Paget  describes  it  as  being  "essentially  a  disea.se  of 
degeneracy,"  and  asserts  ••  tliat  it  increases  in  frequency  in  proportion  to  the  number  of 
persons  living  as  age  goes  on."  When  it  does  affect  an  organ  in  the  full  vigor  of 
its  functional  activity,  it  partakes  of  that  activity  and  runs  its  course  with  marvellous 
rapidity. 

Cancer  appears  to  be  in  its  origin  a  local  disease,  and  to  become  general  either  by  the 
influence  of  the  juices  of  the  primary  tumor  exercising  an  impregnative  spermatic  influ- 
ence (Simon)  upon  other  parts  or  by  dissemination  of  its  elements.  This  dissemination 
at  first  may  radiate  from  its  local  source,  and  at  a  later  period  may  become  general  through 
the  fluids  of  the  body.  The  secondary  growths  will  partake  largely  of  the  characters  of 
the  primarv  ;  thus  tlie  osteoid  cancer  will  propagate  osteoid,  and  the  nielanotic  melanosis, 
each  cancerous  growth,  like  a  parasite,  growing  at  the  expen.se  of  the  tissue  in  which  it 
lies.  Moore,  in  his  work  on  the  Antecedents  of  Omm;  and  De  Morgan  more  recently, 
have,  I  believe,  established  this  fact.  From  a  clinical  point  of  view  this  i.s,  without 
doubt,  of  very  practical  significance;  for  surgeons  now  admit  that  the  earlier  a  cancerous 
tumor  is  removed  the  better  are  the  prospects  of  a  cure,  or,  at  least,  of  a  long  immunity 
from  the  di.sease. 

Trkatment  of  Caxcer. 

The  grnn-al  treatment  of  cancer  resolves  itself  into  the  improvement  of  the  general 
nutrition  of  the  body  by  hygienic  means,  good  nutritious  diet,  and  tonic  medicines.  No 
medicine  has  any  special  influence  on  the  disease. 

The  load  treatment  may  be  summed  up  in  the  word  "  removal ;"  for  all  cancers  should, 
if  practicable,  be  taken  away  as  soon  as  their  true  nature  has  been  established.  In  the 
early  stage  of  a  cancerous  tumor,  before  the  diagnosis  has  been  made  out,  it  should  be 
protected  froiu  external  injury  ami  from  all  irritating  causes.  No  rough  manipulation 
should  be  allowed,  nor  any  nu)vement  of  the  muscles  that  surround  or  influence  it. 
Warm  or  hot  applications  should  be  avoided,  since  they  appear  to  encourage  its  growth. 
The  most  acute  cancer  of  the  breast  I  ever  saw  was  one  that  originated  as  a  chronic  infil- 
tration, and  was  nuule  active  by  the  application  of  hot  fig  poultices  for  a  week.  The 
gland  itself,  and  the  skin  over  it  to  the  limit  of  the  application,  became  infiltrated  to  an 
extreme  degree  with  cancer,  which  rapidly  broke  down  and  destroyed  life. 

Moore  u.sed  to  think  highly  of  the  local  application  of  the  iodide  of  lead  and  opium 
ointment  applied  on  lint  to  the  tumor,  and  he  believed  it  had  some  influence  in  diminish- 
ing and  retarding  its  growth.  Some  have  faith  in  iodine  as  a  local  application,  but  I 
must  admit  that  I  have  never  been  able  to  discover  that  any  of  these  or  other  applica- 
tions had  the  slightest  influence  in  checking  the  progress  of  a  cancer,  and  have  conse- 
quently discarded  them.  When  pain  is  present,  the  belladonna  extract  rubbed  down  with 
glycerine  into  a  fluid  the  consistence  of  treacle,  or  of  the  extract  of  opium  similarly 
diluted,  seems  to  be  a  valuable  application.  An  opium  or  belladonna  plaster  spread  on 
leather  gives  comfort  and  protects  the  part.  The  best  protective  application,  however,  is 
cotton-wool. 

Excision. — When  the  diagnosis  is  established,  the  tumor  should  be  removed  ;  and 
the  best  method,  doubtless,  is  that  of  excision,  delay  being  only  ju.stifiable  when  the  gen- 


140  TREATMENT  OF  CANCER. 

eral  condition  of  the  patient  forbids  the  attempt.  To  delay  is  only  to  increase  the  risk 
of  a  local  dissemination  of  the  cancerous  elements,  and  thus  diminish  the  prospects  of  a 
successful  result;  to  give  time  for  the  lymphatic  glands  to  become  enlarged,  when 
removal  of  the  primary  growth  becomes  of  less  value  ;  and  to  increase  the  chance  of 
some  internal  or  remote  organs  becoming  involved,  when  operative  interference  is  futile. 

Free  Removal. — In  removing  a  cancerous  tumor  the  surgeon  should  not  be  too 
sparing  of  surrounding  tissue;  but  when  it  is  encapsuled,  there  is  no  necessity  for  doing 
more  than  enucleating  the  mass.  When  it  infiltrates  an  organ,  the  only  correct  treatment 
is  its  removal  ;  and  in  removing  it  care  should  be  taken  to  cut  away  all  skin  that  is  in  any 
way  adherent  to  its  surface,  with  as  much  of  the  surrounding  fat  as  circumstances  will  allow. 
When  the  tumor  has  been  removed,  all  surrounding  parts  should  be  carefully  exam- 
ined, because  it  is  not  uncommon  to  find  small  cancerous  tubercles  in  the  connective 
tissue,  fascia,  or  muscular  sheaths,  which  if  passed  by  unheeded  would  soon  increase  and 
give  rise  to  a  recurrent  growth.  It  is  from  these  points,  indeed,  that  such  recurrent 
growths  probably  often  arise,  and  these,  by  care  and  observation,  the  surgeon  may  often 
prevent.  De  Morgan,  after  excision  of  a  cancerous  tumor,  washed  the  wound  with  a 
solution  of  chloride  of  zinc  twenty  grains  to  an  ounce,  in  order  to  destroy  the  cancer 
germs.  The  surgeon,  too,  had  better  remove  all  skin  and  allow  the  wound  to  granulate 
up  than  save  integument  which  is  of  doubtful  integrity  for  the  sake  of  making  an  appar- 
ently more  complete  operation.  When  lymphatic  glands  are  enlarged,  they  should  be 
removed  at  the  time  of  operation  :  and  they  should  be  enucleated  by  the  fingers  or  handle 
of  the  scalpel  rather  than  be  excised.  Their  capsules  ought  to  be  divided  and  the  glands 
turned  out. 

Cancerous  tumors  of  the  tongue,  penis,  clitoris,  labium,  neck  of  the  uterus,  etc.,  may 
be  removed  by  the  wire  or  chain  ccraseur,  either  with  or  without  the  cautery  ;  but  this 
part  of  the  subject  will  receive  attention  in  other  pages. 

Removal  by  Caustics. — When  a  cancerous  tumor  cannot  be  excised  or  the  cut- 
ting operation  is  rejected,  it  may  be  removed  by  caustics;  but  such  a  method  is  more 
painful  and  slower  than  excision,  and  not  so  successful.  When  employed  as  a  substitute 
for  it,  it  is,  like  all  substitutes,  only  second-best;  yet  it  is.  however,  often  applicable 
where  excision  is  not.  The  French  surgeons  do  this  by  inserting  around  and  into -the 
tumor  thin,  conical,  flat  wedges  of  chloride  of  zinc  made  into  a  hard  mass  with  flour  or 
plaster  of  Paris,  holes  being  made  into  the  tissue  by  the  scalpel  for  the  introduction  of 
these  fleches.  Maisonneuve  is  the  chief  practitioner  of  this  school.  These  "  caustic 
arrows  "  of  M.  jNIaisonneuve  are  composed  of  wedge-shaped  pieces  cut  from  a  thin  cake 
of  paste  made  by  mixing  one  part  of  the  chloride  of  zinc  and  three  parts  of  flour  with 
as  much  water  as  may  be  found  necessary.  These  pieces  or  arrows  are  dried,  and  may 
be  kept  in  a  bottle  for  a  long  time  without  injury. 

Strong  Acids  and  Caustic  Paste.— In  England  this  jdan  finds  little  favor. 
The  following  method  is  more  general  :  In  a  tumor  that  is  not  ulcerated  let  the  skin  be 
destroyed  by  the  application  of  some  strong  sulphuric  or  nitric  acid,  and  in  this  slough 
let  one  or  more  incisions  be  made,  and  into  these  incisions  let  a  paste  of  chloride  of  zinc 
and  flour  mixed  with  the  extracts  of  the  Sangvlnnria  CdncKlcm^i!^  and  stramonium  be 
introduced,  fresh  incisions  being  made  through  the  thickness  of  the  slough  thus  I'ornied 
every  other  day  and  fresh  paste  inserted.  By  this  means  the  whole  tumor  may  be 
destroyed  or  enucleated.  The  paste  is  a  modification  of  that  introduced  into  London  by 
Dr.  Fell  of  the  United  States,  and  is,  without  doubt,  the  best  working  caustic  pa.ste  we 
possess.  The  following  is  the  mode  of  its  preparation  :  Boil  down  to  a  liquid  extract 
some  decoction  of  the  Saiiguinaria  Canadensis,  and  with  an  ounce  of  the  extract  dissolve 
a  similar  quantity  of  the  chloride  of  zinc.  ]Mix  this  with  two  ounces  of  the  extract  of 
stramonium,  and  the  soft  paste  is  ready  for  use. 

Caufjuoin's  paste  is  composed  of  chloride  of  zinc  and  flour  in  equal  parts,  a  few  drops 
of  water  being  necessary  to  make  it  into  a  paste.  A  second  form  is  probably  better: 
Chloride  of  zinc,  one  part;  muriate  of  antimony,  one  part;  flour,  one  part  and  a  half; 
water,  a  few  drops.  This  paste  is  of  the  consistence  of  .soft  wax.  At  the  3Iiddlesex 
Hospital  they  use  a  paste  made  by  mixing  chloride  of  zinc  and  boiled  starch  with  lauda- 
num till  it  reaches  the  consistence  of  honey. 

When  the  tumor  is  ulcerating  or  open,  the  paste  may  be  applied  directly  to  the  part 
and  fastened  on  by  cotton-wool  and  strapping  ;  the  thickness  of  half  an  inch  applied  for 
twelve  hours  usually  produces  a  slough  an  inch  deep. 

Some  prefer  a  solution  of  chloride  of  zinc  alone  inserted  on  cotton-wool.  M.  Rivallie 
uses  nitric  acid  applied  on  lint  or  asbestos;  Velpeau,  sulphuric  acid  on  saftVon.     By  some 


a  I!  A  .V  I'LA  Tins   Tl  'MORS. 


the  Vienna  paste  is  prt'tVrrtd.  Ai-t'iiic  as  a  caustic  has  hail  its  day,  ami  is  dangerous  and 
less  t'ft'c'ctivL'  than  zinc 

For  cutancnus  epithelial  cancer  the  caustic  ticatnicut  is  the  best.  The  chloride  of 
zine  made  into  a  paste  with  tluur  or  with  san^'uinaria  may  he  usimI,  if  j»rcl'erred.  The 
potassa  I'usa  is  likewise  a  useful  f<uin.  When  the  galvanic  or  therino-cantery  can  he 
obtained,  epithelial  skin  cancer  may  he  readily  dcstroy<'<l.  I  have  liurnt  down  many  such 
affecting  the  nose,  cheek,  eyelid,  scalp,  hand.  arm.  lip,  and  other  parts.  iiy  it  lar^'c  sur- 
face of  di.scased  tissue  may  he  completely  carhonized  and  a  JH-althy  surface  produced  after 
the  removal  id'  the  eschar.  The  operation  should  he  performed  with  the  aid  of  chloro- 
form and  the  whole  thickness  ami  edtres  (d'  the  diseased  tissue  tlestn»yed.  The  after-pain 
is  very  sliirht.  the  cautery  destroyinj;  all  nerve  sensihility.  It  is  hy  far  the  best  mode  we 
possess  of  dealinir  with  skin  cancer,  is  more  rapid  in  its  action  and  certain  in  its  result. 
besides  bein^  far  less  jtainful.  When  the  di.sease  e.vtends,  it  may  be  removed  with  the 
scalpel  and  the  base  of  the  sore  cauterized.  No  more  efficient  n»ode  of  removin;^  a  .skin 
cancer  is  within  our  reach. 

The  treatment  of  tumors  by  injection  of  fluids  into  their  sub.stance,  as  originally  .sug- 
gested by  Sir  .1.  Simpson,  and  more  recently  practised  })y  J)r.  Broadl>ent,  has  in  it  tlie 
elements  of  a  successful  plan,  but  has  not  yet  been  brought  to  any  available  state  of  per- 
fection. Fattv  tumiU's  may  be  destroyed  by  the  introduction  into  their  substance  of  a 
few  drops  of  deliipiescetit  chloride  of  zinc,  but  cancerous  tumors  do  not  ajipear  amenable 
to  a  like  remedy.  l)r.  Hroadbent  believes  that  he  has  succeedetl  b}'  injecting  a  li<juid 
composed  of  one  part  of  acetic  acid  and  three  of  water,  while  Messrs.  Moore  and  De 
Morgan  assert  that  they  have  each  succeeded  by  these  means  in  obtaining  gradual  diminu- 
tion of  cancerous  growths.  I  tried  the  plan  in  twenty  cases  when  it  was  first  intro<luced. 
bHt  never  found  any  good  result  ensue.  It  was  often  very  painful,  and  many  patients 
refused  to  have  it  repeated,  although  they  asked  for  the  excision  of  the  growth.  More 
recently  the  injection  of  twenty  drops  of  a  solution  of  bromine  dissolved  in  spirit,  rr^v 
to  a  ."jj.  has  had  its  advocates. 

The  treatment  by  pressure  is  of  no  practical  utility. 

By  way  of  summary  it  may  be  stated : 

I.  That  cancerous  tumors  .should  be  excised  when  practicable ;  and  the  sooner  the 
operation  is  pertormed  after  the  diagnosis  is  clear,  the  better:  that  with  the  primary 
growth  all  lymphatic  glands  that  are  involved  should  be  removed  likewise. 

II.  Open  cancerous  tumors,  as  a  rule,  should  be  treated  by  caustics,  the  best  being 
those  which  contain  chloride  of  zinc. 

III.  For  skiu  cancers  caustics  are.  as  a  rule,  the  most  available,  although  excision  in 
some  instances,  as  in  the  lip,  is  to  be  preferred.  The  galvanic  or  thermo-cautery.  how- 
ever, .should  be  employed  when  possible,  it  being  the  most  rapid  and  efficient  destructive 
agent  we  possess. 

D.  Granulation  Tumors 

Include  all  composed  of  granulation  tissue  and  have  their  origin  in  inflammation,  whether 
of  a  specific  or  simple  kind  ;  the  fungating  and  follicular  tumor  and  the  pedunculated 
umbilical  growths  are  its  best  examples,  but  it  occurs  in  many  other  shapes. 

Fungating  and  Follicular  Tumors. — In  neglected  examples  of  sebaceous 

cyst  tile  euiiteiits  oi'  the  tuiimr  may  .soften  down  and.  suppurating,  escape  externally  by 
ulceration.  From  the  inner  surface  of  the  evacuated  cyst  a  new  growth  may  spring  up, 
which,  when  forming  an  irregular,  fungating.  bleeding 
surface,  may  at  times  put  on  an  appearance  which  has 
been  mistaken  for  cancer.  On  examining  the  edges  of 
the  wound,  however,  this  mistake  can  scarcely  be  long 
entertained,  as  it  will  be  at  once  observed  that  the  edges 
of  the  wound  are  healthy,  and  not  infiltrated  with  new 
matter,  as  would  be  the  case  in  a  cancer  (Fig.  37). 
This  fungating  growth  is  really  composed  of  exuberant 
granulations  from  the  cyst  itself.  Abernethy  recog- 
nized this  when  he  said,  •'  I  have  also  seen,  after  the 
bursting  of  an  encysted  tumor,  the  surrounding  parts 
indurate  and  throw  out  a  fungus,  forming  a  disease 
appearing  like  cancer,  and  which  could  not  be  cured." 
And  ■'  it   is  no   uncommon   circumstance   to  meet  with 


Fig.  37 


Kuuguting  Follicular  Tiiiuor. 


wens  that  have  burst  spontaneously  and  have  thrown  out  a  fungus  which,  like  a  fungous 


142 


CYSTS. 


body,  prevents  the  surrounding  integument  from  healing."  The  best  account  of  tlic  afFec» 
tion  is  by  Mr.  Cock  (6r»_y's  Rej).,  1852). 

Treatment. — There  is  but  one  form  of  treatment  which  is  applicable  to  these  tumors, 
and  that  is  their  excision,  care  being  ob.served  to  cut  away  the  whole  of  the  diseased  tissue. 

(jranulatiou  tumors  probably  include  the  keloid. 


Fig.  38. 


E.  Cysts. 

These  are  developed  in  many  ways : 

1.  Some  are  possibly  new  growths  or  largely  developed  cells  having  an  independent 
life  and  being  capable  of  secreting  tlieir  own  contents  or  producing  solid  growths — ••  auto- 
genous cysts,"  as  Sir  J.  Paget  calls  them. 

2.  Some  are  formed  in  an  accidental  way  by  the  simple  effusion  of  fluid  into  the 
spaces  of  connective  or  other  tissues,  the  walls  of  the f^e  false  cijats  gradually  consolidating, 
as  is  commonly  seen  in  bursas  and  in  ordinary  tumors. 

3.  Others,  again,  are  produced  mechanically  by  the  dilatation  of  occluded  ducts  or 
natural  gland  orifices,  the  cyst  enlarging  by  the  secretion  of  the  ducts  or  gland  contents. 
Of  these  the  mucous  cysts  of  the  mouth  and  vagina,  the  sebaceous  cysts  of  the  skin,  and 
the  milk  cysts  of  the  breast  are  the  best  examples.  Alrchow  calls  these  "  cysts  by 
retention." 

In  many  cases,  however,  it  is  impossible  to  ascertain  how  the  cysts  are  formed.  Some 
are  para.sitic. 

Serous  cysts  are  most  commonly  found  connected  with  one  of  the  vascular  glands 
of  the  budv.  as  the  kidney,  ovary,  thyroid,  or  breast ;  but  they  are  not  rare  in  the  con- 
nective tissue,  and  are  found  even  in  bones.  When  seen  in  the  neck,  they  are  described 
as  "hydroceles  of  the  neck."  Some  of  these  are  congenital,  but  the  majority  occur  later 
in  life.  They  appear  as  single  or  multilocular  cysts  made  up  of  thin  membranous  walls 
lined  with  pavement  epithelium.  Like  a  serous  membrane,  they  contain  a  limpid,  watery, 
or  tenacious,  highly  albuminous  fluid  more  or  less  stained  with  blood,  occasionally  hold- 
ing cholesterine  in  suspension.     These  cysts  are  found  in  the  neck  anywhere  between  the 

lower  jaw  and  clavicle,  beneath  which  they  at 
times  pass  (Fig.  38)  ;  they  are  usually  deeply 
seated;  and  occasionally  superficial ;  they  give 
annoyance  only  from  their  size,  and  are  painless ; 
when  inflamed,  they  ma}'  suppurate.  They  are 
recognizable  by  their  globular  cystic  form,  soft 
fluctuating  feel,  and  painless  increase. 

These  cy.sts  are  not  to  be  confounded  with 
those  of  the  tJij/rouJ  gJamf  which  are  far  more 
common,  and  at  times  attain  a  large  size,  grow- 
ing as  quietly  and  painlessly  as  do  the  cervical. 
Usually,  however,  they  have  thicker  walls,  are 
more  tense,  and  are  commonly  multiple  ;  more- 
over, the}'  move  up  and  down  with  the  gland 
on  deglutition.  Their  contents  are  more  viscid 
and  frequently  mixed  with  blood  in  variable  pro- 
portions ;  indeed,  some  of  these  thyroid  cysts  are 
Uood  cjjuts.  which  when  tapped  would  go  on  bleeding,  if  allowed,  even  to  the  death  of  the 
patient.  I  have  recorded  such  a  case  {Giii/\  Reports,  18G4).  It  is  probable,  as  Sir  J. 
Paget  has  suggested,  that  many  of  the  cervical  cysts  are  thyroid  in  their  origin,  spring, 
ing  from  some  outlying  portion  of  the  gland. 

Cysts  are  also  found  over  the  thyroid  cartilage,  but  these  mostly  contain  grumous 
blood  and  rarely  grow  larger  than  half  a  walnut.  In  a  case  under  my  own  observation 
a  cyst  completely  covered  the  thyroid  cartilage,  and  was  lost  on  either  side  in  the  deep 
tissues  of  the  neck.  It  existed  in  an  adult  man  as  a  soft  fluctuating  swelling,  and  had 
been  growing  for  some  years  as  a  painless  formation. 

Cvsts  which  are  possibly  bursal  are  likewise  found  in  connection  with  the  hyoid  bone. 
Treatment. — Cervical  cysts  had  better  be  left  alone,  unless  from  their  size  they 
require  surgical  treatment,  because  there  is  always  danger  in  dealing  with  any  deep-seated 
cvst  in  this  region  from  the  liability  of  subsec|uent  diffused  inflammation  of  the  cellular 
tissues  of  the  neck.  I  lost  a  patient  some  years  ago  from  this  cause,  after  simply  tap- 
ping the  cyst. 


Serous  Cyst  of  the  Neck  (Birkett's  case). 


6'>'.S7'.V.  143 

W'licii  siirL'if:il  trcatinciit  is  calli'il  l'(ir./H////V////r  means  had  better  he  primarily  adopted. 
This  trcatiiii'iit  consists  in  iiit'iily  ihawiiiu  nH  the  ooiitciits  oi'  tlie  cyst  hy  means  of"  a 
trocar  and  cannhi  or  the  '•  aspiratiir.'  Sliuiilil  tin-  fluid  n,'-coih'ct  rapidly,  the  operation 
luav  he  repeated.  In  pi-rlorinin^  tins  operation  tin;  surgeon,  to  j;uard  a^rainst  jmnetiir- 
iiij;  any  oi'  the  snpcrticial  veins  or  deep  vessels,  sliould  recall  their  jiosition  heion-  pune- 
turin,L'. 

Slioulil  tlii'sc  measures  i'ail  even  after  several  repelitiuiis.  the  hest  jtrai-tiee  is  to  intro- 
dtice  into  the  cavity  of  the  cyst  a  draina;:;e-tnl»e.  When  the  tappirijr  has  induced  some 
sup])uvative  action,  the  oj)enini:  may  he  eidarjred  and  the  tuhe  inserted  ;  hut  when  the 
cvst  is  lar<;e,  it  is  well  to  pass  the  tuht;  completely  through  it.  'J'liis  may  readily  he  done 
hv  means  of  a  lonij  trocar  and  eanula,  such  as  that  (Muployed  for  puncturinji  the  hladder 
per  rectum,  the  pilot  tr<iear  heiiig  introduced  into  tlie  cyst  after  it  has  been  ojjetied  and 
made  to  traverse  the  cyst  to  its  most  dependent  jioint,  jio.ssihly  heneath  the  sterti(j-mastoi<l 
muscle.  The  pilot  trocar  should  then  be  removed,  th(!  drainage-tube  pa.ssed  through  tlie 
eanula,  and  the  canitla  taken  away,  the  two  ends  of  the  tubing  being  fastened  tog<!th(!r 
to  ])revent  its  slipping  out.  I  have  treated  niany  eases  of  deep  cervical  cysts  in  this 
manner  with  success.  'J'lie  great  point  to  attend  to  is  the  free  escape  of  pus  and  the  cyst 
contents;  if  air  gets  in,  let  the  opening  be  free  enough  for  it  to  jiass  out.  Slujuld  fetor 
appear,  the  cyst  should  be  washed  out  daily  with  iodine  or  chl(tride-i»f-zinc  lotion,  Condy's 
fluid,  or  some  other  disinfectant.  As  the  cyst  contracts  the  tube  may  be  removed,  but  so 
long  as  any  cavity  remains  it  should  be  lei't.  The  passage  of  a  set(jii  through  the  cyst  is 
another  method  which  may  ])e  adopted,  and  this  is  probably  more  suitable  ibr  small  than 
for  large  cysts.  Injecting  the  cyst  with  iodine  is  a  third  plan  which  has  proved  succes.s- 
I'ul,  though  it  is  as  dangerous  as  any  other  and  not  more  successful.  Extirpation  of  any 
large  cervical  cyst  is  a  mode  of  treatment  which  should  not  be  entertained,  since  it  i.s 
fraught  with  danger  and  difficulties. 

Thyroid  cysts  and  their  treatment  will  receive  attention  in  another  chapter. 

The  student  should  remember  that  nxvi,  when  they  degenerate,  commonly  .show  cyst.s 
in  their  structure  (Fig.  101)  ;  these  are,  however,  usually  clustered  together  in  a  cuta- 
neous or  subcutaneous  group.  When  they  appear  in  the  neck,  they  might  be  mistaken 
for  one  or  other  of  the  cysts  already  alluded  to.  This  mistake  will  be  prevented  by 
remembering  the  fact   that   they  do  occur  and   ]>y  the  history   of  the  ca.se. 

Congenital  cystic  hygroma  or  tumor  is  a  peculiar  affection,  the  nature  of 
which  is  not  clear.  It  may  appear  in  the  neck,  its  most  conimon  seat,  or  elsewhere,  as  a 
cystic  swelling  or  as  a  more  or  less  compact  .solid  growth,  the  cystic  element  varying  in 
each  case.  It  is  always  deeply  j)laced  beneath  the  fascia  and  dips  down  beneath  muscles, 
tendons,  and  vessels.  The  skin  over  the  tumor  is,  as  a  rule,  healthy  and  movable ;  but 
in  some  cases,  from  the  lobulated  nature  of  the  tumor,  the  skin  is  dimpled  as  in  a  lipoma. 
From  its  appearance  and  position  it  may  simulate  many  other  affections,  such  as  naevus  or 
spina  bifida  ;  but  pressure  upon  it  has  no  influence  in  lessening  its  size. 

The  di.sease  has  a  tendency  to  disappear  naturally,  though  at  times  it  may  grow 
rapidly.     In  some  cases  it  inflames  and  then  shrinks. 

When  treatment  is  absolutely  called  for,  that  by  setons,  as  suggested  by  ]Mr.  Thomas 
Smith  (^V.  Baith.  JIosp.  Rtp.^  ISlK!),  is  the  best.  The  knife  should  be  employed  in 
excejjtional  cases  alone.  The  value  of  injection  of  iodine  or  INIorton's  iodo-glycerine 
solution  has  yet  to  be  tested. 

Mucous  cysts  are  found  wherever  mucous  glands  exist,  and  are  caused  by  some 
obstruction  to  the  escape  of  the  gland  contents.  They  contain  highly  tenacious  mucus- 
like liquid  albumen.  They  appear  on  the  mucous  membrane  of  the  lips  as  hihinl  ci/atA, 
and  are  small,  tetise,  glol)ular,  painless  swellings.  They  are  found  within  the  cheeks, 
upon  the  tongue  and  gum,  particularly  of  the  upper  jaw  and  antrum,  and  very  commonly 
beneath  the  tongue,  as  snhlhignal  mucoux  ci/sfs^  when  they  have  been  described  as  cases 
of  '^raniila."  Such  cysts,  however,  are  now  known  to  be  due  to  okstruction  of  the  ducts 
of  Kivini's  mucous  glands,  and  are  not  necessarily  connected  with  the  salivary  organs 
(Fig.  214).  These  cysts  may  develop  about  the  larynx  and  cause  obstruction,  and  they 
have  been  found  in  the  oesophagus.  As  hihinj  and  vnginal  murjnis  ci/stx  they  appear  as 
tense,  globular  tumors  beneath  the  mucous  membrane  of  the  parts.  I  have  seen  them 
as  large  as  an  orange.  These  cy.sts  generally  contain  thick,  ropy,  mucoid  fluid  of  a  color- 
less or  slightly  yellow  tint.  Occasionally  the  fluid  is  mixed  with  blood  in  diflferent  pro- 
portions. I  have  seen  them  contain  black,  milky,  or  coffee-ground  fluid.  Sometimes  they 
inflame  and  suppurate  and  run  on  into  abscesses. 

Treat.ment. — Small  labial  cysts  may  often,  on  dividing  the  mucous  membrane  over 


144  CYSTS. 

I'hetn,  be  turned  out  as  a  whole ;  but  the  sublingual  and  larger  vaginal  cysts,  as  a  rule, 
cannot  be  thus  treated.  A  free  opening  into  them  or  the  removal  of  their  external  wall, 
and  the  introduction  into  the  cavity  of  a  plug  of  lint  soaked  in  iodine  to  excite  suppura- 
tion, may  at  times  suffice  to  bring  about  a  cure,  but  not  always.  In  the  so-called  ranula 
it  may  be  tried  before  other  practice  is  attempted.  In  the  sublingual,  labial,  and  vaginal 
cysts  I  have  for  some  years  been  in  the  habit  of  seizing  the  upper  surface  of  the  cyst 
with  a  pair  of  forceps  or  tenaculum  and  cutting  it  off  with  scissors,  thus  freely  exposing 
the  deeper  wall.  In  the  sublingual  this  practice  is,  as  a  rule,  successful  without  further 
treatment;  but  in  the  labial  and  vaginal  cysts  I  have,  in  addition,  generally  destroyed 
them  by  the  application  of  some  caustic,  such  as  nitrate  of  silver  or  carbolic  acid,  to  the 
exposed  surface,  after  which  the  wound  will  granulate  healthily.  When  these  cysts  can 
be  excised,  the  operation  can  be  performed. 

The  mucous  cysts  of  the  antrum  and  u]>per  jaw  will  be  described  amongst  the  tumors 
of  the  jaw. 

Cutaneous  sebaceous  cysts,  as  they  come  under  the  notice  of  the  surgeon, 
appear  as  ^^ coni/eiut(ir'  and  ^'' dcijuircd"  tumors.  They  are  analogous  to  the  mucous  cysts, 
the  glands  of  the  tissue  being  in  both  instances  at  fault.  Some  are  doubtless  caused,  as 
first  described  by  Sir  A.  Cooper,  by  the  obstruction  to  the  orifice  of  the  sebaceous  glands 
of  the  skin,  for  this  occluded  orifice  may  often  be  seen  as  a  small,  depressed,  black 
umbilicated  spot  upon  the  tumor  ;  the  contents  of  the  cyst  may  often  be  squeezed  through 
this  orifice,  or  into  it  a  probe  may  be  passed.  In  a  larger  proportion  of  cases,  on  making 
an  attempt  to  raise  the  skin  from  the  tumor,  a  dimple  or  evidence  of  connection  between 
the  two  will  be  visible,  thereby  revealing  its  nature.  But  in  other  cases  no  such  obstructed- 
duct,  or  even  cutaneous  depression,  can  be  observed  ;  and,  although  the  tumor  may  be 
developed  within  the  integument,  it  is  probably  a  new  fornuition,  an  adenoid  or  glandular 
skin  tumor. 

The  congenital  sebaceous  tumors  differ  from  those  usually  met  with  in  the  adult, 
or  the  acquired  form,  in  that  they  are  more  deeply  placed  and  mostly  lying  beneath  the 
fascia  of  the  part,  occasionally  beneath  the  muscles ;  they  are  rarely  cutaneous.  They 
are  more  common  about  the  orbit  and  brow  than  any  other  part,  the  external  angle  of 
the  eye  being  their  favorite  seat.  They  appear  as  small,  hard,  semiglobular  masses  deeply 
placed,  and  are  often,  indeed,  upon  the  bone.  Cases,  too,  are  on  record  in  which  by  their 
presence  they  have  produced  perforation  by  absorption  of  the  bone.  In  the  ear  this 
result  is  not  rare.  These  cysts  are  thin-walled  and  often  contain  liquid  secretion,  some- 
times of  a  pearly  whiteness  and  not  rarely  mixed  with  hair.  I  turned  a  complete  ball  of 
hair  out  of  such  a  cyst  on  one  occasion,  though  usually  the  hairs  are  fine  like  eyelashes 
and  are  mixed  with  the  sebaceous  matter.  The  contents  of  these  congenital  cysts  are 
rarely  offensive. 

The  acquired  sebaceous  cysts  may  be  found  on  any  part  of  the  body  that  is  cov- 
ered with  skin.  They  are  more  common  on  the  head  and  lace  than  elsewhere,  two-thirds 
of  all  cases  occurring  in  these  regions.  When  on  the  scalp,  they  are  known  as  "7<v?(.s" 
(Fig.  39).  They  are  always  surrounded  by  a  cyst-wall  composed  of  fibrous  tissue  more 
or  less  dense,  and  which  can  always  be  seen  after  these  tumors  have  been  enucleated  from 
their  beds.  In  "  Avens,"  however,  there  is  a  marked  peculiarity  which  demands  some 
notice.  "  The  chief  peculiarity  consists  in  a  thick,  dense,  horny  capsule  which  is  closely 
in  contact  with  the  fibrous  envelope  of  the  original  gland.  This  horny  capsule  was  for- 
merly regarded  as  the  cyst-wall  altered  by  pressure,  until  Sir  Prescott  Hewett  demon- 
strated its  true  relations  and  anatomical  structure  in  his  lecture  at  the  College  of  Sur- 
geons. It  is  now  clearly  proved  that  when  one  of  these  sebaceous  tumors  is  squeezed  out 
after  the  division  of  the  .skin,  the  fibrous  cyst  remains  behind.  This  cyst  can  be  after- 
ward excised,  and  its  structure  is  identical  with  that  of  all  the  others.  But  the  con- 
struction of  the  horny  capsule  requires  explanation.  If  carefully  examined,  it  is  found 
to  consLst  of  epithelium,  layer  upon  layer,  mixed  up  with  sebaceous  matter.  Sometimes 
a  solid  mass  of  epithelium  is  formed  ;  in  other  instances  a  cavity  exists  in  the  centre, 
filled  with  soft  sebaceous  secretion.  This  capsule,  then,  seems  to  be  a  production  of  the 
epithelium  of  the  sebaceous  gland,  which,  being  subjected  to  the  pressure  of  the  unyield- 
ing textures  in  which  the  tumor  is  developed,  becomes  converted  by  .slow  degrees  into  a 
tissue  closely  resembling  horn  or  fibro-cartilage  "  (Birkett,  Gin/i^  Rf'p.,  1859). 

These  sebaceous  tumors  are  more  frequent  in  women  than  in  men,  and  are,  beyond 
doubt,  hereditary  ;  Sir  J.  Paget  says  "  they  are  certainly  more  commonly  hereditary  than 
are  any  forms  of  cancer." 

The  dermoid  cysts  of  the  ovary  are  only  of  pathological  interest,  as  are  the  dentigerous 


TUK   MIcnoSCOriCAI,    A. \ ATOMY   OF   TUMORS. 


45 


cysts  of  these  parts.     Tlic  di'iitiircrous  cyst   of  tin-  jaw  will  he  trcutcii  of  in  tho  oliuptcr 
on  dist'ast's  of  the  jaw.s. 

Oil  cysts  iiro  iiu't  with,  tliouj^h  rarely,  ami   tiny   an-   prolialily   always  dermoiil.      I 
rcnittviMl  Olio   IVoiii   the  ])arotiil  re- 
gion  of  a  fiirl   iot.    is   which    was  Fio.  .'W. 
coiiir(>nital.      It  eoiitained  liijiiid  oil 
{r„tl,.  Soc.  Trans.,  vol.  .'UJ,  1.SS2). 

Tkkatmknt.  —  The  oidy  cor- 
rect treat  incut  of  tliese  sebaceous 
or  skin  cysts,  wlicthcr  wlioh*,  bro- 
ken, or  l"un<;atini;-,  consists  in  their 
removal.  In  rcniovinji' "  wens"  or 
iivqin'n(/  cysts,  liowever,  it  is  not 
necessary  to  be  too  careful  in  di,s- 
sccting  them  out  entire,  and  the 
most  eft'ective  method  is  to  slit  open 
the  tumor  with  a  bistoury  and  then 
turn  it  out  with  the  forceps  or 
handle  of  the  knife.  In  the  re- 
moval of  sebaceous  cysts  from 
other  parts  of  the  body  the  capsule 
of  the  c^'st  should  be  taken  away, 
while  in  the  funjrating  tumor  the 
whole  mass  ought  to  be  excised. 
In  the  treatment  of  the  roiujenUal 
tumor  it  is  always  better  to  try  and  dis.sect  out  the  cyst  entirely  ;  but  nothing  is  more 
unsatisfactory  than  operating  in  such  cases,  for  the  cyst  is  always  deep,  its  capsule  thin 
and  adherent,  and  any  attempt  to  dissect  it  out  as  a  whole  is  too  often  foiled  by  the  burst- 
ing or  puncturing  of  the  capsule  and  the  escape  of  its  contents.  When  this  occurs,  the 
surgeon  must  take  away  as  much  of  the  capsule  as  he  can  and  then  close  the  wound,  a 
good  result  following,  as  a  rule,  though  at  times  a  recurrence  of  the  growth  will  ensue. 

The  fear  of  erysipelas  after  these  operations  is  really  almost  groundless.  It  niav  arise, 
but  out  of  more  than  one  hundred  cases  consecutively  observed  I  have  not  seen  one 
example.  Pvicmia  may  follow  this,  as  it  may  any  other  minor  operation,  but  not  more 
frequently.  When  patients  are  cachectic,  such  an  operation  of  expediency  as  that  for 
the  removal  of  a  "  wen  "  had  better  be  postponed ;  for  under  low  conditions  of  health 
blood-poisoning  is  likely  to  follow.  Should,  however,  its  removal  be  urged,  this  may  be 
♦lone  by  the  injection  into  the  cy.st  of  some  caustic,  such  as  a  few  drops  of  deliquescent 
chloride  of  zinc,  of  carbolic  acid,  or  the  external  application  of  nitric  acid  or  potassa  fusa, 
to  produce  a  slough  througli  the  skin,  when  the  contents  of  the  cyst  may  be  turned  or 
drawn  out. 


Sebaceous  Tumors  in  .Scalp,  and  Horn. 


THE    MICROSCOPIOAL    ANATOMY    OF    TUMORS. 

By  Dr.  Moxox. 

Every  texture  of  the  body  in  its  earliest  embryonic  stage  of  development  is  alto- 
gether composed  of  cells  which  have  in  their  primitive  condition  no  noticeable  sub- 
stance between  them.  As  the  texture  progresses  in  its  development  the  uniformlv 
cellular  composition  of  its  primitive  substance  undergoes  modification.  Some  of  the 
cells  become  separated  by  intercellular  substances  of  various  kinds ;  others  change  to 
capillaries,  lymphatics,  and  nerves ;  yet  others  retain  their  cellular  form  and  remain  in 
close  contact  with  each  other.  The  general  result  is  that  when  the  .«everal  textures  of 
the  fully-developed  frame  are  studied  in  the  course  of  minute  anatomy,  each  texture  is 
found  to  shew  in  its  ultimate  construction  some  remains  of  its  cellular  oriirin.  more  or 
less  evidently  recognizable.  In  some  tissues,  such  as  the  epithelial  coverings  and  linings 
and  the  cellular  parts  of  the  lymphatic  glands,  of  the  thyroid,  etc.,  the  cells  remain  always 
distinct  from  each  other,  although  in  close  mutual  contact.  In  the  several  kinds  of  tissues 
of  the  connective  class,  including  cartilage,  tendon,  bone,  etc.,  a  large  proportion  of  inter- 
cellular matter  separates  the  cells,  this  intercellular  matter  taking  the  form  of  hyaline  or 
elastic  substance,  as  in  cartilage ;  of  fibres,  as  in  connective  tissue  and  tendon  ;  or  of  cal- 
cified substance,  as  in  bone.  The  cells  remain  separate  in  cartilage,  but  in  the  other 
tissues  of  this  class  they  send  out  processes  which  unite  to  form  a  network  throuirhout 
10 


146  THE  MICROSCOPICAL  ANATOMY  OF  TUMORS. 

the  calcified  or  fibrous  intercellular  substance  which  constitutes  the  greater  part  of  the 
tissue. 

Tumors  of  Nonstriated  Muscle. — In  the  proper  substance  of  mu.^^cle  and 
nerve,  tissues  endowed  with  special  dynamic  powers,  the  original  cells  generally  blend 
more  completely,  composing  tubes  or  fibres.  These  tissues  show  very  little  disposition  to 
form  tumors,  or  even  to  share  in  their  formation.  There  is  one  exception  to  this  indiffer- 
ence in  the  case  of  non.striated  muscle  :  the  fibres  of  this  kind  of  muscle  retain  to  a  large 
extent  their  embryonic  characters  and  never  quite  lose  their  primitive  cellular  composi- 
tion ;  the  original  cells  are  comparatively  little  altered  and  remain  still  distinct.  And 
with  these  embryonic  characters  the  fibres  of  nonstriated  muscle  show  a  capability  of 
extensive  new  growth  ;  rapid  production  of  this  tissue  occurs  during  adult  life  in  the 
pregnant  uterus.  Ana  tumors  of  nonstriated  muscle  fibre  are  not  uncommon  in  the 
uterus  and  elsewhere.  This  texture  is,  indeed,  of  great  interest  pathologically,  as  show- 
ing the  association  of  a  power  of  new  growth  in  a  highly  endowed  tissue,  with  a  persist- 
ence of  embryonic  form  in  its  elementary  fibres.  It  is  perhaps  the  most  striking  example 
of  what  is  generally  true  in  both  normal  and  pathological  histology — namely,  that  with 
embryonic  form  in  texture  elements  goes  always  power  of  increase  and  multiplication. 

Blood  Vessels  in  Ne"W  Growths. — The  behavior  of  the  blood  vessels  in  the 
formation  of  new  growths  is  an  interesting  field  of  study,  in  which  useful  observations 
may  yet  be  made.  It  will  be  found  that  the  blood  vessels  which  arise  in  tumors  com- 
posed of  normal  adult  texture,  such  as  bone,  fibre,  etc.,  are  themselves  composed  of  the 
textures  proper  to  normal  adult  blood  vessels ;  but,  on  the  other  hand,  the  blood  vessels 
of  tumors  which  are  composed  of  embryonic  substance  are  themselves  also  composed  of 
more  or  less  embryonic  cell-forms. 

The  constitution  of  the  blood  vessels  in  any  growth  must  be  considered  when  we  are 
endeavoring  to  throw  light  upon  those  conditions  which  enable  a  tumor  to  infect  the 
blood  passing  through  it,  so  giving  rise  to  secondary  tumors  in  the  course  of  the  circula- 
tion. There  are  tumors  in  which  blood  vessels  attain  to  undue  proportion,  and  sometimes 
tufts  of  blood  vessel  make  up  almost  the  whole  of  a  new  growth.  Such  tufts,  projecting 
on  a  free  surface,  bring  danger  of  serious  hemorrhage. 

Activity  of  Embryonic  Cells. — The  discovery  within  a  tumor  of  any  large 
proportion  ot  embryonic  cells  may  generally  be  taken  as  a  sign  of  active  growing  power. 
Such  cells  are  known  by  their  indefinite  transitional  shapes,  their  large  nuclei  and  many 
nucleoli.  These  cells  were  formerly  looked  upon  as  special  to  the  more  dangerous  kinds 
of  new  growth,  and  were  spoken  of  as  "  cancer  cells."  It  was  thought  that  one  might 
know  a  cancer  by  the  presence  of  such  cells. 

But  you  cannot  find  out  the  character  of  a  new  growth  by  scrutinizing  its  cells  indi- 
vidually. It  is  true  that  .some  kinds  of  tumor  contain  a  large  proportion  of  cells  that  are 
so  far  peculiar  as  to  be  almost  characteristic,  such  as  the  giant  cells  in  a  form  of  sarcoma 
and  the  lymphoid  cells  of  lymphoma  ;  yet  cells  of  either  of  these  kinds  are  met  with  in  other 
forms  of  tumor.  Indeed,  it  is  now  generally  admitted  that  the  hope  of  being  able  to 
determine  the  nature  of  a  growth  by  the  study  of  detached  cells  must  be  given  up,  and 
the  character  of  a  tumor  must  be  estimated  by  a  general  consideration  of  its  whole  struc- 
ture, for  experience  has  established  the  fact  that  the  structure  of  a  tumor  indicates  its 
character ;  so  that  dangerous  tendencies  are  constant  in  tumors  of  certain  construction, 
such  as  carcinoma,  and  are  as  con.stantly  absent  in  the  case  of  tumors  of  a  wholly  differ- 
ent construction,  such  as  adenoma,  whilst  in  yet  other  tumors  there  are  lesser  degrees  of 
danger. 

Xow,  in  every  tumor  the  new  material  is  developed,  like  the  natural  tissues  of  the 
body,  from  embryonic  cells.  And  in  any  growing  tumor  some  proportion  of  such  cells  is 
always  to  be  found  in  the  part  of  the  tumor  then  in  the  act  of  development. 

But  the  several  kinds  of  tumor  differ  exceedingly  in  the  proportion  of  embryonic  and 
adult  material  contained  in  their  composition,  some  appearing  to  the  naked  eye  to  be  alto- 
gether made  up  of  an  adult  texture,  whilst  others  are  throughout  constituted  of  embry- 
onic substance;  and  it  may  be  said  that  the  more  embryonic  substance  present  in  a  tumor, 
the  greater  will  be  its  rate  of  increase,  and  generally  the  greater  the  danger  attaching  to  it. 

A  tumor  whose  substance  differs  much  from  any  of  the  natural  tissues  is  generally  a 
tumor  endowed  with  the  embryonic  ((uality  of  rapid  increase,  and  hence  is  a  dangerous 
tumor ;  whilst  a  tumor  whose  composition  resembles  that  of  any  fully-developed  tissue, 
such  as  bone,  fat.  ligament,  etc.,  is  generally  a  tumor  of  .slow  growth  and  comparatively 
little  danger.  The  most  important  exception  to  this  general  rule  is  in  the  case  of  carti- 
lage.    Tumors  composed  of  cartilage  may  grow  rapidh'  and  prove  dangerous,  but  it  must 


Till-:   MICROSCOI'ICM.    AS  ATOMY   OF   TI'MollS.  117 

be  remembered  that,  altlidugli  cartilaj^e  is  a  tissue  of  the  adult  liuiiiuri  frame,  yet  there 
is  such  a  thing  as  eml)ryoiiie  cartihige  ;  and  thus,  indeed,  cartilage  may  claim  to  he 
regarded   rut  her  as  emhryouic  than   as  adult. 

When  the  substance  (d"  a  tumor  develops  into  adult  tissue,  the  tumor  so  lormed  is 
always  ciunposed  of  one  <d"  the  proper  tissues  of  the  human  body,  ligament,  fat,  hone, 
etc.  The  tissue  thus  developed  is  nearly  always  the  same  tissue  as  that  from  which  the 
tumor  ari.ses — bone  from  bone,  tihre  from  iiltre,  fat  from  fat,  papilUe  from  the  papillary 
layer  (d"  the  skin,  etc.  Uut  it  must  he  iully  understood  that  we  are  here  speaking  only 
of  [»rimary  tumors,  for  it  is  most  curious,  interesting,  and  suggestive  to  observe  how, 
when  a  tumor  in  any  tissue  ari.ses  as  secondary  to  another  tumor  in  another  tissue,  the 
secondary  tumor  contains  the  tissue  of  the  primary  tumor,  and  therefore  usually  the 
tissue  of  the  seat  (d"  origin  of  the  primary  tumor.  Thus,  if  a  tumor  arising  from  the 
humerus  and  containing  bone  gives  ri.'^e  to  a  secondary  tumor  m  the  lung,  the  lung  tumor 
will  then  probably  contain  bone;  but  if  primary  tumors  commonly  reseirible  in  microscopic 
structure  the  i)arts  they  arise  in,  this  resemblance  is  only  reached  when  the  tissue  of  the 
tumor  attains  to  complete  development ;  for  if  the  elementary  cells  of  the  new  growth 
remain  permanently  in  an  incomplete  stage,  and  do  not  go  beyond  the  form  of  embryonic 
cells,  the  suhstanee  of  the  growth  will  of  course  have  characters  differing  from  those  of 
the  adult  tissue  wherever  it  ari.ses,  and  it  may  differ  exceedingly  from  the  adult  form  (d" 
that  tissue. 

Indeed,  if  any  primary  tumor  does  not  resemble  the  texture  it  arises  in,  this  is  nearly 
always  because  its  substance  is  in  an  embryonic  state  or  stage.  But  with  this  embryoidc 
stage  is  naturally  associated  a  power  of  increase ;  and  hence  it  is  that  when  a  tumor  does 
not  resemble  the  tissue  in  which  it  grows,  that  tumor  will  probably  prove  to  be  a  rapidly 
increasing,  and  therefore  a  dangerous,  tumor. 

It  is  not,  however,  only  tlirough  great  growing  power  that  a  tumor  becomes  dangerous. 
The  chief  danger,  and  the  most  dreaded  danger,  lies  in  the  tendency  of  the  tumor  to 
prove  infectious  either  to  the  adjacent  tissues  or  the  corresponding  lymphatic  glands  or 
to  more  remote  organs  and  parts  of  the  system. 

By  infecting  the  neighboring  textures  the  tumor  will  grow  again  from  them  after  the 
surgeon  has  done  his  best  to  remove  it.  By  infecting  the  glands  secondary  tumors  arise 
in  the  seats  of  tho.se  glands,  whilst  by  infecting  the  walls  of  blood  vessels,  or  otherwise 
setting  free  its  germinal  particles  in  the  blood  stream,  the  tumor  gives  rise  to  secondary 
growths  in  the  great  vascular  viscera,  the  lungs  and  liver,  or  in  the  cancellous  tissue  of 
bones,  or  generally  elsewhere. 

The  possession  of  this  infective  power  is  what  is  meant  by  the  term  "  malignant," 
and  the  word  "  cancer "  is  popularly  applied  to  any  malignant  tumor. 

The  microscopic  structure  of  a  tumor  may  throw  some  light  upon  its  malignant  or 
infective  powers.  Thus  careful  inspection  of  sections  of  the  edges  of  the  tumor  may 
discover  that  its  cells  are  already  spreading  into  surrounding  parts  when  no  sign  of  their 
presence  is  given  to  the  unaided  eye.  Or  it  may  be  found  that  minute  blood  vessels 
have  their  walls  invaded  and  transformed  by  the  new  formation.  A  large  proportion  of 
juice  in  the  texture  of  the  growth,  especially  if  there  be  also  a  large  share  of  easily 
movable  particles,  will  usually  be  associated  with  infective  powers.  The  microscope 
reveals  that  these  particles  are  actively-growing  nuclei  and  cells.  It  thus  explains  the 
usual  rough  test  by  \vhich  a  tumor  is  tried  for  malignancy  when  the  cut  surface  of  its 
section  is  scraped,  and  a  milky  juice  being  obtained  is  held  to  characterize  a  cancer. 

But  the  proper  manner  of  judging  a  tumor  is  by  a  thorough  examination  of  its  hi.sto- 
logical  structure  and  a  reference  of  the  tumor  to  its  proper  structural  kind. 

General  experience  has  shown  the  degree  of  danger  belonging  to  each  sort  of  tumor, 
and  by  a  knowledge  of  the  structure  of  tumor  its  tendency  may  be  fairly  inferred.  From 
the  hi.stulogieal  point  of  view  tumors  may  be  divided  into  the  following  groups. 

OSTEOMA,  OSTEOID   CHONDROMA,  EXCHONDROMA. 

•  When  bone  forms  a  large  part,  or  apparently  the  whole,  of  a  tumor,  the  tumor  is 
called  an  osteoma ;  but  no  tumor  is  ever  formed  altogether  of  bone :  there  is  always 
present  an  ossifying  matrix,  by  the  ossification  of  which  the  bony  part  of  the  growth 
enlarges.  The  kind  of  matrix  varies  much.  Thus  sarcomata,  or  even  carcinomata.  may 
directly  ossify,  and  so  we  get  osffo-.saromn  and  osteo-carcinoma  ;  but  the  kinds  of  matrix 
which  produce  growths  of  practically  a  bony  nature  are  generally  two — viz.,  periosteum 
and  cartilage.     Periosteum — or,  to  speak  more  exactly,  a  tissue  resembling  closely  the 


148  ADEXOMA. 

deeper  layer  of  the  periosteum — forms  large  tumors  whose  transformation  into  bone  takes 

place  in  the  manner  shown  in  the  left  side  of  Fig.  40  ;  the  cells  take  the  shape  of  bone 

cells,  and  the  matrix  calcifies.     These  tumors  are  called  osteoid  cltondroma  or  periosteoma. 

Cartilage  often  appears  to  be  ossified  when  it  is  only  petrified  by  deposit  of  calcareous 

Fig.  40. 


Fikromn 


C^ 


V 


^  ^J/irJiondro7n» 


r'eihification 


I  'f<ru  rial  ion. 


s  -f' 


Microscopical  Anatomy  of  Osteoma,  Osteoid  Chondroma,  and  Enchondroma. 

salts  in  its  matrix  (see  right  side  of  Fig.  40)  ;  this  change  is,  as  is  well  known,  the  first 
step  in  ossification  of  cartilage.  In  many  cartilage  tumors  the  process  goes  no  farther, 
or  it  may  proceed  to  complete  ossification  through  the  several  stages  shown  in  the  right 
size  of  a  figure — viz.,  vacuolation,  formation  of  medulla-cells  in  the  vacuoles,  and  direct 
transformation  of  these  to  bone  cells,  as  seen  in  the  lower  and  right  part  of  the  drawing. 
More  rarelj'  the  cartilage  cells,  without  calcifying,  proliferate  and  change  directly  into 
bone,  as  seen  in  the  middle  of  the  figure. 

The  amount  of  cartilage,  periosteum,  or  bone  present  varies  indefinitely  in  different 
cases.  When  cartilage  preponderates,  the  tumor  is  called  an  eticJioiidrovia ;  when  bone 
preponderates,  an  exo^tosis^  osteoma,  etc..  VLCCor^m^  to  its  shape  and  connections;  when 
periosteum  preponderates,  an  osteoid  chond romri ,  as  before  said. 

Occasionally  the  amount  of  bone  and  cartilage  is  so  equal  that  it  is  a  matter  of  diflS- 
culty  to  decide  which  name  shall  be  used,  and  then  the  term  cartilaginous  exostosis  or  e}.'isi- 
fyinej  enchondroma  is  employed.  OsterAd  clwndromata  are  to  be  suspected  of  malignancy  ; 
such  tumors  compose  a  part  of  wliat  were  called  osteoid  cancers,  and  now  called  sarcomata. 

ADENOMA. 

The  essential  character  of  adenoma  lies  in  the  possession  of  a  glandular  structure, 
but  the  comparative  amount  of  the  glandular  element  varies  much.  There  is  also  vai'iety 
in  the  kind  of  tissue  which  is  found  between  the  gland  follicles.  Some  tumors  show 
structure  almost  identical  with  that  of  compound  racemose  glands,  having  natural-look- 
ing follicles  separated  by  delicate  connective  tissue ;  more  commonly  the  follicles  are 
dilated  more  or  less,  so  as  to  form  cysts ;  one  or  more  of  these  may  prevail,  so  as  to  give 
a  cystic  character  to  the  whole  (cystic  adenoma).  Besides  the  cysts  arising  in  this  way, 
others  may  be  formed  by  a  breaking  down  of  the  intermediate  tissue,  especially  if  it 
happen  to  be  mucous  tissue.  But,  as  a  rule,  the  glandular  elements  are  surrounded  and 
separated  by  a  more  plentiful  formation,  which  may  be  so  much  developed  as  to  more  or 
less  entirely  take  away  the  glandular  character  of  the  growth  ;  this  interstitial  tissue 
may  either  be  fibrous,  sarcous,  or  mucous,  or  more  rarely  cartilaginous  or  areolar,  or  it 
may  present  characters  combining  these  or  mediate  between  them  (^adeno-Jibroma — sar- 


LYMI'IIdMA. 


1-49 


coma — myxomn).  Wlicii  the  proportion  of  <rlan(l  is  small,  there  is  doubt  whether  it  is 
not  part  ol"  the  original  ;,'lanti-tissue  persistin-  in  the  new  substance.  Thus,  the  relative 
aujrinentation  of  the  cavities  of  duets  or  follicles  may  make  the  tumor  take  the  charac- 
ter of  cvst,  or  the  relative  auj.Mnentation  of  the  intermediate  tissue  may  make  it  take  the 
character  of  sarcoma,  myxoma,  or  fibroma;  but  if  the  glandular  substance  is  maintained 
in  due  proportidU.  the  natural  resemblance  of  aden<ima  is  to  carcinoma. 

And,  indeed,  if  the  glandular  substance  is  maintained  in  due  proportion,  then  a  very 
little  change  is  needed  to  give  to  adenoma  the  characters  of  carcinoma.  When  the  cha- 
racters of  carcinoma  are  studied,  it  will  be  found  that  these  characters  are  of  the  .same 
general  description  as  those  of  adenoma.  In  either  case  there  is  a  mesh  work  of  fibrous 
or  sarcous  substance,  iVirming  sjtaces  in  which  cells  of  a  more  or  less  epithelioid  type  are 
packed  together.  The  difference  is  one  sometinies  requiring  close  observation,  and  not 
always  to  be  determined  quite  .satisfactorily,  wliilst  in  other  ca.ses  it  is  obvious  enough. 
The  structural  difl'en-nee  between  adenoma  and  carcinoma  lies  in  thi.s — that  in  an  adeno- 
matous tumor  the  glandular  epithelium  is  regular  and  composed  of  even-sized  and  rela- 
tively small  cells  whose  nuclei  are  generally  .single  and  do  not  contain  many  nucleoli ;  the 

/from  dreasij 


Adenoma 
Y-frorn  ireast, 

yroiLC/ry  cystic^ 


Adenoma  ^ 
i^rum  shin 
r^fcrc  arm) 


AdeTio-fibro- 
sarcoTna 
.  fyrum   ftp  J 


Microscopical  Anatomy  of  Adenoma. 

cells  do  not  vary  in  form,  and  line  the  follicles  of  the  adenoid  texture  in  an  even  and 
orderly  manner :  whilst  in  carcinoma  the  nuclei  in  the  cells  are  larger  and  brighter  and 
have  many  nuclei,  and  the  cells  vary  much  in  form  and  size  and  compose  usually  compact 
masses  projecting  into  irregular  bulbs  in  the  sarcous  stroma,  instead  of  lining  follicular 
cavities. 

LYMPHOMA. 

The  name  "  lymphoma  "  is  given  to  such  growths  as  have  a  microscopic  structure 
like  that  of  lymphatic  glands — in  particular,  which  have  a  finely  reticular  meshwork, 
connected  with  which  are  some  fixed  cells  at  tolerably  regular  intervals,  not  unlike  the 
fixed  cells  of  connective  tissue,  but  generally  larger.  AVithin  the  meshes  of  this  net- 
work are  numerous  cells  which  resemble  lymph  cells,  and  hence  are  also  like  pus  cells 
and  white  blood  cells.  The  proportion  of  network  to  the  contained  lymphoid  cells  is 
variable  ;  sometimes  the  quantity  of  fibre  is  great,  and  the  structure  is  then  like  lymph- 
gland  tissue  hardened  by  chronic  inflammation.  In  other  cases  the  proportion  of  cells 
becomes  very  large,  while  the  network  grows  very  delicate  and  open-textured.  The 
fixed  stellate  cells  here  appear  to  multiply  and  produce  a  progeny  of  the  loose  movable 
cells  in  the  meshwork.  as  if  infected  by  the  latter.  The  whole  mass  then  appears  as  fine 
filaments  making  bold  meshes,  which  are  filled  with  round  granular  cells  like  lymph  cells, 
but  generally  larger  than  these,  and  having  large  nucleus  and  many  bright  nucleoli.     Such 


150 


SARCOMA. 


cells  at  first  appear  to  make  up  the  whole  substance,  but  they  easily  brush  or  wash  out 
of  the  meshes,  leaving  the  network  very  conspicuous.  It  will  be  noticed  that  the  degree 
of  structure  here  described  is  very  rudimentary.  Indeed,  sections  of  ante-viorlem  blood 
clot  from  within  a  vein  (see  figui'c)  closely  correspond  to  the  description.  So  also  does 
tubercle  in  the  more  recently  formed  outer  edge  of  it,  where  its  texture  is  very  like  blood 
clot ;  hence  it  is  by  some  classed  with  lymphoma.  Scarlatinous  tonsils  and  typhoid  Pey- 
er's  patches  likewise  have  lymphoma  structure.  However,  the  plan  of  structure  is  so 
meagre  that  it  is  not  enough  to  form  a  bond  of  union  between  diseases  clinically  so 
remote. 

When   found  in   the  form   of  tumors,  more  properly  so  called,  lymphoma  generally 
takes  its  rise  in  the  lymphatic  glands ;  those  of  the  neck  are  especially  liable  to  it,  then 

Fig.  42. 

Ante-morfem 
fi/uocl-  clot 


fffroma 

jltnfi//i 
ouL 


Cervical 
Glani/t 


Tonsil  in 
Scarlatina 


fi/irem/inq 
inlt     '^ 


Tubercle 


_^^, 

I'm/I  aubmiLcoiiE  coat  ojjh  vm/iri7'//i//n//cil/(il 
Microscopical  Anatomy  of  Lymphoma. 

those  of  the  abdomen  and  of  the  mediastinum.  It  is  also  found  in  the  alimentary  canal, 
especially  the  small  intestine  and  stomach,  and  in  the  spleen,  liver,  kidney,  etc.  For- 
mations of  a  similar  structure  have  been  met  with  in  various  organs  in  leukfemia,  chiefly 
in  the  liver,  in  the  form  of  small  grains  of  a  pale  substance. 

Lymphoma  may  prove  malignant — that  is.  infectious  to  parts  around — especially  when 
the  cellular  elements  are  very  numerous  (in  which  case  the  tumor  is  called  ^- lympho-sar- 
coma"  by  Virchow)  ;  it  then' corresponds  to  a  part  of  what  used  to  be  included  under  the 
whole  name  "  medullary  cancer,"  which,  as  formerly  used,  would  include  also  soft  .sar- 
coma and  soft  carcinoma.  Indeed,  these  tumors,  when  the  cell  elements  greatly  prepon- 
derate, become  very  much  like  each  other,  if  not  undistinguishable  as  far  as  their  mere 
structure  is  concerned. 

SARCOMA. 

The  schematic  figure  (43)  is  composed  of  accurate  drawings  of  portions  of  the  several 
kinds  of  sarcoma  named,  but  they  are  gathered  together  in  a  diagrammatic  way.  the  forms 
being  graduated  into  each  other  as  they  are  when  found  side  by  side  in  the  same  tumor. 
You  meet,  indeed,  with  all  gradations  of  intermediate  forms  ;  for  although,  as  a  general 
rule,  one  kind  of  sarcomatous  tissue  prevails  in  a  tumor,  it  is  far  from  unfrequent  to  have 
more  than  one  of  the  kinds  present  together,  the  characters  of  each  changing  into  those 
of  the  other. 

The  distinctive  histological  character  of  surcoma  is  the  possession  of  a  stroma  between 
the  cells,  an  atmosphere  of  intermediate  matter  which  surrounds  each  and  is  between 
them  all ;  the  qualities  of  this  intermediate  or  "  intercellular  "  matter  determine  the  kind 
of  sarcoma,  as  in  the  class  of  connective  tissues  whose  developmental  stages  the  several 
kinds  of  sarcoma  closely  resemble.     The  class  of  connective  tissues  includes  the  several 


MYXOMA. 


lol 


kinds  of  texture  whoso  office  in  ilir  ImmIv  is  ]>as.sively  mechanical,  either  in  serving  as 
adjuncts  to  the  luuscuhir  syslrui  or  l»y  tillinii  up  interstices  between  (»rj;ans  of  the  body 
or  by  entering!  into  textures  to  support  tlu'ir  component  j)arts,  bhjod  vessels,  etc.  Those 
connective  tissues  wliicli  penetrate  info  iiiiy  ol'  tlie  organs  of  the  body  are  modiii<-d  in 
consistence  and  in  arrangemt'Ut  of  ilnir  cIcnKiits  according  t(j  the  re<|uirements  of  the 
organ.  Thus,  in  the  brain  the  coniu'ctive  tissue,  caMed  "neuroglia,"  is  very  dulicate  and 
soft  and  has  scarcely  any  distinctness.  Also  the  connective  tissue  which  enters  into  the 
lymphatic  glands  bcconu-s  reduced  to  very  soft  fibrillar  matter  between  the  lyniph  cells. 
In  these  instances,  and  in  others,  the  connective  tissue  thus  comes  to  have  j»eculiarities 
and  to  constitute  strongly-marked  varieties.  Vet  all  connective  ti.ssues  possess  this  com- 
mon feature  in  their  elenuMitary  structural  composition — that  they  are  made  up  lA'  cell- 
ular bodies  between  wliich  their  proper  substance  forms  an  intercellular  matter. 

The  relation  of  sarconui  to  the  connective  class  of  tissues  appears  to  be  thi.s — that 
when  one  of  these  tissues  i.s  produced  very  rajtidly  it  has  no  time  for  its  intercellular 
matter  to  ac(|uire  the  i)roper  characters,  and  so  remains  indeterminate,  while  it  also  is 
small  in  quantity,  the  cells  greatly  preponderating.  Thus,  any  of  the  normal  connective 
tissues  may  produce  by  rapid  development  a  tumor  of  .sarcous  tissues  or  sarcoma  (the 
name  is  well  chosen  :  thii^,  wliich  e((uals  caro  or  our  word  Jfish,  means  commonlv  any 
soft  animal  substance,  not  blood  nor  bone).  Thus  it  follows  that  there  are  several  kinds 
of  sarcoma,  according  to  the  tissues  from  which  they  are  developed.     The  principal  of 


Fig.  43. 

Lai-ge 
Trabecular  Spindle -cell  Spin  file  rell 
jicutly  cross  cut  ^ 


Giant -cell 
orMyeloid 


Fibro 


Traiecular    /(y\^/r^     >/ 


croKS-cut 
at  -J- 


Sarcoma      VJ /  L/^  ^ff^ 

Glw  Sarcoma        -•  9 
orifwi[li  mucous  Intercellular 
Mys-U  Sarcoma 


Small  Round   Cell 
or  Ly7nj)ho  Sarcoma 


these  are  seen  in  the  above  schematic  figure.  The  round-celled  kinds  generally  arise 
from  lymph  gland  or  neuroglia  or  mucous  tissue ;  hence  they  are  common  in  myxo-  or 
glio-  or  lympho-sarcoma.  The  spindle-celled  kinds  arise  from  connective,  fibrous,  or  bony 
tissue,  and  hence  are  most  common  in  fibro-sarcoma  or  osteo-sarcoma. 

One  other  form  of  sarcoma  is  usually  described,  the  alveolar  sarcoma,  which  is  not 
mentioned  here.  It  is  a  rare  form  of  tumor,  and  resembles  superficially  a  cancer  or  car- 
cinoma. It  is  formed  of  a  stroma,  which  maps  out  large  spaces,  and  these  are  filled  with 
large  round  cells.  By  careful  pencilling  the  characteristic  intercellular  substance  may 
be  distinguished. 

MYXOMA. 

The  name  "  myxoma"  is  given  to  all  tumors  of  connective-tissue  type  (not  epithelial) 
which  contain  mucus  or  mucin  in  their  intercellular  matter.  It  corresponds  nearly  to 
gelatinous  sarcoma,  collonema.  and  fibro-cellular  tumor  of  old  authors  ;  tlie  forms  of  the 
cells  are  very  variable,  but  in  the  most  typical  examples,  and  especially  in  the  older  and 
fully  developed  parts,  the  cells  are  large  and  usually  multipolar  or  ''  stellate."  with  a  dis- 
tinct nucleus  and  nucleolus  :  the  stellate  branching  rays  of  the  cells  are  mutually  con- 


152 


MYXOMA. 


nected.  so  as  to  form  a  more  or  less  open  network,  in  the  interstices  of  which  the  mucous 
semi-fluid  lodges.  Beams  and  bands,  which  generally  have  a  stiff,  rigid  appearance  and 
an  angular  rather  than  a  wavy  disposition,  pass  about,  dividing  up  the  substance  of  the 
tumor  into  very  imperfectly  defined  sections  more  or  less  visible  to  the  naked  eye ;  from 


Fig.  44. 

Myxomatous  EncJumdroma 


Stellate-cell 
Myj.vma 


'^^  LeijiTma 


SruhondwmcK 


Eound  cell 
Myxoma 


Spindle  cell 
Myxoma 


these  arise  fine  fibrils  continuous  with  the  cellulo-fibrillar  network.  Much  of  the  tumor. 
and  especially  the  younger  part,  may  be  found  formed  of  spindle-cells :  these  are  really 
connected,  by  threads  from  their  sides,  with  the  intermediate  fibrillar  network,  and  it  can 
often  be  seen  that  the  stellate  forms  are  produced  by  the  drawing  out  of  these  threads  to 
greater  lengths,  through  the  .separation  of  the  texture  elements  by  the  increasing  quan- 
tity of  mucus.  In  yet  other  examples  or  parts  the  prevailing  form  of  the  cells  is  round 
or  with  one  pole :  the  round  cells  resemble  ordinary  mucous  corpuscles  and  are  scattered 
among  the  fibrils  in  the  mucoid  matter :  they  also  contain  many  fat-grains  and  are  found 
in  the  oldest  part?  of  the  tumor,  representing  the  senescence  of  its  cells.  There  is  also  a 
great  variability  of  the  intercellular  sub.stance — first,  in  proportion  of  the  fibrous  to  the 
cellular  part ;  and  second,  in  the  proportion  which  these  solid  elements  bear  to  the  mucoid 
interstitial  matter :  thus,  there  is  a  fibrous  myxoma  and  a  clear  pellucid  variety,  with 
much  mucous  fluid,  pierhaps  even  forming  cysts  (hyaline  and  cystic  myxoma).  In  some 
examples  there  are  large  polynucleated  cells  identical  with  the  so-called  giant  cells  of 
"  giant-cell  "  sarcoma. 

In  the  theory  of  types,  myxoma  is  affiliated  to  certain  natural  tissues,  in  particular 
the  jelly  of  the  umbilical  cord,  the  vitreous  of  the  eye  at  a  stage  of  its  development,  and 
the  early  stages  of  adipose  tissue,  or  to  a  stage  of  bone  formation  out  of  cartilage.  It 
will  be  seen  that  these  typical  tissues  are  onlv  transitory  in  their  nature  as  compared 
with  .such  stable  tissues  as  bone,  cartilage,  tendon.  In  accordance  with  this  instability 
of  their  type,  myxomas  themselves  .show  many  transitions  to  various  kinds  of  connective 
tissue  :  these  transitions  are  chiefly  toward  cartilage  or  fat  (myxomatous  enchondroma. 
myxomatous  lipoma).  Tumors  are  not  infrequent,  especially  in  the  parotid  region,  which 
are  intermediate  between  cartilage  and  mucous  tissue,  .so  that  one  cannot  say  to  which 
they  most  properly  belong ;  also  many  fatty  tumors  .show  clear  gelatinous  patches  of 
mucous  tissue  in  all  transitions  to  fat,  while  many  myxomata  .show  opaque  spots  composed 
of  true  adipose  tissue. 

rARflXOMA. 

The  term  ••  carcinoma"  is  now  distinctively  applied  to  such  tumors  as  have  a  structure 
of  the  following  description — viz.,  a  mcshwork  of  fibrous  or  sarcous  substance  compo.sing 
an  alveolar  structure,  whose  interstices  are  filled  with  cells.  These  may  have  no  orderly 
or  methodical-looking  arrangement,  being  packed  in  the  crevices  in  the  mcshwork  (or 
alveoli,  as  they  are  called^  and  extending  casually  from  alveolus  to  alveolus,  so  as  to 


C'J/.v7.Vo.i/.|. 


153 


luake  a  oumpleuu'iitary  iiu'sliwork.  TIk-  carciiH.niatous  cliaracter  in  determined  Vjy  the 
presence  dl"  sueli  alveolar  structure  with  cell  ciilleeti(»iis  lodjred  in  it;  the  decisive  point 
consists  in  these  cells  lyinj;  dose  toj^ether  without  any  intercellular  suhstance  ;  the  cells 
generally  vary  in  shape  and  have  larj^e  nuclei,  with  lar^rc  and  bri<rlif  nu<le(»li.  But  often 
the  cells  have  an  arran^renient  very  like  the  e|iith(lial  liniii<r  of  the  follicles  of  the  secret- 
injr  Inlands — a   stnictiirr  wliich   may  Itc  mi  well  iirondunced  as  to  hriii^^  tlnni  almost  into 


Jlitrd 

Cari'inomo 
(Livrrsecoiiitl' 
t,(,r»,xl  l/,r 
right  side  shcu 
halftrmis/'ornwt 
fiver  hysurl/u 
Ifft  scirrhous 
stihstnncc,  I hr  cells 
alinosf  thvimllctl 

Utl'tll/-) 


r^ 


Hard 
Cnrrinoina 
(yifeurn,  scoml^^  \ 
to  brenst,  l/u 
eerr/i/  sluc/r 
at  Uiis  (nil J 


Cen^iJ ,  nr  All  rolrjr 
Curci/idiiia  {'nc/ii/Ji 
frir/ht  side  s/iotis 
lAe  rfids  n/two 
Lider/Kii/infullidcs, 


^  Ctirrinoiiiit 
Cerebrl/iuii,  srcotidtirtf 
lu   l/rcast^ 


&rft  Carruiomn 
(Kidney  steont/z/r'/  iO 
fis.  (K.'iop/ia(^a\'.  louvr 
hfl  /land  coriur  showi 
.  II  mull  (uliuti  u'lHi  a 
C(jsl  ;  l/it  lun  caneir 
.a rent  UP  luxl  III  is  air 
■vidrntli/  transfonna- 
'niris  of'sm:h  lu/ics 
Hiqlil  fdi/c,  new  yra- 
iiiitf  (i^suc  i;/  the 
>tromaf Lefl  edye, 
drve/op  -'  of  l/iis  ialo 
a  spi/idie  cell  Slrai/ia 


Hard  Carcinoma 
(pleura  S(cy 
lu    breast. 

I  he  oldest 
part  at 

I  his  end) 


FipilAe/ioma  or 


uilhelial  CarcC- 


Cy/t  rider  - 
£/iillielieil 

Ce/r,  iiioiiut 

I'coluii,  tt  ^ 

sinit/tirstrito  [^ 
t:urrjFiiiiJid 
in  li'ver  fif 
same  casrj 


I  ma  ^shtfi  of 
':,  e/r  sk/>u  i/iy 
/land-like 
si  rielure  resemS- 
liny  a/so  t/ie  lym  - 
'  phaltc  ducts,  several 
dirds  Pfsl  todies  are 
seen   I  lie  slrvma  it 
of  coi/ntcltve  lis- 
siie  ^  tiiphlu  clierr- 
aid  with    T/ciiiQ 
•    cells.)     -^      ^ 


£/iithelioniei  , 

or  K/iilheliiil 

Curcitio/iKt 


SfitMioma 

or 
Epithrlial 
CarnTuma 


Separate 
Cells 


Microscopical  Anatomy  of  Carcinoma. 

continuity  with  adenomas ;  they  differ  from  these  chiefly  in  their  history,  as  being  infec- 
tious, so  as  to  extend  into  the  neighboring  tissues,  to  the  glands,  or  to  the  viscera,  the 
structure  showing  only  those  minor  peculiarities  which  I  have  just  described. 

Five  leading  types  of  carcinoma  may  at  present  be  conveniently  distingui.shed  : 
1st.  Those  in  which  the  fibrous  meshwork  is  in  preponderance  and  the  epithelioid  con- 
tents of  the  alveoli  arc  scanty,  and  perhaps  also  prone  to  perish  early,  so  that  they  are 
found  more  or  less  degenerate  within  the  fibrous  meshes :   Hard  Carcinoma,  or  Scirrhus. 
2d.   Those  in  which  the  fibrous  meshwork  is  in   smaller  proportion  and  the  epithelioid 


154  CARCINOMA. 

contents  are  plentiful,  making  large  collections  of  cells,  but  with  no  evident  approach  in 
the  form  of  these  collections  to  the  shapes  of  gland  acini,  and  no  evident  resemblance  of 
the  component  cells  either  to  the  columnar  epithelium  of  mucous  glands  or  the  squamous 
epithelium  of  cuticle :  Soft  Carcinoma.  This  kind  occurs  especially  in  glands,  and  the 
transformation  of  the  glandular  tubes  or  follicles  to  cancer  alveoli  can  be  seen  in  all 
stages  in  the  growing  margin  of  the  tumor.  (See  the  two  upper  drawings  in  Fig.  45, 
from  the  liver  and  kidney.) 

'3d.  A  structure  essentially  such  as  that  last  described,  but  with  this  difference — that 
the  epithelioid  cells  have  a  quantity  of  mucus  between  them,  which  is  regarded  as  arising 
from  a  transformation  of  them.  This  change  to  mucus  may  be  carried  to  such  an 
extreme  that  scarcely  any  cellular  elements  are  left,  while  the  alveolar  meshes  in  which 
the  mucus  is  contained  become  very  strikingly  visible  from  their  nakedness  and  the  pellu- 
cidity  of  the  mucus  :  Colloid,  or  Alveolar  Cancer.  A  common  seat  of  this  is  the  wall  of 
the  alimentary  canal,  where  it  may  be  traced  arising  from  Lieberkiihn's  follicles. 

4th.  A  structure  in  which  the  epithelial  cells  resemble  squamous  epithelium  and  form 
masses  which  are  very  like  the  follicles  of  cutaneous  glands,  or  occasionally  like  rudiment- 
ary hairs ;  the  tubular  and  bulbous  forms  may,  however,  be  seen  ramifying  like  the 
lymphatic  vessels  of  the  skin,  as  if  their  form  were  moulded  to  the  lymphatic  plexus : 
Epithelioma.  In  these  cancers  peculiar  bodies  are. found,  composed  of  flattened  cells 
disposed  concentrically  so  as  to  form  a  scaly-walled  globe  (a,  Fig.  45)  who.se  appearance 
is  like  the  section  of  an  onion  or  like  a  bird's  nest ;  these  are  so  large  as  often  to  be  vis- 
ible to  the  naked  eye ;  when  they  are  numerous  and  well  characterized,  they  are  diag- 
nostic. Some  authors  (Billroth)  distinguished  a  variety  of  this  cancer  in  which  the 
stroma  preponderates  over  the  epithelial  part,  calling  it  scirrhus  of  the  skin  :  Squamous 
p]pithelial  Carcinoma. 

5th.  A  structure  in  which  the  epithelial  cells  resemble  ordinary  columnar  epithelium, 
and  the  structure  itself  is  quite  like  normal  mucous  membrane,  in  which  it  always  pri- 
marily arises  (alimentary  canal,  especially  colon,  uterus)  ;  the  secondary  formations 
which  occasionally  occur  in  these  cases,  in  the  liver  especially,  have  the  same  .structure, 
and  thus  a  tissue  like  the  glandular  mucous  membrane  of  the  colon  may  be  found  in  the 
liver  :   Cylindrical  Epithelial  Carcinoma. 

The  fourth  and  fifth  varieties  are  distinguished  from  the  three  first  as  epithelial  can- 
cers or  epitheliomata.  Some  authors  have  used  the  term  "  cancroid  '"  for  the  fourth 
variety,  as  though  it  were  not  completely  cancerous.  These  are  less  likely  to  infect  the 
viscera  than  the  first  two  varieties,  which  are  the  most  infectious  of  all  tumors,  though 
they  are  very  far  from  being  the  only  kinds  of  infectious  tumors. 

YiRCHOW,  7)/e  Krankhaften  Gesehwuhte,  1862— 5. — Paget,  Surylcal  Padiolotjii,  1870. — Abkrnethy, 
On  Tumors. — Pathological  Societi/  Trans. — WiLKS  and  Moxon,  Pathology.— Bu.i.B.OTii,  Eteviens  de 
Pathologie  Chirurgicale,  1868. — Holmes,  System  of  Surgery,  1882. — Debate  on  Cancer  of  Pathological 
Society,  1874. 


SURGERY  OF  THE  CUTANEOL.S  ^V.STEM. 


CHAPTER    IV. 
CONTUSIONS. 

A  "contusion"  is  an  injury,  caused  either  by  a  fall,  a  blow  from  a  blunt  instru- 
ment, or  sevtMv  pressure,  in  which  there  is  no  .solution  of  continuity  of  the  skin.  The 
degree  of  injury  depends  upon  the  amount  of  force  a])])licd  and  the  re.sisting  power  of  the 
tissues  injured.  Ilealthy  tis.sues  .suffer  little  where  the  soft  or  unhealthy  suffer  much. 
The  subjects  of  hioniophilia  fare  worse  than  all  others.  When  the  force  has  been  suf- 
ficient to  produce  rupture  of  the  small  vessels  in  the  skin  and  subcutaneous  tissue,  an 
"  ecrlii/niosiV  or  "  hniixe"  is  said  to  exist;  when  it  so  injures  the  deeper  tissues  a.s  to 
cause  effusions  of  blood  from  rupture  of  some  of  the  larger  vessels,  '•  fxtravasation  of 
hloo(V'  is  said  to  be  present  ;  when  the  blood  effused  fijrms  a  local  swelling,  it  is  known 
as  a  "  hir.mntunKi.' 

After  a  slight  contusion  there  may  be  no  luuising.  but  only  local  pain  and 
swelling,  the  swelling  becoming  red  and  then  disappearing.  The  wheal  that  rises  after  a 
lash  with  a  whip  is  the  best  illustration  of  this  condition. 

An  **  ecchymosis"  is  an  effusion  of  blood  iato  the  skin  and  subcutaneous  tissue, 
and  it  shows  itself,  according  to  the  force  employed  and  depth  of  tissue  injured,  within  a 
few  minutes  or  hours  of  the  injury,  as  a  livid  red,  deep-blue,  or  black  patch,  which  in  the 
course  of  twelve  or  eighteen  hours  becomes  larger  and  lighter  at  its  margins.  About  the 
third  day  it  assumes  a  violet  tint ;  on  the  fifth,  an  olive  brown  ;  on  the  sixth,  a  green  ; 
on  the  seventh  or  eighth  it  has  a  yellow  aspect,  and  this,  fading  into  a  lemon  tint,  then 
disappears  altogether.  An  ordinary  bruise  generally  runs  through  all  the.se  stages  in 
about  two  weeks,  the  rapidity  of  the  process  depending  much  upon  the  amount  of  blood 
effused  and  the  reparative  power  of  the  patient.  When  no  blood  has  been  effu.sed  into 
the  skin,  but  '■  extravasation"  has  taken  place  in  the  deeper  parts  beneath  a  dense  fascia, 
the  discoloration  of  the  integuments  may  not  appear  for  three,  four,  or  even  fourteen, 
days,  while  in  some  cases,  where  the  blood  has  made  its  way  between  the  tissues  and 
reached  the  skin  away  from  the  seat  of  injury,  the  "ecchymosis"  will  be  at  some  distance 
from  the  spot  at  which  the  injury  was  received  and  may  not  show  till  late.  When  much 
effused  blood  exists,  the  swelling  will  be  great. 

The  (tbstiicf  of  ecchymosis  is  no  proof  that  a  contusion  ha.s  not  been  experienced,  since 
a  fatal  rupture  of  deep  parts  or  of  some  viscus  may  be  present  without  any  external  signs 
of  injury. 

On  making  a  section  of  a  bruised  part  the  skin  will  be  found  throughout  its  thickness 
infiltrated  with'  blood  and  firmer  and  thicker  than  natural :  whereas,  when  the  effusion 
has  been  the  result  o?  violence  applied  to  the  body  after  death,  the  blood  will  be  beneath 
or  upon,  but  not  in,  the  cutis,  and  it  will  be  in  small  quantities  and  venous. 

Neither />(/;y)»/v'('  putclii't^  nor  those  o^ ''' erj/thema  ^lodosuni'  ought  to  be  ni'staken  for 
bruises.  The  general  diffusion  of  the  spots  over  the  body  in  the  one  case,  and  the  history 
and  the  general  aspect  of  the  other  affection,  should  prevent  the  error.  It  should  be 
remembered,  however,  that  in  purpuric  patients  and  in  '•  bleeders"  a  slight  blow  or  pinch 
may  be  followed  by  a  severe  bruise. 

A  severe  contusion  may  cau.se  a  rupture  of  a  large  artery  or  vein,  under  which 
circumstances  a  fatal  extravasation  may  ensue  ;  or  it  may  so  crush  or  pulp  the  tissues  as 
to  destroy  their  vitality  :  this  a  spent  cannon-ball  may  accompli.sh  ;  or  it  may  so  rup- 
ture a  viscus  as  to  cause  death.  More  frequently,  however,  a  severe  contusion  causes  a 
separation  of  the  skin  from  the  deep  "tascia  and  deeper  parts,  with  more  or  less  extravasa- 

155 


156  ARROW   WOUNDS. 

tion  of  blood  into  the  split  tissues.  The  effects  of  a  contusion  also  vary  according  to 
locality  ;  thus,  in  an  adult,  a  blow  over  the  scalp  may  be  followed  by  a  local  effusion  of 
blood,  and  in  a  child  this  effusion  may  go  on  so  as  to  form  a  swelling  involving  more  or 
less  of  the  whole  vertex.  In  the  buttocks  and  loins  blood  may  be  so  effused  as  to  give 
rise  to  a  large  fluctuating  tumor.  In  the  loose  cellular  tissue  of  the  scrotum  or  female 
genitals  an  effusion  of  blood  may  give  rise  to  enormous  enlargement,  and  in  the  eye  every 
one  is  familiar  with  the  change. 

Where  the  extravasation  of  blood  has  been  extensive,  the  removal  of  the  clot  is  a 
work  of  time.  In  some  cases  the  blood  remains  fluid  for  a  long  period,  and  at  length 
becomes  absorbed ;  in  others  it  breaks  down  and  gives  rise  to  suppuration.  In  some, 
again,  it  persists  for  weeks  as  a  large  blood  tumor,  and  then  suddenly  softens  down  and 
is  absorbed.  In  exceptional  instances  it  becomes  apparently  encysted  ;  and  "  there  is 
sufficient  reason  to  believe,"  says  Paget,  "  that  blood  extravasated  in  a  contusion  may  be 
organized,  acquiring  the  character  of  connective  tissue,  becoming  vascular,  and  taking 
part  in  the  repair  of  the  injured  tissues,"  as  is  seen  in  the  repair  of  fractures  and  in  liga- 
tured or  twisted  vessels. 

Treatment. — A  slight  bruise,  if  left  alone  and  not  manipulated,  will  get  well ;  for 
blood  is  often  rapidly  absorbed,  as  is  seen  in  the  eye.  To  check  extravasation,  cold  is  the 
best  application,  in  the  form  of  pounded  ice  in  a  bag,  or  a  mixture  of  salt  and  saltpetre, 
or  the  iced  poultice,'  or,  what  is  far  better,  Leiter's  metallic  coil  (Fig.  9,  p.  49),  and  in  an 
extremity  elevation  of  the  limb  with  rest.  To  check  any  inflammatory  action  during  the 
progress  of  the  case  cold  is  equally  effective.  To  hasten  the  absorption  of  the  effused 
blood  tonics  are  often  of  service,  and  the  application  of  gentle  pressure  by  means  of 
bandages  or  strappings  is  valuable. 

A  lotion  of  the  tincture  of  arnica  one  ounce  to  a  pint  of  water,  or  one  of  the  stimu- 
lating liniments,  such  as  the  soap  or  opium,  seems  to  have  some  influence  in  hastening 
the  absorption  of  blood. 

In  cases  in  which  there  is  extensive  effusion  of  blood,  and  where  the  circulation  in 
the  part  is  interfered  with,  lint  soaked  in  oil  and  covered  with  cotton-wool  is  the  best 
dressing  to  maintain  warmth  in  the  part ;  moist  applications  are  not  good. 

When  the  blood  remains  fluid  and  is  not  absorbed,  the  surgeon  need  be  in  no  hurry 
to  interfere,  for  occasionally  interference  brings  trouble,  although,  when  time  pres,ses,  the 
use  of  the  "aspirator"  to  draw  off'  the  blood — or,  rather,  bloody  serum — often  expedites 
recovery.  AVhen  aspiration  has  proved  ineffectual  and  a  blood-clot  remains,  this  should 
be  evacuated  by  a  free  incision,  and  the  exposed  cavity  irrigated  with  iodine,  boracic  acid, 
or  carbolic  lotion  and  then  drained,  well-applied  pressure  and  immobility  of  the  part  being 
employed.  When  the  blood  has  broken  up  and  suppuration  appeared,  a  free  incision  is 
essential,  the  case  subsequently  being  treated  as  an  abscess. 

Arrow  Wounds. 

These,  which  are  punctured  and  incised  wounds,  have  been  made  the  subject  of  a 
special  essay  by  Dr.  Bill  in  the  American  Journ.  of  Med.  Science,  vol.  xliv.,  1862.  He 
tells  us  that  it  is  exceptional  to  meet  with  single  wounds,  the  American  Indians  discharg- 
ing their  arrows  so  rapidly — an  expert  delivering  six  in  a  minute — that  if  one  takes  effect 
it  is  immediately  followed  by  others.  The  Washington  Army  Medical  Museum  contains 
specimens  of  penetrating  arrow  wounds  of  the  skull.  Where  both  tables  are  punctured 
there  is  little  or  no  Assuring  externally  or  internally,  as  the  vitreous  table  is  penetrated 
as  cleanly  as  the  outer.  "  This  is  in  such  marked  contrast  to  the  results  of  bayonet  or 
sword  thrusts,  or  of  the  impact  of  gunshot  projectiles,  as  to  merit  notice." 

Arrow  wounds  of  the  chest  are  not  always  fatal ;  those  of  the  abdomen  are  generally 
so.  Dr.  Bill  tells  us  that  the  Indians,  on  this  account,  always  aim  at  the  umbilicus,  and 
that  the  Mexicans  when  fighting  the  Indians,  on  this  account,  always  protect  the 
abdomen. 

The  velocity  of  the  arrow  when  first  projected  is  so  great  that  it  has  been  estimated 

'/ce  poultices,  as  suggested  by  Maisonneiive,  are  excellent  for  tlie  local  application  of  cold,  and  are 
made  as  follows;  Take  of  linseed  meal  a  sufficient  quantity  to  form  a  layer  from  three-quarters  to 
an  inch  thick  ;  spread  a  clotii  of  proper  size  ;  upon  this,  at  intervals  of  an  inch  or  more,  place  lumps 
of  ice  the  size  of  a  big  marble;  then  sprinkle  them  over  lightly  with  the  meal,  cover  with  another 
cloth,  folding  in  the  edges  to  prevent  the  escape  of  the  mass,  and  apply  the  thick  side  to  the  surface 
of  wound.  The  exclusion  of  air  retards  tlie  melting  of  the  ice,  and  the  I  hick  layer  intervening 
between  it  and  the  surface  prevents  painful  or  injiu-ious  contact.  In  injuries  to  the  abdomen  this 
remedy  is  very  applicable.     Dr.  W.  H.  Doughty  of  the  U.  8.  A.  speaks  highly  of  it.     Circular  No.  3. 


Ji[riL\S  AM>  SCALDS.  157 

to  etjiuil  nearly  that  of  a  imiski't-liull,  hut  arrow-tirin;;  is  incfl't'ctive  over  a  hundrcil  yards. 

At  a  short   distaiici'   an   arrow    will    pcrloratc   tli»; 

larjji'r  hones   without   conMniniitiiiL'  them,  or  will  Fio.  ■!*). 

cause  a  slijjhl    tis.sure  only,   reseinhlini:;    in   these  JB 

respects  the  efieet  of  a  pistol-hall  Kred   throu";!!  ;i  ,    ^^^ 

pane  of  i;lass  a  few  yards  off.      This  is  well   seen    /'  .  .    ^ 

in  the  drawing;  (l'"'^-  ■^^*)-  \  ^^-"^^    ~  j 

The  wound  of  entrance   in   the  soft  parts  is  a    [_        ^--^^^  ^^^''^^  -  ■' 

contusetl  depressed  slit;   tliat  of  exit,  a  mere  slit.  .,  ,    „  ,  ,,         .  ~ 

\\  hen    an   arrow   strikes    tlu?   skin   ol>li(|uely,   tlie  (.surgeouGenfrara  (jtlke,  L.  .s.   <:iiL.  ;.) 

wound  will  l)e  that  of  a  loiii;  incised  wound. 

The  treatment  of  these  wounds  is  thus  summarized  hy  Dr.  IJill  ( Inti  ruationnl  Hniydo- 
j)tri/iit  of'  Siiiyrr//.  vol.  ii.): 

1.  \u  arrow-head  must  he  removed  as  s(jon  as  found. 

2.  in  the  seanli  for  the  arrow  e.vtensive  incisions  are  justifiahle. 
'A.    All  arrow  may  he  j)ushed  out  as  well  as  plucked  out. 

4.  The  tiiiLTcr  should  he  used  for  e.\i)loratioii  in  preference  to  a  probe. 

5.  (Ircat  care  must  be  taken  to  avoid  detachment  of  the  shaft. 

6.  Healing  by  tirst  intention  should  be  encouraged. 

BURNS  AND  SCALDS. 

A  burn  is  caused  by  the  ai>plicatioii  of  concentrated  '////  heat  to  the  body  ;  a  SCald, 
by  the  application  of  hot  or  boiling  li(|uid.  As  a  rule,  scalds  are  les.s  .severe  accidents 
than  burns,  because  water,  being  the  ordinary  fluid  through  which  the  scald  is  produced, 
is  never  hotter  than  212°  Fahrenheit;  yet  when  any  other  chemical  compound  is  the 
scalding  medium,  the  effects  are,  at  least,  often  as  bad  as  the  worst  burns.  The  worst 
local  burn  I  ever  saw  was  when  a  man  put  his  booted  foot  and  ankle  into  a  pot  of  molten 
lead.  Tiie  limb  came  out  covered  with  a  boot  of  metal,  and  was  destroyed  even  to  the  bones. 
Mr.  Aston  Key  amputated  the  limb  at  once  below  the  knee  without  removing  the  metal. 

A  moderate  degree  of  dry  heat  applied  in  the  pursuit  of  a  calling  indurates  the  skin 
and  blunts  its  sensibility,  and  an  iron-worker  or  a  blacksmith  can  maniijulate  pieces  of 
hot  iron  that  would  "  burn  "  ordinary  people.  Thus,  some  .skins  or  parts  of  the  body  are 
more  sensitive  than  others,  and  under  the  same  influence  may  be  differently  affected. 

The  effect  of  heat  when  applied  to  the  body  varies  according  to  its  intensity  and  the 
(hirnfion  of  its  application  ;  it  may  cause  a  simple  redness  of  the  surface  or  the  death  of 
the  part. 

Thus,  its  jirst  effect  is  mere  redness  and  tenderness  of  the  surf^ice,  and  after  a  few 
hours  the.se  .symptoms  may  subside,  the  cuticle  possibly  desquamating. 

In  the  second  (h'tjree  of  heat  inflammation  is  the  result,  this  action  manifesting  its  pres- 
ence by  the  formation  of  a  hiistcr,  from  the  effusion  of  serum  beneath  the  cuticle. 

In  the  third  degree  the  superficial  layer  of  the  true  skin  is  destroyed,  the  siir/nee 
appearinr/  of  a  graij-yeUoicish  or  hrorcn  color,  not  painful  unless  roughly  handled.  The 
vesicles  that  exist  contain  a  blood-stained  or  brown  fluid.  The  papilla?  of  the  skin,  with 
its  nerves,  are  first  destroyed ;  but  when,  in  the  course  of  a  day  or  so,  the  dead  surface 
has  been  -'shed"  and  the  nerves  exposed,  the  pain  is  very  severe  and  the  exposed  surface 
has  a  reticulated  surface. 

In  the  /our f/i  degree  the  whole  thickness  of  skin  is  destroyed,  with  more  or  less  of  the 
subcutaneous  cellular  tissue,  the  parts  being  converted  into  a  hard,  tough,  dry.  and  insensi- 
ble eschar  mottled  with  blood :  vesication  does  not  exist  in  this  degree,  all  the  superficial 
tissues  having  been  destroyed.  The  skin  surrounding  the  eschar  may  be  blistered,  but 
where  it  comes  in  contact  with  the  injured  part  it  will  ])e  drawn  into  folds  from  the  con- 
traction, owing  to  the  drying  of  the  burnt  integument  ;  this  puckering  fairly  indicates 
the  important  fact  that  the  whole  skin  has  been  destroyed.  The  eschar  does  not  begin 
to  separate  fur  four  or  five  davs,  an  inflammatorv  zone  of  redness  with  pain  of  some  sever- 
ity indicating  the  commencement  of  a  process  that  will  not  be  completed  for  two  or  three 
weeks.  When  the  slough  has  come  away,  a  long  and  tedious  process  of  suppuration  and 
granulation  must  be  gone  through  prior  to  the  repair  of  the  exposed  parts. 

In  the  Jj/th  degree  the  skin  with  the  deeper  parts  is  involved,  a  black,  brittle,  charred 
mass  taking  the  place  of  healthy  tissues. 

In  the  sixth  degree  the  whole  thickness  of  a  limb  is  carbonized. 

These  divisions,  originally   made  by  the  great  French   surgeon   Dupuytren,  .so  well 


158  BURNS  AND  SCALDS. 

accord  with  all  observation  that  they  have  been  invariably  adopted  by  modern  surgeons ; 
and,  although  in  burns  and  scalds  one  degree  passes  imperceptibly  into  another  and  in 
bad  cases  coexist,  in  the  main  they  can  be  made  out. 

Prognosis. — Next  to  the  intensity  of  the  heat  and  duration  of  its  application,  the 
extent  of  surf  ace  involved  is  the  most  important  point;  indeed,  as  regards  life,  it  is  of  far 
greater  importance  than  the  other  two,  because  a  superficial  burn  spread  over  a  large  sur- 
face, although  not  locally  so  injurious  as  a  more  severe  one,  is  more  fatal.  In  the  major- 
ity of  cases  of  deaths  from  burns  and  scalds,  more  particularly  in  children,  the  ri.sk  to 
life  is  fairly  to  be  measured  by  the  extent  of  surface  involved  ;  when  more  than  half  the 
body  is  injured,  a  fatal  result  generally  ensues.  A  severe  burn  of  a  limited  character 
may  be,  however,  only  a  local  affection. 

Thus,  the  danger  to  life  turns  upon  many  points.  In  both  young  and  old  all  burns 
or  scalds  of  any  extent  are  serious.  At  any  age  extensive  burns,  however  superficial, 
are  to  be  feared,  and  they  become  serious  from  their  immediate  depressing  effect  upon  the 
system  ;  patients  sometimes  die  from  shock,  and  the  very  bad  cases  are  marked  by  the 
sensation  of  coldness  and  persistent  shivering.  When  the  period  of  shock — which  varies 
from  twelve  to  forty-eight  hours — has  passed,  and  that  of  reaction  has  set  in,  other  dan- 
gers appear.  Should  the  injury  be  over  the  thoracic  cavity,  chest  complications  may  be 
looked  for  ;  and  if  over  the  abdomen,  intestinal  and  peritoneal  troubles.  Burns  and  scalds 
of  the  head  are  not  so  likely  to  be  followed  by  intracranial  as  those  of  the  chest  are  by 
thoracic  mischief.  All  intestinal  complications  should  be  carefully  observed,  as  there 
seems  to  be  a  liability  to  irritation  of  the  inte.stinal  mucous  tract,  which  may  terminate 
at  times  in  ulceration.  Dupuytren  first  observed  this  in  a  general  way,  but  Long  (Lond. 
Med.  Gaz.,  1840)  and  Curling  (Med.-Chitr.  Trans.,  \o\.  xxv.,  1842)  showed  that  ulceratioi. 
of  the  duodenum,  as  proved  by  inspection  after  death,  and  indicated  during  life  by  vomit- 
ing and  purging  of  blood,  is  by  no  means  an  unfrequent  result. 

Out  of  125  fatal  cases  collected  by  Holmes  and  Erichsen,  16  presented  ulceration  iii 
the  duodenum,  of  which  5  died  during  the  first  week  and  5  in  the  second,  the  situation 
of  the  burn  in  all  but  two  being  on  the  chest  or  abdomen.  "  The  ulcer  always  has  an 
indolent  aspect  and  is  situated  below  the  pylorus ;  often  there  are  two  or  three  close 
together ;  the  edges  of  the  ulcers  are  neither  raised  nor  everted ;  there  is  little  or  xuo  evi- 
dence of  inflammatory  effusion  in  their  neighborhood  ;  w^hen  they  ai-e  recently  formed, 
they  look  simply  as  if  a  pjortion  of  the  mucous  membrane  had  been  cut  out ;  but  when 
the  ulcer  has  penetrated  more  deeply,  so  as  to  threaten  perforation  of  the  gut,  lymph  may 
often  be  found  effused  on  its  peritoneal  surface.  Sometimes  the  glands  of  the  duodenum 
may  be  found  enlarged  "'  (Holmes). 

The  symptoms  of  duodenal  ulceration  are  most  obscure,  as  neither  pain  nor  tender- 
ness exists  ;  diarrha?a  is  neither  constant  nor  excessive  ;  vomiting  is  perhaps  a  more  com- 
mon symptom  ;  and  the  presence  of  blood  in  the  motions  is  highly  su.spicious.  When 
the  ulcer  has  perforated  the  intestine,  intense  pain,  vomiting  of  blood,  melrena,  collapse, 
and  abdominal  distension  mark  the  fact. 

It  should  be  noted  that  cicatrized  duodenal  ulcers  have  been  found  in  patients  who 
have  died  of  other  complications. 

Casting  Off  of  Sloughs. — In  the  second  or  injiamm atari/  stage  the  injured  parts 
are  being  thrown  off,  and  most  writers  allow  for  this  process  about  fourteen  days,  though 
in  some  cases  it  is  less  and  in  others  more.  When,  however,  the  slough  has  separated 
and  the  parts  begin  to  suppurate,  the  third  stage,  or  that  of  suppuration,  has  commenced. 
In  this  stage,  although  there  may  be  less  probability  of  visceral  complications  appearing, 
there  is  the  equally  great  danger  of  exhaustion,  hectic,  or  pyaemia,  Should  these  risks 
have  been  surmounted,  there  is  yet  the  long  and  tedious  process  of  the  healing  of  the 
granulating  surface,  and  at  a  still  later  period  evils  arise  connected  with  the  gradual  con- 
traction of  the  cicatricial  tissue.  This  contraction  only  takes  place  when  the  tcholc  skin 
has  been  destroyed.  When  the  surface  of  the  skin  merely  has  been  involved,  and  not 
its  depth,  the  sore,  on  the  removal  of  the  slough,  has  a  peculiar  net-like  appearance,  with 
a  whitish  or  yellowish  ground,  through  the  meshes  of  which  granulations  project. 

Cause  of  Death. — When  a  person  dies  from  a  burn  within  forty-eight  hours,  it 
arises  from  shock  or  collapse,  pain  doubtless  having  its  full  influence  ;  when  a  similar 
result  takes  place  during  either  the  stage  of  reaction  or  of  inflammation,  it  is  from  vi.s- 
ceral  complication  ;  and  when  during  the  third  or  suppurative  stage,  from  exhaustion, 
visceral  changes,  or  pya>mia. 

When  a  person  is  said  to  have  been  "burnt  to  death,"  he  dies  from  suffocation,  the 
fumes  of  the  fire  destroying  by  asphyxia,  and  the  fire  subsequently  burning  the  body. 


BURNS  AM)  .SCALDS.  159 

II:iH'  tho  oases  of  burn  aihniltiil  intu  a  hospital  <lir.  and  half  of  those  that  die  do  so 
within  tile  first  thfee  (hiys. 

The  total  deaths  in  Kn^land  and  Wales  in  a  y^'ar  (Voin  hnrns  and  sealds  are  about 
21M)(t,   the   feniah'S   not   hrinj;   uiiich   in   excess   of  the   males. 

Out  td"  ddS  eases  eonseeutively  admitted  into  (iuy  s,  275  were  femahis,  14.'{  males, 
the  majority  beiiiji,'  ehihlren  under  five  years  old.  Dr.  Steele  has  ahso  shown,  in  liis  Sep- 
t'liniiii  licjiint  of  Giii/'s  for  ISCtS,  tl\at  out  of  111')  cases  of  burns  from  fire  60  per  cent, 
died;  of  !(!!•  sealds,  ItJ.o  per  cent,  died;  of  18  burns  from  jras  e.xplosions,  11  percent, 
proved  fatal ;  and  of  28  ca.ses  of  burns  from  gunpowder,  14  per  cent,  succumbed,  the 
differonee  between  the.se  clas.ses  of  eases  being  very  great,  burns  lieing  four  times  as  fatal 
as  sealds,  and  tliese  half  as  fatal  again  as  gas  explosions,  ete. 

P.\Tli<»LO(}Y. — Holmes  has  gone  into  this  (juestiou  more  thoroughly  tlian  anv  other 
autlior  (Si/sfrtii,  ed.  :{d,  vol.  i.  p.  '-VJl),  and  has  given  us  an  analysis  of  <;8  fatal  cases 
examined  after  death.  Nine  died  from  shock  ir.  the  first  two  days,  all  being  children  ; 
17  from  exhaustion.  ')  within  the  week  and  12  at  later  periods;  .S,  all  burns  of  the  scalp, 
from  erysipelas;  .'5  from  pya-mia  ;  and  2  from  tetanus.  In  11  cases  of  children  cerebral 
complications  caused  deatn.  and  in  most  of  these  the  symptoms  appeared  soon  after  the 
accident.  In  ll  eases  infiammation  of  the  larynx  proved  fatal,  evidently  from  the  direct 
inhalation  of  the  flames;  in  12  ca.ses,  in  which  the  burn  was  thoracic,  chest  cf»mplication.s 
killed  ;  in  4,  abdominal  couiplications  proved  fatal,  and  one  of  the.se  had  peritonitis,  the 
result  of  a  deep  burn,  two  had  hemorrhage  from  ulceration  of  the  duodenum,  and  one 
had  vomiting  from  the  same  cause. 

Holmes  and  Erichsen  also  dwell  upon  the  fiict  that  cerebral  and  general  visceral  con- 
gestions are  always  present  in  fatal  cases  ;  indeed,  in  all  the  congestion  is  a  passive  con- 
dition due  to  the  "  sudden  revulsion  (jf  blood  from  the  surface,"  caused  by  the  skin 
injury. 

Tre.\t.ment. — In  all  burns  great  care  should  be  observed,  in  removing  the  clothes, 
to  save  the  cuticle.  Blisters  should  be  carefully  punctured  and  their  contents  evacuated, 
the  raised  cuticle  being  gently  pressed  down  to  the  true  skin  and  covered  by  dressings. 
When  the  patient  is  cold  or  shivering  exists,  he  should  be  covered  with  a  warm  blanket 
and  placed  near  the  fire,  some  wine  or  brandy  and  hot  water  being  administered.  Pro- 
fessor Hebra  speaks  well  of  the  warm  bath  under  these  circumstances.  When  the  injury 
is  extensive,  one  part  should  be  uncovered  and  dressed  before  the  other,  as  a  free  exposure 
of  the  surface  tends  to  increase  the  shock  and  adds  to  the  pain. 

Exclusion  of  Air. — As  pain  is  the  constant  accompaniment  of  all  burns  and  scalds, 
and  the  exclusion  of  the  air  from  the  injured  surface  the  best  means  of  neutralizing  it, 
the  surgeon's  object  has  ever  been  to  find  some  method  of  treatment  by  which  this  result 
can  be  secured  ;  and  at  Guy's  Hospital  the  application  of  carron  oil,  consisting  of  equal 
parts  of  lime  water  and  linseed  oil,  applied  on  lint  and  covered  with  cotton-wool,  has  long 
been  the  favorite  remedy,  the  whole  being  carefully  kept  in  place  by  a  bandage.  At 
University  College  the  burnt  surface,  of  whatever  degree,  is  well  covered  with  the  finest 
wheaten  flour  l)y  means  of  an  ordinary  dredger.  At  the  London  Hospital  the  application 
of  zinc  ointment  on  lint  is  employed.  Dr.  S.  Gross  of  America  used  white  lead  paint,  and 
more  recently  powdered  clay  has  been  employed.  Some  surgeons  advocate  the  use  of  a 
lotion  of  colnmon  soda.  I  have  recently  been  treating  burns  of  all  degrees  with  va.seline 
and  finely-powdered  boracie  acid  spread  on  lint  with  marked  success.  The  dressings  must 
not  be  changed  for  some  days — not,  indeed,  until  they  have  been  loosened  by  the  dis- 
charges or  become  offensive,  inasmuch  as  the  process  of  dressing  any  large  burn  is  neces- 
sarily painful,  and  consequently  injurious.  To  obviate  the  necessity  of  frequent  changes 
of  dressing,  carbolic  acid  has  been  used  dissolved  in  the  oil  in  the  proportion  of  one  part 
to  ten  or  more. 

Small  burns  or  scalds  may  be  treated  by  water  dressing,  lead  lotion,  collodion,  Friar's 
balsam,  goldbeater's  .skin,  flour,  chalk  and  water,  etc.  Two  parts  of  collodion  to  one  of 
castor  oil  is  also  an  excellent  application.  In  superficial  burns  this  treatment  is  probably 
all  that  is  required,  the  cuticle  being  re-formed  in  three  or  four  days,  and  beyond  some 
increase  of  redness  in  the  parts  the  cure  is  nearly  complete.  Opium  should  be  given 
early  to  relieve  pain,  and  where  it  is  severe  the  hypodermic  injection  of  morphia  should 
be  emploved. 

When  the  fraf  dressing  has  been  removed  and  the  surgeon  is  able  to  make  out  the 
extent  of  tissue  injured  as  well  as  the  depth  of  the  sloughs  that  are  expected  to  separate, 
some  stimulating  dressing  may  be  called  for,  to  hasten  the  sloughing  process.  Carbolic 
oil,  made  of  one  ounce  of  carbolic  acid  to  a  pint  of  olive  or  linseed  oil,  is  very  eff"ective, 


160  '  BUBNS  AND  SCALDS. 

or  an  ointment  made  of  carbolic  acid  5iv,  lard  5iv,  and  castor  oil  5j  ;  l^ut  these  drugs 
will  not  avail  when  a  very  large  surface  is  involved,  and  under  such  circumstances  they 
had  better  be  applied  to  the  sloughing  parts,  and  the  vaseline  and  boracic  acid,  carron  oil, 
or  zinc,  resin,  or  creosote  ointment,  n|^x  of  the  last  to  an  ounce  of  lard,  to  the  other  parts. 
A  lotion  composed  of  one  drachm  of  the  compound  tincture  of  iodine  to  a  pint  of  water 
or  powdered  iodoform  is  also  beneficial.  Sloughs,  as  they  loosen,  should  be  cut  away, 
but  never  dragged.  Deep  sloughs  are  well  treated  by  poultices,  the  turpentine  oint- 
ment hastening  their  separation.  When  the  surface  is  granulating  it  must  be  treated  as 
any  other  open  sore  ;  and  when  the  entire  thickness  of  skin  has  been  lost,  as  in  burns  of 
the  fourth  degree,  the  surgeons  closest  attention  is  needed  to  counteract  the  contraction 
of  the  wound  that  will  take  place,  thereby  preventing  the  advent  of  those  frightful 
deformities  with  which  all  are  too  familiar. 

This  can  be  done  by  extension,  applied  in  some  instances  through  mechanical  appli- 
ances, in  others  by  means  of  bandaging  and  strapping.  "When  the  latter  is  used,  the 
pressure  should  be  exerted  over  the  granulating  surface  as  well  as  over  the  cicatricial 
border.  The  strapping  must  be  good  and  made  of  linen,  thin  calico  and  leather  yielding 
too  much  ;  and  in  the  majority  of  cases  nearly  all  requirements  can  be  met  by  these 
means.  The  process  of  extension  must  be  kept  up  during  the  whole  period  of  granula- 
tion and  cicatrization.  Thus,  in  burns  of  the  anterior  surface  of  the  neck,  the  chin  must 
be  extended  to  the  utmost  from  the  sternum  ;  in  those  of  the  thorax,  the  arm  must  be 
kept  from  the  side  ;  and  where  the  groin  and  parts  around  are  involved,  the  thigh  mu.st 
be  kept  extended. 

Skin- Grafting. — In  addition  to  these  means,  we  possess  M.  Reverdin's  method  of 
skin-grafting — a  practice  consisting  of  the  transplantation  of  small  portions  of  true  skin, 
these  centres  of  cutification  not  only  rapidly  growing  in  healthy  granulations,  but  having 
the  power  of  imparting  to  the  margins  of  the  granulating  tissue  a  skin-forming  power 
which  is  as  remarkable  as  it  is  beautiful  to  witness. 

By  these  means  large  granulating  surfaces  may  not  only  be  rapidly  healed,  but  healed 
without  such  a  surface  of  cicatricial  tissue  as  necessarily  exists  after  ordinary  burns  or 
scalds,  and  therefore  without  that  tendency  to  subsequent  contraction  that  appertains  to 
cicatrices. 

When  Amputation  Necessary, ^ — AVhen  a  hand  or  finger,  foot  or  toe,  is  charred, 
amputation  must  be  performed ;  and  where  the  soft  parts  are  so  injured  as  to  slough,  the 
same  practice  may  be  called  for.  The  time,  and  also  the  necessity,  for  operation  in  any 
patient's  case  must  be  left  to  the  judgment  of  the  surgeon. 

The  constitutional  treatment  of  burns  in  the  first  stage  is  to  prevent  coIlaj)se  by  the 
judicious  use  of  stimulants  and  external  warmth;  allay  pain  by  local  treatment  and 
soothing  drugs,  such  as  chloral  or  morphia  ;  maintain  the  poice.rs  of  the  patient  by  simple 
nutritious  food,  such  as  milk,  beef-tea,  eggs,  etc.;  and  after  the  stage  of  reaction,  when 
that  of  suppuration  has  set  in,  to  prescribe  good  food  of  all  kinds  and  tonic  medicine. 

Complications  are  to  be  treated  on  ordinary  principles,  understanding  that  the 
injury  is  depressing  and  requires  no  additional  lowering  influence  in  the  way  of  treat- 
ment. 

Thoracic  complications  may  be  dealt  with  by  moderate  doses  of  tartar  emetic  and 
salines,  as  well  as  nutritious  and  possibly  stimulating  diet. 

Abdominal  complications,  with  opium,  alkaline  remedies  such  as  lime  water  in  bark, 
and  simple  diet. 

For  children  an  opiate  is  best  given  in  the  form  of  the  opium  ointment ;  while  for 
adults,  where  the  drug  upsets  digestion,  the  same  plan  is  equally  effective. 
Scalds  of  the  glottis  will  be  considered  in   Chapter  XVIII. 

Burns  and  accidents  from  lightning  rarely  occur  in  this  country  [England], 
and  average  about  twelve  a  year.  In  1861  there  were  twenty-six,  in  1862  twelve,  in  1863 
three,  andin  1864  six.  Holmes,  who  has  written  a  careful  compilation  on  the  subject, 
tells  us  that  a  person  struck  by  lightning  is  usually  more  or  less  completely  deprived  of 
consciousness  at  the  time.  In  many  cases  this  is  not  so,  as  in  a  remarkable  example 
which  occurred  in  the  practice  of  G.  Wilks  (Clinical  Society  s  Trans.,  vol.  xiii.,  1880). 
This  is  sometimes  a  consequence  of  the  shock  given  to  the  brain,  and  is  accompanied  by 
more  or  less  paralysis  of  motion  and  of  common  or  special  sensation.  Occasionally,  and 
perhaps  more  usually,  it  is  merely  the  effect  of  fright,  and  is  then  only  transient.  This 
insensibility  sometimes  lasts  for  a  considerable  time.  The  paralysis  by  which  it  is  usually 
accompanied  may  last  for  an  indefinite  period  :  in  one  case  it  lasted  four  months  ;  in  an- 
other, three.     It  is  more  common  in  the  lower  than  in  the  upper  limbs.     Other  affections 


THE   DISEASES  AS  It    THE  ATM  EST  OF  CICATRICES. 


•  il 


caused  l>y  lif^htniiij^  arc  burns,  criipiiims  of  crvtlieiim  or  urticariu,  loss  of  hair  over  parts 
or  the  whole  of  the  body,  woiimls,  heiiiorrhafre  from  the  mouth,  nose,  or  ears,  loss  of 
sight,  smell,  spciech,  hearing,  and  taste,  or,  in  rare  eases,  exaltation  of  tliese  special  senses, 
eataract,  imliccility.  or  abortion.  It  somotina-s  k-aves  arbonisccnt  marks  on  the  body,  even 
on  parts  eoveri'd  liy  elotlics,  which  have  (iftcn  bccdi  (htseribed  as  a  kind  of  jdiotograph  of 
neighboring  trees  or  (»ther  subjects.  Persons  not  killed  on  the;  spot  usually  recover,  thougli 
some  die  from  exhaustion  ;  recovery  can  be  hastc^ned  by  tonic  treatment,  and  galvanism  is 
l»enelieial  in  paralysis.  liurns  caused  by  lightning  are  deep  and  obstinate;  sometimes, 
however,   they  arc   mere   vesications  and  should   be  treated  as  other  burns. 

In  Wilks's  ease  the  man  was  thrown  down  and  strij)pe<l  naked  of  a  well-nuide  suit 
secured  with  straps  and  buckles,  and  stout  lu'w  hob-iuiiled  l)0(»ts.  The  clothes  were 
stripped  into  shreds  aiul  boots  burst  asunder.  The  man  was  burnt  su[)erficially  where 
the  flannel  touched  the  skin,  but  deejdy  where  the  cotton  trou.sers  were  in  contact.  He 
had  also  a  compouiul  fracture  of  one  leg.  Wherever  there  was  a  piece  of  metal  (waist- 
belt,  watch,  boots)  there  was  an  explosion,  or  at  least  a  greater  development  of  heat.  The 
man  recovered  completely. 

In  sudden  deaths  from  lightning  the  shock  to  the  brain  is  the  cause;  the  heart  is 
found  flaccid  and  empty,  the  blood  sometimes  coagulated  ;  and  Taylor  tells  us,  from  Sir 
C.  Scudamores  experiments,  that  in  animals  killed  h)y  electricity  the  same  conditions 
existed. 

The  Diseases  and  Treatment  of  Cicatrices. 

Cicatrices  or  scars,  however  produced,  grow  with  the  growth  of  the  individual, 
and  at  the  same  time  have  a  tendency  to  disappear ;  so  that  indurated  scars  may  indeed 
in  time  become  non-indurated.  In  small  scars  this  is  often  observed,  and  even  in  larger 
it  is  so  occasionally,  the  large  cicatrices  of  burns  becoming  soft  and  pliable.  As  often  as 
not,  however,  the  opposite  occurs,  and  the  disposition  to  contract  is  very  formidable,  pro- 
ducing deformities  of  a  frightful  kind,  those  of  the  neck  being  perhaps  the  most  hideous. 
The  arm  may  be  fastened  to  the  side  (Fig.  47),  and  I  have  seen  in  one  case  the  head  of 


Fig.  4" 


Fig.  48. 


Axillary  Cicatricial  Web  after  Burn. 


Mode  of  .Supplying  Extension  after 
its  Division. 


the  humerus  displaced  forward  beneath  the  clavicle,  and  in  a  second  beneath  the  coracoid 
process  and  the  development  of  the  upper  extremity  arrested  by  the  contraction.  There 
is  no  limit,  indeed,  to  the  effects  of  such  a  powerful  and  constant  force  as  that  of  cicatri- 
cial contraction. 

Operative  Measures. — The  surgeon  is  called  upon  not  unfre(juently  to  remedy 
these  delects,  and  where  his  eff'orts  are  successful  the  surgery  is  satisfactory,  but  too 
often  the  result  is  far  from  what  is  required. 

The  operation  consists  in  the  free  division  of  the  cicatrix  and  its  subjacent  tissues,  the 
subsequent  extension  of  the  divided  parts  during  the  healing  process,  and  the  transplan- 
tation of  diff"erent  centres  of  '•  cutification  ''  during  the  granulating  stage,  after  the 
method  of  Keverdin. 

In  dividing  the  cicatrix  the  incision  may  be  directly  across  the  scar,  running  into 
healthy  tissue  on  either  side,  or  in  the  form  of  a  natural  or  inverted  V.  according  to  the 
line  of  induration,  the  V-flap  being  dissected  from  the  tissues  beneath;  or  a  number  of 
n 


162 


THE  DISEASES  AND  TREATMENT  OF  CICATRICES. 


Fig.  49. 


small  incisions  may  be  made,  subcutaneous  or  otherwise.  But  in  all  these  divisions  the 
surgeon  must  remember  that  the  seat  of  the  contracting  cicatricial  material  is  in  die  sub- 
cutaneous tissue  as  well  as  in  the  skin,  and  that  unless  it  also  is  divided  no  permanent 
good  can  be  expected.  It  is  on  this  point — and,  indeed,  upon  it  alone — that  a  prognosis 
can  be  based.  The  most  favorable  cases  for  operation  are  those  in  which  a  web  of  tissue 
connects  an  extremity  with  the  body,  or  the  chin  with  the  chest  ;  for  such  a  web  contains 
within  itself  most  of  the  cicatricial  material  upon  which  the  deformity  depends,  and  on 
its  division  the  whole  will  be  freed.  Great  care  is  needed,  however,  in  the  division  of 
these  webs  ;  for  they  often  contain  important  parts,  such  as  nerves  and  vessels  that  have 
been  displaced  by  the  contracting  process.  Thus,  in  treating  a  case  in  which  the  right 
arm  was  fixed  by  a  web  from  the  axilla  and  elbow  to  the  chest,  the  web  seemed  to  be  so 
cutaneous  that  I  was  half  tempted  to  perforate  with  my  knife  and  slit  it  up.     Had  I  done 

so  in  the  position  I  had  noted,  I  should  have  passed  my 
bistoury  across  the  brachial  plexus,  artery,  and  biceps 
muscle — these  parts  having  been  completely  drawn  across 
to  the  thorax  by  the  affection — and  then  been  forced  to 
amputate  the  extremity.  I  did,  however,  what  I  should 
always  advise  others  to  do — divided  the  parts  carefully 
and  deliberately,  and  thus  steered  clear  of  any  harm,  I 
brought  also  a  piece  of  healthy  skin  from  the  posterior 
part  of  the  wound  and  fixed  it  to  the  anterior  about  the 
lower  border  of  the  axilla,  thus  dividing  the  large  ex- 
posed surface  by  a  bar  of  healthy  integument,  and  kept 
the  arm  at  a  right  line  to  the  shoulder  with  a  splint 
extending  from  the  elbow  to  the  hip.  When  the  wound 
had  assumed  a  healthy  aspect,  I  inserted  ten  pieces  of 
skin  the  size  of  hemp-seed,  and  after  this  cicatrization  went 
on  with  wonderful  rapidity,  the  child  recovering  with  a 
useful  arm  and  movable  cicatrix.  In  this  case  I  have 
fairly  indicated  the  points  requiring  attention  to  secure  a 
successful  operation  :  free  but  deliberate  division  of  the 
cicatrix  and  subcutaneous  tissue,  extension  from  the  first 
during  the  healing  process  by  some  fixed  mechanical 
appliance,  and  skin-transplantation  when  the  surface  of 
the  sore  has  assumed  a  healthy  granulating  surface,  the  surgeon,  where  he  can,  partially 
detaching  a  piece  of  integument  from  one  side  and  connecting  it  with  the  opposite,  in 
order  to  divide  the  wound  and  thus  increase  its  skin  margin  for  granulation.  Where  a 
bend  in  a  joint  exists  this  practice  is  still  more  valuable.  After  the  operation  the  wound 
should  be  dressed  with  vaseline  on  lint  and  covered  with  cotton-wool,  as  in  a  burn.  Fig. 
48  illustrates  a  simple  method  of  applying  extension  of  the  arm  after  the  division  of  an 
axillary  cicatrix  of  great  size,  and  Fig.  49  illustrates  the  effects  of  a  burn  upon  the  neck. 
In  dcfonnitieii  affecting  the  jaw  in  which  immobility  of  the  bone  has  been  produced, 
Esmarch  and  Rizzoli  have  proposed  the  division  of  the  bone  and  the  excision  of  a  small 
wedge  of  bone  at  the  fixed  side  with  a  view  of  making  a  false  joint.  The  operation  is  a 
sound  one,  and  has  been  accomplished  successfully  by  Mr.  C.  Heath  and  others.  In 
suitable  cases  it  should  be  repeated. 

Ulcerating  cicatrices  are  not  uncommon,  for  "  new  cutis  and  new-formed  granu- 
lations are  neither  so  strong,  nor  have  they  the  living  principle  so  active  in  them,  as  the 
old  cutis"  (John  Hunter,  1787),  and  an  old  scar  may  break  up  and  become  the  seat  of 
an  indolent  sore  when  its  possessor  has  been  weakened  by  any  fever  or  exhausting  pro- 
cess, in  the  san)e  way  as  old  subcutaneous  cicatricial  tissue  may  give  rise  to  a  residual 
abscess.  I  have  seen  this  repeatedly  occur  in  adults  in  cicatrices  formed  in  infancy.  In 
one  case  the  cause  of  the  scar  was  a  burn,  in  another  an  injury,  in  a  third  an  operation  ; 
but  in  all  the  scars  were  alike,  and  they  underwent  the  same  degenerating  process.  These 
sores  require  to  be  treated  by  rest  and  local  stimulants,  the  patient  receiving  tonics  and 
good  food  to  improve  the  weakened  powers.  In  one  case  I  transplanted  with  complete 
success.  These  "  cicatricial  sores  "  are,  however,  always  obstinate,  those  over  the  ends  of 
bones  being  unusually  stubborn. 

Warty  and  Cheloid  scars  are  classed  together,  because  it  is  difficult  to  distin- 
guish the  indurated,  lumpy,  warty  scar  from  the  true  cheloid.  The  former,  however, 
appears  directly  after  the  wound  has  healed,  and  is  clearly  connected  with  the  healing 
process ;  while  the  latter  attacks  any  scar  at  any  period  of  its  existence. 


Effects  of  Burn  on  Neck  :  Contraction  of 
Cicatrix. 


rili:  DISEASES  AS  I)   TREATMENT  OF  CICATRICES. 


163 


Tlu'  tliifki'iifil  warty  scar  appt-ars  as  an  iiiilmatiitn  nf  tlu-  wliolc  cicatrix  and  is  often 
associated  with  heat  and  irritation.  It  is  l>cst  treated  l>y  hjcal  stimuhmts,  such  as  iodine 
or  l)listerin,u  Hiiid.  the  ohject  heinu:  to  l>reaii  up  hy  some  h)cal  inHaniuialory  process  the 
hiwlv-nriraiii/.ed  tihrmis  productinn. 

Cheloid  tumors  uniw  as  indurated  smooth  tiihendes,  at  first  havinj;  a  red  or 
pinkish  cohir,  but  as  they  increase  Itecouiing  pale.  Tliey  arc  at  times  painful — or.  at 
least,  irritable — and  rarely  attain  a  larue  size.  They  had  better  be  left  alone,  for  they 
are  apt  to  return  in  the  cieatri.\  formed  after  their  removal.  Cheloid  tunujrs  <renerally 
grow  from  cicatrices.  These  cheloid  tumors  are  known  as  those  of  Alibert,  to  distinguish 
them  from  those  named  after  Dr.  Thomas  Addison,  who  in  1854  (Mfd.  ('hir.  Traun.) 
described  another  form  of  cheloid,  which  he  calls  the  "  true  cheloid,"  the  induration 
beginning  in  the  skin  and  stibcutancous  areolar  tissue,  and  often  going  on  to  produce 
such  a  contraction  of  the  part  afi'ected  as  to  resemble  the  indurated  cicatrix  of  a  burn. 
Figs.  ;")()  and  T)!  rejtresent  the  two  affections. 

The  cheloid  tumor  which  follows  the  perforation  of  the  ear  for  an  ear-ring  is  a  curious 


Fio.  50. 


Fig.  51. 


0¥ 


Cheloid  of  Alibeit. 


Cheloid  of  Addison. 


Thus, 


(From  models  in  Guy's  Museum.) 

form,  and  seems  less  liable  to  return  than  others  of  a  like  nature.  From  the  deformity 
it  causes,  it  should  be  excised  with  a  portion  of  the  healthy  lobule. 

Cancer  may  attack  a  scar ;  and  when  it  does  so,  the  scars  are  generally  old. 
I  have  treated  a  man  who  had  a  cancerous  lip,  the 
disease  having  developed  in  a  scar  he  had  had  for 
fifty  years.  It  began  as  a  thickening  of  the  scar, 
and  then  showed  itself  as  a  tubercle,  which  grew, 
broke  down,  and  ulcerated,  the  ulceration  rapidly- 
spreading. 

In  December,  1871,  I  was  called  upon  to  ampu- 
tate above  the  knee  in  a  man  aet.  58  a  leg  stump 
that  was  the  seat  of  a  frightful  cancerous  disease 
which  had  existed  for  two  years,  and  had  appeared 
in  the  cicatrix  of  an  old  amputation  performed  fifty- 
four  years  before  for  gangrene  after  fever  (Fig.  84). 

Cancers  in  cicatrices  mostly  appear  after  this 
fashion,  are  usually  epithelial,  and  are  to  be  treated 
bv  the  removal  of  the  growth. 

Painful  cicatrices  ;ii-e  often  due  to  the  divided 
ends  of  the  nerves  being  bound  in  by  the  cicatricial 
tissue,  and  as  often   as  not   they  are  caused  by  a 

bound-down    bulbous    growth  at    the   extremitV   of  a    Congenital  Cicatrix  of  Lip,  Fissure  of  Nostril, 
_  ,    >  ,  ••  ,  and  Contracted  Evelid. 

nerve,     in  a  case  1  had  .some  years  ago  the  external 

popliteal  nerve,  as  it  wound  round  the  head  of  the  fibula,  was  so  bound  down  by  the  cicatrix 
of  a  burn  as  to  cause  severe  agony  in  the  whole  course  of  its  distribution.  The  sj'mptoma 
were  relieved  by  two  free  vertical  incisions  through  the  cicatrix,  and  the  patient  recovered. 


164  OX  SKIX-GEAFTIXG. 

Should  I  ever  see  a  similar  case.  I  shall  pursue  the  same  course,  except  that  I  shall  sub- 
sequently transplant  pieces  of  skin  in  the  wounds  as  soon  as  they  assume  a  healthy  appear- 
ance. When  the  pain  is  due  to  an  adherent  or  bulbous  nerve,  the  nerve  must  be  freed  and 
removed.  When  doubt  as  to  its  condition  exists,  Mr.  Hancock's  suggestion  may  be  adopted, 
to  divide  subcutaneously  the  suspected  nerve.  Where  no  such  causes  as  have  been  men- 
tioned are  to  be  made  out,  the  case  may  be  treated  as  one  of  neuralgia  by  full  doses  of 
qixinine.  arsenic,  or  iron,  and  local  sedatives  (the  extract  of  stramonium  or  belladonna 
rubbed  down  with  glycerine  being  a  good  application).  Cases,  however,  of  painful  stump? 
or  cicatrices  are  sometimes  met  with  that  defy  treatment. 

Congenital  cicatrices  are  met  with  in  practice.  Thus,  I  have  seen  four  patients, 
all  females,  with  cicatrices  in  their  upper  lips,  as  if  they  had  been  operated  upon  for 
harelip  (Fig.  52  was  taken  from  one  of  them,  and  Fig.  188,  Chapter  XII.,  from  another). 
In  the  former  there  was  likewise  a  fissure  of  the  nostril  and  a  narrowing  of  the  fissure 
of  the  eye.  Bridles  connecting  the  lip  with  the  gum  in  an  unusual  manner  are  not 
uncommon. 

ON  SKIN-GRAFTINa. 

When  John  Hunter,  a  century  ago,  succeeded  in  transplanting  the  spur  of  a  young 
chicken  from  its  leg  to  its  comb,  as  well  as  into  the  comb  of  a  second  bird,  and  found 
that  it  not  only  lived,  but  grew,  he  probably  never  dreamt  in  any  flight  of  his  genius 
that  the  fact  which  he  then  established  would  be  so  applied  in  the  practice  of  surgery  as 
to  mark  an  era  in  its  progress,  and  to  bring  a  class  of  cases  which  surgeons  were  apt  to 
look  upon  with  little  interest  amongst  the  most  curable  and  tractable  of  local  aifections. 
And  yet  this  has  come  to  pass,  M.  Reverdin  of  Geneva,  on  October  IG,  1869.  having  suc- 
ceeded in  transplanting  small  portions  of  skin  taken  from  one  part  of  a  mans  bod}'  to  the 
granulating  surface  of  a  large  sore,  under  which  treatment  the  ulcer  healed.  He  read 
the  case  before  the  Surgical  Society  of  Paris  on  December  15,  1869,  and  asked.  "  Is  the 
growth  of  skin  due  to  the  effect  of  contact  or  neighborhood,  or  is  it  due  to  proliferation 
of  the  transplanted  elements?"' 

Mr.  G.  D.  Pollock  of  St.  George's  Hospital,  encouraged  by  M.  Reverdin's  success, 
followed  up  tlie  practice,  and  the  good  results  he  and  his  colleagues  obtained  soon  induced 
all  other  surgeons  to  follow  in  their  wake.  The  facts  can  be  read  in  the  Transact  ions  of 
the  O'tnical  Society  for  1871,  and  at  the  present  moment  it  may  now  be  considered  as  a 
well-established  practice. 

Since  its  introduction  I  have  very  extensively  carried  it  out.  and  in  most  instances 
with  success.  I  look  upon  the  suggesrion  as  very  valuable,  its  adoption  rendering  many 
cases  curable  that  were  not  so  previously,  facilitating  the  cure  of  as  many  more,  and  giv- 
ing interest  to  a  class  of  patients  in  whom  formerly  there  was  but  little.  In  the  manage- 
ment of  healing  ulcers  it  is  a  great  boon,  while  in  the  treatment  of  the  large  granulating  sur- 
faces so  common  after  extensive  burns  its  value  cannot  be  overestimated.  As  an  adjuvant 
to  many  plastic  operations,  more  particularly  on  the  face  and  in  the  case  of  deformities, 
it  is  invaluable. 

Under  the  action  originated  by  the  transplanted  fragments  of  skin,  a  process  of  repair 
goes  on  which  at  first  appears  almost  magical :  the  grafts  soon  become  islets  of  skin, 
round  which  cicatrization  proceeds;  the  margin  of  the  sore  receives  an  impulse  in  cica- 
trization, which  rapidly  extends  ;  and  between  the  grafts  themselves  and  the  margin  of 
the  sore  connecting  links  of  new  skin  rapidly  form,  which  divide  the  sore  into  sections 
(Figs.  53  and  54).  '  By  these  means  large  surfaces  speedily  cicatrize  which  under  former 
circumstances  would  have  required  many  months. 

Moreover,  the  contractions  and  subsequent  deformities  that  under  other  conditions 
were  too  well  known  to  follow  in  such  cases  do  not  occur. 

The  practice  seems  applicable  wherever  a  large  granulating  surface  exists,  and  in  its 
adoption  the  only  desirable  point  to  observe  is  that  the  mrface  of  the  sore  should  he  healthy. 
This  clinical  fact  includes  another — that  the  patient's  health  is  good,  for  there  is  no 
better  barometer  of  health  than  a  sore,  its  surface  assuming  a  healthy  or  unhealthy 
appearance  with  every  alteration  in  the  general  condition  of  the  body.  I  have  attempted, 
however,  by  way  of  experiment,  to  graft  skin  upon  sores  that  were  not  quite  healthy, 
and  have  sometimes  succeeded.  In  some  indolent  sores  in  which  a  small  patch  of  healthy 
granulations  sprang  up  I  have  succeeded  in  securing  by  tran.splanting  a  new  centre  of 
"  cutification,''  which  proved  of  great  value  in  aiding  the  healing  process  ;  in  some  others 
the  graft  has  been  enough  to  excite  a  more  healthy  action  in  the  sore  ;  still,  in  many, 
poor  success  followed  the  practice.     It  may,  therefore,  be   accepted  as  a  truth   that  a 


O.V  SKIS-CllAlTISa. 


1 0.5 


hcitUhji  rfritintlnttii'i  siirfarr  is  iiii  unjinrldiit,  iiIiIkiiiijIi  not  an  essnitinl,  rrtjiu'siff  f'i,r  siiccesn 
in  shin-</i(iJ'lliiij. 

I'lKdi  this  l)a.si.s  I  imw  [yrocciod  t<»  roiisidi-r  liuw  the  opi-ration  is  to  l>c'  ])L'rf<jrin('<l. 

I'tillofk  tells  us  that  Hcvcrdiii's  method  is  to  remove  a  very  minute  portion  of  tlie 
skin,  plaee  it  on  the  surtaee  of  the  f^ranuiations,  and  there  retain  it  with  a  strip  of  plaster. 
He  writes:  "1  have  usually  removed  the  skin  hy  nipping  up  a  very  small  jinrtinn  with  a 


Fio.  r)3. 


Fig.  54. 


Drawings  illustrating  the  Cicatrization  of  Sores  by  Skin-G  rafting. 

fine  pair  of  forcejts  and  cutting  it  off  close  with  sharp  scissors.  At  first  I  made  a  slight 
cut  in  the  surface  of  the  granulations  and  then  embedded  the  piece  of  skin,  but  of  late 
I  have  only  laid  it  on  the  surface  of  the  ulcer.  I  cannot  say  that  I  have  found  any  dif- 
ference in  tlie  result.  I  do  not  think  there  is  great,  if  any,  advantage  to  be  gained  by 
the  transplantation  of  a  large  piece,  but  where  the  ulcer  is  large  I  think  much  is  gained 
by  the  transplantation  of  numerous  small  pieces.  The  disadvantage  of  transplanting  a 
hirge  piece  is  the  sore  it  creates ;  while  the  small  sores  formed  by  the  removal  of  the 
minute  pieces  heal  in  a  short  time  and  without  trouble"  (Clin.  Soc.  Trans.,  vol.  iv.). 
My  DWii  experience  in  every  point  confirms  that  of  Pollock. 

Mode  of  performing  Trans- 
plantation.— For  the  removal  of  the  ^^^-  '^^• 
sound  skin  I  either  employ  a  pair  of 
scissors  (here  figured)  which  Messrs. 
Krohne  made  for  me  after  Macleod's 
suggestion  in  a  medical  journal,  or  a  fine 
lancet,  after  the  elevation  of  the  skin 
upon  the  point  of  a  needle.  I  generally 
take  the  skin  from  the  fore  part  of  the 
arm  or  the  side  of  the  thorax. 

Having  taken  away  the  skin,  the 
fragment  should  be  cut  into  three,  four, 
or  more  pieces,  and  these  placed  about 


Scissors  for  Skin-G  rafting. 


half  an  inch  or  three-quarters  of  an  inch  from  the  margin  of  the  sore,  and  ahoiit  one  inch 
apart ;  for  there  is  no  doubt  that  the  engrafted  centre  has  a  stronger  influence  in  excit- 
ing a  healing  action  in  the  margin  of  the  sore  when  placed  near  it  than  when  i.solated  in 
the  centre  of  a  granulating  surface. 

The  pieces  should  be  placed  upon  the  granulations  and  gently  pressed  in.  There  is 
no  necessity  to  wound  the  granulating  surface.  They  should  be  covered  with  a  piece  of 
oiled  gutta-percha  skin  and  the  whole  supported  with  cotton-wool,  a  bandage  being  sub- 
sequently applied  .so  as  to  press  moderately  upon  the  part  and  keep  the  dressing  in  posi- 
tion. On  the  third  day,  but  not  before,  the  dressings  may  be  removed  with  the  greatest 
care,  and  a  fresh  piece  of  oiled  gutta-percha  skin  should  be  subse(|uently  applied. 

The  appearance  of  the  engrafted  pieces  on  the  removal  of  the  first  dressing  vary  con- 
siderably. At  times  they  will  seem  palpably  to  have  taken  root  and  be  alive  ;  at  others 
to  have  disappeared  altogether ;  whilst  in  a  third  class  the  surface  of  the  cuticle  will  be 


166 


O.V  SKIS-GRAFTING. 


Fig.  56. 


Fig. 


seen  floating  as  a  thin  film  upon  the  secretion  of  the  sore,  the  basement  membrane  of  the 
cuticle — the  essential  part — being  left  (Fig.  53). 

Under  all  these  circumstances,  however,  the  surface  of  the  sore  is  to  be  cleaned  with 
the  greatest  care,  a  stream  of  tepid  water  from  a  dressing-can  or  .squeezed  from  a  sponge 
over  the  part  being  the  best  means  to  employ.  The  surface  is  on  no  account  to  be  wiped, 
for  the  grafted  portions  of  skin  are  easily  uprooted,  whilst  those  that  seem  to  have  died 
or  that  have  disappeared  often  show  themselves  again  later  as  "  cutifying  centres."  As 
soon  as  the  new  centres  are  established  in  large  sores  other  pieces  should  be  engrafted,  at 
about  the  same  distance  from  the  new  pieces  as  those  were  originally  inserted  from  the 
margin  of  the  sore ;  and  in  this  way  the  whole  granulating  surface  may  be  speedily 
covered  with  new  skin,  and  a  rapid  recovery  follow. 

How  the  engrafted  pieces  act  in  the  healing  process  is  now  satisfactorily  settled,  for 
experience  has  proved  that  the  grafts  not  only  grow  themselves  by  cell  proliferation,  but 
they  stimulate  the  skin-forming  powers  of  the  margin  of  the  sore,  for  as  .soon  as  the 
'' grafts"  have  taken,  the  margin  of  the  sore  nearest  to  them  is  seen  to  cicatrize  and  to 
send  out  prolongations  of  new  cicatrizing  tissue  to  meet  similar  prolongations  from  the 
new  cutifying  centres,  the  sore  in  this  way  becoming  .subdivided  by  bands  into  smaller 
sores  and  then  rapidly  healing  (Fig.  54). 

That  the  engrafted  portions  grow  b\'  the  pro- 
liferation of  their  own  cells  is  likewise  proved 
by  the  fact  that  in  the  case  of  a  white  man  upon 
whose  granulating  ulcer  I  engrafted  four  small 
pieces  of  black  skin,  the  whole  being  no  larger 
than  a  barley-corn,  the  Vjlack  skin  grew  twenty- 
fold  in  ten  weeks,  to  the  extent  illustrated  in 
Fig.  5(J,  the  grafts  subsequently  enlarging  and 
sending  out  prolongations  which  joined  to  form 
one  patch  of  black  skin  (vide  Fig.  57).  The 
sore  healed  as  rapidly  where  the  black  skin 
was  grafted  as  where  the  white  was  placed. 

The  same  result  may  likewise  ensue  when  large 
pieces  of  skin  are  transplanted  from  the  patient 
or  from  some  recently  amputated  limb.  But 
there  .seems  to  be  no  advantage  in  this  practice, 
and  in  the  cases  in  which  it  has  been  adopted 
a  large  proportion  have  failed.  In  a  case  of 
mine  the  grafts  took  root  and  excited  a  healthy 
action  in  the  margin  of  the  sore  ;  they,  however, 
grew  but  little,  and  remained  on  the  cicatrix 
of  the  sore  as  bosses  of  skin  with  well-marked  borders.  They  were  grafted,  it  is  true, 
but  the  grafts  seemed  to  have  no  power  of  assimilating  themselves  to  the  tis.sues  on 
which  they  were  placed  (ride  model  Guys  Mus.j.  When  this  practice  is  adopted,  the 
pieces  of  skin,  on  removal,  should  be  dropped  into  warm  water  in  their  passage  to  the 
wards  where  they  are  applied. 

To  take  large  pieces  of  skin  from  the  patient's  own  body  is  an  objectionable  practice 
on  account  of  the  large  wound  it  creates,  and.  moreover,  is  unnecessary  in  the  majority 
of  cases,  as  small  pieces  appear  to  do  better.  To  take  them  from  another  suVjject  is  also 
objectionable  for  like  reasons,  but  .still  more  so  from  the  risk  that  is  necessarily  run  of 
introducing  into  the  blood  of  the  living  subject  some  new  or  poisonous  element — a  risk 
to  which  I  think  a  patient  should  not  be  subjected,  and  that  I  would  not  allow  on  myself. 
.  For  these  reasons  I  have  forbidden  my  dres.sers  adopting  the  practice. 

In  the  case  where  black  skin  was  tran.splanted  I  did  it  with  the  full  concurrence  of 
both  patients ;  indeed,  both  were  rather  disappointed  that  the  operation  could  not  be 
repeated.     They  were  firm  friends,  and  the  link  I  formed  bound  them  closer ! 

There  seems  to  be  no  objection  to  dividing  the  portion  of  integument  which  is  to  be 
employed  into  minute  fragments — that  is.  into  pieces  the  size  of  millet-seeds — the  thumb- 
nail of  the  surgeon  being  the  best  table  for  the  purpo.se.  In  children,  where  it  is  unad- 
visable  to  remove  much  health}-  skin  and  the  granulating  surface  to  be  covered  is  large, 
the  plan  is  excellent,  though  I  prefer  pieces  the  size  of  half  a  hemp-seed,  when  they  can 
be  obtained.  The  practice  of  applying  '■  skin-dust.'  or  the  products  obtained  by  scraping 
the  skin,  cannot  be  recommended,  as  it  is  rarely  successful. 

Whether  this  newly-engrafted  skin  pos.sesses  the  same  power  of  resisting  disintegrating 


Drawings  illustrating  the  Growth   of  Black  Skin 
when  (irafted  on  to  the  Sore  of  a  White  Man. 


CUILELAiyS.  167 

chanjrt" s  as  the  old  skin  is  not  yf t  proved.  Some  observations  I  have  made  lead  nie  to  sus- 
pect that  it  is  in  some  cases  rather  liable  to  break  down  and  ulcerate  as  soon  as  the  patient 
begins  to  walk  after  the  sore  has  completely  healed,  whilst  in  others  I  have  found  a  sore 
in  this  way  healed  is  more  capable  of  resisting  disintegrating  changes  than  another  healed 
by  unassisted  natural  ])rocesses.  At  any  rate,  it  is  necessary  to  observe  as  much  care  in 
the  after-treatment  of  the  case  as  ought  always  to  be  observed  after  the  cure  of  any  other 
sore,  and  nmre  ]iarticularly  to  afford  moderate  supj>ort  and  pnttection  to  the  part.  For 
this  purpose  there  is  nothing  better  than  to  bind  on  a  piece  of  sheet-lead  over  the  cicatri.x 
when  the  seat  of  mischief  is  on  the  leg,  as  by  it  equal  pressure  as  well  as  protection  is 
afionU'd. 

The  new  skin  soon  becomes  as  sensitive  as  the  old  ;  the  sensibility  of  the  cicatrix 
under  these  circunjstances,  indeed,  seems  to  be  greater  than  when  unaided  cicatrization  is 
allowed  to  take  place. 

Sponge  Grafting. 

Dr.  Hamilton  of  Edinburgh  introduced  this  practice  into  surgery  with  a  view  of 
expediting  the  repair  of  deep  wounds  in  which  much  loss  of  tissue  has  taken  place,  and 
he  did  so  "  thinking  that  sponge  would  imitate  the  interstices  of  the  fibrinous  network  in 
a  blood  clot  or  in  fibrinous  lymph, ''  and  that  the  blood  vessels  of  the  new  surrounding 
tissues  would  push  into  these  interstices  and  grow,  and  so  fill  up  the  cavity,  the  sponge 
eventually  becoming  absorbed.  He  gave  cases  which  were  apparently  successful,  and 
many  have  been  recorded   since. 

To  carry  out  the  practice,  a  fine  section  of  sponge  should  be  applied  to  a  healthy 
granulating  surface  and  the  sponge  covered  with  oil  silk.  A  layer  of  lint  saturated  with 
carbolic  or  terebene  oil  should  then  be  applied,  and  the  whole  wrapped  in  some  antiseptic 
gauze  or  boraeic  or  salicylic  wool.  The  dressing  should  be  removed  every  second  or 
third  day,  according  to  the  quantity  of  discharge.  The  sponge  is  prepared  by  being 
steeped  in  diluted  nitro-muriatic  acid,  to  dissolve  the  silicious  and  calcareous  salts,  and 
later  on  washed  in  a  solution  of  ammonia  or  potash,  to  remove  all  excess  of  acid.  Before 
being  applied  it  is  purified  by  prolonged  treatment  with  a  five-per-cent.  solution  of  carbolic 
acid.  In  the  original  paper  Hamilton  recommended  thick  sections  of  sponge;  he  now  u.ses 
fine  ones,  fresh  layers  being  con.secutively  applied  as  granulation  tissue  grows.  I  have 
employed  sponge  grafts  on  many  occasions,  and  have  seen  more  cases  in  which  the  prac- 
tice has  been  carried  out ;  and  I  can  testify  to  the  fact  that  the  sponge  becomes  as  it  were 
incorporated  with  the  granulation  tissues,  but  whether  it  really  expedites  repair  or  not,  or 
becomes  of  any  practical  value  in  the  repair  of  deep  wounds.  I  am  not  prepared  to  say. 

Chilblains. 

Chilblains  are  local  inflammations  of  the  skin,  and  are  to  be  met  with  in  subjects 
of  a  feeble  circulation.  They  are  more  common  in  the  young,  and  in  women  than  in  men, 
are  generally  seen  on  the  toes,  fingers,  nose,  or  ears,  and  are  caused  by  any  sudden  change 
of  temperature  or  any  sudden  application  of  cold  or  warmth. 

They  show  themselves  as  simple  congestions  of  the  skin  attended  with  tenderness  or 
itching;  vesication  of  the  skin,  when  the  inflammation  is  more  severe',  or  .sloughing  arid 
ulceration  of  the  skin,  when  a  broken  chilblain  occurs.  The  disease  may  begin  and  stop 
at  the  first  or  congestive  stage  or  run  through  all  the  stages. 

Toward  evening  the  symptoms  of  irritation  are  always  increased,  and  any  external 
warmth,  as  of  a  fire  or  bed.  any  full  diet  or  stimulating  drink,  aggravates  them  :  in  fact, 
anything  that  excites  the  circulation  in  the  part,  at  any  hour  of  the  day  or  night,  is  apt 
to  increase  the  symptoms. 

Tre.\tment. — The  local  treatment  of  chilblains  is  no  less  important  than  the  general, 
and  more  successful ;  for,  whilst  tonics,  good  diet,  external  warmth,  and  exercise  are  neces- 
sary to  improve  the  general  powers  of  the  patient  and  the  circulation,  local  stimulants 
are  of  great  value.  When  the  chilblain  is  not  broken,  the  local  application  of  the  tinc- 
ture of  iodine,  of  a  solution  of  sulphate  of  copper  (three  grains  to  the  ounce),  of  camphor 
liniment,  of  soap  liniment  with  opium  or  one-fourth  part  of  the  tincture  of  cantharides, 
of  compound  tincture  of  benzoin,  or  of  simple  spirit,  not  only  gives  comfort,  but  hastens 
the  cure  of  the  disease.  The  parts  should  also  be  covered  with  strapping  spread  on 
leather. 

When  the  parts  are  broken,  vaseline,  boracic-acid  ointment,  with  the  use  of  thick  lint 
'  Edinburgh  Med.  Joiirn.,  Nov.,  1881. 


168  FROSTBITE. 

and  oil  silk  or  elastic  tissue,  are  tlie  safest  remedies,  stimulating  lotions  being  used  later 
when  the  parts  are  indolent  in  healing,  such  as  terebene  and  oil  or  carbolic  oil  with  opium. 
Warm  socks  and  loose  shoes  or  boots  are  always  indicated,  but  anything  like  pressure 
is  most  detrimental.  Exercise  also  should  be  taken  when  possible,  and  an  equable  tem- 
perature ought  to  be  maintained. 

Frostbite. 

It  has  already  been  shown  that  the  sudden  application  of  cold  to  any  exposed  part  of 
the  body  of  a  feeble  or  depressed  subject  is  liable  to  be  followed  by  '■'■  chilhlahi  ;^'  and 
when  concentrated  cold  is  applied,  under  these  circumstances,  for  a  period  sufficient  to 
arrest  the  circulation  in  a  part,  a  ^^ frostbite^'  is  the  result.  Sudden  and  severe  alterna- 
tions of  heat  and  cold  under  exposure,  even  in  healthy  subjects,  may  produce  this  result ; 
in  military  life  this  fact  is  well  known. 

The  first  eifect  of  cold  upon  a  part  is  a  sense  of  numbness  and  weight  with  a  feeling 
of  tingling.  To  the  eye  the  skin  will  probably  appear  redder  than  usual ;  and  if  the  part 
be  removed  from  the  influence  of  the  cold  at  this  time,  recovery,  or  in  feeble  subjects  a 
superficial  '•  chilblain,"  may  follow.  If  the  cold,  however,  be  allowed  to  act  longer,  the 
parts  will  become  stiif,  and  at  last  insensible,  feeling  ''  dead."  To  the  eye  they  will 
assume  a  white  and  waxy  aspect  and  be  senseless  to  all  impressions,  the  blood  having 
been  completely  driven  from  the  surface.  When  the  cold  has  been  suddenly  applied  and 
is  sufficient  to  kill  the  structure  outright,  the  frozen  part  will  have  a  mottled  aspect, 
from  the  retention  of  blood  within  the  tissues.  Many  of  these  effects  may  be  produced 
by  the  aether  spray. 

The  constitutional  effrcti^  of  cold  are  at  first  stimulating,  and  subsequently  depres.sing, 
excitement  passing  into  sleepiness,  and  this  into  torpor.  If  the  latter  be  yielded  to,  the 
sleep  will  end  in  death,  the  blood  being  sent  from  the  surface  of  the  body  to  the  brain 
and  other  viscera,  and  death  being  produced  by  blood  engorgement,  as  in  apoplexy. 

In  the  "  sleepy  and  depressed  stage  "  of  cold,  if  the  patient  be  brought  suddenly  under 
the  influence  of  warmth  and  placed  too  near  a  fire,  the  risks  of  lung  engorgement,  as  well 
as  of  rapid  gangrene  of  the  frozen  parts,  are  very  great ;  for  by  sudden  reaction  the  arte- 
rial circulation  becomes  quickened  when  the  parts  gorged  with  blood  have  lost  their 
power  of  propelling  onward.  In  gangrene  from  frostbites  there  seems  reason  to  believe 
that  ulceration  of  the  duodenum  may  follow,  as  after  burns.  Mr.  Adams  has  recorded 
such  a  case  in  the  American  Med.  Times,  for  18G3. 

Treat.ment. — Any  sudden  alternation  of  temperature  being  most  injurious,  the  aim 
of  the  surgeon  should  be  to  recall  the  affected  parts  fjrinJnally  to  their  normal  condition 
— firstly,  by  assisting  the  venous  circulation  by  gentle  friction  in  the  course  of  the  veins 
with  furs  or  flannel ;  and  secondly,  the  arterial  by  comparative  warmth  applied  externally 
and  gentle  stimulants  administered  internally.  Neither  warm  water  nor  air  nor  fire 
should  be  allowed  to  approach  the  parts  until  the  natural  temperature  has  been  partially 
restored,  and  then  only  with  great  care.  Friction  with  snow  or  iced  water  is  most  useful. 
On  reaction,  the  parts  may  be  raised  and  lightly  covered  with  flannel  or  cotton-wool  or 
exposed  to  the  warm  air  of  a  chamber ;  whilst  food  and  stimulating  drinks  are  carefully 
administered,  warm  milk  with  a  little  brandy  being  the  best.  Should  reaction  be  too 
severe,  it  must  be  checked  by  lead  or  spirit  lotions. 

When  gangrene  follows — and  it  mostly  does  when  the  third  degree  of  freezing,  or  the 
mottling  stage,  has  been  reached — and  only  small  portions  of  the  body  suffer,  such  as  the 
integument,  the  parts  may  be  dressed  by  some  stimulating  application  to  hasten  the  sepa- 
ration of  the  slough,  and  should  be  kept  warm.  Carbolic  acid  and  oil  are  probably  the  best 
applications;  tonics  should  also  be  given. 

When  large  portions  of  the  body  suffer,  such  as  the  whole  foot  (and  in  this  country  I 
have  seen  a  coachman  who  had  on  new  tight  boots  on  a  bitter  winter  day  lose  both  feet), 
amputation  may  be  called  for,  the  surgeon  always  waiting  till  the  line  of  demarcation  or 
limit  to  the  sloughing  process  is  fairly  marked. 

Boils. 

Boils  are,  in  a  measure,  allied  to  carbuncles,  and  both  are  due  to  inflammation  of  the 
skin  and  subcutaneous  tissue,  though  the  disease  probably  commences  in  the  latter.  In 
both  there  is  effusion  of  lymph  into  the  areolar  tissue  of  "the  part,  and  in  both  this  gene- 
rally sloughs,  although  in  the  boil  the  slough  is  local  and  confined  to  one  central  point, 


BOILS.  169 

whilo  ill  rarhiinclo  tlio  process  may  cover  an  extent  of  integument  varying  from  the  size 
of  half  a  eniwn  to  that  of  a  phite. 

Boils  are  met  with  in  two  forms — '<»'■  as  a  subcutaneous  affection  atten<Je<l  with  litth) 
pain  until  the  skin  over  it  intiames  and  supj)urates.  It  then  appears  as  a  conical-pointed 
swellinjj;,  with  inflamed  indurated  areola;  this  causes  .severe  distress  until  the  parts  give 
way,  when  the  feeling  of  tension  and  throbbing  is  followed  by  relief  due  to  the  termina- 
tion of  the  sloughing  process  and  discharge  of  the  '*  core."  \Vhen  the  slough  has  been 
di.sdiarged,  an  irregular  orifice  in  the  skin  is  seen  covering  in  a  cavity  in  the  cellular  tis- 
sue, which  subse<juently  granulates,  leaving  a  depressed  and  indurated  cicatrix.  The 
core  or  slough  is  eomposed  of  skin  infiltrated  with  lymph. 

The  secoiii/  form  of  boil  begins  as  an  inflamed  follicle  or  pimple,  which  occasionally 
becomes  vesicular  and  has  a  scarlet,  exi|uisitely  sensitive  areola.  It  suppurates  slowly, 
and.  as  a  rule,  terminates  with  a  less  well-n)arked  slough  than  the  former  kind.  Such 
boils  are  more  usually  multiple  than  the  other,  and  are  often  caused  by  the  application 
of  moist  dressiiiiTs  or  of  some  cadaveric  irritant. 

Causes  of  Boils. — With  respect  to  the  cdusrs  of  ialU  nothing  definite  can  be  laid 
down.  That  they  are  always  associated  with  some  debilitating  or  allied  cause  is  belied 
by  daily  experience,  for  they  are  certainly  often  seen  in  men  and  women  in  whom  no 
such  condition  exists,  and  in  subjects  who  often  declare  that  they  '"  never  felt  better  in 
their  lives."'  As  a  rule,  however,  this  is  not  the  case,  because  they  more  commonly 
occur  in  subjects  who  have  either  been  fed  to  excess  or  been  subjected  to  some  sudden 
change  in  the  nature  of  their  diet — such,  for  instance,  as  in  men  who  undergo  training 
for  athletic  pleasures,  or  who  are  subjected  to  the  influence  of  fetid  animal  exhalations 
as  met  with  in  a  skin-yard,  pathological-room,  or  dis.secting-room.  They  are  seen  also  in 
the  diabetic  and  cachectic  subject,  as  well  as  in  patients  enfeebled  by  any  fever  or  other 
debilitating  cause.  Ganigee  tells  us  that  they  are  often  the  result  of  eating  di.sea.sed 
meat.  They  are  also  produced  by  the  local  contact  of  certain  cadaveric  emanations,  the 
newly-appointed  post-mortem  clerks  of  our  hospitals  often  falling  victims,  the  poison  act- 
ing at  first  as  a  direct  irritant  upon  the  follicles  to  which  it  is  applied.  They  are  far 
more  common  in  some  years  than  in  others.  In  persons  who  are  predisposed  to  their  for- 
mation any  local  irritation  is  apt  to  produce  them,  such  as  the  friction  caused  by  rowing, 
the  application  of  a  poultice,  water  dres.sing,  strapping,  or  a  blister.  They  attack  the 
integument  of  any  part  of  the  body,  the  palms  of  the  hands  and  soles  of  the  feet  being 
apparent  exceptions. 

In  the  dense  integument  of  the  nape  of  the  neck,  buttock,  and  outside  of  the  thighs 
they  are  more  chronic  and  painful  than  in  the  .skin  of  looser  texture.  They  are  trouble- 
some local  affections,  but  seldom  endanger  life.  In  rare  instances  they  are  followed  by 
septicaemia  and  death,  but  only  in  one  instance  have  I  known  this  to  occur. 

Treatment. — The  general  treatment  must  depend  upon  the  condition  of  the  body 
and  the  apparent  cause  of  the  complaint,  any  unwhole.some  habit  being  corrected  and  any 
evident  want  supplied.  Under  other  circumstances,  the  practice  must  be  directed  on 
general  principles.  The  diet  should  be  nutritious,  but  not  too  stimulating ;  exercise 
short  of  fatigue  should  always  be  allowed,  and  fresh  air  obtained  when  possible.  The 
secretions  .should  be  looked  to,  and  when  out  of  order  corrected,  mild  laxatives  being 
often  of  service.  AVhen  the  skin  is  secreting  unhealthily,  the  Turkish  or  warm  bath  is 
of  great  benefit.  Moreover,  alkalies  or  acids  ought  also  to  be  given  when  the  condition 
of  the  stomach  needs  them  ;  alkalies  and  bitters  are  often  of  great  benefit. 

When  debility  exists,  quinine  is  invaluable  :  and  in  London  or  large  towns  its  com- 
bination with  iron  is  required.  When  diabetes  is  present,  the  "  full-feeding'  treatment  is 
probably  the  best.  Dr.  Jackson  of  the  United  States  gives  twelve  to  sixteen  grains  of 
quinine  a  da}-,  increa.sing  the  dose  daily  until  its  special  effects  are  produced,  and  then 
decreasing  it.  He  continues  the  treatment  for  a  month.  Veast  in  doses  of  a  tablespoon- 
ful.  taken  fasting  three  times  a  day,  occasionally  appears  to  have  a  rapidly  marked  bene- 
ficial effect,  although  in  what  way  it  acts  it  is  diflScult  to  .say. 

The  local  treatment  must  be  directed  much  by  the  local  symptoms,  it  being,  as  a  rule, 
a  better  course  to  let  the  boil  discharge  it.self  or  dry  up  than  to  lance  it.  In  the  early 
stage  of  the  papular  or  follicular  form  of  boil  the  free  application  of  alcohol,  spirit  of 
camphor,  the  nitrate  of  silver,  liquor  potassfe.  or  iodine  tincture  is  often  followed  by  its 
disappearance  ;  but  in  the  other  kind  all  such  applications  are  worse  than  u.seless.  Cov- 
ering up  the  areola  of  the  boil  with  a  perforated  piece  of  plaster  is  a  good  practice.  At 
times  painting  the  areola  with  collodion  or  colloid  styptic  answers  well. 

When  the  pain  is  great  from  the  tension  of  the  part,  and  the  areola  of  inflammation  is 


170  CARBUNCLE. 

spreading,  relief  may  generally  be  given  by  lancing ;  and  when  the  slough  is  slow  in 
separating,  the  introduction  into  the  opening  of  a  point  of  potassa  fusa  is  followed  by  the 
rapid  cleansing  of  the  wound  and  its  granulation.  Poultices  may  be  applied  for  a  limited 
period  during  the  sloughing  stage,  but  not  for  any  length  of  time,  as  they  often  encour- 
age the  appearance  of  others.  When  boils  succeed  one  another  seriatim  without  any 
definite  cause,  change  of  air  is  a  most  successful  remedy. 

Carbuncle. 

This  is  a  far  more  serious  affection  than  a  boil,  for  it  is  almost  always  met  with  in  the 
feeble  and  cachectic  subject,  and  generally  in  men,  rich  or  poor,  over  forty-five.  It  is 
very  frequently  associated  with  diabetes,  and  gouty  patients  are  particularly  prone  to  its 
attack. 

It  generally  occurs  singly  and  is  slow  in  its  progress,  the  inflammation  in  the  skin 
and  cellular  tissue  beneath  spreading  as  a  brawny  inflammatory  effusion  with  no  defined 
border.  The  redness  of  skin  is  rarely  vivid,  more  frequently  livid  ;  at  times  the  local 
pain  is  severe  and  constitutional  depression  very  great.  The  sloughs  separate  slowly, 
many  openings,  as  of  many  boils,  allowing  them  to  escape,  and  the  whole  skin  at  times 
separates  as  an  ash-colored  layer,  leaving  an  irregular  cavity  undermining  the  neighboring 
tissues.  The  favorite  seats  of  carbuncle  are  the  skin  and  subcutaneous  tissue  of  the  nape  of 
the  neck,  back,  and  buttock.  The}-  occur,  however,  on  the  front  of  the  body  and  the  extrem- 
ities and  on  the  lip  or  face.  The  disease  is  so  slow  in  its  progress  as  at  times  to  occupy 
many  weeks,  one  part  going  through  its  course  while  it  spreads  in  another.  It  may- 
destroy  life  by  exhaustion  or  by  pyremia.  The  worst  form  of  pyaemia  arises  from  it ; 
indeed,  M.  Labat  {Med.-Chir.  Soc.  Bordeaux,  1868)  believes  pyagmia  to  be  the  most  com- 
mon cause  of  death  in  carbuncle.  Rare  cases  have  been  recorded  in  which  peritonitis 
was  caused  by  the  extension  of  the  disease  from  the  abdominal  walls  into  the  peritoneal 
cavity. 

When  the  treatment  by  incision  is  adopted,  life  is  too  often  shortened  by  loss  of  blood. 
As  a  general  rule,  however,  carbuncle  is  not  a  fatal  disease.  Its  danger  depends  much 
upon  its  extent,  and  more  upon  the  complication  with  which  it  is  associated. 

Treatment. — In  former  days  the  one  form  of  local  treatment  that  every  surgeon  fol- 
lowed was  that  of  the  crucial  inci.sion,  +,  the  knife  being  passed  freely  through  the 
tissues  to  the  base  of  the  inflammatory  effusion  ;  the  object  of  this  was  to  give  room  for 
the  slough  to  separate  and  come  away.  In  modern  times  the  value  of  this  practice  has 
been  much  questioned,  for  it  was  too  often  found  to  be  followed  by  loss  of  blood  where 
blood  was  much  needed  ;  nor  has  it  been  thought  that  the  incision  did  much  to  hasten 
the  progress  of  the  ease  or  the  separation  of  the  slough.  It  is  still,  however,  a  popular 
form  of  practice.  I  was  taught  it,  but  after  observing  its  effects  have  long  given  it  up, 
believing  that  it  did  little  or  no  good  and  was  often  followed  by  a  harmful  hemorrhage. 

The  treatment  I  prefer,  and  have  adopted  for  many  years,  has  been  that  by  caustic  ; 
and  the  more  I  see  of  it,  the  better  I  like  it.  It  has  been  strongly  advocated  in  this 
country  by  Pritchard,  and  in  America  by  Dr.  Physick.  It  is  applicable  in  the  stage  of 
the  disease  when  the  cellular  tissue  is  brawny  and  the  early  inflammation  of  the  skin  has 
subsided ;  it  may  be  used  before  any  openings  in  the  skin  are  found,  either,  as  Pritchard 
advises,  by  rubbing  the  caustic  potash  freely  in  the  centre  of  the  carbuncle  until  an 
eschar  is  fully  formed,  or,  which  is  preferable,  by  puncturing  with  a  scalpel  and  inserting 
the  stick  or  a  small  piece  the  size  of  a  pea  well  into  the  diseased  tissues.  When  the  car- 
buncle is  large,  many  punctures  may  be  made,  one  to  every  area  of  surface  of  the  dimen- 
sions of  half  a  crown.  Where  openings  exist,  the  surgeon  has  only  to  insert  the  caustic 
and  allow  it  to  melt,  either  in  the  stick,  or,  what  is  better,  in  pea-like  masses,  by  means 
of  dressing  forceps,  passing  them  well  down  into  the  subcutaneous  tissue.  By  this  prac- 
tice the  slough  is  certainly  cast  off  more  readily  than  when  incisions  are  made  or  the  case 
left  to  nature.  No  bleeding  takes  place,  and  very  little  pain  is  given  excepting  at  the 
time.  W^ith  this  treatment  large  carbuncles  become  soon  healthy  granulating  wounds. 
The  only  care  required  is  to  pi'event  the  caustic  running  over  the  sound  skin.  During 
this  treatment  a  wad  of  absorbent  cotton-wool  should  be  applied,  with  some  lotion,  such 
as  that  of  boracic  acid,  carbolic  acid,  or  alcohol ;  a  solution  of  opium  applied  to  the  part 
often  gives  relief  to  pain.  Tonics,  good  living,  and  fresh  air  are  also  essential.  The 
French  surgeons  prefer  the  iise  of  the  A^ienna  paste.  Paget  prefers  the  common  resin 
cerate.  By  these  means,  unless  the  carbuncle  is  associated  with  some  serious  malady, 
euch  as  diabetes  or  pygemia,  a  good  result  may  be  looked  for. 


rKIlFonATISll    ULCER    OF  TnE  FOOT.  171 

Tilt'  |)lim  (if  iiiakiii};  ii  sulx-utaiioous  iiici.sioii  lias  hcon  alily  advficatcd  liy  Mr.  French 
and  -M.  (iiuTiii,  ami  that  nl"  ('((niprcssiiui  liy  .Messrs.  O'Ferrall  and  .M.  II.  ('(dies  of  hiildin 
{/)i(h.  (Jiiiirf.  Jiiiir..  1S(»4).  The  fnniu'r  plan  1  have  trie<l,  hut  have  failed  t(i  find  its 
advantage.  The  latter  I  have  not  eni|doyed,  having  been  already  well  satisfied  with  the 
eaustie  treatment. 

Facial  Carbuncle. 

This  has  hei'ii  often  miscalled  "malignant  imstule,"  to  whi(di  attention  has  been 
drawn  (p.  108).  It  was  pndiably  first  described  by  a  clever  young  surgeon,  Harvey 
Ludlow  (Med.  Tiinis  anil  (!az.,  Septemlxir,  1852).  It  is  generally  found  on  the  lip.  the 
upper  one  being  the  more  commonly  involved,  as  an  ccdematous  inflammatory  swelling  of 
the  part,  involving  the  nose  and  cheek,  often  preceded  by  some  pustule  or  vesicle,  and 
generally  accompanied  by  tliem.  It  is  almost  always  a.ssociated  with  severe  pain.  It 
ends,  as  do  most  ca.ses  of  carbuncle,  with  sloughing,  and  at  times  the  whole  substance  of 
the  li|>  or  cheek  gives  way.  It  is  associated,  like  carbuncle,  with  great  constitutional 
de|)ression,  and  its  special  danger  is  thrombosis  ami  phleltitis  of  the  c<!rebral  sinuses;  the 
inflammation  of  the  veins  extends  from  tlie  affected  parts  through  the  ojihthalmic  veins  to 
the  cavernous  sinus.  I  have  seen  six  cases  at  least  of  this  affection — four  of  the  ujiper 
and  two  of  the  lower  lip — ami  all  recovered.  In  only  one  did  the  disease  extend  beyond 
the  lip,  while  in  all  the  disease,  as  far  as  local  treatment  was  concerned,  was  left  to  natu- 
ral processes,  cleanliness  and  fomentations  being  alone  employed.  Tonics  and  good  diet 
were  given,  and  quinine  with  iron,  in  full  doses,  appeared  the  best.  Paget  advises  quinine 
in  sufficient  doses  to  produce  symptoms  of  cinchonism. 

jM.  Keverdin  of  Oeneva  gives  a  very  elaborate  essay  on  this  subject  in  the  Archives 
Generab'n  de  Medecim-,  1870.  At  p.  1(52  of  the  August  number  he  thus  sums  up  his 
conclusions : 

1.  Anthrax  and  furuncle  of  the  face  present  a  special  gravity.* 

2.  This  gravity  is  due  to  the  ready  complication  with  [ihlebitis. 

3.  The  facial  phlebitis  is  attended  with  death,  eitlier  by  extension  to  the  sinuses  of  the 
dura  mater  or  by  becoming  the  source  of  purulent  infection. 

4.  Of  anthrax  of  the  face,  that  of  the  lips  is  more  frequently  complicated  with  phle- 
bitis than  the  others.     This  may  be  explained  by  the  peculiar  texture  of  tlie  lips. 

5.  Anthrax  of  the  lips  has  nothing  in  common  with  malignant  pustule. 

6.  The  involving  of  the  orbit  in  the  phlebitis,  as  demonstrated  by  exophthalmia,  shows 
almost  for  certain  the  implication  of  the  sinus. 

7.  Incision,  speedily  and  extensively  performed,  seems  to  be  the  best  means  of  pre- 
venting, and  sometimes  of  arresting,  the  phlebitic  complications. 

Perforating  Ulcer  of  the  Foot. 

This  affection  was  so  called  by  Vesigne  of  Abbeville  in  1850.  It  is  an  aff"ection  which 
Mr.  Hancock  brought  prominently  before  us  in  an  able  paper  published  in  the  Bn'f.  Mfd. 
Joimud^  June  2(),  18G9,  although  Cloquet,  Boycr,  and  Nelaton,  of  Paris,  have  also 
described  it.  Nelaton  says  it  "  commences  with  phlyct.-cna  in  the  pad  of  the  foot.  The 
epidermis  is  raised  by  a  small  quantity  of  purulent  serum.  Others  describe  it  as  com- 
mencing like  a  flat  corn,  which  ulcerates.  When  this  is  opened  the  subjacent  dermis 
appears  of  a  rose  color,  and  when  touched  is  highly  sensitive.  This  state  may  continue 
for  some  time,  when  the  dermis  in  its  turn  gradually  ulcerates,  and  a  small  fi.stulous  open- 
ing is  established  in  the  subcutaneous  cellular  tissue,  which  will  not  heal,  but  continues 
to  discharge  serum  slightly  tinged  with  pus.  If  after  five  or  six  weeks  the  sinus  is  exam- 
ined by  a  probe,  the  subjacent  bone  is  felt  rough  and  necrosed,  and  a  sequestrum  subse- 
quently forms."  An  attempt  has  been  made'  to  connect  this  local  affection  with  nerve 
lesion,  central  or  peripheral ;  but  evidence  is  still  wanting  to  prove  that  there  is  more 
than  an  accidental  connection  between  the  two  conditions. 

Treat.ment. — The  disease  is  most  obstinate  in  its  character,  generally  spreading  over 
years.  It  is,  however,  chiefly  local  and  confined  to  the  anterior  portion  of  the  foot, 
^ledicine  has  little  power  over  it ;  Fowler's  solution  has  been  much  vaunted  for  its  cure, 
but  with  insufficient  evidence  ;  and,  as  far  as  facts  can  guide  us,  it  appears  Hancocks 
conclusion — that  when  dead  bone  exists  it  should  be  removed — is  the  only  right  one. 
"  But  if,  notwithstanding,  the  disease  returns,  there  can  no  longer  be  a  question  that, 
when  once  perforating  ulcer  of  the  sole  of  the  foot  is  established  and  recognized,  it  is 
1  Savory,  Med.  Chir.  Trans.,  vol.  Ixii.,  1879. 


172  MYCETOMA,  OR   THE  FUXGUS  DISEASE  OF  INDIA. 

better  at  once  to  remove  the  whole  of  the  metatarsal  bones  either  by  Chopart's,  Syme's, 
or  PirogofF's  amputation.'" 

These  cases  are  not  to  be  confused  with  the  suppurating  bursje  or  bunions  found  in 
feet  deformed  from  short  or  tight  boots. 

Delhi  or  Oriental  Sore. 

This  disea.se,  which  is  identical  with  the  Moultan  sore,  Aleppo  boil,  or  Bi.skra  bouton, 
''  yaws  of  the  West  Indies,"  and  Parange  of  Ceylon,  is  a  cutaneous  disease  due  to  the 
entrance  of  a  parasite  into  the  body,  during  bathing  or  washing,  through  an  opening  in 
the  cuticle  caused  by  an  abrasion  of  the  skin,  such  as  a  mosrjuito-bite.  The  parasite 
is  supposed  by  Messrs.  Alcock  and  Fleming  of  the  Indian  army  (J/^r/.  R'p..  1868)  to 
dwell  in  the  foul,  brackish,  hard  well-water  (the  Delhi  well-water  containing  45  to  50 
grains  of  carbonate  of  lime  per  gallon).  Such  good  observers  as  Messrs.  Lewis  and  Cun- 
ningham ( Appenih'x  to  12th  Report  of  Sonituri/  Commissioners  icifh  Government  of  Tndia^ 
assert,  however,  that  the  disease  is  of  the  nature  of  a  lupus  and  should  be  treated  as  such. 
Indeed,  they  describe  it  as  "lupus  endemicus "'  (^Lancet,  April  7.  1S77).  It  may  attack 
dogs  and  horses.  "  It  appears  on  the  exposed  parts  of  the  body,  at  fir.st  as  a  small  pimple, 
like  an  irritated  mosquito-bite,  and  remains  in  this  .state  for  several  days  or  weeks,  some- 
times for  months.  It  then  slowly  increases,  and  a  thin  fluid  escapes  from  the  top.  which 
dries  and  forms  a  circular  scab,  gradually  increasing  in  size  and  thickness.  When  this 
scab  is  removed,  an  indolent  ulcer  is  exposed,  with  undermined  edges  and  lobulated 
granulations  in  the  centre,  in  healthy  subjects  like  raspberries,  but  paler  and  more  blue 
in  cachectic  cases.  These  ulcers,  when  very  broad,  show  signs  of  cicatrizing  from  the 
centre;  in  all  there  remains  a  depressed  cicatrix  after  healing.  The  disease  may  last 
from  six  months  to  two  years"  (Surgeon-Gen.  Murray.  Epidem.  Society,  March, 
1862). 

Treatment. — It  is  to  be  treated  by  personal  cleanliness,  the  avoidance  of  the  use  of 
foul  hard  water,  the  early  destruction  of  the  sore  by  the  cautery  or  caustic,  and  the  appli- 
cation of  metallic  astringents.  Tonic  treatment,  a  good  diet,  and  if  possible  change  of 
locality  and  climate,  should  be  secured. 

Mycetoma,  or  the  Fungus  Disease  of  India. 

This  disease  has  been  described  by  Dr.  Carter  of  Bombay  in  the  Trans,  of  the  Med. 
and  Phys.  Sejc.  Bombay,  1861,  and  in  a  memoir  publi.slied  by  Churchill.  1874,  and  it  is 
supposed  by  him  to  be  due  to  the  presence  of  a  fungus.  Other  authors  have  thrown 
doubt  upon  this  point,  and  amongst  them  F.  B.  Lewis  and  D.  Cunningham  of  Calcutta, 
who  conclude  that  it  is  reasonable  to  infer  that  localized  spots  in  the  tissues  undergo 
degenerative  changes  into  a  sub.stance  peculiarly  adapted  to  the  development  of  filament- 
ous growths.  The  origin  of  the  fungus  in  situations  where  no  spore  could  penetrate 
must  remain  a  matter  of  perplexity  (3L  J.  Berkeley,  Xature.  November  9,  1876).  The 
disease,  however,  is  well  recognized.  Berkeley  observes  that  the  bodies  found  in  the 
disease  "  so  nearly  simulate  fungous  growths  that  it  is  diflScult  to  get  rid  of  the  notion 
that  they  are  really  vegetable  growths"  (InteUerf.  Observ..  1863).  The  disease  is  more 
frequent  in  men  than  in  women,  and  affects  all  classes,  rich  as  well  as  poor ;  but  it  has 
never  attacked  an  European. 

The  disea.se  is  chronic  and  affects  most  commonly  the  foot,  sometimes  the  hand,  and 
but  rarely  other  parts  of  the  body.  It  is  very  slow  in  its  progress  and  has  no  tendency 
to  get  well  if  left  alone.  L^sually  it  begins  on  the  plantar  surface  of  the  foot  or  the 
palmar  of  the  hand,  as  an  induration  in  or  under  the  skin  ;  this  subsequently  softens 
down ;  a  bleb  then  forms  over  the  spot  and  bursts,  leaving  a  sinuous  opening,  from  which 
exudes  a  thin,  sanious,  sero-purulent  discharge.  As  the  disease  progres.«es  other  indura- 
tions, followed  by  sinuses,  form,  till  the  foot  or  hand  becomes  one  indurated  diseased 
mass  riddled  with  holes,  the  orifices  of  sinuses,  which  may  or  may  not  lead  to  bone ;  and 
in  extreme  cases  the  bones  are  tunnelled.  These  sinuses  discharge  freely  a  putrid  sero- 
purulent  fluid  containing  '■'  fungus  particles."  The  fungi  are  of  two  kinds,  each,  accord- 
ing to  Dr.  Carter,  marking  a  variety  of  the  disease.  One.  the  dark  or  dark-brown,  is 
globular  or  ovoid  in  form,  hard  and  friable  in  consistence,  and  of  the  size  varying  from  a 
pin's  head  to  that  of  a  bullet.  The  other  is  pale  or  yellowish  in  color,  soft  and  cheesy  in 
consistence,  and  of  the  size  of  a  minute  .<peck  or  pea.  Dr.  Carter  and  others  believe  that 
excision  or  amputation  of  the  affected  part  is  the  only  sound  practice  to  be  adopted. 


ir.iA'7\  MOLLS,  AM)  coiiys.  173 


Warts. 


Tlicso  AW  ontf^mwtlis  (if  the  jcipill.-o  of  tlu-  skin,  the  ]iapill;e  Ix-iii^'  usually  elongated 
ami  their  cpitlit'liul  covering  tliiekeneil.  They  an;  eonmioii  on  the  liands  and  other  partH 
of  the  hotly  of  the  young,  and  nmre  rare  in  the  adult.  When  on  expo.sed  part.s  of  the  body, 
they  assume  a  horny  hardness;  hut  when  surrounded  with  moisttire  or  the  secretion  of 
the  skin,  they  are  .soft  and  more  sensitive. 

The  flat  wart  is  called  nrrncii  siiti/ilex  ;  the  pedunculated,  tw/'Ho/  iU(jil(it<i ;  and  these 
are  said  to  be  more  common  in  the  scalp.  I  have  seen  them  on  the  neck,  orifice  of  the 
nose,  mouth,  eyes,  ears,  and  anus,  also  on  the  prepuce  and  labia.  I  have  .seen  them  also 
on  the  tongue.  Thi'y  occur  at  times  beneath  the  nails  un<l  are  very  painful — nub-unyual. 
The  worst  crop  of  warts  I  ever  saw  was  around  the  anus  of  a  boy. 

The  flat  warts  occasi(Uially  come  and  go  in  a  way  which  cannot  be  accounted  for;  as 
a  rule,  they  are,  however,  jiersistent.  They  rarely  last  into  adult  life  ;  but  wlien  they  do, 
they  .seldom  grow  or  give  trouble.  Tn  excei)tional  cases,  under  stnne  local  irritation,  they 
mav  increa.se  and  assunu'  more  the  character  of  an  epithelial  cancer.  When  on  the  face, 
this  change  is  peculiarly  liable  to  occur.  Not  long  ago  I  destroyed  an  eiiithelial  cancer  by 
the  ala  of  the  nose,  the  size  of  a  florin,  that  had  suddenly  a])peared  in  a  wart  which  had 
existed  for  sixty  years — nearly  all  the  patient's  life  ;  and  I  have  removed  from  the  lip  of 
a  man  a  cancer  that  had  grown  from  a  wart  which  had  existed  as  long  as  he  could 
remember. 

Venereal  warts  are  very  abundant,  whether  they  grow  from  the  glans  penis  or 
prejiuce  (»f  the  nuile  or  labia  of  the  female.  They  are  pedunculated,  moist,  and  highly 
vascular,  and  are  clearly  contagious.  Warts,  however,  may  occur  at  times  in  these  part.s 
without  any  venereal  contact. 

Treatment. — Some  powerful  alkali,  such  as  ammonia,  to  dissolve  the  cuticle,  and 
the  subsetjuent  application  of  the  glacial  acetic  acid,  nitric  acid,  or  acid  nitrate  of  mer- 
cury, to  destroy  the  jiupilh^,  is  the  best  plan  to  get  rid  of  the  harder  or  flat  warts.  Lunar 
caustic  is  an  unsatisfactory  and  tedious  remedy.  Pedunculated  dry  warts  should  be  cut 
oft"  with  the  knife  or  scissors,  and  the  mo{>^t  may  be  treated  in  the  same  way  when  not  too 
extensive.  When,  however,  they  are  extensive,  they  may  be  made  to  dry  up  by  the 
application  of  some  powder,  such  as  the  oxide  of  zinc,  or  even  starch.  Powdered  fresh 
savine  is  a  good  application  ;  Mr.  T.  Smith  recommends  it  to  be  mixed  with  the  powdered 
diacetate  of  copper.  The  perchloride  of  iron  in  tincture  is  also  serviceable.  Venereal 
warts  and  others,  when  extensive,  may  be  readily  destroyed  by  means  of  the  galvanic 
cautery,  the  patient  being  under  chloroform.  At  times  excision  is  the  best  practice.  In 
the  large  masses  that  are  found  on  the  genital  organs  of  women,  of  venereal  origin, 
nothing  but  the  removal  of  the  whole  with  the  labium  can  be  entertained  ;  when  the 
ecraseur  of  the  galvanic  cautery  cannot  be  obtained,  the  ordinary  wire  instrument  may 
be  used.  The  hemorrhage  from  these  venereal  warts  is  generally  severe,  and  the  surgeon 
should  never  attempt  to  remove  them  by  excision,  when  they  are  exten.sive,  without 
having  at  hand  some  good  styptic,  such  as  the  solution  of  the  perchloride  of  iron,  matico, 
alum  dry  and  in  solution,  or  the  cautery  in  one  of  its  forms. 

Moles. 

Using  the  word  in  the  broad  sense  to  include  .«mall  spots  of  discolored  skin,  and 
cutaneous  connective-tissue  tumors  with  pigment,  with  or  without  unnatural  growth  of 
hair  or  skin  glands,  they  are  very  common,  few  people  being  without  one  or  more  upon 
the  surface  of  the  body,  while  many  have  them  in  numbers.  I  have  seen  a  woman 
studded  all  over  with  hairy  moles,  the  hairs  having  been  in  some  half  an  inch  long  and 
bi-istly.  Moles  are  generally  congenital,  but  at  times  put  in  an  appearance  later  in  life ; 
they  are  rarely  of  any  great  importance  beyond  the  disfigurement  they  produce.  Occa- 
sionally, however,  they  degenerate  or  become  the  seat  of  a  cancerous  disease;  the  mela- 
notic sarcoma  has  frequently  its  origin  in  such  congenital  spots.  This  clinical  fact,  which 
is  now  fairly  recognized,  is  important,  and  renders  it  expedient  for  the  surgeon  to  excise 
any  mole  that  has  a  tendency  to  grow  or  to  become  indurated  in  middle  life.  Many  of 
the  most  virulent  forms  of  multiple  cancer  the  surgeon  sees  have  their  origin  in  moles. 

Corns. 

These  are  thickened  cuticle,  the  result  of  occasional  pressure,  whether  on  the  toes  or 
feet,  from  tight  or  hard  boots,  or  on  the  hands,  from  the  mechanical  irritation  of  tools,  etc., 


174  BUNIONS. 

or  elsewhere.  It  should  be  remembered  that  they  are  the  result  of  occasional,  and  not 
constant,  pressure,  the  latter  causing  atrophy  and  absorption.  "  Not  only,"  wrote  Hunter, 
"  the  cuticle  thickens,  but  the  parts  underneath  ;  and  a  sacculus  (bursa)  is  often  formed 
at  the  root  of  the  great  toe,  between  the  cutis  and  ligaments  of  the  joint,  to  guard  the 
ligaments  below.''  This  bursa  is  found  under  all  corns  when  the  pressure  is  not  removed. 
A  corn,  when  newly  formed,  can  by  maceration  be  elevated  from  its  position  as  thickened 
cuticle  only,  the  cutis  being  unaffected  ;  but  in  old  corns  the  cutis  appears  to  atrophy  and 
the  papillce  to  disappear.  Such  corns,  writes  Mr.  T.  Smith  (^Holmes's  St/st.,  vol.  v.),  "  may 
be  found  based  upon  the  fibrous  tissue  of  the  sheaths  of  the  extensor  tendons  of  the 
toes,  all  intermediate  structures  having  been  absorbed."  When  a  bursa  has  formed,  it 
may  inflame  or  suppurate  and  give  rise  to  troublesome  conditions  such  as  will  be  described 
under  "  Bunion." 

A  corn  is  called  " soft"  when  it  forms  between  the  toes.  It  is  far  more  painful  and  sen- 
sitive than  the  ''  hard  ;"  it  grows  also  more  rapidly,  probably  owing  to  its  greater  moisture. 

Treatment. — Remove  the  cause  and  the  disease  will  disappear.  This  is  a  doctrine 
which  applies  to  corns  of  all  forms  when  acted  upon  early.  Boots  which  are  too  loose 
are  as  injurious  as  those  which  are  too  tight :  where  one  presses  the  other  rubs,  the  result 
being  the  same.  A  well-fitting  boot  with  a  broad  sole,  straight  inner  border^  and  square 
top  is  the  best.  To  remove  the  cuticle  nothing  equals  warm  water ;  and  after  soaking 
the  part  in  it  for  some  time,  or  keeping  the  corn  covered  for  a  night  or  more  with  water 
dressing  and  oiled  silk,  the  whole  may  be  carefully  peeled  off  by  means  of  a  knife. 
After  the  removal  of  the  corn  the  skin  should  be  protected  by  a  piece  of  soap  plaster 
spread  on  leather.  The  application  of  nitrate  of  silver  has  been  recommended,  but  I 
have  known  it  produce  great  pain,  and  when  applied  to  an  inflamed  corn  much  harm — 
indeed,  in  one  case,  sloughing  of  part  of  the  integuments  covering  the  little  toe.  In  old 
people  it  is  dangerous.  The  application  of  the  glacial  acetic  acid  is  to  be  preferred. 
When  suppuration  takes  place  beneath  a  corn,  it  should  be  relieved  by  a  puncture  as  soon 
as  possible,  and  water  dressing  applied.  Bursal  swellings  are  to  be  treated  as  bunions. 
Soft  corns  are  best  treated  by  taking  away  pressure  by  means  of  the  introduction  between 
the  toes  of  absorbent  cotton-wool  and  the  use  of  some  dry  powder,  such  as  the  oxide  of 
zinc ;  the  corn  thus  soon  becomes  a  dry  one  and  is  easily  eradicated.  Acetic  or  carbolic 
acid  is  a  good  application  in  obstinate  cases. 

Bunions. 

When  from  excessive  or  long-continued  pressure  a  bursa  forms  over  one  of  the  tar- 
sal or  metatarsal  articulations,  a  "  bunion  "  is  said  to  be  present ;  and  the  most  common 
seat  for  this  affection  is  the  metatarsal  joint  of  the  great  or  little  toe.     This  fact  is  to  be 

explained    by   the   evil  tendency   which   boots,  as 
Fig.  58.  Fig.  59.  generally  made,  have   to   draw   the   toes  together 

toward  the  central  line  of  the  foot,  the  central  axis 
of  the  undeformed  great  toe,  which  runs  parallel 
with  the  metatarsal  bone  through  the  centre  of  the 
heel,  being  thus  made  to  deviate  from  the  normal 
to  an  abnormal  line,  in  which  the  great  toe  itself, 
looking  outward,  forms  with  the  metatarsal  bone 
at  the  joint  an  angle  pointing  inward,  and  the  axis 
of  the  toe  falls  far  within  the  normal  one  of  the 
_     .  foot  (Fig.  58). 

BuniouT''"*'^       Toe-Ca^lb^  the  Cure  of         Aston  Key,'  however,  attributes  this  deformity 
Bunion.  more  to  exces.sive  weight  received  on  a  weak  tarsus 

and  metatarsus  from  over-standing,  the  great  toe  being  gradually  forced  outward  by  the 
oblique  bearing  of  the  foot  on  its  inner  plantar  surface  when  the  arch  of  the  foot  has 
given  and  the  foot  becomes  flat.  Too  short  boots  greatly  favor  this  change,  the  foot  by 
such  being  compressed  longitudinally  and  the  arch  of  the  tarsus  increased,  the  toes  even 
being  drawn  up  to  form  angles  with  the  metatarsal  bones,  the  great  toe  suffering  the  most. 
When  bursae  form  over  the  projecting  bones,  it  is  to  save  the  joints  from  injury  ;  and  at 
times  these  form  over  the  dorsum  itself.  Under  extreme  conditions  the  bursa  may  inflame 
and  suppurate,  giving  rise  to  obstinate  and  troublesome  sores.  In  still  more  extreme  or 
neglected  cases  the  joint  of  the  great  toe  may  be  involved,  ending  in  its  destruction  with 
or  without  exfoliation  of  bone. 

1  Gtiy's  Hosp.  Rep.,  1836. 


i.y-ajiowy  tok-sml.     ■  176 

TiiKATMKNT. — Wlipn  tlip  nuturt!  of  a  luuiion  is  un<lerstoofl,  the  principles  of  its  treat- 
ment lu'conu'  clear.  Preventive  treatment  is  the  best,  and  consists  in  maintainin<r  the 
natural  eimdition  of  the  foot;  in  y«)ung  children,  and  in  jrirls  especially,  hy  jruarding 
aj^ainst  the  flattening  of  the  foot  from  over-standing  or  walking  during  the  jteriod  of 
growth,  and  against  altering  the  axis  of  the  great  toe  by  keeping  the  inner  line  of  the 
boot  straight;  and  in  no  way  by  too  short  boots  cramping  the  foot  longitudinally. 

When  a  bunion  has  formed,  the  oidy  consistent  treatment  is  that  which  tends  to 
restore  the  mis])laced  toes  to  their  natural  position — when  the  great  toe  i.s  inv»jlved,  either 
by  Key's  jilan  of  having  a  .separate  compartment  made;  in  the  boot,  so  Cfjiistructed  as  to 
keep  it  in  a  straight  line  with  the  foot,  or  by  the  simple  apparatus  given  in  Sayre's  work 
on  orthopii'die  surgery  (  Fig.  •")!•),  which  consists  of  buckskin  or  linen  caps  to  the  toe  («), 
a  few  inches  of  elastic  webbing  (h)^  a  piece  of  adhesive  plaster  to  go  round  the  foot  (c), 
and  two  circular  j)ieces  of  the  same  ('/)  to  retain  all  in  position.  Even  in  .severe  cases 
this  practice  may  be  successful,  and  in  the  old  and  confirmed  cases  the  same  is  to  be 
adopted  ;    palliative  treatment,  however,  is  at  times  alone  practicable. 

The  common  ])lan,  wrote  Key  in  l.S!:5U  ((tiu/s  Ifosp.  Ji«p.),  "resorted  to  for  the  relief 
of  bunion  palliates  the  evil  in  some  degree  by  removing  the  pain  and  taking  off  the  press- 
ure, but  it  does  not  go  to  the  root  of  the  evil.  The  plasters  on  thick  soft  leather  are 
agreeable  to  a  painful  bunion  by  keeping  the  skin  in  a  pliant  .state  and  by  protecting  the 
part  from  pressure,"  but  they  do  not  cure  the  di.sease. 

Under  all  circumstances,  pressure  is  to  be  removed ;  nothing  like  a  tight  boot  ought 
to  be  thought  of.  a  wide  and  easy  one  being  worn.  To  the  inflamed  bunion  water  dress- 
ing is  the  best  application.  Should  suppuration  take  place,  an  early  incision  into  the 
bursa  should  be  made.  In  old  people,  however,  .some  caution  is  called  for  in  carrying  out 
this  practice,  because  in  such,  where  from  diseased  arteries  or  other  causes  the  circulation 
is  feeble,  gangrene  of  the  part  or  a  troublesome  suppuration  may  ari.se.  AVhen  suppurat- 
ing sores  exist,  they  may  in  the  aged  ret|uire  stimulating  applications;  in  the  middle-aged, 
the  bursa  may  be  laid  open  and  allowed  to  granulate  or  be  excised.  In  the  early  stage 
of  a  bunion  the  mechanical  means  suggested  may  be  aided  by  the  local  application  of  a 
small  blister,  and  Mr.  Thomas  Smith  speaks  highly  of  the  local  use  of  the  biniodide  of 
mercury  ten  grains  to  an  ounce  of  lard  {Holmes's  S>/sf.,  vol.  ii.  p.  938,  3d  edition). 

In  the  last  stage,  when  the  joint  is  destroyed,  the  case  may  have  to  be  treated  by 
incision  of  the  parts,  excision,  or  even  amputation. 

In-Grown  Toe-Nail. 

This  is  a  troublesome  and  painful  affection,  and  is  more  commonly  met  with  on  the 
outer  side  of  the  great  toe-nail  than  on  the  inner,  though  it  may  occur  in  both  places.  It 
is  usually  caused  by  external  pressure  upon  the  soft  parts,  the  movable  soft  parts  being 
pressed  upon  the  immovable  nail.  As  often  as  not  it  is  due  to  the  collection  of  cuticle 
beneath  the  edge  of  the  nail,  this  cuticle  acting  as  a  foreign  body  and  by  its  pressure 
causing  ulceration.  Ulceration  having  once  been  set  up.  the  healing  process  is  prevented 
by  the  presence  of  this  cuticle,  together  with  the  pressure  of  the  edge  of  the  nail  and 
the  soft  parts  covering  it  in  ;  fungous  granulations,  as  a  consequence,  frequently  form, 
and  copious  discharge  takes  place,  the  affection  being  attended  with  severe  pain. 

Treatment. — The  disease  being  the  result  of  pressure  applied  from  without  in  the 
shape  of  tight  boots,  or  from  within  in  the  form  of  indurated  cuticle  beneath  the  nail,  the 
surgeon's  main  object  in  the  treatment  is  to  take  away  the  exciting  cause,  and  when  the 
collection  of  cuticle  exists,  by  the  careful  introduction  of  a  probe  beneath  the  nail,  to 
procure  the  evulsion  of  the  foreign  body.  In  the  early  stages  of  the  disease  this  treat- 
ment is  often  sufficient.  When  external  pressure  has  been  the  cause  and  ulceration 
exists,  the  soft  parts  may  be  carefully  pressed  away  from  the  sharp  edge  of  the  nail  by 
the  careful  introduction  beneath  the  overhanging  integument  of  a  .small  roll  of  lint,  which 
should  be  well  pressed  down  to  the  bottom  of  the  sore  and  fixed  in  position  by  means  of 
strapping,  applied  so  as  to  draw  the  soft  parts  away  from  the  nail.  This  treatment,  by- 
removing  all  pressure  from  the  sore,  as  a  rule,  is  successful.  When  the  fungous  granula- 
tions are  excessive  and  the  discharge  is  profuse,  the  free  use  of  the  powdered  nitrate  of 
lead  before  the  application  of  the  lint  is  of  great  value.  After  one  or  two  applications 
of  the  lint  in  the  manner  described,  the  soft  parts  will  have  been  so  pressed  to  one  .side 
as  to  expose  the  edge  of  the  nail  with  the  surface  of  the  .sore,  when  the  lint  or  a  piece 
of  thin  sheet  lead  or  tinfoil  may  be  introduced  beneath  the  edge  of  the  nail  and  the 
dressings  renewed.     By  this  treatment  a  rapid  cure  readily  ensues;  and  if  no  external 


176 


ONYCHIA  MALIGNA. 


Fig.  60. 


pressure  be  reapplied  and  the  nail  is  allowed  to  grow  up  in  its  normal  square  form,  there 
will  be  no  recurrence.  In  severe  cases,  where  the  soft  parts  so  overhang  the  nail  as  to  be 
unaffected  by  the  means  here  suggested,  or  where  the  nail  perforates  the  soft  parts  (Fig. 
GO),  the  best  course  is  to  excise  the  overhanging  integument  by  means  of  a  scalpel ;  the 
ulcer  by  this  method  is  exposed,  and  the  sore  during  the  process  of  cicatrization  so  con- 
tracts as  to  draw  the  soft  parts  away  from  the  nail,  which  will  then  grow  up  in  its  normal 
form  and  act  as  a  covering  to  the  toe. 

When  the  ulcer  has  spread  far  under  the  nail,  it  may  be  expedient  to  remove  a  portion 
of  the  latter  to  allow  of  cicatrization,  though,  in  a  general  way,  to 
remove  half  the  nail,  to  take  away  a  V-piece  from  the  central  part  of 
its  edge,  to  scrape  or  notch  it,  are  only  temporary  remedies.  They  may 
succeed  for  a  time  and  allow  the  sore  to  heal,  but  it  is  certain  to  recur 
in  all  severity  as  soon  as  nature  has  restored  the  parts  which  the  sur- 
geon has  removed. 

To  cut  the  corner  of  the  nail  under  the  idea  that  it  is  the  offending 
body  is  a  futile  proceeding ;  it  may  for  the  moment  appear  to  be  of  ser- 
vice, but  in  the  end  it  is  injui'ious.  Indeed,  the  nail  should  be  left 
square,  as  nature  made  it,  and  care  should  be  taken  to  see  that  the  soft 
parts  are  in  no  way  pressed  over  its  edge. 

Onychia  Maligna. 

luvLludllKJIlOll  ™,  .      .  ,.  „      ,  .,  .  in  11. 

Inis  IS  a  disease  oi  the  nail  matrix,  and  a  lar  more  severe  and  obsti- 
nate affection  than  the  last.     It  is  found  most  commonly  in  unhealthy  children,  and,  as  a 

rule,  is  started  by  some  local  injury,  such  as 


Fig.  61. 


Fig.  62. 


a  squeeze.  It  commences  as  a  swelling  of 
the  end  of  the  toe  or  finger,  with  the  other 
external  signs  of  inflammation — redness, 
heat,  and  pain.  These  symptoms  are  soon 
followed  by  the  exudation  from  beneath  the 
nail  of  a  serous  and  often  fetid  fluid ;  the  nail 
itself  loosens,  sometimes  falls  off,  or  either 
flattens  out  or  curls  up  at  its  edges  (Fig.  61). 
When  this  occurs,  a  foul  ulcer  is  visible  be- 
neath. In  extreme  cases  the  affected  parts 
assume  a  flattened  bulbous  form  and  look  as 
incurable  as  any  local  affection  can  well  ap- 
pear, and  in  rare  instances  the  disease  in- 
volves the  last  phalangeal  joint  or  bone.  It 
is  never  found  in  other  than  feeble  and  ca- 
chectic children.  The  worst  case  of  this 
nature  I  have  seen  occurred  in  a  child  ast.  10, 
in  whom  the  fingers  and  thumbs  of  both 
hands  were  involved  ;  and  the  disease  had 
existed  for  years. 

Treatment. — In  favorable  and  not  extreme  examples  of  this  affection  tonics  inter- 
nally and  water  dressing  externally  suffice  to  bring  about  a  cure  ;  while  in  others  more 
active  local  treatment  is  called  for,  such  as  the  application  of  some  mercurial  lotion,  as 
black-wash  or  Abernethy's  lotion  (formed  of  the  liquor  potassae  arsenitis  3ij  to  Sj  of 
water)  or  the  red-oxide-of-mercury  ointment.  In  the  case  to  which  I  have  already 
alluded  all  this  treatment  failed,  even  after  the  evulsion  of  the  nails — a  plan  of  treat- 
ment that  should  always  be  adopted  in  obstinate  cases.  The  cure  was  at  last  effected 
by  making  a  clean  shave  of  the  dorsal  aspect  of  the  extreme  phalanx,  taking  away  nail 
and  soft  parts.  This  course  was  resorted  to  only  after  the  disease  had  existed  for  five 
or  six  years  and  had  resisted  every  form  of  treatment,  even  to  the  repeated  evulsion  of 
the  nails,  the  pain  being  agonizing  and  demanding  surgical  interference.  Fig.  61  was 
taken  from  one  of  the  fingers  of  this  patient.  Professor  Vanzetti  of  Padua  strongly 
advocates  the  application  of  the  powdered  nitrate  of  lead  to  the  ulcer,  and  my  own  expe- 
rience of  its  value  justifies  me  in  strongly  recommending  it.  Constitutional  treatment, 
with  tonic  regimen,  is  always  necessary. 

The  disease  may  at  times  have  a  syphilitic  origin,  when  it  will  be  wise  to  adopt 
specific  treatment. 


Acute  Onychia. 


Chronic  Onychia. 


ELEPHANTIASIS.  1 77 

Other  Diseases  of  the  Nails. 

TIiultT  the  iiifliiciicr  of  sitiiic  aciitc  diseiisiis,  the  nails  cease  to  <jrow,  and  tlio  arrest 
becniiics  inanit'cst.  as  (•(divalescH-nce  advances,  by  a  transverse  groove  in  tlic  nail,  while 
the  width  of  the  irroove  denotes  the  duration  of  the  arn^sted  <rrowtli. 

Ridged  Nails. — As  a  result  of  hereditary  .syphilis  .Mr.  IIut(diin.son  has  shown  that 
the  nails  niav  herduie  completely  riilired,  while  even  in  ac((uired  syphilis  llut(diinsi>n, 
Wilks,  and  Fair,u;e  have  fairly  provtid  that  the  nails  may  hecome  narrow,  thick,  ill-fnrmed 
bodies,  or  concave,  rough,  and  hiaek. 

Psoriasis  att'ects  the  nails  somewhat  in  the  same;  way.  the  nail  thicktMiing  and  split- 
ting \  ertically  ;  and  in  fariis  Fagge  has  shown  that  the  nails  may  become  thickened  and 
of  a  yollow  color  from  the  interstitial  deposit  of 

the  parasitic  disease.      Wilks  in  the  Lancef  for  '  Fio.  63.  Fig.  64. 

ISCS,  and  Fagge  in  Giu/s  IIosj,.  Rep.,  18611-70, 
have  written  fully  on  these  j)oints.  At  time.s  \)^ 
the  nails  become  .soft  and  in  feeble  subjects 
very  oonve.x.  This  condition  is  .said  to  be  com- 
mon in  phthisical  su])jects,  but  in  .surgical  dis- 
ease I  have  often  observed  the  same  condition 
appear  during  illness  and  disappear  as  strength 
returned.  I  regard  it  only  as  an  evidence  of 
feeble  power. 

Horny   growths   occasionally   spring   up 

beneath  the  nail,  as  seen  in  Fig.  03,  and  ungual 

^„^.-,4-^^;^  1  •   1     ;      „    u    .,„    „,,* ,..4^k    4^',.   ...   Horuy Growth  from  beneath       fngual  Kxostosia. 

exostosis — which  IS  a  bony  outgrowth   trom  •'        jj^jj  ^ 

the  extreme  phalanx  of  the  great  or  otlier  toe — 

very  frequently  appears  as  seen  in  Fig.  G4.     Both  require  excision. 

ELEPHANTIASIS. 

This  term  has  been  applied  to  two  very  different  diseases- — the  Elephantiasis  Grx- 
corinn,  or  true  kjrrosy,  and  the  E/epJtanfiasis  Arahiim,  or  Cochin  or  Borhadoes  hfj.  The 
former  is  probably  constitutional  and  appears  as  a  tubercular  affection  of  the  skin,  more 
especially  of  the  face,  attended  with  some  loss  of  sen.sation  ;  it  is  usually  ushered  in  with 
slight  febrile  disturbance  and  local  oedema.  As  it  advances  the  skin  thickens  and  the 
tubercles  multiply  ;  the  disease  spreads  and  involves  the  tongue,  mouth,  no.se,  eyes,  and 
even  larynx  and  lungs.  In  extreme  cases  ulceration  and  disease  of  the  bones  exist,  the 
subjects  of  the  affection  dying  from  exhaustion  if  not  from  suffocation.  It  is,  happily, 
rare  in  this  country,  although  it  does  occur  occasionally  ;  it  is,  however,  common  in  Nor- 
way, in  the  Mediterranean,  and  in  the  Indies.  Dr.  Webster  in  the  Meil.-Chir.  Trtnn^.  for 
1854,  and  Mr.  Day  in  the  Madron  Quart.  Journal  for  1800,  give  valuable  information 
upon  the  subject;  and  Dr.  Carter  in  the  Trans.  Med.  and  Phijs.  Society  of  Bombay,  vol. 
viii..  new  series,  enters  fully  into  its  pathology. 

The  disease  has  been  regarded  as  incurable,  although,  since  the  introduction  in  1873 
of  the  Ourjun  or  wood  oil  by  Dr.  Dougall  of  the  Indian  medical  service,  better  results  of 
its  treatment  have  been  realized.  The  oil  is  used  as  an  external  application,  made  into 
an  emulsion  with  lime  water,  in  the  proportion  of  one  part  to  three,  and  should  be  well 
rubbed  in  twice  a  day  for  two  hours  at  a  time.  It  has  ahso  to  be  taken  internally  in  two- 
drachm  doses  mixed  with  the  same  quantity  of  lime  water  twice  a  day.  With  this  treat- 
ment the  tubercles  are  said  to  soften  down,  and  in  their  place  watery  blebs  form,  which 
burst  and  discharge  a  clear  .serous  fluid,  and  then  the  induration  gradually  subsides.  The 
oil  taken  internally  is  a  diuretic  and  purgative. 

Elephas. 

To  the  surgeon  the  second  form  of  elephantiasis,  or  the  Elephantiasis  Arahnm,  is  of 
the  greatest  interest.  It  is  quite  distinct  from  the  true  leprosy.  It  appears  generally  in 
one  or  other  of  the  lower  extremities  or  in  the  male  or  female  genital  organs.  It  shows 
itself  as  a  general  infiltration  into  the  skin  and  subcutaneous  tissue  of  an  organizable 
material,  whereby  the  integument  becomes  hypertrophied  and  greatly  thickened.  It  is 
commonly  associated  with  some  enlargement  of  the  lymphatic  glands,  and  frequently  with 
dilatation  of  the  Ivmphatics.  It  is  occasionally  associated  with  chyluria.  In  advanced 
12 


178 


ELEPHAS. 


Fig.  65. 


disease  the  skin  falls  into  great  folds,  and  between  these  fissures  form,  which  subse- 
quently pass  into  oozing  ulcers.  At  times  the  foot  and  leg  become  the  seat  of  extensive 
ulceration,  which  rarely  cicatrizes. 

It  generally  begins  with  some  febrile  attack,  and  the  aifected  part  becomes  the  seat  of 
erythematous  redness  and  swelling,  which  sub.side,  again  to  recur  ;  each  attack  leaves 
some  extra  thickening  behind  it.  I  have  ohserved  this  very  clearly  in  many  cases,  and 
have  no  doubt  that  the  erythema  had  some  di.stinct  relation  to  the  disease. 

Treatment. — Dr.  Wise  of  Calcutta  in  1835  looked  upon  elephas  as  a  disease  of  the 
venous  system  and  inflammatory.  31r.  Day.  in  the  paper  already  alluded  to.  regards  it 
as  consecutive  to  malarious  fever,  while  31r.  Dalton  {Loncet,  18-lG)  looks  upon  it  as  a 
constitutional  disease,  like  the  leprosy;  and  upon  this  theory  the  sciatic  nerve  of  the 
afiected  limb  has  been  resected  by  Dr.  J.  S.  Morton  of  Pennsylvania  with  some  success. 
Dr.  Carnochan  of  New  York  believes  it  to  be  associated  with  an  enlargement  of  the 
arterial  trunks  of  the  part,  and  upon  this  theory  based  his  practice  of  tying  the  main 
artery  of  the  limb,  thereby  starving  the  disease.  He  performed  this  operation  for  the 
first  time  (in  January-,  1851),  and  the  success  he  met  with,  as  published  in  a  memoir  on 
the  subject  in  1858,  induced  me  to  follow  his  example  in  1865.  My  case  in  all  its  details 
was  published  in  the  Med.-Chir.  Trans.,  1866,  and  the  benefit  of  the  operation  was  most 
striking.  It  occurred  in  the  case  of  a  Welsh  girl  aet.  25  ;  the  disease  had  been  of  two 
years'  standing  and  was  spreading.  The  thigh  of  the  affected  limb  (Fig.  65)  measured 
twenty-seven  inches  round  and   the  leg  nearly  twenty-three,  the  affected  leg  being  nine 

inches  in  circumference  larger  than  the  sound  one. 
and  the  thigh  seven.  Five  weeks  after  the  ligature 
of  the  external  iliac  artery  the  calf  of  the  aff'eeted 
limb  measured  .seven  inches  less  than  it  did  at  the 
time  of  operation  ;  and  when  she  left  the  hospital^ 
the  limb  apjieared  as  in  Fig.  66.  The  rapid  disap- 
pearance of  the  thickened  tissue  was  very  remark- 
able. Since  the  operation  the  girl  has  gone  on 
well,  is  companion  to  a  lady,  and  can  now  walk  ten 
or  twelve  miles.  The  limb  becomes  slightly  (Ede- 
matous only  on  over-exertion. 

I    have    performed    the    same    operation    three 
times  since,  but    not  with  similar  success.      I  liga- 
tured the   femoral   artery   of  a   man  who  had  the 
whole  limb  involved,  the  thigh   being  only  slightly 
so,  and  for  a  time  everything  promised  to  be  as  suc- 
cessful as  in  the   case  previously  recorded  ;  but  an 
attack  of  erythema   came  on.  followed  by  renewed 
swelling  of  the  extremity,  which  never  disappeared. 
In    this    case    the    size   of   the   superficial   femoral 
artery  was  extraordinary,  the  loop  of  the  .silk  liga- 
ture when  it  came  away  being  capable  of  admitting 
a  No.  12  catheter.     The  vessel  seemed  to  be  nearly  the  diameter  of  my  finger  and  was 
very  thick.     In  a  more  recent  case,  however,  gangrene  of  the  foot,  followed  b}"  death, 
took  place. 

When  this  operation  is  performed,  the  vessel  should  be  ligatured  well  above  the  dis- 
ease. I  may  add  that  Butcher  in  1863  and  Alcock  in  1866  had  succes.sful  cases,  though 
Sir  Joseph  Fayrer  and  Buchanan  of  Glasgow  have  not  met  with  successful  results. 

AVhen  surgical  interference  of  this  kind  is  not  applicable,  elevation  of  the  affected 
limb  or  pressure  should  be  employed.      In  severe  cases  amputation  may  be  called  for. 

On  three  occasions  I  have  had  to  circumcise  patients  with  elephas  of  the  penis  and 
scrotum,  and  in  each  after  the  operation  the  whole  of  the  thickening  of  the  scrotum  dis- 
appeared.     This  fact  is  worthy  of  record. 

Pathology. — Within  recent  times  an  opinion  has  gained  ground  that  the  true  pathol- 
ogy of  this  elephantoid  disease  is  to  be  found  in  the  lymphatics  and  that  it  is  due  to 
lymphatic  obstruction.  It  has.  moreover,  been  thought  by  Dr.  T.  Lewis  that  the  pres- 
ence of  the  Filaria  .fant/iiiin's  hominis  might  have  something  to  do  with  it.  since  the  para- 
site has  been  found  in  the  blood  of  patients  who  have  had  elephas. 

In  support  of  this  view  a  very  striking  paper  has  recentlv  been  published  by  Dr. 
I'atrick  ]NIanson  in  the  China  Customs  Ca-effe.  Medical  Report,  for  the  six  months  ending^ 
March.  1882.  an  abstract  of  which  mav  be  read  in  Med.  Times  and  Gazette,  Feb.  12,  1883. 


Case  of  Elephantiasis  Arabum  before  and  after 
the  Application  of  a  Ligature  to  the  Femoral 
Arterv. 


n\  I'M:. [SITES. 


179 


"  In  the  instances,  "  writes  Munson,  •  in  wliicli  tlic  jcucnt  worm  lias  hccn  diM-fivcreil, 
she  was  f'(iun<l  in  lyinjihatic  vessels  (»n  tlu-  disial  sidt-ot'  the  ;.'lan<ls.  This  has  been  shown 
to  he  in  many,  if  not  in  all,  eases  her  normal  hahitat.  Her  pro^reny.  therefore,  must 
travel  aloni:  the  atVereiit  vessels,  throntdi  the  L'laml.-.  and  so  on  to  the  thoraeic  dnet,  and 
theiiee  into  the  hlood.  The  lonii-.  sinuous,  and  powertul  Intdy  of  the  embryo  is  well 
a<la|ited  to  ju-rfuMn  this  journey.  Hut  su|i|Mise.  instead  of  this  mature  emliryo,  an  ovum 
is  launched  into  the  lymph-stream  prematurely  atid  helore  the  contained  iinhryo  has  suf- 
tieientlv  extended  its  chorion  :  then  this  jtassive  (»vum  must  certainly  he  arrested  at  the 
first  Ivmjdiatie  L'land  to  which  it  is  carried  l»y  the  advancin^'^  lymjih-current.  It  measure.s 
tV(("  '  zhji" •  ^^''"^''"i"''''  '''*^'  outstretched  emhryo  is  only  ahout  ■^X)^(j"  in  diameter.  It  is 
much  too  lar'j:e  to  pa.ss  the  glands,  and  the  emhry<»,  rolled  uj*  in  its  chorional  envelope, 
cannot  aid  itself.  It  becomes,  in  fact,  an  embolus.  Now,  tilari;e  are  jtnjdi<^iou.sly  prolific. 
Myriads  of  younj;  are  exjielled  in  a  very  short  time.  I  have  watched  the  process  of  par- 
turition in  the  minute  Flhnla  rarri  loii{ii((ti.  Every  few  seconds  a  peristaltic  contraction, 
bejjinnitiL'  low  down  in  the  uterine  horns  and  extending  to  the  vagina,  expels  some  twenty 
or  thirty  emltryo>^.  If  this  process  of  parturition  occurs  prematurely,  or  peristalsis  is  too 
vigorous  and  extends  to  a  point  high  up  in  the  uterine  horns  where  the  embryo  has  not 
yet  comjiletely  stretched  its  chorional  envelope,  then  ova  are  expelled.  These,  as  they 
reach  the  glands,  where  the  afferent  lymphatic  breaks  up  into  fine  capillary  vessels,  act  as 
emboli  and  jdug  u|)  the  lymph-channels  one  after  another  until  the  fluid  that  carries  them 
can  no  longer  jiass.  In  this  way  the  gland  or  gland.s  directly  connected  with  the  lym- 
phatic in  which  the  aborting  female  is  lodged  are  thoroughly  obstructed.  Anastomoses 
for  a  time  will  aid  the  passage  of  lymph,  but  the  anastomosing  ves.sels  will  carry  the 
embolic  ova  as  well  as  the  lymph.  The  corresponding  glands  will  then  in  their  turn  be 
invaded,  and  so  on  until  the  entire  lymphatic  system  connected  directly  or  indirectly  with 
the  vessel  in  which  the  parent  worm  is  lodged  becomes  obstructed."  The  degree  of 
embolism  and  location  f>f  the  worm  determine  the  site  and  character  of  the  resultant 
disease. 

ON  PARASITES. 

Guinea- W^orm. — The  Drdcmicnlus  or  Filaria  inedinensis  is  one  of  the  most  trouble- 
some parasites  known  in  Africa,  Asia.  India,  and  tropical  America.  In  Europe  it  is  only 
occasionally  met  with  in  those  who  have  visited  the  above  districts. 

The  mature  worm  varies  in  length  from  two  to  six  feet.  It  is  cylindrical  in  form, 
white  in  color,  has  a  smooth  surface,  is  tough  and  elastic ;  its  mouth  appears  as  a  circular 
orifice  and  it  has  no  anus.      How  it 

enters  the  body  is  unknown,  although  ^'^'-  "'• 

it  is  evident  that  it  does  so  from  .> 
without,  and  probably  through  the  ^i 
skin  of  some  part  that  has  been  in  ij^ 
contact  with  water,  inasmuch  as  it  '^ 
is  more  eomnmn  in  the  feet  than  in 
other  parts  of  the  body,  although 
the  Madras  water-carriei's  are  said 
to  have  them  in  the  V»ack.  At  any 
rate,  the  worm  gets  into  the  subcu- 
taneous areolar  tissue,  where  it  re- 
mains. Busk  tells  us  that  it  does 
so  usually  for  aVjout  twelve  months, 
although  it  may  l^e  eighteen.  When 
mature  and  tlie  time  has  come  for  the  discharge  of  the  embryos  with  which  it  is  filled,  it 
makes  its  presence  known  by  boring  the  skin,  protruding  its  head  under  the  cuticle,  rais- 
ing a  bleb,  and  coming  out  bodily,  discharging  its  young  filariae  externally. 

Treat.ment. — The  first  manifestation  of  the  disease  is  usually  a  circular  bleb,  as  rep- 
resented in  Fig.  (57.  although  it  often  happens  that  pain  and  stiffness  of  the  affected  part 
have  been  complained  of  for  some  time  previously.  The  bleb  contains  sero-purulent 
fluid,  and  the  surgeon,  in  order  to  find  the  worm,  should  cut  the  raised  cuticle  off. 
"  There  will  then  be  seen  protruding  from  a  little  hole  in  the  centre  of  the  denuded  cutis 
one  or  more  inches  of  the  worm,  of  the  size  and  color  of  vermicelli  or  of  a  wax  match. 
The  surgeon  now  makes  a  small  quill-like  roll  of  adhesive  pla.ster,  rolls  the  worm  around 
it,  and  gently  draws  as  much  as  will  come  without  the  risk  of  breaking;  and  this  is 
repeated  day  after  day.  till  at  last  the  tail,  which  end-   in  a  small  hook,  comes  wriggling 


Guinea-Worm  Bleb  just  (  ut  oH".     (Dr.  Druitt,  Med.  Times  and  Gaz., 
Jauuary  3,  1874.) 


180  ON  PARASITES. 

out,  and  the  case  is  at  an  end." '  Under  these  circumstances  a  rapid  cure  takes  place. 
Should  the  worm  break,  a  subcutaneous  abscess  is  almost  sure  to  form  higher  up  ;  and 
when  this  is  opened,  a  loop  of  the  worm  can  most  likely  be  got  out  on  a  probe,  and  so  be 
extracted  as  before. 

At  times  no  bleb  forms,  but  merely  a  subcutaneous  abscess.  In  exceptional  ca.ses 
more  than  one  worm  may  exist.  Druitt  quotes  a  case  in  which  nineteen  had  been 
extracted. 

Cnn,-<i(lL-rable  constitutional  di.stuj'bance  often  attends  these  local  changes. 

Chigoe,  Chigger,  or  Gigger,  or  Sand-Flea. — This  is  found  in  the  "West  Indies 
and  in  South  America,  but  the  impregnated  female  only  infects  man.  It  makes  its  way 
beneath  the  nails  or  between  the  toes  by  means  of  its  long  proboscis,  and,  having  gained 
an  entrance,  rapidly  increases  to  a  white  globular  vesicle  the  size  of  a  pea.  Some  local 
irritation  attends  its  presence.  To  prevent  trouble,  the  insect  should  be  carefully  turned 
out  of  its  bed  by  dilating  the  orifice  through  which  it  entered  with  a  needle,  care  being 
observed  not  to  rupture  the  globular  vesicle  which  contains  the  ova  ;  for  if  these  escape 
into  the  cellular  tissue,  the  accident  is  often  followed  by  tedious  suppuration  and 
ulceration. 

The  echinoCOCCUS,  or  hydatid,  the  larva  of  the  Tsenia  echhwcoccus,  is  a  common 
entozoon  in  the  human  subject,  and  it  may  exist  as  a  microscopical  object  or  as  a  cyst  of 
many  inches  in  diameter.  It  has  highly-elastic  laminated  walls  lined  with  a  granular 
layer,  and  it  is  usually  enclosed  in  the  parts  of  the  body  infected  by  it  in  a  distinct  cap- 
sule formed  by  exudation  into  and  the  consolidation  of  the  surrounding  tissue.  It  con- 
tains a  clear,  watery,  non-albuminous  fluid,  in  which  at  times  float  some  taenia  heads  or 
scolices,  the  so-called  echinococci.  or  in  which  are  found  the  booklets  which  surround  the 
head. 

These  hydatids  are  met  with  in  any  part  of  the  cellular  tissue  of  the  body — in  the 
lungs,  liver,  abdominal  cavity,  pelvis,  and  even  in  the  bones;  a  specimen  exists  at  Guy's 
in  which  the  spinal  column  was  so  aftected.  I  have  seen  them  turned  out  of  the  breast, 
tongue,  thyroid  gland,  pelvis,  vagina,  uterus,  thorax,  and  bladder,  and  have  removed  cysts 
containing  them  from  the  muscles  of  the  neck,  axilla,  and  thigh,  and  have  also  treated 
many  in  the  liver. 

At  times  an  acephalocyst  contains  many  secondary  cysts.  I  removed  a  basinful  from 
one  occupying  the  pelvis,  and  they  were  of  all  sizes  (Path.  Soc.  Traits.^  vol.  xvii.).  Hy- 
datid tumors  are  to  be  recognized  by  negative  symptoms ;  they  appear  as  tense,  globular, 
elastic  swellings  in  a  part,  and  give  rise  only  to  such  symptoms  as  are  to  be  explained 
mechanically  by  their  presence;  when  dead,  they  give  rise  to  suppuration. 

Treatment. — This  must  var}-  with  the  position,  size,  and  growth  of  the  hydatid 
tumors.  When  the  parasite  occupies  some  position  other  than  one  of  the  great  cavities 
and  can  be  turned  out  of  its  bed  by  means  of  a  free  cut  into  its  capsule,  no  better  treat- 
ment is  required.  When  it  occupies  one  of  the  abdominal  viscera  or  one  of  the  serous 
cavities,  it  should  be  left  alone,  unless  from  its  size  it  interferes  with  important  functions 
or  threatens  life,  when  it  should  be  tapped  ;  but  this  point  will  be  discussed  in  another 
page. 

The  CysticerCUS  Cellulosse,  the  cystic  scolex  of  the  common  tapeworm,  is  found 
in  man,  and  is  said  to  be  the  common  parasite  of  the  "measly  pig.  '  It  has  a  quadran- 
gular head,  short  neck,  and  cylindrical  vesicular  body,  the  head  being  .surrounded  with 
characteristic  booklets.  It  is  found  more  particularly  in  the  muscles  and  intermuscular 
tissue,  and  may  afl'ect  the  viscera  as  the  former  hydatid.  It  is  known  to  occur  in  the 
eye,  brain,  heart,  etc.,  and  can  be  treated,  when  interference  is  called  for,  by  an  incision 
into  the  part  and  removal. 

Trichiniasis  will  be  con.sidered  in  the  chapter  devoted  to  the  aflections  of  the  mus- 
cles. 

'  Druitt,  Med.  Times  and  Gaz..  Jan.  3,  1874. 


SURGEllV  OF  THK  LYMPHATIC  SYSTEM. 


CHAPTER    V. 

INFLAMMATFOX    OF    TIIK    LYMPHATICS    AND   TFIEIR    GLANDS. 

Lv.Mi'iiATlcs  iiiav  !>(■  wouikUhI  by  accitlcnt  <ir  by  dosiLMi  and  im  bad  result  ensue.  At 
times,  however,  a  fistulous  opening  that  diseharires  lymph  may  remain.  The  same  con- 
sequenee  may  be  the  result  of  disease.  Dr.  IL  V.  Carter  of  Bombay  has  recorded  three 
such  cases  in  the  Me<l.-(li!r.  Tntiis.,  vol.  xlv.,  and  ])r.  Day  another  in  the  Clim'ad  Soc. 
Trans.,  vols.  ii.  and  xi.,  which  through  his  kindness  1  had  an  opportunity  of  seeing.  It 
was  reported  on  by  a  committee  of  the  society,  and  they  confirmed  the  view  taken  of  it. 
It  was  one  of  hypertrophy  of  one  lower  extremity  of  a  boy.  with  the  occasional  discharge 
of  chyle  from  vesicles,  which  were  formed  on  varicose  lymphatics.  The  hypertrophy 
had  clearly  an  intimate  connection  with  the  distended  .state  of  the  lymphatics  of  the 
limb. 

An  obstructed  condition  of  the  lymphatic  vessels,  giving  rise  to  lymphatic  oedema  is 
now  accepted  as  a  cause  of  "  Elephas "'  or  f^lephantiasis  Arabura  (rUi^  page  178). 

Occasionally  the  lym])hatics  after  inflammation  appear  as  a  hard  cord  beneath  the 
skin.  In  a  case  I  had  under  my  care  some  years  ago  this  cord  remained  hard  and  con- 
tracted for  many  weeks  after  all  .signs  of  inflammatory  action  had  ceased.  It  occurred 
in  a  gentleman  who  was  in  the  habit  at  night  of  going  through  .<ome  simple  muscular 
exercises,  and  in  doing  this  the  cord  in  the  arm  snapped  on  the  inner  side  of  the  biceps. 
I  saw  him  a  few  minutes  after  the  accident,  and  felt  the  two  ends  of  the  cord,  which  were 
apart  for  about  an  inch.  Next  morning  the  thin  skin  covering  the  anterior  surface  of  the 
fore-arm  was  elevated,  loose,  and  baggy  from  the  effusion  of  fluid  beneath.  There  were 
no  signs  of  inflammation  or  pain  beyond  local  tenderness  at  the  point  of  rupture  of  the 
lymphatic  cord.  In  four  or  five  days  the  fluid  was  reabsorbed  and  convalescence  restored; 
the  hard  cord  gradually  disappeared  a:nd  all  traces  of  its  separation  became  lost.  I  looked 
upon  the  eff"used  fluid  as  lymph  that  had  been  poured  out  by  the  divided  lymph  tube,  and 
which  had  been  taken  up  again.     I  have  not  seen  a  similar  accident  since. 

The  absorbent  glands,  with  their  ducts,  are  liable  to  inflammation  (-^  adenitis"  or  "a?;- 
geioleucitis').  and  this  action  is  probably  the  result  of  the  absorption  of  some  septic  mate- 
rial. It  is  almost  always  associated  with  a  wound,  punctured  or  open,  inflamed,  suppu- 
rating, healing,  or  scabbing ;  with  some  point  of  irritation  or  suppuration,  such  as  a 
papule  or  pustule;  with  some  centre  from  which  morbific  elements  may  be  taken  up.  In 
what  is  called  a  simple  wound  the  inflammation  of  the  absorbents  may  be  acute,  but  in 
the  poisoned  it  is  violent  and  difi'used.  The  inflammation  always  follows  the  course  of 
the  absorbents,  leading  from  the  centre  of  absorption  toward  the  glands — that  is,  toward 
the  body — and  it  never  spreads  backward.  When  it  has  reached  the  glands,  the  diseased 
action  ceases  to  spread — that  is,  it  expends  its  force  upon  the  group  of  glands  in  which 
the  absorbents  naturally  end  and  does  not  extend  through  another  series  of  absorbents  to 
a  second  group.  The  morbific  material  is  arrested  in  the  glands ;  at  least,  such  is  the 
usual  course  of  the  aff"ection.  AVhen  pyjemia  follows  or  complicates  the  case,  it  may  be 
open  to  question  whether  the  poisonous  fluid  circulating  in  the  lymphatics  has  not  been 
allowed  to  pass  into  the  blood  through  its  usual  channels — that  is.  through  the  inflamed 
glands  onward  ;  but  it  is  at  least  as  probable  that  the  same  septic  material  that  poisoned 
the  lymphatics  and  set  up  inflammation  in  the  tubes  and  glands  was  taken  directly  into 
the  blood  through  x\\v  vrimus  clianiu'ls.  thus  giving  rise  to  blood  poisoning. 

Absorbent  inflamination  usually  manifests  its  presence  in  a  definite  way.  Pain 
and  tenderness  in  some  of  the  glands  are  irenerally  early  symptoms ;  with  them,  or  soon 

ISl 


182  IXFLAMMATIOy   OF  LYMPHATICS  AXD   THEIR   GLAXDS. 

following  them,  will  be  seen  a  painful  band  of  redness  leading  from  the  wound  or  infect- 
ing centre  toward  the  gland.  This  red  liifb  may  be  continuous  or  interrupted,  it  may  be 
a  thin  streak  or  a  broad  stripe  of  redness,  and  in  some  instances  it  may  so  radiate  into 
the  surrounding  tissues  as  to  simulate  erysipelas.  It  should  be  noted  that  the  red  lines 
follow  the  course  of  the  absorbents,  and  not  of  the  veins.  With  these  local  symptoms 
there  will  be  some  febrile  disturbance,  and  very  probably  the  attack  will  have  been  ush- 
ered in  with  a  rigor. 

Under  favorable  circumstances  and  treatment  these  symptoms  mav  subside,  and  the 
red  line,  with  the  swelling  of  the  glands  and  cellular  tissue  around  the  inflamed  parts, 
together  with  the  constitutional  symptoms,  will  disappear. 

In  less  favorable  examples  suppuration  may  take  place,  either  as  a  local  or  diflfused 
suppuration  of  the  affected  glands  and  surrounding  cellular  tissue,  as  a  local  abscess  in 
the  course  of  the  lymphatics,  or  as  a  series  of  local  absces.ses.  In  extreme  cases  the 
suppuration  may  partake  more  of  a  diff"used  character,  such  as  that  already  described 
as  taking  place  in  phlegmonous  ervsipelas. 

With  these  local  changes  the  constitutional  symptoms  will  assume  diflferent  features : 
the  febrile  disturbance  will  be  probably  great  and  marked  by  depression ;  rigors  may 
repeat  themselves  at  regular  intervals,  and  will  generally  indicate  some  suppurative  pro- 
cess. When  typhoid  symptoms  appear  with  rigors  and  sweating,  the  case  has  clearly 
become  one  of  blood  poisoning  or  septicjemia. 

There  are  thus  three  diff'erent  classes  of  cases : 

The  '•  simj^Ie,"  terminating  in  resolution  ;  the  -  ynore  severe^"  ending  in  local  glandular 
or  lymphatic  suppuration  ;  and  the  "  complicated,''  marked  by  diff"used  inflammation  and 
suppuration,  with  general  blood  poisoning. 

In  the  simple  form  the  poisonous  element  is  probably  of  a  diluted  or  but  slightly 
irritating  nature,  and  is  generally  .some  altered  secretion  of  a  simple  wound  due  to  exter- 
nal irritation.  In  the  more  complicated  or  severe  forms  the  poisonous  element  is  of  a 
more  active  kind,  and  has  been  either  introduced  from  without  in  the  form  of  a  distinct 
animal  poison,  such  as  is  derived  from  a  dissection  wound  or  the  bite  of  an  animal,  or  is 
generated  from  within,  as  seen  in  puerperal  cases. 

Inflammation  of  the  absorbents,  erysipelas,  phlegmonous  or  otherwise,  and  septicaemia 
are  all  closely  connected. 

The  eff"eets  of  inflammation  of  the  absorbents,  however,  are  not  constant  or  alike  in  all 
cases.  In  some  the  glandular  enlargement  alone  is  to  be  recognized,  with  more  or  less 
extensive  suppuration  of  the  glands  and  their  surrounding  connective  tissue,  without  any 
external  evidence  of  inflammation  of  the  lymphatics  leading  to  the  glands.  In  others 
the  red  line  of  inflamed  absorbents  will  be  visible  without  glandular  complication  or  little 
more  than  a  .slight  induration  of  the  gland.  At  times  there  will  be  suppuration  only 
along  the  track  of  the  lymphatics,  but  none  in  the  glands,  this  suppuration  taking  the  form 
of  local  abscesses.  I  have  seen  in  a  case  of  absorbent  inflammation  of  the  fore-arm  and  arm 
four  distinct  abscesses  in  the  line  of  inflammation,  with  only  axillary  glandular  tenderness. 

This  absorbent  inflammation  is  most  common  in  the  extremities,  though  it  may  occur 
anywhere.  There  seems  no  doubt  that  a  large  number  of  the  cases  of  glandular  abscesses 
are  of  this  nature.  Pelvic  abscesses  in  women  are  known  to  be  of  this  kind,  because  pus 
has  been  found  in  the  absorbents  of  the  part. 

Glandular  .suppuration  in  the  neck  is.  from  its  position,  a  dangerous  aff"ection.  the  con- 
nective tissue  of  the  parts  being  so  loose  and  the  fascia  covering  them  so  firm  that  bur- 
rowing suppuration  often  takes  place.  These  deep-seated  suppurations  .should  be  opened 
early  and  as  soon  as  any  local  evidence  of  pus  exists,  and  in  this  way — viz..  by  cutting 
through  the  fascia  with  a  lancet  and  thrusting  a  director  or  forceps  into  the  deep  con- 
nective tissue.  I  have  opened  an  abscess  at  the  base  of  the  tongue  in  this  manner  from 
beneath  the  jaw  with  an  excellent  result.  The  swelling  aflfected  deglutition  and  re.>jpira- 
tion  and  threatened  life. 

Treatment. — When  indications  of  absorbent  inflammation  appear,  the  wound  or  sore 
should  be  well  cleansed,  the  scab  removed,  and  any  collection  of  pus  let  out.  The  affiected 
limb  should  be  raised,  the  foot,  when  involved,  brought  higher  than  the  hip.  the  hand  or 
elbow  than  the  shoulder,  and  warm  poppy  fomentations  should  be  applied  along  the  whole 
course  of  the  lymphatics  up  to  the  group  of  glands  in  which  they  terminate.  Some  sur- 
geons, particularly  the  French,  advise  that  the  inflamed  line  should  be  pencilled  with 
caustic  and  dry  warmth  applied,  such  as  cotton-wool ;  but  I  prefer  the  practice  already 
indicated,  as  4t  gives  more  comfort.  The  application  of  the  extract  of  belladonna  and 
glycerine  to  the  part  is  also  most  beneficial. 


ISFLAMMATIDS   <>l'   LYM I'lIATU'S   AM)    THEIR   (iLANDS.  1«3 

As  soon  as  su|>|)iiratii)ii  a])|)oars  tlio  abscess  must  be  opened,  whether  tliis  follows 
directly  upon  the  iiitlaniniation  or  subse(|U(!ntly.  At  the  vc^ry  earliest  period  of  the 
intlanunation,  when  the  tonj.nie  is  foul,  an  emetic  has  some  influ<'nc«i  in  checking  its  prog- 
ress.     A  good  saline  ))urge  is  also  beneticial. 

Sedatives  slionld  bo  given  to  allay  pain,  su(di  as  small  doses  of  morphia  three  times  a 
(lav,  with  a  donl)le  dose  at  night  to  induce  sleep.  When  siip)Hiration  has  taken  place, 
tonics   may   be  administered,  of  which   iron   is  the  best. 

In  chronic  cases,  where  induration  in  the  track  of  the  ducts  remains,  mercurial  (unt- 
ments  and  IViction  are  sotnetimes  valuable. 

Glands,  and  particularly  those  in  the  neck,  are  very  apt  to  inflame  after  fevers  or  the 
exanthemata,  and  to  give  rise  to  much  local  distress.  In  j)atients  who  are  not  extremely 
feeble  these  eidargements.  as  a  rule,  subside  by  themselves  under  careful  management, 
though  in  exceptional  cases  they  suppurate. 

Local  warmth  a])plied  by  means  of  cotton-wool,  tonics,  and  nutritious  food  are  the 
best  remedies  ;  but  when  supjiuration  threatens,  warm  fomentations  are  more  grateful  to 
the  patient.  Ab.sce.s.ses  should  be  opened  early.  Before  opening,  however,  it  is  well  to 
try  what  drawing  ofi"  the  pus  by  means  of  the  "aspirator"  may  acc'omplish,  repeating 
the  operation  as  the  pus  re-collects.  In  some  instances  a  cure  may  Vje  effected  by  these 
means,  and  thus  a  scar  is  prevented.     Should  aspiration  fail,  an  incision  ought  to  l>e  made. 

The  local  application  of  iodine  under  these  circumstances,  although  ii  common  remedy, 
does  n(tt  ajipear  to  be  of  much  value. 

Chronic  glandular  enlargement  is  a  very  common  affection.  It  is  found  in 
the  strumous  and  feeble  child  as  a  chronic  and  slightly  painful  enlargement  of  a  gland 
or  glands,  more  particularly  those  beneath  the  jaw  and  about  the  neck,  and  comes  on 
either  after  exposure  to  cold,  some  slight  illness  or  local  irritation,  such  as  bad  teeth,  or 
without  any  definite  cause.  It  often  subsides  spontaneously  on  the  removal  of  the  cause 
or  on  the  improvement  of  the  general  health.  At  times  these  glands  suppurate  and  leave 
ugly  sores,  the  cellular  tissue  around  the  gland  becoming  destroyed  and  the  skin  conse- 
quently undermined.  The  pus  from  these  glandular  enlargements  is  sometimes  ill  formed 
and  curdy  ;  and  when  it  attends  the  breaking  down  of  some  old  disease,  it  may  contain  a 
chalkv  deiHisit,  the  produce  of  some  degenerated  or  dricd-up  tuberculous  or  other  matter. 

Hodgkin's  Disease  of  the  Glands,  or  General  Lymphadenoma.— 

There  is,  however,  another  chronic  enlargement  of  the  glands  that  appears  to  diflFer  in 
all  ways  from  the  local  enlargements  to  which  attention  has  just  been  drawn.  It  was 
first  described  by  Dr.  Hodgkin  in  the  Med.-Chlr.  Trans.,  vol.  xvii.,  and  may  be  called 
Hodgkin's  disease  of  the  glands,  or,  for  the  sake  of  distinction,  glandular  tumors.  He 
observed  it  first  in  the  mesenteric  glands,  though  any  or  all  may  be  affected.  In  it  the 
glands  become  very  much  enlarged,  even  to  the  size  of  an  egg,  and  apparently  more 
numerous;  they  present  a  smooth  external  appearance  and  have  a  soft  semi-fluctuating 
elastic  feel.  On  section  the  surface  of  the  gland  presents  a  .smooth,  bloodless,  semi-trans- 
parent, loose,  succulent  structure  ;  microscopically,  it  is  made  up  of  glandular  tissue  and 
abundance  of  fibro-nucleated  tissue  ;  it  is  of  a  tough,  leathery  consistence  and  exudes  a 
clear  serous  fluid.     The  tumors  are  always  free,  each  being  separable  from  the  others. 

To  the  surgeon  the  disease  at  times  appears  as  a  local  movable  glandular  tumor  of  a 
slow  painless  growth  which  medicine  has  little  or  no  power  of  influencing ;  it  has  the 
local  clinical  appearance  of  a  benign  fibro-cellular  tumor,  and  has  often  been  excised 
as  such. 

In  other  instances  the  tumors  are  multiple,  three,  four,  or  many  more  existing  in  one 
locality,  chiefly  in  the  neck.  In  exceptional  instances  the  tumors  are  more  numerous. 
I  have  seen  cases  in  which,  on  one  side  of  the  neck,  the  subcutaneous  tissue  seemed  filled 
with  loose  glandular  tumors  readily  movable  one  upon  the  other,  as  if  simply  confined  by 
skin,  in  the  same  way  as  the  adenoid  tumors  of  the  brea.st  are  occasionally  met  with.  In 
still  rarer  examples  the  whole  glandular  .system  seems  to  be  affected,  every  group  of 
glands  not  only  being  apparently  enlarged  in  size,  but  also  increased  in  number. 

This  disease  is  often  associated  with  an  enlarged  spleen,  and  appears  pathologically 
to  be  allied  to  that  blood  disea.se  now  known  as  leucocythfemia,  notwithstanding  that  in 
many  in.stances  the  white  corpuscles  are  not  in  excess. 

On  one  occasion  I  had  an  opportunity  of  watching  the  gradual  development  of  this 
aflfection.  It  began  in  the  cervical  glands  and  gradually  involved  the  whole  glandular 
system,  the  patient,  a  boy  at  the  age  of  fifteen,  dying  with  an  enormous  spleen  and  gland- 
ular tumors  in  every  region.  His  blood  was  made  up  almost  entirely  of  white  blood  cor- 
puscles, death  resulting  from  exhaustion. 


184  DISEASES  OF  THE   THYROID   GLAND. 

Another  ease  I  treated  five  years  ago,  a  woman  aet.  56,  has  lately  returned  conva- 
lescent from  lymphadenoma,  but  affected  with  an  acute  cancer  of  her  breast. 

Treatment. — For  the  ordinary  or  strumous  enlargement  of  the  glands  in  children 
there  is  no  drug  equal  to  cod-liver  oil,  the  syrup  of  the  phosphate  or  of  the  iodide  of  iron 
or  the  tincture  of  quinine  being  capital  additional  remedies. 

I  have  not  much  faith  in  the  local  application  of  iodine  in  the  form  of  the  tincture, 
as  after  the  second  application  the  skin  ceases  to  be  an  absorbing  surface,  and  the  iodine 
becomes,  therefore,  a  mere  irritant.  For  some  years  I  have  been  accustomed  to  order 
the  solid  iodine  to  be  placed  in  a  perforated  wooden  box  and  on  a  shelf  in  the  sitting- 
and  bed-rooms,  the  iodine  in  this  way  evaporating  gradually  and  iodizing  the  air.  In  all 
glandular,  as  in  thyroid,  enlargements,  this  mode  of  employing  the  drug  seems  to  be  of 
considerable  value. 

The  iodide  of  ammonium  as  an  ointment  is  a  useful  application  when  rubbed  in,  the 
iodide  by  this  process  becoming  absorbed. 

Good  food  and  fresh  air  are  also  essential  points  in  the  treatment  of  these  cases. 

In  Hodgkin's  glandular  tumors  full  doses  of  iron,  as  well  as  of  cod-liver  oil,  seem  to  be 
the  best  remedies — that  is,  patients  who  can  take  them  appear  to  improve  in  their  general 
health,  while  the  disease  does  not  progress  so  rapidly  under  their  use  as  without  it;  but 
upon  the  ultimate  issue  no  remedy  seems  to  have  any  decided  influence.  The  late  Mr. 
Bradley  advocated  strongly  the  administration  of  pihosphorus  in  doses  of  one-fiftieth  to 
one-fifteenth  of  a  grain  twice  a  day.  Indeed,  I  am  disposed  to  think  that  where  the 
enlarged  glands  can  be  removed  they  should  be,  for  I  am  sure  that  I  have  seen  life  pro- 
longed by  such  an  operation,  if  not  a  cure  of  the  disease  brought  about.  When,  however, 
the  spleen  or  liver  is  involved,  no  operation  is  justifiable.  When  isolated  glandular  tumors 
exist,  they  may  be  dealt  with  as  local  tumors  and  removed. 

In  all  glandular  enlargements,  however,  the  local  cause  of  irritation  should  be  looked 
for,  with  a  view  to  its  removal ;  for  practically  it  is  well  to  regard  all  glandular  enlarge- 
ments as  due  to  a  chronic  source  of  irritation,  in  the  same  way  as  acute  adenitis  is  known 
to  be  a  result  of  inflammation  of  the  lymphatics. 

Disease  of  the  glands,  as  connected  with  cancer  and  syphilis,  is  referred  to  in  the 
chapters  devoted  to  these  subjects. 

DISEASES  OF  THE  THYROID   GLAND. 

The  thyroid  is  a  lobulated,  encapsuled,  ductless  gland  with  a  cellular  structure,  the 
cells  of  which  contain  a  glairy  fluid.  It  is  highly  vascular,  and  has  as  large  a  vascular 
supply  as  any  gland  in  the  body  ;  it  is  supposed  to  have  some  connection  with  blood 
formation.  It  is  also  freely  supplied  with  lymphatics.  The  entire  gland  may  be  congeni- 
tally  absent.  When  it  is  simply  enlarged,  it  is  said  to  be  hypertrophied,  or  the  seat  of 
goitre  or  hronchoceJe — simjyle  adenoid  enlargement — and  it  is  well  known  that  these  goitres 
attain  a  large  size.  Sometimes  they  are  apparently  composed  of  simple  increase  of  tissue, 
the  enlarged  gland  having  much  the  same  appearance  on  section  as  the  small  and  healthy 
one ;  at  other  times  the  structure  of  the  tumor  is  coarser,  more  cellular,  or  cystic — n/atic 
hronchoceJe— i\ie  cysts  occasionally  assuming  large  dimensions  ;  while  in  a  third  the  gland 
is  more  solid  and  fibrous  or  more  or  less  mixed  with  cysts — -fihron>^  Irronchocele.  The  thy- 
roid gland  may  inflame  as  well  as  suppurate,  and  may  be  the  seat  of  distinct  adenoid 
tumors  or  of  cancer.  Hydatid  cysts  have  also  been  enucleated  from  its  body  (^vide  Prep., 
Guy's  Hosp.  Mus.,  171 1"'")- 

Goitre — or  Derbyshire  neck,  as  it  is  generally  known  in  England — is  very  common. 
In  its  most  usual  form  it  appears  as  a  simple  bronchocele  or  hypertrophy  of  the  thyroid 
gland,  and  gives  rise  to  symptoms  which  are  mainly  attributable  to  the  size  of  the  tumor. 
At  times,  however,  small  tumors  cause  symptoms  such  as  dyspnoea  or  the  cough  as  of  a 
broken-winded  horse  on  exertion,  and  even  difiiculty  in  breathing  on  the  slightest  cause. 
At  other  times  they  mechanically  press  upon  the  large  vessels  and  respiratory  tract,  pro- 
ducing headache  and  a  feeling  on  stooping  or  coughing  of  fulness  in  the  head,  with 
evident  respiratory  obstruction,  and  even  difficulty  in  deglutition.  These  symptoms  may 
also  appear  for  a  time  and  then  disappear,  leaving  the  patient  comfortable  in  all  respects 
during  the  intervals.  In  other  cases  goitres  which  appear  to  be  of  the  simple  kind  begin 
to  pulsate  under  excitement  or  other  unknown  cause,  and  are  attended  with  some  pro- 
trusion of  the  eyeballs.  These  symptoms  disappear  with  rest  and  time,  and  the  case 
subsequently  reassumes  the  clinical  features  of  a  simple  goitre.  All  tliese  tmnors  rise  and 
fall  icith  the  larynx  in  deglutition. 


disI':asI':s  of  riih:  tiiyi:<)Ii>  i.la.M). 


185 


Fig.  68. 


Such  cases  as  these  stan«l  as  a  kind  of  link  lictwccn  tin-  sini|ilf  and  tliat  known  as  the 
e.roj>h//iii/mir  ^'oitre,  (iraves  s  or  IJasedow  s  dist-asi-;  and  yet  Ix-twi-cn  these  lw(»  affections 
there  innst  be  some  wide  differenee.  lor  the  siniide  jroitre  appears  to  he  a  hical  affV-etiun, 
whereas  the  exophthahnie  lorni  is  prohaltly  part  of"  u  more  <:eneral  disease  marked  hy  the 
enlargement  of  the  thyroid  hody,  often  hy  prominenee  of  the  eyohalls.  always  hy  palpita- 
tion <d"  the  lieart.  a  peculiar  thrill  in  the  hlood  vessels,  and  a  jreneral  want  (»f  mnscnlar 
and  hrain  power  (KijT-  <)!^).  "'There  is  no  known  post-mortem  condition  of  the  thyroid 
gland  proper  to  this  disease  "  (Wilks  and  Moxonj.  .Modern  notions  tend  to  indicate  that 
this  form  <d'  goitre  is  a  neurosis  of  the  cervical  sympathetic.  '  'i'iie  numerous  functional 
disorders  which  occur  in  (Jraves's  disease  are  either  due  to  temporary  congestion  of  the 
sympathetic  nerve  or  a  permanent  structural  alteration  of  the  ganglionic  nervous  system  " 
(Trousseau's  Ciin.  Mid.).  This  view,  however,  of  the  affection  is  not  yet  pri>ved.  and 
the  whole  suhject  requires  investigation. 

TuK.VTMKNr. — Siin])le  goitres  are  to  he  treated  on  ordinary  jirinciples — viz.,  hy  atten- 
tion to  the  genera'  health,  the  inhalation  of  fresh  air.  and  hy  tonic  medicines.  Filtered 
or  distilled  water  such  as  the  salutaris  should  always  he  taken,  more  particularly  in  dis- 
tricts where  chalk,  lime,  and  magnesia  ahound.  In  Derhysliire  and  the  Tyrol  districts  it 
is  generally  believed  that  it  is  from  the  water  that  the  disease  is  produced.  Iodine  has 
always  been  held  in  high  repute  in  this  aff"ection,  originally  as  burnt  .sponge  and  recently 
in  the  form  of  the  iodide  of  potas.sium  ;  and  in  four-  or  five-grain  doses,  given  with  bark 
or  (juinine,  this  drug  is  of  use.  For  .';ome  years,  how- 
ever. I  have  given  tonics  alone  by  the  mouth,  and  have 
ordered  the  air  of  the  room  to  be  kept  iodized  by 
means  of  solid  iodine  put  into  a  box  with  a  per- 
forated lid.  as  already  described  ;  the  metal  thus 
evaporates  steadily  into  the  room  where  the  patient 
sits  and  sleeps,  and  in  this  way  it  becomes  absorbed. 
Under  its  influence  I  have  often  been  surprised  to  find 
how  rajtidly  goitres  disappear.  With  this  treatment  I 
at  times  rub  in  an  ointment  of  the  iodide  of  ammonium, 
a  drachm  to  an  ounce.  To  paint  a  goitre  with  the 
tincture  of  iodine  is  useless,  as  one  application  renders 
the  skin  hard  and  incapable  of  absorption.  Dr.  R. 
Stoerk  of  Vienna  (1874)  injects  alcohol  into  the  soft 
parenchymatous  and  cystic  varieties,  one  or  two 
drachms  being  introduced  by  means  of  a  Pravaz  .syr- 
inge, turning  the  goitre  hard  by  causing  coagulation  of  its  colloid  contents.  The  injec- 
tions should  be  repeated  at  intervals  of  several  days  in  diff"erent  parts  of  the  tumor.  He, 
however,  advises  that  a  few  drops  of  iodine  should  be  added  to  the  alcohol,  to  prevent 
fermentation  taking  place.  Dr.  Llicke  of  Berne  is  in  the  habit  of  treating  hard  goitres 
by  injecting  strong  tincture  of  iodine  into  the  tumor,  one  or  more  punctures  being  made 
at  a  time  according  to  the  size  of  the  tumor,  and,  he  reports,  with  good  success  (Lancet, 
1859).  Dr.  Mouat  of  Bengal  spoke  (Indian  Annafs  of  Med.  Science,  1857)  very  highly 
in  favor  of  the  use  of  biniodide  of  mercury  in  combination  with  the  rays  of  the  sun  for 
the  cure  of  goitre.  He  used  the  mercury  as  an  ointment  of  the  strength  of  three 
drachms  to  a  pound  of  lard.  It  was  rubbed  in  for  t*en  minutes  an  hour  after  sunrise,  and 
the  patient  had  afterward  to  sit  with  his  goitre  held  well  up  to  the  sun  as  long  as  he 
could  endure  it.  After  this  a  fresh  layer  of  ointment  was  to  be  applied  with  a  careful 
and  tender  hand,  the  patient  sent  home,  and  the  ointment  left  to  be  absorbed.  In  ordi- 
nary cases  this  treatment  was  said  to  have  been  sufficient  to  eff'ect  a  cure,  and  that  only  in 
exceptional  cases  was  a  fresh  application  necessary.  He  gives  his  cases  of  recover}'  by 
thousands.  It  is  possible  that  in  England  the  treatment  has  failed  for  want  of  the  rays 
of  the  sun.  I  have  tried  it  without  the  .slightest  beneficial  result.  The  practice  I  have 
followed  with  encouraging  success  during  the  last  few  years  has  been  the  injection  into 
the  tumor  of  20  or  30  drops  of  a  mixture  in  equal  parts  of  the  tincture  of  iodine  and 
alcohol.     In  some  cases  one  injection  brings  about  a  cure ;  in  others  many  are  required. 

In  Graves's  di.sease  iodine  appears  to  be  not  only  useless,  but  injurious.  Tonics,  more 
particularly  iron,  are  apparently  the  most  applicable. 

In  exceptional  cases  a  goitre  may  so  increase  and  press  upon  the  larynx  and  sur- 
rounding parts  as  to  threaten  life,  and  may  even  cause  death  by  a  gradual  process  of 
suff"ocation,  but  more  commonly  by  exciting  some  sudden  laryngeal  spasm.  In  1869  I 
treated  such  a  case,  sent  to  me  by  Mr.  Holman  of  East  Hoathly.  in  which  a  large  thyroid 


Exophthalmic  Goitre  (Wilks's  case). 


186  DISEASES  OF  THE   THYROID   GLAND. 

gland  was  causing  chronic  suffocation  by  its  mechanical  pressure,  and  it  ultimately  pro- 
duced immediate  death  by  exciting  some  laryngeal  spasm.  Dr.  Herbert  Da  vies  has 
recorded  a  similar  ease  {FoJh.  Soc.  Trans. ,  1849).  and  in  the  museums  of  St.  Georges 
and  Bartholomews  hospitals  preparations  exist  with  similar  histories. 

In  .some  cases  the  treatment  by  setons  has  been  of  value,  suppuration  of  the  thvroid 
having  been  followed  by  a  rapid  subsidence  of  the  hypertrophied  or  fibrous  structure  of 
the  gland.  Mr.  Hey  of  Leeds  adopted  this  practice  with  much  success.  In  other  exam- 
ples of  goitre  the  question  of  operative  interference  may  have  to  be  entertained,  and  will 
be  considered  in  another  page. 

Cystic  Bronchocele. —  Cysts  are  often  met  with  in  this  gland,  and  occasionally 
they  assume  large  dimensinns.  They  appear  as  more  or  le.ss  globular,  tense,  fluctuating 
tumors  moving  up  and  down  with  the  larynx,  as  all  thyroid  tumors  do.  Thev  mav  con- 
tain only  the  glairy  fluid  of  the  gland,  or  a  more  serous  or  sanguineous  fluid  or  old  gru- 
mous  blood.  Occasionally,  on  being  punctured,  they  will  go  on  bleeding,  even  to  the 
death  of  the  patient.  Such  cysts  appear  either  in  one  or  other  lobe  or  in  the  isthmus. 
In  1872  I  treated,  with  Dr.  Hess,  a  case  of  blood  cyst  of  the  isthmus- in  a  girl,  and  drew 
off  about  half  an  ounce  of  a  thick,  grumous.  coff"ee-looking  fluid.  In  1803  I  tapjied  a 
cyst  the  size  of  a  cocoanut  in  the  right  lobe  of  the  thyroid  of  a  woman  aet.  2(J  which 
bled  pjrofusely.  and  the  hemorrhage  was  onl}-  arrested  by  closing  the  wound.  The  cyst 
filled  up  at  once  nearly  to  its  former  size,  but  subsequently  gradually  contracted  ;  and 
after  five  or  six  years  scarcely  any  remains  of  it  could  be  found.  Simply  tapping  a 
serous  cyst  may  cure  it.  "When  it  fails,  the  cyst  should  be  injected  with  half  a  drachm 
of  the  mixture  of  iodine  and  alcohol,  mentioned  above,  or.  on  this  failing,  of  one  of  the 
.same  mixture  and  the  liq.  ferri  perchloridi  in  equal  parts.  When  these  fail,  a  .seton  ha.«» 
been  recommended :  but  the  practice  is  dangerous  and  .should  only  be  adopted  when  sim- 
pler means  are  unavailing  and  further  intei-ference  is  requisite.  In  cysts  of  the  isthmus, 
more  particularly  blood  cysts,  an  incision  into  the  cavity  is  a  good  and  successful  opera- 
tion. Should  a  cyst,  after  tapping,  suppurate,  it  must  be  dealt  with  as  an  ab.scess  and 
freely  opened  as  soon  as  the  existence  of  pus  can  be  made  out ;  for  the  thyroid  is  in  a 
dangerous  -position  for  suppuration  to  occur.  I  have  .successfully  treated  one  case  of 
suppurating  thyroid  cyst  after  tapping  by  incision,  but  the  cases  in  which  this  treatment 
is  called  for  are  rare. 

Dr.  M.  Mackenzie  has  (Lancet.  May.  1872)  advocated  the  practice  of  converting  the 
cy.stic  disease  of  the  thyroid  into  a  chronic  abscess  by  the  following  means  :  ••  First 
empty  the  cyst.  When  p»racticable.  it  is  well  to  make  the  puncture  as  near  as  possible 
to  the  median  line  and  to  select  the  most  dependent  portion  of  the  tumor  for  the  intro- 
duction of  the  instrument.  As  soon  as  the  trocar  is  felt  to  pierce  the  cyst-wall  it  should 
be  withdrawn,  and  the  canula  passed  farther  in  by  means  of  a  blunt-pointed  key.  The 
fluid  having  been  withdrawn  through  the  canula.  a  solution  of  the  perchloride  of  iron 
(two  drachms  of  the  salt  to  an  ounce  of  water)  is  injected  through  the  canula  by  means 
of  a  syringe.  The  plug  is  reinserted  and  the  canula  secured  in  position  by  a  strip  of 
plaster.  The  injection  of  iron  is  repeated  at  intervals  of  two  or  three  days  until  suppura- 
tion is  e.stabli.shed.  A\'hen  this,  point  is  reached,  the  tube  is  withdrawn,  poultices  are 
applied,  and  the  case  treated  as  a  chronic  abscess.  Where  the  tumor  consists  of  more 
than  one  cyst,  it  may  be  necessary  to  make  a  second  or  a  third  puncture  ;  but  it  fre- 
quently happens  that  other  cysts  carf  be  opened  through  the  cyst  originally  punctured." 
Some  cysts  become  calcareous  and  should  be  treated  by  excision.  The  practice  is  only, 
however,  to  be  entertained  when  the  cyst  cau.ses  symptoms  which  threaten  life.  In 
Guys  Hosp.  Museum  there  is  a  preparation  of  a  calcareous  cyst  with  an  intra-cystic 
growth. 

Acute  inflammation  of  the  thyroid  gland  is  doubtless  a  rare  affection.    I 

have  never  seen  such  a  case.  Holmes  Coote  records  one  in  Holmes's  System.  Suppura- 
tion of  a  cyst  in  the  daiid  after  surgical  interference  is  more  common. 

Acute  hypertrophy  may  appear  and  produce  dangerous,  if  not  fatal,  symptoms. 
Sir  Risdon  Bennett,  in  his  interesting  Lnmleian  Lectuns  for  1871.  has  recorded  such  an 
instance,  which  I  had  the  advantage  of  seeing  in  consultation  with  him  and  Mr.  Jack.son 
of  Highbury.  It  was  in  a  young  man  aet.  Ifi.  who  three  months  before  became  the  .sub- 
ject of  paroxysmal  attacks  of  asthmatic  dyspnoea,  associated  at  times  with  a  wheezing  or 
whistling  respiration  and  some  general  enlargement  of  the  base  of  the  neck.  Three  days 
before  his  death  this  difficulty  became  extreme,  the  paroxysms  became  more  frequent  and 
severe,  and  on  the  day  of  his  death  a  severe  paroxysm  took  place,  which  passed  on  to  a 
forced  and  heaving  respiration  bevond  anvthinsr  T  had  ever  before  witnessed,  and  speedy 


DfSIJASKS   OF   Till-:   TUYHoin   f.'f.AXl). 


87 


death  resulted.  I  performed  tracheotomy  upon  the  ]):itit'iit  with  the  slender  liope  that 
some  lijrht  inijjht  he  thrown  H])(m  the  nature  (jf  tlic;  (rase  to  ^'uidc  us  in  its  treatment,  if 
not  to  <i'\vc  relief;  hut  in  doinjj;  so  what  was  prohal)le  hefore  heeame  evident  then — viz., 
that  the  ohstruetion  was  l)eh)W.  I  had  no  ]>erforated  instrument  with  me  lon<r  eiiou^rh  to 
foree  l)eyon(l  the  point  of  oh.structiou  e.veept  a  fomalc  cathctiT.  which  struck  a;:ainst 
some  solid  Ixidy  that  prevented  its  projrres.s.  After  death  tlie  tliyroid  hodv  was  found  to 
he  much  enhirued,  and  niaiidy  helow  the  sternum  and  ah>nir  the  sides  of  the  trachea. 
The  trachea  Ixdow  my  o|»eninf;  was  flattened  laterally  to  within  half  an  inch  (d"  the  hifur- 
eation  and  was  also  twisted  to  the  left,  hein;^  surrounded  hy  the  t:reatlv  enlarged  and 
firm  lateral  lohe  of  the  thyroid.  The  structure  of  this  eidarged  gland  was  clearly  that  of 
hypertrophy,  not  of  cystic  or  other  aj)j)arent  disease.  As  an  examj)le  of  acute  rapid 
hypertrophy  of  the  thyroid,  the  case,  says  liennett,  "points  to  the  propriety  of  regarding 
any  acute  enlargement  of  this  gland  in  young  ))e()ple  with  more  anxiety  than  we  are  per- 
haps accustomed  to  do."  particularly,  it  should  he  added,  when  the  lohes  of  the  gland 
pass  down  heliiml  the  sternum. 

Thyroidal  tumors  ilouhtless  exist,  although  they  are  ncjt  common  ;  these  may  he 
adciifiiil  and  iiuioeent  or  cunceroiix  growths. 

An  adenoid  growth  may  appear  as  a  tumor  within  the  gland  itself  or  connected  with 
it,  or  more  commonly  as  an  intra-cystic  growth  similar  to  that  seen  so  frequently  in 
the  hreast.      In  their  clinical  history 

such  cases  cannot  well  he  diagnosed  iui.  C>9.  Fig.  70. 

from  the  ordinary  goitre,  although, 
when  the  disease  is  unilateral  and 
assumes  a  rounded  or  irregular  form 
and  appears  to  be  an  isolated  out- 
growth of  the  gland  itself,  the  nature 
of  the  tumor  may  he  suspected  ;  when 
placed,  however,  within  the  gland  it- 
self or  within  a  cyst  in  the  gland, 
the  diagnosis  is  impossible.  In  Fig. 
69.  taken  from  a  drawing  by  Dr. 
Moxon  of  an  old  preparation  in  the 
Guy's  Hospital  Museum  (1711^'),  a 
tumor  the  size  of  a  grape  is  depicted 
hanging  down  loosely  by  a  pedicle 
attached  to  a  lobe  of  the  gland.  In 
the  gland  there  is  a  well-marked, 
cuplike  depression,  from  which  the  tumor  had  fallen  out,  the  pedicle  mainly  consisting  of 
a  large  artery  emerging  from  the  gland.  The  growth  had  an  ossified  capsule  and  was 
composed  of  a  structure  like  that  of  thyroid  tissue  (Fig.  70).  My  late  colleague,  3Ir. 
Poland,  has  recorded  a  like  case  in  which  excision  was.  successfully  performed  (Gui/'s 
Hasp.  Rep.^  1871).  Frerichs,  Rokitansky,  and  Virchow  record  somewhat  similar  instances. 
Paget  thus  refers  to  the  subject  of  accessory  thyroid  tumors  :  "  These  growths  of  new 
gland  tissue  may  appear  not  only  in  the  substance  of  the  enlarging  thyroid,  but  external 
to  and  detached  from  the  gland.  Such  outlying  masses  of  thyroid  gland  are  not  rare 
near  bronchoceles,  lying  by  them  like  the  little  spleens  one  sees  near  the  larger  mass. 
Their  history  is  merged  in  that  of  bronchoceles  (see  Virchoic,  lect.  22),  with  which  they 
are  usually  associated,  whether  imbedded  as  di.stinct  masses  in  the  enlarged  gland  or  lying 
close  to  it.  but  discontinuous." 

Cancerous  growths  appear  as  infiltrating  affections  of  the  gland  or  as  distinct 
tumors :  they  have  no  special  clinical  characters  until  they  attack  the  surrounding  tissues 
by  continuity  or  break  down.  In  a  case  of  my  own  the  disease  perforated  the  trachea. 
The  Guy's  Hosp.  Mus.  contains  four  preparations  of  this  disease. 


Pedunculated 
Tlivroidal  Tumor. 


Microscopical  .\p])earance  of  Thyroid 
Glands.   (From  Dr.  .Moxon's  drawing.) 


Operative  Interference  in  Thyroidal  Tumors. 

Many  operative  proceedings  have  been  suggested  and  adopted  for  goitre  and  thyroidal 
tumors.  Sir  AV.  Blizard.  Earle,  and  Coates  (Med.-Chir.  Trans.,  vol.  x.)  tied  the  superior 
thyroid  arteries,  with  the  view  of  .starving  the  disease,  and  Coates's  attempt  was  attended 
with  success ;  but  the  operation  is  necessarily  a  severe  one,  and  the  free  arterial  supply 
from  the  inferior  thyroid  arteries  tends  to  neutralize  its  good.  At  the  present  day  it  is 
properly  discarded.     Setons  have  likewise  been   used  with  good  success  an<l  deserve  a 


188  OPERATIVE  INTERFERENCE  IN  THYROIDAL   TUMORS. 

more  extended  trial.  Injections  of  the  tincture  of  iodine  or  of  iron  have  been  of  proved 
value. 

Removal  of  the  isthmus  is  an  operation  which  commends  itself  to  our  attention,  since 
it  is  said  to  have  been  of  use  in  the  hands  of  continental  surgeons,  and  Mr.  Sydney 
Jones  related  at  the  Clinical  Society  on  May  25,  1883,  a  case  in  which. a  complete  cure 
followed  the  measure  in  a  boy  with  a  large  goitre  attended  with  dangerous  symptoms. 
The  isthmus  was  excised  after  having  been  ligatured  on  both  sides,  and  after  the  opera- 
tion the  lateral  lobes  withered. 

Excision  is  an  operation  worthy  of  consideration  when  life  is  jeopardized  from  the 
growth  and  less  severe  measures  have  failed  or  are  inapplicable.  That  it  can  be  done 
successfully  has  been  proved  by  Reverdin  of  Geneva,  P.  H.  Watson  of  Edinburgh,  and 
Dr.  W.  Warren  Greene  of  Maine. 

Hemorrhage  is  the  chief  danger  to  be  dreaded  in  the  operation  ;  but  if  the  fingers  be 
well  used  to  enucleate  the  growth,  without  dividing  or  cutting  into  its  capsule,  and  if  the 
pedicle  containing  the  vessels  which  supply  it  be  rapidly  reached  and  ligatured,  bleeding 
may  be  disregarded.  As  an  extra  point  of  caution  it  appears  to  be  a  sound  practice  to 
ligature  before  cutting  all  parts  that  req-uire  division,  in  the  same  way  as  the  surgeon  does 
in  ovarian  cases,  and  for  the  same  reason.  Should  the  tumor  turn  out  to  be  an  adenoid 
growth  in  or  connected  with  the  gland,  as  in  Poland's  case,  it  may  be  removed  with  com- 
parative facility  ;  and  should  it  be  an  enlarged  gland  simply,  even  a  pound  and  a  half  in 
weight,  success  may  follow,  as  was  proved  by  Greene's  and  Watson's  cases.  Indeed,  I 
cannot  do  better  than  give  the  several  steps  of  the  operation  in  Dr.  Greene's  own  words : 

"  1st.  Exposure  of  the  tumor  by  linear  incision  of  ample  length,  avoiding  most  sed- 
ulously any  wounding  of  the  tumor  or  its  fascia  propria. 

"  2d.  Division  of  the  fascia  propria  upon  the  director. 

'•  3d.  The  reflection  and  the  enucleation  of  the  tumor  with  the  fingers  and  handle  of 
the  scalpel,  paying  no  attention  to  hemorrhage,  however  profuse,  but  going  on  as  rapidly 
as  possible  to  the  base  of  the  gland  and  compressing  the  thyroid  arteries. 

"  4th.  Transfixion  of  the  pedicle  from  below  upward  with  a  blunt  curved  needle 
armed  with  a  double  ligature,  and  tying  each  half,  or,  when  practicable,  dividing  the 
pedicle  into  as  many  portions  as  there  are  main  arterial  trunks  and  tying  each  portion 
separately. 

"  5th.  Excision  of  the  gland  and  subsequent  dressing  of  the  wound,  as  in  ordinary 
cases." 

Dr.  P.  Heron  Watson,  in  an  interesting  paper  on  the  operation  (Edin.  Med.  Jotiri)., 
September,  1873),  strongly  advises  that  •'  the  investing  fascial  sheath  of  the  thyroid 
should  be  left  undivided  until  the  mediate  ligature  of  the  vessels  included  in  their  fine 
cellular  sheath  has  been  effected  ;"  and  he  proved  by  cases  that  this  can  readily  be  effected 
through  the  wound  made  for  the  removal  of  the  gland.  He  condemns  anything  like 
roughness  in  the  removal  of  the  gland,  and  believes  that  the  operation  he  advocates,  and 
had  successfully  performed  in  five  cases,  is  easy,  rapid  in  execution,  and  devoid  of  risk. 

I  cannot  forbear,  however,  from  fjuoting  Dr.  Greene's  concludiiig  remarks,  which  are 
so  full  of  sound  sense  and  wisdom  :  "  I  cannot  refrain  from  one  Avord  of  warning  to  my 
younger  brethren,  whose  ambition  may  make  their  fingers  tingle,  lest  they  should  in  the 
light  of  these  successful  cases  be  too  ea.sily  tempted  to  interfere  with  these  growths.  It 
is,  and  always  will  be,  exceedingly  rare  that  any  such  interference  is  warrantable — never 
for  relief  of  deformity  or  discomfort  merely,  only  to  save  life  ;  and  if  it  is  beyond  all 
question  determined  in  any  given  case  that  such  an  operation  gives  the  only  chance  for 
snatching  a  fellow-being  from  an  untimely  grave,  be  it  remembered  that  accurate  anatom- 
ical knowledge  and  a  perfect  self-control  under  the  most  trying  ordeals  through  which  a 
surgeon  can  pass  are  indispensable  to  its  best  performance." 


suuijiEin'  or  T\\\<]  XKKVors  systExM. 

INJURIES    OF    THE    HEAD. 


CHAPTER    VI. 


CONTUSIONS   AND    WOL  NDS   OF   THE   SCALP.— BLUUD   TUM(JliS.— 

OSTITIS. 

Inmiries  of  tlie  head  .should  alway.s  be  estimated  primarily  with  reference  to  the 
amount  of  injury  tlio  cranial  contents  have  sustained;  and  sfcinulnrili/.  with  reference  to 
the  risk  of  their  V>econiing  involved. 

However  trivial  an  injury  of  the  head  may  appear  to  be.  it  is  never  to  be  lightly 
regarded,  since  what  may  seem  a  simple  cutaneous  bruise  the  result  of  a  blow  upon  the 
head  unaccompanied  by  any  symptoms  of  brain  disturbance  may  be  followed  by  an  acute 
inflammation  of  the  diploe  of  the  skull — a  condition  fraught  with  great  danger — or  a 
chronic  inflammation  of  the  bone,  which  is  scarcely  less  serious ;  and  when,  as  a  primary 
effect  of  injury,  there  is  evidence  of  brain  concussion,  which,  as  a  rule,  means  brain 
bruising,  the  risks  of  secondary  hemorrhage  or  intracranial  inflammation  are  not  slight. 
The  latter  complication  follows  the  slighter  as  well  as  the  graver  injuries.  It  is  well  for 
the  student  to  have  these  truths  impressed  on  his  mind  at  the  beginning  of  a  chapter  on 
injuries  of  the  skull,  for  they  have  a  practical  bearing  of  wide  importance. 

Contusions  of  the  Scalp  and  Blood  Tumors. 

The  integuments  of  the  scalp  have  this  peculiarity — that  they  are  intimately  con- 
nected with  the  aponeurosis  of  the  occi])ito-frontalis  muscle  ;  indeed,  practically,  the.se 
parts  may  be  regarded  as  one,  for  they  are  not  to  be  separated  and  move  together 
over  the  cranium.  They  are  well  supplied  with  vessels,  and,  conse(|uently,  have  consid- 
erable power  of  repair ;  they  rarely  slough.  When  any  great  effusion  of  blood  compli- 
cates a  contusion,  a  blood  tumor  is  said  to  exist ;  and  when  this  occurs  on  the  scalp,  the 
affection  is  known  by  the  term  cephal-hsematoma.  In  newly-born  children  this  affection  is 
frequently  met  with,  and  it  is  commonly,  although  not  always,  a  result  of  a  diflScult  or 
instrumental  labor.  It  is  usually  situated  over  the  parietal  bone,  showing  itself  as  a 
more  or  less  circumscribed,  soft,  fluctuating  tumor;  but  the  largest  I  have  ever  seen  was 
over  the  occipital  bone.  When  the  tumor  is  small  and  confined  to  one  bone,  the  blood  is 
probably  effused  beneath  the  pericranium  (.sj/6/;^'/v'cr<7?( /a/ yb/-?>i).  When  the  swelling  is 
larger  and  spread  over  more  than  one  bone,  the  effusion,  doubtless,  is  poured  out  beneath 
the  apoueurosis  of  the  .scalp  (^linlxiponeurotic  form'). 

In  the  subpericranial  form  the  indurated  base  may  organize,  or  inflammatory  matter 
may  be  poured  out  around  it  and  assume  the  character  of  bone  :  whil.st  in  neglected  cases 
suppuration  may  follow,  which  occasionally  passes  on  to  involve  the  bone  itself. 

In  the  subaponeurotic  form  the  blood  is  generally  rapidly  absorbed,  and  during  the 
process  a  peculiar  characteristic  crackling  sensation  will  be  often  given  to  the  hand  in 
manipulation.  In  feeble  infants  this  process  of  absorption  may  be  delayed  or  may  fail 
altogether ;  under  which  circumstances,  surgical  aid  is  called  for. 

In  the  adult,  in  addition  to  the  forms  of  blood  tumor  just  described  as  a  consequence 
of  injury,  blood  may  be  effused  into  the  skin  it.self.  and  appear  as  a  hard  unyielding 
lump. 

When  a  blood  tumor  has  an   imlurated  base,  rising  from,  and  apparently  continuous 

1S9 


190  SCALP  WOVXDS. 

with,  the  bone,  with  a  defined  edge  toward  the  centre,  the  idea  may  present  itself  that  a 
fracture  with  depression  exists.  Under  such  circumstances  the  surgeon  will  be  assisted 
in  his  diagnosis  by  firmly  pressing  his  thumb  or  finger  for  a  few  seconds  upon  the  ridge : 
this  act  in  a  recent  case,  by  displacing  the  fibrin,  reveals  the  uninterrupted  continuity  of 
the  bony  surface,  and  thus  proves  the  nature  of  the  case — more  particularly  when  there 
is  an  absence  of  symptoms  of  fracture.  "When  the  case  is  complicated  with  brain  symp- 
toms or  a  ruptured  artery,  giving  rise  to  pulsation  in  the  tumor,  some  difficulty  in  diag- 
nosis may  be  experienced. 

Treatment. — A  simpk  contusion  of  the  scalp,  uncomplicated  with  any  great  eff"usion 
of  blood  or  other  local  injury,  requires  little  surgical  attention  ;  it  has  a  tendency  to 
recover  like  contusions  of  other  parts.  Its  best  application  is  a  cold  or  spirit  lotion, 
muriate  of  ammonia  in  solution  being  as  good  as  any.  "When  a  blood  tumor  exists  which 
feels  tense  or  pulsates,  broken  ice  in  a  bag  or  one  of  Leiter's  coils  (Fig.  9,  p.  -id)  should 
be  applied,  the  cold  checking  the  further  flow  of  blood  and  encouraging  absorption. 
When  the  rupture  of  a  large  artery,  such  as  the  temporal  or  occipital,  is  suspected,  as 
indicated  by  the  pulsation  of  the  tumor  or  other  significant  symptom,  it  may  be  advisable 
to  apply  pressure  over  the  trunk  of  the  vessel.  When  absorption  of  the  effused  blood 
does  not  take  place,  the  cystic  swelling  should  be  aspirated  and  pressure  applied, 
sponge  pressure  being  the  best ;  and  this  operation  may  be  repeated  several  times. 
Should  tapping  fail,  an  incision  ought  to  be  made  sufficient  to  allow  of  the  free  escape 
of  the  pent-up  fluid  and  to  prevent  its  re-collection ;  gentle  pressure  should  subsequently 
be  applied  on  the  part.  In  very  obstinate  cases  the  tumor  may  be  treated  as  a  serous 
cyst  and  injected  with  iodine.  When  the  effused  blood  breaks  up  and  causes  suppura- 
tion— a  somewhat  rare  result — a  free  incision  with  drainage  is  required  and  the  case  must 
be  treated  as  one  of  abscess.  During  this  period  tonic  treatment  is  often  requir<;d  to 
improve  the  patient's  powers.  When  the  tumor  is  large,  the  patient  should  be  kept  quite 
free  from  excitement  and  the  diet  carefully  regulated  according  to  the  special  wants  of  the 
case.     As  a  rule,  all  such  cases  do  well. 

Scalp  Wounds. 

Wounds  of  the  scalp  are  very  common,  and  large  portions  of  the  scalp  may  be  torn 
away  from  its  connections  with  the  pericranium  or  bone  and  on  readjustment  live,  though 
much  bruised  and  injured,  the  extreme  vascularity  of  the  scalp  favoring  its  repair.  Such 
injuries,  when  not  complicated  with  injury  to  the  skull  or  its  contents,  generally  do  well. 
Blunt  instruments,  forcibly  applied,  produce  scalp  wounds  very  like  those  caused  by  sharp- 
cutting  ones.'  Wounds  which  exhibit  entire  hair  bulbs  projecting  from  the  surface  of 
their  sections  have  been  probably  produced  by  a  blunt  instrument,  while  on  the  other 
hand,  when  the  hair  bulbs  are  found  cut,  the  wound  has  to  a  certainty  been  caused  by 
a  sharp  one. 

It  is  generally  thought  that  scalp  wounds  are  especially  "  liable  to  prove  the  exciting 
cause  of  erysipelas."  I  doubt  the  accuracy  of  such  an  assertion,  because  from  my  notes 
of  175  cases  of  .scalp  wounds  admitted  consecutively  into  Guy's  in  eight  years — and  it 
must  be  added  that  only  the  severe  are  admitted — I  find  that  erysipelas  followed  only  in 
three,  or  in  1.71  per  cent.,  this  proportion  being  about  the  same  as  that  obtaining  in  sur- 
gical cases  generally. 

Lacerated  or  contu?;ed  wounds  of  the  scalp  rarely  slough  and  should  be  treated  as  the 
incised.  Punctured  wounds  are.  however,  liable  to  be  followed  by  diffused  inflammation 
beneath  the  scalp. 

Treatment. — Under  all  circumstances  and  conditions,  scalp  wounds  should  be  gently 
and  carefully  cleaned  with  tepid  water  and  their  edges  adjusted  and  maintained'in  posi- 
tion ;  and  to  aid  this  the  hair  should  be  removed  in  the  neighborhood  of  the  wound. 
When  the  wound  is  not  exten.sive  and  its  edges  can  be  adjusted  by  plaster,  sutures  are 
not  needed;  but  when  any  difficulty  is  experienced,  they  may  be  as  fearles.sly  applied  to 
the  scalp  as  to  other  parts.  In  extensive  lacerations,  indeed,  the  application  of  sutures 
is  decidedly  preferable  to  any  other  form  of  practice,  ina.smuch  as  with  their  use  the 
wound  can  be  kept  clean  and  moist  by  dressings,  which  is  not  possible  where  a  quantity 
of  strapping  has  been  employed.  In  the  application  of  the  suture,  however,  care  must 
be  taken  not  to  include  the  aponeurosis  of  the  occipito-frontalis  muscle,  for  there  is  more 
danger  of  setting  uyj  mischief  in  the  cellular  tissue  beneath  this  tendon  when  this  prac- 
tice is  adopted  than  when  the  sutures  simply  pass  through  the  .skin  itself.  The  kind  of 
^Vide  paper  Glasgow  Med.  Jonru.,  January,  1876,  bv  Dr.  Wm.  MacEwen. 


CONTUSION  OF   Tin:   HOSES  OF   THE  SKULL.  191 

HUturo  is  iiiiiiii|Mirt;iiit.  altliuutrli  iimiiy  sur<.M'(iiis  prcl'tT  the  iiii'tallic.  All  sutures  sliouid 
be  rciiidVi'd  (111  till'  sccdiid  day,  as  wnuiuls  of  the  sral|i  Ileal  raiiidly.  Tlic  head  in  all 
tlu'Sf  i-asi'S  sliduld    Ik'  kept  cunl. 

W'lu'ii  tlu'  iiericraiiiuiii  is  t(trii  ott'  and  tin-  Ikuk-  cxjioscd,  no  diflcrcnff  in  ])racticc  i« 
iK'fdfd.  I  lie  jinisiR'cts  oi"  a  satisfactory  rc'covi-ry  under  these  eircuiiistaiiees  heiiij:  as  <;ood 
as  ill  a  less  eoiiiidieated  ease.  When  the  Immic.  however,  has  heeii  iniieli  iiijure(l,  super- 
tic'ial  neerosis  may  lollow.  Should  e.xudative  or  inHaiiiiiiatory  fluid  eolleet  heiieath  the 
flaps,  the  sooner  a  free  escape  is  jiiveii  to  it  the  better,  since  by  its  retention  suppuration, 
wliieli  is  always  as.soeiated  with  great  danger  to  the  perio.steiini,  to  the  bone,  and  even  to 
the  life  (d"  the  patient,  is  encouraged.  To  attain  this  end  the  edges  rd"  the  wound  should 
be  .separated  in  parts  l>y  iiieans  of  a  jirobe.  (»r  iiniifn/  incisions  should  be  made  through 

the  tissues  down  to  the  1 e.      By  adopting  this  practice  early  the  inflammation  will  often 

be  prevented  or  cheeked  and  the  extent  of  mischief  limited. 

When  diffused  supjuiratioii  has  taken  place  beneath  the  scalji.  the  juis  sliouhl  be  evac- 
uated by  incisions  well  placed  for  drainage,  the  acticjii  lA'  the  occipito-frontalis  muscle  con- 
trolled by  tlu"  jtressure  of  a  circular  elastic  liandage  or  strapjiing.  and  the  surfaces  of  the 
suppurating  cavity  ke)>t  in  apposition  by  spfuige  pressure. 

To  the  wounds  absorbent  aiitisejitic  dressings  should  be  applied. 

When  extensive  sloughing  takes  place,  there  is  no  reason  why  a  good  recovery  should 
not  follow  if  the  powers  of  a  patient  be  good  and  his  kidneys  sound. 

The  powers  of  a  patient  must  be  kept  up  by  tonic  medicines,  such  as  iron  or  quinine, 
generous  diet  allowed,  and  stimulants  employed  when  needed.  Sedatives  to  procure  sleep 
are  also  essential. 

When  bleeding  is  troublesome,  the  arteries  should  be  twisted,  acupressed.  or  ligatured  ; 
when  it  occurs  merely  as  a  general  oozing  of  blood,  pressure  may  be  applied  either  to  the 
wound  or  to  the  trunks  of  the  supplying  vessels.  In  rare  cases,  where  the  deep  vessels 
of  the  temporal  fossa  are  wounded  and  bleeding  cannot  be  arrested,  the  question  of  apply- 
ing a  ligature  to  the  external  or  common  carotid  may  have  to  be  entertained.  It  has  never 
fallen  to  my  lot,  however,  to  witnes's  such  a  case. 

Contusion  of  the  Bones  of  the  Skull. 

This  is.  doubtless,  a  common  consetjuence  of  scalp  injuries  both  with  and  without  a 
wound,  as  is  a  scratching  or  abrasion  of  the  bones;  and  yet  in  the  majority  of  such  cases 
a  good  recovery  takes  place.  In  exceptional  cases,  however,  a  ditterent  result  is  met  with, 
in  the  shape  of  either  an  acute  inflammation  of  the  bone  with  all  its  dangers,  or  a  chronic 
inflammation  with  all  its  difficulties. 

Acute  nifiamiiuition  of  the  bone  is  a  severe  affection,  more  particularly  when  the  diploe 
is  involved;  for  the  diseased  action  may  extend  inward  and  give  rise  to  a  local  suppura- 
tion between  the  bone  and  the  dura  mater  or  between  the  layers  of  the  arachnoid,  running 
on  to  a  diffused  inflammation  of  this  membrane  and  of  the  brain  itself. 

A  chronic  injiammntion  of  the  Itorte  may  be  followed  by  very  similar  results  or  by  a 
thickening  of  the  injured  bone. 

W^hen  neerosis  of  the  skull  is  present,  these  results  are  always  liable  to  occur,  and 
with  it  a  low  kind  of  jthlebitis  of  the  cerebral  sinuses  and  pyjemia  are  prone  to  follow. 

Symptci.ms. — The  symptoms  which  indicate  either  of  these  two  conditions  appear  at 
variable  periods  after  the  accident  and  vary  in  intensity  according  to  the  action.  In 
OAiite  cases  the  symptoms  may  show  themselves  within  a  few  days  with  severe  constitu- 
tional irritation  and  headache,  passing  on  to  general  brain  disturbance,  convulsions, 
paralysis,  coma,  and  death.  In  chronic  disease  the  symptoms  may  not  appear  for  weeks 
or  months,  and  they  will  be  less  severe ;  but  persistent  headache  is  always  present. 
When  the  inflammation  spreads  inward  toward  the  arachnoid  and  brain,  other  symp- 
toms show  themselves,  such  as  severe  local  pains,  delirium,  twitching  of  the  muscles, 
convulsions,  paralysis,  coma,  and  death,  the  rapidity  of  the  progress  of  the  disease  gov- 
erning the  symptoms.  When  marked  rigors  appear,  suppuration  is  indicated,  often  of 
the  py.-emic'kind  ;  and  convulsions  of  an  epileptic  nature  are  frequently  found  in  the 
chronic  form  of  the  disea.se.  Fersi.slent  hemhiche  after  an  injury  to  the  head  is  always  a 
symptom  demanding  anxious  attention,  as  it  too  often  means  progressive  mischief  within 
the  skull.  This  subject  will,  however,  receive  further  elucidation  in  the  chapter  on 
"  Intracranial  Inflammation." 


192 


FRACTURES  OF  THE  SKULL. 


INJURIES  OF  THE  CRANIUM. 

There  are  some  leading  practical  facts  or  principles  which  should  be  impressed  upon 
the  memory  of  every  surgeon  who  has  to  deal  with  injuries  to  the  head.  These  I  have 
formulated  as  follows,  believing  it  to  be  well  to  place  them  at  the  beginning  of  a  chapter 
on  such  injuries. 

1.  A  concussed  should  be  regarded  clinically  as  a  bruised  brain. 

2.  Fractures  or  injuries  of  the  skull  are  of  importance  so  far  as  they  are  associated 
with  damage  to  the  skull  contents,  a  compound  fracture  uncomplicated  with  .shaking  of 
or  injury  to  the  cranial  contents  being  less  liable  to  be  followed  by  bad  results  than  a 
simple  fracture  associated  with  brain  mischief. 

3.  The  amount  of  injury  to  the  brain  cannot  be  estimated  by  the  severity  of  the  pri- 
mary symptoms,  a  severe  injury  to  the  brain  being  frequently  associated  at  first  with 
mild,  and  a  slight  injury  with  severe,  symptoms. 

4.  A  general  shaking  (concussion)  of  the  brain,  whether  associated  or  not  with  simple 
or  compound  fracture,  may  give  rise  either  to  temporary  suspension  of  brain  functions, 
ending  in  recovery,  to  laceration  of  the  membranes,  to  a  more  or  less  severe  bruising  of 
the  cortical  structure  of  the  brain,  or  to  laceration  of  its  deeper  substance.  The  amount 
of  hemorrhage  which  complicates  the  case  depends  upon  the  size,  number,  and  healthi- 
ness of  the  ruptured  vessels.  Thus  a  general  shaking  or  concussion  in  a  healthy  brain 
may  only  produce  a  temporary  suspension  of  cerebral  functions,  when  the  same  injury  in 
an  unhealthy  or  aged  one  in  which  diseased  vessels  ramify  may  be  followed  by  a  fatal 
hemorrhage  or  apoplexy. 

5.  Under  certain  conditions  of  the  system,  and  particularly  where  the  kidneys  are 
diseased,  a  slight  concussion  will  be  followed  by  a  fatal  secondary  inflammation  of  the. 
brain-coverings;  while  under  other  conditions  a  severe  injury  to  the  brain  will  be  fol- 
lowed by  no  such  result. 

6.  Intracranial  inflammation  is  as  prone  to  follow  the  milder  as  the  graver  cerebral 
injuries. 

7.  The  character  of  the  accident  and  the  mode  of  its  production  furnish  the  best 
means  for  estimating  the  nature  and  severity  of  the  injury  and  its  probable  results,  since 
a  fall  upon  the  head  from  a  height  or  a  blow  from  a  heavy  weight  causes  a  generul  injury 
of  the  brain,  and  a  fall  upon  or  a  blow  from  a  sharp  instrument  a  local  one. 

With  these  general  propositions,  which  the  student  should  learn  and  think  over  as  a 
guide,  I  now  proceed  to  consider  the  subject  of  fractures  of  the  skull. 


FRACTURES  OF  THE  SKULL. 

These  may  be  divided  into  fractures  of  the  '•  vmdt  "  and  fractures  of  the  "  hnse^''  a  third 
and  large  division  including  those  of  the  '•  vault  and  base."  They  may  likewise  be  "  sim- 
ple'^ or  ^'  compouiid."  ''^  comminuted^"  "■  depres-^ed"  or  "undepressed." 

Fractures  of  the  vault  are  generally  caused  by  direct  blows  upon  the  part  or 
falls   upon    sharp   bodies.      They   include   most    of  the  punctured  fractures   and   incised 

wounds  of  the  bone,  as  in  sword  wounds, 
etc.  They  are  of  necessity  compound,  and 
often  comminuted ;  and  the  brain  injury 
which  is  associated  with  them  is  for  the 
most  part  local. 

When  not  punctured,  the  fracture  may 
appear  as  a  simple  fissure,  the  extent  of 
which  is  determined  by  the  amount  and 
character  of  the  force  employed,  the  line  of 
fracture  being  influenced  by  the  sutures  and 
ridges  of  bone.  When  the  force  is  local  and 
moderate,  the  fracture  may  be  limited ;  when 
concentrated  and  severe,  the  fracture  will 
be  "starred,"  and  generally  "comminuted."  the  fissures  radiating  in  all  directions,  involv- 
ing many  bones,  and  passing  downward  toward  the  base.  When  inflicted  with  a  blunt- 
edged  instrument,  the  fracture  will  be  depressed  in  a  gutter  shape  (Fig.  71)  ;  when 
with  a  round  one,  as  a  hammer,  the  bone  will  be  depressed  more  like  a  '•  saucer " 
(Fig.  72). 


Gutter-  and  Saucer-Shaped  Fractures  of  the  Sku 


FiiAcniiKs  or  Tin:  shTi.L. 


193 


Coniiiiiiiuted  Fracture  of  Skull 
with  JJepre^^sion  of  luner 
Talile  from  Direct  Local  Vio- 
lence (Prep.  Guy's  Mus.;. 


Cunnniuiiftif  /rncfitrrs  ure  trcni-rally  the  ri'.siilt  of  a  coiict'titratiMl  local  violence,  and  are 
coiiseijucntly  fomid  chu-tly  in  tin-  vault  and  are  mostly  conijioiind  (Vijs.  7-i). 

In  sonjo  cases  of  fracture  of  the  vault  the  hone  will  he  (h'presscd  ttr  driven  in  upon 
the  cranial  contents  ;  in  sabre  wounds  it  may  he  elevated,  ploughed  up,  or  displaced 
outward. 

The  fracture  will  he  confined  in  some  cases  to  the  outer  tahle  of  the  skull,  in  rarer 
instances  to  the  inner,  a  fracture  with  depression  <d"  the  inner  tahle  occasionally  existing 
without  any  fracture  of  the  outer. 

When  the  force  acts   from  iritliuni  mul   is  <ji<<it.  the  whole  thickness  of  hone  may  he 
hrokcn,  the  inner  tahle  prohahly  irivinir  way  first  and  being  fractured  to  a  <rreater  extent 
than  the  outer;   hat  when  the  force  is  sllijht.  the  inner  tahle 
niav   be  alone   fissured,   loo.seiied.  or  driven   in. 

When  the  force  acts  from  irithln.  upon  the  inner  tabic 
first,  the  reverse  of  the  above  holds  jrood.  the  outer  table 
giving  way  before  the  inner  and  being  fractured  to  a  greater 
extent.  In  Preji.  1082'".  in  Guy".s  Museum,  this  not  suffi- 
ciently recognized  fact  is  well  demonstrated.  In  it,  the  force 
having  been  applied  by  a  pistol  bullet  which  was  sent  by  a 
suicide  through  his  brain,  the  point  of  impact  on  the  inner 
table  is  represented  by  a  black  mark,  whilst  the  outer  table  is 
starred;  and  in  Prep.  1083",  taken  from  a  boy  aet.  12,  fracture 
of  the  outer  and  inner  tables  exists,  but  not  in  correspondini; 
parts. 

An  interesting  paper  on  this  subject  will  be  found  in  the 
Anu'ruaii  Jnnru.  nf'  .]//:>/.  Srfeuc<\  April,  1882.  b}'  Mr.  J. 
Lidell. 

As  points  of  practice,  however,  it  is  well  to  remember 
that  in  all  ordinary  ca.ses  of  fracture,  with  depression  of  the 
bones  of  the  skull,  the  injury  to  the  inner  table  is  far  greater  than  to  the  outer,  and 
the  point  of  exit  of  any  foreign  body  through  the  skull  is  always  larger  than  that  of 
entrance. 

Whether  depression  of  the  bones  of  the  skull  of  an  adult  ever  occurs  without  a  frac- 
ture is  an  open  question.  There  is  certainly  no  good  evidence  in  support  of  the  fact.  In 
children  it  has  happened  without  giving  rise  to  any  symptoms  of  brain  compression  ;  yet 
even  here,  says  P.  Hewett.  ••  .some  of  tlie  bony  fibres  must  have  given  way."  In  these 
cases  tlie  dcprc-st'il  bone  may  subsequently  rise  up  again  to  its  natural  level. 

Brain  Complications. — The  practical  interest,  however,  attached  to  all  these 
varieties  of  fracture  is  concentrated  in  the  question  as  to  how  far  the  cranial  contents 
are  involved  in  the  injury.  Has  the  brain  been  slightly  concussed,  or  so  .shaken  as  to 
have  been  bruised  or  lacerated?  Have  the  membranes  of  the  brain  been  torn,  lacerated, 
or  injured?  Is  the  fractured  bone  a  .source  of  irritation  to  the  dura  mater?  Is  there  a 
loose  fragment  of  the  inner  taVde  of  bone  acting  as  an  irritant  ?  A  compound  fracture 
with  or  without  depression,  not  complicated  with  brain  di.sturbance  or  brain  injury,  is  a 
cause  of  far  less  anxiety  than  a  simple  fracture  in  which  severe  brain  concussion  has 
taken  place  and  is  indicated  by  symptoms ;  a  severe  shaking  of  the  brain,  whether  com- 
plicated or  not  with  a  fracture,  is  a  far  more  serious  accident  than  any  local  injury  to  the 
skull  alone. 

Fractures  of  the  base  of  the  skull  or  vault  and  base  combined — 

for  the.se  conditions  ought  to  be  considered  together — are  invariably  severe  injuries. 
They  are  generally,  except  when  produced  by  a  crushing  of  the  head,  caused  by  a  dif- 
fused force,  such  as  that  occasioned  by  a  fall  from  a  height  upon  the  vertex  or  by  a 
heavy  blow.  '-When  the  former,  the  plunge  of  the  body  is  suddenly  arrested  by  the 
vertex  coming  in  contact  with  the  ground,  and  the  entire  superincumbent  weight,  with 
the  superadded  momejitum  ac(|uired  by  the  velocity  of  the  fall,  is  concentrated  around 
the  condyles  of  the  occipital  bone,  and  the  central  compartment  of  the  base  of  the  sknill 
is  thus  broken  across"  (Fig.  74).  The  fracture  is  the  result  of  direct  violence,  and  not 
of  so-called  contre-coup. 

"  Thus,  if  the  injury  be  inflicted  by  the  fiill  of  a  hm-d  and  heavy  body  on  the  vertex, 
this  part  would  be  fractured  ;  and  if  the  weight  were  not  very  great,  the  mischief  might 
end  there,  as  the  resistance  offered  by  the  head  ma)"  so  far  exhaust  the  momentum  of 
the  falling  body  that  the  force  would  not  be  transmitted  in  sufficient  amount  to  cause 
fracture  of  the  base.     But  if  the  weiirht  and  momentum  of  the  falling  body  were   in 

12 


194 


FRACTURES  OF  THE  SKULL. 


Fig 


Fracture  of  Base  of  Skull  from  Fall  on  Vertex. 


excess  of  the  expenditure  of  force  in  causing  fracture  of  the  vertex,  the  impulse  would 
drive  the  head  down  upon  the  summit  of  the  spinal  column,  and  fracture  of  the  base 
would  result ;  in  that  case,  viewed  mechanically,  the  lower  fracture  would  be  succes- 
sive to  the  upper.  But  if  the  falling  weight 
which  struck  the  vertex  were  of  a  yielding 
material,  fracture,  if  any,  would  be  in  the 
base,  and  not  of  the  vertex,  because  the  vis 
iiierfia  of  the  skull  would  be  overcome,  and 
it  would  be  driven  down  upon  the  spine 
without  the  application  of  circumscribed 
force  to  the  vault.  The  same  reasoning 
applies  when  fracture  of  either  the  vault 
or  base,  or  of  both  together,  is  the  effect 
of  a  fall  on  the  vertex  ;  or  this  result  may 
be  varied  by  the  blow  being  received  on  the 
forehead  or  occiput,  the  anterior  or  posterior 
divisions  being  thin  and  severally  more  ob- 
noxious to  fracture." 

Injuries   to   the   occiput   are   commonly 

followed    by    longitudinal    fracture    of   the 

base,    involving    both    the     posterior    and 

middle  fossae. 

Injuries  to   the  temporal   region  or  about  the  ear  are  followed  by  fracture  of  the 

petrous  bone  and  the  middle  fossa  ;  they  are  always  serious. 

But  it  is  rare  in  diffused  injuries  to  the  head  to  find  one  fossa  alone  involved  :  fissures 
generally  pass  through  two  fossae  and  extend  from  the  vault  or  part  struck. 

The  evidence  afforded  by  my  notes  of  two  hundred  cases  of  fatal  head  injuries  clearly 
establish  these  points,  which  have  also  been  experimentally  proved  by  Dr.  Aran. 

"  In  precipitating  a  large  number  of  bodies. from  various  heights  on  to  the  head.  Dr. 
Aran  found  that  the  part  of  the  vault  which  first  struck  the  ground  gave,  as  it  were,  the 
key  to  the  fracture  which  would  take  place  at  the  base.  Similar  results  were  also 
obtained  when  diffused  blows  were  dealt  upon  different  parts  of  the  skull  by  means  of  a 
large  and  heavy  hammer.  In  the  front  part  of  the  vault  injuries  thus  produced  led  to  a 
fracture  of  the  anterior  fossa,  in  the  middle  part  of  the  vault  they  led  to  a  fracture  of 
the  middle  fossa,  and  at  the  back  of  the  head  to  a  fracture  of  the  posterior  fossa.  In  no 
single  instance  was  a  fracture  detected  at  the  base  without  a  line  of  fracture  in  the  cor- 
responding part  of  the  vault.  The  truth  of  this  has  been  proved  by  an  analysis  which 
I  made  of  all  the  cases  of  fractured  base  of  the  skull  admitted  into  St.  George's  Hos- 
pital during  a  period  of  ten  years  "  (Prescott  Hewett). 

My  own  observations  go  entirely  to  prove  the  correctness  of  tlaese  views.  The  mid- 
dle fossa  is  the  one,  however,  most  frequently  involved. 

Compound  fractures  of  the  skull  are,  as  a  rule,  local  fractures.  They  are  gen- 
erally the  result  of  a  concentrated  blow  upon,  or  a  puncture  of,  the  part,  the  force 
employed  having  been  expended  in  producing  the  local  injury.  They  are,  consequently, 
often  starred  or  comminuted  and  depres.sed  fractures.  When  the  brain  is  involved  in  the 
injury,  it  is  chiefly  beneath  the  seat  of  fracture  ;  it  is  rarely  shaken  or  concussed  as  much, 
as  it  is  in  simple  fractures  the  result  of  a  diffused  blow. 

The  dangers  attending  a  compound  fracture  do  not,  therefore,  arise  so  much  from  the 
direct  injury  to  the  brain  as  from  secondary  intracranial  inflammation  the  direct  result 
of  irritation  of  the  dura  mater  by  the  depressed  or  comminuted  bone,  the  dura  mater 
being  frequently  punctured  or  torn  and  in  all  cases  irritated  by  the  depressed  bone. 
These  facts  have  an  important  bearing  on  practice,  since  they  encourage  the  surgeon  to 
remove  the  depressed  and  irritating  portions  of  bone,  which  have  such  an  injurious  influ- 
ence on  the  progress  of  the  case.  When  the  brain  is  injured  by  the  accident,  the  danger 
is  far  greater. 


THE  DIAGNOSIS   OF  FRACTURE  OF  THE  SKULL. 

There  are  no  special  symptoms  by  which  a  fissure  of  the  vault  uncomplicated  with  a 
wound  can  be  recognized.  The  best  guide  to  the  diagnosis  of  a  fracture  of  the  skull  is  the 
nature  of  the  injury.  Extensive  fractures  of  this  kind  are  constantly  found  upon  the 
post-mortem   table   where   no   suspicion  of  their   presence  was  entertained   during   life. 


Tin:  /)/ K/.vo.sY.v  OF  rn.Krrni-:  of  the  skull.  195 

Wtiin  :i  wuiiiiil  complicates  the  ca.sc,  a  iVacliiii"  can  usually  be  made  out,  as  the  fissure 
can  l>c  seen  as  a  red  line.  ('ar(>,  however,  slioiijil  lie  taken  in  these  cases  not  to  mistake 
a  auturi'  for  a  fracture. 

When  depressed  lione  exists  with  I'ractiire,  the  dia;;nosis  is  rarely  difficult,  unless  it 
should  so  happen  that  the  fracture  has  taken  jilace  hcneath  the  body  rd"  the  temporal 
imisele,  when  it  is  almost  impossilile  to  diaLTUose  its  existence  by  direct  signs. 

An  efiusion  of  blood  beneath  the  pericranium  may  be  mistaken  for  a  fracture  with 
depressed  boiu',  unless  care  bi'  observed,  as  may  a  natural  depression  in  the  skull,  [lar- 
ticularly  in  the  occipital  rt>i;ion. 

Fracture  of"  the  skull  the  result  of  a  jnnicfiiml  wound  can,  as  a  rule,  be  reailily  recog- 
nized, thouuch  when  the  point  of  the  perforatiiiL:  instrument  has  been  broken  short  off  at 
the  surface  of  the  bone  much  care  is  needed. 

T/ir  (h'lii/iiiisis  of  n  frticlnrv  of  tftc  haur,  or  of  the  base  and  vault  combined,  is  always 
a  source  of  difficulty,  since  there  are  no  signs,  but  only  symptoms,  to  assist  ((pinion.  The 
nature  of  the  accident  is  without  doubt  the  surgeon's  best  guide  ;  a  fall  from  a  height  or 
a  heavy  blow  ujmiii  the  head  is  the  usual  cause  of  such  an  accident,  though  a  crushing 
force  ap]died  in  any  direction  may  produce  the  same  result. 

Should  the  fall  have  been  upon  or  the  force  applied  to  the  vertex,  the  middle  fo.s.sa  of 
the  skull  will  probably  be  the  seat  of  injury  ;  and  the  diagnosis  of  a  fracture  through 
the  petrous  bone  may  with  some  confidence  be  made  when  such  an  injury  is  followed  by 
profuse  or  ])ersistent  hemorrhage  from  the  ear,  succeeded  by  the  copious  discharge  of  a 
watery,  and  perhaps  saccharine  or  slightly  albuminous,  fluid,  and  jiaralysis  of  the  parts 
supplied  by  the  facial  nerve.  Slight  hemorrhage  from  the  ear  is  no  po.sitive  sign  ;  the 
moderate  discharge  also  of  a  water}-  fluid  alone  is  not  characteristic,  nor  is  facial  paraly- 
sis. But  profuse  and  prolonged  bleeding  from  the  ear,  or  .slight  hemorrhage,  followed 
by  a  watery  discharge,  is,  however,  strongly  indicative  of  a  fracture,  as  is  also  a  copious 
watery  discharge  directly  following  the  injury.  Facial  paralysis,  however,  combined  with 
either  of  these  symptoms,  renders  the  diagnosis  complete.  This  watery  discharge  is  now 
generally  admitted  to  be  an  escape  of  cerebro-spinal  fluid  through  a  fracture  of  the 
petrous  bone,  passing  across  the  internal  auditory  canal,  and  attended  with  rupture  of  the 
membrana  tympani.     I  have  known  this  to  continue  for  eight  days. 

In  injuries  to  the  mastoid  process,  if  a  local  emphysema  exists,  the  presence  of  a 
fi'acture  may  be  diagnosed. 

Fracture  of  the  Anterior  Fossa. — Should  the  blow  or  fall  have  been  upon 
the  anterior  part  (d"  the  skull,  the  probaliilities  of  the  case  point  to  fracture  of  the 
anterior  fossa  ;  and  where  any  injury  to  any  of  the  nerves  of  the  orbit  can  be  made  out, 
as  indicated  by  local  paralysis  of  some  of  the  muscles  of  the  eye,  or  when  hemorrhage 
has  taken  place  beneath  the  conjunctiva,  the  diagnosis  is  certain.  Hemorrhage  into  the 
eyelids  by  itself  is  of  no  value  as  a  diagnostic  sign,  although  when  it  follows  the  acci- 
dent at  a  later  period  and  is  consecutive  to  subconjunctival  hemorrhage  it  is  a  symptom 
of  some  importance. 

Falls  upon  the  occiput  coniinonly  produce  longitudinal  fissures  of  the  base. 

Copious  and  obstinate  bleeding  from  the  nose  or  pharynx  is  by  no  means  unfrequent 
in  a  case  of  fractured  base,  and  when  accompanied  with  other  suspicious  symptoms  is  of 
diagnostic  value.  I  have  the  notes  of  a  case  of  injury  to  the  head  in  which  the  patient 
apparently  died  from  bleeding  from  the  nose  and  mouth,  no  blood  coming  from  the  ear; 
and  after  death  a  fracture  of  the  base  was  foiind  completely  separating  the  petrous  por- 
tion of  the  temporal  bone  from  its  connections  and  laying  open  the  lateral  sinus.  The 
right  tympanum  was  full  of  blood,  but  the  membrana  tympani  was  entire.  The  stomach 
was  full  of  blood,  the  blood  from  the  lateral  sinus  having  apparently  found  its  way 
through  the  Eustachian  tube  into  the  pharynx  and  stomach. 

I  have  also  the  particulars  of  a  second  case,  in  which  the  carotid  artery  was  divided  in 
its  passage  through  the  petrous  bone  and  the  lateral  sinus  laid  open,  the  lungs  and 
bronchial  tubes  being  found  filled  with  blood,  even  down  to  the  air  cells.  Each  of  these 
patients  lived  only  two  hours  after  the  accident. 

Fracture  of  the  base  unassociated  with  any  injury  to  the  brain  itself  is  of  no  more 
conse((uencc  than  fracture  of  another  part ;  but  as  the  base  is  the  most  delicate  part  of 
the  brain,  and  any  injury  to  it  is  sure  to  be  followed  by  severe,  if  not  fatal,  symptoms, 
the  subject  of  fracture  of  the  bones  upon  which  it  rests  becomes  of  proportionally  greater 
interest. 

This  fracture  of  the  base  may  be  associated  with  all  the  intracephalic  injuries  to 
which  fractures  of  the  vault  are  liable.     It  may  be  complicated  with  simple  concussion 


196 


THE  DIAGNOSIS  OF  FRACTURE  OF  THE  SKULL. 


of  the  brain,  or  with  the  more  severe  form  associated  with  laceration  of  the  brain  struc- 
ture, or  extravasation  of  blood  upon  or  within  the  brain  itself.  If  blood  is  eflFused,  there 
may  be  compression  of  the  brain  followed  by  death,  or  the  same  result  may  be  produced 
by  a  secondary  inflammation  of  the  membranes  and  injured  parts. 

It  is  difficult,  upon  the  whole,  to  separate  the  two  cla.sses  of  cases,  inasmuch  as  the 
dangers  arising  from  injuries  to  the  skull  do  not  depend  upon  the  seat  of  fracture,  but 
upon  the  injuries  to  the  cranial  contents ;  and,  as  the  same  injuiies  may  be  produced  by, 
or  rather  ma}-  be  associated  with,  fractures  of  the  base,  the  complications  and  dangers 
are  the  same  in  each. 

Having,  then,  so  far  shown  that  the  dangers  of  all  forms  of  fracture  of  the  skull  are 
really  alike,  and  that  the  same  intracephalic  complications  attend  fractures,  whether  of  the 
vault  or  of  the  base,  I  now  proceed  to  illustrate  the  special  symptoms  generally  regarded 
as  being  diagnostic  of  such  injuries  by  a  brief  analysis  of  cases  from  my  note-book. 

Among  thirty  examples  which  are  there  recorded,  twelve  were  associated  with  .simple 
concussion,  in  all  of  which  recovery  took  place.  In  three  cases  the  fractures  extended 
through  the  orbit,  as  indicated  by  subconjunctival  ecchymo.sis.  In  eight  there  was 
hemorrhage  from  the  ears ;  in  all,  this  was  followed  by  a  discharge  of  serum,  and  in 
seven  of  the  cases  it  was  associated  with  paralysis  of  the  facial  nerve  upon  the  same  side. 
In  these  it  is  quite  fair  to  conclude  that  the  line  of  fracture  extended  through  the  petrous 
portion  of  the  temporal  bone.  In  two  there  was  bleeding  from  the  nose ;  in  one  there 
was  a  serous  discharge  from  the  ear.  accompanied  by  paralysis  of  the  facial ;  in  another 
this  discharge  followed  hemorrhage  from  the  ear  and  was  unaccompanied  b}'  paralysis. 

To  test  the  value  of  these  different  symptoms  as  indicating  fracture  of  the  base  in 
various  positions,  the  following  analysis  of  the  fatal  cases  will  prove  of  value  ;  and,  taking 
the  symptoms  separateh',  subconjunctival  hemorrhage  will  first  claim  our  attention,  as 
being  one  which  more  or  less  accurately  marks  a  fracture  through  the  orbital  plate.  In 
the  eighteen  fatal  examples,  this  symptom  was  manife.sted  in  four  instances,  the  line  of 
fracture  extending  in  each  of  these  through  the  orbit. 

In  two  cases  there  was  copious  hemorrhage  from  the  ear,  while  in  both  the  fracture 
passed  through  the  petrous  bone. 

In  three  examples  there  was  some  epistaxis.  In  one  of  these  the  fracture  extended 
across  the  ethmoid  bone,  in  another  the  frontal  sinuses  were  full  of  blood  and  fractured, 
and  in  the  third  the  tympanum  was  found  full  of  blood,  the  membrana  tympani  perfect, 
and  upon  careful  examination  the  lateral  sinus  of  the  brain  was  found  to  have  been 
lacerated. 

Seven  of  the  eighteen  fatal  cases  died  from  direct  injury  to  the  brain,  the  post-mortem 
examination  in  all  revealing  severe  contusion  or  laceration  of  the  brain  structure,  with 
effusion  of  blood  upon  the  surface  of  the  brain  or  upon  the  membranes. 

Seven  other  cases  died  from  arachnitis  as  a  result  of  the  injury.  In  four  of  these 
there  was  contusion  of  the  brain,  and  in  one  ecchymosis  of  the  ventricles  ;   in  two  there 


Fig.  75. 


Fig.  76. 


"^?<=>> 


Fracture  of  Anterior  Fossa  of  the  Base  of  Skull. 
(Prep.  No.  10858^,  (Juy's  Hosp.  Mus.) 


a,  Punctured  Wound  through  Frontal  Bone. 
6,  Portion  of  Wood  which  perforated  Bone. 
(Prep.  No.  1086M  Guy's  Hosp.  Mus.) 


was  no  evidence  of  contused  brain,  nor  was  there  any  effusion  of  blood ;  in  one  interest- 
ing case  the  inflammation  spread  from  the  internal  ear.  In  three  the  cerebral  mischief 
was  complicated  with  some  thoracic  or  abdominal  injury  which  caused  death,  and  in  one 
hemorrhagre  was  the  immediate  cause  of  death. 


CONCUSSIOS   OF   THE   IIHAIX,    AM)    ITS   I! I' F i:CTS.  197 

A  sevcro  hlow  ii|miij  tlic  iioso,  hy  driving  in  the  otiniutid  horn-,  may  cause  fracture  of 
the  uiitcriur  fossa  of  the  base*  of  the  skull  (riilr  ]•'!•;.  7')),  and  1  liavc  had  under  my  care 
several  cases  in  wliicli  a  severe  Itlow  m|miii  tlic  jaw  produced  a  fracture  of  the  niiddh; 
fossa.  At  St.  (JcurLM's  Hospital  there  is  a  s|ii'ciinen  in  which  a  fracture  of  the  base  was 
caused  hy  ilif  tondylf  nf  the  hiwcr  jaw  hein;;  driven  aj^ainst  the  ;j;lenoid  fossa  with  such 
force  that  the  condyif  proji-cted  into  the  cavity  of  the  skull,  and  in  (luv's  Ur)spital 
Museum  there  is  a  simihir  specimen,  whicdi  was  sent  in  with  Mr.  Hutchinson's  prize 
essay.  I'unctured  wounds  of  the  orhit  arc;  Ity  no  means  infre(|uent  causes  of  i'racture  of 
the  base  ;  many  are  recorded.  I  was  once  called  to  a  case  in  which  a  lead-pencil  had 
perforated  tlii'  l)one  and  the  brain  throuL'h  the  orbital  plate,  and  Fijr.  7<>  was  taken  from 
a  preparation  in  which  the  fnnital  Itoiie  was  perforated.  The  diu^'intsis  of  these  ca.ses  is 
not  dillicult.  When  bruin  matter  escajies  externally  throu<:h  the  wound,  there  is  no  room 
for  duulit. 

The  treatment  of  fractures  of  the  skull  will  be  described  after  the  subjects  of  injuries 
to  the  brain  and  extrava.sation  of  blood  within  the  cranial  cavity  have  been  considered. 

CONCUSSION  OF  THE  BRAIN,  AND  ITS  EFFECTS. 

'•  A  man  receives  a  blow  on  the  head  by  wliich  he  is  only  stunned  for  a  longer  or  a 
shorter  period.      Wiiat  is  said  to  have  happened?     Concus.sion  of  the  brain. 

"  A  man  dies  instantaneously  or  lingers  some  time  perfectly  uncon.scious  after  an 
injury  of  the  head;  there  arc  no  marks  of  external  violence.  Again,  what  is  said  to  have 
happeiu'd  ?     Concu.ssion  of  the  brain. 

"  The  head  is  opened,  and  what  is  found  ?  In  one  case  no  deviation  from  the  healthy 
structure  ;  in  another,  simply  great  congestion  of  the  cerebral  vessels  ;  in  another,  numer- 
ous points  of  extravasated  blood  scattered  through  the  brain  substance ;  in  another,  a 
bruised  appearance  in  some  parts  of  this  organ.  In  all,  the  ca.se,  in  common  parlance,  is 
said  to  have  been  one  of  concussion  of  the  brain.  Such  are  the  after-death  appearances 
ascribed  by  different  surgeons  to  concussion  of  the  brain." 

These  words  of  an  eminent  surgeon  (P.  Hewett)  so  accurately  describe  the  ordinary 
teaching  of  the  schools  that  I  have  transcribed  them  as  a  fitting  introduction  to  the  sub- 
ject of  which  I  am  about  to  treat.  They  arc  likewise  practically  true,  although  expe- 
rience of  the  post-mortem  room  shows  that  in  ca.ses  of  death  from  concussion  of  the  brain, 
with  the  rarest  exception,  some  changes  in  structure  are  to  be  found  if  carefully  looked 
for,  some  bruising  or  laceration  of  the  brain,  some  bleeding  into  its  substance.  In  fact, 
death  from  concussion  of  the  brain  without  change  of  .structure  hardly  ever  takes  place, 
concussion  untl  vontiixion  of  the  brain  being.  <ts  <i  rnle,  associafed  in  fafol  casis.  At  Guy's 
Hospital,  for  twenty  consecutive  years,  no  case  is  recorded  of  death  from  concussion  with- 
out change  of  brain  structure,  and  it  is  only  quite  recently  that  an  example  has  occurred. 

"  In  every  case,"  remarks  P.  Hewett,  "  in  which  I  have  seen  death  occur  shortly 
after,  and  in  consequence  of,  an  injury  to  the  head,  I  have  invariably  found  ample  evi- 
dence of  the  damage  done  to  the  cranial  contents." 

Concussion  and  Contusion  of  Brain  Identical.— Mr.  Le  Gros  Clark  states : 

'•  I  have  never  made  nor  witnessed  a  post-mortem  after  speedy  death  from  a  blow  on  the 
head  where  there  was  not  palpable  physical  lesion  of  the  brain  ;"  and  Dr.  Xeudorfer  of 
the  Austrian  army  declares  that  he  has  never  seen  concussion,  properly  so  called,  except 
in  a])parently  trivial  injuries. 

M.  Fano,  a  recent  French  writer,  has  al.so  come  to  the  conclusion  "  that  the  symptoms 
generally  attributed  to  concussion  are  due,  not  to  the  concussion  itself,  but  to  contusion 
of  the  brain  or  to  extravasation  of  blood."  In  fact,  all  authorities  now  agree  that  when 
death  follows  a  severe  shaking  or  concussion  of  the  brain,  contusion  or  bruising  of  the 
brain  is  almost  invariably  found. 

How  far  these  views  arc  correct  in  cases  of  concussion  that  are  not  fatal  is  an  open 
question,  but  in  the  few  cases  of  concussion  recorded  in  which  death  has  followed  from 
other  causes  some  injury  to  the  brain  sub.stance  has  always  been  found,  and  in  all 
instances  in  which  a  fatal  result  has  taken  place  from  secondary  inflammation  evidence 
of  some  bruising  of  the  brain  has  been  detected.  A  bruising  of  the  brain,  however,  with 
a  slight  extravasation  of  blood,  may  be  recovered  from  ;  but  when  there  is  extensive  effu- 
sion, compression  of  the  brain  and  death  are  the  usual  result. 

Whf-n  if  /.s  (jincrnllij  accepted  as  true  that  concussion  and  contusion  of  the  brain  are 
practical/^  s^non^mous,  the  principles  of  the  treatment  of  such  injuries  ivill  be  better 
appreciated. 


198  CONCUSSIOX  OF  THE  BRAIN,   AND  ITS  EFFECTS. 

In  the  simjilcsf  form  of  concussion  of  a  healthy  brain  a  slijiht  and  transient  loss  of 
power  and  consciousness  is  the  only  symptom. 

In  the  more  severe  form,  when  a  blow  or  injury  produces  some  severe  shaking  of  the 
cranial  contents,  this  shaking  is  followed  by  a  loss  of  consciousness  more  or  less  complete 
and  a  loss  of  all  power  of  motion  ;  the  skin  of  the  patient  will  be  cold,  the  features  more 
or  less  contracted,  the  pulse  slow  and  intermittent,  and  the  pupils  very  variable:  in  some 
cases  they  will  be  dilated,  in  others  contracted,  while  in  a  third  one  pupil  will  be  dilated 
and  the  other  contracted.  If  the  case  be  neither  one  of  great  severity  nor  complicated 
with  any  grave  injury  to  the  cranial  contents,  after  a  variable  period  the  patient  will 
show  signs  of  movement,  and  may,  perhaps,  move  a  limb  in  an  impatient  and  purposeless 
manner.  If  he  is  spoken  to  in  a  loud  A'oice,  he  Avill  perhaps  show  some  signs  of  return- 
ing consciousness,  either  by  making  some  inarticulate  noise  or  by  merely  opening  his 
eyes,  and  afterward  returning  to  his  stolid  condition.  If  the  case  be  still  carefully 
observed,  the  mode  of  respiration  may  be  seen  to  be  altered,  and  from  being  slow  and 
labored  it  will  be  irregular,  and  perhaps  sighing.  After  a  time,  if  recovery  is  to  take 
place,  other  signs  of  what  are  termed  reaction  will  make  their  appearance.  The  skin  will 
become  warmer  and  more  natural,  the  shrunken  and  contracted  features  will  return  to 
their  normal  condition,  the  pulse  be  more  regular  and  rapid,  and  vomiting  may  occur. 
The  appearance  of  this  symptom  is  generally  of  moment  and  the  first  result  of  a  more 
active  circulation  through  the  cerebral  centres.  As  the  case  proceeds,  if  all  goes  well 
the  patient  rapidly  recovers  and  returns  to  his  natural  condition,  feeling,  perhaps,  some- 
what heavy  and  dull  for  a  few  days,  and  indisposed  for  any  bodily,  and  much  less  for 
mental,  labor.  But  if,  on  the  other  hand,  the  case  goes  wrong,  the  symptoms  may  either 
persist  or  pass  into  those  of  compression,  as  indicated  by  complete  insensibility,  coma, 
and  death,  or  the  symptoms  of  reaction  may  become  excessive  and  run  into  those  of 
inflammation  of  the  brain  or  its  membranes. 

In  this  brief  sketch  of  an  ordinary  example  of  concussion  of  the  brain  the  symptoms 
described  are  of  a  typical  kind,  and  have  been  purposely  dissociated  from  those  of  such 
complications  as  are  liable  to  occur  cither  primarily  or  after  the  period  of  reaction  has 
taken  place. 

Effects  of  Concussion  on  the  Brain. — What  change  of  structure  is  present 
in  such  an  injury  is.  of  cuur.se.  an  open  question.  In  the  simplest  case  the  local  injury 
must  be  slight ;  in  the  more  severe  there  is  every  probability  that  some  bruising  of  the 
brain  has  been  produced  ;  while  in  the  worst  laceration  of  the  brain  and  extravasation  of 
blood  will  probably  have  taken  place. 

In  what  is  called  concussion  of  the  brain  epistaxis  is  very  frequent  and  hemorrhage 
into  the  lids  of  both  eyes  is  not  uncommon,  though  beneath  the  conjunctiva  it  is  very 
rarely  met  with.  Hemorrhage  from  the  ear  directly  after  the  accident  is  occasionally 
seen,  and  I  have  known  it  continue  for  several  hours;  the  extravasation  of  blood  takes 
place  in  all  these  cases  as  a  direct  result  of  the  accident. 

Again,  in  certain  cases,  a  patient,  having  regained  his  consciousness,  relapses  into 
insensibility — relapsing  tincrjuscioui^jios — from  which  he  may  recover  as  perfectly  as  if  no 
relapse  had  taken  place.  It  would  appear  as  if  this  condition  were  produced  by  the  ear- 
liest effects  of  reaction,  the  vessels  yielding  too  freely  to  the  heart's  pulsations  and  thus 
producing  a  plethora  of  the  pai't,  which  induces  a  comatose  or  semi-comatose  condition. 
The  following  case  illustrates  these  points. 

A  boy  tet.  11,  having  received  a  blow  upon  the  head  from  a  falling  piece  of  timber, 
became  perfectly  unconscious  and  quiescent.  He  remained  in  this  state  for  fifteen  min- 
utes, but,  recovering,  he  walked  home,  some  short  distance.  He  soon  began  to  feel  sick 
and  vomited,  the  vomiting  being  attended  with  ejnstaciis.  He  was  then  brought  to  Guy's 
with  a  cold  skin  and  laboring  pulse.  He  was  very  slightly  conscious  and  unable  to 
answer  any  questions,  while  his  limbs  remained  in  the  position  in  which  they  were  placed. 
The  pupils  were  dilated,  but  active.  He  was  left  in  bed  with  the  head  raised  and  a  cold 
lotion  applied  to  it.  Warmth  was  applied  to  the  feet.  He  gradually  recovered,  and  left 
the  hospital  in  ten  days  convalescent. 

The  epistaxis  and  relapsing  unconsciousness  in  this  case,  coming  together  at  the  time 
of  reaction,  point  clearly  to  the  cause. 

Again,  in  children,  reaction  is  not  unfrequently  attended  with  convulsions,  which 
generally,  however,  ]>ass  away  and  leave  no  mark  behind.  Convulsions,  when  they 
appear  in  an  adult,  are  symptoms  of  grave  anxiety,  since  they  almost  always  indicate 
brain  injury  and  forbode  mischief. 

When  reaction  is  excessive,  it  is  attended  with  symptoms  of  fever  and  brain  disturb- 


7:;a'77M  r. I.S.I  v'/o.v  nr  hlood  as  iii:sri/r  of  ('(jycfssioy.  199 

aiit'O,  siuli  :is  tlflirium,  fxcilriiicnt,  and  coma.      Tlw  suhjijct  <tf"  intracranial   iiiHainmation 
will  claim  alti-ntinn  in  amttlicr  pairc. 

Extravasation  of  Blood  as  Result  of  Concussion. 

If  the  liraiu  be  violently  shaken,  hnii.sinLC  of"  it.s  .snh.staiice  ami  more  or  Ics.s  extravasa- 
tiiin  of  hlood  must  ensue 

When  the  iiijurv  is  the  result  of  a  direct  l>lo\v,  the  hruisinir  may  he  hut  local  ;  yet  it 
is  more  usual  to  find  jhe  opposite  side  of  the  hrain  also  hruisetl,  hy  what  is  riirhtly  termed 
"  contre-coup,  "  and.  indeed,  it  very  often  hapitens  that  tin;  mis(diief  t<j  thir  hrain  liy  coiifre- 
aiiif)  is  jjreater  than  that  at  the  seat  of  hlow.  When  the  fall  or  hlow  has  heeii  upon  the 
vortex,  the  base  is  bruised;  when  on  the  occiput,  the  anterior  lobe;  when  on  the  rij^ht 
parietal  rejiion,  tlu;  base  of  the  left  middle  lobe  ;  in  fact,  the  base  of  the  brain  is  almost 
always  the  seat  of  injury. 

The  amount  of  extravasateil  blood  will  depend  upon  the  de^rree  (jf  force  a])pIiod  ; 
but  when  the  ves.sels  are  diseased,  the  hemorrhat^e  may  be  excessive.  When  the  extra- 
vasation of  blood  is  upon  the  surface  of  the  brain,  it  will  be  either  within  the  cavity  of 
the  arachnoid  or  the  meshes  of  the  pia  mater;  and  under  both  circumstances  the  blood 
will  gravitate  to  the  ba.se.  When  the  extrava.satioii  of  blood  takes  place  into  the  struc- 
ture of  the  brain,  it  may  be  found  in  anj*  part  of  the  cerebrum,  cerebellum,  or  pon.s 
N'arolii,  or  oven  in  the  ventricles,  the  extravasation  rarely  showing  itself  in  the  form  of 
one  large  clot,  but  commonly  in  small  and  numerous  spots  of  extrava.sation. 

Results  of  Post-Mortem. — On  referring  to  my  notes  on  this  subject.  I  find,  in 
n  case  of  concussion  wliicli  proved  fatal  sixty  hours  after  the  injury,  that  the  brain  was 
Itruised  all  over  and  blood  eti'used  at  the  injured  spots;  the  fluid  in  the  ventricles  was 
blood-stained,  and  the  ventricles  themselves  ecchymosed.  In  another  ca.se  of  death  from 
<'oncussion,  the  result  of  a  f\\ll,  in  a  man  tet.  31,  in  whom  convulsions  and  coma  super- 
vened on  the  tifteenth  day  after  the  injury,  a  layer  of  blood  was  found  universally  dif- 
fu.sed  over  both  hemispheres,  dipjiiiig  between  the  convolutions  and  passing  downward 
toward  the  base.  The  clot,  which  was  .shreddy,  of  a  dull,  reddish-black  color,  had  evi- 
dently been  efi'used  for  some  days.  The  surface  of  the  brain  beneath  the  seat  of  injury 
was  softened,  and  at  the  base,  where  it  had  been  injured  by  con f re-coup,  similar  changes 
had  taken  place.  The  vessels  were  healthy.  In  a  third  case,  where  deatli  followed  from 
concussion  and  the  vessels  were  diseased,  multiple  extravasations  were  detected  after 
<leath  throughout  the  substance  of  the  brain. 

In  all  these  typical  cases,  illustrating  the  different  effects  of  '•  concussion,"  fatal 
results  took  place  from  changes  brought  about  by  severe  .shaking  of  the  brain  iinassoci- 
ated  with  fracture  ;  but  it  is  to  be  remembered  that  where  a  fracture  is  present,  unless  it 
be  atteiuled  with  depressed  bone,  the  .shaking  of  the  brain,  and  not  the  fracture,  is  the 
main  .source  of  danger. 

From  what  has  been  thus  stated  the  conclusion  nuiy  be  drawn  that  the  tiature  of  the 
accident  is  the  best  guide  to  the  diagnosis  of  contusion  of  the  brain,  and  the  severity  of 
the  symptoms  or  their  persistency  is  doubtless  a  valuable  indication  as  to  its  extent. 
^'  Tonic  spasms  of  the  limbs ;  intense  restlessness,  with  con.stant  rolling  and  tossing  about 
in  bed ;  unconsciousness,  more  or  less  complete ;  drowsiness,  without  any  stertorous 
breathing,  and  in  the  slighter  cases  simply  contraction  of  one  pupil  or  of  one  eyelid ; 
spasmodic  movements  about  some  one  muscle  or  another  of  the  face  or  lips,  giving  rise 
to  a  difficulty  of  pronunciation," — are  by  the  French  surgeons  looked  upon  as  diagnostic 
of  a  contused  brain  ;  and  Mr.  Le  Gros  Clark  lays  stress  upon  the  following:  '-More  or 
less  constant  restlessness,  accompanied  by  spasm,  in  which  some  particular  member  is 
affected  or  amounting  to  general  convulsion.  If  capable  of  giving  expression  to  his  feel- 
ings, the  patient  will  point  to  some  particular  part  of  the  head  as  the  seat  of  pain.  In 
some  instances  noisy  incoherency  and  (d)tuseness  of  intellect  accompany  this  condition 
from  the  first ;"  and  these  symptoms  are  doubtless  enough  to  point  to  brain  injury. 
When  they  a))pear  rapidly  after  the  accident,  tliey  may  be  accepted  as  suggestive  of  a 
bruising  of  the  organ  ;  but  when  they  come  on  a  few  days  later,  they  are  as  likely  to  be 
due  to  .secondary  inflammation  of  the  brain  as  to  contusion. 

The  diagnosis  of  primary  concussion  and  contusion  of  the  brain  is  unnecessary.  The 
symptoms  are  so  intermixed  that  the  real  nature  of  the  lesion  is  not  apparent.  The  signs 
attributed  to  concussion,  such  as  loss  of  consciousness,  collapse,  small,  scarcely  perceptible 
pulse,  and  lowered  temperature,  merely  indicate  that  the  functions  of  the  brain  and  their 
influence  on  the  system  at  large  are  in  a  state  of  abeyance  :  and  it  can  only  be  declared 


200  REMOTE  EFFECTS   OF  HEAD   INJURIES. 

that  the  brain  was  contused  in  the  first  instance  (/'///e  sj/mjjtoms  continue  or  become  aggra- 
vated. 

Seat  of  Injury  indicated  by  Paralysis. — The  seat  of  injur}-  to  the  brain 

may  likewise  often  be  indicated  b}'  some  paraly>is,  partial  or  complete,  of  one  or  more  of 
the  cerebral  nerves.  This  paralysis  may  be  either  a  passing  or  a  permanent  symptom. 
Paralysis  of  the  seventh  pair,  including  the  facial  nerve,  has  been  already  alluded  to  as  a 
somewhat  typical  symptom  of  fracture  through  the  petrous  portion  of  the  temporal  bone. 
This  may  appear  as  an  immediate  result  of  the  injury,  indicating  laceration  of  the  brain 
by  the  fracture,  or,  what  is  more  usual,  at  a  later  date,  when  it  .may  be  the  effect  of 
pressure  by  effused  blood  upon  the  nerve  trunk  in  some  part  of  its  course,  or.  at  still  later 
period,  by  inflammatory  effusion. 

On  referring  to  my  own  notes  of  cases  admitted  into  Guys  Hospital  at  different 
periods  during  the  last  twenty  years.  I  find  examples  of  injur}"  to  the  optic  nerves,  as 
indicated  by  blindness,  paralysis  of  the  muscles  of  the  globe  of  the  eye  as  a  whole,  and 
paralysis  of  the  external  rectus  muscle  alone.  Paralysis  of  the  facial  and  auditory  nerves 
is  very  frequent,  and  at  times  there  is  paralysis  of  the  fifth  nerve,  as  indicated  by  com- 
plete loss  of  sensation  of  the  face,  etc.  Paralysis  of  the  hypoglossal  has  also  been 
observed.  In  "the  majority  of  these  cases  the  symptoms  appeared  as  a  direct  result  of  the 
injury;  in  some  they  came  on  two  or  three  days  later,  associated  with  febrile  symptoms, 
biit  in  most  they  disappeared  in  the  course  of  a  few  weeks.  In  some  instances,  however, 
of  facial  paralj'sis  the  symptoms  were  permanent.  In  all  these  there  must  have  been 
injury  to  the  base  of  the  brain.  "  The  coexistence  of  hemiplegia  on  one  side  with  paral- 
ysis of  the  third  nerve  of  the  opposite  side  is  indicative  of  lesion  of  the  crus  cerebri 
on  the  side  on  which  the  third  nerve  is  paralyzed  "  (Le  Gros  Clark). 

I  had  once  under  my  care  a  man  who  received  a  severe  blow  on  the  left  side  of  the 
head,  above  the  ear.  The  injury  was  followed  by  symptoms  of  concussion,  which  soon 
passed  away  ;  but  he  had  complete  aphasia.  In  the  course  of  a  few  days  he  partially 
recovered  the  ability  to  speak,  but  then  spoke  so  thickly  that  he  was  unintelligible ;  in 
about  three  weeks  he  could  be  understood,  but  he  did  not  recover  his  natural  powers  of 
speech  for  at  least  three  months.  During  the  greater  part  of  this  time  he  was  subject  to 
headache,  which  the  least  exercise  or  excess  in  diet  made  wor.se.  There  can  be  little 
d(»uV>t  that  in  this  case  the  base  of  the  middle  lobe  of  the  right  side  had  been  contused. 
Mr.  Callender'  tells  us  "  that  symptoms  of  aphasia  are  more  apt  to  follow  injury  of  a  part 
of  the  left  hemisphere  outside  the  corpus  striatum  than  any  other  part,  that  injuries  to 
the  right  hemisphere  are  more  rapidly  fatal  than  are  equal  injuries  to  the  left,  and  that 
the  right-side  brain  lesions  are  more  often  as.sociated  with  convulsions  than  are  similar 
hurts  at  the  opposite  side."     The  evidence  of  these  opinions  is  not  strong. 

Remote  Effects  of  Head  Injuries. 

There  are.  however,  many  injuries  to  the  head  which,  without  producing  such  definite 
symptoms  as  have  been  described  as  the  result  of  concussion,  etc..  yet  cause  .serious  and 
often  permanent  damage  to  the  patient. 

The  effects  of  a  blow  on  the  head  are  by  no  means  to  be  determined  by  the  immediate 
symptoms  that  result,  for  a  person  may  receive  a  trifling  or  severe  injury,  from  which  he 
is  supposed  to  have  completely  recovered,  and  yet  the  case  may  end  in  a  permanent  enfee- 
blement  of  the  mental  powers  or  be  followed  by  paroxysms  of  uncontrollable  excitement. 
It  behoves  the  surgeon,  therefore,  to  be  mo.st  cautious  in  giving  an  opinion  as  to  the 
issue  of  a  case  of  injury  to  the  head. 

Insanity. — The  records  of  lunatic  asylums  and  convict  prisons  prove  unhappily, 
that  many  cases  of  apparently  trivial  injury  to  the  head,  unaccompanied  by  .symptoms 
which  would  indicate  any  positive  affection,  such  as  concussion,  paralysis,  etc..  have  ended 
in  an  affection  of  the  brain  which  has  rendered  the  patient  hopelessly  demented  or  a 
criminal,  and.  moreover,  has  left  no  visible  traces  of  the  malady  in  the  brain  after  death. 
The  following  may  suffice  as  illu.strations : 

A  boy  aet.  16  fell  from  a  tree  and  was  found  partly  insensible.  After  a  few  days' 
treatment  he  was  dismissed  from  the  hospital  as  •'  cured."  In  a  few  months  he  was 
obliged  to  be  placed  in  a  lunatic  asylum,  where  he  remained  several  years. 

A  gentleman  put  his  head  out  of  the  window  of  a  carriage  while  travelling  by  rail- 
way, and  received  a  scalp  wound  from   striking  against  a  post.      He  was  rendered  insensi- 

^Brit.  Med.  Jour.,  June  6,  1874. 


i\.iri!i/:s  or  rur:  /.•//. i/.v  <(imi-li<-  \risi;  FiiAcrriu-:.  -joi 

l)I('  at  tlic  liiiif,  liiit  smiii  iiii|ini\  ('(1.  Tin  re  were  no  si<:iis  of  iiii|i(iihiiic(',  vt  in  a  l"<'\v 
WCi'ks  ho  was  in  a  state  ot'  inc-ntal  ulirrratiori,  aiitl  ilit-cl  in  a  year. 

A  man  was  kicki'tl  l»y  a  liorse  in  tlie  stomach  ami  fell,  strikin<r  his  head  on  the  stahh; 
floor,  l)iit  had  no  ccrchral  symptoms.  Iti  :i  I'rw  weeks  he  jrot  ileliiioiis  and  conlnsed  in 
mind,  and   heeame   in   lime  liopehissly  insane. 

Such  instances  mij;ht  he  mnltiplied  endlessly,  all  |»ointin<r  to  the  .supreme  importance? 
of  injuries  to  the  head,  however  slij^ht  the  immediate  symptoms.  The  reader  may  fitid 
tliis  suhject  well  discussed  and  illustrated  hy  Dr.  J.  ('.  Browne  in  the  first  volume  of  the 
Wist  lildliKf  Asi//iii)t  I^rpnrfs,  in  Abercroinliie's  works,  Dr.  Azane,  Arcltlrfs  (Inifi-dlm  tie 
Mhhciiir,  Kehruary,  IMHl,  and  ehsewhere. 

It  may  be  laid  down  as  a  jtrinciple  that  jiersons  with  any  hereditary  predisposition  to 
insanity  or  nervous  di.sease  are  more  liable  to  sufi'er  from  cranial  injuries  than  others.  The 
temperate  have  a  better  chance  of  esca|)e  than  those  addicted  to  excesses  of  any  .sort. 

INJURIES  OF  THE  BRAIN  AND  ITS  MEMBRANES  COMPLI- 
CATING FRACTURE. 

When  the  student  has  recognized  the  fact  that  a  blow  upon  the  head  //"/  comjilicated 
with  fracture  is  capable  of  producing,  by  "concussion  of  the  brain,'  injuries  such  as 
have  been  sketched  in  the  previous  pages,  he  will  be  quite  ready  to  understand  that  a 
blow  upon  the  head  complicated  with  fracture  is  likely  to  be  followed  by  results  that  are 
at  least  equally  severe,  since  the  force  required  to  produce  a  fracture  of  the  skull  is,  as  a 
rule,  either  more  violent  or  more  concentrated  than  that  required  to  produce  what  has 
been  described  as  a  concussion  of  the  brain.  There  are,  moreover,  complications  which 
are  frequently  associated  with  or  peculiar  to  fracture,  such  as  depression  of  bone  with  or 
without  compression  of  the  brain  ;  extravasation  of  blood  external  to  the  dura  mater 
from  rupture  of  a  blood  vessel,  .such  as  the  middle  meningeal  artery  or  venous  sinus; 
injury  to  the  dura  mater  or  membranes;  and  direct  injury  to  the  brain.  He  must  also 
be  aware  of  the  fact  that  a  fracture  of  the  skull  may  take  place  without  producing  any 
cerebral  disturbance  ;  for  example  : 

A  man  aet.  '11  received  a  blow  over  tlie  vertex  from  a  broken  sword.  An  exten.sive 
scalp  wound  was  the  result,  and  a  very  evident  incised  wound  in  the  upper  portion  of  the 
frontal  bone,  apparently  involving  only  the  external  table.  It  was  not  complicated  with 
the  slightest  cerebral  disturbance,  and  good  recovery  followed. 

A  boy  received  a  compound  fracture  over  the  frontal  region  from  the  kick  of  a  horse; 
he  had  no  head  symptoms  whatever,  and  he  recovered. 

In  the  former  case  there  was  an  incised  wound  of  the  skull,  and  in  the  latter  an  unde- 
pressed compound  fracture.  In  neither  was  the  brain  materially  shaken,  bruised,  or  other- 
wise injured,  and  in  both  a  good  recovery  ensued.  Cases  such  as  these,  however,  are 
comparatively  rare,  the  more  frequent  being  examples  of  fractured  skull  associated  with 
brain  symptoms  similar  to  those  which  have  been  described  under  the  head  of  .simple  con- 
cussion— cases  in  which  the  functions  of  the  brain  are  for  a  time  more  or  less  interfered 
with  or  suspended,  but  which  have  a  tendency  gradually  to  return  to  their  normal  condi- 
tion ;  in  which  the  injury  to  the  skull  has  been  severe  enough  to  break  the  bone  and  gen- 
eral enough  to  shake  the  brain  and  cause  a  suspension  of  its  functions.  The  importance 
of  these,  however,  lies  in  the  injury  the  brain  has  sustained,  and  not  upon  the  fracture, 
the  fracture  being  only  a  complication  ;  and,  so  long  as  there  is  no  depressed  bone  irritat- 
ing and  compressing  the  brain,  the  danger  is  in  no  way  increased.  If,  however,  in  any 
given  instance,  the  injury  is  complicated  with  laceration  of  one  of  the  large  arteries  of  the 
bone,  such  as  the  middle  meningeal  artery  or  large  venous  sinus,  other  conditions  may 
arise  which  produce  special  symptoms. 

Fractures  of  the  Skull  associated  "with  Extravasation  of  Blood 

BETWEEN   the   DuRA   MaTER   AND   THE   BoNE. 

As  a  result  of  an  injury  to  the  .skull,  whether  with  or  without  a  fracture,  small  extra- 
vasations of  blood  between  the  dura  mater  and  the  bone  are  not  unfrecjuent,  and  are  due  to 
the  rupture  of  some  of  the  small  vessels  which  pass  from  the  dura  mater  to  the  bone. 
They  give  rise  to  no  symptoms  by  which  they  can  be  recognized,  and  usually  are  only 
discovered  after  death. 

When  any  large  extravasation  occurs,  tlie  blood  comes,  as  a  rule,  from  either  the  trunk 
or  one  of  the  branches  of  the  middle  meningeal  artery,  which  runs  upward  in  a  groove 


202 


IS  JURIES  OF  THE  BRAIN  COMPLICATING   FRACTURE. 


Fig. 


of  the  anterior  inferior  angle  of  tlie  parietal  l)one  and  divides  to  sui)ply  the  lateral  parts 
of  the  base  and  vault  of  the  cranium,  or  it  may  come  from  a  venous  sinu.s.  A  fissure, 
therefore,  of  a  bone  involving  any  of  these  parts  may  lacerate  one  of  these  vessels  and 
give  rise  to  a  hemorrhage  sufficiently  copious  to  produce  symptoms  of  compression  of  the 
brain. 

It  is  well  to  know,  however,  that  the  brain  will  sustain  a  great  deal  of  pressure  with- 
out giving  rise  to  any  sj'mptoms,  and  that  several  ounces  of  effused  blood  rapidly  poured 
out  are  required  to  produce  sucfi  symptoms  as  ai'e  recognizable. 

The  following  is  an  excellent  case  to  illustrate  the  accident : 

Case.^A  man  aet.  49,  when  riding  in  a  gig,  was  thrown  out  upon  his  head.  The 
accident  produced  a  scalp  wound  over  the  h-ft  side  of  the  vertex  and  some  slight  insensi- 
bility. He  got  up  and  walked  for  half  an  hour,  when  he  became  confused,  staggered,  and 
went  into  a  shop,  being  supposed  by  the  shopkeeper  to  be  intoxicated;  but,  as  he  gradu- 
ally became  quite  insensible,  he  was  brought  to  Guy's.  When  admitted,  he  was  perfectly 
unconscious  and  comatose,  with  dilated  pupils,  laboring 
pulse,  and  slow  respiration.  Soon  afterward  he  became 
convulsed,  the  r?///;/  arm  being  more  affected  than  any 
other  part;  in  a  few  hours  it  was  completely  paralyzed. 
He  remained  in  this  condition  for  two  days,  and  died 
comatose.  After  death,  upon  removing  the  calvaria, 
which  was  fissured  in  a  vertical  direction  from  the  mid- 
dle of  the  left  parietal  bone  to  the  jugular  foramen,  a 
large  clot  of  blood  was  seen  lying  upon  the  dura  mater, 
clearly  proceeding  from  the  middle  meningeal  artery. 
This  was  about  two  and  a  half  inches  in  diameter  and 
moi'e  than  an  inch  in  thickness.  It  formed  a  glohuhir 
tumor  and  caused  an  extensive  depression  upon  the  left 
cerebral  hemisphere,  which  pressed  the  longitudinal 
fissure  to  the  right  side.     The  brain  itself  was  healthy. 

Prep.  1606'"'  in  Guy's  Hosp.  Mus.  shows  the  condition.   Drawing  showing  clot  (ft)  external  to  the 

In  Fio-s    77  and  78  these  iioints  avp  wpII  s.^ph  ^'""'^   Mater  (c,  from   Laceration   of  the 

in  rigs,    i  i   duu   lo  luese  p(juus  die  \\eu  seen.  ^  Middle  Meningeal  Artery  (»)  following  a 

Such  a  case  may  fairly  be  accepted  as  a  typical  Fracture.  (Drawing  su^",  uuy's  Hosp. 
example  of  this  form  of  injury,  and  special   attention 

should  be  paid  to  the  fiict  that  the  man  recovered  from  the  immediate  effects  or  shock 
of  the  accident,  remained  sensible  for  a  definite  period,  and  then  gradually  became  uncon- 
scious. In  compression  from  hemorrhage  this  "interval  of  time" — provided  it  be  a  short 
time — between  the  accident  and  the  occurrence  of  the  symptoms  is  most  important  from 
a  diagnostic  point  of  view.  It  is  very  commonly,  although  not  constantly,  present ;  but 
when  present,  it  is  characteristic  of  hemorrhage  in  some  form.  The  symptoms,  to  be 
those  of  compres.sion,  must  also  be  lasting ;  nor  must  they  be  mistaken  for  the  "  relaps- 
ing unconsciousness"  of  a  shaken  brain,  to  which  attention  has  been  already  directed.  The 
persistency  of  the  symptoms  is  consequently  a  valuable  diagnostic  symptom. 

But,  it  may  be  asked,  how  is  extravasation  of  blood  outside  the  dura  mater  the  result 
of  a  lacerated  meningeal  artery  to  be  diagnosed  from  extravasation  of  blood  either  within 
the  cavity  of  the  arachnoid  or  upon  the  surface  of  the  brain,  or  within  the  brain  itself? 
For  under  all  these  varied  circumstances  the  symptoms  may  appear  some  time  after  the 
accident,  and  the  inference  drawn  from  the  "  interval  of  time"  is  the  same  in  each; 
under  all  the  symptoms  of  compression  will  be  identical,  for  they  will  be  those  of  apoplexy, 
and,  as  in  apoplexy,  varying  in  each  case  ;  for  '•  when  extravasation  takes  place  on  the 
surface  or  within  the  substance  of  the  brain,  it  is  accompanied — and,  indeed,  produced — 
by  lesion  of  the  cerebral  texture,  which  lesion  is  mostly  indicated  by  paralysis,  by  irritation 
and  spasmodic  action  affecting  some  particular  part,  by  derangement  of  the  pupils,  or  by 
other  symptoms"  (Cock).  The  surgeon's  best  guide,  however,  in  forming  his  diagno.sis 
will  always  be  the  history  of  the  case  and  the  nature  of  the  accident. 

In  uncomplicated  cases  of  hemorrhage  exteryial  to  the  dura  mater  the  injury  is  gene- 
rally a  local  one,  produced  by  a  sharp  blow  or  fall ;  the  brain,  as  a  whole,  is  not  .shaken 
or  injui'ed;  the  symptoms  of  compression  are,  moreover,  generally  very  marked  and 
rapidly  produced,  and  the  paralysis  of  half  the  body  is  also  commonly  complete. 

In  cases  of  hemorrhage  itito  the  arachnoid'  cavihf  or  ripon  the  surface  of  the  hrain  the 
injury  is  mostly  of  a  general  character,  such  as  a  fall  from  a  height  or  a  blow  from  a 
iieavy  weight,  the  whole  brain  having  been  violently  shaken  or  "  concussed,"  and,  as  a 
result,  its  delicate  structure — more  particularly  that  of  the  base — has  been  bruised  or 


n.KMOlirJIAdl'.    ISTO    IIIIMX. 


203 


Dura,  mater. 


hiceratod,  weak  nr  iliscasi'd  vessels  Ix'in;^  very  apt  tu  f^ive  way,  producinjr  lieiaorrhage. 
lieiiinrrhage  external  tu  the  dura  mater  may.  it  is  true.  In;  present  in  tliese  cases  of 
jreiieral  injury,  Imt  it  will  l»e  enmjdieated  with  extravasation  into  deep<.'r  parts;  and  thi.s 
point  of  diajrnosis  is  all-important,  since  in  the  former  class  of  cax-s,  when  the  hlood  \a 
between  the  hone  ami  dura  mater,  surjrical  treat- 
ment may  he  of  itiestimahle  value,  wliilst  in  the 
latter  it  can  he  of  no  service. 

llemi>rrhaire  Upnn  tlir  siir/drr  >>/'  tin-  Innln  is 
a  very  important  siihject,  occurriuL'  in  variable 
detrrees  in  every  case  of  severe  or  jreneral  in- 
jury to  the  skull,  whether  complicated  or  not 
with  fracture  ;  the  hrain'itself  may  be  not  only 
brui.sed  at  the  .seat  of  injury,  but  it  will  be 
etjually.  if  not  more,  injured  at  the  opposite 
pitint  bv  coiifff'-roii/i.  and  this  Ijruisintr  and  ex- 
travasation is  irenerally  found  at  the  base  of  the 
brain.  The  hen»orrha<re  associated  with  this 
bruising  may  l)e  so  slight  as  to  give  rise  to  no 
symptitms  and  recovery  may  take  place,  or  it 
may  be  .so  great  as  to  induce  symptoms  of  com- 
pression. But  when  a  larL:e  vessel  of  the  pia 
mater  is  ruptureil.  the  bleeding  will  Vje  severe; 
and  under  these  circumstances  the  Vjlood  may 
spread  into  all  the  parts  down  to  the  base,  cov- 
ering in  the  cerebellum  and  spinal  cord. 

It  is  this  fact  that  renders  all  cases  of  geu- 
ei'ff I  iiijiin/  to  the  brain  so  serious  and  tells  so  *.».vv„i««^.  Blood  dot. 

powerfully   again.st   any   operative  interference  Transverse  section  of  skull  with  frauiai  "rontents. 

in  such  a  class  of   cases,  the  surgeon  beintr  quite       s^liowing   Fractured   Skull,  Kupture   »(    Mfnlngeal 

,  ,  ,        ,  n  '•  1  Arterv.  a  f'lot  of   Blood  outside  I»ura  Mater,  and 

unable   to   reacll    the    source    or    COmpre.SSlon    by       Compiessed  Brain,  d-rom  Prep,  (iuy's  Hosp.  Mus., 
tr.<>i.1i!i<iiirr  lo9;'/''.)  "A  life  lost  that  perchance  might  have  been 

trephining.  .         ^     ,  ,        .,      saved' (Good  ham.  ^ 

Iletnorrhage  nifo  th'  cnvity  of  the  ara'linoiti 
is  ])y  no  means  a  common  consequence  of  head  injury,  but  it  may  occur  as  a  result 
either  of  a  local  or  direct  or  of  a  diffused  injury  to  the  skull,  and  the  effused  blood 
may  be  poured  out  upon  one  or  both  sides  of  the  cerebrum.  When  the  effusion  is  gradual 
and  not  extensive,  no  definite  symptoms  of  compression  will  be  produced  :  but  when  exten- 
sive, although  symptoms  of  compression  may  appear,  there  will  be  nothing  to  indicate  the 
precise  position  of  the  hemorrhage. 

In  patients  who  have  albuminaria  or  diseased  arteries  there  is  reason  to  think  that  a 
slight  injury  to  the  head  may  cause  extravasation  of  blood  into  the  arachnoid,  and  this 
fact  has  an  important  practical  bearing,  furnishing  a  key  to  the  .solution  of  many  a 
doubtful  ease  of  head  injury. 

Pathology  has  taught  us  that  blood  clot  may  organize  and  form  what  are  now  known 
as  arachnoid  cysts,  having  smooth  external  surfaces  like  a  .serous  membrane,  which  when 
recent  will  be  .soft  and  pulpy,  when  old  fibrous.  They  may  contain  only  serous  fluid 
more  or  less  blood-stained,  or  clots  of  blood  altered  by  time.  Sometimes  the.se  cysts  are 
found  to  be  loo.se  in  the  arachnoid  cavity  ;  at  others,  fixed  to  the  parietal  arachnoid. 
They  are  usually  found  ncddenfdllt/  after  death  in  those  who  have  suffered  from  mental 
disorder  or  general  paralysis,  and,  although  more  commonly  they  exist  on  one  side  of 
the  head  only,  they  are  .sometimes  found  on  both. 

Dr.  Crichton  Browne  (Journal  of  I\i/c]iolo(i>cal  Mprliciiv,  December,  1875)  telLs  us 
thit  out  of  1240  post-mortem  examinations  made  at  the  West  Riding  A.sylum  there  were 
51)  examples  of  arachnoid  cysts — 48  occurred  in  males.  16  in  females — and  the  majority 
were  in  the  left  side.  In  half  the  cases  general  paraly.sis  was  the  cause  of  death.  Dr. 
Browne  does  not  think  that  these  cysts  have  a  traumatic  origin,  but  are  due  to  the  rup- 
ture of  a  vessel  from  cerebral  hyperajmia. 

To  Sir  Prescott  Hewett  ( Med.-C/ii'r.  Tmns..  vol.  xxviii.)  must  be  assigned  the  credit 
of  explaining  how  these  cysts  are  formed  from  a  chronic  change  in  previously  effused 
blood.  For  a  full  elucidation  of  the  subject,  however,  we  are  indebted  to  Drs.  Wilks, 
Ogle.  Bacon,  and  Sutherland  (^Journal  of  Mental  Science,  vols.  x.  and  xi.  ;  Bep.  ^yest 
Riding  Aai/htm.  vol.  i.). 


204  COMPRESSION  OF  THE  BRAIN. 

COMPRESSION  OF   THE  BRAIN. 

The  brain  may  be  compressed  in  many  ways,  though  there  are  four  special  causes  of 
compression  :  Compression  from  "  depressed  bone."  the  resuh  of  fracture,  simple  or  com- 
pound ;  compression  from  the  '-extravasation  of  blood"  into  any  part  of  the  cranium; 
compression  from  the  ^^  formation  of  matter''  between  the  dura  mater  and  the  bone;  and 
compression  from  the  "effusion  of  injiammatori/  protfucfs'  into  the  brain  or  its  membranes. 

The  .symptoms  of  compression'  under  all  these  different  circumstances  are  much  alike, 
although  the  clinical  history  of  the  cases  and  the  date  of  the  appearance  of  the  symptoms 
after  the  injury  vary  in  each  class.  When  the  symptoms  are  due  to  depressed  bone,  they 
follow  immediately  the  accident.  When  caused  b}"  extravasation  of  blood,  there  is  almost 
always  some  interval  of  time  between  the  accident  and  the  accession  of  the  symptoms, 
although  that  interval  may  be  but  short.  When  caused  by  the  effusion  of  inflammatory 
products  into  or  on  the  brain,  the  symptoms  generally  appear  some  days  after  the  acci- 
dent and  are  gradttal :  and  when  the  result  of  the  formation  of  matter  between  the  dura 
mater  and  the  bone,  the  symptoms  rarely  show  them.?elves  for  two  or  three  weeks  after 
the  accident.  In  both  of  the  latter  classes  of  cases,  morepver,  headache  and  other  inflam- 
matory symptoms  coexist. 

The  si/mpfoma  of  comjrrension  of  the  brain  are  those  of  apoplexy,  and  their  severity 
depends  entirely  upon  the  suddenness  and  amount  of  the  compression.  The  skull  may 
be  fractured  and  the  bone  depressed,  and  still  no  symptoms  arise.  Extravasation  of  blood 
may  also  take  place  to  a  limited  degree  within  the  skull  and  not  be  recognized.  There  is 
good  reason  to  believe,  indeed,  that  a  considerable  amount  of  blood  may  be  poured  out 
sloxdy  upon  the  surface  of  the  brain  without  giving  rise  to  compression,  the  brain  gradu- 
ally accommodating  itself  to  the  pressure.  The  most  marked  cases  of  compression  are 
usually  due  to  rapid  extrava.sation.  When  the  bones  are  much  depressed,  or  when  the 
brain  is  saddeidj/  compressed  by  the  local  effusion  of  blood,  symptoms  show  themselves, 
such  as  complete  insensibility,  slow.  diflBcult.  and  perhaps  stertorous,  respiration,  and  a 
full,  slow,  laboring  pulse.  In  very  severe  cases  the  respiration  will  be  of  a  peculiar 
p^iffing  character.  There  may  also  be  complete  loss  of  the  power  of  swallowing,  inability 
to  retain  feces,  and  retention  of  urine,  incontinence  or  overflow  of  urine  being  the  last 
symptom.  The  pupils  may  be  either  dilated  or  contracted,  but  they  will  be  always  fixed, 
and  will  not  respond  to  light  :  whereas  in  alcoholic  coma.  Dr.  ^lacf^wen  tells  us.  •*  the 
pupil  is  contracted  when  the  person  is  left  undisturbed,  and  it  is  dilated  when  an  attempt 
is  made  to  rouse  him  "  (  GJnu'ion:  Jonrvol.  January.  1879). 

When  the  brain  is  widely  and  uniformly  compressed,  the  symptoms  are  ''  general  " — 
i.  e.,  one  side  is  not  more  paralyzed  than  the  other.  When  the  compres.sion  is  localized.^ 
the  paralysis  is  partial  and  corresponds  with  the  region  affected,  though  when  extravasa- 
tion is  extensive  the  general  effect  may  mask  the  local  symptoms.  The  best  examples  of 
this  form  of  limited  compression  are  found  in  cases  of  fracture  of  the  skull  from  a  local 
injury  and  extravasation  of  blood  between  the  bone  and  the  dura  mater.  The  case 
quoted  on  page  202  is  a  good  one  in  point,  though  the  following  is  probabl\-  a  better, 
as  it  is  complete  : 

J.  P ,  aet.  46,  a  painter,  having  fallen  from  a  height  upon  his  head  on  a  piece  of 

iron,  received  a  severe  scalp  wound  on  the  right  side  of  the  median  line  of  the  head,  with 
slight  concussion.  He  was  admitted  into  Guy's  under  Mr.  Cock's  care  in  1841,  con- 
scious, and  remained  so  for  eleven  hours ;  four  hours  later,  however,  he  was  found  in  a 
state  of  utter  unconsciousness,  with  stertorous  breathing  and  insensible  pupils.  He  con- 
tinned  gradually  to  get  worse.  The  left  arm  and  leg  when  pinched  were  readily  retracted. 
The  right  side  was  completely  paralyzed.  No  fracture  could  be  discovered.  Trephining 
was  performed  above  and  behind  the  anterior  inferior  angle  of  the  left  parietal  bone  over 
the  trunk  of  the  middle  meningeal  artery  ;  a  large  piece  of  bone  was  removed.  A  gush 
of  blood  then  took  place,  and  a  large  coagulum  was  removed  from  outside  the  dura  mater. 
The  deep  stertor  at  once  ceased,  and  the  next  day  the  man  moved  his  right  arm  and  leg 
freely  and  recognized  his  wife.  He  progressed  favorably  after  the  operation,  though 
recovery  was  retarded  by  bone  exfoliation.  He  resumed  his  work  and  occupation,  and 
continued  in  good  health  for  thirteen  years.  During  this  period,  however,  he  had  at  inter- 
vals exfoliation  of  some  portion  of  the  skull  at  the  seat  of  injury  ;  in  the  ninth  year  he 
had  fits,  which  during  the  last  six  years  of  his  life  recurred  at  intervals,  the  attacks,  as 
Mr.  Cock  reported,  becoming  gradually  more  frequent  and  severe  in  their  character.  Six 
months  before  his  death  he  had  paralysis  of  the  opposite  side  of  the  body  to  that  of  the 
injury  ;  the  face  was  included  in  the  paralysis,  and  his  speech  was  somewhat  affected. 


COMI'liKSSloX   OF   Tllh:   HUMS.  205 

lie  (lioil  af'tor  II  severe  miopleetir  lit.  Alter  dcatli  tin-  ))raiii  )»ftii;atli  the  iiijiireil  l)i»ne 
was  foiiml  snf'teiuMl  and  aillien-iil  tu  tlw  nkull,  ami  it  cuiitaiiM'd  a  recent  clot  of  thniti  or 
four  ounces  ttf  hlooil,  which  liMcil  tlic  ventricles.  •  it  appeared  prohahle,"  ways  Dr.  Wilks, 
who  math'  the  c.\aniination.  "that  a  softeiiin^^  had  hecn  ;;oinjr  on  for  .some  months  in  the 
middle  lii-niispherc  of  the  hrain,  involvinj;  tiic  contij;uous  surfaces  of  the  corpus  striatum 
and  thalamus,  and  that  at  last  a  rupture  ^^'  the  V(!S.sel  had  taken  place,  intiltratinj:  all 
these  disi-ased  structures,  as  well  as  the  ventricles."  The  trephine  opening:  was  tilled  in 
liV  a  touirh  niemhrane,  and  around  its  inarL'ins  then,'  was  evidenci!  that  cousiderahle  ostitis 
liad  taken  place  (Cock,  (lui/'s  J/osji.  liijunts,  \s7u  ). 

When  a  patient  receives  a  direct  hlow  u|>nn  oni-  siile  of  the  head,  causing;  a  fracture 
with  depression  of  the  hone,  and  attende(l  with  |)aralysis  of  the  opposite  side  of  the  hody 
and  a  tixt-d  and  dilated  pupil  on  the  side  of  the  injury,  the  conclusion  is  int.-vitahle  that 
the  depres.sed  hone  is  the  cau.se  of  the  paralysis  hy  producin;.'  ])ressnre  upon  the  hrain  : 
the  dejircssion  must,  however,  he  very  •j;reat  to  f::ive.rise  to  sucdi  symptoms. 

When  a  patient  sustains  a  similar  injury,  with  or  without  depression  of  the  hone,  hut 
followed  after  a  distinct  interval  of  time  hy  paralysis  of  one  side  of  the  hody,  whether  of 
the  injured  side  or  not,  it  is  (juite  fair  to  assunu-  that  hemorrluifre  has  taken  place  inside 
the  skull  and  is  the  cause  of  the  compression. 

In  both  these  ca.ses  a  local  injury  is  followed  hy  local  mischief,  causinir  a  local  paral- 
ysis ;  consequently,  surjiical  treatment  is  of  i.rreat  promi.se. 

When  a  patient  receives  a  <^encral  injury  to  the  head — such  as  commonly  results  from 
a  fall  ui)on  tlic  head  from  a  height  or  a  diffu.sed  hlow  from  a  heavy  falling  body — and  this 
is  followed  directly  or  after  an  interval  of  time  by  symjitoms  of  compression,  whetlier 
a.ssociated  or  not  with  a  fracture,  the  paralysis  is,  as  a  rule,  ireiieral  ;  and  even  if  more 
complete  on  one  side  than  another,  the  injury  to  the  brain  is,  for  the  most  part,  too  dif- 
fused or  extensive  to  admit  of  surgical  relief.  The  case  is  clearly  of  a  mixed  nature, 
contusion  or  laceration   of  brain   structure  being  a.ssociated   with  hemorrhage. 

Symptoms  of  Brain  Injury. — When  a  patient  suffering  from  brain  shock,  with 
or  without  a  fracture,  is  unconscious,  motionless,  and  perhaps  pulseless,  has  lost  control 
over  the  action  of  the  bowels  and  the  bladder,  and  has  a  feeble  respiration  and  paralyzed 
pupils,  it  is  impossible  for  the  surgeon  to  form  any  opinion  as  to  the  nature  of  the  cere- 
bral injury.  These  symptoms  may  be  the  result  of  so-called  concussion,  from  which 
recovery  may  take  place,  and  not  of  severe  brain  contusion  ;  they  may  be  associated 
with  bruising  of  the  brain  and  extravasation  of  blood — not  sufficient,  perhaps,  to  cause 
fatal  compression  of  the  brain  structure,  but  enough  to  set  up  cerebral  symptoms,  which 
cannot  pass  away  for  many  months  under  the  most  favorable  conditions  ;  or  they  may  be 
accompanied  by  severe  brain  laceration  or  extravasation  of  blood  upon  or  into  its  struc- 
ture, which  wiil  prove  fatal  by  coma.  The  position  of  the  extravasation  has  no  influence 
on  the  symptoms,  although  it  would  appear  that  death  is  very  rapid  when  it  takes  place 
into  the  ventricles.  The  primary  symptoms  of  severe  concussion  and  of  general  com- 
pression are  identical,  and  are  often  not  to  be  distinguished ;  both  may  be  the  result  of 
the  same  kind  of  accident.  '■  But,"  says  P,  Hewett,  "  there  is  this  marked  difference : 
in  concussion  the  effects  are  instantaneous,  and  in  compression  from  extravasated  blood 
some  little — it  may  be  very  short — time  elapses  before  the  symptoms  manifest  them- 
selves. In  the  former,  also,  the  symptoms  gradually  pass  off,  but  in  the  latter  they 
become  more  and  more  marked." 

'•  The  symptoms  of  concussion  may  be  continued  or  renewed  either  by  extravasation 
of  blood,  pus,  or  both"  (John  Hunter,  MS.,  1787). 

''  The  diagnostic  .signs  of  concussion  and  compression  are,  no  doubt,  distinct  in  a  certain 
sense,  yet  compression  rarely  exists  as  a  consequence  of  violence  without  concussion,  and 
both  are  complicated  with  shock.  Further,  symptoms  of  simple  concussion  may  become 
developed  at  a  later  period  into  those  which  indicate  some  more  serious  le.sion  ;  and  it  is 
in  exceptional  cases  only  that  we  can  identify  with  any  degree  of  certainty  the  efficient 
and  sole  cause  of  compression.  Thus,  in  the  stunning  effects  which  succeed  a  blow  on 
the  head,  if  we  can  rouse  a  patient  from  his  state  of  unconsciousness,  even  for  a  few 
moments,  if  the  breathing  is  calm  and  noiseless,  if  the  pulse  is  feeble,  the  pupils  are 
contracted,  and  reflex  action  can  be  excited,  we  conclude  that  the  condition  is  one  of 
concussion.  The  intensity  of  the  effects  of  so-called  concussions  are  marked  by  the 
character  of  the  symptoms  and  by  their  duration.  The  probable  explanation  of  pro- 
tracted somnolence  and  other  evidences  of  brain  disturbance  is  the  presence  of  diffused 
extravasation  of  blood  over  the  surfiice  of  the  hemispheres  "   (F.  Le  Gros  Clark). 

Hemorrhage  into  Brain  with  Fracture. — Again,  in  a  general  shaking  of 


206 


WOUNDS  OF  THE  BRAIN. 


the  brain,  blood  may  be  extrava.sated  into  the  brain  itself;  and  when  the  injury  has  been 
sufficient  to  produce  fracture,  there  is  no  limit  to  the  amount  of  hemorrhage  or  its  seat. 
"  But  in  dealing  with  such  cases  great  caution  is  necessary  in  order  to  avoid,  if  possible, 
mixing  up  cases  of  apoplexy  with  those  of  traumatic  effusions.  An  accident  coexisting 
with  an  extravasation  of  blood  into  the  cerebral  substance  does  not  necessarily  imply 
cause  and  effect.  The  previous  condition  of  the  brain  or  the  outpouring  of  blood  from 
diseased  vessels  may,  in  fact,  have  been  the  cause  of  the  accident"  (Hewett). 

On  referring  to  my  notes,  I  see  that  in  a  case  of  brain  injury  which  lived  only  one 
hour  blood  was  found  filling  the  ventricles.  In  another  the  ventricles  were  bruised  and 
the  septum  lucidum  lacerated.  In  other  cases  blood  was  poured  out  into  the  thalamus 
opticus  or  into  the  corpus  striatum. 

In  all  these  the  brain  had  been  severely  shaken,  the  hemorrhage  being  doubtless  the 
result  of  the  shake  and  the  cause  of  death,  while  the  fracture  of  the  skull  was  merely  a 
complication. 

General  Summary. — It  has  been  already  shown  that  concussion  of  the  brain  too 
often  implies  contusion  or  laceration  of  its  structure,  with  extravasation  of  blood,  and -in 
the  same  way  compression  indicates  as  severe,  if  not  more  severe,  injury.  Concussion 
does  not  by  itself  produce  definite  symptoms ;  and  when  paralysis,  vertigo,  sickness,  or 
other  such  phenomena,  arise,  the  inference  is  that  there  is  some  structural  damage  to  the 
brain.  Compression  implies  a  more  severe  degree  of  the  same  sort  of  injury,  with  effu- 
sion of  blood  or  depression  of  bone.  Compression  of  the  brain,  when  not  excessive,  is 
seldom  the  durct  cause  of  death.  It  proves  fatal  in  the  majority  of  cases  by  being  the 
starting-point  of  an  intracranial  inflammation,  since  it  has  been  proved  that  blood  can  be 
absorbed  or  encysted  and  depressed  bone  may  be  gradually  raised  by  the  brain  itself,  or 
the  brain  may  accommodate  itself  to  the  pressure. 

Compression  of  the  brain  as  a'  result  of  traumatic  encephalitis  will  receive  attention 
in  a  subsequent  page. 

Wounds  of  the  Brain. 

In  some  injuries  to  the  skull  the  brain  may  be  wounded  or  lacerated,  and  brain  matter 
may  even  escape  from  the  wound  directly  after  the  accident.  Such  accidents  are  always 
of  a  very  grave  nature,  and,  as  a  rule,  fatal.  Wounds  of  the  anterior  and  upper  portions 
of  the  hemispheres  are  the  least  dangerous ;  wounds  of  the  posterior  hemisphere  or  base 
of  the  brain,  the  most  so.  Recovery  may,  however,  at  times  follow  very  severe  injuries 
when  no  secondary  inflammation  takes  place. 

When  brain  matter  is  pressed  out  of  the  skull  in  cases  of  fractured  base,  a  grave 
injury  is  always  indicated,  since  the  crushing  force  must  have  been  severe  to  have  given 

rise  to  such  a  complication.  Some  remarkable 
instances  of  recovery  after  the  escape  of  brain 
matter  are,  however,  i-ecorded;  and  several  have 
passed  under  my  own  observation,  but  they  are 
too  rare  to  be  dwelt  upon  as  holding  out  any 
hope  in  bad  cases.  Foreign  bodies  may  like- 
wise lodge  in  the  skull  for  a  long  period  without 
causino;  death.  Wounds  of  the  brain  are  not 
cluiracterized  by  any  special  symptoms  apart 
from   those  of  concussion   or  compression. 

Wounds  of  Dura  Mater.— Wounds 

of  the  dura  nuUer  are  pr()l)ably  as  dangerous 
as  wounds  of  the  brain,  for  inflammation  of  the 
membranes  is  readily  set  up  by  such  injuries. 
It  is  from  this  fact  that  compound  fractures 
of  the  skull  are  so  serious,  that  simple  frac- 
tures associated  with  comminution  of  the  inner 
table  of  the  skull  are  so  often  fatal,  and  that 
punctured  fractures  have  so  dangerous  a  tend- 
ency ;  for  in  all  these  cases  the  dura  mater  is  not  oidy  torn,  but  irritated,  by  the  pro- 
jecting spiculae  of  bono,  and  secondary  inflammation  is  the  result.  This  inflammation, 
as  a  rule,  rapidly  spreads  over  the  brain  and  causes  death. 

Prognosis. — Wounds  of  the  dura  mater,  as  well  as  wounds  of  the  brain,  are  some- 
times recovered  from,  but  the  prognosis  in  either  case  must  be  unfavorable. 

Hernia  cerebri,  or  protrusion  of  brain  matter  alone,  or  brain  matter  mixed  with 


Fig.  79. 


Hernia  Cerebri. 


ENCEVUM.ITIS.  207 

inflaiiim.itDry  priMliicts,  is  always  tlic  result  ni'  ;i  wiiiiinl  nr  s](iii<:h  of  the  iliira  mater 
sectmdarv  citluT  ti>  a  n)ni|Mimnl  t'ractiin'  (»r  to  tin-  rciimval  nl"  }'ractur('<l  nr  <liscasi'(l  Ixjik-. 
It  is  probalily  always  assdciiitcd  with  some  sii|i])iiratii)ii  (lucal)  (»i'  tlie  hraii).  due  to  exten- 
sion of  iiiflaiiiinatoiy  inischift"  to  that  part  in  contact  with  the  diseased  dura  mater  and 
bone.  It  is  t<t  he  treated  with  jrreat  caution.  Some  surj^eon.s  are  in  tht;  iiahit  of"  eut- 
tinj;  ott"  the  projecting!  mass,  others  of  applying  pressure;  hut  proliahly  the  hest  practice 
lies  in  doinj;  very  little,  in  keeping  the  parts  clean  and  dry,  and  leavinj;  their  repair  to 
natural  processes.  If  the  local  aflection  lie  sfi  limited  in  its  nature  as  to  \h'.  cajialile  of 
repair,  the  pntjectinjj;  mass  will  sloufrh  naturally  after  a  time,  and  cicatrization  will  follow  ; 
whereas  interference  on  the  part  of  the  surj^eon  does  harm.  The  hest  treatnient  is  at 
first  to  apply  a  piece  of  lint  to  the  jtart,  and  at  a  later  stage  to  keep  the  hernia  dry  by 
dustinj:;  it  with  oxide  of  zinc  or  powdered  alum.  Exci.sion  and  the  application  of  cau.stics 
or  pressure  do  not  appear  to  be  .satisfactory  forms  of  treatment. 

The  ex]»erience  of  army  sur<reonsdiirin<j:  the  American  war  confirms  these  ob.servations. 

INFLAMMATION  OF  THE  CRANIAL  BONES,  BRAIN,  AND  MEM- 
BRANES THE  RESULT  OF  AN  INJURY  TO  THE  HEAD. 

In  all  cases  of  injn'"}  to  the  head,  simple  or  severe,  attended  or  unattended  by  frac- 
ture, in  all  cases  of  concussion,  contusion,  compression,  or  laceration  of  the  brain,  or  of 
injurv  to  the  dura  mater,  inflammation  of  the  bones,  of  the  brain,  or  of  its  nn'inbranes  i.s 
liable  to  arise ;  and  when  it  does,  it  is  a  very  grave  complication.  It  is  this  fact  which 
makes  all  injuries  of  the  head,  even  simple  contusions  of  the  bone,  sources  of  danger, 
becau.se  inflammation,  commencing  in  the  bone,  too  frequently  spreads  inward  to  the 
membranes  of  the  brain  and  to  the  brain  itself,  and  thus  destroys  life.  The  free  com- 
munication between  the  pericranium  and  the  dura  mater  by  means  of  the  blood  vessels 
of  the  diploe  is  a  probable  explanation  of  this  occurrence  in  simple  scalp  and  bone  con- 
tusions. In  injuries  to  the  bones  of  the  skull  and  to  the  brain  or  its  membranes,  the  lia- 
bility to  encephalic  inflammation  appears  to  be  greatly  determined  by  the  severity  of  the 
accident. 

In  the  present  chapter,  traumatic  encephalitis,  acntr  and  chronic,  as  the  result  of  brain 
shocks,  whether  with  or  without  a  fracture,  will  claim  attention. 

The  itcKfc  or  diff'used  form  of  arachnitis  is  the  cause  of  death  in  most  of  the  cases  of 
head  injury  that  survive  the  immediate  results  of  the  accident. 

These  cases,  for  the  most  part,  are  the  result  of  a  severe  general  .shaking  of  the  brain, 
with  or  without  fracture,  complicated  with  contusion  or  laceration  of  the  brain  .structure  or 
its  membranes.  They  are  consequently  cases  of  arachnitis  and  inflammation  of  the  brain 
substance  itself,  the  inflammation  of  the  membranes  being  general.  "  I  have  never 
known,"  says  Wilks,  ''such  an  aff"ection  as  arachnitis  spring  up  as  a  spontaneous  disease; 
and  therefore,  when  met  with,  you  should  always  look  for  some  mischief  w'ithout.  When 
arising  in  this  way.  the  interarachnoid  eftusion  is  often  purulent  and  so  copious  that  it 
may  pour  cut  when  the  dura  mater  is  removed.  I  have  never  seen  extensive  eff"usion 
into  the  interaraelinoid  space  without  an  injury  on  the  head." 

Chronic  Result  of  Injury. — The  chronic  ca.ses  are.  for  the  most  part,  the  result 
of  a  locul  injury  and  begin  in  the  bone,  spreadine;  inward  to  the  dura  mater,  and  at  last 
involving  the  two  layers  of  the  arachnoid  membrane,  the  pia  mater,  and  even  the  brain 
itself.  Localized  sujipuration  is  frequently  found  in  these  cases,  either  between  the  bone 
and  dura  mater  or  in  the  brain  itself,  from  extension  of  inflammatory  action  from  without 
inward.  The  same  localized  changes  may  take  place  in  all  cases  of  chronic  ostitis  of  the 
calvarium,  whether  from  accident  or  disease. 

The  symptoms  of  the  acute  aflection  appear  in  the  stage  of  reaction  ;  indeed,  they 
may  be  looked  upon  as  indicating  reaction  in  excess,  febrile  symptoms,  headache,  convul- 
sions or  convulsive  twitchings,  delirium  or  mania  more  or  less  acute,  terminating  rapidly 
in  paralysis,  coma,  and  death,  being  the  general  order  of  symptoms.  Suffusion  of  serum 
takes  ]»lace  into  the  ventricles  and  upon  the  brain,  causing  at  times  compression,  or  effu- 
sion of  pus  or  ptiriform  lymph  occurs  either  upon  the  brain  itself  or  in  the  meshes  of  the 
pia  mater,  or  into  the  cavity  of  the  arachnoid. 

Whenever  the  brain  has  been  severely  shaken,  and  consequently  bruised  or  lacerated, 
inflammation  may  appear  at  the  injured  spots;  hence  it  at  times  shows  itself  beneath  the 
seat  0/  the  hloir.  but  more  frequently  begins  on  the  opposite  side  of  the  brain  to  the  seat 
of  injury  where  the  brain  has  been  hruised  or  lacerated  by  contre-coup.  From  these  cen- 
tres inflammation  may  spread  either  to  the  membranes  from  the  cortical  structure  of  the 


208  ENCEPHALITIS. 

)jrain  or  to  the  substance  of  the  brain  itself;  thus,  in  all  cases  of  a  general  shaking  of  the 
brain,  the  seat  of  inflammation  is  in  most  cases  at  the  base  of  the  brain.  The  pia 
mater  and  cortical  substance  of  the  brain  are  commonly  the  seats  of  inflammation,  but 
the  cavity  of  the  arachnoid  is  likewise  involved  in  many  cases  secondarily  by  exten- 
sion of  the  morbid  action.  There  are  no  symptoms  by  which  the  precise  seat  of 
inflammation  in  the  brain  or  its  membranes  can  be  made  out  ;  they  are  alike  in  all 
cases. 

In  chronic  encepludilis  the  symptoms  may  show  themselves  soon  after  the  injury,  but, 
as  a  rule,  they  do  not  appear  for  weeks,  or  even  for  months.  They  are  most  insidious  in 
their  nature  ;  they  may  begin  by  want  of  sleep,  with  an  irritability  of  brain  and  inapti- 
tude for  any  bodily  exertion,  but  headache  of  a  constant  exhausting  kind,  aggravated  by 
mental  or  physical  exertion,  is  a  most  prominent  symptom.  As  the  disease  progresses 
the  patient  gi-adually  becomes  emaciated  and  exhausted,  and  toward  the  close  of  the  case 
epileptiform  convulsions,  local  paralysis,  and  coma  supervene. 

It  will  thus  be  seen  that  the  two  classes  of  cases  of  acute  and  chronic  encephalitis  are 
distinct  in  a  measure.  The  acute  is  the  result  of  a  bruising  of  the  brain  by  a  severe 
shaking  or  concussion,  the  bruising  being,  as  a  rule,  at  the  base  of  the  brain  by  contre- 
coup.  The  inflammation  begins  in  the  pia  mater,  spreads  outward,  and  is  for  the  most 
part  diff"u.sed,  and  not  local.  Consequently,  it  is  beyond  the  reach  of  surgical  opera- 
tion. The  chronic  is  generally  the  result  of  contusion  or  fracture  of  the  bone  and 
local  in  its  action.  It  involves,  by  extension  from  without,  the  dura  mater,  the 
arachnoid,  pia  mater,  and  brain  consecutively  in  the  same  way.  It  is  consequently 
loithin   the  reach  of  surgical  art,  particularly  in  its  early   stage. 

Treatment. — Acute  encephalitis,  when  following  a  general  injury  to  the  brain,  for 
the  most  part  runs  such  a  rapid  course  that  there  is  little  time  for  treatment  to  take 
effect.  It  attacks  patients,  moreover,  who  have  been  already  knocked  down  by  the 
injury,  in  more  ways  than  one,  in- whom  there  is  rarely  much  resisting  force;  and  there 
is,  consequently,  not  much  chance  of  success  by  treatment.  Still,  there  is  much  to  be 
done. 

The  head  must,  of  course,  be  shaved  and  raised  on  a  pillow,  and  cold  should  be 
applied  to  it  by  means  of  one  of  Leiter"s  coils  (Fig.  9,  p.  49),  or  an  ice-bag  where  the 
former  instrument  cannot  be  obtained.  The  ice,  when  applied  in  a  bag.  must  be  broken 
up  into  small  fragments  ;  while  the  bag  containing  it  should  be  large,  in  order  to  cover 
the  whole  vault  of  the  skull.  The  cold  douche  is  also  a  powerful  remedy.  Free  purging 
should  be  resorted  to,  the  old  dose  of  calomel  mixed  with  butter  introduced  into  the 
mouth  being  probably  the  best  mode  of  administration,  or  an  enema  of  turpentine  or 
castor  oil  may  be  administered. 

In  a  strong  man,  when  symptoms  of  acute  encephalitis  appear  after  a  slight  injury, 
bleeding  is  a  mo.st  valuable  practice.  It  should  be  performed  boldly  and  freely  at  the 
first  onset  of  the  symptoms,  so  as  to  take  effect  upon  the  patient,  during  the  state  of 
excitement,  before  effusion  has  taken  place  and  brain  oppression  appeared,  and  it  may  be 
repeated.  In  severe  general  injuries  it  is  useless.  Some  employ  leeching  and  cupping 
on  the  nape  of  the  neck,  and  speak  highly  of  the  practice. 

French  surgeons  still  employ  blisters  to  the  scalp,  but  these  cannot  be  compared  in 
value  with  bleeding  and  the  local  application  of  ice  in  the  early  stage  of  the  affection. 
In  the  chronic  stage  they  may  be  beneficial.  When  they  are  employed,  they  should  be 
applied  to  the  nape  of  the  neck,  and,  where  mercury  is  relied  upon,  the  latter  may  be  used 
in  the  form  of  an  ointment  to  dress  the  blister.  Antimony  is  still  given  by  some  surgeons 
of  eminence.  I  have  no  experience  of  its  use,  and  therefore  cannot  recommend  it. 
\yhen  recovery  takes  place — a  rare  result — the  patient  must  be  cautioned  as  to  the 
future  ;  for  any  excess  of  diet  or  of  mental  or  physical  exercise  may  produce  a  relapse. 
The  greatest  quiet  ought  to  be  observed  for  many  weeks,  and  the  patient  should  live  on 
the  simplest  food.  Milk  diet  and  animal  broths  are  sufficient  for  some  time,  solid  animal 
food  being  taken  with  great  caution.  Stimulants  should  only  be  administered  if  the 
patient's  powers  are  feeble. 

In  chronic  cases  calomel,  given  in  small  and  repeated  doses  to  touch  the  gums,  com- 
bined or  not  with  opium,  has  its  advocates,  and  patients,  doubtless,  have  recovered  under 
its  use.  The  gray  powder  in  three-  or  four-grain  doses,  with  five  grains  of  Dover's 
powder,  is  a  useful  combination  when  delirium  is  present,  and  at  times  larger  doses  of 
opium  or  morphia  may  be  given.  Great  care,  however,  must  be  observed  in  the  use  of 
these  drugs,  for,  unless  they  are  carefully  given  and  their  effects  watched,  they  are 
injurious. 


ENCEPHALiriS.  209 

Wlu'ii  syniptoius  ol'  coinpri'ssiKii  ol'  tin-  hiMiii  inllow  tlinso  of  nmtr  encephalitis  the 
result  of  a  tjinmil  Injiinj  nr  shakiii^^  of  the  hraiii,  tliirre  is  little  (hmbt  that  its  cnnipri'ssioa 
is  (luc  to  the  effusion  ol"  inflaniniatory  fluid  into,  upon,  or  hcrn'ath  the  hrain  ;  ami  undtT 
sueh  ciri'Uinstanci's  the  (juestion  ol"  sur;_'ieal  interl'crt'net;  sliouM  not  he;  entertained.  Such 
is  to  lie  thouirht  of  only  in  eases  of  local  i-hnniif  suppuration  tli<!  result  of  a  local  c<jntu- 
sion  of  the  hone  or  otlu-r  injury.  (»r  of  disease,  and  when  tlie  seat  of  suppurati(Mi  is  usually 
between  the  hone  and  the  tlura  mater.  At  times,  however,  a  local  abscess  is  formed  in 
tlie  cavity  of  the  arachnoid  ;  and  under  the  circumstances  when  stronj^  evidence  of  this 
condition  exists  the  j)arietal  layer  may  be  punctured,  since  jrood  results  have  followed 
this  ))ractice.  . 

Puncturing  the  Brain  for  Suppuration.  —  In  niore  advanced  cases  suppura- 
tion may  involve  the  iirain  itself,  and  it  is  a  serious  (|Uestion  whether  a  surjreon  is  ever 
justified  in  ])unctnrini;-  this  orjian  with  a  view  of  layinjr  oj»en  the  supjiuratin^'-  cavitv. 
Should,  however,  good  evidence  exist  of  suppuration  in  the  cerebral  hemisphere  beneath 
the  seat  of  injury,  I  have  no  doubt  as  to  the  surgeon  being  justified  in  making  an 
ex])loratory  puncture;  for  Mr.  Ilolden  has  recorded  in  <SV.  liartholoinrir's  llm^it.  ll<^t.  for 
iSTi^  a  case,  and  Mr.  Ilulke  others,  and  in  the  American  Jonrn.  of  M>d.  Scitticr  for  July, 
IST.'K  five  otlier  instances  may  be  referred  to  in  which  success  f(dlowed  this  practice. 
Dupuytren  had  a  successful  case  of  the  kind,  and  pathological  anatomy  furnishes  exam- 
ples in  which  such  a  practice  might  have  been  of  use.  On  the  other  hand,  many  bold 
attempts  are  on  record  in  which  surgeons  have  punctured  the  brain  to  relieve  symptoms  of 
suspected  suppuration  in  its  substance.  Weed's  case  is  without  doubt  the  best,  as  it  was 
successful  (Nashi-i//''  Journ.  Med.,  April,  1872),  but  Detmold's  and  Maisonneuve's  are 
encouraging. 

I  am  disposed  to  think  that  surgeons  are  too  apt  to  leave  these  cases  alone  too  long 
and  allow  them  to  get  beyond  relief. 

A  man  receives  a  blow  upon  the  head,  followed  by  passing  symptoms  of  .so-called  con- 
cussion ;  he  has  a  slow  convalescence,  attended,  and  perhaps  followed,  by  headache.  He 
may  display  some  irrital)ility  of  brain,  inability  to  do  much  work  or  to  undergo  any  phys- 
ical fatigue  ;  some  febrile  disturbance  may  perhaps  manifest  it.self,  but  a.s  often  as  not 
none  appears.  The  pulse  probably  will  be  feeble  and  irritable,  at  other  times  slow  and 
hi))oring.  On  examining  the  seat  of  injury  tenderness  on  pressure  may  be  experienced, 
and  occasionally  increase  of  heat  will  be  felt.  Pressure  upon  the  injured  part  may  even 
excite  a  convulsion  where  such  had  previously  occurred.  Under  these  circumstances, 
which  are  fairly  indicative  of  local  inflammation  of  the  bone,  spreading  inward — though 
how  far  is  uncertain — a  free  inci-sion  to  the  bone  is  of  great  value.  I  have  known  this 
operation  relieve  immediately  all  the  symptoms,  general  and  local,  and  have  never  known 
it  followed  by  harm.  It  should  always  be  performed  when  evidence  of  local  inflammation 
exists,  with  umlefined  and  persistent  brain  svni]itonis. 

Symptoms  of  Abscess  beneath  Bone. — When,  however,  evidence  exists  that 
the  inflammation  has  spread  from  the  bone  to  the  ])arts  beneath,  as  indicated  by  symptoms 
of  feverishness,  severe  headache,  and  probably  rigors,  with  sleeplessness,  delirium,  con- 
vulsions, and  paralysis,  particularly  when  hemiplegic.  other  surgical  treatment  may  be 
thought  of;  for  if  these  sym])toms  are  associated  with  such  a  history  as  has  just  been 
sketched,  there  is  every  probability  that  suppuration  exists  within  the  skull  and  that  sur- 
gical art  may  reach  it.  General  treatment,  moreover,  in  these  cases  is  both  unsatisfac- 
tory and  unsuccessful ;  and  if  the  case  be  left  alone,  bad  results  always  follow.  Surgical 
interference,  it  is  true,  as  a  rule,  is  not  very  .satisfactory,  though  some  striking  examples 
of  success  exist.  In  the  hands  of  Pott  trephining  the  skull  for  matter  beneath  the  bone 
outside  the  dura  mater  yielded  a  good  result  in  five  out  of  eight  cases.  No  modern  sur- 
geon, however,  can  show  a  like  success;  '"indeed,"  says  Sir  P.  Hewett.  "the  successful 
issue  of  a  ca.se  of  trephining  for  matter  between  the  bone  and  dura  mater  is,  I  believe,  all 
but  unknown  to  surgeons  of  our  own  time.''  Xevertheless.  the  operation  is  clearly  justi- 
fiable under  such  severe  circumstances  as  have  been  described  :  for  our  want  of  success  is 
probably  due  to  the  fact  that  surgeons  are  too  readily  disposed  in  these  cases  of  local 
encephalitis  to  wait  too  long,  to  trust  too  far  to  natures  own  processes,  and  by  so  doing 
to  allow  the  local  suppurative  action  to  spread  inward  beyond  the  dura  mater  to  the  brain 
itself,  when  the  prospects  of  a  successful  result  are  certainly  poor.  They  wait  for  what 
are  called  well-marked  brain  symptom.s — coma  and  hemiplegia — before  they  interfere ; 
which  well-marked  symptoms  too  often  mean  fatal  brain  complications.  Trephining  the 
seat  of  injury,  therefore,  under  such  circumstances  is  clearly  a  justifiable,  if  not  a  hopeful, 
measure,  should  the  operation  be  performed  as  soon  as  it  is  manifest  from  the  history  of 
U 


210  TREATMENT  OF  CONCUSSION. 

the  case  that  the  local  action  is  spreading.  When  pus  is  found  between  the  bone  and  the 
dura  mater,  great  hopes  may  be  entertained  of  a  successful  issue,  although,  when  the  same 
suppurative  "action  has  involved  the  cavity  of  the  arachnoid  and  the  brain,  the  prospect  is 
not  good. 

Should  no  pus  be  found,  however,  between  the  bone  and  dura  mater,  is  the  surgeon 
justified  in  opening  the  membrane?  Without  doubt  he  is  when  there  is  strong  reason  to 
believe  that  pus  exists,  when  the  dura  mater  on  exposure  hubjcs  firmly  into  the  opening  in 
the  bone  which  has  been  made  with  the  trephine,  and  is  tense  as  well  as  absolutely  puhr- 
lesa;  for  cases  of  success  after  this  operation  have  been  recorded  by  Guthrie,  Ptoux,  Dum- 
ville,  and  Hulke.  The  evidence  required  to  sanction  any  incision  into  the  brain  in  search 
of  suppuration,  as  has  been  already  stated,  must  be  very  strong. 

Acute  encephalitis  as  a  result  of  blood  poisoning  needs  only  to  be  mentioned.  It  is  a 
hopeless  condition  from  the  first,  and  is  always  associated  with  the  worst  and  most  general 
form  of  pyaemia. 

TREATMENT  OF  CONCUSSION  AND  COMPRESSION  OF  THE 
BRAIN,  AND  OF  FRACTURES  OF  THE  SKULL. 

"A  mere  crack  in  one  of  the  bones  of  the  cranium,  ahstractedli/  consuhrcd.  is  not  more 
likely  to  produce  any  serious  complaints  than  a  simple  fissure  in  any  other  hone ;  and  if 
symptoms  of  consequence  do  frequently  attend  the  accident,  they  proceed  either  from  the 
bone  being  beaten  inward,  so  as  to  press  upon  the  brain,  or  from  the  mischief  done  to  the 
parts  within  the  skull  by  the  same  force  that  broke  the  bone  itself.  The  same  violence 
which  breaks  the  cranium  may  occasion  a  concussion  of  the  brain,  an  extravasation  of 
blood  in  or  upon  it,  or  subsequent  inflammation  of  that  organ,  and  its  usual  consequences" 
(Sam.  Cooper). 
■  The  truth  embodied  in  this  extract  renders  it  necessary  to  consider  the  treatment  of 
head  injuries  as  a  whole,  since  it  is  impossible  to  say.  in  any  case  of  severe  injury  to  the 
skull,  whether  two  or  more  of  the  conditions  mentioned  are  not  associated. 

When  brain  concussion  has  taken  place,  it  may  or  may  not  be  associated  with  fracture, 
and  it  may  or  may  not  be  followed  by  symptoms  of  compression,  either  from  extravasation 
of  blood  or  secondary  inflammation  ;  and  when  a  fracture  is  known  to  exist,  either  with  or 
without  depression  of  bone,  the  difficulty  is  not  lessened.  The  symptoms  may  be  a  mere 
temporary  suspension  of  the  brain's  functions — or.  as  they  are  commonly  called,  those  of 
a  passing'  concussion — or  they  may  be  of  a  much  more  serious  nature  and  such  as  indi- 
cate brain  contu.sion,  laceration,  or  blood  extrava.sation.  The  severest  complications  are 
often  ushered  in  by  the  mildest  symptoms,  and  therefore  the  surgeon  should  always  treat 
every  case  of  injury  of  the  cranium  and  its  contents  as  serious.  He  should  also  be  as 
guarded  in  his  prognosis  as  he  necessarily  is  uncertain  in  his  diagnosis. 

In  any  case,  therefore,  of  concussion,  however  slight,  the  patient  ought  to  be  kept 
quiet,  and  should  observe  moderation  in  diet,  take  little  or  no  meat,  and  avoid  all  stimu- 
lants. If  he  moves  about,  it  is  at  a  risk — a  risk  of  fatal  secondary  inflammation  of  the 
shaken  or  bruised  brain.     These  precauitions  should  be  continued  for  at  least  three  weeks. 

In  severer  concussion,  in  which,  after  an  injury  to  the  head,  there  is  a  more  or  less 
complete  suspension  of  the  functions  of  the  brain,  whether  with  or  without  a  fracture, 
equal  care  is  needful.  Should  the  collapse  indicative  of  the  first  stage  be  severe,  reaction 
may  be  hastened  by  means  of  warmth  to  the  body  generally,  more  particularly  to  the 
feet,  and  by  the  application  of  some  stimulant  to  the  nostrils.  It  is  seldom  right  to  do 
more  than  this,  because,  if  reaction  does  not  set  in  naturally  and  is  not  hastened  by  the 
means  mentioned,  it  is  tolerably  certain  that  the  brain  mischief  is  of  a  severe,  if  not  fatal, 
character.  Under  these  circumstances,  any  more  powerful  means,  such  as  the  adminis- 
tration of  alcoholic  stimulants  or  powerful  enemata,  are  likely  to  excite  reaction  to  excess 
and  either  encourage  secondarv  hemorrhage  or  inflammation  within  the  skull. 

Reaction  and  its  Treatment.— When  reaction  has  set  in  after  the  collapse— 
the  second  stage  of  authors — every  source  of  excitement,  mental  or  phy.sical,  should  be 
removed.  The  patient  should  be  kept  in  bed  with  his  head  raised  and  shaved,  and  the 
bowels  emptied  with  a  mild  saline  or  mercurial  purge.  Leiter's  coil  (Fig.  9),  cold  lotions, 
or  an  ice-bag  .should  be  applied  to  the  head,  and  particularly  if  it  be  hot.  the  pulse  rapid, 
and  other  symptoms  of  general  febrility  and  brain  excitement  show  themselves.  When  the 
symptoms  of  excessive  reaction  are  persistent,  the  commencement  of  traumatic  encephalitis 
should  be  suspected  ;  and  under  such  circumstances  venesection,  boldly  performed,  is  a 
valuable  remedy.     It  may  even  be  repeated  should  the  symptoms  return  and  the  pulse 


TIlKATMF.yr  OF  COMrRKSSfOX.  211 

* 

ami  tfiiipfratun'  rist-.  In  fcrMo  jcitii'iits.  IidWcvcr,  lilci'diiif:  is  inadmissible,  ami  umlcr 
all  i-ircuiiistaiu-rs  it  oiitrlit  only  t(»  In-  resorted  to  after  careful  eoiisidoratioii. 

The  diet  should  ln'  li(|ui<l  ami  of  a  simple  kind.  Milk,  when  it  can  he  taken,  is  tlie 
best  ;  hut  w  hi'u  it  eaniiot.  weak  heef  tea  or  l)roth  should  he  given,  and  then  otdy  in 
moderation. 

Treatment  of  Fracture  and  Concussion. — Coneussion  of  the  hrain  eompli- 

eated  witii  lither  siui]ile  or  eoiu|MMind  UM<le](re>sed  fracture  of  the  vault  or  fracture  of 
the  base  is  to  be  treated  upon  like  principles  and  with  e(|ual  persistency  and  care,  for 
simple  fractures  of  the  vault,  compound  fractures  of  the  vault,  and  simple  fractures  of 
the  base,  or  of  the  vault  and  base  combined,  ituttssociated  with  t/ixji/tiretjient,  require  no 
special  treatment  beyond  that  indicateil  by  the  l)rain  symptoms. 

It  should  be  here  .stated  that  the  treatment  of  all  the.se  conditions  is  to  be  continued 
f(»r  at  least  a  month  or  six  weeks  after  the  injury,  since  there  are  many  cases  on  record 
in  which  sec(mdary  inflammatory  .symptttms  appeared  at  least  a  montli  after  the  accident 
or  after  the  suli<iilrin-e  i>\'  tlie  primary  symptoms. 

Treatment  of  Compression. — When  the  brain  symptoms  fidlowint:  an  injury 
to  tlie  liead  partake  more  of  the  nature  of  compression — that  is,  when  they  are  persistent 
in  their  character,  and,  instead  of  iroiiiK  on  toward  recovery  or  to  the  restoration  of  the 
natural  functions  of  the  brain,  tend  rather  toward  their  more  complete  abeyance — other 
<|uestions  of  treatment  come  before  the  surgeon  ;  and  the  most  important  has  reference  to 
the  fact  whether  surgical  art  can  do  anything  toward  relieving  the  condition. 

The  student  who  has  carefully  read  the  remarks  that  have  already  been  made  can 
now  understand,  when  the  injury  to  the  brain  or  skull  has  been  the  result  of  some  (j'-ueral 
iiijnn/.  such  as  a  fall  upon  the  head  from  a  height  or  a  blow  from  a  heavy  body,  that  the 
brain  mischief  which  follows  is  certain  to  be  of  a  general  character;  and  when  sj'mptoms 
of  local  mischief  complicate  the  case,  little  good  is  to  be  gained  by  treating  these  local 
symptoms  when  others  of  a  more  general  or  fatal  character  exist.  In  examples  of  brain 
or  skull  injury,  therefore,  as  a  result  of  diffused  or  general  .shaking  of  the  head  and  its 
contents,  local  interference  of  any  special  character  is  generally  useless. 

In  hcdf  injuries,  however,  the  question  may  be  seriou.sly  discussed. 

In  cases  of  dt-prrssed  fracturr^  ought  the  bone  to  be  elevated?  and  should  the  fact  of 
the  fracture  being  compound  influence  the  decision?  I  have  no  hesitation  in  answering 
both  questions  and  asserting  that  in  neither  instance  ought  surgical  interference  to  be 
adopted  as  a  rule  of  practice,  since  experience  has  taught  us  that  depressed  bone  jier  se 
may  exist  to  a  great  degree  without  giving  rise  to  any  serious  brain  complications,  and 
that  when  even  brain  symptoms  follow  as  an  immediate  result  of  the  injury  they  may  all 
pass  away. 

Extravasation  of  Blood  between  Bone  and  Dura  Mater. — Should, 

however,  the  symptoms  indicate  the  ]>resence  of  effused  blood  beneath  the  fracture  suf- 
ficient to  cause  compression  of  the  brain,  as  shown  by  the  lapse  of  an  "  interval  of  time  " 
between  the  accident  and  the  symptoms,  and  should  local  paralysis  point  out  its  seat, 
surgical  interference  is  called  for ;  and  in  both  simple  and  compound  fractures  the 
trephine  may  be  required  in  order  to  elevate  the  bone.  The  operation  is  necessary  on 
account  of  the  brain  .symptoms  present  in  the  case  and  has  no  reference  to  the  character 
of  the  local  injury — to  the  presence  or  absence  of  a  scalp  wound. 

In  cases  of  simple  fracture  in  which  brain  symptoms  exist  a  free  incision  down  to  the 
injured  part  for  purposes  of  exploration  is  often  called  for. 

In  compoiiiid  fracture  of  the  skull,  however,  associated  with  depression  and  commi- 
nuti'iu  of  the  bone,  both  with  or  without  brain  symptoms,  the  surgeon  ought  to  remove 
loose  pieces  of  bone  and  may  elevate  the  depressed  portions  when  this  can  be  done  with 
the  elevator  without  difficulty,  as  splintered  bone  is  always  a  dangerous  body  when  in 
contact  with  the  dura  mater. 

When  the  brain  is  injured,  the  same  course  should  be  followed,  the  greatest  care 
being  observed  not  to  add  to  the  irritation  by  any  rough  manipulation.  Should  difficulty 
be  felt,  however,  in  removing  bone,  it  had  better  be  left  in  sifii  rather  than  by  inter- 
ference incur  any  extra  ri.sk  of  injuring  the  brain  or  its  membranes. 

Should  there  be.  on  the  removal  of  Vione.  severe  hemorrhage  from  a  meningeal  artery, 
the  piece  should  be  left  ;  and  should  this  practice  fail  to  arrest  the  bleeding,  a  small  piece 
of  sponge  or  plug  of  carbolized  catgut  in,serted  beneath  the  bone  may  succeed,  or  the 
ajiplication  of  a  pair  of  spring  forceps  may  be  called  for.  It  is  not  often,  however,  that 
such  a  complication  is  met  with. 

In  every  case  of  punctured  fracture  of  the  skull  trephining  should  be  resorted  to. 


212 


TREPHINING  FOR  HEAD  INJURIES. 


General  Summary  to  Surgical  Interference. — It  thus  appears  that  in  sim- 
ple or  compound  unamiminuttal  depressed  fracture  from  a  local  injury  operative  interfer- 
ence is  not  called  for  unless  associated  with  marked  symptoms  either  of  compression  of 
the  brain  or  extravasation  of  blood  between  the  bone  and  the  dura  mater ;  whereas  in 
compound  commiuided  fracture  and  m punctured  fracture,  with  or  without  symptoms  of 
brain  compression,  the  bone  should  be  elevated  and  all  fragments  removed.  In  other 
cases,  as  in  fracture  of  the  base,  no  surgical  interference  can  be  justified. 

Did  space  permit,  many  instances  might  be  quoted  to  illustrate  these  points,  for  cases 
of  fracture  of  the  skull  with  depressed  bone  without  brain  symptoms  in  which  recovery 
has  taken  place  are  numerous ;  indeed,  experience  has  proved  that  there  may  be  much 
depression  of  bone  without  brain  symptoms,  and  I  am  tempted  to  believe  that  depressed 
bone  by  itself  never  gives  rise  to  marked  symptoms  of  compression,  and  that  when  these 
are  present  hemorrhage  exists  with  it. 

Many  cases  might  also  be  quoted  illustrating  the  value  of  surgical  interference  in 
compound  fractures  with  depression  ;  I  give  the  following : 

Compound  fracture  of  skull  with  depression  from  local  injury.  A  feeling  of  perma- 
nent weight  on  the  head  was  the  only  symptom,  which  was  at  once  relieved  by  removal 
of  the  bone,  and  recovery  followed. 

Compound  fracture  of  skull  with  depressed  bone  from  local  injury.  Constant  vomit- 
ing and  pain  in  the  head,  which  was  relieved  at  once  by  removal  of  the  bone,  the  patient 
recovering  on  the  fourth  day. 

Compound  fracture  of  skull  with  depressed  bone  from  local  injury.  Persistence  of 
symptoms  of  oppressed  brain.     Elevation  of  depressed  bone,  and  rapid  recovery. 

THE  OPERATION  OF  TREPHINING  OR  FOR  THE  ELEVATION 

OF  DEPRESSED  BONE. 

"Much  has  been  written  and  said  on  the  treatment  of  injuries  to  the  head,  and  the 
result  of  modern  experience  and  judgment  has  so  far  altered  the  practice  of  our  prede- 
cessors as  to  render  us  cautious  of  inflicting  an  additional  injury  on  our  patient  for  the 
sake  of  gratifying  an  impertinent  and  useless  curiosity  as  to  the  exact  nature  and  extent 
of  the  original  lesion."  Thus  wrote  my  colleague,  Mr.  Cock,  forty  years  ago;  and  what 
he  then  said  is  true  now,  although,  perhaps,  surgeons  at  the  present  day  are  less  disposed 
to  trephine  in  head  injuries  than  they  were  even  at  that  time. 

At  Guy's  Hospital  trephining  and  elevation  of  bone  for  bead  injuries  have  been 
performed  in  fifty-one  cases  during  seven  years,  and  of  these  only  twelve  recovered.     At 


Fig.  80. 


Fig.  81. 


Fig.  82. 


Showing  the  Operation  of  Trephining. 


A,  Trephine  prepared  for  use,  with  centre  pin  clown. 

B,  With  centre  pin  withdrawn,  the  outer  table  having  been  divided. 


Elevator.  Hey's  Saw. 


St.  Bartholomew's  Hospital  it  was  recorded  by  Callender  in  1SG7  that  the  operation  had 
not  been  performed  for  six  years.  At  University  College,  Erichsen  gives  six  cases  of 
recovery  out  of  seventeen. 

The  operation  is,  however,  valuable  in  two  classes  of  cases: 


Tin:  <)ri:i:.\ri()S  of  i/nriiiMNa.  213 

First.  To  relieve  e(im|ire>si()ii  dl'  tlie  Inairi  iliie  to  either  depres.sed  hone  or  exlravasa- 
tiuii  of  blood. 

SiToiuUi/.  To  j)rcvi'iit,  ehock,  or  relieve  initalidii  nl'  tlie  Inaiti  or  its  uienibratics  when 
caused  by  (1 )  depressed  and  coiiiiiiiiiuted  boiie,  by  ( '1)  iiifiaiiied  and  .swollen  bone  (whether 
the  result  of  aeeident  or  disease),  or  by  (!>)  an  aectiinnlation  of  pus  Itetween  the  bone 
and  dura  mater  eonipressini;  the  brain  ;  and  it  may  be  stated  at  on<e  that  the  operation 
<»f  trephininjr  uMius  mure  support  from  the  seeond  than  from  the  first  ^n(jup  <»f  cases. 

With  respect  to  the  first,  it  will  have  been  j;athered  from  preceding  chapters  that 
depression  of  the  bones  of  the  skull  is  rarely  sufficient  of  itself  to  give  ri.se  to  persistent 
symjitoms  of  compression;  that  when  it  is,  the  injury  has  ju-()bal»ly  been  of  such  a 
severe  nature  as  to  produce  grave  intracranial  complications  fntm  which  any  operation 
would  be  iiica])able  of  affording  relief;  and  that  hemorrhage  l)etween  the  bone  and  the 
dura  mater  is  rarely  so  mieomplicated  with  brain  miscliief  as  to  render  it  jirobable  that 
the  operation  of  trephining  will  ]»e  successful. 

When,  however,  it  can  be  fairly  determined  that  brain  .symptoms  of  a  defined  and 
aggravated  character  are  the  re.sult  of  either  of  the.se  two  causes,  .separately  or  combined, 
the  operation  of  trephining  may  be  performed.  In  diffused  injuries  to  the  skull  the 
probabilities  are  all  against  the  operation,  while  in  local  injuries  they  are  in  its  favor. 

In  both  simple  and  compt)und  fractures  of  the  skull,  with  or  without  depression  of 
bone,  the  symptoms  of  compression  of  the  brain  as  a  ])rimary  result  of  the  accident  must 
be  very  marked  indeed  to  justify  the  ojjcration  of  trephining,  altliough  in  coihixjiukI  frac- 
turex  it  is  expedient  to  elevate  depressed  bone  wlieri  any  .symptoms  of  brain  irritation 
manifest  themselves,  such  as  local  pain  and  weight,  spasms,  or  convulsions ;  and  under 
all  circumstances  it  is  best  to  remove  fragments  when  the  bone  is  comminuted.  In  a 
eomjiound  comminuted  fracture  of  the  skull  the  dura  mater  is  jirobably  exposed,  and  is 
likewise  irritated  by  the  broken  bone.  A  careful  elevation  of  tlie  depressed  portion  of 
the  bone  and  the  removal  of  the  connninuted  fragments  can  in  no  way  add  to  the  mis- 
chief, but  must  tend  toward  its  diminution. 

In  local  injuries^  whether  simple  or  compound,  when  incipient  symptoms  of  brain  irri- 
tation or  inflammation  appear  two  or  three  days  after  the  injury,  the  use  of  the  trephine  is 
indicated,  inasmuch  as  there  is  a  probability  that  the  symptoms  originate  in  the  presence 
of  a  fragment  of  bone  irritating  the  brain  or  its  membranes,  which,  if  left,  must  set  up 
encephalitis. 

In  all  cases  of  pan(tin\il  fidcturc  the  treidiine  should  be  employed. 

Pus  between  Dura  Mater  and  Bone. — When  an  abscess  can  be  made  out 
as  existing  between  the  bone  and  the  dura  mater  after  a  head  injury,  the  operation  of 
trephining  is  demanded,  though  the  diagnosis  of  such  cases  is  difficult.  The  chief  indica- 
tions are  found  in  the  prolonged  period  which  fre(juently  elapses  between  the  injury  and 
the  supervention  of  the  symptoms,  their  gradual  and,  it  may  be  said,  irregular  approach, 
the  general  and  cerebral  irritation  that  is  present  as  a  rule,  the  exacerbation  of  all  these 
symptoms,  and,  above  all,  the  constant  headache. 

The  direct  symptoms  of  compression  produced  by  the  formation  of  pus  are,  moreover, 
in  no  ways  so  definite  as  those  afforded  by  blood  extravasation ;  they  are  of  a  less  decided 
nature  and  are  never  associated  with  the  deep-toned  stertor  and  rapid  progress  of  the 
symptoms,  ''  which  with  overwhelming  influence  (juickly  annihilate  both  motion  and  con- 
sciousness when  blood  has  been  poured  out  in  any  considerable  quantity  after  injury  to 
the  cranium  "  (Cock).  They  are,  however,  fairly  marked  by  the  clinical  history  of  the 
case,  and  can  be  generally  recognized. 

The  Operation  of  Trephining. 

The  instruments  required  for  the  operation  are  the  trephine^  or  circular  hand-saw,  of 
which  there  are  two  sizes;  a  small  aaiv  with  a  straight  and  circular  edge,  generally  known 
as  Hey's  saw  ;  a  sharp  scalpd  with  a  handle  rounded  at  the  end,  to  press  back  the  perios- 
teum and  soft  parts  from  the  bone  ;  a  //rt/  probe  thin  enough  to  introduce  into  the  groove 
made  by  the  trephine,  to  guide  the  surgeon  in  his  attempt  to  perforate  the  bone  and  to 
prevent  him  going  too  far ;  a  pair  of  cntting  forceps,  to  remove  sharp  points  and  edges  of 
bone ;  an  elevator,  to  raise  depressed  bone  ;  and  dissecting,  dressiniz-,  and  torsion  forceps. 
(  FiV/e  Figs.  81  and  82.) 

The  patients  head  having  been  placed  upon  a  pillow,  shaved  so  far  as  requisite,  and 
held  firmly,  the  first  thing  the  surgeon  has  to  do  is  to  expose  the  bone  he  wishes  to  per- 
forate or  elevate.      This  must  be  done  freely,  eithi'r  by  enlarging  the  wound  that  pre- 


214  THE  OPERATIOX  OF  TREPHINING. 

viously  existed  or  by  an  incision  crucial  or  otherwise.  The  soft  parts  should  be  divided 
by  one  cut  down  to  the  bone,  and  these,  including  the  periosteum,  should  be  gently 
pressed  back  with  the  handle  of  the  knife.  Bleeding  at  this  stage  should  be  arrested  by 
ligatures,  torsion,  or  the  application  of  a  cold  sponge  and  pressure. 

Supposing  the  case  to  be  one  of  fracture  with  depression,  and  that  fragments  of  bone 
exist,  they  should  be-  removed,  great  care  being  taken  in  their  removal  not  to  twist  the 
broken  bone  and  thus  run  the  risk  of  tearing  the  dura  mater  ;  and  when  an  opening  is 
thus  formed,  the  depressed  bone  may  be  raised  by  means  of  the  elevator  carefully  intro- 
duced beneath  its  free  border.  To  facilitate  this  proceeding,  perhaps  the  removal  of  a 
piece  of  projecting  bone  by  forceps  or  Heys  saw  will  be  found  beneficial ;  and  if  so,  the 
trephine  is  not  required,  for  the  surgeon's  object,  under  the  circumstances — to  raise  the 
depressed  bone  and  remove  the  comminuted  portions — may  be  completed  without  the 
trephine. 

Should  the  bone  be  so  depressed,  however,  as  not  to  present  an  edge  for  the  surgeon's 
forceps,  as  is  seen  in  the  '-gutter'  fracture  illustrated  in  Fig.  71,  the  trephine  must  be 
emplo3'ed.  The  instrument  should  be  previou.sly  prepared,  the  central  pin  being  made  to 
project  sufficiently  far  to  perforate  the  external  table,  and  so  fixed  as  to  allow  the  saw  to 
bite  the  bone  (Fig.  80.  a).  In  a  depressed  fracture  this  pin  should  never  he  placed  vpon  the 
fractured,  but  upon  the  border  of  the  sound,  bone.  The  instrument  is  then  to  be  applied 
and  the  external  table  cautiously  divided  with  a  few  semi-rotatory  movements  of  the  sur- 
geon's wrist.  A  groove  having  been  made  deep  enough  to  allow  the  saw  to  work  steadily, 
the  instrument  is  to  be  removed  and  the  central  pin  withdrawn  and  fixed  (Fig.  80,  b),  as  it 
would  be  a  fatal  error  to  go  on  working  with  the  pin  projecting  through  the  inner  plate 
of  bone  into  the  dura  mater.  The  surgeon  ought  now  to  proceed  with  the  utmost  caution, 
and  feel  his  way  ever}-  few  turns  with  the  flat  probe,  for  as  soon  as  he  has  divided,  or 
even  reached,  the  inner  plate,  the  elevator  may  be  employed  and  the  loose  ring  of  bone 
removed.  When  the  inner  plate  is  fractured  to  a  greater  extent  than  the  outer,  it  may 
not  be  necessary  to  divide  it,  the  removal  of  the  external  table  with  the  diploe  being 
sufficient  to  allow  of  the  introduction  of  the  elevator  and  the  removal  of  fragments. 
Should  this  not  be  the  case,  however,  the  inner  table  must  be  perforated  ;  for  the  whole 
thickness  of  the  bone  must  be  removed.  The  operator  cannot  be  too  careful  at  this  .stage 
of  the  operation,  and  should  always  proceed  with  the  conviction  that  the  bone  is  thinner 
at  one  spot  than  another,  and,  further,  that  '•  there  is  only  the  thinness  of  paper  between 
eternity  and  his  instrument ''  (Sir  A.  Cooper's  MS.  lectures).  The  depressed  bone  may 
then  be  raised  by  the  elevator. 

If  the  operation  has  been  performed  for  extravasation  of  blood  beneath  the  bone  and 
a  clothe  discovered,  it  should  be  removed,  the  utmost  gentleness  being  used.  Should  pus 
exist,  it  will  e.scape  naturally. 

Should  troublesome  hemorrhage  from  a  meningeal  artery  ensue,  it  may  be  arrested  by 
tucking  a  small  portion  of  sponge  or  carbolized  catgut  beneath  the  vessel  and  compres.sing 
it  against  the  bone,  or  it  may  be  held  by  a  short  pair  of  spring  forceps  against  the  bone. 
Free  bleeding  of  this  kind,  however,  is  not  frequent. 

On  Puncturing  the  Dura  Mater. — If.  however,  no  blood  or  pus  be  found 
external  to  the  dura  mater,  and  strong  evidence  exist  that  it  is  placed  beneath  this 
membrane,  the  dura  mater  may  be  punctured.  This  step,  however,  is  not  to  be  under- 
taken without  grave  consideration.  Yet,  it  may  be  asked,  if  the  operation  fail  in  its 
object,  is  the  operator  ever  justified  in  making  a  second  opening  into  the  skull  in  search 
of  blood  or  of  pus?  Certainly,  it  mu.st  be  answered,  not  at  a  hazard;  although,  when 
there  is  evidence  to  point  to  a  second  position  in  which  it  is  reasonably  probable  that  the 
offending  fluid  may  be  found,  a  second  perforation  may  be  performed.  Cases  are  on  record 
in  which  three  or  more  pieces  have  been  removed  with  a  good  result. 

The  wound,  after  the  operation,  must  be  treated  on  general  principles,  the  edges  of 
the  soft  parts  being  gently  brought  together,  but  not  stitched;  boracic  acid  lotion  on 
absorbent  cotton  is  the  best  dressing,  and  the  head  should  be  kept  cool  by  the  ice-bag. 
If  the  parts  heal  and  the  case  does  well,  a  metallic  .shield  may  be  required  as  a  protec- 
tion, although  it  is  interesting  to  see  how  firm  the  membrane  that  fills  in  the  cavity 
becomes  after  a  time. 

Hernia  Cerebri. — Should  a  hernia  of  the  brain  follow  at  a  later  stage,  the  same 
local  treatment  should  be  employed.  Excision  of  the  projecting  fungous  mass  is  a  prac- 
tice that  is  not  advisable.  The  whole  will  probably  wither  by  natural  processes  if  a  cure 
takes  place  ;  and  the  less  the  surgeon  interferes,  the  better. 


a  Eyh'Ii .  I A    t'OSCL  us  I  OSS.  2 1 0 

General  Conclusions  on  Injuries  of  the  Head  and  their  Treatment. 

1.  Iiijurit's  of  the  head  arc  id' iiiiiiortaiifo  only  "^<»  far  as  tli(;y  primarily  or  Sfoondarilv 
iiivolvo  the  cranial  contents,  a  east;  of  simple  tuie<implicated  fractiin;  of  the  skull  heing 
of  less  danger  than  one  of  ireneral  concussion  of  the  hrain. 

2.  A  slijrht  shakin;,'  of  the  hrain.  which  manifests  itself  by  a  pa.ssin;,'  .suspen.sion  of 
tlie  cerehral  functions.  a.s.sociated  or  not  with  a  fracture  of  the  vault  or  of  the  base  of  the 
skull,  generally  does  well. 

!{.  A  severe  eoneus.sion  or  shaking  of  the  brain  a.ssociated  or  not  with  a  fracture  of 
the  vault  or  of  the  base  of  the  skull  is  probably  associated  with  contusion  or  laceration 
of  the  brain  substance,  either  uj)on  its  surface  or  within  its  ventricles,  and  consequently 
with  more  or  less  extravasation  of  blood  ;  when  the  vessels  are  disea.sed,  a  copious  hemor- 
rhage often  follows  a  slight  injury. 

4.  In  ca.ses  of  .severe  concussion  the  l)rain  is  at  least  as  much  injured  by  cmtt-p-coup  as 
it  is  at  the  .seat  of  injury,  its  base  suffering  the  most.  Fracture  by  coiiln-roiip  does  not 
take  place. 

5.  A  fall  upDU  the  vertex  from  a  height  or  a  blow  upon  the  head  from  a  blunt  instru- 
ment may  or  may  lujt  be  followed  by  fracture  of  the  skull,  but  such  an  accident  produces, 
as  a  rule,  a  general  concussion  of  the  V^rain,  with  contusion  or  laceration  of  its  structure 
and  efTusion  of  blood  either  upon  its  surface  or  within  its  substance  or  ventricles. 

G.  Falls  upon  a  pointed  object  or  blows  with  a  sharp  instrument  are,  as  a  rule,  fol- 
lowed by  local  fracture;  and  if  the  brain  be  injured,  it  is  at  the  seat  of  injury.  As  a 
conse(|uence.  the  symptoms  may  be  accounted  for  by  local  causes  only,  and  the  surgical 
treatment  should  be  directed  b\"  local  considerations. 

7.  When  symptoms  of  compression  of  the  brain  imraediatelj'  follow  an  injury  to  the 
skull  which  has  been  ))roduced  by  a  fall  from  a  height  or  by  a  blow  from  a  heavv  and 
blunt  instrument,  the  cerebral  injury  will  be  general,  the  brain  will  be  contused  and  lace- 
rated, particularly  at  the  base,  by  contrr-conp;  and  if  extravasated  blood  be  found  external 
to  the  dura  mater,  blood  will  also  be  found  upon  the  surface  of  the  brain  or  within 
its  membranes.  The  ojieration  of  trephining  under  these  circumstances  can  be  of  no 
avail. 

8.  If  symptoms  of  compression  of  the  brain  follow  a  local  injury  produced  by  a  fal\ 
upon  a  sharp  object  or  a  quick  blow  from  a  pointed  one,  such  .symptoms,  as  a  rule,  are 
produced  by  local  causes,  such  as  depressed  bone  or  extravasation  of  blood  from  a  rup- 
tured vessel,  and  such  local  injuries  should  be  treated  by  the  elevation  of  the  depressed 
bone  or  by  trephining. 

9.  W^hen  compres.sion  of  the  brain  follows  a  local  injury  over  the  cour.se  of  the 
meningeal  artery,  and  the  symptoms  come  on  after  reaction  has  been  establi.shed  and  the 
lapse  of  an  interval  of  time  from  the  receipt  of  the  injury,  the  operation  of  trephining 
may  be  performed,  although  no  depressed  bone  be  present. 

10.  Encephalic  tnjiiimmation  may  follow  the  slightest  concussion  or  injurv  to  the 
brain,  whether  complicated  or  not  with  fracture  ;  and  the  danger  of  such  a  result  is  in 
proportion  to  the  encephalic  injury.  In  cases  of  contusion  or  laceration  of  the  brain  with 
extravasation  of  blood,  inflammation  is  almost  sure  to  occur,  and.  as  a  rule,  will  cause  a 
fatal  termination.  This  inflammation  may  appear  within  a  few  hours  of  the  accident  or 
it  may  be  po.stponed  for  days ;  it  may  be  very  rapid  in  its  course  or  very  in.sidious  in  its 
nature.  If  the  brain  alone  be  affected,  either  a  diffused  or  local  abscess  may  result ; 
while  if  the  membranes  are  involved.  eflFusions,  convulsions,  general  or  partial  paralysis, 
coma,  and  death  will  rapidl}-  take  place. 

11.  Fractures  of  the  base  of  the  skull  may  take  place  alone  and  be  marked  by  only 
special  symptoms.  They  may  be  associated  with,  and  are  generally  found  in.  all  cases 
of  severe  fracture  of  the  vault  when  produced  by  a  heavy  fall  or  blow,  the  fissures  radiat- 
ing downward  in  a  direction  parallel  to  the  forces  employed. 

12.  Fractures  of  the  base  may  be  complicated  with  encephalic  injuries  similar  to  tho.se 
which  complicate  fractures  of  the  vault  ;  consequently,  they  may  be  manifested  by  gene- 
ral as  well  as  special  symptoms,  and  in  severe  cases  the  former  completely  mask  the 
latter. 

13.  All  injuries  to  the  head  should  be  treated  with  extreme  care  and  always  regarded 
as  serious,  rest  in  the  horizontal  posture,  freedom  from  excitement,  bland,  nutritious, 
unstimulating  food,  being  essentials  under  all  circumstances,  the  great  principles  of 
practice  consisting  in  warding  off"  excess  of  reaction  and  inflammation  of  the  cranial 
contents. 


216  DISEASES  OF  THE  SCALP  AND   CRANIUM. 

DISEASES  OF  THE  SCALP  AND   CRANroM. 

Besides  the  blood  tumors  of  the  scalp  to  which  attention  has  been  already  directed, 
the  head  is  very  frequently  the  seat  of  the  common  skin  or  sebaceous  tumor  which  is 
called  a  ''  wen,"  these  morbid  growths  being  more  frequently  found  on  the  head  than  on 
any  other  part  of  the  body.  They  are  more  common  also  in  women  than  in  men,  seventy 
out  of  one  hundred  and  seven  consecutive  cases  of  sebaceous  cysts  which  I  have  analyzed 
having  occurred  in  women  and  eighty-four  on  the  head.  In  many  instances  these  wens 
are  doubtless  due  to  an  obstruction  of  the  duct  of  a  sebaceous  follicle,  as  the  orifice  of 
the  duct  is  often  visible  and  through  it  the  contents  of  the  cyst  can  be  squeezed  ;  while 
in  others  no  such  obstruction  can  be  made  out,  it  being  probable  that  .some  of  these 
tumors  are  new  formations — true  adenoid  tumors  of  the  skin,  such  tumors  usually  lying 
beneath  the  skin,  but  without  any  connection  with  it.  These  cases  have,  however,  been 
fully  considered  at  page  144. 

The  scalp  may  likewise  be  the  seat  of  other  tumors,  simjjle  or  malignant,  of  epithelial 
cancer  of  the  skin,  or  of  any  other  affection  of  the  integument.  These  require  no  special 
attention  here. 

NaBvi  are  very  common  in  all  their  forms — cutaneous,  subcutaneous,  or  mixed ;  but 
this  subject  will  be  considered  in  another  chapter.  Let  me  caution  the  student,  however, 
not  to  adopt  hastily  any  surgical  proceedings  with  a  ntevus  situated  over  a  fontanelle ; 
for,  although  such  may  be  dealt  with  with  impunity,  I  have  known  a  fatal  inflammation 
attack  the  membranes  of  the  brain  after  the  application  of  a  ligature  to  an  undoubtedly 
cutaneous  na^vus  placed  over  this  region.  If  possible,  he  should  wait  till  the  bones  have 
closed  before  he  interferes. 

Perforating  tumors  of  the  skull  occasionally  come  under  the  surgeon's  notice, 
and  demand  attention.  The  majority  of  them  have  their  origin  from  the  membranes  cov- 
ering the  brain,  and  mainly  from  the  dura  mater.  They  are  generally  cancerous  and  are 
often  secondary  deposits,  though  occasionally  they  seem  to  be  of  the  "  sarcomatous  " 
nature.  They  were  first  described  by  Louis  in  1744  under  the  term  ''  fungus  of  the 
dura  mater"  (Mem.  cle  TAcad.  Boj/.  tie  Chlr.,  tome  v.).  Since  his  day  all  perforating 
tumors  of  the  skull  have  been  included  under  this  heading.  It  must  be  remembered  that 
a  tumor  growing  within  the  skull  and  pressing  outward  will  cause  absorption  of  the  cran- 
ial bones ;  which  fact  is  rendered  familiar  to  pathologists  by  the  enlargement  of  the 
Pacchionian  bodies. 

Symptoms.- — The  symptoms  indicating  the  presence  of  this  aff'ection  are  very  uncer- 
tain, although  headache  more  or  le.ss  constant*  and  severe  may  exist  with  epileptiform 
convulsions  and  other  brain  symptoms  ;  yet  as  often  as  not  the  first  marked  condition  to 
which  the  patient's  attention  is  directed  is  a  swelling  in  one  of  the  bones,  the  disease  hav- 
ing progressed  thus  far  without  having  given  rise  to  any  symptoms  whatever.  When  the 
diseased  mass  has  perforated  the  bone,  the  swelling,  receiving  its  impulse  from  the  brain, 
will  be  pulsatile ;  and  this  symptom  is  of  importance  as  a  distinctive  one  between  tumors 
of  the  bone  itself  and  the  perforating  tumors  of  the  membranes.  In  cancerous  disease 
the  bone  itself  will  be  infiltrated  with  cancerous  elements  and  destroyed,  while  in  benign 
tumors  the  bone  will  be  absorbed  simply  by  pressure,  as  is  seen  in  aneurism.  In  the 
former  case  the  opening  in  the  bone  will  be  ill-defined  and  irregular,  and  in  the  latter  it 
will  be  smooth  as  well  as  regular. 

Treatment. — With  respect  to  treatment,  it  is  almost  needless  to  say  that  nothing  can 
be  done  by  way  of  removal  of  the  growth.  The  symptoms  to  which  it  gives  rise  can  only 
be  relieved  by  sedatives,  and  life  can  only  be  prolonged,  if  at  all,  by  general  treatment. 

The  bones  of  the  skull  are  liable  to  tumors,  cancerous  or  benign,  to  exostoses,  particu- 
larly of  the  ivory  kind,  and  to  myeloid  growths,  though  in  this  place  it  is  only  necessary 
to  mention  the  fact. 

Meningocele  and  Encephalocele. 

These  terms  are  applied  to  conditions  of  the  head  found  in  children  at  the  time  of 
birth,  and  infants  thus  aiFected  are  generally  hydrocephalic.  The  words  indicate  a  pro- 
trusion, a  hernia,  through  the  skull,  either  of  the  membranes  of  the  brain  or  of  the  brain 
itself,  the  protrusion  appearing  as  an  elastic  tumor  in  the  line  of  one  of  the  sutures.  Such 
cases  are  always  associated  with  some  deficiency  of  the  bones  of  the  skull — it  may  be  of 
some  portion  of  the  frontal  bone,  near  the  root  of  the  nose  (Fig.  83)  or  near  its  external 
angular  process,  and  by  far  the  most  frequently  of  the  occipital  bone.     In  rare  examples 


MENiy< ; 0(  'EL E  A SJ)   E.\(  El'JI. IL0( 'EL E. 


217 


the  tloticii'iit  V  may  Ik'  at  the  liase  of  the  skull.  I>r.  Mclitcriltcr^'  has  roconlud  a  case  in 
the  Tnniftfirh'iiiiH  nf  tin  PuthnUxjlritl  Sorlrtif^  vol.  xviii.,  in  which  the  tumor  was  haii^'iuc 
out  of  tlie  ehihl's  imiiitli  and  (•nimiimiicalinic  with  the  .-l^ull  thrmiL'h  an  o[M'nin;i-  in  front 
of  the  seMa  turcica. 

Varieties.  —  In  ii  inniinijiii;  h  the  incmhranes  may  protnich'  as  a  whoh-,  hut  sometimes 
the  dura   niatcr  ah)ue  projects  (c/iA  I'rcp.  inti.")"",  (luy's  Museum).      In  the  true  inirji/ut- 

/iiri/f  the   hrain  itself  is  pres.sed  out  of  tlie  skull  into  the 
J"'"-  ^•»-  external   tuiiuu'.      This  was  well   .seen   in  a   patient   from 

wlutin  the  accompany inj;  drawinj^  i^^^iC-  H4)  was  taken  ; 

the  skull  contained  the  anterior  and  part  of  the  middle 

lobes  of  tlie  brain,  and  the  sac  the  remainiiif.^  portions. 

Via.  84. 


Meninpocele  at  Root  of  Nose. 
(Mr.  Poland's  case.) 


Meningocele. 
(Drawing  501'«',  (iuy's  Hosp.  Mus.) 


The  ventricles  were  likewise  divided  between  the  two.  The  posterior  lobe.s  were  adherent 
to  the  membranes  that  formed  the  sac.  In  a  hydnncephalocch',  in  additimi  to  tlie  brain 
substance,  there  will  be  a  portion  of  one  or  both  of  tlie  ventricles  filled  with  fluid. 

"An  enceplmloci li\''  writes  Sir  P.  Hewett  (*SV.  Georcfe'ii  Ho!<p.  Rcji..  vol.  vi.j,  "is  of  a 
round  or  oval  .shape  ;  in  .size  it  seldom  exceeds  that  of  a  small  orange  ;  its  attachment  is 
broad  ;  the  integuments  covering  it  present  little  or  no  alteration.  In  the  earlier  periods 
it  has  the  characteristics  of  a  watery  bag.  but  later  on,  as  the  fluid  gradually  di.sappears, 
the  brain  matter  fills  the  sac,  and  then  the  tumor  becomes  soft  and  doughy." 

A  hyil rencephalorele  "•  in  shape  is  more  or  less  pyriform,  with  a  marked  contraction  at 
its  attachment,  and  sometimes  a  long  and  narrow  stem  ;  in  size  it  is  apt  to  become  much 
larger  than  an  encephalocele.  The  integuments  over  it  are  thinner ;  fluctuation  exi.sts 
about  the  hernia,  and  large  veins  may  be  traced  under  the  skin." 

When  the.se  tumors  are  small  and  have  a  very  minute  communication  with  the  cranial 
contents,  they  have  been,  and  may  be  again,  mistaken  for  some  simple  cyst  or  tumor. 
The  surgeon  should  therefore  always  suspect  that  a  cy.stic  tumor  situated  over  a  fonta- 
nelle  or  suture,  and  particularly  when  over  the  nose,  may  have  some  communication  with 
the  membranes,  and  he  should  coii.secjuently  po.stpone  all  operative  interference  till  the 
diagnosis  is  clear.  As  the  bones  ossify  the  opening  between  the  tumor  and  the  cranial 
contents  may  close.  The  cyst,  if  small,  may  then  be  excised  ;  if  large,  it  may  be  injected 
with  iodine  or  ^lorton's  iodo-glycerine  solution.  The  utmost  caution,  however,  must  be 
employed  in  the  treatment  of  these  cases,  and  where  uncertainty  exists  as  to  their  true 
nature  or  attachments  the  prudent  surgeon  had  lietter  leave  the  case  to  nature  than  risk 
life  by  any  hazardous  enterprise. 

Serous  cysts  simulating  encephaloceles  are  met  with.    Billnjth  {CUn. 

Siir;/., -p.  4ii)  and  Atlee  [  Auicriatii  Janni.  of  Mrd.  »SV/r'«ci".  January,  188.3)  have  each 
recorded  an  example.  Both  were  congenital  and  on  the  back  of  the  head,  with  serous 
contents.  In  Billroth's  case,  when  the  child  died,  the  cyst  was  found  to  consist  of  a  thin 
wall  with  a  very  smooth  lining.  It  lay  in  the  cellular  tissue  beneath  the  scalp  and 
was  entirely  removable  from  the  bone.  Atlee's  case  was  tapped,  and  two  ounces  of 
serous,  not  cerebro-spinal.  fluid  were  drawn  ofl"  with  success,  and  the  sac  subsequently 
withered. 

Ostitis  and  periostitis  of  the  bones  of  the  cranium  are  common  afl^ee- 

tions,  and  may  occur  either  as  a  conse(|uence  of  a  local  injurv.  of  svidiilis.  of  ostitis,  or 
of  other  causes.  They  are  also  often  associated  with  brain  complications.  Under  the 
heading  of  •'  Traumatic  Encephalitis  "  this  subject  was  discussed,  together  with  its  treat- 
ment, and  ostitis  coming  on  from  any  cause  other  than  injury  presents  very  similar  symp- 
toms.    I  have  seen  in  an   infant  periostitis  the   result  of  hereditary  syphilis,  and  ostitis 


218 


MENINGOCELE  AND  ENCEPHALOCELE. 


ending  in  necrosis.  I  have  seen  also  half  the  frontal  bone  of  a  babe  exfoliate  after  a 
punctured  wound  from  a  nail  without  any  brain  symptoms.  In  the  adult  the  complica- 
tions attending  inflammation  of  the  bones,  syphilitic  or  otherwise,  are  very  variable. 

Symptoms. — The  symptoms  are  generally  local  so  long  as  the  inflammation  is  con- 
fined to  the  periosteum  covering  in  the  bone,  the  chief  being  pain  and  tenderness  with 
local  swelling,  though  when  the  inflammation  has  spread  to  the  inner  periosteum  or  dura 
mater  other  symptoms  appear,  such  as  constant  headache  and  great  irritability  of  brain  ; 
any  worry  or  work  increases  pain,  causes  fever,  restlessness,  and  want  of  sleep.  As 
the  disease  progresses  delirium,  convulsions,  paralysis,  coma,  and  death  may  be  the 
result. 

The  inflammation  in  the  bone  may  go  on  to  suppuration  or  necro.sis,  and  the  dead 
bone  may  exfoliate  in  masses  (Fig.  85)  or  in  small  portions.  Should  no  external  outlet 
for  the  pus  form  or  be  made,  either  by  natural  processes  or  by  the  surgeon,  the  retained 
pus  within  the  skull  may  give  rise  to  symptoms  of  compression  of  the  brain,  when  it  is 
probable  that  the  brain  itself  and  its  serous  membrane  will  become  involved  and  the  case 
assume  a  most  serious  aspect.  It  is,  con.sequently,  a  point  of  gi-eat  importance  for  the 
surgeon  to  anticipate  such  a  complication,  and,  if  possible,  to  prevent  it. 

Treatment. — When  a  patient  has  had  a  blow  upon  the  head  and  been  either  the 
subject  of  syphilis  or  of  chronic  suppuration  of  the  ear,  and  as  an  after  symptom  has  a 
local  swelling  associated  with  pain  of  a  constant  and  wearying  character,  the  presence  of 
a  local  ostitis  should  be  suspected.  When  the  swelling  is  tender  to  the  touch  and  pain  is 
aggravated  by  local  pressure,  this  suspicion  should  be  strengthened ;  and  when  these  con- 
ditions are  attended  by  pyrexia  more  or  less  severe,  by  sleeplessness,  a  quick  irritable 
pulse,  and  a  contracted  pupil,  inflammation  of  the  bone,  probably  implicating  the  dura 
mater  within  and  the  periosteum  without,  may  safely  be  diagnosed.  Under  these  circum- 
stances a  free  incision  down  to  the  bone 
^^'^^  "^ '  should   be    made,   since   experience    has 

proved  that  by  the  adoption  of  this  prac- 
tice pain  and  other  symptoms  are,  as  a 
rule,  relieved,  and  serious  brain  compli- 
cations are  often  pi-evented.  When  ex- 
ternal suppuration  is  present  and  dead  or 
dying  bone  is  exposed,  it  is  less  common 
to  meet  with  cerebral  symptoms,  since 
the  pus  finds  its  way  externally  through 
the  wovxnd,  and  there  is  consequently 
less  irritation  of  and  pressure  on  the 
dura  mater,  as  well  as  less  brain  irrita- 
tion. Should,  however,  brain  complica- 
tions appear,  it  is  important  to  prevent 
their  spreading  for  the  surgeon  to  interfere,  as,  when  confirmed  brain  symptoms  have 
manifested  themselves,  the  case  is  almost  hopeless.  The  surgeon,  under  these  circum- 
stances, should  attempt  to  remove  the  necrosed  bone  or  perforate  it  by  the  trephine,  both 
these  operations  having  one  common  object — viz.,  to  give  free  vent  to  the  pus  beneath 
the  bone.  Indeed,  trephining,  under  such  circumstances,  is  not  only  a  ju.stifiable  but  a 
valuable  operation,  and  if  performed  with  care  can  do  little  harm.  When  operation  is 
postponed  till  confirmed  brain  symptoms  have  appeared,  there  is  too  much  reason  to 
believe  that  irremediable  changes  have  taken  place,  such  as  suppuration  within  the  hemi- 
sphere or  arachnitis,  which  no  operation  is  likely  to  relieve;  and  yet  "trephining"  has 
been  of  use  even  in  such  cases  when  complicated  with  epileptiform  convulsions.  The 
surgeon,  however,  should  anticipate  this  stage  of  the  disease  when  he  can  and  interfere 
before  such  symptoms  appear,  headache  of  a  local  and  persistent  character  associated  with 
evident  signs  of  local  ostitis  or  necrosis  being  always  an  indication  of  the  propriety  of 
trephining. 

I  need  hardly  add  that  constitutional  treatment  such  as  has  been  mentioned  under  the 
heading  of  "  Encephalitis,"  and  will  be  alluded  to  when  the  subject  of  syphilis  is  consid- 
ered, ought  to  be  carefully  followed  out. 

M.  Akan,  Archives  Genevales  cle  Medecine,  1844. — CoCK,  Gm.?/'.s  Hosp.  Reports,  1842. — Hewett, 
iSystevi  of  Surrjery,  by  Holmes,  3d  ed.,  1883. — Le  Gros  Clark,  Lectures  at  Royal  College  of  Surf/eons, 
1869. — Pott,  Injuries  of  the  Head,  1768. — Guthrie,  Coximentaries  on  Surgery,  1853. — Erichsen's 
Surgery,  5th  ed.,  1869.— Hutchinson's  Prize  Essay  (Astley  Cooper),  18(55. — Brodie,  Med.-Chir. 
Trans.,  vol.  xiv. — Wilks  and  Moxon's  Lectures  on  Pathology. — Callender,  St.  Bartholomew's  Hosp. 


Necro.sis  of  Frontal  Bone. 


(From  Emily  ,s- 
1S70.J 


*t  I'l,  June, 


Oy    TJilSMrs   AM)    TI'lTANVS.  219 

Reports,  \nh.  i.  and  iii. — IIii/roN,  "  (  linicul  Lectures,"  Lnnret,  1853. — NAlaton,  Alice's  edition, 
185."). — (i.vMA,  'J'railfM  ilfx  I'laie*  lU  Ti'te,  l.S.'}5.— Ada.Ms,  Ihnpir'n  Surg.  Dictioiutnj,  1801. — J.  Nkidoii- 
Ki;u,  M.D.,  I'rafiiie,  Udmlbitck  dir  Kreii/nchirun/ie,  18f)7.— I'liuxioKK,  N.  Leipzig,  18t)4. — Stroiiiever'rt 
oilitioii  nt'  W.  MacCdH.MAi's  XoleH  of  an  Atnhuldnre  Surgr.on,  1871. — Wk-st,  Mul.-Chir.  Traiw.,  1880, 
vol.  Ixiii. 

ON  TRISMUS  AND  TETANUS. 

WluMi  a  patient  i.s  the  sul)jt;i;t  <il"  an  uneuntiullahle  .spa.iinmlif  contraction  of  the  mu.s- 
clo.s  of  the  lower  jaw,  he  is  .said  to  have  "  (risiiins,"  or  h)ek-jaw  ;  and  wlien  the  same  con- 
dition attacks  other  or  all  the  voluntary  nui.seles  of  the  hody.  he  is  said  tr»  have  '■•  (efmius." 
Tetanus  includes  trismus,  and  jrcnerally  hejj^ins  with  it,  though  trismus  may  be  a  local 
attection.  It  is  found  in  children  as  a  result  of  dentition,  and  in  adults  as  a  (;oiise(|uenec 
of  diseases  involving  the  teeth,  gums,  or  jaws.  It  is  a  spasmodic  affection  produced  l>y 
reticct(Ml  irritation  set  uj)  by  a  local  disease,  is  rarely  ass(»ciated  with  any  constitutional 
disturl)ance.  and  is.  for  the  most  ])art,  cured  on  the  removal  of  its  cause. 

Varieties. — Tetanus  is  likewise  generally  as.sociated  with  some  local  source  of  irri- 
tati(Ui,  sonic  wound  or  injury,  and  is  then  called  '••  frinniKitir.'  When  no  external  or  visi- 
ble cause  can  be  made  out,  it  is  denominated  ''  Uliopntliir."  Wiieii  rapid  in  it.s  cour.se,  it 
is  called  "  tiriitt' ;"  when  slow,  ••■  clironir."'  The  acute  form  is  usually  the  re.sult  of  an 
accident,  and  generally  fatal.  The  chronic  is  for  the  mcst  part  idiopathic  and  more 
curable. 

Infantile  Tetanus. — Tetanus  is  met  with  in  new-born  infants,  and  is  then  known 
as  tris)iiiis  iKiaccutiniii  or  frdtmts  infantum.  It  usually  comes  on  the  second  week  after 
birth,  and  may  be  so  acute  in  its  course  as  to  destroy  life  in  from  ten  to  thirty  hours,  or 
life  may  be  prolonged  to  eight  or  nine  days.  It  is  a  common  affection  in  the  West  Indies, 
aiul  has  been  known  to  occur  frequently  in  ill-ventilated  lying-in  hos])itals.  Bad  ventila- 
tion, conse(|uently.  has  been  put  down  as  one  of  its  causes,  the  others  being  cold,  exposure, 
internal  irritation,  an<l  the  division  f)f  the  umbilical  cord. 

Predisposing  Causes  of  Tetanus. — Dismissing  the  last  form  of  the  disease 
from  our  consideration,  it  seems  that  tetanus  may  be  found  at  any  period  of  life,  though 
more  than  half  the  cases  occur  between  ten  and  thirty  years  of  age.  The  youngest  case 
on  record  was  in  a  child  of  twenty-two  months,  and  the  oldest  in  an  adult  of  seventy-five 
years. 

It  is  more  than  seven  times  as  common  in  males  as  in  females,  and  it  is  found  in  the 
healthy  as  frequently  as  in  the  cachectic ;  nor  do  the  intemperate  seem  more  prone  to  its 
attack  than  the  temperate.  It  is,  too,  as  frequent  in  the  winter  as  in  the  summer  months, 
though  in  warm  climates  the  natives  are  more  susceptible  to  its  attacks  than  Europeans. 
Exposure  to  damp,  cold,  or  sudden  changes  of  temperature  have  doubtless  a  powerful 
influence  in  exciting  this  disease,  in  both  the  idiopathic  and  traumatic  forms.  Larrey 
records  that  after  a  great  battle  a  hundred  soldiers  were  found  affected  by  it  in  one 
morning. 

Exciting  Causes. — Tetanus  is  rare  in  the  course  of  ordinary  surgical  disease, 
altliougli  it  may  follow  any  form  of  injury,  from  the  slightest  contu.sion  to  the  severest 
compound  fracture.  It  may  occur  after  the  extraction  of  a  tooth  or  the  gravest  operation 
in  surgery,  and  it  is  known  in  obstetric  practice  as  ^}«''/;/>e;7/Metanus.  It  is  most  common 
after  the  more  severe  varieties  of  accidents,  such  as  burns,  compound  fractures,  and 
injuries  to  the  fingers  and  toes,  though  there  is  no  evidence  to  prove  that  it  is  more  fre- 
quent after  slight  injuries  to  the  fingers  and  toes  than  to  other  parts.  Lacerated  seem  to 
be  more  frequently  followed  by  tetanus  than  incised  wounds,  particularly  in  children  ; 
but  the  state  of  the  wound  does  not  appear  to  have  any  influence  on  the  disea.se.  Seven 
years'  experience  at  Guy's  Ho.spital  gives  the  following  facts  (Poland)  : 

Tetanus  occurred  in  1  ca.se  out  of  1304  cases  of  major  and  minor  operations. 
"  "  9  cases      "       594      "     of  wounds  of  all  varieties. 

"  "  1  case        "       856      "     of  injuries  and  contusions. 

"  "  3  cases      "       456      "     of  burns  and  scalds. 

"  "  9     "  "       398      "     of  compound  fractures. 

23  3698      "     or  1  in  every  160  cases. 

Date  of  Appearance. — There  is  no  definite  period  at  which  tetanic  symptoms 
are  prone  to  appear.  When  they  set  in  soon  after  the  injury,  they  are  for  the  most  part 
acute  and  very  fatal ;  after  the  lapse  of  three  weeks,  the  chances  of  their  appearance  are 
very  small.  Acute  cases,  however,  occasionally  occur  during  the  second  week  ;  upon  this 
point  Poland  gives  us  the  following  facts : 


220  ON  TRISMUS  AND  TETANUS. 

Of  277  cases,  130  began  before  the  tenth  day,  and  of  these  101  died. 

"  "       126      "      between  the  tenth  and  twenty-second  days,  and  of  these  65  died. 

"  "         21      "      after  the  twenty-second  day,  and  of  these  8  died. 

In  tetanus  following  exposure  to  cold  the  symptoms  generally  appear  rapidly  after 
the  exciting  cause,  and  with  the  same  exciting  cause  similar  results  occur  in  the  trau- 
matic  form. 

Symptoms. — There  are  no  general  or  local  premonitory  symptoms  by  which  the  onset 
of  this  aifection  can  be  recognized,  and  the  earliest  indications  of  it>s  approach  are  gen- 
erally a  difficulty  in  opening  the  mouth  and  stiffness  in  the  muscles  of  the  lower  jaw  ;  yet 
these  symptoms  may  be  so  slight  as  to  pass  unheeded  or  be  misinterpreted.  When,  how- 
ever, some  rigidity  of  the  muscles  of  the  neck,  throat,  or  abdomen  can  be  made  out  and 
the  first  indications  of  the  "tetanic  grin,"  or  risus  sardoiiicii>' — which  is  caused  by  the 
drawing  down  of  the  corners  of  the  mouth  by  the  muscles  of  the  face — are  recognized, 
the  diagnosis  becomes  certain.  Difficulty  in  swallowing  will  then  soon  appear  (any 
attempt  to  drink  fluids  exciting  spasm  of  the  muscles  of  deglutition,  and  often  of  respira- 
tion), with  pain,  due  to  spasm  of  the  diaphragm,  shooting  through  the  body  from  the 
scrobiculus  cordis. 

As  the  disease  progresses  the  muscular  system  of  the  body  generally  will  be  more  or 
less  affected,  and  in  different  cases  different  groups  of  muscles  will  be  involved.  Those 
of  the  back  are  the  most  frequently  attacked,  and  their  contraction  may  be  so  powerful 
as  to  cause  an  arching  backward  of  the  frame,  producing  what  is  known  as  '■'■  opisthotonos.'" 
In  rare  cases  the  body  is  bent  laterally  or  forward,  the  terms  '■'■  jileurosthotonos'''  and 
"  emjirosthotonos  "  being  respectively  applied  to  such  conditions. 

The  muscles  of  respiration  are.  as  a  rule,  affected  in  acute  cases,  and  the  chief  danger 
to  life  consists  in  the  severity  of  the  spasms  which  attack  them.  When  severe,  the  first 
spasm  may  be  fatal  and  may  occur  at  an  early  or  at  a  remote  period  of  the  affection.  In 
a  case  under  my  care  of  severe  traumatic  tetanus  all  the  symptoms  were  disappearing 
and  recovery  was  confidently  expected,  when,  on  the  tenth  day  of  the  disease,  the  first 
spasm  of  the  laryngeal  muscles  took  place,  which  destroyed  life. 

When  the  jaw  is  unlocked  by  a  fepasm  of  the  depressor  muscles,  the  tongue  is  some- 
times suddenly  shot  out  from  between  the  teeth,  and  often  wounded. 

Progress  of  Disease. — As  the  disease  advances  the  jaws  become  completely 
fixed,  and  deglutition  is  then  impossible.  The  spasms  of  the  muscles  of  the  frame 
become  more  intense  and  frequent  and  the  powers  of  the  patient  rapidly  decline.  The 
pulse,  which  was  rapid,  becomes  more  feeble,  while  the  expression  of  the  countenance 
betokens  agony  of  the  body  and  despair  of  mind.  The  slightest  manipulation  or  move- 
ment of  the  patient  sets  up  a  fresh  spasm,  and  any  emotion  may  do  the  same.  The  skin 
becomes  bathed  with  a  cold  sweat;  and  if  death  is  not  caused  by  suffocation,  exhaustion 
soon  puts  an  end  to  suffering. 

There  is  rarely  any  fever  during  the  whole  course  of  the  disease ;  the  bowels  are 
always  costive,  the  stools  offensive,  and  the  urine,  as  a  rule,  natural. 

The  intellectual  faculties  of  the  patient  almost  always  remain  unimpaired  throughout, 
while  the  senses  are  morbidly  acute.      Anything  like  delirium  is  rarely  seen. 

Should  the  case  tend  toward  recovery,  the  spasms  will  become  milder  in  character  and 
recur  at  longer  intervals  till  they  disappear.  It  should  he  rcmemhered .,  however,  that  as 
long  as  the  slightest  evidence  of  disease  exists  a  sudden  sjJasni  of  the  glottis  may  at  any  time 
destroy  life. 

Diagnosis. — This  should  not  be  a  difficult  task,  and  in  every  instance  of  lock-jaw  the 
possibility  of  its  being  the  commencement  of  tetanus  ought  to  be  entertained.  Local 
irritations,  however,  may  produce  a  locking  of  the  jaw  more  or  less  complete ;  but  such 
are  never  accompanied  by  uncontrollable  spasm,  as  is  the  case  in  tetanus. 

To  diagnose  between  tetanus  and  poisoning  by  strychnine  may  be  difficult,  the  symp- 
toms of  both  being  very  similar ;  yet  in  tetanus  the  symptoms  are  progressive,  while  in 
poisoning  they  appear  suddenly  in  all  their  severity.  In  tetanus  muscular  rigidity  is 
always  present,  and  aggravated  at  intervals ;  in  poisoning  there  are  complete  intervals  of 
relaxation  of  muscle.  In  tetanus,  too,  there  is  constant  rigidity  of  the  muscles  of  the 
jaw  ;  in  poisoning,  the  jaw  is  never  locked  except  during  the  spasm.  These  points  of 
difference  are  sufficient  to  assist  the  surgeon  in  the  investigation  of  a  doubtful  case. 

Again,  hydrophobia  and  tetanus  have  been  mistaken  the  one  for  the  other;  but  any 
one  who  has  seen  the  former  disease  could  hardly  fall  into  such  an  error.  The  peculiar 
restlessness  of  mind  and  body,  the  complete  intervals  of  rest  and  absence  of  spasm,  the 
peculiar  aversion  that  is  shown  to  fluid,  accompanied  by  thirst — all  symptoms  character- 


ON  TRTSMUS  AM)   TETASUS.  221 

istic  *>['  liydrophobia — are  ciiouf.'!!  to  ilistiiit;uisli  between  the  two.  Nevertheless,  it 
shniild  hi'  rt'iiu'iiihtTcd  that  Dr.  J.  W.  Otrh-,  hitc  nf  St.  (Jeorge's,  lia.s  recorded  a  case  of 
tetanus  and  h3<lr(i|)liohia  coinhiiieil.' 

l'K(i(i.\(»sis. — III  acute  traumatic  cases  tiierc  are  small  Impes  of  recovery,  while  in 
chronic  the  chances  are  jxreater.  The  lonj;er  the  j)atient  lives,  the  better  .seem  the  pros- 
pects (if  a  fjood  result;  and  it"  ten  days  pass  after  the  tirst  appearance  of  tlie  .symptoms 
and  the  disea.se  is  on  the  decline,  the  projrnosis  is  i'avorable. 

Takiiit;  all  cases  toi;ether,  Poland  <;ives  one  recovery  to  seven  and  a  half  deaths.  More 
than  half  die  within  five  days.  The  most  rajtid  death"  has  been  in  from  i'our  to  live 
hours,  and  the  loni^icst  duratinii  of  life  on  record  in  a  fatal  case  is  thirty-nine  days. 

How  Death  is  Caused. — There  can  be  little  doubt  that  acute  tetanus  connuonly 
destroys  life  liy  apinea,  spasm  of  the  muscles  of  res])iration,  and  more  particularly  those 
of  the  larynx,  beinji;  the  immediate  cau.se.  Poland  tells  us  that  this  was  the  ca.se  in 
thirty-two  out  of  forty-six  cases  at  Guy's  Hospital  in  which  the  mode  of  death  was 
noticed. 

In  chronic  tetanus  death  is  commonly  caused  by  exhaustion.  These  facts  have  an 
inijiortant  bearinu'  on  the  treatment  of  the  disease. 

Patii(»i,(»(JV. — The  late  Mr.  William  King  of  Guy's  is  stated  by  Poland  to  have  been 
in  tlie  habit  of  remarking  at  the  post-mortem  table  whenever  there  was  an  examination  of 
a  case  of  death  from  tetanus,  '•Gentlemen,  we  will  now  proceed  to  give  you  a  demonstra- 
tion of  a  case  of  healthy  anatomy,  for  there  will  be  no  visible  morbid  appearances  other- 
wise than  congestion  of  the  organs  in  various  degrees,  owing  to  accidental  circumstances." 
And  at  the  present  day  these  remarks  hold  good.  It  is  true  that  Kokitansky.  Demme, 
Lockhart  Clarke,  and  JJickinsoii  have  given  us  some  descriptions  of  structural  changes  in 
the  spinal  cord  which  they  have  observed,  and  their  ob.servations,  moreover,  seem  to  coin- 
cide. These  changes  consist  of  disintegration  and  softening  of  a  portion  of  the  gray  sub- 
stance of  the  cord,  which  appears  in  certain  parts  to  be  almost  diffluent.  The  semi-fluid 
substance  thus  formed,  however,  "is  at  first  more  or  less  granular,  bedding  in  suspension 
the  fragments  and  particles  of  the  disintegrated  tissue,  but  in  many  ])laces  it  is  perfectly 
pellucid.''  Yet  it  is  to  be  remembered  that  Billroth  and  other  pathologists  have  failed  to 
find  these  changes  in  the  instances  which  they  have  examined,  and  it  cannot,  therefore, 
be  accepted  as  certain  that  these  pathological  conditions  are  constant  in  tetanus.  There 
can  be  little  doubt,  however,  that  the  nerves  of  the  injured  part  are  at  times  found 
inflamed  and  irritated,  and  from  this  fact  the  theory  has  been  advanced  that  through  the 
injured  nerves  of  the  ])art  the  spinal  centres  become  involved,  and  manifest  these  states 
of  excitement  through  the  motor  nerves  by  producing  muscular  spasm,  the  disease  being 
one  essentially  of  the  excito-motory  system.  Clarke  believes  "  that  the  spasms  of  tetanus 
dej)end  on  the  conjoined  operation  of  two  separate  causes :  First,  that  they  depend  on  an 
abnormalh'  excitable  state  of  the  gray  nerve  tissue  of  the  cord  induced  by  the  hypera'mic 
and  morbid  state  of  its  blood  vessels,  with  the  exudations  and  disintegrations  resulting 
therefrom  ;  second,  that  the  spasms  depend  on  the  persi-stent  irritation  of  the  ]>eripheral 
nerves,  by  which  the  exalted  excitability  of  the  cord  is  aroused."' 

Treatment. — Every  imaginable  form  of  treatment  has  been  employed  in  this  disease 
with  success,  to  be  discarded  in  its  turn  for  something  new.  No  settled  form  of  practice 
can  consequently  be  laid  down.  Still,  much  can  be  done  in  guiding  the  patient  through 
this  disease,  in  keeping  him  alive,  and  in  warding  off  death. 

To  keep  the  patient  alive  the  most  careful  attention  to  feeding  is  required,  milk  and 
concentrated  liquid  animal  food  being  the  best  diet.  If  these  can  be  taken  in  sufiicient 
quantities,  no  other  mode  of  administration  is  required;  but  if  not,  they  must  be  given 
as  enemata  every  four  or  six  hours,  as  the  case  demands.  Stimulants  must  be  used  cau- 
tiously, though  when  the  powers  are  failing  they  may  be  freely  given. 

Upon  this  principle  of  practice  quinine  has  been  strongly  recommended ;  it  may  be 
given  in  full  doses  to  an  adult,  such  as  five  grains  every  three  or  four  hours,  and  then 
increased,  or  in  one  large  dose,  such  as  twenty  grains,  to  be  followed  by  the  smaller  one. 

Among  specific  remedies  that  have  been  greatly  vaunted,  the  Calabar  bean  stands 
foremost,  and  may  be  trusted;  it  should  be  given  in  full  doses,  such  as  half  a  grain  of  the 
extract  every  two  or  three  hours,  or  one-twenty-eighth  of  a  grain  of  its  essential  prin- 
ciple, eserine,  increased  to  double,  even  the  tenth  of  a  grain.  Camphor  also  recommends 
itself  to  our  notice  in  doses  of  from  five  to  ten  grains.  The  woorara  poison  has  failed  in 
its  purpose.  The  bromide  of  ammonium  or  potassium  has,  however,  been  administered 
with  advantage. 

'  Bril.  and  For.  Med.  Reiieii:  1868. 


222  DELIRIUM  TREMENS. 

It  was  hoped  that  a  valuable  drug  for  this  disease  had  been  found  in  chloroform,  but 
experience  has  not  justified  the  expectation.  The  hydrate  of  chloral  has  now  taken  its 
place  and  been  of  some  service.  Demme  has  advocated  with  much  success  the  use  of  the 
curara,  eight  cases  out  of  twenty-two  having  recovered  under  such  treatment.  In  India 
the  Indian  hemp  has  been  highly  recommended.  Nicotine  and  tobacco  have  also  been 
successful.  Aconite  is  another  drug  that  offers  some  advantages,  while  opium  has  an 
unquestionable  influence  in  allaying  pain  and  mitigating  the  severity  of  the  spasm.  Ice, 
also,  applied  in  bags  along  the  spine,  has  apparently  been  of  great  value  in  the  hands  of 
American  surgeons.  The  administration  of  remedies  by  subcutaneous  injection  in  these 
cases  promises  to  be  a  valuable  adjunct  to  practice,  enabling  us  rapidly  to  introduce  into 
the  system  drugs  that  act  antagonistically  to  tetanic  spasm. 

The  patient  should  always  be  kept  quiet,  warm,  and  free  from  draught.  He  should, 
moreover,  be  so  watched  that  in  his  spasms  no  injury  can  be  sustained  ;  attention  should 
be  paid  to  his  bladder  and  bowels,  for  catheterism  is  sometimes  called  for;  and  purgatives 
and  enemata  to  clear  out  the  intestines  are  beneficial,  although  violent  purgation  cannot 
be  advised. 

Question  of  Amputation. — With  respect  to  hcaJ  treatment,  much  may  some- 
times be  done.  In  severe  local  injury  when  the  nerves  of  the  part  are  probably  involved 
amputation  ought  certainly  to  be  performed,  for  a  sufficient  number  of  cases  have  been 
recorded  in  which  success  has  followed  the  practice.  In  1845,  Mr.  Key  amputated  a  leg 
on  account  of  tetanus  which  had  appeared  six  days  after  an  unreduced  dislocation  of  the 
astragalus;  the  symptoms  disappeared  at  once  after  the  operation.  On  dissecting  the  foot 
the  posterior  tibial  nerve  was  found  to  have  been  put  violently  on  the  stretch  by  the  pro- 
jecting astragalus. 

In  some  cases  soothing  applications,  such  as  opium,  may  be  applied  to  the  wound,  and 
in  all  perfect  cleanliness  should  be  enforced. 

One  other  means  of  cure  remains  to  be  noticed  which  has  reference  to  the  mode  of 
death  in  this  disease.  It  has  been  shown  that  in  the  larger  proportion  of  cases — in  all 
the  acute — death  is  caused  by  suffocation  from  spasm  of  the  laryngeal  muscles.  It  is 
also  fairly  recognized  that  this  disease  runs  its  course,  and  that  the  most  our  science  can 
accomplish  is  to  maintain  life  and  ward  off  death.  To  this  end  the  operation  of  trache- 
otomy seems  to  be  of  value,  for  with  a  tube  in  the  trachea  death  by  laryngeal  spasm  can- 
not take  place,  and  a  better  prospect  of  recovery  is  consequently  given. 

I  have  employed  this  practice  in  one  acute  case,  in  which  the  Calabar  bean  was  like- 
wise given,  and  the  patient  sank  from  exhaustion,  free  from  spasm  ;  and  there  seems  good 
reason  to  believe  that  if  I  had  performed  the  operation  in  the  case  I  recorded  in  the  early 
part  of  this  chapter  life  would  have  been  saved.  This  matter,  however,  requires  grave 
consideration,  and  the  practice  is  not  to  be  rashly  followed. 

Morgan,  On  Tetanus,  1833. — Curling,  On  Tetanus. — Poland,  Guy's  Hospital  Reports,  1857. — 
Dr.  Ogle,  Brit,  and  For.  Med.  Review,  1868.— Dr.  Dickson,  Med.  C'hir.  Trans.,  vo\.  vii. — Dr.  L. 
Clarke,  ibid.,  vol.  xlviii. — Dr.  Dickin.son,  ibid.,  vol.  11. — Demme,  Schmidt's  jahrb.,  vol.  112. — 
TiiAMHAYN,  O.,  (■6i(/.— Fea/'-£ooi-,  Sydenham  Society,  1862-64,  etc.— "  Puerperal  Tetanns,"  Dublin 
Quart.  Jour.,  1865;  Med.  Times  and  Gaz.,  1865. — Billroth,  Pathol.  Chirurg.,  1868. 

DELIRIUM  TREMENS. 

It  often  falls  to  the  surgeon  to  treat  cases  of  pure  delirium  tremens  uncomplicated 
with  any  surgical  malady,  and  it  is  well,  therefore,  to  refer  to  this  subject  by  itself. 
There  are  other  cases,  perhaps,  more  aptly  described  by  the  term  "  traumatic  delirium" 
in  which  the  nervous  symptoms  are  developed  as  a  consequence  of  an  injury  received. 
In  both  classes  the  symptoms  are  essentially  the  same  and  the  treatment  required  is  sim- 
ilar; still,  it  is  right  to  bear  in  mind  the  difference  in  causation,  as  in  the  one  we  have  to 
deal  with  a  nervous  disease  in  an  intemperate  person,  and  in  the  other  with  the  same 
symptoms  as  an  incident  in  a  surgical  case.  In  simple  delirium  tremens,  to  use  the 
familiar  term,  we  have  to  deal  with  the  case  of  a  person  who  has  indulged  for  an  uncer- 
tain time  in  injurious  doses  of  alcoholic  liquors.  It  may  be  that  a  young  man  after  a 
prolonged  debauch  has  an  attack  of  the  "  horrors,"  but  the  symptoms  more  frequently 
occur  in  those  who  have  for  a  long  period  accustomed  themselves  to  the  excessive  use 
of  beer  or  spirits,  even  without  amounting  to  drunkenness,  and  who  at  length  are  sub- 
jected to  some  shock  or  depressing  influence.  Inasmuch  as  the  habits  which  have  been 
mentioned  as  superinducing  this  disease  are  opposed  to  the  simplest  laws  of  health,  it 
follows  that  they  cannot  be  indulged  in  with  impunity  for  long,  and  consequently  we  find 


DELIRH'M    rilKMESS.  223 

the  subjocts  of  if,  as  a  rule,  ol"  t'rclilc  |M)\vcrs  of  rcsistiiiicc  ami  ol'tcti  with  disoascti  vIh- 
cera.  Sucli  persons  arc  hatl  siihjcfts  I'nr  any  aihnfrit,  and  it  often  lia|t|M'iis  that  when  a 
person  ol'this  sort  breaks  his  h'U'  or  meets  with  some  injury  rc(|niriii^'  sur;_'ical  treatnn-nt 
he  becomes  the  subject  of  (U'lirium  tremens.  Other  causes  are  oceasionally  at  work,  such 
as  starvation,  mental  an.viety.  ami  the  overuse  of  tobacco  or  opium. 

'Pile  disease  is  at  times  ushered  in  by  certain  premonitory  symptoms,  as  patients  who 
have  onci'  been  the  subject  of  an  attack  are  sometimes  conscious  of  tin;  approach  of 
another.  .\  brewer  who  liad  been  treated  for  this  affection  at  («uy's  some  years  af,'o,  when 
lie  felt  warninj:;s  of  its  advance  on  several  occasions  applied  for  admission,  and  as  a  result 
the  attack  was  warded  off. 

Depression  of  mind  and  de))re.ssioii  of  body  are  the  chief  premonitory  .symptoms, 
with  restlessness  and  agitation,  <floom,  and  foreboding  of  evil.  Home  slight  febrile  dis- 
turbance may  also  exist,  but  the  out'  invarialile  and  most  important  symptom  is  sleepless- 
ness. The  tongue  is  generally  pale  and  flabby,  as  well  as  coated  with  a  whitish  i"ur,  and 
is  never  dry.  The  appetite  is  bad.  the  breath  often  fetid,  and  the  bowels  confined.  The 
pulse  may  be  quick,  though  soft  and  powerless.  Tiie  skin  is  always  moist,  and  at  times 
bathed  in  perspiration.  With  the.se  .sym]»toms  the  characteristic  delirium  with  trembling 
is  not  far  off.  It  may,  however,  in  surgical  practice  set  in  suddeidy  without  warning. 
The  nature  of  the  delirium  is  very  characteristic  and  is  always  accompanied  by  allusions 
which  are  generally  spectral.  The  patients  see  objects  that  do  not  exist  and  hear  sounds 
that  are  imaginary,  these  being  always  of  a  strange  or  frightful  nature.  At  times  some 
delusion  as  to  business  or  home  matters  agitates  the  mind.  These  same  unsound  ideas 
are  sometimes  fixed  during  the  whole  attack,  but  more  commonly  succeed  one  another  in 
rapid  rotation.  Sleeplessness,  under  these  circumstances,  is  a  constant  accompaniment. 
The  patient  will  be  quiet  for  a  time,  muttering  words  without  meaning,  or  he  will  be  rest- 
less and  get  out  of  bed  in  obedience  to  some  imaginary  call.  He  will  pull  about  his  bed- 
clothes, will  rise  up  in  bed  at  one  moment  under  one  impression  and  lie  down  again  under 
another.  If  asked  to  put  out  his  tongue,  he  will  do  so,  but  probably  with  a  jerk  ;  if  to 
give  his  hand,  he  will  project  it  with  a  thrust.  A  nervous  trembling  of  the  extremities, 
with  an  utter  want  of  control  or  steadiness  of  purpose,  is  characteristic.  If  the.se  symp- 
toms continue  and  rest  cannot  be  obtained,  prostration  of  all  the  powers  will  rapidly 
appear  and  death  will  supervene  from  exhaustion  or  coma.  If  sleep — sound  sleep — can 
be  .secured,  the  symptoms  usually  mitigate  rapidly. 

The  PROGNOSIS  must  depend  on  several  considerations.  If  the  patient  be  young 
and  the  attack  ensue  after  a  short  period  of  drinking,  the  chances  of  recovery  are  hope- 
ful ;  but  if  the  attack  occur  in  a  man  of  middle  age  habituated  to  overdrinking,  and  if 
his  liver  or  kidneys  be  unsound,  it  is  fraught  with  much  greater  danger.  If  the  attack 
be  associated,  moreover,  with  an  injury  such  as  a  wound  or  fracture,  another  element  of 
danger  is  introduced.  The  best  guide  to  the  patient's  real  condition  is  the  study  of  the 
pulse — not  merely  as  to  the  number  of  its  beats,  but  with  regard  to  its  character.  The 
sphygmograph  is  of  great  service  in  such  cases,  as  by  its  help  a  '•  dicrotic  "  state  of  pul.se 
is  often  shown  where  the  finger  would  not  indicate  it ;  and  such  a  condition  is  a  bad  omen. 
The  most  frecjuent  ciunplication  is  pneumonia,  which  often  comes  on  rapidly  and  insidi- 
ously and  is  a  frequent  cause  of  speedy  death  even  when  the  excitement  has  subsided. 

Treatment. — This  disease  essentially  being  one  of  depression  of  the  nervous  system 
associated  with  sleeplessness,  the  main  object  of  the  surgeon  is  to  induce  .sleep,  to  calm 
the  excited  brain,  and  to  give  it  time  to  recover  its  normal  functions ;  and  with  this  end 
absolute  quiet  and  the  use  of  bland  and  nutritious  food  are  most  essential. 

Easily-digested  nutritious  food  mu.st  be  administered  when  it  can  be  taken  by  the 
mouth  ;  but  when  refused  or  rejected,  resort  must  be  had  to  enemata.  Milk  is  undoubtedly 
the  most  suitable  form  of  nourishment,  either  alone  or  mixed  with  eggs ;  but  it  does  not 
suit  all  stomachs.  The  question  of  giving  stimulants,  and  to  what  extent,  is  one  of  great 
importance.  As  a  rule,  the  less  given  the  better,  but  in  some  cases  it  is  advisable  to  give 
them  ;  and  that  form  of  alcohol  to  which  the  patient  has  been  accustomed  is  the  best. 
Young  men  with  an  acute  attack  may  do  well  without  any,  but  in  other  cases  the  feeble 
powers  of  the  patient  re<(uire  some  such  aid  to  stand  against  the  exhaustion  caused  by 
the  restlessness  and  excitement.  The  chief  reliance,  however,  should  be  placed  on  other 
forms  of  food,  such  as  strong  animal  broths.  Darby's  fluid  meat,  or  .similar  preparations. 

Opium  in  one  of  its  forms  is  a  drug  still  in  favor,  although  some  reject  its  u.se  alto- 
gether and  trust  to  feeding  and  time,  relying  upon  the  knowledge  that  the  disease  has  a 
natural  tendency  to  terminate  in  sleep  after  the  second  or  third  day.  In  an  ordinary  case 
of  the  disease  one  grain  may  be  given  as  a  dose,  or  ni^xx  of  the  tincture,  repeated  every 


224  SHOCK  AND  COLLAPSE. 

tliree  or  four  hours  or  oftener.  till  sleep  is  procured.  In  other  cases  two  or  three  grains 
may  be  given  at  once  and  followed  by  grain  or  half-grain  doses. 

The  best  naethod  of  administering  drugs  in  this  disease,  however,  is  by  subcutaneous 
injection  :  and  I  recommend  the  injection  of  morphia  in  solution  in  doses  of  a  quarter  or 
half  a  grain  in  preference  to  any  other  plan,  because  the  condition  of  the  stomach  of 
patients  suffering  from  the  disease  is  far  from  satisfactory  either  for  absorption  or  assimila- 
tion, and  by  the  hypodermic  method  of  introducing  the  narcotic  into  the  system  its 
absorption  is  more  certain  and  rapid.  In  some  cases  the  beneficial  influence  of  morphia 
thus  employed  is  very  remarkable,  and  only  in  exceptional  instances  the  treatment  fails. 

The  use  of  chloroform  has  also  been  urged,  though  such  a  plan  is  not  devoid  of  dan- 
ger and  can  hardly  be  advised  except  for  some  temporary  purpose,  such  as  to  dress  a 
wo«nd  or  to  enable  an  enema  to  be  given.  The  hydrate  of  chloral  is  a  drug  of  great 
value  as  possessing  hypnotic  qualities  without  the  evils  attendant  on  other  drugs  of  this 
class.  It  may  be  given  in  doses  of  twenty  or  forty  grains,  and  repeated  at  moderate 
intervals  till  sleep  is  procured  ;  when  combined  with  ten-grain  doses  of  the  bromide  of 
potassium,  it  seems  to  be  of  more  use.  Drs.  Kinnear  and  Lawson  in  the  Melville  Hos- 
pital have  treated  from  seventy  to  eighty  cases  successfully  with  large  doses  of  cayenne 
pepper,  from  twenty  to  eighty  grains  having  been  given  as  a  dose.  Dr.  Maclean  of  Net- 
ley  trusts  to  quiet  and  the  use  at  short  intervals  of  strong  beef  tea  highly  charged  with 
cayenne  pepper. 

Of  late  years  the  value  of  digitalis  has  been  greatly  extolled,  but  vl\\  experience  of  it 
has  not  been  favorable.  It  is  given  in  large,  if  not  poisonous,  doses,  such  as  two  drachms 
of  the  tincture  every  hour  for  three  or  four  doses  till  sleep  is  produced.  It  is  a  dangerous 
mode  of  treatment,  and -cannot  be  recommended. 

When  great  excitement  and  some  fever  exist,  antimony  in  small  doses  has  been  much 
advocated.  The  condition  of  the  bowels  almost  always  demands  attention,  as  the  tongue 
is  usually  foul  and  the  secretions  morbid.  A  purge  sufficient  to  empty  the  colon  is  con- 
sequently of  service,  but  violent  purgation  is  injurious. 

Tonics,  such  as  quinine  and  iron,  with  or  without  opium,  will  be  required  as  the 
disea.se  .subsides.  The  combination  of  the  tincture  of  iron  with  the  tincture  of  opium  in 
carefully  regulated  doses  is  preferable.  In  other  cases  ammonia  with  bark  may  be 
administered. 

Question  of  Restraint. — With  respect  to  coercive  measures  in  the  treatment  of 
these  cases,  there  is  no  doubt  that  they  ought  to  be  condemned.  In  exceptional  instances, 
where  sufficient  help  cannot  be  obtained  to  prevent  the  patient  from  injuring  himself  or 
others,  the  jacket  doubtless  must  be  employed,  but  under  no  other  circumstances  is  it 
justifiable.  An  attendant  who  combines  decision  of  character  and  firmness  with  a  gentle 
and  soothing  manner  will  almost  always  succeed  in  '■  influencing"  the  most  troublesome 
patient.  He  is  to  inflvpnce  him,  however,  and  not  to  direct  him  :  for  contradiction  and 
the  exercise  of  authority  over  the  subjects  of  this  disease  invariably  excite  opposition. 

Chronic  Intemperance. — There  are  some  people  who  are  never  drunk,  yet  are 
always  drinking — in  whom  the  tissues  are  so  weak  that  under  injury  they  rapidly  break 
up  and  under  disease  show  no  power  of  repair.  In  such  it  is  difficult  to  induce  wounds 
to  heal  or  show  any  vigorous  action. 

The  best  remedy  is  to  supply  such  patients  with  all  sorts  of  nutritious  food,  to  give 
tonics  and  a  moderate  amount  of  stimulants,  and  thus  endeavor  to  improve  their  habits 
as  well  as  restore  them  to  a  more  healthy  tone. 

SHOCK  AND  COLLAPSE. 

Sh.OCk. — A  man  receiving  unexpectedly  some  startling  news  which  excites  severe 
emotion,  and  dying  suddenly,  is  said  to  die  from  shock  ;  a  .second  receives  a  fatal  blow 
upon  the  epigastrium  ;  a  third  is  struck  dead  by  lightning  :  death  in  each  case  is  said  to 
be  due  to  .shock.  In  all  the  heart's  action  is  suddenly  arrested  through  the  nerve  centre 
— in  one  case  through  the  mind,  and  in  the  others  through  the  body.  Under  these  cir- 
cumstances the  heart  is  found  full  of  blood,  distension  having  paralyzed  its  action. 

Collapse. — A  man  receives  a  severe  compound  fracture,  gunshot  or  other  injury, 
and  is  not  killed,  but  collapsed.  Another,  or  possibly  a  child,  is  much  burned  or  has  a 
large  portion  of  the  integuments  of  a  limb  torn  away  or  crushed,  in  which  the  peripheral 
nerves  are  seriously  involved,  and  as  a  result  reflex  paralysis  of  the  heart  occurs.  Both 
have  sustained  a  shock  more  or  less  intense,  and  as  a  consequence  become  cold  and 
almost,  if  not  quite,  pulseless.     In  either  case  the  skin  appears  to  be  bloodless  and  cov- 


sirof'K  A\i>  foLLM'si-:.  225 

ert'd  with  ;i  cold  claniiiiy  swi'at.  lie  may  lircallic  aliintst  iiiipcrccptildy,  fctrlily,  or  with 
sijj;hs  and  ;;as|>s.  His  imstrils  will  innliahly  he  dilaliMl,  his  eyes  ilull,  his  vision  imperfect, 
and  eonseioiisncss  may  In-  lost  in  vny  variaMe  de<;rees ;  the  patient  may  j)ossil»ly  he 
roused,  yet,  as  a  riUe.  he  n-ijuires  roiisin<;  to  prove  the  existence  of  consciousness.  At 
otiu'r  times  the  intellect  remains  quite  clear. 

'riu'se  are,  briefly,  the  sii^ns  of  c(dlapse  or  shock  the  result  of  injury.  They  are  to  be 
found  in  variable  decrees  after  most  accidents,  and  are  by  no  means  usually  fatal  urdes.s 
the  injury  it.self  is  fatal.  Of  course,  if  the  shock  from  the  injury  is  very  jrreat,  the  heart 
may  cease  to  l»eat  and  the  luiijis  to  breathe,  collapse  passing  more  or  li!ss  slowly  into 
death  ;  but  m()rt^  usually,  after  a  variable  period,  the  heart's  action  frradually  improves, 
the  respiratory  act  becomes  more  rcLiular,  and  jicrfect  color  returns  to  the  bloodless  lip.s 
and  skin,  w.irmth  rcap]icars  on  the  surface  of  the  body,  and  consciousness  becomes  more 
manifest.  Tlu'se  syni|)toms  indicate  what  is  known  as  reaetimi  ;  and  when  they  are 
excessive,  febrili'  .symptoms  nuiy  appear.  It  sliould  be  noted  that  voniitin<r  is  often  the 
first  indication  of  reaction  in  jrcneral  collapse,  as  it  is  often  in  that  of  head  injuries.  Should 
the  nature  of  the  accident  be  such  that  heni<jrrha<r(;  complicates  the  ca.se,  the  collapse 
will  be  more  lasting,  the  shock  of  the  accident  passing  into  collap.se  from  hemorrhage ; 
under  such  circumstances  a  fatal  result  is  very  likely  to  ensue  (the  amount  of  bleeding 
and  its  rapidity  determining  the  result),  for  it  should  be  known  that  hemorrhage  by 
it.self  is  enougli  to  produce  collapse,  or  syncope,  and  this,  addcil  to  the  shock  of  the 
injury,  is  often  more  than  enough  to  destroy  life.  Li  abdominal  injuries  this  combina- 
tion is  well  .seen,  the  hemorrhage  from  a  lacerated  liver  or  other  organ,  as  a  rule,  appear- 
ing with  the  first  manifestations  of  reaction  from  the  .shock  of  the  accident,  and  thereby 
proving  fatal. 

The  longer  the  reaction  is  delayed,  the  more  grave  is  the  a.spect  of  the  case  ;  not 
nnfrecjuently  relapses  appear,  signs  of  reaction  and  of  collapse  alternating  in  variable 
degree,  till  one  or  the  other  asserts  itself  in  recovery  or  in  death. 

In  rare  cases,  even  from  the  .shock  of  a  slight  accident,  reaction  is  followed  by  excep- 
tional symptoms  ;  thus  I  had  a  man  under  care  who  was  admitted  with  a  slight  concus- 
sion of  the  brain,  in  whom  reaction  was  attended  with  an  acute  attack  of  maniacal 
excitement  which  left  him  after  two  days  to  pass  on  to  a  steady  convalescence,  A  woman 
with  a  similar  injury  attended  with  a  scalp  wound  had  a  like  attack,  which  lasted  a  fort- 
night and  then  subsided  without  any  bad  results.  I  have  recorded  also  in  another  page 
a  ease  of  general  tetanic  spasm  which  showed  itself  in  the  reaction  after  a  ca.se  of  spinal 
injury.  More  commonly,  however,  reaction  is  attended  with  what  Travers  has  described 
as  '-prostration  with  excitement" — a  state  bordering  on  and  often  passing  into  that  known 
as  delirium  tremens. 

Under  some  conditions  of  the  S3'stem  shock  and  collapse  are  more  readily  produced 
than  at  others  ;  thus  very  young  and  very  old  subjects,  those  enfeebled  from  age  or 
other  cause,  mental  or  physical,  are  ])articularly  apt  to  die  of  shock  after  injury  or 
operation.  When  bones  are  involved  in  the  injury  and  .symptoms  of  '•  shock"  appear 
after  a  day  or  two's  satisfactory  progress.  Professor  Nussbaum  believes  them  to  be  due  to 
fat  embolism  as  evidenced  by  severe  dyspnoea,  oedema  of  lungs,  and  sudden  death. 
Patients  with  bad  kidneys,  also,  are  very  liable  to  suffer  from  shock  and  to  succumb  to 
any  operation,  however  trivial.  Surgeons  see  this  at  times  in  the  sinking  after  small 
operations.  Thus  I  lost  some  years  ago,  after  the  removal  of  a  fatty  tumor,  a  woman  of 
middle  age,  simply  from  asthenia,  the  operation  having  been  unattended  by  any  loss  of 
blood  :  also  a  child  vet.  8  after  some  operation  on  a  cicatrix  of  the  neck  in  the  .same  way. 
In  both,  bad  kidneys  were  found  after  death.  The  idio.syncrasy  of  the  individual  has 
ahso  a  powerful  influence  on  "  shock." 

Treat.ment. — Shock  or  eollap.se  uncomplicated  with  hemorrhage  may  be  treated  in 
one  way.  shock  or  collapse  the  consequence  of  or  combined  with  hemorrhage  in  another. 

In  both  cases  the  hearts  action  must  be  either  excited  or  maintained;  ''the  heart 
must  beat  and  the  patient  must  breathe."  or  life  will  fiiil.  Even  in  the  worst  cases,  as 
long  as  any  signs  of  life  exist,  the  respirator}'  process  may  be  aided  by  artificial  respira- 
tion and  the  warmth  of  the  body  kept  up  by  external  applications.  Savory  in  an  able 
article  (llohurs's  Si/ste7n,  ed.  2,  vol.  i.)  advises  as  the  result  of  experiment  and  reasoning 
that,  should  no  evidence  of  the  heart's  action  be  detected  and  no  hemorrhage  con)plicate 
the  case,  a  vein  should  be  opened— ^as  the  external  jugular — in  order  that  the  overdis- 
tended  heart  may  resume  its  action  as  soon  as  it  is  relieved  from  its  paralysis  by  distension. 

In  the  extreme  collapse  following  hemorrhage  transfusion  is  also  "  a  fair  and  rational 
expedient." 


226  SHOCK  AND   COLLAPSE. 

In  less  severe  examples  the  surgeon's  object  should  be  to  keep  the  patient  alive,  but 
he  ought  not  to  try  to  do  more,  as  to  force  nature  is  always  injurious,  and  sometimes  fatal. 
The  failing  powers  of  a  feeble  subject  may  be  excited  to  act  only  to  give  way  again  ;  they 
may  not  a  second  time  respond  to  the  former  stimulant. 

A  too  rapid  reaction  may  so  stimulate  the  heart  as  to  set  up  a  fatal  hemorrhage,  when 
by  the  collapse  the  wounded  artery  might  have  become  sealed  by  nature's  own  blood-clot. 

In  all  cases  of  shock  and  collapse,  therefore,  complicated  with  lucal  injury,  great  judg- 
ment is  called  for.    To  do  enough  to  maintain  life  is  essential,  but  to  do  more  is  injurious. 

The  horizontal  position  under  all  circumstances  should  be  observed,  and  external 
warmth  secured  by  means  of  blankets  and  hot  flannels  applied  to  the  pit  of  the  stomach. 
Sir  J.  Simpson's  i)lan  of  applying  heat  to  the  body  is  very  beneficial — by  filling  six  or 
eight  soda-water  bottles  with  boiling  water  and  tightly  corking  them,  and  then  drawing- 
over  each  a  woollen  stocking  wrung  out  of  hot  water.  The  bottles  so  covered  are  then 
to  be  packed  around  the  patient  in  bed.  Stimulants  in  carefully  adjusted  (juantities  may 
be  given,  and  brandy  is  the  best.  This  should  be  given  in  small  quantities;  and  if  the 
heart's  action  fail  to  respond  to  its  administration  after  two  ounces  or  so  have  been  swal- 
lowed, more  is  of  little  service,  the  stomach  usually  rejecting  it.  When  the  stomach 
rejects  brandy  or  the  patient  cannot  swallow,  an  enema  of  brandy  in  warm  starch,  milk, 
or  gruel  sometimes  acts  very  rapidly.  As  soon  as  the  heart's  action  is  estal)lished  liquid 
food,  such  as  warm  milk,  may  be  given,  though  only  in  small  quantities,  and  the  case 
should  be  carefully  watched  ;  food  and  stimulants  should  be  given  with  discretion  and  as 
the  symptoms  indicate,  the  greater  the  loss  of  blood,  the  greater  being  the  necessity  for 
food. 

Excess  of  reaction  is  to  be  checked  by  soothing  remedies  — ojiium  in  any  of  its  forms, 
henbane,  and  chloral  are  also  very  valuable — a  few  hours'  calm  sleep  generally  acting  like 
a  charm  ;  yet  when  brain  comjilication  appears,  this  treatment  is  to  be  adopted  with  care. 
Anything  like  coma  contraindicates  it. 

Amputation  in  Collapse. — In  compound  fractures  and  other  local  injuries 
demanding  operation  the  question  of  operating  on  a  patient  in  a  state  of  shock  is- 
important.  Can  the  operation  act  as  a  stimulant  and  tend  to  rouse  him?  or  may  it 
act  as  a  second  shock  and  tend  the  other  way  ? 

When  the  shock  is  severe  and  the  patient  almost  pulseless,  it  is  doubtless  the  wiser 
plan  to  postpone  all  operative  interference  till  the  heart's  action  is  re-established.  To 
amputate  a  limb  under  extreme  collapse  is  to  destroy  what  chance  of  life  exists  or  to  do 
an  unnecessary  operation.  To  amputate  when  reaction  has  set  in  after  the  lapse  of  a  few 
hours,  when  external  warmth,  stimulants,  and  tonics  have  had  their  influence,  is  likel}'  to 
prove  successful. 

In  less  severe  examples  of  collapse,  however,  the  same  practice  does  not  seem  to  be 
necessary,  especially  when  hemorrhage  has  been  the  partial  cause  and  is  still  continuing,, 
because  the  loss  of  very  little  extra  blood  by  oozing  forbids,  when  collapse  is  present,  any 
hope  of  a  good  reaction  being  established  ;  and  under  such  circumstances  no  benefit  can 
be  acquired  by  delay,  but  only  harm.  The  administration  of  an  anfesthetic  has,  more- 
over, a  stimulating  influence  upon  the  heart  and  nervous  system  which  is  often  very  val- 
uable. I  have  fre((uently  performed  primary  amputation  upon  subjects  in  a  state  of 
partial  collapse  after  injury  under  these  cii'cumstances,  and  have  never  regretted  it. 

With  a  patient  in  a  state  of  collapse  no  amputation  should  be  performed  when  by 
delay  no  harm  can  accrue.  When  hemorrhage,  however  trivial,  is  going  on  or  is  likely 
to  recur  at  any  moment,  the  surgeon  should  interfere  and  remove  the  part  when  it& 
removal  is  essential.  When  the  collapse  is  associated  with  semi-consciousness,  chloro- 
form is  not  needed,  the  operation  itself  acting  as  a  sufficient  stimulant ;  but  when  the 
mind  is  clear  as  to  what  is  going  on,  its  use  .should  not  be  withheld,  because,  although  it 
is  true  its  secondary  effects  are  sometimes  depressing  and  may  be  injurious,  in  a  general 
way  it  has  a  beneficial  influence  and  tends  to  prevent  a  second  shock,  both  mentally  and 
physically. 

When  Extreme  Collapse  Exists. — "  How  far,"  writes  Savory,  '•  the  patient 
should  be  allowed  to  rally,  and  when  he  has  reached  that  state  which  will  enable  him  to 
bear  the  operation,  are,  of  course,  questions  which  cannot  be  answered  in  a  general  man- 
ner, but  which  must  be  decided  by  the  surgeon  in  each  case." 

When  the  surgeon  is  in  doubt  about  acting,  he  had  better  decide  in  favor  of  delay. 
When  no  doubt  exists  as  to  the  wisdom  of  removing  an  injured  part  and  by  delay  harm 
must  or  may  probably  ensue,  he  should  act  at  once,  even  when  the  patient  has  not  quite 
rallied  from  the  shock  of  the  injury.     When,  so  far  a%  the  local  injury  is  concerned,  the 


rh'ii;M:i>  wn  iivsrhn/cAL  o/:  Mnii('Ki:i>  disease.  Til 

(Iclav  nt'  a  I'rw  (la\>  (ir  Imiirs  is  iiiiiiii|iiiitaiit .  all  ii|icrat  ivt;  iiitfriVrciicc;  should  be  post- 
|i(iii(-il. 

ill  severe  e(iiii|MMiii(l  IVael  iirc-:s.  ^iiiislmt  (ir  utlieiuise,  liemurrliaj;<*  is  almost  suro  to 
occur  as  soon  as  reaction  apitears.  ami  the  ^hoclv  of  the  removal  ot"  a  limit  is  not  so  much 
to  he  (Ircudcil  as  tin*  loss  ol"  hlood. 

•  Wounds  <d'  the  lari^e  arteries  ol'  the  Iclcs  and  arms  I'rom  halls  ami  shells  always  hlced 
more  or  less  at  the  tinu-  of  reception,  and  more  freely  as  the  shock  to  the  nervous  system 
passes  oil  and  reaction  comes  on.  Kvi-n  when  this  nervcms  shock  is  not  sufficient  to  pro- 
duce immetliatc  death,  \\w  chances  of  ultimate  recovery  must  frequently  turn  <jn  the 
mere  (|uestion  of  loss  of  hlood.  " 

In  military  practice  primary  amputation  upon  the  field  is  now  ^em.Tally  preferred  to 
soccuulary,  and  in  civil  practice  a  like  rule  should  generally  he  enforced. 

Sr.M.MAUY. — To  perform  any  capital  operation  on  a  patient  in  a  condition  of  extreme 
collapse  or  shock  is  bad  practice.  To  do  so,  however,  when  a  minor  degree  exists  and 
the  ])ulse  can  he  felt,  when  by  delay  other  dangers,  such  as  continued  or  renewed  hemor- 
rhage are  to  l)e  expected,  is  soutul  ami  good  surgery.  To  an  uticonscious  or  only  slightly 
conscious  patient  an  an;usth(!tic  is  not  necessary.  To  the  conscious  it  has  often  a  bene- 
ticial  action,  and  ten<ls  toward  the  encouragenu'nt  of  reaction. 

FEIGNED  AND  HYSTERICAL  OR  MIMICKED  DISEASE. 

I  have  placed  these  two  classes  of  cases  together  for  purposes  of  convenience,  and  in 
this  section,  as  they  are  cs.scntially  diseases  of  the  nervous  system.  Both  in  a  measure, 
and  with  ditl'erent  degrees  of  accuracy,  simulate  real  or  organic  disease.  In  feigned  dis- 
ease the  will  of  the  patient  is  strong  to  deceive ;  it  is  bent  to  simulate  the  symptoms  of 
an  affection  of  which  the  individual  knows  something,  though  not  all,  and  from  this  the 
full  knowledge  of  the  surgeon  or  physician  is  to  override  the  imperfect  knowledge  of  the 
impostor  and  expose  him.  In  the  hysterical  the  will  of  the  patient  is  weak  ;  functional 
derangement  is  allowed  to  assume  the  garb  of  organic  disease  ;  subjective  symptoms  are 
intensitied — not.  however,  from  motives  of  deception,  but  from  a  want  of  the  controlling 
influence  of  health,  more  particularly  of  the  nervous  centres,  a  condition  of  hypertesthesia 
commoidy  existing  I'rom  some  imperfect  nutrition  of  the  nervous  centres.  In  exceptional 
cases  anaesthesia  is  present,  more  particularly  in  the  larynx. 

Feigned  disease  is  a  voluntary  deception  from  beginning  to  end  and  is  unreal.  Hys- 
terical disease  is  an  involuntary  exaggeration  of  some  functional  derangement,  '■  an 
unwilling  imitation   of  organic  disea.se,  '  and  real. 

Fdijncd  iiffecfli'iis  are  met  with  chiefly  in  the  intellectuall}'  weak  or  those  of  crafty 
character,  and  in  a  general  point  of  view  are  attended  with  an  exaggeration  of  symptoms 
far  beyond  those  met  with  in  real  or  organic  disease;  pain  is  said  to  be  far  more  intense 
than  is  usually  met  with,  and  paralysis  more  complete ;  every  symptom  simulated  is 
extreme;  inconsistencies  are  present  which  are  not  reconcilable  with  the  .symptoms 
usually  met  with  in  the  disea.se  .simulated.  These  inconsistencies  and  exaggerations 
should  always  excite  suspicion  in  the  mind  of  the  practitioner,  causing  him  to  test 
quietly  every  symptom  or  grou]>  of  symptoms  and  to  doubt  his  diagnosis  until  he  has 
proved  its  truth.  To  the  sn/t/rrfive  symptoms,  or  those  complained  of  by  the  jtatient, 
these  remarks  are  very  applicable  ;  but  to  the  o/>Jec/ire,  or  those  palpable  to  the  observer, 
they  are  so  to  a  degree.  The  subjective  symptoms  are  always  exaggerated,  the  objective 
inconsistent,  the  former  being  too  bad  for  truth,  the  latter  inconsistent  with  experience. 
For  example,  the  rigor  of  an  ague  may  be  simulated,  while  the  hot  and  the  sweating 
stage  is  impossible.  Epileptic  convulsions,  catalepsy,  or  madness  may  undoubtedly  be 
imitated,  but  in  all  these  there  will  be,  when  present,  some  exaggeration  or  incon.sistency 
not  found  in  the  real  disease.  Nerve  pains  may  be  felt,  but  they  will  nor  follow  any 
anatomical  nerve  distribution.  Paralysis  can  also  be  readily  simulated,  but  it  will  prob- 
ably be  too  complete ;  it  will  on  testing,  more  particularly  when  done  unexpectedly,  be 
associated  with  a  greater  degree  of  sensibility  in  the  skin  than  is  usuallj-  present.  When 
of  long  standing,  it  will  not  be  attended  with  the  usual  wasting.  Vomiting,  coughing, 
or  spitting  of  blood  can  be  artificially  produced,  though  under  these  circumstances  the 
severity  of  the  symptom  will  probably  contrast  strangely  with  the  mildness  of  any  others 
with  which  it  nuiy  be  attended. 

In  fact,  in  feigned  diseases,  on  a  careful  investigation  into  the  history  of  the  case, 
the  succession  of  symptoms,  their  progress,  intensity,  and  duration,  some  element  will 
be  brought  out  which  is  irreconcilable  with  truth,  some  suspicion  that  deception  is  at 


228  FEIGNED  AND  HYSTERICAL   OR  MIMICKED  DISEASE. 

work  will  be  excited,  which,  if  worked  out,  must  unmask  the  imposture  and  prevent 
error. 

The  subjects  of  hysterical  disease  or  of  nervous  mimicry  are  mostly  what  are  called 
nervous  and  emotional.  They  have  commonly  "  a  very  unusual  mental  character :  in 
the  majority  there  is  something  notably  good  or  bad,  higher  or  lower,  than  the  average 
— something  outstanding  or  sunken."  In  this  affection  "  every  part  of  the  body  may 
become  under  provocation  the  seat  of  an  apparent  disease  that  in  reality  does  not  exist ; 
it  may,  and  often  does,  assume  all  the  attributes  of  reality  with  an  exactness  of  imitation 
which  nothing  short  of  careful  and  accurate  diagnosis  can  distinguish  from  the  real  dis- 
ease." In  joint  and  spinal  disease  the  truth  of  this  is  most  frequently  seen,  Brodie 
having  stated  "  that  among  the  higher  classes  of  society  at  least  four-fifths  of  the  female 
patients  who  are  commonly  supposed  to  labor  under  diseases  of  the  joints  labor  under 
hysteria." 

Di.\GNOsis. — How,  then,  it  may  well  be  asked,  is  the  hysterical  affection  to  be  made 
out  from  the  real  ?  How  is  the  surgeon  to  avoid  falling  into  the  error  of  treating  some 
functional  derangement  as  organic  disease  ? 

In  a  general  sense,  it  may  with  truth  be  laid  down  that  in  hysterical  affection  of  a 
part  local  pain  and  sensitiveness  on  manipulation  are  always  great  and  bear  no  relation 
to  the  amount  of  changes  visible  or  to  be  detected  in  the  part.  The  slightest  touch 
excites  pain,  which  probably  a  bold  one  fails  to  do ;  the  pain,  too,  rarely,  if  ever,  follows 
the  anatomical  course  of  any  nerve  or  nerves,  and  the  onset  of  the  symptoms  is  generally 
more  sudden  and  severe  than  that  usually  ushering  in  organic  affections.  Febrile  dis- 
turbance or  increase  of  temperature,  moreover,  rarely  complicates  the  case,  however 
severe  the  local  symptoms  may  be,  and  the  nervous  "disturbance  very  rarely  takes  the 
form  in  which  morbid  nervous  influence  produces,  not  mimic,  but  real,  organic  changes." 
In  fact,  all  the  subjective  symptoms  are  much  more  severe  than  the  objective,  the  latter 
being  either  very  slightly  marked  or  non-existing.  For  example,  a  girl  is  suddenly  seized 
with  severe  and  lasting  pain  in  the  hip,  knee,  or  other  joint,  aggravated  by  movement  or 
the  slightest  touch,  and  yet  no  visible  alteration  in  its  outline  or  structure  can  be  detected, 
even  after  the  lapse  of  many  months.  Another  is  as  suddenly  affected  with  spinal  affec- 
tion, as  indicated  by  local  pain  in  the  back,  inability  to  stand,  etc.,  without  any  local 
evidence  of  organic  disease.  A  third  suddenly  finds  herself  unable  to  flex  or  extend  a 
limb,  and  the  slightest  force  excites  severe  muscular  spasm  and  pain.  A  fourth  is 
attacked  without  a  cause  with  some  muscular  spasm,  possibly  involving  a  finger  or 
fingers — a  spasm  that  resists  all  attempts  at  extension.  A  fifth  suddenly  loses  sensation 
or  the  power  of  motion  in  some  part  of  a  limb,  quite  irrespective  of  nerve  supply.  In 
these  cases,  again,  however  severe  the  pain  may  be  during  the  day,  it  is  rarely  felt  at 
night.  Such  patients,  as  a  rule,  sleep  well  and  quietly.  During  sleep,  also,  it  often 
happens  that  joints  which  are  immovable  by  day  are  found  to  be  more  flexed  or  more 
extended.  Patients  with  supposed  diseased  spine  are  found  on  their  sides  coiled  up  in  a 
natural  attitude.  As  an  aid  to  diagnosis,  the  value  of  some  anaesthetic  cannot  be  too 
highly  praised,  as  with  a  patient  under  its  influence  rigid  parts  rapidly  yield  and  rigidity 
of  muscle  returns  only  with  consciousness ;  parts  supposed  to  be  paralyzed  often  move, 
and  suspected  joint  disease  disappears  by  a  close  examination  where  previously  doubt 
existed. 

Hysterical  disease  is  more  commonly  met  with  in  female  than  in  male  subjects,  in  the 
single  than  in  the  married,  in  those  whose  nei'vous  systems  have  been  unstrung  from 
some  mental  or  physical  trial,  or  where  the  emotional  centres  are  inadequately  balanced 
by  the  higher  controlling  ganglia.  It  is  characterized  by  the  suddenness  of  its  attack 
and  the  severity  of  all  its  subjective  symptoms,  neither  the  clinical  history  of  the  case 
nor  the  objective  symptoms  present  being  consistent  with  those  usually  met  with  in 
organic  disease  ;  the  exaggeration  of  certain  symptoms  and  the  absence  of  others,  coupled 
with  the  anomalies  of  its  nature,  mark  the  hysterical  affection  over  the  organic,  and  are 
sufiicient  to  excite  a  doubt  as  to  the  true  nature  of  the  affection. 

For  valuable  information  on  this  subject,  the  reader  may  be  referred  to  the  lectures 
of  Brodie,  Skey,  and  Paget,  Russell  Beynolds's  essay  on  hysteria,  and  Anstie's  lectures  in 
Lancet. 


.V/7.V.I     ItlllHA. 


229 


CHAPTER    VIT. 


INJURIES    AND    DISKASKS    Ol'    TIIK    Sl'TNi:,    KTC. 


Spina  Bifida. 

A  SPINA  i{iK(i>A  is  essentially  a  con<:ciiital  licniia  ofthe  membranes  of  the  cord  through 
an  oponin;^:  in  the  spine,  due  to  deficiency,  IVoiu  arrest  of  development,  of  the  neural 
arches  of  some  td"  the  hones  formin<r  th(i 


spinal  column.  It  is  analogous  to  the 
meningoceles  of  the  craniiim,  which  have 
It  always  con- 


been  already  described 
tains  subarachnoid  fluid,  and  often  the 
spinal  cord  itself  or  large  nerve  trunks. 
Sir  P.  Hewctt  believes  that  when  the 
fluid  has  collected  in  the  subarachnoid 
space  or  between  the  cord  and  the  mem- 
branes the  cord  is  pressed,  and  that 
when  fluid  alone  is  present  the  collection 
is  situated  in  the  cavity  of  the  arachnoid. 
In  the  specimen  figured  (Fig.  8G),  taken 
from  a  dissection  kindly  made  for  me  by 
Dr.  Pye-Smith,  there  was  a  funnel- 
shaped  opening  leading  from  the  tumor 
into  the  persistent  central  canal  of  the  Aradmoiu 
cord,  the  nerves  being  spread  out  under 
the  internal  lining  of  the  sac,  and  thus 
forming  one  of  the  layers  of  its  wall. 

Characters  of  the  Tumor. — 

The  spinal  hernia  is  sometimes  covered 
by  the  whole  thickness  of  integument ; 
at  others  the  integument,  though  pres- 
ent, is  very  thin  ;  while  occasionally  the 
walls  are  represented  only  by  a  transpa- 
rent membrane.  This  last  condition  was 
present   in  ten  out  of  twenty-seven  qow- 


Opening 

into   central 

Canal  r,f 

Cord 


Dissection  of  Spina  Bifida. 


secutive  cases  that  have  fallen  under  my  care.  The  tumor  may  have  a  broad  base  and 
free  communication  with  the  spinal  canal,  or  a  narrow  and  more  or  less  pedunculated 
one.  Under  the  former  circumstances,  the  probabilities  of  the  cord  being  directly 
involved  are  greater  than  under  the  latter.  The  tumor  is  always  more  or  less  globular, 
ten.se.  and  elastic.  When  the  child  is  asleep  or  quiet,  the  swelling  may  be  soft ;  but 
when  the  child  cries,  the  tumor  will  rapidly  fill  out.  The  edges  of  the  bony  orifice  are 
occasionally  to  be  felt.  The  integument  is  in  some  instances  ulcerated  even  at  birth, 
while  in  others  there  will  be  a  small  opening  in  the  walls,  through  which  the  serous 
spinal  fluid  exudes. 

Associated  with  Hydrocephalus. — The  tumor  is  often  associated  with  hydro- 
cephalus, and  in  exceptional  instances  is  double  (Fig.  87).  A  nsevus  is  not  seldom  found 
situated  over  the  tumor.  Such  complications  as  club-foot  or  paralysis  of  the  lower  limbs 
frequently  coexist  with  it,  and  under  such  circumstances  it  is  tolerably  certain  that  the 
cord  is  included  in  the  hernia  :  and  possibly  the  nature  of  the  deformitv  may  have  been 
determined  by  the  special  nerves  which  are  involved.  Paralytic  symptoms  are  more  com- 
mon in  the  broad-based  hernia  than  in  the  narrow.  Incontinence  of  urine  or  of  feces  may 
coexist  with  the  paralysis  or  be  independent  of  it. 


230 


SPIXA   BIFIDA. 


Fig.  87. 


r 


The  lumbo-sacral  portion  of  the  euluinn  is  more  frequently  affected  than  any  other, 
but  the  cervical  and  dorsal  portions  are  also  liable  to  the  defect.  Thus,  in  twenty-seven 
examples  which  came  consecutively  under  my  care,  thirteen  occurred 
in  the  lumbar  region,  four  in  the  lumbro-sacral,  and  nine  in  the  sacral. 
One  was  double,  a  small  tumor  being  in  the  lumbar  and  a  large  one 
in  the  sacral  region  (Fig.  87).  Twelve  of  these  cases  were  uncom- 
plicated with  any  paraly.sis  or  deformity.  In  eleven  there  was  incon- 
tinence of  urine  and  feces,  associated  in  four  with  paralysis  of  the 
lower  extremities.  Four  were  complicated  with  hydrocephalus,  two 
with  na^vus,  and  one  with  talipes.  I  have  seen  but  two  examples 
in  which  the  tumor  was  in  the  cervical  region.  AVhen  the  tumor 
is  complicated  with  hydrocephalus,  fluctuation  may  often  be  felt 
between  the  two  parts,  pres.sure  on  the  head  causing  a  fulness  of 
the  spinal  hernia,  and  vie  versa.  In  exceptional  cases  the  spinal 
i  i  -|.  hernia  may  protrude  on  the  anterior  part  of  the  spine, 
t        -  f''      i  Diagnosis. — In  a  general  way.  there  is  no  difficulty  in  diagnosing 

'  a  spina  bifida.     In  anv  infant  a  congenital  tumor  over  the  spine  is 

Double    Spina    Bifida,   probably  a  spina  bifida  :  if  globular  and  tense  or  capable  of  becom- 
3^momh*'f*^      '^^    ^"?  tense  when  the  child  cries,  the  probabilities  are  almost  converted 
into  a  certainty,  inasmuch  as  the  only  cases  for  which  this  affection 
is  liable  to  be  mistaken  are  congenital  tumors  unconnected  with  the  spine — cystic,  fibrous, 
fatty,  or  foetal  tumors.     These  may  be  hard  and  tense,  but  they  are  rarely,  if  ever,  made 
so  much  more  tense  from  the  child  crying,  as  is  the  spinal  hernia. 

Prognosis. — The  majority  of  these  cases  prove  fatal.  Many  of  the  subjects  are 
ill-developed  and  die  within  a  few  days  of  birth ;  death  from  convulsions  is  verj-  usual 
when  the  sac  bursts  and  its  fluid  contents  escape,  more  particularly  when  the  escape  is 
rapid.  The  rupture  of  the  sac  is  not,  however,  necessarily  followed  by  this  result.  I 
have  watched  a  child  with  this  affection  for  four  years,  in  which  at  birth  the  tumor  was 
transparent  and  soon  burst,  and  subsequently  discharged  at  intervals  for  three  years ;  it 
has  now  gradually  contracted  up  into  a  solid  mass.  This  case  is  an  example  of  a  natural 
cure,  which  takes  place  by  the  gradual  approximation  of  the  bony  walls  and  closure  of 
the  orifice  of  the  hernial  sac.  The  more  pedunculated  the  tumor,  the  better  the  progno- 
sis, so  long  as  no  complication  exists  that  threatens  life. 

Treatment. — Palliative  treatment  is  all  that  can  be  adopted  in  the  majority,  although 
in  exceptional  instances  operative  interference  promises  to  be  of  service.  The  tumor  must 
alwavs  be  guarded  from  injury  by  some  soft  protective  material,  such  as  cotton-wool  or 
spongio-piline.  Slight  pressure  sufficient  to  prevent  rapid  increase  of  the  tumor  is  also 
beneficial,  and  the  best  method  of  applying  it  is  by  a  casing  of  gutta-percha  or  felt 
moulded  to  the  part.     The  application  of  collodion  is  sometimes  useful. 

Successful  cases  are  recorded  in  which  tapping  of  the  hernia  has  been  performed. 

The  practice,  however,  is  dangerous,  as  the  drawing  ofl^ 

of  the  fluid  has  been  followed  by  convulsions,  and  even 

death.     Xevertheless,  it  is  the  least  formidable  form  of 

■^    practice  that  can  be  undertaken,  and  should  always  be 

"^1    employed  before  more  active  treatment  is  resorted  to,  if 

/     only  as  a  preliminary  measure.     The  puncture  should 

/      always  be  made  at  the  side  of  the  tumor,  for  the  cord 

/      when  present  is  probably  placed  in  the  median  line.    The 

whole  of  the  fluid  should  never  be  drawn  ofi"  at  once. 

'  Fig.  88  represents  a  case  cured  by  puncture.     It  oc- 

\        eurred  in  the  person  of  a  man  aet.  20.  who  came  under  my 

\       care  at  Guy"s  Hospital  in  1874  for  some  ulceration  of  his 

I       left  foot,  which,  with  the  left  lower  extremity,  was  wasted 

i       from  infantile  paralysis.      He  had  also  a  lateral  curva- 

t      ture  of  the  spine  toward  the  right  side   and   a  cured 

spina  bifida  in  the  lumbar  region.    I  discovered  from  the 

patient  that  he  had  been  treated  for  the  spina  bifida  by 

Mr.  AV.  E.  Image  of  Bury  St.  Edmund's,  who.  in  answer 

to  a  note,  kindly  sent  me  the  following  account  of  the 

case : 

"  The  child  was  brought  to  me  when  about  two  years 
old  because  the  tumor  was  increasing  in  size,  and  convulsions  were  produced  whenever 


Fig.  88. 


>'^t3fe 


^ 


Cured  Spina  Bifida.    (Taken  from  a  man 
set.  26.) 


SACRAL   AM)  cnrCYGKAL   TUMORS.  231 

any  jirt'ssurt'  was  ii|)])lii>il  lu  tin-  tiiinnr.  ev«Mi  from  tlie  woi^'ht  of  the  Ixxly  when  i*iaced 
ill  the  supiiH'  |)(tsitiiiii.  The  tiiiiinr  was  lar;.'e  ainl  si'iui-traiisparetit.  1  punctured  it 
i)lili([uelv  with  a  tiarninir-iK'iMlh'  at  intervals  of  two  or  three  days,  four  or  six  tinn-s.  and 
applied  a  compress  of  lint  liy  means  of  strajipini:  over  the  tumor.  After  this  the  fluid 
was  not  airain  seereted.  the  eonvulsions  eeased.  and  the  ease  pit  well."  At  the  i»resent 
time  a  hard  pucken-d  tumor  alone  «'xi>ts  to  indicate  tiie  atfeetion.  \  model  of  the  ea.se 
may  now  he  found  in  (Juy's  .^Iu.se^lm. 

Dr.  James  .^Il(rton  of  (llasirow  has  advocateil  the  injection  at  intervals  of  .seven  or  ten 
days  of  half  a  drachm  of  a  solution  made  hy  di.^solving  ten  irrains  of  iodine  and  thirty 
i  jrrains  of  iodide  of  potassium  in  an  ounce  of  trlyeerine.  The  injection  should  he  thrown 
into  the  sac  after  tl»e  withdrawal  of  some  small  ])ortion  of  the  spinal  fluid.  Dr.  Morton 
reports  (  (iliKi/inr  Mol.  Jouni..  May.  ISSl)  that  out  of  twenty-nine  cases  operated  upon 
there  were  hut  si.x  failures.  Tiiis  success  is  enei.urai^injr.  The  operation,  however,  has 
its  daiiLTers.  In  a  ease  of  my  own.  after  the  .second  tapjiinir.  there  was  .so  much  draining 
of  the  fluid  from  the  cord  that  the  child  died  from  exhaustion.  After  death  there  were 
no  signs  of  inflammation  of  the  memhranes. 

Tn  no  ease  where  the  ha.se  or  neck  of  the  tumor  is  lar<;e.  injr  in  others  in  which  it  is 
evident  the  cord  is  implicated  or  larire  nerve  trunks  are  involved,  .should  this  or  any  other 
operation  he  |)erformed.      In  pedunculated  tumors  it  may  be  attemjited. 

With  respect  to  the  pxrisiuu  of  the  tumor,  a  succes.sful  case  has  been  recorded  in  the 
Filth.  Soc.  TniD.s.,  vol.  xiv.,  in  which  Dr.  Wilson  of  Clay  Cross  removed  the  tumor  five 
days  after  the  closure  of  its  neck  by  means  of  a  clamp:  and  when  excision  is  entertained, 
this  plan  is  probably  the  soundest.  It  should,  however,  only  be  thought  of  when  the 
nock  of  the  tumor  is  narrow  and  there  is  no  paralysis  of  the  lower  limbs  or  incontinence 
of  feces  or  urine.  In  all  broad-based  tumors  associated  with  paralysis  operative  measures 
are  out  of  the  question. 

Exceptional  cases  of  recovery  are  on  record  after  every  form  of  practice,  but.  on  the 
whole,  the  results  of  treatment  are  not  very  encouraging. 

Sacral  and  Coccygeal  Tumors. 

Congenital  tumors  are  by  no  means  unfrequent  in  the  neighborhood  of  the  coccyx  or 
sacrum.  They  are  sometimes  composed  of  cysts,  occasionally  of  fat  or  fibre  tissue,  and 
also  of  fuetal  remains.  They  are  generally  central.  Many  of  these  have  doubtless  been 
described  as  false  spina  bifida,  and  in  rare  examples  there  is  reason  to  believe  they  are 
cured  cases  of  spina  bifida,  the  sac  of  the  hernia  having  been  occluded  at  its  neck  by  the 
natural  contraction  of  the  surrounding  parts.  I  have  seen  one  such  ca.se  in  an  adult 
where  the  tumor  was  successfully  excised.  Mr.  Pollock  has  recorded  in  the  eighth  vol- 
ume of  the  J\i'/t.  J/-a//.s.  an  example  of  a  congenital  fatty  tumor  which  he  successfully 
removed  from  the  central  lumbar  i-egion  of  a  child  jet.  7,  and  Mr.  Athol  Johnson,  in  the 
same  volume,  a  rare  ca.se  of  fatty  tumor  clearh'  developed  in  the  spinal  canal  itself.  I 
have  had  occasion  to  remove  a  large  congenital  sebaceous  cy.st  placed  between  the  anus 
and  coccyx  from  a  child  xt.  10,  and  from  another  child  a  tumor  containing  ftetal 
remains,  situated  between  the  sacrum  and  the  bowel.  I  may  further  refer  to  a  third 
interesting  case  of  cystic  tumor  of  the  sacrum,  possibly  spina  bifida,  in  which  the  cyst 
burst  and  complete  recovery  followed.  The  following  are  the  brief  notes  of  the  two 
latter  cases. 

Marie  B ,  ret.  seven  weeks,  was  brought  to  me  in    1SG8  with  a  congenital  tumor 

the  size  of  a  large  orange  projecting  from  between  the  bowel  and  coccyx  and  apparently 
passing  up  in  front  of  the  bone  fFig.  JsO).  It  had  been  growing  rapidly  .since  birth  and 
was  pressing  upon  the  bowel,  though  the  child  in  all  other  resjiects  was  healthy.  I 
excised  the  growth  and  found  that  microscopically  it  was  made  up  of  fat.  fibro-cellular 
tissue,  mucous  membrane,  cartilage,  and  bone  elements.  Recovery  ensued,  and  the  child 
has  kept  well. 

A  male  child  two  days  old  was  brought  to  me  on  July  30,  18G8,  with  a  large  cystic 
tumor  covering  in  the  lower  half  of  the  sacrum  and  occupying  the  perina?uni.  It  was 
the  size  of  a  cocoanut  and  transparent  as  a  spina  bifida,  yet  in  all  other  respects  the  child 
was  wellformed.  The  next  day  it  burst  and  many  ounces  of  a  blood-stained  fluid  escaped. 
The  .sac  collapsed,  but  no  evil  result  followed  this  bursting  of  the  cyst.  I  watched  the 
child  for  many  months,  and  on  November  80.  1871.  the  tumor  had  contracted  up  to  an 
irreizular  indurated  mass  of  integument.     The  child  was  very  healthy. 

Treat.ment. — The   only   effective  treatment  is  the   excision   of   the   growth,  which 


232  INJURIES  OF  THE  SPINE,    CONCUSSION,   ETC. 

should  be  done  unless  symptoms  exist,  such  as  extensive  or  dangerous  connections  of 
the  tumor,  to  contraindicate  the  practice.     Special  care  should  be  taken  to  ascertain  that 

no  communication  exists  between  the  tu- 
FiG.  89.  Fig.  90.  mor  and  the  spinal  canal. 

1^  ^  ^j  Fig,  00  represents  a  most  interesting 

case,  the  particulars  of  which  were  kindly 
forwarded  to  me  by  Dr.  Mercer  Adams 
of  Boston,  Lincolnshire,  who  operated. 
The  tumor  was  successfully  removed 
from  a  female  cliild  get.  10,  and  meas- 
ured 22  inches  in  circumference  ;  it  wa.s 
composed  of  cysts,  and  the  largest,  which 
was  central,  was  lined  with  true  skin  cov- 
ered with  long  silky  hair.s.  This  cyst  con- 
tained thick  putty-like  material.  From 
one  of  its  walls  grew  an  improperly  de- 
veloped foetal  leg  and  foot  having  three 
Congenital  Coccygeal  Tumors.  toes  with  perfect  nails.     There  were  also 

several  curiously  shaped  foetal  bones  scat- 
tered through  the  tumor — one  like  two  coalesced  ribs,  and  another  a  parietal  bone.  The 
tumor  had  deep  pelvic  attachments,  and  had  to  be  dissected  from  the  rectum.  The  lower 
part  of  the  sacrum  merged  on  the  tumor. 

Hewett,  Med.  Gnz.,  vol.  xxxiv. — Behrend,  Jourii.  f.  Kinderkrankheilen,  vol.  xxxi. — Xelaton, 
Path.  Chir.,  vol.  ii. — Holmes,  Snrrjical  Treatment  of  Children's  Disease.",  1869. 

INJURIES  OF  THE  SPINE,  CONCUSSION,  ETC. 

The  spine  is  a  flexible  tubular  column  composed  of  ring  bones  alternating  with  a 
dense  elastic  intervertebral  substance.  These  bones  articulate  by  means  of  joints,  and 
are  bound  together  by  strong  yet  elastic  ligaments.  From  the  upper  orifice  of  the  tube 
the  spinal  cord  with  its  membranes  is  suspended  in  a  chamber  filled  with  cerebro-spinal 
fluid  and  surrounded  by  large  venous  plexuses.  The  coi'd  terminates  opposite  the  second 
lumbar  vertebra,  but  the  membranes  are  continued  down  to  the  second  piece  of  the  sacrum. 
It  is  suspended  in  position  by  the  nerve  trunks  that  pass  with  the  processes  of  dura 
mater  that  accompany  them  outward  between  the  bones. 

A  local  injury  to  the  spine,  such  as  a  forcible  bend  forward,  may  sprain  or  lace- 
rate the  ligaments  that  hold  the  bones  in  position.  A  still  more  forcible  bend  may 
crush  the  bodies  of  the  vertebrae  that  form  the  anterior  portion  of  each  ring.  If  the 
force  be  still  continued  upon  the  broken  bones,  displacement  may  take  place,  when  the 
delicate  cord  itself  will  either  be  slightly  pinched  between  the  displaced  bones  and  con- 
tused or  completely  crushed  or  divided.  In  the  cervical  and  lumbar  regions — not  in  the 
dorsal — the  bones  may  be  dislocated,  the  amount  of  injury  to  the  cord  depending 
entirely  upon  the  amount  of  displacement  that  has  taken  place.  When  such  displace- 
ment is  very  slight,  the  cord  may  be  uninjured.  Sprains  of  the  back  may  also  at  a  later 
period  be  followed  by  disease  both  of  the  joints  and  bones  of  the  spine. 

A  diffused  injury  to  the  spine,  such  as  that  caused  by  a  fall  from  a  height 
upon  the  back  or  by  a  heavy  falling  body,  may  produce  some  fracture  or  dislocation  of 
the  bones  of  the  spine,  but  it  must  to  a  certainty  likewise  cause  a  severe  shaking,  as 
from  a  railway  accident,  or  a  concussion  of  the  spinal  cord  itself,  as  manifested  by  a 
more  or  less  complete  suspension  of  all  the  functions  of  the  cord,  either  for  a  short 
period  or  for  life.  This  concussion  or  shaking  of  the  spine  may  be  accompanied  by 
hemorrhage  into  or  upon  the  cord,  giving  rise  to  compression,  or  may  be  followed  by 
acute  or  chronic  intraspinal  inflanmiation.  terminating  in  paralysis  and  death. 

In  both  local  and  d'lffnaed  injuiiea  of  tlie  .yjuie  the  (jrarity  of  the  cat^e  dependn  chlcfli/ 
upon  the  amount  of  injury  the  cord  hai<  sKsfa^'ned ;  a  severe  local  injury  to  the  osseous 
part  of  the  spine  can  be  completely  repaired  without  danger  to  life,  whilst  any  injury  to 
the  cord  and  its  membranes  is  fraught  with  danger,  either  directly  by  suddenly  arresting 
the  functions  of  the  parts  to  which  the  injured  nerves  are  distributed,  or  indirectly  by 
setting  up  chronic  inflammatory  changes  in  the  cord. 

Concussion  of  Spine. — When  the  functions  of  the  cord  have  been  directly  sus- 
pended by  any  local  or  diffused  injury  to  the  spine,  the  patient  is  said  to  have  suff"ered 
from  concussion  of  the  spine.     Should  the  symptoms  be  complete  and  persistent,  there  is 


i\.iii:ii:s  or  Tin-:  sr/XK  coscussios,  etc  233 

fjdod  rcasdii  tu  liclicvc  tliat  tlic  ciinl  l)a>  Ittcii  (•ni>Iic(l  Ky  .'»<>iin'  (lis|»lacciii('iit  of  a  f'rac- 
turril  or  dislocated  Imiic.  Should  soiiu'  interval  of  tiiiu-  have  taken  plaee  hctweeri  the 
roeeipt  of  the  aeeideiit  and  the  )»aralysis.  there  is  a  lair  suspicion  that  the  paralysis  is 
th<'  result  of  some  heinorrhatrc  into  or  around  the  cord.  Should  the  paralytic  symptoms 
have  i'ollowi'd  the  accident  after  a  few  days  and  he  attende(l  with  constitutional  disturh- 
aiice  (U"  spasm  of  the  muscles  of  the  limhs,  the  cause  of  the  paralysis  was  prohahly  some 
inflammation  of  the  cord  and  its  memhranes  ;  and  should  the  paralysis  liuve  been  of  a 
slow  and  |»roirressive  nature,  the  jirohahilities  are  that  it  is  the  consequence  of  some 
chronic  softening  of  the  cord,  because  all  those  different  results  have  followed  local  and 
difiused  injuries  to  the  spine.  Moreover,  it  is  the  knowledge  that  they  may  take  place 
which  renders  any  spinal  injury  a  matter  of  importance,  both  as  regards  the  immediate 
effects  of  the  injury  and  its  secondary  eonsef|uences.  I  am  bound,  however,  to  add  that 
Mr.  I'age  in  his  recent  interesting  book  on  spinal  injuries  "doubts  whether  any  jiassing 
paralysis  following  a  severe  l»low  on  the  vertebral  column  is  not  m<tst  likely  to  be  due  to 
the  pressure  of  extravasatcd  blood,  which  in  course  of  time  bec(tmes  ab.sorbed,  "  for  he 
states  that  '•  we  know  of  no  case,  nor  can  we  discover  the  history  of  any,  where  a  tran- 
sient parajdegia  or  a  suspension  of  the  functions  of  the  cord  has  followed  a  lilow  or  fall 
upon   the  spine. 

In  rare  instances  symptoms  similar  to  tetanus  follow  spinal  injury.  T  have  seen  such 
in  two  cases.  One  was  that  of  a  man  ?et.  85.  who  fell  from  a  height  on  liis  head,  bend- 
ing the  neck  forward.  He  was  paralyzed  for  a  few  hours  from  the  neck  downward,  and 
on  the  appearance  of  reaction  had  marked  tetanic  symptoms  with  the  contracted  brow 
and  risus  sardonicus.  Spasms  could  be  excited  on  the  slightest  touch  being  applied  to 
his  neck.  In  twelve  hours,  however,  all  these  symptoms  disappeared,  and  recovery 
ensued. 

In  the  second  case  a  man  received  a  crush  in  the  loins  between  two  carts.  Lock-jaw 
followed,  with  general  spasms  of  all  the  muscles  of  the  body.  In  five  hours  the  spasms 
subsided,  but  they  were  followed  for  five  days  by  hyperiv?sthesia  of  the  integument,  and 
on  the  sixth  day  by  weakness  of  one  leg.     In  a  month  he  was  convalescent. 

Analogy  between  Spinal  and  Cerebral  Injuries. — In  former  chapters  it 

was  shown  that  the  functinns  of  the  brain  may  for  a  time  be  interfered  with  or  sus- 
pended by  a  simple  shake  or  concussion  of  its  substance  :  that  a  severe  concussion  may 
give  rise  to  contusion  of  the  brain,  either  at  the  seat  of  injury  or  on  the  opposite  side  by 
contre-coup ;  that  extravasation  of  blood  either  upon  the  surface  of  the  brain  or  within 
its  structure  may  follow  such  an  injury  :  that  fractures  of  the  skull  are  of  importance 
in  proportion  to  the  severity  of  the  intracranial  complications;  and  that  intracephalic 
inflammation  is  too  frequently  the  result  of  any  head  injury.  In  injuries  to  the  spinal 
column  and  its  contents  similar  results  have  to  be  recorded.  A  simple  coiicusst'oii  or  shak- 
ing of  the  spine  may  produce  a  partial  or  complete  suspension  of  the  functions  of  the 
cord,  yet  by  rest  and  quiet  these  symptoms  may  disappear  and  a  perfect  recovery  follow. 
A  wo/r  xpi-ere  shaking  may  give  rise  to  some  injury  of  the  nervous  structure,  to  some 
extravasation  of  blood  upon  or  into  the  cord  itself.  Such  a  complication  will  necessarily 
be  associated  with  more  marked  symptoms,  more  complete  and  per.si.stent  paralysis  and 
anaesthesia  of  that  portion  of  the  body  supplied  with  nerves  from  the  injured  centre,  the 
completeness  and  persistency  of  the  paralysis  and  anaesthesia  depending  upon  the  .severity 
of  the  mischief  and  on  the  seat  of  injury.  When  the  paralysis  is  severe,  but  incomplete, 
there  will  be  retention  of  urine,  this  symptom  arising  from  loss  of  voluntary  power  over 
the  mu.scles  that  regulate  luicturition.  But  when  the  paralysis  and  ansesthesia  are  com- 
plete,  there  will  be  absolute  paralysis  of  the  bladder  and  all  its  muscles,  with  incontinence 
of  urine.  This  incontinence,  however,  must  not  be  confused  with  the  dribbling  of  an 
overdistended  viscus  from  retention,  the  incontinence  of  retention  of  Gross,  such  as 
occasionally  occurs  in  the  less  severe  cases. 

When  the  injury  is  in  the  cervical  region,  one  or  both  arms  may  be  more  or  less 
paralyzed;  when  in  the  lower  dorsal,  one  or  both  legs;  but.  as  a  rule,  the  paraly.sis  is 
symmetrical  and  the  symptoms  depend  on  the  nerves  that  are  involved.  The  loss  of  sensa- 
tion is  also  generally  complete.  In  one  case,  however,  there  may  be  paralysis  of  one 
limb  and  loss  of  sensation  of  the  other;  in  a  second,  exalted  sensibility  with  paralysis. 
In  one  the  power  of  motion  may  be  regained,  while  that  of  .sensation  remains  lost,  and 
in  another  the  reverse  ;  indeed,  on  these  points  there  is  every  possible  variety,  the  seat 
of  injiirv  clearly  determining  the  nature  of  the  paralysis. 

Brown-Sequard's  observations  and  experiments  on  the  decussation  of  the  motor  and 
sensory  fibres  of  the  cord  have  done  much  toward  the  elucidation  of  these  points,  and  it 


234  INTRASPINAL  INFLAMMATION,  ETC. 

may  now  with  some  confidence  be  asserted  that  when  one  antero-lateral  column  of  the 
cord  is  divided  or  irreparably  injured  there  must  be  motor  paralysis  of  the  same  side  of 
the  body  below  the  seat  of  injury  and  loss  of  sensation  upon  the  opposite  side  of  the 
body,  the  motor  paralysis  being  due  to  the  destruction  of  the  white  substance  and  the 
loss  of  sensation  to  that  of  the  gray. 

When  any  portion  of  the  white  substance  is  left  intact,  some  motion  will  remain  ;  and 
when  any  part  of  the  gray  is  uninjured,  some  sensation.  Complete  division  of  the  cord 
is  necessarily  followed  by  complete  paralysis  and  loss  of  sensation  in  the  parts  below, 
although,  by  what  is  called  reflex  action,  the  muscles  of  the  parts  may  be  made  to  con- 
tract on  the  application  of  any  stimulant,  such  as  tickling,  to  the  sensory  nerves. 

Pain  in  the  course  of  a  sensory  nerve  or  in  an  extremity  is  to  be  taken  as  represent- 
ing the  irritation  of  the  cord  or  nerve  at  its  central  origin,  and  in  cases  of  fracture  as  the 
spot  where  the  bone  has  been  broken.  Symmetrical  pains  mean  central  mischief;  uni- 
lateral pains,  local. 

■  A  severe  blow  upon  the  upper  cervical  region  may  produce,  according  to  Erichsen, 
instantaneous  death  from  concussion  When  the  va(jHs  nerve  is  affected,  a  .sense  of  suffo- 
cation, with  irregular  action  of  the  heart  or  constant  vomiting,  may  be  produced.  When 
the  spiji((l  accessor//  is  injured,  spasm  of  the  trapezius  or  sterno-mastoid  muscles  occurs ; 
and  irritation  of  the  phrenic  nerve  causes  hiccup,  as  well  as  the  sensation  of  an  iron-band- 
like constriction  round  the  bod}'.  When  the  injury  is  in  the  lumbar  region,  the  paralysis 
is  always  partial,  as  the  cord  terminates  at  the  second  lumbar  vertebra. 

The  temperature  of  the  paralyzed  limb  is  always  lower  than  the  rest  of  the  body,  even 
when  to  the  patient  it  may  feel  hot  or  burning. 

The  PROGNOSIS  in  any  case  of  concussion  of  the  spine  depends  entirely  upon  the 
changes  that  are  produced  in  the  cord  by  the  injury,  and  the.se  are  fairly  to  be  measured 
by  the  severity  of  the  symptoms  and  i\\e\Y  persistency.  This  latter  guide  is  very  reliable, 
the  persistency  of  symptoms  being  generally  indicative  of  organic  change.  Again,  when 
organic  change  has  taken  place,  there  is  the  greater  probability  of  some  secondary  inflam- 
matory action  in  the  injured  part,  and  on  this  the  prospects  of  the  case  hinge  ;  for  in 
injuries  to  the  spinal  cord  or  membranes,  as  in  injuries  to  the  brain,  this  intracephalic  or 
intraspinal,  inflammation  is  the  cause  of  danger  or  of  death  in  every  case  that  survives 
the  immediate  effects  of  the  accident,  while  it  leaves,  even  when  life  is  spared,  more  or 
less  complete  paralysis  of  the  parts  below  the  seat  of  injury. 

INTRASPINAL  INFLAMMATION.— SPINAL  PARALYSIS  AFTER 
CONCUSSION.— RAILWAY  CONCUSSION. 

Intraspinal  Inflammation. — "  Every  injury  of  the  spine  should  be  considered 
as  deserving  of  minute  attention.  Inflammation  of  the  cord  and  its  membranes  may 
supervene  upon  very  slight  injuries  of  the  spine ;  it  may  advance  in  a  very  insidious 
manner  even  after  injuries  that  were  of  so  slight  a  kind  that  the}-  attracted  at  the  time 
little  or  no  attention."  Thus  wrote  Abererombie  in  1829,  and  his  observations  are  as  true 
now  as  they  were  then  ;  indeed,  it  is  upon  such  views  that  the  whole  treatment  of  injuries 
to  the  spine,  simple  or  severe,  ought  always  to  be  based. 

The  preventive  treatment  of  spinal  as  of  head  injuries  means  the  adoption  of  such 
measures  as  experience  has  proved  are  most  valuable  in  warding  off  the  acces.sion  of 
intraspinal  and  inti'acephalic  inflammation  and  thus  preventing  paralysis.  The  simplest 
shock  or  concussion  of  the  spinal  cord,  the  slightest  blow  upon  the  spine  or  sprain  of  its 
ligaments,  any  bruising  of  the  former  or  laceration  of  the  latter,  and,  a  fortiori,  any 
severer  lesion,  is  apt  to  be  followed  by  an  acute  or  chronic  intraspinal  inflammation,  and 
by  changes  in  the  structure  of  the  cord  that  may  give  rise  to  a  paralysis,  partial  or  com- 
plete. The  surgeon  has,  moreover,  no  guide  by  which  to  measure  the  danger  or  calculate 
the  probabilities  of  the  occurrence  of  this  secondary  inflammation,  since  it  may  follow  a 
slight  accident  and  fail  to  follow  a  severe  one  ;  at  the  same  time,  the  prospects  of  its 
appearence  and  its  danger  depend  much  upon  the  gravity  of  the  injury. 

When  the  cord  has  been  much  contused  or  crushed  by  a  fractured  or  dislocated  ver- 
tebra, the  paralysis  that  necessarily  follows  such  a  lesion  is  not  likely  to  be  aggravated  by 
any  secondary  inflammatory  changes  in  the  injured  cord,  although  the  termination  of  the 
case  may  be  hastened  by  these  changes.  Under  such  circumstances,  the  complication  is 
not  of  such  a  nature  as  to  add  to  the  surgeon's  anxiety.  In  less  severe  examples  of 
injury,  however,  in  which  the  primary  symptoms  do  not  indicate  any  organic  lesion  beyond 
that  which  manifests  its  presence  by  some  temporary  suspension  of  the  functions  of  the 


/.V77M.S7'/.V.I/,    ISri.AMMATIOS,    KT(\  2.35 

curd,  it  Iti'CKint's  a  iiiattcr  ul'  primary  iiiipurtaiice  ti>  rcco^nizi,'  \\ut  very  oarliost  iiidicution 
of  iiitlaiimiatiiiy  artimi,  in  unli-r  that  it  may  \n'  arn'strd  ;  f'ljr.  as  it  lias  been  shown  tliat 
tin.'  cliifi' aim  in  tin*  trcalnu-nt  ot"  all  tlu'si-  injuries  is  to  prevcMit  the  occurrL-not'  of  inflam- 
mation, sti  the  si'cund  is  t(i  try  and  arrest  its  inoj^ress  as  soon  as  it  has  a|i|ieaied.  When 
it  has  liecome  thoronirhly  estahlished,  neither  medical  nor  siir<;ieal  art  has  much  power  in 
eheekini;  its  projrress  or  in  correetini:'  its  etteets,  as  the  delicate  structure  of  the  spinal 
cord  ap])ears  to  ho  incapahle  of  underjroin;;  material  repair  when  softcMied  hy  disease  or 
crushed  Itv  accident.  The  cord  structure,  whi-n  once  destrtjyed,  is  replaced  hy  means  of 
a  fihrous  suhslance.  I'aralysis  or  loss  of  function,  under  these  circumstances,  is  jM-rma- 
neiit.  [n  any  case,  therefore,  of  spinal  injury,  when  the  symptoms  are  persistent  or  tend 
to  hevome  worst',  when  after  their  partial  or  complete  disajjpearance  for  three  or  four  or 
more  days  they  recur  or  appear  in  s(>me  altered  form,  when  local  pain  is  increased  and 
inovemont  of  the  hack  is  more  difficult  or  distressing,  when  pain  follows  tlie  course  of 
the  nerve  trunks  that  emanate  from  the  injured  spinal  centre  and  muscular  spasm  or 
paralysis  is  ])resent,  and,  moreover,  when  constitutional  disturbance  or  general  fehrility  is 
present. — whtu  any  or  all  of  these  symj)toms,  few  or  many,  are  found  to  follow  a  spinal 
injury  after  the  first  effects  of  the  accident  have  passed  away,  the  diagnosis  of  secondary 
inflammation  of  the  cord  may  fairly  be  made  and  action  taken  upon  it. 

In  ii'  ni'iiil  r(iiicKssit)iis  of  the  ^piuid  cord,  more  particularl}'  from  railway  accidents, 
when,  owing  to  some  general  shaking  of  the  body,  the  spinal,  cerebral,  sympathetic,  and 
circulatory  systems  are  all  more  or  less  involved,  there  is  an  undoubted  disposition  for  a 
chronic  inflammatory  change  of  a  most  insidious  and  creeping  kind  to  supervene.  In 
some  eases,  however,  the  change  is  rapid,  as  in  the  case  of  a  matj  get.  46  who  was  admit- 
ted into  Cruys  with  complete  paralysis  and  loss  of  sensation  of  his  body  below  the  first 
rib,  the  result  of  a  fall  down  twelve  stairs  the  day  previously.  The  day  following  his 
admission  some  slight  feeling  returned  in  his  body,  and  a  few  days  later  he  could  move 
his  legs.  The  paralysis,  however,  never  left  him,  and  he  died  on  the  thirty-eighth  day, 
of  lung  di.sease.  After  death  the  spine  was  found  uninjured,  but  the  spinal  cord  opposite 
the  sixth  dorsal  vertebra  was  soft  and  diffluent  and  contained  granules.  There  was  no 
trace  of  eftused  blood. 

It  is  now  well  known  that  the  primary  sjiinal  symptoms  are  often  so  mixed  up  with 
the  general  as  to  be  masked,  and,  beyond  a  general  but  temporary  loss  of  power  and  con- 
sciousness, there  is  often  nothing  special  by  which  spinal  mischief  is  manifested.  On 
recovering  from  the  shock  of  the  accident  and  the  mental  disturbance  the  sufferer  often 
feels  no  definite  injury,  no  special  local  symptoms,  and  it  may  be  that  it  is  not  till  after 
some  time  has  elapsed — the  duration  of  which  is  also  uncertain — that  any  special  symp- 
toms make  their  appearance. 

It  will  then  probably  be  found  that  the  patient  has  never  been  himself  since  the  acci- 
dent ;  he  has  been  unable  to  work,  mentally  or  physically,  with  the  same  force  or  energy 
that  he  did  previously,  is  irritable  in  his  manner,  and  perhaps  feeble  in  his  powers.  Sleep- 
lessness, too,  has  been  more  complete  or  common  than  it  was  before,  and  headache  with 
general  malaise  now  often  exists. 

Premonitory  Symptoms. — Some  slight  unsteadiness  of  gait  is  often  the  first 
observed  symjitoni.  a  feeling  of  heaviness  in  the  limbs,  some  abnormal  sensation,  such  as 
that  of  pins  or  needles,  numbness  along  the  course  of  a  nerve,  cramps,  perhaps  retention 
of  urine,  or  some  evidence,  in  fact,  of  want  of  control  or  power  over  the  muscular  appa- 
ratus, and  more  marked  generally  in  the  lower  extremities  than  in  the  upper.  The  cen- 
tres of  sensation  may.  at  the  same  time,  show  indications  of  disturbance,  either  by  a  .state 
of  lessened  sensibility  or  perhaps  by  a  hypenvsthetic  condition.  From  sj'mptoms  such 
as  the.se  the  attention  of  the  surgeon  is  probably  arrested.  On  testing  the  muscular 
apparatus  thoroughly  it  will  probably  be  found  that  the  patient  will  be  unable  to  stand 
steadily  on  one  leg,  or,  what  is  a  better  test,  if  he  place  his  heels  together,  he  will  totter 
on  making  the  attempt  to  raise  his  body  on  his  toes.  When  asked  to  stoop  to  pick  up 
anything  from  the  ground,  he  will  probably  bend  his  knees  rather  than  his  back  and  walk 
with  a  rigid  spine.  On  giving  him  a  small  object,  such  as  a  pin.  he  will  take  it  clumsily 
and  with  tremor — will  fumble  at  most  things  with  his  hands  and  stumble  at  anything 
that  is  in  his  way. 

On  examining  the  spine  some  tenderness  may  be  manifested  on  firm  pressure,  but 
probably  only  in  certain  places.  Percussion  on  the  bones  is  hardly  a  fair  test ;  when 
employed,  it  should  be  indirect,  through  the  fingers.  Pressure  applied  to  the  spine 
causes  at  times  severe  pain,  as  does  any  movement;  it  is  the  latter  condition  which 
induces  the  rigidity  of  the  spine  in  walking,  before  alluded  to. 


236  INTRASPINAL  INFLAMMATION,   ETC. 

The  brain  and  organs  of  special  sense  may  likewise  be  aifected,  either  by  over-  or 
under-sensibility.  Vixion  may  be  imperfect  either  in  one  or  both  eyes ;  luuriiui  may  he 
over-sensitive  or  defective  ;  taste  and  touch  may  be  perverted  or  lost  and  Rmdl  at  times 
destroyed  or  morbid.  In  fact,  the  whole  nervous  system,  cerebral  and  spinal,  may  be 
disturbed  and  its  functions  more  or  less  damaged. 

The  course  which  such  cases  run  is  very  uncertain,  and  the  prognosis  is  therefore 
difficult.  When  the  motor-power  has  been  lost  from  spinal  mischief,  the  best  test  is  gal- 
vanism. A  healthy  muscle  supplied  from  a  healthy  nerve  centre  will  always  contract  on 
the  application  of  the  galvanic  current.  When  the  nerve  centre  is  so  diseased  as  to  cause 
paralysis,  the  galvanic  current  produces  no  movement — no  contraction.  This  test  is 
beyond  the  patient's  control  and  cannot  be  resisted;  it  is  consequently  valuable. 

Caution  in  Interpreting  Symptoms. — In  interpreting  these  symptoms,  more 
particularly  in  a  railway  case,  or  in  any  where  the  question  of  damages  is  involved,  it  is 
most  important  for  the  surgeon  to  separate  the  symptoms  of  which  the  patient  complains, 
the  suhjWfive.  from  those  he  can  himself  perceive,  the  objective.  Let  him  doubt  and  cross- 
examine  in  every  way  upon  each  of  the  former  to  test  their  accuracy.  He  may  rely, 
however,  upon  the  latter,  and  any  positive  opinion  ought  to  be  based  upon  these  alone. 
There  always  hangs  a  suspicion  over  the  former  because  self-interest  points  to  making 
the  worst  of  them. 

All  the  symptoms,  taken  as  a  whole,  undoubtedly  indicate  a  chronic  or  subacute 
inflammatory  change  of  nerve  tissue,  an  inflammation  of  the  membranes  or  of  the  cord. 
When  they  appear  as  a  consequence  of  a  general  concussion  of  the  spine,  the  cord  is 
probably  the  seat  of  mischief,  its  delicate  structure  being  more  liable  to  injury  than  the 
tougher  membranes,  and,  consequently,  to  secondary  changes.  When  they  follow  some 
local  injury,  such  as  a  twist,  blow,  or  forcible  bending  of  the  back  with  laceration  of  liga- 
nients,  the  disease  in  the  cord  probably  is  secondary  to  disease  in  the  membranes,  the 
inflammation  of  the  latter  being  due  to  the  extension  of  inflammatory  action  from  the 
injured  part  inward.  '•  Inflammation  of  the  membranes  of  the  cord,  as  of  the  brain,  is  a 
disease  not  idiopathic,  but  proceeding  from  some  cause  without."  But  whenever  this 
commences  it  is  progressive,  and  in  the  end  involves  all  the  tissues  in  its  destructive 
changes. 

Pathological  Changes. — The  pathological  changes  themselves  are  tolerably  defi- 
nite. In  the  cord  they  put  on  the  appearance  of  red  softening  in  recent  disease,  and  of 
white  in  chronic.  The  parts  are  .soft  and  pulpy,  the  microscope  showing  them  to  contain 
granule  corpuscles  and  elements  of  the  inflammatory  process.  The  wlnte  matter  of  the 
cord  will  appear  at  times  sound,  while  the  gray  substance  is  soft.  The  disease  may  be 
local  or  more  general.  In  concussion  the  latter  is  the  more  common  condition.  When  it 
is  in  the  cervical  region,  death  is  rapid  ;  when  in  the  lower  dorsal,  life  may  be  prolonged 
for  some  time.     This  fact  is  well  illustrated  in  fracture  and  dislocation  of  the  spine. 

Treatment. — In  all  cases  of  concussion  of  the  spinal  cord,  simple  or  severe,  absolute 
rest  m  the  horizontal  posture  is  most  essential,  and  in  mild  cases  this  is  probably  the  only 
treatment  called  for ;  the  symptoms,  by  the  observance  of  this  rule,  gradually  disappear, 
and  the  health  is  restored.  The  prone  position  in  more  severe  cases  is  generally  to  be 
preferred  to  the  supine,  but  the  best  guide  in  this  matter  is  the  ease  which  the  patient 
experiences.  The  surgeon,  however,  must  enforce  quiet  for  many  days  after  the  disap- 
pearance of  all  symptoms,  even  in  the  mildest  cases,  on  account  of  the  primary  danger 
of  intraspinal  inflammation,  and  the  period  of  rest  to  be  enforced  must  be  in  proportion 
to  the  severity  of  the  .symptoms.  In  cases  of  railway  concussion  this  practice  is  of 
primary  importance,  and  I  am  disposed  to  attribute  the  frequent  occurrence  of  obscure 
railway  spinal  cases  to  the  non-observance  of  this  rule.  It  is  true  that  in  the  majority 
of  cases  there  are  no  definite  indications  of  spinal  injury  after  the  accident,  though  the 
nature  of  the  accident  itself  is  a  sufficient  guide  to  the  case.  A  general  shaking  of  the 
body  means  a  general  concussion  of  the  spinal  cord  with  every  other  part,  and  the 
nerve  centres,  by  reason  of  their  structure,  are  most  liable  to  injury.  It  would  be  well, 
therefore,  to  keep  all  patients  who  have  been  the  subjects  of  such  injuries  quiet  and  in 
repose  for  several  weeks  after  the  accident.  By  doing  this  much  mischief  would  often  be 
avoided. 

After  concussion,  when  severe  local  pain  is  experienced,  relief  is  often  given  by  the 
application  of  a  dry  cupping-glass  on  either  side  of  the  painful  part,  and  the  operation 
may  be  repeated.  In  exceptional  cases  the  local  extraction  of  blood  may  be  found  of 
benefit.  The  application  of  cold  is  a  powerful  remedy  for  good  when  there  is  much  eflFu- 
sion  of  blood  or  pain  in  the  part,  and  when  the  symptoms  of  reaction  are  too  marked. 


FiiAcrrinis  am>  hisi.ocArioys  or  riir.  sriM-:.  2:i7 

The  ilift  >liuiilil  III-  iiiitrilii)iis,  Imt  iiiist iiiuilat iri<;,  and  iiijtliiii<r  likdy  to  ki;c|i  up  or 
caiisi'  iiu'iital  ur  |>liysi<al  cxcittfiiieiit  alli)\vt'il.  WIk-ii  recovery  of*  power  in  the  linihs  is 
slow  anil  no  syniptoius  ol"  secondary  inflammation  of  tin;  coni  exist,  convalescence  is  pro- 
moted Ity  the  application  of  electricity  in  one  or  other  oi"  its  forms  to  the  enfeebled 
muscles. 

When  svniptonis  of  intraspinal  inflammation  have  appeared,  some  advocate  moxas  or 
setons  in  addition  to  the  ahove  treatment  ;  and  <d'  the  two  the  moxa  is,  perhaps,  prcfer- 
al)le.  Mercury  in  one  of  its  forms  appears  to  he  a  valuable  remedy,  and  the  perchhjride 
is  perhajts  the  best  ])reparation,  jriven  in  doses  of  one-sixteenth  ol'  a  j.'rain  two  (jr  three 
times  a  day  combined  with  bark,  (|uininc,  or  s(»me  other  vejretable  bitter  accordinj^  to  the 
wants  of  the  patient.  When  mercury  is  inapplicable,  the  iodide  of  potassium  should  be 
substituted.  Sedatives  should  be  allowc(l.  to  procure  sleep,  and  the  hytlrate  of  eldoral 
.seems  to  be  the  best,  in  twenty-  or  tliirty-!j.rain  doses,  at  bedtime.  ShoiiM  pain  be  con- 
stant, fifteen  ,<;rains  of  the  same  dni;^  may  be  given  twice  a  day.  a  double  dose  being 
allowed  at  night.  The  extract  of  belladonna  in  one-third  of  a  grain  or  half-grain  doses 
is  likewise  a  valuable  sedative.  Strychnine  is  a  dangerous  drug  in  sj)inal  disease — at 
least,  in  progressive  spinal  disease.  It  is  a  distinct  stimulant  to  the  spinal  centres,  and  i.s 
conset|uently  most  injurious  as  long  as  any  progressive  inflammatory  action  exists.  When 
only  the  eflects  of  the  disea.se  remain  and  all  inflammation  has  cea.sed,  strychnine  may  be 
given.  Should  general  feebleness  exist,  iron  may  be  given  with  it ;  amJ  1  know  of  no 
nervine  tonic  so  beneficial  as  the  combination  of  the  tincture  of  the  perchloride  of  iron 
in  doses  of  fifteen  minims  with  five  minims  of  the  tincture  of  nux  vomica  or  one  or  two 
grains  of  (juinine.  Cod-liver  oil  is  a  valuable  adjunct  to  all  treatment  in  this  as  in  many 
other  cases. 

Great  care  should  be  observed  throughout  the  treatment  of  these  affections  to  prevent 
the  occurrence  of  bedsores.  They  form  very  rapidly  when  spinal  paralysis  is  present.  I 
have  seen  .several  instances  in  which  all  the  soft  parts  over  the  bones  sloughed  and  the 
spinal  canal  was  opened,  while  in  others  the  .sacral  bone  may  partially  exfoliate.  The 
back  should  be  kept  very  clean  and  dry  and  occasionally  sponged  with  spirit  lotion  or 
spirits  of  camphor.  It  should  also  be  protected  further  by  leather  strapping,  felt  plaster, 
and  by  cushions  of  air  or  water. 

When  retention  of  urine  complicates  the  case,  the  utmost  caution  is  required  in  pass- 
ing the  catheter.  An  elastic  instrument  should  be  preferred  and  of  a  large  size,  the 
French  vulcanite  catheter  being  the  best.    The  catheter  .should  be  kept  scrupulously  clean. 

FRACTURES  AND  DISLOCATIONS  OF  THE  SPINE.— WOUNDS 

AND  SPRAINS. 

In  a  practical  point  of  view,  it  is  expedient  to  consider  fractures  and  di.slocations  of 
the  spine  together.  They  are  not,  however,  invariably  combined,  for,  although  in  four- 
fifths  of  the  injuries  to  the  spinal  column  involving  the  bones  some  fracture  is  present,  in 
the  remaining  fifth  .simple  dislocation  exists.  The  majority  of  these  cases  of  pure  dislo- 
cation occur  in  the  cervical  region  ;  in  the  dorsal  such  an  accident  is  almost  impossible, 
while  in  the  lumbar  it  is  very  rare.  The  difference  in  the  anatomical  arrangement  of 
these  divisions  of  the  column  affords  an  explanation  of  these  facts.  To  the  practical  sur- 
geon these  points  are,  however,  of  small  importance ;  that  which  concerns  him  the  most 
in  any  injury  to  the  spine  has  reference  to  the  cord  :  How  much  injury  has  it  sustained? 
Is  it  reparable  or  not? 

When  complete  paralysis  follows  the  injury,  there  is  little  douljt  that  the  cord  has 
been  injured.  It  may  be  that  it  has  been  more  or  le.ss  completely  crushed,  or  even  divided 
by  displaced  bone.  In  less  severe  injuries,  le.ss  severe  symptoms  show  themselves.  The 
nearer  the  injury  is  to  the  respiratory  centre,  the  greater  the  danger:  thus  injuries  of 
the  cervical  are  more  dangerous  than  those  of  the  dorsal  region,  and  the.se  again  than 
those  of  the  lumbi  r.  Any  crushing  of  the  cord  above  the  third  cervical  vertebra  is,  as 
a  rule,  followed  by  instant  death,  this  point  being  above  the  origin  of  the  chief  respiratory 
nerve,  the  phrenic.  In  cases  of  injury  to  the  cervical  vertebra  giving  ri.se  to  any  .symp- 
toms of  paralysis  death  generally  takes  place  within  three  days,  and  commonly  within 
two.  Thus,  out  of  thirty-six  fatal  cases  extracted  for  me  by  Mr.  Rendle  from  the  Guy's 
records,  twenty-five  died  in  less  than  seventy-two  hours  and  twenty  in  less  than  forty- 
eight  ;  eight  only  survived  the  former  period,  and  in  those  there  were  no  symptoms  of 
paralysis  as  an  immediate  result  of  the  accident.  Eleven  of  the  thirty-six  were  cases  of 
pure  dislocation,  twenty-five  were  examples  of  fracture  and  dislocation  combined,  and  all 


238 


FRACTURES  AND  DISLOCATIONS  OF  THE  SPINE. 


were  below  the  third  cervical  vertebra.     In  every  case,  also,  of  dislocation  the  upper  ver- 
tebra was  thrown   forward   upon   the   lower,  as  seen  in  Fig.  91.     The  reverse  holds  good 


Fig.  91. 


Fig.  93. 


Dislocation  of  the  Spine 
Forward.  ((iuy's 

Hosp.  Mus.,  No.  103:5.) 


Fracture  of  Spine  and  I'isplace- 
ruent  of  Upper  Vertebra  Far- 
iviird.  (Ciuy  s  Hosp.  Mus.,  No. 
10a.5-'5.) 


Fracture  of  Spine  and  Displace- 
ment of  Upper  Vertebra  Back- 
wiirn.    A  fifth,  B  sixth,  vertebra. 


only  in  exceptional  cases,  as  in  the  one  illustrated  by  Fig.  93,  in  Avhich  a  man  set.  20 
struck  his  head  against  the  bottom  of  a  bath  when  jumping  for  a  dive  a  height  of  twelve 
feet.  The  drawing  shows  a  displacement  of  the  fifth  cervical  vertebra  hack  ward,  with  a 
fracture  of  the  fourth  and  fifth  and  crushed  cord.     The  man  lived  seventeen  months. 

Fractures  of  the  dorsal  and  lumbar  vertebrae  associated  with  displacement  and  giving 
rise  to  paralysis  below  the  seat  of  injury  are  less  speedily  fatal  than  those  of  the  cervical 
region. 

Fracture  of  the  spine  may,  however,  take  place  and  not  be  associated  with  any 
paralysis.  The  spinous  processes  of  any  of  the  vertebrae  may  be  fractured  and  no  spinal 
symptoms  follow.  This  accident  is  generally  the  result  of  a  direct  blow.  When  I  was  a 
dresser,  I  saw  a  case  of  fracture  of  the  spinous  processes  of  three  cervical  vertebrae  asso- 
ciated with  a  temporary  paralysis,  and  in  this  instance  complete  recovery  en.s«ed.  I  have 
since  treated  successfully  a  case  of  fracture  and  displacement  of  the  spinous  process  of 
the  fourth  cervical  vertebra  without  paralysis. 

In  other  cases  fracture  of  the  spine  may  take  place  and  not  be  detected  until  after 
death.  Thus,  in  1879,  a  man  aet.  23  was  admitted  into  Guy's  Hospital  under  Dr.  Wilks 
for  some  throat  aifection,  as  suggested  by  difficulty  in  swallowing  and  inflammation  of 
the  soft  paltite,  with  a  sloughy  patch  of  tissue  in  the  pharynx.  The  symptoms  had  come 
on  after  a  fall  of  ten  feet  down  a  ship's  hold  three  days  previously.  There  were  no  symp- 
toms of  paralysis.  The  man  died  on  the  fifth  day  of  his  admission  and  eighth  day  after 
the  accident  with  dysphagia  as  his  most  prominent  symptom,  associated  with  febrile  dis- 
turbance and  delirium  with  tremor.  After  death  the  body  of  the  fifth  cervical  vertebra 
was  found  fractured  and  its  lower  fragment  projecting  forward.  The  cord  was  not 
aiFected.  There  was  a  sloughing  prevertebral  abscess  communicating  with  the  pharyn- 
geal wound  which  had  been  clearly  caused  by  the  fractured  fifth  vertebra.  A  portion  of 
the  laminje  of  the  fifth  vertebra  was  necrosed  and  bathed  with  putrid  pus,  which  had 
spread  upward  to  the  base  of  the  brain  and  caused  death.  In  1857  a  woman  in  an  attack 
of  mania  was  admitted  into  Guy's  under  the  care  of  Mr.  Cock  for  some  contusion  of  the 
back  caused  by  a  fall  out  of  a  window.  Beyond  the  contusion,  no  injury  could  be  made 
out.  There  was  no  paralysis,  but,  on  the  contrary,  violent  muscular  movement.  On  one 
occasion  the  patient  got  out  of  bed  and  struggled  to  open  a  window  to  throw  herself  out. 
She  lived  sixteen  days,  and  during  the  last  week  of  her  life  rested  (|uietly  in  bed  with 
her  eyes  closed.  She  would  only  at  times  rouse  herself  and  speak.  After  death  atrophy 
of  the  brain  was  found,  with  general  fatty  degeneration  of  the  viscera.  The  last  dorsal 
and  three  upper  lumbar  vertebrae  were  fractured  through  their  bodies,  but  not  displaced  \ 
one  or  two  spinous  processes  were  also  fractured.     The, spinal  marrow  was  uninjured. 


FiLirTii:i:s  AM>  insLor.vnnsss  or  Tin:  sn.\i:.  239 

Till'  fact  of  tluTf  btMn<;  im  (lis|ilac«'iiu'iit  of  tlic  luokcn  Itoncs  and   no  injury  to   tho  cord 
pn-vciitoil  a  correct  diagnosis  hcint:  made. 

I  have  seen  also  u  case  of  fracture  of  the  spinous  processes  rtf  the  last  dorsal  an<l  the 
first  luiiiliar  vertebnv,  with  lateral  displacement,  the  injury  havinjr  been  treated  for  some 
months  previously  as  a  simple  contusion  of  the  hack.  In  this  ca.se  no  paralysis  existed 
or  other  spinal  sympt<ims. 

Fractures  and  dislocations  of  the  sjtine  are  irt'iitrally  the  result  iA'  litilliftf  /nrriK,  such 
as  severe  falls.  A  forcible  bendinf.'  forward  of  the  cervical  spine  may  cause  dislocation 
of  tlie  cervical  vertcbne.  and  a  similar  accident  to  the  dorsal  spine  mav  cause  fracture. 
In  tlicse  cases,  too.  there  is  always  some  laceration  of  the  liframents  and  crushinjr  of  the 
anterior  edges  of  the  bodies  (»f  the  vertebnv.  (  Vide  ¥i<^.  !t2. )  A  forcible  beiidiriL'  back- 
ward <if  the  spine  may  jiroduce  a  like  result,  the  lamina*  of  the  dorsal  or  lumbar  vertebrae, 
under  these  circumstances,  beinir  much  broken.  Direct  viiilencc  to  the  cervical  rejrion  of 
the  spine  may  produce  dislocation  ;  whilst  to  the  lower  vertebne  it  jrenerally  cau-ses  frac- 
ture of  the  spinous  processes  or  laminae.  Mr.  Holmes  has  recorded  in  the  P<(th.  Soc. 
Trans.,  vol.  X..  an  interesting  case  of  displacement  of  the  last  dorsal  from  the  first  lumbar 
vertebra,  associated  with  some  slight  fracture  of  the  processes  the  result  of  a  direct  blow. 

Fracture  of  the  sternum  is  not  uncommonly  associated  with  injuries  to  the  spine  from 
the  forcible  bending  forward  of  the  head.  It  was  found  in  four  out  of  fifty-six  fatal  ca.ses 
that  occurred  at  Guys. 

Of  the.se  fifty-six.  fatal  cases  of  fracture  and  dislocation  of  the  spine,  thirty-six  were 
of  the  cervical  region,  eleven  being  examples  of  pure  dislocation,  eighteen  of  the  dorsal, 
and  two  of  the  lumbar,  injuries  of  the  cervical  being  apparently  twice  as  frequent  as  those 
of  the  dorsal  region,  the  greater  mobility  of  the  cervical  vertebrae  and  the  obliquely  hori- 
zontal aspect  of  their  articular  processes  favoring  di.slocation. 

In  the  thirty-six  the  injury  was  below  the  third  cervical  vertebra  in  all  but  three 
examples.  In  one  of  these  it  involved  the  second,  third,  and  fourth  vertebrae:  in  another, 
the  arch  of  the  atlas  and  spinous  processes  of  the  second  and  third  vertebrae;  and  in  the 
third  case  the  bodies  and  arches  of  the  third,  fourth,  and  fifth  vertebrae. 

In  the  eighteen  dorsal  .seven  were  in  the  upper  and  eleven  in  the  lower  half,  the  lower 
part  of  the  cervical  and  of  the  dorsal  regions  being  clearly  more,  liable  to  injury  than  the 
upper. 

When  the  cord  was  sufficiently  injured  in  the  cases  of  injury  to  the  cervical  region  to 
give  rise  to  paralysis,  death  generally  took  place  within  three  days,  and  in  the  majority 
of  instances  within  two. 

When  it  occurred  as  a  result  of  injury  to  the  dorsal  region,  suppuration  of  the  kid- 
neys, cystitis,  or  bedsores  were  the  most  common  causes  of  death. 

Of  the  eleven  cases  of  pure  dislocation  of  the  cervical  vertebrae,  four  were  between 
the  fourth  and  fifth,  two  between  the  fifth  and  sixth,  three  between  the  sixth  and  seventh, 
and  two  between  the  seventh  cervical  and  the  first  dorsal.  In  none  of  these  was  there 
the  smallest  trace  of  fracture.  In  .six  the  displacement  was  so  great  as  to  crush  the  cord. 
In  five  there  was  no  displacement  and  no  marked  paralysis  as  a  direct  result  of  the  injury, 
although  secondar}-  paralysis  appeared  subsetjuently.  from  stretching  or  other  injury  to 
the  cord. 

In  injuries  to  the  cervical  region  pure  di.slocation  occurs  in  thirty  per  cent,  of  the 
cases. 

Cases  of  sudden  death  after  a  fall  from  a  height  upon  the  vertex  are  doubtless  often 
due  to  a  fracture  or  dislocation  of  the  cervical  spine.  It  may  be  a  fracture  of  the  pro- 
cessus dentatus  of  the  axis,  a  laceration  of  the  transverse  ligament  binding  it  in  po-sition. 
or  a  fracture  of  the  atlas  allowing  the  head  to  slip  forward.  Dislocation  of  the  occipital 
bone  from  the  atlas  has  been  described  :  it  is.  however,  verv  rare. 

When  fracture  of  the  odontoid  process  takes  place,  as  it  may  from  external  violence 
or  during  the  progress  of  some  disease  in  the  vertebrfe.  death,  as  a  rule,  occurs  suddenly, 
the  victim  being  literally  pithed.  In  other  cases — and  these,  generally,  of  disease — the 
displacement  may  be  gradual,  death  being  then  often  preceded  by  paraly.sis  of  an  arm  or 
leg,  or  both,  with  difficulty  in  swallowing,  pain  in  the  neck,  and  inability  to  raise  the  head 
into  the  erect  position  or  to  rotate  it. 

Vide  paper  on  fractures  of  the  odontoid  process,  by  Dr.  Stephen  Smith  of  New  York 
(American  Jounnd  of  Med.  Sci..  October.  1871). 

Diagnosis. — When  a  patient  has  received  a  severe  injury  to  the  spinal  column  fol- 
lowed by  complete  paralvsis.  the  cord  has  been  injured,  and  it  is  probable  that  a  fracture 
or  dislocation,  with  displacement  of  the  vertebrae,  has  taken   place.     When  the  paralysis 


240  FRACTURES  AXD  DTSLOCATTOXS   OF  THE  SPINE. 

is  ptirtiaL  it  is  probable  that  the  cord  has  been  only  partially  involveJ,  but  more  or  less 
bruised  or  stretched,  according  to  the  nature  of  the  accident  and  the  extent  of  the  dis- 
placement of  the  injured  bones.  When  no  paralysis  is  present,  the  dianrnosis  of  fracture 
or  dislocation  is  difficult. 

When  any  inequality  or  irregularity  in  the  spinous  processes  is  present,  any  pain  in 
one  spot  aggravated  by  pressure,  any  crepitus  on  manipulation,  any  local  eflPusion  of  blood 
about  the  spine,  any  inability  to  move  the  spine  or  support  the  body ;  when  priapism 
appears  early  in  the  case  ;  when  one  or  more  or  all  of  these  .symptoms  come  on  after  such 
an  accident  as  is  liable  to  produce  them, — the  diagno.sis  of  a  fracture  or  dislocation  is 
tolerably  clear. 

When  paralysis  of  an  arm  or  leg  follows  a  spinal  injury,  it  is  possible  that  the  paral- 
ysis may  be  caused  by  pressure  upon  one  or  more  of  the  nerves  that  pass  outward  from 
the  spine,  or  by  laceration  of  a  nerve  trunk  from  some  partial  displacement  of  the  injured 
bone.  When  paralysis  is  incomplete,  the  motor-power  is  generally  more  completely  lost 
than  that  of  sensation  :  indeed,  it  often  happens  that  there  is  hyperajsthesia  in  that  por- 
tion of  the  body  contiguous  to  the  paralyzed  part,  owing  to  the  portion  of  cord  above  the 
injury  being  overactive  or  irritated  by  the  .sharp  parts  of  the  fractured  bone.  Intense 
pain  in  the  line  of  junction  of  the  paralyzed  and  non-paralyzed  parts  signifies  fracture, 
in  Mr.  Erichsen's  opinion.  In  estimating  the  seat  of  injury  from  the  po.sition  of  the 
paralysis,  it  is  right  to  remember  that  the  nerves  come  off  obliquely  from  the  .spinal  cord 
and  pass  downward,  the  cervical  and  dorsal  nerve  trunks  leaving  the  spine  one  or  two 
vertebrae  lower  than  the  spot  whence  they  are  given  off,  while  the  cord  terminates,  at  the 
second  lumbar  vertebra.  Thus,  when  fracture  takes  place  below  the  second  lumbar  ver- 
tebra, the  patient  may  be  unable  to  stand  or  walk  wholly  or  in  part,  yet  there  may  be  no 
paralysis,  for  place  him  on  his  back  and  there  will  be  free  movement  of  his  legs.  In 
other  cases  the  nerve  trunks  around  the  cauda  equina  may  be  involved. 

When  a  patient  has  received  a  severe  spinal  injury,  there  may  or  ma\-  not  occur  what 
is  called  '•  shock  ;"  but  when  these  symptoms  have  passed  off  and  those  of  reaction  appear, 
there  will  commonly,  in  cervical  injuries,  exist  some  throbbing  of  the  arteries  and  increase 
of  the  temperature  of  the  paralyzed  parts.  These  conditions  are  due  to  paralysis  of  the 
arteries  as  a  result  of  injury  to  their  vaso-motor  nerves.  At  a  later  period,  however,  this 
increase  of  temperature  subsides  and  a  diminution  can  be  detected.  In  exceptional  cases 
the  vaso-motor  paralysis  is  associated  with  coldness  of  the  parts,  and  it  is  probable  that 
when  this  coldness  exists  it  is  due  to  great  depression  of  the  heart's  action. 

Priapism  is  a  common  consequence  of  spinal  injuries,  and  more  particularly  of  cervical 
and  upper  dorsal.  It  may  occur,  however,  in  lower  dorsal,  not  so  in  the  lumbar.  I  have 
recorded  an  example  occurring  in  the  lower  dorsal  (Path.  Soc.  i^a??s.,  vol.  vii.,  p.  332). 

Prognosis. — The  nearer  the  injury  is  to  the  respiratory  centre,  the  greater  the  danger 
to  life.  Thus,  in  injuries  to  the  cervical  spine  above  the  origin  of  the  phrenic  nerve  or 
third  cervical  vertebra  causing  paralysis,  death  may  be  instantaneous  ;  when  below  this 
position,  and  the  respiratory  process  is  maintained  only  through  the  diaphragm,  life  is 
rarely  prolonged  beyond  the  third  day.  and.  as  a  rule,  not  be\ond  the  second.  Exceptions 
to  this  rule,  however,  are  met  with.  Mr.  Hilton  has  recorded  in  his  lectures  On  Rtst  a 
case  in  which  a  man  lived  for  fourteen  years  completely  paralyzed  from  the  neck  down- 
ward after  a  fi-acture  of  the  cervical  vertebrae,  and  in  my  own  practice  I  had  a  case  in 
the  person  of  a  gentleman  aged  29,  whom  I  saw  with  Mr.  Roberts  of  Southgate,  Novem- 
ber 25.  1870.  with  complete  paralysis  of  the  whole  bodv-  below  the  fifth  cervical  vertebra, 
caused  by  a  fall  upon  the  neck ;  he  lived  nearly  ten  j-ears  and  died  from  lung  disease, 
breathing  solely  by  the  diaphragm. 

When  the  cord  has  been  injured  in  the  lower  dorsal  or  lumbar  region,  life  may  be 
prolonged  for  many  months,  the  immediate  cause  of  death  being  generally  some  renal  or 
vesical  mischief,  some  bedsore  or  other  complication  the  direct  result  of  loss  of  nerve 
power  in  the  paralyzed  parts.  The  longer  these  complications  are  delayed  by  careful 
nursing  and  attention,  the  longer  can  life  be  maintained. 

In  other  ca.ses.  again,  in  which  only  partial  or  no  paralysis  at  all  is  present  as  a  direct 
consequence  of  the  injury,  inflammatory  changes  may  ensue  in  the  injured  part,  and, 
spreading  upward,  cause  death.  The  prognosis  in  such  instances  will  be  mainly  deter- 
mined by  the  seat  of  the  injury  and  the  extent  of  the  mischief  in  the  cord. 

The  lovctr  the  seat  of  injuri/.  the  hetter  the  prospects  of  a  cure  ;  and  the  less  the  cord  is 
involved  in  the  mischief,  the  greater  the  chances  of  a  recovery. 

Thus  fractures  of  the  lumbar  region  are  quite  capable  of  a  complete  cure,  and  frac 
tures  of  the  lower  dorsal  vertebrae  are  not  unfrequently  recovered  from.     Injuries  to  the 


FiiAcrniEs  AM)  Disi.oiwrioss  of  rill:  si'iM-:.  iMl 

cervical  part  uf  tin-  >|iiri('  arc  f^oncrally  fatal  witliiii  tlin-i-  days.  Iiijiirirs  to  the  dorsal, 
when  not  proviii;^  fatal  witliiii  tin-  tliinl  wtnk.  may  l)o  surviviMl  fur  iiKtiiths,  and  even 
years,  the  duration  ol"  lil"e  JMinir  greatly  determined  !)y  the  warilin^'  off  of  the  secondary 
eoni|>lications  wiiieh  so  frcijiiently  arise. 

Tkk.vT.MKNT. — The  iliairnosis  of  a  fracture  or  dislocation  of  the  s](ine  having'  lieen 
made,  the  most  essential  point  to  attend  to  is  to  keep  the  part  aljsoliitely  unmoved.  The 
patient  should  he  examined  with  the  j^reatest  care  and  moved  with  every  pos.sihie 
])recaution,  as  any  motion  may  add  to  the  injury  the  cord  has  sustained  and  increase  the 
danger  to  the  patient.  Ivxtension  of  the  spine  may  be  employed  when  much  deformity 
exists,  and  j)articnlarly  when  severe  pain  ari.ses  fnnn  nerve  j)ressure,  but  extreme  caution 
is  reijuired  in  followiiiL;  this  practice  ;  it  is  not  to  be  employed  in  every  instance,  but 
onlv  when  local  svmptoius  seem  to  suggest  the  probabilities  of  a  reduction  of  the  dislo- 
cated or  disphiced  bone  or  the  relief  of  pain.  I  have  known  cases  in  which  a  successful 
reduction  of  displaced  bone  has  been  effected  by  extensitjii,  and  seen  others  in  which 
marked  relief  was  afforded  ])y  this  course.  Practised  with  discretion,  extension  of  tht 
spine  is  doul)tless  a  valuable  means  of  treatment.  A  good  example  of  this  occurred  in 
the  ])ractice  of  my  colleague,  Mr.  Davies-Colley,  on  March  14,  ISS!^,  when  a  n)an  ;et.  50 
was  brought  into  (Juys  after  having  been  double<l  u]»  forward,  with  projection  of  the 
first  lumbar  vertebra  three-((uarters  of  an  inch  behind  the  level  of  the  last  d<irsal.  and 
some  paralysis  of  motion  and  sensation  of  the  right  lower  extremity.  Under  chlorol'orm 
powerful  traction  was  made  upon  the  legs  by  assistants,  and  3Ir.  Davies-Colley,  who.se 
hand  was  placed  upon  the  projecting  bone,  felt  it  gradually  sink  to  the  level  of  the  upper 
vertebra  ;  at  the  same  time  crepitation  and  mobility  were  felt,  as  if  the  bone  immediately 
above  had  been  broken.  A  plaster-of- Paris  jacket  was  then  applied.  For  ten  days  the 
urine  had  to  be  drawn  off.  At  the  end  of  a  month  sensation  had  returned  in  the  right 
leg.  but  the  foot  was  in  the  position  of  talipes  valgus  from  paralysis  of  the  peronei 
muscles.  The  jacket  was  removed,  and  no  deformity  existed.  The  man  could  move  in 
bed  without  pain.      He  left  the  hospital  cured,  but  with  the  talipes. 

When  the  injury  is  in  the  mid  or  lower  dorsal  region,  the  application  of  a  plaster  or 
other  jacket,  with  the  patient  in  a  horizotital  position,  gives  comfort  by  ensuring  immo- 
bility and  helps  recovery. 

"When  the  patient  is  placed  on  his  back,  the  parts  have  a  natural  disposition  to  fall 
into  place  ;  this  j)osition,  therefore,  must  be  maintained.  The  bed  should  be  firm,  yet 
elastic,  and  a  water  bed  is  the  best  when  it  can  be  obtained;  otherwi.se,  a  spring  mattress 
or  ono  of  horsehair  should  be  employed.  It  .should  be  well  protected  by  waterproof 
cloth,  etc.  from  all  contact  with  urine  or  feces. 

The  condition  of  the  bladder  should  be  attended  to  from  the  very  first.  Retention  is 
certain  to  be  present  for  a  time,  and  overdistension  is  most  injurious.  The  utmost  care 
ought  to  be  employed  in  drawing  off  the  water.  A  moderate-sized  elastic  or  the  French 
vulcanite  catheter  .should  be  used,  and  the  operation  repeated  twice  a  day,  night  and 
morning.  If  the  urine  becomes  offensive,  the  l)ladder  must  be  washed  out  with  a  lotion 
of  boracic  acid  ten  grains  to  the  ounce  ;  but  no  syringe  should  be  used.  A  stream  of 
medicated  water  ought  to  be  allowed  to  run  in  and  out  of  the  bladder  through  an  elastic 
tube  attached  to  the  irrigator  and  fitted  to  the  top  of  the  catheter,  no  force  being  applied. 
(  Viife  Fig.  350.)  The  api)lication  of  leeches  to  the  spine  or  cupping  is  seldom  called  for. 
The  condition  of  the  bowels  must  be  attended  to.  and  enemata  are  to  be  preferred  rather 
than  ])urgatives.  The  greatest  care  is  needed  to  keeji  the  patient  clean,  particularly 
when  incontinence  exists. 

There  are  no  special  medicines  applicable  to  these  ca.ses.  The  general  health  of  the 
patient  should  be  maintained  by  tonics  and  simple  nutritious  food,  and  .sedatives  should 
be  given  to  procure  rest  and  relieve  pain. 

The  condition  of  the  back  mu.st  be  daily  watched  to  prevent  bedsores.  This  is  best 
secured  by  removing  pressure  as  far  as  possible  or  in  relieving  it  by  means  of  soft 
cushions  and  pads,  the  water  cushion  being  the  best,  and  also  by  keeping  the  parts  dry. 
The  application  of  a  soft  felt  plaster  over  the  sacrum  and  hips  is  sometimes  beneficial ; 
so  also  is  the  freijuent  application  to  the  parts  of  some  spirit  lotion.  Should  it  be  neces- 
sary to  turn  the  patient  on  one  or  other  side,  the  attendants  ought  to  be  taught  to  rotate 
the  hips  and  shoulders  at  the  same  time.  By  great  care  and  attention  life  may  be  pro- 
longed, and  even  recovery  may  occur. 

The  subject  of  trephining  the  spine  requires  brief  consideration.  Cline  was 
the  first  to  put  it  into  jiraotice,  and  on  his  great  authority  the  operation  has  been 
repeated,  but  with  no  success.  The  great  argument,  however,  against  the  operation  is 
16 


242  SPRAiy  OF  THE  BACK. 

derived  from  the  fact  that  in  few  post-mortem  examinations  has  the  condition  of  parts 
indicated  that  the  slightest  good  could  have  been  derived  from  its  performance.  The 
danger  of  a  fractured  or  dislocated  spine  lies  in  the  injury  to  the  cord,  the  result  of  a 
stretching  or  crushing  of  its  substance.  When  the  cord  is  much  injured  by  the  acci- 
dent, the  mischief  has  been  done,  and  no  removal  of  the  displaced  bone  can  undo  it  or 
neutralize  its  evil.     If  the  cord  is  uninjured,  no  operation  is  called  for. 

One  successful  instance  of  trephining  is  recorded  by  Dr.  Gordon  of  Dublin,  and  in 
rare  and  exceptional  cases  it  is  possible  the  operation  may  be  justifiable.  To  perform  it 
because  it  may  by  chance  do  good  is  not  advi.-^able.  The  onus  of  proving  that  an  ope- 
ration is  likely  to  be  of  use  always  devolves  upon  the  surgeon  who  performs  it.  There 
is,  however,  reason  to  believe  that  a  cord  may  at  times  be  only  squeezed  or  pressed  upon 
by  effused  blood,  and  under  such  circumstances  relief  might  be  afforded  by  removing 
enough  bone  to  take  away  the  pressure  and  thus  give  the  cord  a  chance  of  recovering 
itself. 

In  the  ease  of  Mr.  Roberts"s  patient,  referred  to  at  p.  240,  such  a  probability 
seemed  reasonable,  and  three  months  after  the  accident  I  cut  down  upon  the  injured 
vertebra  and  removed  the  spinous  process  and  lamina  of  the  fourth  cervical,  thereby 
exposing  the  cord.  No  harm  followed  the  operation,  although  no  immediate  good  was 
produced.  The  wound  healed  rapidly,  and  in  the  course  of  a  few  weeks  some  slight 
power  returned  in  the  muscles  of  the  shoulders,  the  patient  being  able  to  raise  the  arms 
from  the  bed.  He,  however,  made  no  further  progress  ;  and  yet  I  look  upon  the  case 
as  an  encouraging  one. 

"  The  end  proposed  in  an  operation  of  this  kind.'"  says  Le  Gros  Clark,  '•  is  to  remove 
displaced  bone  which  is  supposed  to  press  upon  or  irritate  the  cord ;  but  it  is  most  likely 
to  prove  abortive,  from  the  inaccessibility  of  the  displaced  bone.  If  the  cord  have  been 
crushed  and  the  operation  have  been  consequently  useless,  probably  life  may  thereby  be 
only  curtailed;  but  if  the  cord  be  not  cru.shed,  it' appears  to  me  that  the  bek  chance  of 
the  patient's  recovery  is  thereby  extinguished.  Indeed,  my  conviction  is  that  the  ope- 
ration has  been  advocated  on  the  erroneous  hypothesis  tliat  tlie  spinal  cord  can  be  com- 
pressed without  serious  disintegration  of  its  texture." 

Wounds  of  the  Spinal  Cord. 

These  are  very  rare  in  civil  life.  They  may  take  place,  however,  as  the  result  of  a 
stab  or  gunshot  wound.  If  the  cord  is  injured,  some  .symptoms  of  paralysis  will  appear 
corresponding  with  the  part  that  is  involved,  the  extent  of  the  paraly.sis  and  its  seat 
fixing  the  position  of  the  wound.  Mr.  Holmes  has  recorded  (Mfd.  Chir.  Trans.,  vol. 
Ixv.,  18S2)  an  interesting  case,  in  which  the  theca  vertebralis  was  opened  in  the  lumbar 
region  with  a  knife,  and  in  which  cerebro-spinal  fluid  escaped  in  considerable  quantities 
for  seven  days  without  any  bad  result. 

Sprain  of  the  Back. 

The  word  '•'  sprain  "  is  very  broad,  and  when  applied  to  the  back  is  indeed  vague.  It 
may  mean  simply  a  stretching  of  the  muscles  or  ligam.ents  of  the  back,  or  a  more  com- 
plete laceration  of  the  latter  and  separation  of  the  spinous  processes  of  the  vertebrae,  with 
exposure  or  injury  of  the  cord.  The  number  of  articulations  in  the  spine — nearly  eighty 
— renders  such  an  accident  as  a  sprain  a  common  occurrence ;  any  twist  of  the  spine  or 
forcible  flexion  may  consequently  injure  .some  of  these  joints.  Sprains  may.  moreover, 
be  followed  by  acute  or  chronic  joint  disease  of  a  serious  and  in.«idious  nature :  and  this 
truth  .should  ever  be  before  the  surgeon  to  influence  his  practice.  When  the  head  is 
bent  violently  forward,  the  muscles  and  ligaments  may  be  so  torn  as  to  give  rise  to 
effusion  of  blood,  .swelling,  and  severe  local  pain.  Wlien  the  body  is  flexed  with  vio- 
lence not  .suflacient  to  give  rise  to  fracture,  there  may  be  the  same  results ;  and  so  also 
when  a  man  falls  upon  his  buttocks.  In  each  case  there  may  be  external  evidence  alone 
of  injury,  or  there  may  be  evidence  of  some  affection  of  the  cord  such  as  is  afforded  by 
the  presence  of  paraly.sis,  proving  that  the  cord  has  been  stretched,  if  not  permanently- 
injured.  If  the  symptoms  rapidly,  or  even  gradually,  subside,  no  grave  mischief,  prob- 
ably, may  have  taken  place.  When  they  are  persistent  or  obstinate,  a  less  favorable 
opinion  should  be  formed.  If  the  lumbar  region  is  the  part  involved,  it  is  not  uncommon 
for  haematuria  to  appear;  and  this  may  be  slight  and  pass  away  or  be  more  persistent.  It 
is  not  generally  a  very  serious  .symptom,  unless  the  kidney  is  ruptured ;  as  a  rule,  it  dis- 


l.ATEHM.    <rnVATl'llE   OF   THE  SI'LSE.  24;$ 

appears  f^radually,  and  no  ovidi'iicc  remains  that  i»r;^ani<-  n-nal  disease  is  ever  the  conse- 
(juenee.  "  Of  the  many  casi-s  I  have  witnessed,  "  says  \m  (Iros  Chirk,  "  T  liave  never  had 
reason  to  suspeet  that  nephritis  nr  orj^anic  disease  foHowed  "  (Hi  it.  Miii.  ./onrn.,  Octol)er 
;>,  ISllS).  Mr.  Sliaw,  in  /Iii/ims's  Siiiyrri/,  <.Mves  a  case  where  the  hh'edin<:  lasted  lor 
lour  days,  eeased  lor  two,  and  then  rea|>peared  in  all  its  severity.  Alh-r  tin;  lapse  of 
two  more  days  it  aj^ain  eeased  for  twenty-four  hours,  reappearin*;  lor  a  third  time  severely, 
then  eeasinir.  and  a  j/ood  recovery  folhtwed.  When  tin-  kidneys  are  dis(!used.  and  when 
ealeuli  :i1mp  f\i^t  in  tlnni.  tlii-  «-ynipl>im  i-  luorc  lik<'ly  to  appear  after  injury. 

Hemorrhage  into  Spinal  Canal. —  ileniorrha^t'  may  take  plaee  into  the  spinal 
canal  as  the  result  of  a  sprain  or  laceration  of  the  li;^aments,  the  hlood  prohahly  ll(»wiiif^ 
from  a  laceration  of  some  of  the  larjre  veins  that  surround  the  cord  or  from  a  spinal 
artery.  Sir  !'.  Ihwett  has  related  a  ease  of  sudden  death  from  a  fall  on  the  head, 
recorded  hv  Mr.  heville  in  1S4;)  ( Mnu.  ilr  ht  .Sue.  tic  C/iinny.  <lc  Purls,  t.  iii.J,  in  which 
no  other  injury  was  found  to  the  nervtuis  centres  than  hemr)rrhage  into  the  canal  in  its 
wlude  leuirth.  Mr.  Ijc  (Jros  Clark  has  recorded  a  second,  in  which  a  man  was  struck 
viidently  on  the  hack,  though  there  were  no  immediate  spinal  symptfuns.  Paraplegia 
soon  followed,  however,  which  extended  upward,  destroying  life  hy  asphyxia;  and  after 
death  the  theca  was  found  distended  with  fluid  blood  derived  from  a  ruptured  spinal 
artery.  lie  gives  al.>io  another  ca.se  somewhat  similar  in  symptoms,  though  not  in  result, 
where  the  patient  recovered  after  two  year.s 

Tre.vt.mf.nt. — In  all  the.se  cases  of  sprain,  slight  or  severe,  re.st  is  es.sential,  the  suf- 
ferer being  allowed  to  assume  the  position  in  which  the  greatest  ease  can  be  rtbtained. 
The  application  of  cold  by  an  ice-bag  or  a  metallic  coil  is  al.so  of  great  .service  where 
much  swelling  or  jiain  exists.  In  other  ca.ses  a  warm  poppy  fomentation  gives  relief,  or 
a  mixture  of  belladonna  and  opium  rubbed  down  with  glycerine  and  applied  on  lint. 
When  spinal  symptoms  are  present,  the  greatest  caution  is  needed,  and  the  case  ought  to 
be  treated  as  one  of  concussion  of  the  cord. 

In  bad  cases  it  is  wise  to  fix  the  spinal  column  in  a  surgical  ca.sing,  with  the  object 
of  guarding  against  secondary  inflammatory  changes  both  of  the  spine  and  cord ;  and 
this  absolute  immobility  of  the  spine  should  be  maintained  for  months. 

Rest  in  the  horizontal  position  for  seven  or  eight  weeks  is  essential  in  less  .severe 
cases,  and  even  in  the  mildest  forms  exercise  must  be  sanctioned  with  caution. 

When  hicmaturia  occurs,  it  requires  no  special  treatment  unless  severe,  when  gallic 
acid  in  gr.  v  or  gr.  x  doses  two  or  three  times  a  day  may  be  given,  or,  what  is  better,  the 
subcutaneous  injection  of  ergotin  in  doses  of  two  to  five  grains  dissolved  in  five  or  ten 
minims  of  distilled  water  employed. 

CURVATURE  OF  THE  SPINE. 

There  are  two  forms  of  curvature  of  the  spine — iateral  and  angnhir.  The  lateral  is 
due  to  a  relaxation  of  the  ligaments  and  muscles  of  the  spine,  which  in  a  healthy  subject 
maintain  the  bony  column  in  its  normal  position.  The  angular  is  secondary  to  organic 
disease  of  one  or  more  of  the  bodies  of  the  vertebrae  or  of  the  intervertebral  substances, 
and  is  generally  known  as  "  Pott's  curvature." 

Lateral  Curvature  of  the  Spine. 

This  is  by  far  the  more  common  form  of  spinal  curvature.  It  is  generally  found  in 
girls  between  ten  and  twenty  years  of  age,  sometimes  in  young  children,  and  is  fre- 
quently, though  not  always,  associated  with  want  of  power.  It  is  more  common  in  the 
middle  and  higher  classes  of  society,  where  sedentary  occujiations  and  luxurious  ener- 
vating habits  too  often  exist,  than  in  young  women  who  make  full  use  of  all  their  mu.s- 
cles  and  lead  an  active  life. 

It  is  encouraged  by  any  one-sided  posture  of  the  body,  whether  this  be  the  result 
of  some  fault}-  habit  or  of  occupation,  of  overuse  of  one  limb,  or  of  any  disease  or 
deformity  of  a  lower  extremity  which  occasions  shortening  of  the  limb. 

In  its  early  stage  it  is  seldom  discovered,  and  attention  is,  as  a  rule,  drawn  to  the 
disease  by  some  "  growing  out  '  of  one  shoulder,  generally  the  right,  .some  distortion  of 
the  chest,  or  some  tilting  upward  of  a  hip.  The.se  deformities  are  frequently  fir.st  noticed 
by  dancing-  or  drill-masters.  When  a  curve  has  taken  place  in  the  upper  dorsal  region 
of  the  spine  to  the  right  side,  a  compensatory  curve  is  certain  to  be  found  in  the  lumbar 
to  the  left.     In  investigating  a  case  it  is  important  to  bear  this  fact  in  mind,  as  the  con- 


244 


LATERAL  CURVATURE  OF  THE  SPINE. 


Fig.  94. 


Fig.  95. 


Anterior  view.                                            Posterior  view. 
Lateral  Curvature  of  the  Spine. 
(Guy's  Hosp.  Mus.,  No.  \m&».    Taken  from  Emma  J ,  ret.  14.) 


secutive  or  compensatory  curve,  unless  of  long  standing,  will  soon  be  remedied  when  the 
original  one  has  been  cured. 

Associated  with  the  lateral  curvatures  there  nece.ssarily  must  be  some  rotation  of  the 
spine.  The  amount  of  this  is  very  variable  and  depends  upon  the  extent  of  the  curva- 
ture;  it  is  doubtless  due  to 
the  forcible  bending  of  the 
bones  downward  with  the 
ribs,  these  latter  helping  to 
rotate  the  vertebrae  upon 
their  axes.  The  bones  may 
be  so  twisted  that  their 
transverse  processes  project 
backward,  carrying  the  ribs 
with  them,  the  anterior  sur- 
ftices  of  the  bodies  of  the 
vertebrae  looking  toward  the 
convexity  of  the  curve  and 
the  spinous  processes  later- 
ally toward  the  concavity. 
The  thorax  is  thus  much 
distorted,  the  side  corre- 
sponding to  the  curve  being 
expanded  and  the  oppo- 
site one  greatly  contracted. 
This  is  well  seen  in  the 
annexed  drawings,  Fig.  95 
taken  from  a  living  patient  and  Fig.  94  from  a  preparation. 

In  some  otherwise  healthy  and  in  rachitic  subjects  there  exists  an  exaggeration  of  the 
natural  curves  of  the  back.  When  it  is  in  the  upper  dorsal  region  and  backward,  it  is 
called  '■^  q/pliosis;''  when  in  the  lumbar  and  forward,  "lordosis."  This  latter  curve  is  very 
frequently  found  as  an  accompaniment  and  result  of  hip  disease  when  the  thigh  is  flexed 
or  adducted,  and  it  is  always  present  in  congenital  displacement  backward  of  the  head  of 
the  femur. 

The  DIAGNOSIS  is  not  very  difl&cult  when  the  deformity  is  well  developed,  the  double 
curve  giving  the  spine  a  sigmoid  form,  which  is  typical.  In  less  severe  cases  this  curve 
can  readily  be  removed  by  extension  of  the  body,  either  by  lifting  the  patient  from  the 
ground  by  a  hand  in  each  axilla  or  by — what  is  better — the  vertical  suspension  of  the 
patient  by  his  hands  from  a  bar  or  a  pulley.  In  the  more  severe  forms,  such  as  that 
shown  in  the  above  figures,  the  deformity  is  permanent ;  the  ribs  are  thrown  out  in  an 
extreme  degTce,  pushing  the  scapula  outward  and  upward,  and  the  lumbar  curve  is  in 
the  opposite  direction  to  the  dorsal.  The  whole  thorax,  abdomen,  and  pelvis  are  alterec^ 
in  shape  and  position  by  the  deformity. 

Treatment. — In  treating  these  cases  it  is  necessary  in  the  first  place  to  determine 
the  cause  of  the  deformity.  Should  there  be  any  structural  disease,  such  as  a  growth  or 
carious. bone,  this  will  require  attention,  and  the  alteration  in  the  spine  becomes  thereb}' 
a  secondary  matter.  But  in  the  great  majority  of  cases  of  lateral  curvature  the  spinal 
affection  is  the  result  of  impaired  health,  and  constitutional  remedies  are  demanded.  The 
treatment  must  be  directed  to  an  improvement  of  the  general  health,  and  tonics  should 
be  administered,  such  as  iron,  quinine,  and  cod-liver  oil.  Good  air  and  good  food  are  also 
essential.     In  certain  cases  local  treatment  is  of  great  value. 

The  feeble  muscles  and  weakened  ligaments  should  have  rest,  though  they  are  to  be 
kept  in  health  by  moderate  exercise  ;  they  are  never,  however,  to  be  fatigued.  If  fatigue 
be  experienced  from  walking  one  hour,  such  exercise  must  be  curtailed  to  a  shorter 
period.  If  backache  be  produced  by  exertion,  less  must  be  taken.  Exercise  is  to  be 
allowed,  but  not  to  the  extent  of  producing  fatigue.  Sitting  and  standing  ought  not  to  be 
sanctioned.  The  patient  should  recline  at  stated  intervals  in  any  position  that  gives  the 
greatest  ease.  When  the  deformity  is  definite  and  the  dorsal  curve  is  to  the  right  side,  as 
is  nearly  always  the  case,  the  patient  should  rest  upon  that  side  with  a  pillow  beneath  the 
right  arm,  the  weight  of  the  body  in  that  position  acting  as  an  extending  force  upon  the 
curved  spine,  and  thereby  tending  to  reduce  the  curve.  By  resorting  to  this  practice  two 
or  three  times  a  day  for  a  definite  period,  depending  upon  the  nature  and  severity  of  the 
alFection,  much  good  may  be  obtained  and  very  severe  curvatures  remedied.     Cold  sponge 


sr/XAL  i>fsj:As/:. 


245 


or  slmwtr  ImiIis.  if  tlicy  fan  lie  Iportic,  arc  always  iMinficial ;  sd  also  is  a  iiKnIi-ratcl  v  firm 
hi'd,  a  sjiriiiLC  luattri'ss  lii-iii^  Ixtti-r  than  a  Icatlicr  linl.  (itMitlc  falistlicni<-  exorcises  are 
valiialilc  ailjuncts  to  treatment  when  practised  with  (liscreti(»n,  and  jtariicularlv  the  volun- 
tary vertical  extension  of  the  jiatient's  iKtdy  }»y  manual  suspension  IVom  a  liar  or  pulley; 
yet  it  should  he  n-meniliered  that  a  weak  sjiini!  is  heinj.'  dealt  with,  and  ativthin^'  like 
vioh-nee  may  he  very  detrimental. 

Should  the  curvature  have  heen  cncouraLreil  hy  any  faulty  hahit.  such  as  slaridiii;:  on 
one  \v<x  <»r  in  one  position,  or  the  use  of  one  arm,  it  is  almost  needless  to  say  that  the 
habit  should  he  disecuitinued. 

The  objeet.s  of  treatment  arc,  therefore,  1.  To  imprf>ve  the  jreneral  condition  of  the 
body  ;  2.  To  give  rest  to  the  strained  atul  weakened  muscles  and  liframents ;  ;>.  To 
streuirthen  the  muscles  that  .support  the  spine  by  exerci.se  carefully  regulated,  .so  as  to 
prevent  fatigue  ;  4.  To  restore  the  spine  to  its  normal  direction  by  posture,  muscuhir 
extension,  aiul  l)y  pressure  applied  in  the  horizontal  position. 

Mechanical  contrivances  have  l»een  much  vaunted  and  are  often  employed.  I 
confess,  however,  to  having  little  faith  in  their  value  as  cnrtitirc  iKjciita.  They  tend  to 
cause  atrophy  of  the  muscles  tliat  support  the  back  instead  of  strengthening  them,  and 
thus  to  make  the  deformity  permanent.  In  bad  and  exceptional  cases  they  may.  how- 
ever, be  employed  when  the  treatment  sketched  out  cannot  be  borne  or  is  inapplicable. 
The  best  supjtort  is  that  of  Sayres  or  one  of  the  felt  jackets.  When  the  deformity  is 
irremediable  and  sujiport  essential  to  allow  the  patient  to  move  about,  an  instrument  is 
of  great  value. 

It  is  probable  that  the  deformity  in  its  early  stage  chiefly  arises  from  a  compres.sed 
condition  of  the  intervertebral  substance,  it  being  well  known  that  this  material  is  capa- 
ble of  being  compressed  one-fourth  of  its  thickness.  Hence  a  person  by  maintaining 
the  erect  posture  during  the  day  will  be  an  inch  shorter  at  night  than  in  the  morning. 
Any  lateral  curvature  of  the  spine,  however  ju-oduced,  unless  remedied,  will  increase  and 
be  complicated  with  rotation.  When  unequal  vertical  compression  is,  therefore,  kept  up, 
the  deformity  produced  by  it  becomes  permanent,  and  the  growing  bones  necessarily 
assume  shapes  and  positions  corresponding  to  the  deformiiy  and  tending  to  increase  it. 


Organic  Disease  of  the  Spine  and  Angular  Curvature. 

This  disease  of  the  spine  is  due  to  a  destructive  inflammatory  change  of  the  bodies 
of  the  vertebra  and  intervertebral  sukstances.  It  begins  usually  in  the  latter  structure, 
although  the  bone  itself  may  be  its  primary  seat.  It  is  at  times  associated  with  tuber- 
cular deposit  in  the  tissue,  though 


Fio.  9( 


Fig.  97.  there  is  no  evidence  to  prove  that 

it  is  always  due  to  the  presence  of 
tubercle.  The  curvature,  gener- 
ally known  as  "  Pott's  curvature," 
is  directly  due  to  the  destruction 
of  the  bodies  of  the  vertebne  and 
the  intervening  intervertebral  sub- 
.stance,  the  upper  vertebra  falling 
down  toward  the  lower  and  join- 
ing with  it.  When  the  bodies  of 
many  of  the  vertebra*  are  involved, 
the  deformity  will  be  .severe ;  a 
prepai-ation  in  Guy's  Museum 
(lOOr)^.  Fig.  OG)  shows  the  bodies 
of  twelve  vertebriv  implicated, 
but  a  cure  resulted.       Paralysis 

Angular  Curvature  of  the  .Spine,  the  "'''*}'  attend  this  aff"ection.  though 
same  as  ih.it  iiiustraieU  in  Fig.  9r..  it  is  rare  to  find  the  cord  involved 

('taken  from  a  iiatient  iet.  :>5.) 


^i/^'\ 


Angular  Curvature  of  the 
Spine. 

in  the  disease,  even  when  the 
most  destructive  changes  have  taken  place  in  the  bones.  Great  deformity,  even  to  an 
acute  bending  of  the  cord,  may  exi.st  without  giving  rise  to  nervous  complication  (Fig. 
97).  The  paralysis,  too,  may  be  lasting,  but  more  commonly  is  only  temporary.  Angu- 
lar curvature  may  occur  at  any  period  of  life,  but  is  more  liable  to  appear  during  the 
growth  and  development  of  the  spine,  and  consequently  is  more  frequently  found  in  child- 
hood.    From  a  remarkable  preparation  in  the  Guy's  Hosp.  Mus.  (1004*')  it  would  seem 


246 


SPINAL  DISEASE. 


that  it  may  attack  the  foetus  in  iitero  and  be  repaired,  the  bodies  of  three  or  four  of  the 
dorsal  vertebra?  in  this  case  being  clearly  fused  together  from  disease,  thus  giving  rise  to 
angular  curvature. 

When  a  cure  takes  place,  it  is  generally  by  anchylosis ;  occasionally,  however,  the 
parts  are  held  together  simply  by  fibrous  tissue. 

Tlie  disease  more  commonly  attacks  the  lower  dorsal  region  of  the  spine  than  any 
other,  although  the  cervical  and  lumbar  regions  are  not  seldom  implicated.  In  rare  cases 
it  attacks  two  different  regions  of  the  spine.  It  may  run  through  its  whole  course,  even 
to  a  cure,  without  giving  rise  to  any  extei'nal  suppuration  ;  more  comnionlv,  however, 
an  abscess  makes  its  appearance. 

Spinal  Abscess. — Pus  will  sometimes  find  its  way  from  the  dorsal  region  beneath 
the  fascia  that  covers  in  the  psoas  muscle  under  Poupart's  ligament,  and  then  appear  as 
a  swelling  in  the  groin  at  its  inner  half  (psoas  abscess).  The  swelling  may  burrow  down- 
ward and  involve  the  whole  thigh  in  one  large  abscess.  When  the  disease  is  in  the  lum- 
bar region,  pus  may  burrow  between  the  dense  layers  of  fasciae  that  bind  in  the  quadratus 
lumborum  muscle  and  appear  in  the  front  of  the  abdomen  above  Poupart's  ligament,  and 
in  rare  cases  pass  down  the  inguinal  canal  and  appear  in  the  groin,  simulating  an  inguinal 
hernia,  or  in  the  loin  (lumbar  abscess).  In  other  cases  it  will  make  its  way  under  the 
fascia  that  covers  in  the  iliacus  muscle  and  appear  beneath  Poupart's  ligament,  but  at  its 
outer  half.  In  other  instances,  again,  the  matter  will  find  a  passage  downward  into  the 
pelvis,  and  either  make  its  way  through  the  sciatic  notch  into  the  gluteal  region  (t/fufeal 
abscess)  or  pass  downward  behind  the  trochanter  major  to  the  thigh.  In  still  rarer  cases 
the  pus  appears  by  the  side  of  the  rectum. 

When  the  cervical  region  is  the  seat  of  the  disease,  suppuration  may  appear  in  the 
pharynx  as  a  pharijuge.al  abscess^  or  externally  in  the  neck  behind  the  sterno-cleido- 
mastoid  muscle.     The  following  case  is  a  good  example  of  this : 

A  boy  Jet.  3  was  brought  to  me  at  Guy's  in  1862  for  some  affection  of  his  upper  cer- 
vical vertebrae  consequent  on  a  fall  down  stairs  vipon  his  head.  x\n  abscess  formed  two 
months  after  the  accident  behind  the  left  sterno-cleido-mastoid  muscle,  from  which  place 
a  piece  of  the  lamina  of  a  vertebra  escaped  six  months  afterward.  He  kept  his  bed  for 
upward  of  a  year,  when  he  got  up  with  a  stiff  neck.  He  was  unable  to  nod  or  rotate  the 
the  head,  clearly  showing  that  the  joints  between  the  occipital  bone  and  the  first  two 
vertebrjB  had  been  diseased  and  become  anchylosed.  In  18(37  this  boy  again  came  under 
my  notice.  His  head  was  quite  fixed  ;  the  cervical  vertebrae  seemed  shorter  than  usual, 
but  no  irregularity  existed. 

The  annexed  drawings  (Figs.  98.  99,  lOU),  taken  from  Ellen  T .  set.  1-4,  a  patient 

of  Mr.  Poland's,  illustrate  a  severe  case  of  cervical  disease  with  lateral  deformity.    In  this 


Fig.  98. 


Fig.  99. 


Fig.  100. 


patient  a  good  result  was  obtained  by  means  of  the  apparatus  depicted  in  Fig.  100,  the 
cure  resulting  in  anchylosis. 

Exfoliation  of  Bone. — From  any  of  these  abscesses  bone  may  exfoliate,  and  it 
may  be  coughed  up  from  the  phar3-nx  or  discharged  through  the  neck.  I  have  seen  a 
mass  of  bone  the  size  of  a  nut  come  away  from  a  lumbar  abscess,  and  a  piece  of  bone 
clearly  spinal  discharged  from  an  abscess  of  the  thigh,  opening  above  the  knee-joint.  In 
a  case  brought  under  my  notice  by  a  valued  dresser,  Mr.  Burgess,  the  anterior  half  of 
the  atlas,  with  its  articular  facets,  was  expectorated,  recovery  ensuing,  the  man  being 
well  eight  years  subsequently  ;  and  in  Gruy's  Hosp.  Museum  (prep.  1018'^)  there  is  a  prepa- 
ration of  the  odontoid  process  which  a  woman  who  had  had  a  stiff  neck  for  months  coughed 
up,  and  from  which  complete  recovery  ensued.     Mr.  Keate  so  long  ago  as  1835  recorded 


si'f.wii.  hrsi-:.\si':. 


247 


(^Mfil..  Gaz.)  a  case  in  wliicli  the  aiiti'iiur  liull"  of  the  atlas  (•xf'uliate*!,  ami  Mr.  CoHis  in 
his  honk  on  .SV/y/A/V/.s,  uiid  Mr.  ('(ippiii^er  of  l>ul)liii,  in  the  iJiihlin  .lonni..  Dccfiiiher.  1S7U, 
have   both   jmlilished  iiistaiiees  in  whieh  the  eorn'SpoiKling 


portion  of  hone  exloliati-tl.      In   fact,  from   all  these  sni'mt/     . 

4ih.'ifrsgis  hone  may  i)e  (liseliarired,  ami,  wliat  is  more,  recov-    p^^5^Js^.    7V«/i»n 

cry  fdllow. 

Anchylosis  without  Suppuration.— Suppura- 
tion, liowevtM",  does  not  always  take  plaee.      A  woman   let. 
.'{0  came   iinder  my  eare  in  lS,")lt  f(»r  a  stiHtiess  of  her  head 
nn<l  neck  that  had  heeii  inereasini:;  for  two  years,  and  which 
she  regarded  as  rhenmatic.      When  I  saw  her.  the  head  was 
imniovahly   fixed    and   slii^htly   rotated   to  the    ri<;ht  side. 
Rotation  and   nodding  were  impossible.      There  was  much 
thickening  about  the  cervical  vertebno,  with  pains  darting 
upward  to  the  vertex  and  downward  to  the  shoulder.      JJy 
rest  in  bed,  fomentations,  and  tonics  all  these  disappeared   4>^,"iv'^^ 
and  recovery  ensued,  but  with  a  stiff'  neck.     My  colleague,   ^i!^X''^^<jt,<^J 
Dr.  Fagge,  has  also  recorded   in   the  J'ath.  Soc.   TroHS.  for    '^'J^^S^'^j 
1877  a  remarkable  case  of  synostosis  of  the  arches  of  the    li^^^-'^- ^?^  \?'/ 
vertebrjv,  of  the  ribs  to  the  vertebra),  and  of  the  hi])-joint,    t^^^^VEt^V 


rrJte  process 


in    whiidi   a   bending  of  the  dorsal  vertebrjv;  forward   with    ^^^;;*{^^ 

immoliilitv  were  the   oidy  symptoms  of  spinal  disease  that    i\f^7^- 

existed  durint!;  life  fFiu'.  KM).      It   occurred  in   a  man  ivt. 

r,  I         1        1-     1  "^^    -xi     •    ii  '  ,■  1    T1    ^    i-  !•  ii       1  Synostosis  of  Kills  to  VertebrtE,  etc. 

.54.  who  died  with  intlammation  and  duatatioii  ot  the  bron-     ' 

chial  tubes  from  asphyxia,  his  breathing  having  been  entirely  diaphragmatic  from  a  want 
of  movement  in  the  costal  joints. 

DiAONOsis. — When  an  angular  curvature  of  the  spine  exists,  there  can  be  no  diffi- 
culty in  recognizing  the  nature  of  the  disease  or  the  process  by  which  the  curvature  has 
been  brought  about.  When  a  large  abscess  coexists  with  the  deformity,  there  is  good 
reason  to  suspect  that  the  one  is  the  direct  result  of  the  other,  more  particularly  when 
the  suppuration  can  be  traced  up  to  the  spinal  deformity.  But  in  the  early  stage  of  the 
disease  the  diagnosis  is  not  .so  easy,  and  yet  it  is  here  that  a  correct  one  is  most  needed ; 
for  if  any  decided  good  is  to  be  gained  by  treatment,  it  is  at  this  early  period.  AVhat, 
then,  are  the  indications  which  denote  the  presence  of  incipient  spinal  disease?  Local 
avd  pirxliiteiif  pain  is  probably  the  earliest;  and  when  this  is  accompanieil  by  local  tender- 
ness on  firm  pre.ssure  and  pain  is  experienced  in  the  distribution  of  any  of  the  nerves  com- 
ing from  the  seat  of  the  affection,  as  over  the  shoulders  and  dow^n  the  arms  in  lower 
cervical  disease,  around  the  abdomen  and  above  the  umbilicus  in  upper  dorsal,  and  below 
the  umbilicus  and  down  the  thighs  in  lumbar  disease,  the  surgeon's  suspicions  should  be 
excited.  When  the  patient  complains  of  any  sudden  jar  of  the  back  by  a  slip  down 
stairs  or  by  any  jump,  when  added  to  these  symptoms  he  exhibits  extreme  caution  and 
a  rigidlt/j  of  the  spine  in  walking  or  mov- 
ing, and  when,  on  being  told  to  pick  up 
anything  from  the  ground,  he  bfnds  his 
knees  in  prefcreiice  to  hending  his  hack 
(Fig.  102),  and  when,  moreover,  he  rolls 
off  a  couch  instead  of  rising  up  boldly 
from  the  recumbent  posture,  and  sup- 
ports his  body,  when  standing,  with  his 
hands  either  upon  his  thighs  or  neighbor- 
ing piece  of  furniture  (Fig.  lOi^),  the 
diagnosis  becomes  certain.  When,  more- 
over, coughing  or  sneezing  excites  pain, 
and  last,  but  not  least,  when  any  consti- 
tutional disturbance  is  present,  such  as  a 
quick  pulse,  occasional  febrility,  and  a 
furred  tongue, — when  all  these  symptoms, 
or  man}'  in  combination,  exist  during 
that  period  of  life  when  bones  are  grow- 
ing and  bone  disease  is  apt  to  appear, 
the  surgeon  .should  always  suspect  disease  of  some  portion  of  the  spine,  and  until  he  can 
satisfy  himself  that  none  such  exists  it  is  a  wi.se  plan  to  treat  the  case  as  if  it  were  pres- 


FiG.  102. 


Fig.  103. 


248  CURVATURE  OF  THE  SPINE. 

ent.  It  is  true  that  by  adopting  this  rule  of  practice  he  will  he  occasionally  misled  and 
at  times  treat  a  case  of  hysteria  as  one  of  spinal  disease,  but  then  what  harm  ?  He  will 
probably  do  good  to  the  hysterical  patient  by  the  treatment  he  would  adopt  for  the 
spinal  complaint,  while  he  would  certainly  do  much  harm  to  the  latter  by  neglecting  such 
measures  as  are  essential  for  its  successful  treatment. 

TreaTjMENT. — It  is  an  interesting  clinical  fact  that  the  best  cases  of  recovery  from 
the  worst  examples  of  spinal  curvature  and  disease  are  to  be  found  amongst  that  misera- 
ble class  of  patients  who  have  never  had  any  chance  of  receiving  proper  treatment,  who 
have  never  had  rest  or  any  care,  in  whom  the  disease  has  run  its  course  untended  and 
uncared  for,  and  yet  in  whom  a  cure  has  taken  place  with  firm  anchylosis,  although  with 
deformity.  The  majority  of  these  cases  are  examples  of  disease  of  the  dorsal  vertebrae. 
How  far  this  deformity  might  have  been  lessened  or  prevented  by  proper  treatment  is  an 
open  question.  Nevertheless,  it  is  beyond  all  doubt  that  in  the  early  stage  of  this  dis- 
ease immobility  of  the  spine,  rigidly  and  persistently  maintained,  and  the  removal  of 
downward  pressure  upon  the  vertebrae,  are  absolutely  essential  points  of  practice  to  be 
observed.  Not,  however,  rest  upon  the  back,  for  in  many  instances  this  supine  position 
tends  rather  to  separate  parts  that  ought  to  be  kept  in  contact,  but  rest  in  any  position, 
prone  or  supine,  the  patient  feels  to  be  most  comfortable. 

The  general  health  of  the  patient  must  be  maintained  as  much  as  possible  by  simple 
nutritious  food,  stimulants  enough  to  assist  digestion  and  no  more,  with  tonics,  such  as 
iron,  quinine,  and  cod-liver  oil. 

When  pain  exists,  local  fomentations  are  often  a  comfort ;  occasionally,  too,  the  appli- 
cation of  a  few  leeches  relieves.  Small  flying  blisters  placed  alternately  on  either  side 
of  the  painful  spot  are  sometimes  of  use,  and  a  plaster  of  belladonna  or  opium  rubbed 
down  with  glycerine  over  the  part  is  a  valuable  adjunct.  When  severe  nerve  pain  is  pres- 
ent, the  hypodermic  injection  of  morphia  may  be  used.  Sedatives  must  be  given  to 
induce  .sleep  when  it  cannot  otherwise  be  obtained.  Setons,  moxas,  and  mercury  are  not 
to  be  recommended. 

By  the  adoption  of  this  line  of  treatment  a  cure  may  be  obtained.  It  must,  however, 
be  followed  out  for  months,  and  even  years,  the  greatest  care  being  taken  that  the  patient 
is  not  released  too  soon,  for  a  relapse  is  always  a  very  serious  affair. 

Dr.  Lewis  A.  Sayre's  plaster-of-Paris  jacket  appears  to  me  to  be  the  best  kind  of 
apparatus,  for  it  is  simple,  economical,  easily  applied,  and  efficient,  securing  absolute 
immobility  of  the  spine  and  at  the  same  time  giving  comfort  to  the  wearer.  It  can  be 
readily  applied  by  any  medical  practitioner  with  little  expense,  and  does  not  debar  the 
patient  from  the  benefit  of  fresh  air  and  change  of  scene. 

The  body  of  the  patient  to  whom  it  is  to  be  applied  is  first  to  be  covered  with  a  thick 
closely-woven  merino  .shirt,  which  is  to  be  fastened  above  over  the  shoulders  and  below 
between  the  thighs ;  in  a  female  over  a  handkerchief.  A  pad,  which  Sayre  calls  a  dinner 
pad,  made  of  cotton-wool,  folded  in  a  handkerchief  so  as  to  form  a  wedge-shaped  mass 
with  the  thin  edge  downward,  is  then  to  be  introduced  beneath  this  shirt  over  the  region 
of  the  stomach,  of  sufficient  size  to  supply,  when  it  is  removed,  a  space  which  will  permit 
of  distension  of  the  abdominal  parietes.  All  projecting  spinous  processes  of  vertebrae  are 
to  be  protected  from  pressure  by  the  application  on  either  side  of  them  of  a  strip  of  thick 
felt  plaster.  The  patient  is  then  to  be  supported  by  straps  carefully  adjusted  to  the 
axilla?,  symphysis  mentis,  and  occiput  (Fig.  104),  attached  to  the  extremities  of  a  cross 
bar  which  may  be  suspended  from  a  hook  fastened  to  a  beam  or  high  door  by  a  compound 
pulley,  the  body  being  sufficiently  suspended  to  allow  of  its  w^eight  serving  as  an  extend- 
ing force,  but  af.ic(n/s  icithln  tlie  limit  of  pain.  Elevation  of  the  heels  is  enough  for  the 
purpose.  The  trunk  is  then  to  be  carefully  encased  from  below  the  crests  of  the  ilia 
upward  to  the  axillag  by  the  rapid  application  of  coarse  muslin  or  crinoline  bandages,  2j 
inches  wide,  into  which  dnj  frrshltz-grinind  plaster-of-Paris  has  been  rubbed,  the  bandages 
just  before  they  are  used  being  placed  vertically  in  tepid  water  deep  enough  to  cover 
them  and  left  a  sufficient  time  to  allow  all  bubbles  to  escape.  The  bandages  should  be 
well  squeezed  before  they  are  rolled  round  the  body,  and  in  their  application  care  should 
be  taken  to  see  that  they  are  applied  flat,  without  making  any  traction,  and  well  smoothed 
down.  It  is  well  also  during  this  process  to  wet  the  jacket  with  water  and  rub  in  more 
plaster. 

The  patient  should  be  laid  down  in  the  recitmbent  position  upon  a  mattress  before  the 
plaster  is  quite  set,  the  dinner  pad  removed,  and  the  casing  slightly  flattened  in  front  of 
the  anterior  supei'ior  spinous  processes  of  the  ilium,  to  guard  against  pressure.  The 
merino  jacket  may  then  be  unfastened  beneath  the  thighs  and  above  the  shoulders  and 


crnvATvni:  nr  riii:  si'im-: 


249 


turm-d  at  both  vuds  u\vr  tlii'  casing,  tlie  emls  In-iii':  fastciiecl  down  by  a  few  extra  t\iriirt 
of  till-  jilasttT  baiulap'. 

Ill  the  course  of  a  f(»rtiii^'ht,  if  all  things  •:<>  on  well  and  no  evidence  of  undue  pressure 
in  anv  j>art  exists,  the  casin;;  may  be  split  up  alon<:  the  frdot.  its  edj/es  bound,  eyelets 


Ki(i.  1(14. 


Fig.  104.— Description  of  S.ayre's  Apparatus  as  improved  by  Golding  Bird,  by  which  tl>e  drag  on  the  amis  and  head 
can  be  varied  by  altering  the  relative  length  of  cords  I  and  o.  The  smaller  the  angle  at  g,  the  more  the  drag  on 
the  head,  and  i-ur  rersa." 

A  fross-bar  suspended  by  running  tackle  to  Sayre's  tripod  or  to  hook  secured  to  cross-beam  of  a  folding-door.  b. 
Pulley  acting  upon  central  bar,  to  the  end  of  which  are  suspended  the  iron  rings  c,  attached  to  the  head-piece,  e. 
D.  Pulleys  connected  with  arm  suspender,  F.  by  hook  g,  and  h,  ring,  worked  by  running  cord  :16  inches  long, 
■which  can  be  lengthened  at  will  and  fastened  by  cleats,  o.  K.  Head-piece  made  of  2-inch  worsted  webbing  sewn 
into  a  circle  '2'k  inches  for  adult,  2:J  inches  for  children,  with  ^0  chin-piece  made  of  wash  leather,  and  (fti  two 
circular  sliders  of  same  wel>,  fi  inches  round,  attached  to  iron  rings,  c.  The  sliders,  by  being  slid  forward  or 
backward,  can  be  made  to  pull  more  or  less  against  the  chin  or  occiput.  F.  .Arm-pieces  made  of  2-inch  cotton- 
web  1  yard  round,  capable  of  being  shortened  by  buckle.  They  are  softly  padded  with  horsehair  in  the  middle 
and  covered  with  wash  leather :  each  carries  an  iron  ring,  h.  On  first  suspending  a  patient  the  running  cord,  g, 
should  be  at  its  shortest,  the  centre  cord,  /',  at  its  longest. 

Fig.  105.  Sayre's  .Tury-Mast  Apparatus  —a.  Two  pieces  of  malleable  iron  bent  to  fit  the  curve  of  the  back.  6.  Three 
or  more  roughened  strips  of  tin  attached  to  iron,  long  enough  to  encircle  the  body.  c.  Central  shaft  carried  in  a 
curve  over  the  top  of  the  head  and  capaMe  of  being  elongated  at  will,  springing  from  cross-pieces  of  n.  </.  Swivel 
cross-bar  with  hooks  attached  to  end  of  c,  from  which  straps  depend  to  support  head  and  chin  collar,  e.  This 
apparatus  is  applied  over  the  jacket  with  a  plaster  bandage. 

introduced,  and  a  lace  inserted,  in  order  that  it  may  at  times  be  removed  for  personal 
cleanliness  and  comfort  and  reapplied.  The  jacket  should  be  worn  .so  long  as  it  is  easy  ; 
and  when  worn  out,  another  should  be  substituted. 

When  the  cervical  or  upper  dor.sal  region  is  diseased,  a  vertical  splint.  Sayre's  jury- 
mast  apparatus  (Fig.  105),  to  take  off  pressure  of  the  head  and  prevent  rotation,  will 
be  re<|uired. 

When  this  splint  is  used  for  lateral  curvatures,  the  patient  should  suspend  himself 
by  his  arms. 

In  female  patients  a  pad  should  be  placed  over  each  breast  and  removed  with  the 
dinner  pad  ju.st  before  the  plaster  sets.  Smaller  pads  may  likewise  be  placed  over  the 
anterior  iliac  spines.  "  When  the  disease  is  situated  in  the  dorsal  region,  the  jacket 
should  not  be  opened,  for  the  reason  that  if  the  respiratory  movements  of  the  chest 
are  permitted  to  go  on  without  restraint  the  heads  of  the  ribs  will  necessarily  move 
freely  and  the  disease  will  be  increased  rather  than  diminished.  But  if  the  ribs  be  held 
still  and  the  diaphragm  thus  made  to  act  more  fully,  the  breathing,  instead  of  being 
thoracic,  is  rendered  diaphragmatic  and  abdominal,  and  all  the  short,  grunting,  catching 
respiration  ceases." 

Caution. — In   acute  or  progressive   disease   suspension  is  dangerous,  and   vertical 


250  SPINAL  ABSCESSES. 

extension  is  to  be  applied  with  the  greatest  caution.     Immobility  of  the  spine  is   the 
essential  object  to  secure. 

Treatment. — Spinal  abscesses  should  not  be  opened  hastily,  inasmuch  as  they  may 
become  absorbed  and  wither  away.  When  steadily  progres.sing,  however,  they  must  be 
dealt  with,  and  a  good  method  without  doubt  is  to  makea  free  opening  under  a  piece  of 
lint  saturated  with  oil,  carbolized  or  not.  I  have,  however,  in  recent  years  made  a  free 
opening  into  the  abscess  without  any  such  precautions,  washed  out  the  abscess  cavity 
with  iodine  water,  boracic  acid,  or  chloride  of  zinc  lotion  two  grains  to  the  ounce,  with 
equally  good  resailts,  making  the  opening  so  free  that  no  pus  could  be  retained  ;  and  if 
air  got  in,  it  as  freely  got  out  again.  In  all  cases  a  drainage  tube  should  be  introduced 
and  the  cavity  kept  empty  and  clean  by  repeated  irrigation.  Retained  pus  and  air  are 
sure  to  decompose  ;  but  if  a  free  vent  be  made  for  both,  harm  rarely  ensues.  To  allow 
abscesses  to  enlarge  to  any  extent  without  interfering  is  not  good  surgery,  as  the  amount 
of  constitutional  disturbance  that  follows  the  opening  of  an  abscess  is  closely  propijrtioned 
to  its  size,  and  a  large  abscess  cavity  secretes  more  pus  than  a  small  one.  It  is  true  that 
after  the  opening  of  a  chronic  abscess  a  patient  who  may  have  been  fairly  well  becomes 
feverish,  and  possibly  exhausted  by  hectic  ;  but  it  should  be  remembered  that  by  delay 
the  abscess  will  become  larger,  and  the  constitutional  disturbance  as  a  consequence  more 
severe,  when  the  opening  has  taken  place. 

Disease  of  the  Upper  Cervical  Vertebrae.— Disease  of  the  upper  two  cer- 
vical vertebrie  and  of  the  occipital  articulation  is  often  found,  and  may  be  accounted  for 
by  the  greater  mobility  of  the  joints,  and  consequent  liability  of  the  ligaments  to  sprain 
and  laceration.  Disease  may  be  situated  in  the  bones  entering  into  the  formation  of  the 
joints  or  in  the  soft  parts  binding  them  together,  and  with  the  disease  some  displacement 
of  one  of  the  vertebrae  is  occasionally  met  with.  When  the  disease  is  in  the  second  ver- 
tebra, the  odontoid  process  may  separate,  and  even  exfoliate. 

When  the  transverse  ligament  is  diseased,  the  odontoid  process  may  become  displaced 
and  the  cord  injured  (Guy's  Musuem,  Prep.  1289*').  When  the  displacement  is  great, 
sudden  death  may  take  place  under  these  circumstances;  and  when  partial,  more  or  less 
paralysis  may  ensue,  according  to  the  amount  of  pressure  the  cord  has  sustained.  Fixed 
pain  about  the  cervical  vertebrae,  with  pain  in  the  occipital  region,  in  the  distribution  of 
the  occipital  nerves,  and  stiff  neck,  is  always  suspicious  of  cervical  disease;  and  when  to 
this  is  added  a  disinclination  to  rotate  the  head  and  a  preference  to  rotate  the  body  instead, 
when  the  chin  is  tilted  up  and  a  modified  form  of  opisthotonos  exists  or  there  is  slight 
torticollis,  when  the  patient  supports  the  chin  with  his  hand  to  prevent  it  falling  forward 
on  the  sternum,  and  when  pain  is  aggravated  by  rotation  or  downward  pressure  of  the 
head,  the  case  is  serious  and  the  diagnosis  clear. 

Treatment  must  be  conducted  on  recognized  principles.  The  danger  of  sudden  death 
by  the  displacement  of  the  bones  must  be  diminished  by  the  application  of  a  support  to 
keep  the  head  straight  and  prevent  its  falling  forward,  and  this  may  be  accomplished  by 
the  application  of  a  collar  round  the  neck,  passing  under  the  chin  with  a  support  embra- 
cing the  head,  an  inflating  rubber  collar  being  by  far  the  best,  or  by  Sayre's  jury-mast 
apparatus  (Fig.  105).  Rest  in  the  horizontal  position,  is,  however,  of  greater  value,  care 
being  observed  to  keep  a  small  firm  pillow  underneath  the  neck  to  preserve  the  liollow, 
and  in  this  way,  as  pointed  out  by  Hilton  in  his  classical  work  On  Rest,  "to  lift  up  the 
body  of  the  second  vertebra  and  remove  the  odontoid  process  fiom  the  lower  part  of  the 
medulla  oblongata,  and  thus  prevent  the  fatal  results  of  pressure  upon  it."  At  the  same 
time,  the  head  should  be  kept  at  rest  by  means  of  sand-bags  applied  laterally.  Remedies 
that  have  been  mentioned  in  th^  treatment  of  angular  curvature  of  the  spine  are  here  of 
use.  In  cases  of  severe  spinal  curvature  there  is  good  reason  to  believe  that  the  span  of 
life  is  often  shortened  on  account  of  the  interference  with  the  respiratory  and  circulatory 
functions  caused  by  the  deformity.  My  colleague.  Dr.  Fagge,  has  written  an  interesting 
paper  on  this  subject  {Gni/s  Hosp.  Rep.,  1874)^^ 

INJURIES  AND  DISEASES  OF  THE  NERVES. 

When  a  nerve  is  struck  or  contused,  pain  is  produced ;  and  it  may  be  of  a  passing 
tingling  character  or  of  a  far  more  severe  kind.  Most  people  are  rendered  familiar  with 
these  facts  by  an  occasional  blow  upon  the  ulnar  nerve,  or  what  is  called  the  "  funny 
bone."  When  the  blow  has  been  severe,  the  pain  may  be  lasting  and  the  functions  of  the 
nerve  so  disturbed  or  interfered  with  as  to  give  rise  to  loss  of  power  or  sensation  in  the 
parts  supplied  by  the  injured  nerve.     A  man  aet.  29  went  to  sleep  with  his  elbow  resting 


W'orxDs  OF  .\i-:r\i:s.  251 

on  a  tal)l(' ;  and  wln'ii  lie  awcikf.  iIhtc  was  <-inii|ilctc  paralysis  Imtli  nf  iiidtidri  ami  sensa- 
tion of  tlio  jtarts  .sii|>|ilit'(l  Ky  tlir  ulnar  nt'ivc.  When  1  saw  liiin.  two  days  afterward, 
tliesi'  syni|>t<inis  wrre  very  marked,  there  was  also  tendc^riiess  over  the  nerve  hehind  the 
inner  eomlylc,  to  which  spot  a  hlister  was  applied.  in  a  fortnij^ht  returnin<r  sensation 
appeared,  with  some  slitiht  power  of  nmtion,  and  in  live  weeks  he  was  well.  This  wu.«i 
cK'arlv  a  ease  of  ])aralysis  id' a  nerve  from  eontiision.  A  man  ;et.  K!  received  a  hlow  npoti 
his  ulnar  nerve  against  a  chair.  No  ]>ain  appeareil  at  tin;  time,  hnt  three  hours  later  pain 
and  nnmliness  showed  themselves,  and  at  this  time  some  thickenin;r  over  the  spot  could 
he  made  out.  In  the  course  of  three  weeks  these  .symjitoms  di.sappcared  and  recovery 
was  eoinph'te.  In  this  case  it  would  appear  as  if  some  hemorrliajre  liad  taken  place 
into  the  nerve  sheath,  {livinir  rise  to  the  jiaralysis.  wliiidi  disajipeared  as  the  hlood  was 
absorhed. 

Wounds  of  Nerves. 

When  a  nerve  is  vouinhil,  pain  is  produced  ;  and  this  may  be  of  a  passinj^  (jr  more 
permanent  (diaracter.  In  nervous,  hysterical  suV^jects  the  nerve  pain  is  .sometimes  severe 
and  persistent,  and  is  then  called  "*  neuralgia.  It  may  be  confined  to  a  branch  of  the 
injured   nerve  or  it  may  involve  the  whole  trunk. 

Wlu'u  a  nerve  is  dividtd.  coin})lete  paralysis  of  the  i>arts  sujjjjlied  V>y  it  follows.  It 
may.  however,  reunite  and  recover  its  functions.  Paget  has  related  a  case  of  complete 
division  of  the  meilian  nerve  in  which  the  trunk  had  nearly  recovered  its  conducting 
power  a  month  after  the  wound.  I  have  seen  a  similar  case  in  which  recovery  ensued  in 
four  months.  The  following  is  another  example  in  point :  A  woman  ;ct.  'M)  came  to  me 
with  an  incised  wound  behind  the  inner  condyle  of  the  humerus.  The  ulnar  nerve  had 
been  divided,  and  there  was  complete  paralysis  of  motion  and  sensation  of  the  parts  sup- 
plied by  it.  The  edges  of  the  wound  were  adju.sted  and  the  arm  placed  in  a  sling.  A 
month  later  .she  returned  with  a  burning  pain  in  the  little  finger,  which  was  really  cold, 
but  red,  swollen,  .shining,  and  blistered  ;  and  when  touched,  some  slight  sen.sation  was 
produced.  Cotton-wool  and  oiled  lint  were  applied,  and  the  arm  was  fi.xed  upon  a 
straight  splint.  The  original  wound  had  nearly  healed.  In  two  weeks  the  finger  looked 
natural ;  sen.sation  in  it  and  all  other  pai'ts  supplied  by  the  nerve  had  improved.  In 
another  month  she  returned  with  the  old  symptoms  as  l)ad  as  ever.  They  had  reappeared 
upon  the  removal  of  the  splint  two  weeks  previously,  but  on  its  rcapplication  with  the 
cotton-wool  they  again  disappeared.  The  splint  was  then  kept  on  for  two  months,  when 
sensation  became  natural,  complete  repair  having  taken  place  in  four  months.  When 
seen  six  months  later,  she  was  still   well. 

The  red,  swollen,  shining,  and  blistered  condition  of  a  finger  deprived  of  nerve  force 
is  characteristic,  and  is  generally  a.ssociated  with  the  sensation  of  a  burning  pain  and  loss 
of  temperature,  amounting  sometimes  to  a  depression  of  9°  or  10°  Fahr.  There  may 
likewise  be  a  curving  of  the  nails,  as  seen  in  phthisis,  or  ulceration  of  their  roots. 
These  symptoms  are  clearly  due  to  malnutrition.  When  the  nerve  repair  does  not  take 
place,  these  .^symptoms  are  very  apt  to  return  from  time  to  time  on  any  change  of  tem- 
perature or  depression   of  the  general   power  of  the  patient. 

Joint  Affections. — The  joints  of  /imhs  in  which  the  nerve  supply  has  been  inter- 
fered with,  after  injury  undergo  a  change  which  consists  essentially  in  a  painful  swelling 
of  these  joints,  which  may  attack  any  or  all  of  the  articulations  of  a  member.  It  is. 
says  Mitchell,  distinct  from  the  early  swelling  due  to  the  inflammation  about  the  wound 
itself,  although  it  may  be  ma.sked  by  it  for  a  time ;  nor  is  it  merely  part  of  the  general 
oedema  which  is  a  common  consequence  of  wounds.  It  is  more  than  these — more 
important,  more  persistent.  Once  fully  established,  it  keeps  the  joints  stiff  and  sore  for 
weeks  or  months.  When  the  acute  stage  has  departed,  the  tissues  about  the  articulations 
become  hard  and  partial  anchylosis  results ;  so  that  in  many  cases  the  only  final  cause 
of  loss  of  motion  is  due  to  this  state  of  the  joints  (W<ir  of  RelwUiou.  part  iii..  vol.  2, 
p.  745).  When  the  uliuir  nerve  is  completely  paralyzed — in  which  case  atrophy  of  the 
muscles  supplied  by  it  ensues — the  aspect  of  the  hand  is  very  characteristic,  the  wasting 
of  the  interosseous  muscles,  with  the  abductor  indieis  (also  an  interosseous),  and  all 
those  of  the  little  fingers,  giving  rise  to  a  peculiar  hollowing  of  the  parts  between  the 
metacarpal  bones  which  is  typiical.  Nerves  when  divided  do  not.  however,  always 
reunite.  When  a  piece  has  been  removed  either  by  accident  or  by  design,  as  in  the 
operation  for  tic  douloureux,  the  restoration  of  function  is  very  rare,  though  it  may 
occur. 

Treatment. — Bruised  nerves  are  to  be  left  alone,  natural  processes  being,  as  a  rule, 


252  NEURALGIA,  TIC  DOULOUREUX. 

amply  sufficient  to  effect  a  cure.  When  recovery  is  slow  and  associated  with  pain  in  the 
injured  part,  the  application  of  a  small  Vjlister  is  beneficial.  Divided  nerve  should  always 
be  brought  together  by  .sutures  and  the  limb  placed  in  the  best  po.sition  to  prevent  any 
separation  of  the  divided  ends ;  the  paralyzed  parts  should  be  kept  warm  with  cotton- 
wool and  of  an  equable  temperature,  and  the  whole  limb  at  rest,  until  complete  repair 
has  taken  place.  Even  after  a  nerve  has  been  divided  for  some  weeks  there  is  a  good 
prospect  of  the  divided  ends  uniting  on  their  readjustment  by  sutures  after  fresh  trans- 
verse sections  have  been  made  of  the  separated  ends  (vir/e  Hulke,  Ciin.  Sor.  Trans., 
vol.  xii.).  Mr.  Favell  of  Sheffield  has  recently  puVjlished  some  good  cases  in  favor  of 
the  practice.'  and  Dr.  Weir  Mitchell'  has  shown  that  in  one  hundred  and  twenty  ca.ses  of 
nerve  section  regeneration  of  nerve  took  place  in  most  in  about  six  months.  When  much 
pain  exists,  belladonna  or  opium  ruVjbed  down  with  glycerine  is  a  nice  application,  and 
the  hypodermic  injection  of  morphia  is  often  of  much  value.  The  application  of  a 
suture  to  a  divided  nerve  is  not.  however,   uniformly  successful. 

NEURALGm,  Tic  Douloureux. 

The  subject  of  neuralgia  belongs  more  properly  to  the  physician  than  to  the  surgeon, 
yet  the  latter  is  often  called  upon  to  consider  cases  of  this  nature.  The  first  point  to 
determine  is  whether  the  pain  is  due  to  any  local  cause,  and  if  .so.  to  remove  it.  Thus  a 
decayed  tooth  too  often  is  the  cause  of  pain  in  the  cour.se  of  branches  of  the  fifth  nerve, 
although  the  tooth  may  have  neither  ached  nor  exhibited  any  external  evidence  of  decay. 
The  pressure  of  a  small  tumor  on  a  nerve,  some  irregularity  in  the  bone,  or  a  cicatrix 
involving  a  nerve  are  causes  which  sometimes  require  the  .surgeons  interference  to  effect 
a  cure.  The  following  example  illustrates  these  remarks:  A  man  set.  41  came  under  my 
care  in  ISOG  for  severe  pain  down  the  anterior  and  outer  portion  of  his  left  leg  and  foot, 
with  almost  complete  paralysis  of  the  extensor  muscles.  The  symptoms  had  been  com- 
ing on  gradually  for  years,  and  had  followed  a  severe  wound  sustained  twelve  years  pre- 
viously over  the  head  of  the  fibula.  There  was  a  hard  cicatrix  over  the  head  of  the 
fibula  which  clearly  involved  the  external  popliteal  nerve.  I  made  two  deep  vertical 
incisions  on  either  .side  of  the  cicatrix,  by  this  means  taking  tension  off  the  nerve  and 
affording  complete  relief ;  six  weeks  later  he  was  still  well.  Whenever  neuralgic  pain  is 
associated  with  a  cancerous  tumor  or  comes  on  after  its  removal,  the  surgeon  should  sus- 
pect the  existence  of  some  secondary-  cancerous  deposit  in  the  course  of  the  sensory 
nerve. 

The  great  majority  of  cases  of  neuralgia,  however,  have  a  con.stitutional  origin,  and 
their  cause  is  to  he  found  in  .some  hereditary  tendency,  in  depression,  anxiety,  or  some 
obvious  derangement  of  health  such  as  is  expressed  by  the  term  -  anaemia."  Many,  too, 
have  a  malarious  origin  and  depend  on  climatic  influences,  such  as  residence  in  a  damp 
or  wet  place.  The  disease  known  as  ••  tic  douloureux  is  an  affection  of  the  fifth  nerve 
and  its  branches,  but  any  nerve  in  the  body  is  liable  to  suffer.  The  pain  is  often  very 
intense,  and  recurs  in  paroxysms  at  certain  hours  or  on  exposure  to  draught  or  cold. 

Treatment. — The  treatment  of  these  cases  of  neuralgia  must  be  regulated  entirely 
by  their  cause.  When  a  local  cause  can  be  made  out.  its  removal  is  the  only  remedy — 
for  example,  the  removal  of  a  tooth,  of  a  tumor,  or  of  a  bulbous  extremity  of  a  nerve. 
When  hy.steria  complicates  the  case,  or  any  uterine  disturbance,  tonics  are  suggested, 
such  as  iron,  zinc,  or  quinine,  and  of  these  full  doses  may  be  given.  When  malaria 
appears  to  be  the  cause,  bark  or  quinine  is  invaluable.  In  all  forms  of  local  neuralgia, 
more  particularly  in  sciatica,  the  hypodermic  injection  of  morphia  in  one-third  or  half- 
grain  doses,  injected  in  the  cour.se  of  the  nerve,  often  acts  as  a  charm.  Chloroform, 
belladonna,  and  opium,  locally  applied,  are  also  valuable.  The  general  condition  of  the 
patient  should  always  be  attended  to  and  the  treatment  directed  to  its  improvement. 
Good  food,  fresh  air.  and  tonics  are  always  essentials.  Purgatives  are  seldom  necessary, 
and  must  be  regulated  so  as  not  to  depress.  Stimulants,  but  not  in  excess,  are  of  great 
use.  In  females  the  condition  of  the  uterine  organs  should  always  be  carefully  attended 
to. 

Division  of  Nerve. — In  obstinate  cases  of  neuralgia  the  division  of  the  nerve 
has  been  performed  with  occasional  success.  It  is  not.  however,  an  operation  in  favor  of 
which  much  can  be  said.  When  the  cause  of  the  neuralgia  is  peripheral,  it  may  succeed 
for  a  time,  but  in  these  cases  spontaneous  recovery  is  not  unusual ;  and  when  some  cen- 

'  "Address  on  Surgery,"  Brit.  Med.  Jovrn.,  Aug.  5,  1876. 
'  Amer.  Journ.  of  Med.  Sci.,  April,  1876. 


SEC  ROMA.  253 

tral  mispliit'f  is  the  source  of  tho  pain,  tlio  opfratiun  is  nut  likely  to  be  of  service. 
Novortlu'lfss,  ill  (lespcrato  cases  the  exeisinn  ut'  a  portimi  mI'  the  <(fferi(iiiifr  nerve  is  a 
justitiable  operation  ;  it  has  been  of  use,  ami  may  be  so  aj^ain.  Sir  .1.  Kayrer  has  related 
in  the  Mtil.  y'iitiis  lor  iStlO  a  ease  of  sciatica  in  a  syphilitic  man,  ;t't.  .']0,  in  whom  swell- 
ing was  detected  in  the  nerve  sheath,  ami  pain  was  at  once  relieved  by  puncturing  the 
j)art  with  a  knife. 

As  much  may  likowi.so  be  said  for  iuTve-stret(;hinL'.  which  is  to  I*c  preferrc<l. 

Neuroma. 

Any  tumor  connected  with  a  nerve  is  called  a  ••  neuroma."  These  neuromata  may  be 
of  a  til)rous  or  of  a  fibro-ctdlular  kind,  and  there  is  reasoji  to  believe  that  they  have  an 
inflanunatory  origin.  They  may  be  very  small  or  of  large  dimen.sions  ;  and  when  large, 
they  may  contain  cysts.  Sometimes  they  are  developed  vithiu  the  nerve  sheath  ;  at 
others  they  are  situated  iipnu  it.  In  a  third  class  the  fibrillai  of  the  nerve  trunk  appear 
to  be  separated  by  the  new  tissue  or  to  become  incorporated  with  the  growth.  They  are 
at  times  single,  but  more  fref|uently  multiple,  and  occasionally  involve  nearly  every  cer- 
cbro-spinal  nerve  in  the  body.  Wilks  has  recorded  sucli  a  case  in  the  Path.  Soc.  Trnna., 
vol.  X.,  in  which  after  death  neuromata  were  found  all  over  the  body,  appearing  as  nod- 
ules on  some  nerves  and  as  distinct  tumors  on  others  ;  the  nerves  aj)peared  of  irregular 
size  and  were  indurated,  the  til)rous  tissue  being  infiltrated  among  the  nerve  fibres.  The 
pneuniogastric  nerve  had  a  tumor  the  size  of  an  egg  upon  it.  Dr.  Smith  of  Duldin,  in 
his  unrivalled  monograph  on  the  subject,  has  recorded  an  instance  in  which  many  hun- 
dreds of  such  tumors  existed  ;   other  similar  cases  might  be  quoted. 

Symptoms. — These  tumors  are  not  painful,  as  a  rule;  indeed,  in  the  most  marked 
examples  of  this  disease,  in  which  the  tumors  are  multiple,  they  are  often  not  recogniz- 
able till  after  death.  Pain,  however,  is  sometimes  present,  aggravated  on  pressure  and 
apparently  depending  much  upon  the  mode  in  which  the  nerve  is  involved.  The  affection 
is  not  to  be  confounded  with  the  jyainful  suhcutaiteouA  tumor. 

When  the  ends  of  a  divided  nerve  become  bulbous  from  fibrinous  effusion,  what  is 
called  a  traumatic  neuroma  is  formed.  When  this  becomes  involved  in  the  cicatrix  of  a 
stump,  it  is  an  exceedingly  jiainful  affection,  and  is  thought  by  some  surgeons  to  be  more 
common  after  flap  amputations  than  others.  It  must  be  remembered,  however,  that  all 
nerve  trunks  become  more  or  less  bulbous  after  amputation. 

Treatment. — There  is  no  reason  why  neuromata  should  be  removed  or  touched  unle.ss 
they  are  large  or  painful.  When  from  these  causes  they  require  treatment,  the  operation 
should  be  performed,  care  being  observed  to  di.ssect  the  tumor  from  the  nerve  when  it  is 
possible,  which,  however,  can  rarely  be  done.  In  1882  I  removed  a  cy.stic  tumor  the  size 
of  a  large  nut  with  permanent  success  from  the  upper  cord  of  the  left  brachial  plexus 
of  a  lady-patient  of  mine  who  had  suffered  continual  agonies  of  pain  down  the  arm ;  the 
cyst  was  in  the  nerve  cord  itself.  I  have  removed  others  from  the  median  and  sciatic. 
In  the  former  case  the  tumor  had  been  treated  by  another  surgeon  as  a  ganglion  and 
punctured.  3Iany  cases  ai"e  on  record  in  which  large  neuromata  have  been  excised  with 
the  nerve  trunk  and  a  good  recovery  has  followed,  even  with  a  restoration  of  the  func- 
tions of  the  divided  nerve.  Traumatic  neuromata  should  always  be  excised  when  caus- 
ing much  pain  ;  but  when  associated  with  symptoms  of  spinal  irritation,  which  may 
possibly  be  due  to  a  neuritis  travelling  up  the  affected  nerve  trunk,  the  forcible 
stretching  of  the  nerve,  as  recommended  by  Billroth  and  Nussbaum  and  practised  by 
others,  should  be  employed. 

On  Nerve- Stretching. 

In  1869,  Billroth  cut  down  upon  the  sciatic  nerve  with  the  view  of  removing  a 
neuroma,  and,  though  no  tumor  was  found,  the  manipulation  and  stretching  of  the  nerve 
brought,  unexpectedly,  permanent  relief  to  the  pain  the  patient  had  experienced.  Three 
years  later  (February,  1872)  Nussbaum  of  Miinich  cut  down  upon  the  brachial  plexus  to 
stretch  some  of  its  trunks  for  painful  spasmodic  contraction  of  the  ilexors  of  the  arm  and 
hand,  and  the  operation  was  successful. 

Since  these  early  operations  of  nerve-stretching  many  have  been  undertaken  with 
yery  variable  success. 

It  would  seem  from  the  excellent  papers  noted'  that  when  a  nerve  is  stretched 
'  Revue  de  Chirurc/ie,  18S2,  Paris;  J/erf.  Rec.  Xew  York,  September,  1S82, 


254  PAINFUL  SUBCUTANEOUS  TUMORS. 

extravasation  of  blood  takes  place  within  its  sheath  above  and  below  the  point  of 
traction  where  the  vessels  from  the  nerves  penetrate  the  sheath,  and  that  these  extra- 
vasations entirely  disappear  in  about  five  or  six  weeks ;  that  embryonic  cells  under  the 
sheath  and  wasting  of  the  superficial  nerve-fascicles  with  some  segmentation  of  the 
nerve  cells  are  found ;  that  if  the  nerve  be  drawn  away  from  the  spinal  cord  anaes- 
thesia with  slight  paresis  follows,  but  iT  toward  the  cord  the  paresis  is  increased  and 
there  may  be  a  loss  of  reflexes. 

There  is  also  evidence  to  show  that  the  stretching  may  produce  some  change  in  the 
nerve  centres  themselves,  as  indicated  by  more  or  less  persistent  modifications  of  function 
of  different  parts  of  the  body. 

In  seventy  operations  for  sciatica  statistics  indicate  that  in  sixty  the  patient  was 
either  cured  or  greatly  relieved,  and  that  in  the  majority  of  cases  the  relief  was  per- 
manent. 

In  thirty-seven  operations  on  the  fifth  pair  of  nerves  success  was  reported  in  twenty- 
nine,  and  that  in  traumatic  neuralgia  the  success  was  equally  good. 

Xerve-stretching  for  locomotor  ataxia  has  been  attempted  in  fifty-seven  cases,  and  in 
sixteen  with  decided  success.  It  has  likewise  been  employed  for  traumatic  tetanus  in 
fifty  cases,  with  ten  recoveries. 

Langenbeck  states  very  decidedly  that  it  is  better  to  stretch  the  sciatic  nerve  in  its 
middle  or  lower  third  below  its  muscular  branches,  there  being  thus  less  risk  of  the  ope- 
ration being  followed  by  atrophy  of  the  limbs. 

The  dangers  of  the  measure  are  such  as  attend  all  operations.  It  is,  consequently,  an 
operative  proceeding  of  a  justifiable  kind,  but  one  that  requires  caution  in  its  application. 

The  operation  consists  in  the  free  exposure  of  the  nerve  trunk  by  incision  and  the 
application  of  forcible  traction  to  it,  both  proximally  and  distally.  The  traction  has 
been  great,  as  one  author,  in  describing  the  operation  as  applied  to  the  sciatic  nerve,  says 
that  "  the  limb  of  the  patient  should  be  lifted  from  the  table  by  the  sciatic  nerve."  This 
is  probably  unnecessary,  but  under  all  circumstances  the  stretching  should  be  enough  to 
destroy  the  sensibility  of  the  nerve  for  some  days. 

Painful  Subcutaneous  Tumors. 

These  tumors  are  clinically  to  be  sepai'ated  from  the  neui*omata,  which  have  just  been 
considered,  although  they  have  often  doubtless  been  confused  with  them.  They  are  not, 
however,  nerve  tumors.  They  were  first  described  by  Wood  in  the  Edinburgh  Mediad 
Journal  for  1812.  They  are  usually  single  and  situated  in  the  subcutaneous  tissue,  and 
are  rarely  larger  than  a  small  bean.  They  are  encysted  and  give  to  the  finger  a  hard 
elastic  touch.  To  the  eye  they  appear  bright  yellowish  or  a  pearl}-  white,  and  are  made 
up  of  fibro-cellular  or  fibrous  tissue.'  Intense  pain/ulness  is  their  clinical  peculiarity, 
although  they  have  no  such  nerve  connection  as  will  explain  their  excessive  sensibility. 
The  pain,  says  Sir  J.  Paget,  is  of  the  nature  of  that  morbid  state  of  nerve  force  which 
we  call  neuralgia. 

The  painful  character  of  these  tumors  is  very  peculiar.  It  is  not  constant,  nor  does 
it  appear  to  depend  upon  any  injury,  and  sometimes  comes  on  without  any  assignable 
cause  or  after  only  the  slightest  touch,  the  pain  beginning  in  the  tumor,  gradually  increas- 
ing in  intensity  and  extent  till  it  becomes  almost  unendurable,  darting  from  the  tumor  up 
and  down  the  limb  or  over  the  body.  The  muscles  of  the  limb  may  likewise  be  spas- 
modically affected.  The  paroxysm  may  last  only  a  few  minutes  or  may  continue  for 
hours,  and  subsides,  as  it  appears,  gradually,  leaving  the  parts  tender  that  were  the  seat 
of  pain.  These  painful  tumors  are  most  frequent  in  the  female,  the  neuromata  more  fre- 
quent in  the  male. 

TreaTiMENT. — The  only  treatment  is  the  excision  of  the  growth,  which  is  generally 
effectual.  These  tumors  rarely  recur,  although  Sir  J.  Paget  has  recorded  one  or  two 
examples  of  recurrence. 

'  Rtvue  de  Chirur<jie,  1872,  Paris. 


L'XA.^fiSA'rioy  or  nir:  faehali.  a.\j>  rj's  aj'I'ENDAges.         255 


en  APTKK     VITT. 
DISEAS l-:s  A N I »   I  N.I  I  I ;  I  lis  ( » I"  T 1 1  K  HYE,  ETC. 

Hv  CIlAin.KS   IIHi(ilN.S. 

EXAMINATION  OF  THE  EYEBALL  AND  ITS  APPENDAGES. 

The  exaniiiiatioii  of  the  eyeball  will  be  coiisideretl  under  lour  heads: 
1st.    By  the  unaided  eye. 
2d.     By  lateral  illuniinati(tn. 
3d.     By  the  iiphthahnoseupe. 

(a)  Direct  examination. 

(/<)  Indirect  exaniiiuitiou. 
4th.  By  manipulation. 
The  rtfrxctitiii  of  the  eyeball,  the  field  of  vision,  etc..  will  also  receive  a  .short  notice. 

I.  Examination  by  the  Unaided  Eye. 

In  order  to  examine  the  outer  surface  of  the  eyelid.s,  ocular  conjunctiva,  cornea, 
anterior  portion  of  sclerotic,  aqueous  chamber,  and  lachrymal  apparatus,  it  is  necessary 
to  place  the  patient  in  a  jrood  light  (as  before  a  window)  and  direct  him  at  first  to  close 
the  eyes,  then  open  them  widely  and  look  by  turns  in  different  directions. 

To  examine  the  palpebral  conjunctiva  it  is  necessary  to  evert  the  upper  lid  and  to 
draw  the  lower  one  downward.  Ever.sion  of  the  upper  lid  can  be  accomplished  thus: 
The  surgeon,  standing  in  front  of  the  patient,  should  direct  him  to  look  downward  and 
close  the  eyes ;  he  should  then  place  the  forefinger  of  one  hand  upon  the  lid  at  the 
attached  or  upper  border  of  the  tarsal  cartilage  and  make  gentle  pressure  downward  and 
backward,  so  as  to  cause  the  free  edge  of  the  lid  to  stand  away  from  the  eyeball,  then 
place  his  thumb  beneath  the  margin  of  the  lid  and  make  a  slight  upward  movement,  at 
the  same  time  continuing  the  pressure  with  the  finger ;  by  this  means  the  lid  will  be  made 
to  turn  u])on  itself  and  become  everted.  The  lid  may  also  be  everted  by  pre.ssing  a  probe 
horizontally  upon  its  outer  surface  and  drawing  it  upward  by  means  of  the  lashes,  at  the 
same  time  making  pressure  downward  with  the  probe. 

To  examine  the  conjunctiva  covering  the  lower  lid.  all  that  is  necessary  is  to  place  the 
finger  upon  the  margin  of  the  lid  and  draw  it  strongly  downward,  when  its  conjunctival 
surface  will  become  exposed. 

Normal  Appearances. 

The  outer  surfiice  of  the  eyelids  is  covered  by  soft,  delicate  skin,  which  is  thrown 
into  folds  on  every  contraction  of  the  orbicularis ;  their  free  margins  are  of  some  thick- 
ness. From  the  outer  edge  of  this  free  margin  project  the  lashes  in  two  or  three  rows, 
those  of  the  upper  lid  being  thicker  and  longer  than  those  of  the  lower.  The  la.shes 
extend  along  the  whole  outer  edge  of  each  lid,  but  are  much  fewer  and  more  delicate  in 
that  portion  extending  from  the  tear  punctum  to  the  inner  canthus. 

The  inner  edge  of  each  margin  is  occupied  by  the  orifices  of  the  Meibomian  glands, 
which  are  seen  as  a  close  set  of  yellowish  points. 

T/ie  ocular  coiijuucfini  is  smootn.  moist,  .shining,  and  transparent,  allowing  the  white 
sclerotic  to  show  plainly  through  it ;  a  few  vessels  are  generally  seen  running  from  the 
outer  and  inner  canthi  toward  the  cornea,  but  these  are  perfectly  consistent  with  a 
healthy  condition  of  the  membrane.  The  caruncle  and  semilunar  fold  occupy  the  space 
immediately  external  to  the  inner  canthus.  the  former  appearing  as  a  small  reddish-gray 
projection,  the  latter  as  a  well-defined  pinkish  fold.  The  palpebral  covjimctiva  is  also 
smooth,  moist,  shining,  and  transparent,  and  appears  to  have  somewhat  of  a  yellowi.sh 
color,  from  the  tar.sal  cartilage,  to  which  it  is  closely  and  evenly  united,  showing  through 
it.  That  portion  of  conjunctiva  reflected  from  the  lids  to  the  globe  {fornix)  appears 
somewhat  thickened  and  wrinkled  and  is  slightly  more  vascular  than  the  ocular  and 
palpebral  portions. 

Parts  requiring  Special  Notice. — Certain  parts  of  the  conjunctiva  require  to 


256  EXAMINATION  OF  THE  EYEBALL  AND  ITS  APPENDAGES. 

be  specially  examined.  The  portions  next  the  thickened  margin  of  the  lid,  the  fornix, 
and  about  the  caruncle  are  the  most  likely  situations  for  the  lodgment  of  a  foreign  body. 
That  portion  covering  the  attached  border  of  the  tarsal  cartilage  also  should  be  noticed, 
as  it  is  here  that  granular  ophthalmia  manifests  itself  most  plainly. 

The  cornea  is  smooth,  shining,  and  perfectly  transparent  throughout,  except  in  the 
case  of  old  people,  in  whom  a  bluish-white  rim  (arcus  senilis)  is  often  seen  occupying 
more  or  less  of  the  structure,  somewhat  within  its  margin  ;  no  blood  vessels  are  seen  on 
its  surface  or  in  its  substance. 

The  anterior  jyort ion  of  the  sclerotic  is  pearly  white  or  of  a  pale  bluish  tint  and  shining. 
It  is  plainly  visible  through  the  transparent  conjunctiva  covering  it;  some  fine  vascular 
twigs  may  occasionally  be  seen  traversing  it  in  front  of  its  equatorial  region.  The  aque- 
ous chamber  is  filled  by  the  aqueous  humor,  which  is  transparent,  colorless,  and  of  such 
quantity  as  to  preserve  the  proper  curvature  of  the  cornea  without  causing  tension  or 
allowing  of  laxity,  and  to  keep  it  separated  from  the  iris  by  a  considerable  interval. 

The  iris  varies  in  color  in  diiferent  individuals  ;  it  is  bright,  shining,  and  marked  by 
slight  radiating  ridges  around  the  pupil ;  it  presents  in  health  no  appearance  of  blood 
vessels.  Its  plane  is  exactly  vertical ;  the  pupil,  situated  somewhat  to  the  inner  side  of 
the  centre  of  the  iris,  is  perfectly  circular  and  dilates  and  contracts  quickly  with  vari- 
ations of  light. 

The  examination  of  the  lachrymal  apparatus  gives  chiefly  negative  results  ;  the  posi- 
tion of  the  tear  puncta  closely  in  contact  with  the  ocular  conjunctiva  must  be  noticed  ; 
pressure  with  the  finger  over  the  lachrymal  sac  causes  no  escape  of  fluid  through  the 
puncta,  neither  can  the  lachrymal  gland  be  felt  or  seen  in  a  normal  condition  of  the 
parts. 

n.  Examination  by  Lateral  Illumination. 

By  this  method  all  the  parts  mentioned  above  are  seen  more  clearly  ;  minute  foreign 
bodies,  slight  opacities  of  the  cornea,  etc.,  which  might  be  overlooked  in  examining  with 
the  unaided  eye,  are  discovered,  and  in  addition  the  whole  of  the  lens  and  the  anterior 
portion  of  the  vitreous  can  most  satisfactorily  be  looked  into. 

The  method  of  examination  should  be  as  follows :  The  patient  should  be  seated  in  a 
dark  room  (the  pupil  having  been  previously  dilated  with  atropine)  and  a  lamp  placed 
at  abovit  two  feet  distance  on  the  left  and  rather  in  front  of  his  face.  The  surgeon  should 
stand  nearly  in  front,  or  rather  to  the  patient's  right  side,  and  facing  him ;  he  should  then 
take  in  his  right  hand  a  bi-convex  lens  of  about  2i  inches'  focal  length.*  and  with  it  con- 
centrate the  light  on  the  surface  of  the  cornea  ;  with  a  little  manoeuvring  he  will  find  that 
he  can  thi'ow  the  light  through  the  pupil  to  a  considerable  depth  into  the  eye.  The 
patient  should  be  told  to  look  in  various  directions,  so  that  all  parts  of  the  anterior  por- 
tion of  the  eye  may  be  examined. 

Results  Obtained. — The  results  obtained  by  lateral  illumination  are  chiefly  nega- 
tive. The  lens  in  health  is  perfectly  transparent  and  in  youth  is  nearly  colorless,  but 
some  bluish  lines  showing  its  division  into  diff"erent  segments  can  be  recognized  by  care- 
ful examination.  As  age  advances  these  lines  become  more  marked  and  the  whole  lens 
appears  of  a  bluish-gray  color,  though  its  transparency  is  still  unaff"ected. 

Behind  the  lens  all  appears  dark,  but  any  tumor,  hemorrhage,  etc.,  occupying  the 
anterior  part  of  the  vitreous  would  be  discovered. 

It  should  be  noticed  in  the  examination  by  lateral  illumination  that  opacities  of  the 
cornea,  etc.,  always  appear  with  greatest  distinctness  on  the  side  which  is  farthest  from 
the  light.  A  second  lens  may  also  be  used  to  magnify  the  parts  illuminated  by  means 
of  the  first. 

in.  Examination  by  the  Ophthalmoscope. 

Description  of  the  Instrument. — The  ophthalmoscope,  as  used  at  the  present 
day,  consists  essentially  of  a  mirror  of  silvered  glass  or  polished  metal  having  a  central 
opening,  with  certain  accessory  portions  in  the  shape  of  convex  lenses  of  different  foci, 
used  as  objective  lenses,  clips  and  other  contrivances  for  holding  ocular  lenses  behind  the 
sight-hole  of  the  ophthalmoscope,  together  with  the  ocular  lenses  themselves.  The  oph- 
thalmoscope since  its  introduction  has  undergone  innumerable  modifications,  both  in  prin- 
ciple and  detail,  the  number  of  diff'erent  instruments  now  in  use  being  nearly  or  quite 
as  great  as  that  of  ophthalmic  surgeons. 

^  A  lens  of  2|  inches'  focal  length  is  about  equal  to  one  of  sixteen  dioptrics  in  the  metrical 
svstem. 


(H'liril ALMnscoriC  /•;.V.1.1//.V.I770.V. 


257 


Fig.  lOG. 


Till'  IlKist  USfl'iil  t'linii  nf  (i|ilitli:illiin>rii|)c  IS  tli.it  n\'  I ii el ircidi  ;  tlic  latest  liioililiciition 
(Fi<,'.  Hit!)  (if  this  iiistniiMciit  cdiisists  <it"  a  silvcffd  ;^l:iss  (•(Hicavc  iiiirfor  oi' almut  H  inclics' 
fui'al  k'ligtii,  liaviii';  a  rcntral  opi-iiiiij;  in  the  silvi'riiij;  ui"  a  line  and  a  half  (liaiiictcr.  The 
luirrttr  is  fixi'd  in  a  metal  hack,  havin<::  a  central  perforation  ahout  douhle  the  diameter 
of  the  opeidnir  in  the  silvering.  l')>on  the  metal  hack  is  fixed  a  clip  for  the  j)nrpo>e  of 
holilini:;  an  ocular  lens;  the  hack  is  screwed  to  a  liandle  ahout  U  1  inches  lonj;.  The  acces- 
sorv  jxirtions  consist  of  t\V(t  ohjeet  lenses  of  21  and  '.'»  inches"  local  leiijrth  respijctively,' 
autl  live  ocular  lenses — two  convex,  of  (I  and  12  inches  positive  foci /^  three  concave,  of 
S,  12,  and  24  inches  nepitive  i'oci  ;''  all  are  made  to  lit  into  the  ahove-mentioiied  clip  A 
Verv  convenient  case  contains  the  whole. 

Method  of  Using  the  Ophthalmoscope. — There  are  two  methods  of  usinp 

tliis  instrument.      The  lirst,  which   re(|uires  much  |iracticc,  i.s  called  the  direct  method  of 
examination,  or  examination  of  the  im/  iiiiiuj>\  with  the  ophthalmoscope    alone,  witliout" 
the  aid  of  a  hi-coiivex  ohjeet  lens. 

The  secoiul,  which  is  much  the  easier  of  the  two.  is  called  the  indirect  method,  or 
examination  of  tlic  Inverted  imaeje ;  in  it  hotli  tlie  ophtlialmoscope  and  a  bi-convcx  lens 
are  used. 

Direct  (//i/il/id/Di'isiiijiir  Kxaniiiudion. — In  this  method  a  virtual  erect  image  situated 
behind  the  eye  is  seen.      The  examination  is  conducted  in  the  followiii'.''  manner: 

The  patient  being  seated  in  a  dark  room,  a  gas  or  other  lamp  (gas  being  preferable) 
should  be  placed  at  the  side  corresponding  to  the  examined  eye,  on  a  level  with  it,  but  so 
situated  as  to  leave  the  cornea  in  shade  ;  he  should  then  be  directed 
to  look  forward  and  a  little  upward,  at  some  distant  object,  and  to 
keep  the  eyes  as  steady  as  possible. 

Supposing  the  right  eye  to  be  examined,  the  lamp  should  be 
placed  at  the  patient's  right  side ;  the  observer,  standing  in  front  at 
a  distance  of  LS  inches  or  2  feet,  should  take  the  ophthalmoscope  in 
his  riglit  hand,  look  through  the  sight-hole  with  the  right  eye,  and 
reflect  the  light  from  the  lamp  through  the  pupil  of  the  patient's 
right  eye.  If  the  examination  be  conducted  properly,  the  pupil 
will  appear  of  a  bright-red  color.  The  observer  should  then  look 
for  the  optic  disc,  which  is  situated  rather  to  the  inner  side  of  the 
axis  of  the  eyeball ;  he  will  know  that  the  disc  is  in  view  from  the 
alteration  in  c(jlor  of  the  pupil,  which  will  turn  from  red  to  white 
or  pinkish  white.  Having  obtained  the  peculiar  reflection  of  the 
optic  disc,  the  observer  (taking  care  to  relax  his  own  accommoda- 
tion) should  approach  the  eye  until  an  interval  of  only  2  inches 
separates  his  cornea  from  that  of  the  examined  eve.     Some  difficulty  Liebreich's    Ophthalmo- 

.  .  ,  .  ,  "^  "^  scope 

will  be  experienced  in  keeping  the  eye  illuminated,  increasing  as  the 

distance  between  the  observed  and  the  observer  becomes  less ;  this,  however,  will  be  over- 
come by  practice.  When  the  observed  eye  has  been  approached  to  within  a  distance  of 
2  to  8  inches  (supposing  both  the  examining  and  examined  eye  to  be  emmetropic),  a  dis- 
tinct erect  and  greatly  magnified  image  of  the  parts  occupying  the  fundus  of  the  latter 
should  be  obtained ;  most  observers  will,  however,  find  the  image  sharpened  in  outline 
and  detail  by  using  a  weak  concave  lens  behind  the  sight-hole  of  the  ophthalmo.scope. 
Should  either  the  observer  or  the  patient  be  myopic,  it  will  be  found  necessary,  in  order 
to  examine  the  erect  image,  to  place  behind  the  sight-hole  of  the  ophthalmoscope  a  con- 
cave lens  which  rather  more  than  neutralizes  the  existing  ametropia. 

The  examination  of  the  erect  image,  although  requiring  considerably  more  practice 
than  that  of  the  inverted,  should  never  be  neglected,  as  it  gives  much  more  satisfactory 
evidence  of  minute  changes  in  the  fundus  oculi,  all  the  parts  being  seen  liighly  magnified 
(about  fourteen  and  a  half  times).  It  gives,  however,  a  less  extensive  field  of  vision,  on 
account  of  the  size  of  the  objects,  wdiich  only  allows  small  portions  of  them  to  be  seen 
through  the  pupil  at  one  time. 

The  optic  disc,  retinal  ves.sels,  and  other  parts  occupying  the  fundus  should  be  exam- 
ined by  looking  in  different  directions  through  the  pupil,  the  observed  eye  being  kept 
steadily  fixed  during  the  examination  upon  some  distant  and  suitably  situated  object. 

The  right  eye  having  been  examined,  the  lamp  should  be  placed  on  the  patients  left 
side  aud  the  manaMivre  repeated,  the  observer  using  the  left  hand  and  left  eye  instead  of 

'  Sixteen  and  thirteen  dioptrics,  metrical  system. 

^  Ahout  .'ieven  and  three  dio])trics,  convex. 

^  About  five,  tliree,  and  one  decimal  five,  dioptrics  concave. 

17 


258 


OPHTHALMOSCOPIC  EXAMINA  TION. 


the  right  hand  and  right  eye.     The  condition  of  refraction  of  the  eye  can  be  diagnosed 
by  the  direct  method  of  examination. 

Indirect  Ophtludmoscopic  -Examination. — In  this  metliod  of  examination  an  inverted 
aerial  image  of  the  fundus  oculi  is  formed  by  the  interposition  of  a  bi-convex  lens 
between  the  observer  and  observed  eye.     (See  Fig.  107.) 

Fig.  107. 


A  observer's.  B  observed,  eye.  F,  the  light.  S,  the  mirror.  L,  the  biconvex  lens,  a  fi,  some  portion  of  the  retina 
or  the  disc,  a'  /3',  its  inverted  aerial  image  formed  between  the  mirror  and  bi-convex  lens.  (From  Carter's  trans- 
lation of  Zaiider  on  the  Ophtlialmoscope.) 

The  position  of  the  patient  and  observer  should  be  the  same  as  for  the  direct  exami- 
nation ;  the  same  lamp  also  can  be  used,  but  should  be  placed  rather  farther  back  and 
kept  on  the  patient's  left  side  during  the  examination  of  either  eye.  The  ophthalmoscope 
should  be  held  in  the  same  manner  and  the  light  reflected  through  the  pupil  as  detailed 
above ;  but,  the  red  I'eflection  having  been  obtained,  the  observer  must  not  approach  the 
eye,  but  remain  at  a  distance  of  about  18  inches. 

The  patient  should  be  directed  to  look  at  some  distant  object  so  situated  that  the  axis 
of  the  observed  eye  is  turned  slightly  inward;  this  brings  the  optic  disc  (which  lies  some- 
what to  the  inner  side  of  the  optic  axis)  opposite  the  ophthalmoscope,  and  its  peculiar 
bright  reflection  will  be  at  once  ob.served. 

The  bi-convex  lens  should  then  be  held  in  front  of  the  observed  eye  at  a  distance 
about  equal  to  its  own  focal  length  from  the  cornea,  and  steadied  by  the  observer  resting 
his  ring-finger  and  little  finger  on  the  patient's  brow.  By  this  means  an  inverted  image 
of  the  optic  disc  and  vessels  of  the  retina  is  immediately  seen,  which,  although  apparently 
within  the  eye,  is  in  reality  formed  in  the  air  between  the  observer  and  the  bi-convex 
lens,  and  (in  emmetropia)  at  a  distance  from  the  latter  corresponding  to  its  focal  length. 

If  the  image  of  the  disc  appear  indistinct,  the  observer  may  be  sure  that  his  own  eye 
is  not  accommodated  for  the  distance  at  which  the  image  is  situated,  which  is,  in  reality, 
shorter  by  some  inches  than  it  appears  to  be.  Should  this  be  the  case,  the  observer  must 
increase  the  ten.sion  of  his  accommodation  or  withdraw  somewhat  farther  from  the  observed 
eye. 

A  better  method,  however,  than  either  of  the  foregoing  is  to  employ  habitually  behind 
the  sight-hole  of  the  ophthalmoscope  a  convex  ocular  lens  of  about  10  or  12  inches'  focal 
length.  If  this  be  done,  a  clear  and  well-defined  image  will  always  be  obtained  without 
tension  of  accommodation,  provided  precautions  be  taken  that  the  distance  between  the 
observer's  eye  and  the  image  be  not  greater  than  the  focal.  length  of  the  convex  ocvlar  lens. 

The  disc  and  parts  immediately  surrounding  having  been  examined,  the  patient  should 
be  directed  to  look  straight  forward,  so  as  to  bring  the  region  of  the  yellow  spot  opposite 
the  ophthalmoscope  ;  this  having  been  carefully  examined,  the  eye  should  be  turned 
upward,  downward,  to  the  right  and  left,  so  that  all  parts  of  the  fundus  ma}'  be  exam- 
ined in  turn. 

In  the  indirect  method  of  examination  the  observer  should  use  his  right  eye  and  hold 
the  ophthalmoscope  in  his  right  hand  and  the  bi-convex  lens  in  his  left  in  examination  of 
the  right  eye,  and  vice  veraCi  in  examination  of  the  left. 


Difficulties  of  Opthalmoscopic  Examination. 

Considerable  practice  is  required  in  order  to  become  proficient  in  the  use  of  the  ophthal- 
moscope ;  the  beginner  will  be  frequently  much  disheartened  at  his  want  of  success. 
Some  of  the  difiiculties  are  only  to  be  overcome  by  practice ;  others  are  easily  remedied. 
Reflections  of  the  mirror  from  the  two  surfaces  of  the  object  lens  often  prove  very 
troublesome ;  the  inconvenience  ari.sing  from  this  source  is  obviated  by  holding  the  lens 

^  Four  or  three  dioptrics. 


OrilTllALMOSCOPia  EXAMISATlnX.  259 

KoiiR'wliat  ()l)li(|uely,  wlu-ii  tlio  two  iiiia^(!.s  will  recede  from  each  other  and  leave  a  clear 
.space  Ix'twffii  tlu'iii.  llefleetioii  IVnm  the  surface  of  the  cornea  may  he  trouhlesoine,  hut 
can  n>u;ill\  lie  overcome  hy  a  little  nian<euvriiijr-  Cniitraction  of  the  pupil  is  also  an 
iiisuriiiouiitahle  ohstade  to  the  he<;inner,  hut  can  he  removed  hy  dilatation  with  atropine; 
fi>r  this  purpose  a  solution  of  one  grain  to  one  ounce  of  water  should  he  dntpped  into  the 
eye  ahout  half  an  hour  hefore  the  examination  is  made,  or  the  patient  may  he  ordered  to 
use  a  solution  of  (tne-eighth  grain  t<t  one  ounce  two  or  tliree  times  on  the  day  preceding 
it.  When  e.xperientu'  has  heen  gained,  however,  atropine  can  he  dispensed  with,  except 
in  some  few  eases  or  in  those  where  it  is  nece.s.sary  to  make  a  very  careful  examination 
hv  l:it(M-al  illuniiiiatiiiii. 

II"  the  patient  ln'  diroeted  to  look  at  a  distant  ohjecf ,  the  accommodation  is  relaxed,  and 
sutheieiit  increase  in  the  j)upillary  area  will  generally  take  jdace. 

KiVery  ophthalmoscopic  examination  should  be  conducted  on  a  certain  delinite  system. 

The  Jirst  xh-p  should  he  to  examine  the  condition  of  the  refractive  media  by  lateral 
illumination. 

Xf'xf,  the  cnwUtion  of  refrttrli'nu  of  the  eye  and  tlie  state  of  the  vitreinis  cliamher 
should  he  ascertained  by  the  direct  metliod  of  examination. 

Thinllj/,  II  i/eiienil  sitrvet/  of  tlie  fundus  oculi  should  he  made  ])y  the  indirect  method. 

Ami,  f'onrthli/,  any  ahnttrmalities  having  l»een  discovered  hy  the  indirect  examination 
should  he  fully  and  carefully  studied  in  detail  by  the  direct  method. 

If  tliis  systematic  plan  of  examination  be  carried  out,  few  mistakes  will  be  made,  and 
no  abnormality  of  importance  is  likely  to  be  overlooked. 

Normal  Appearance  of  Parts  seen  by  the  Ophthalmoscope. 

The  refractive  media  (cornea,  aqueous  humor,  lens,  and  vitreous),  as  stated  under 
"  Lateral  Illumination,"  are  perfectly  transparent. 

The  retina  is  either  quite  tran.sparent  and  colorless,  or  in  dark  eyes  may  appear  as  a 
faintly  gray  cloud  covering  the  choroid ;  its  position  is  marked  by  that  of  its  blood  ves- 
sels. The  bright-red  reflection  previously  mentioned  is  due  to  the  blood  in  the  choroid ; 
the  depth  in  color  of  the  reflection  varies  with  the  amount  of  pigmentation  of  this  vas-' 
eular  tunic :  in  blue  or  gray  eyes  it  is  light  red,  in  dark  ones  of  a  much  deeper  tint,  and 
in  the  negro  a])pears  to  be  dark  blue.  The  parts  of  the  fundus  oculi  retjuiring  special 
attention  are  the  oj)tie  disc  and  parts  immediately  surrounding  it  and  the  region  of  the 
yellow  spot. 

The  disc  appears  at  first  sight  to  be  of  a  uniform  pale  pink  color,  hut  on  closer 
examination  different  portions  are  found  to  present  different  shades. 

Its  centre  is  pale,  or  even  white ;  next  to  this  succeeds  a  zone  of  pink,  this  being 
again  bounded  by  an  apparently  double  border  of  lighter  color.  The  pale  appearance  of 
the  central  portion  of  the  disc  is  caused  by  connective  tissue  surrounding  the  blood  ves- 
sels in  this  situation.  The  succeeding  pink  zone  consists  entirely  of  nerve  fibres  and 
delicate  capillaries.  The  outer  pale  double  border  is  formed  by  the  margins  of  the  sclero- 
tic and  choroidal  rings,  which  do  not  accurately  cover  each  other,  the  choroidal  ring  being 
somewhat  greater  in  diameter  than  the  sclerotic  opening,  the  margin  of  which,  being  left 
uncovered  by  pigment,  shines  through  the  transparent  nerve  fibres. 

Both  the  white  central  portion  and  the  outer  ring  are  in  some  cases  so  distinctly 
marked  that  the  appearance  produced  might  be  taken  by  an  inexperienced  observer  as 
evidence  of  disea.sc,  but  both  conditions  are  perfectly  consistent  with  health.  From  the 
pale  central  portion  of  the  disc  proceed  the  retinal  blood  vessels ;  the.se  appear  upon  its 
surface  usually  at  the  same  point,  but  may  emerge  separately  or  in  groups  of  two  or 
three. 

As  a  rule,  ahout  eight  ves.sels  are  seen  upon  or  close  to  the  disc,  four  of  these  being 
arteries,  with  a  corresponding  number  of  veins  ;  two  of  each  pass  upward  and  a  like  num- 
ber downward,  to  be  distributed  over  the  retina.  The  lateral  branches  are  comparatively 
insignificant,  and  are  given  off  from  the  principal  trunks  either  upon  the  nerve  surface 
or  in  the  retina  near  its  margin. 

Distinction  between  Arteries  and  Veins. — The  veins  are  distinguished  from 

the  arteries  by  being  of  greater  calibre,  the  proportion  being  ahout  3  to  2.  There  is  also 
a  difference  in  color  between  the  two,  the  veins  being  the  darker ;  the  arteries  are  marked 
by  a  double  contour  and  their  central  ]iortion  is  much  lighter  than  their  borders. 

Occasionally  a  dark  spot  is  noticed  in  one  of  the  vessels  at  its  origin  or  termination  in 
the  disc.     This  might  be  taken  for  a  clot,  but  the  appearance  is  caused  by  a  peculiar 


260  OPHTHALMOSCOPIC  EXAMINATION. 

arrangement  of  the  vessel,  which  at  this  point  is  seen,  as  it  were,  on  end  and  foreshort- 
ened. 

Spontaneous  pulsation  of  some  of  the  retinal  veins  may  also  be  observed  ;  the  occur- 
rence of  venous  pulsation  is.  however,  perfectly  consistent  with  health  and  has  no  patho- 
logical import. 

In  any  eye.  pulsation,  both  arterial  and  venous,  can  be  produced  by  pressure  upon  the 
globe,  but  should  it  occur  spontaneously  in  the  arteries  has  the  gravest  significance.  (See 
"  Glaucoma.") 

Anomalies  of  Optic  Disc,  etc.,  consistent  with  Health. 

Certain  phenomena  are  not  unfrequently  obsei'ved  with  the  ophthalmoscope  which, 
although  contrary  to  the  condition  usually  met  with,  are  perfectly  consistent  with  a 
normal  state  of  the  parts. 

The  appearances  caused  by  the  connective  tissue  surrounding  the  central  vessels,  the 
occurrence  of  pulsation,  unusual  distribution,  and  existence  of  dark  spots  in  the  latter, 
together  with  the  unusual  distinctness  of  the  sclerotic  ring,  have  been  already  mentioned. 

Other  anomalies  are : 

1-  A  dark  crescentic  figure  bordering  some  portion  of  the  margin  of  the  disc. 
This  appearance  is  caused  by  a  peculiar  arrangement  of  the  choroidal  pigment ;  it  is 
congenital. 

2.  Variations  in  the  depth  of  color  of  the  disc  are  frequently  met  with, 
Due  regard  must  be  had  to  the  color  of  the  surrounding  fundus  in  forming  an  opinion  as 
to  whether  the  tint  in  any  particular  case  is  so  much  deepened  or  lessened  as  to  consti- 
tute a  diseased  condition. 

In  light  eyes  the  disc  appears  much  redder  than  in  dark,  the  apparent  difference 
being  due  more  to  contra.^t  with  the  surrounding  parts  than  to  actual  change  in  color. 

Slight  deviations  are  only  to  be  determined  by  careful  examination  and  long  experi- 
ence. 

3.  Excavation  of  the  Optic  Disc. — Not  unfrequently  a  sloping,  or  even  an 
abrupt,  depression  is  met  with  occupying  the  centre  of  the  disc,  but  usually  extending 
somewhat  farther  toward  the  yellow  spot  than  in  other  directions.  The  whole  nerve 
surface,  however,  is  never  included  in  the  cup ;  the  vessels  do  not  bend  under  its  edge, 
their  calibre  is  not  altered,  neither  is  spontaneous  arterial  pulsation  observed,  as  may  be 
the  case  in  the  excavation  of  glaucoma.     (See  "  Glaucoma."') 

4.  Persistence  of  the  Hyaloid  Artery. — Occasionally  a  small  whiti.sh  cord 
may  be  seen  extending  from  the  centre  of  the  disc  to  the  back  of  the  lens ;  it  is  the 
remains  of  a  vessel  which  during  foetal  life  nourished  the  latter  structure. 

5.  Senile  Changes. — As  age  advances  the  refractive  media  become  less  trans- 
parent, the  retina  grows  somewhat  hazy,  and  the  disc  appears  whiter  than  natural. 

6.  An  appearance  of  white  wisp-like  patches,  extending  from  some 

part  of  the  margin  of  the  disc  over  the  surrounding  fundus.  These  patches  have  in-egular 
jagged  borders  and  are  often  of  considerable  size  ;  the  retinal  vessels  pass  through  and 
are  obscured  by  them.  Occasionally  white  threads  may  be  continued  for  a  considerable 
distance  along  the  sides  of  the  vessels. 

The  patches  are  caused  by  the  opac(ue  nerve  sheaths,  which  should  end  at  the  lamina 
cribrosa.  being  accidentally  continued  beyond  this  point  into  the  transparent  retina ;  they 
are  congenital  and  do  not  interfere  with  vision. 

7.  the  choroidal  vessels  are  at  times  Tespecially  in  light  eyes)  very  plainly 
visible,  appearing  as  an  irregular  network  of  pale  pink  bands. 

The  region  of  the  yellow  spot  presents  in  health  no  very  marked  ophthalmo- 
scopic signs,  but  requires  special  notice,  as  it  is  frequently  the  seat  of  pathological  lesions. 
In  the  normal  condition  it  is  recognized  by  the  absence  of  blood  vessels,  which  appear  to 
avoid  this  part  of  the  retina  and  pass  above  and  below  it.  by  some  deepening  in  color, 
and  occasionally  an  indistinct,  dark,  transversely  oval  figure  can  be  detected. 

IV.   Examination  by  Manipltlation. 

The  fourth  method  of  examination,  hy  manipulation,  consists  simply  in  ascertaining 
the  tension  of  the  globe  by  digital  pressure.  The  examination  should  be  conducted  as 
follows : 

Tension  of  Globe. — The  patient  being  directed  to  look  downward  and  close  the 


REFRACTION. 


2t;i 


eye  prcntly.  Imt  not  to  sorow  up  the  lids,  tlie  surtreoii  .sIimiM  make  pentle  alternate 
pressure  with  the  f'nretiiitrer  of  each  hand  placed  upon  the  closed  upper  lid;  the  pressure 
should  be  made  in  a  direction  liackward  ami  somewhat  downward,  s<j  as  to  compress  the 
glohe  a<;ainst  the  flcinr  ol'  the  orhit. 

In  health  the  eyeball  is  firm,  tense,  and  semi-fluctuating;  in  disease  the  tension  may 
deviate  in  the  direction  of  increase  or  decrease.  The  degree  of  tension  may  be  expres.sed 
as  follows  : 

If  normal,  as  Tn  ;  if  above  par,  as  T  4-  1,  T  -r  2,  T  +  3,  according  to  the  amount  of 
increase  ;  if  below  par,  as  T  —  1,  T  —  2,  T  —  3.  If  a  doubt  exist,  as  T  -}-  ?  or  T  —  ?, 
according  as  the  doubt  is  on  the  side  of  increase  or  decrease. 


REFRACTION,  ACCOMMODATION,  ACUTENESS,  AND  FIELD 

OF  VISION. 

DEFlNlTtoN. — By  refraction  of  the  eye  we  understand  the  power  which  the  refractive 
media  (cornea,  humors,  and  lens)  possess  by  virtue  of  their  curvatures  and  densities  of 
bringing  together  y>")v</A7  rays  of  light  and  forming  them  into  an  image  at  a  certain  spot 
(known  as  the  principal  focus  of  the  refractive  or  dioptric  system)  irithoiit  the  employiwnt 
of  iini/  adjust iiiij  poirer. 

The  refraction  is  said  to  be  normal  or  abnormal  according  to  the  position  of  the  retina 
with  regard  to  the  focus  of  the  dioptric  system.  The  former  condition  is  known  as 
emmetropla.  the  latter  as  ametropia,  the  terms  "  normal  "  and  "  abnormal "'  being  seldom 
applied. 

Emmetropia. — The  emmetropic  eye  (Fig.  lOS)  is  of  such  a  shape  that  the  retina 
is  situated  at  the  focus  of  the  dioptric  system,  and  in  such  a  po.sition  that  a  distinct  and 
inverted  image  of  any  object  (Me  rays  of  light  ju-occedimj  from  uhich  are  parallel )  is 
formed  upon  the  layer  of  rods  and  cones. 

Ametropia. — The  ametropic  eye  differs  from  the  emmetropic  in  two  opposite  direc- 
tions ;  the  deviations  are  known  as  atiomalies  of  refraction.  In  the  first  and  (m  this 
country')  most  commonly  met  with  anomaly  the  retina  lies  irithin  the  focus  of  the  diop- 
tjic  system — that  is  to  say,  the  axis  of  the  eyeball  is  too  short  from  before  backward  ; 

Fig.  108.2 


a.  Erametropia.  6.  Myopia.  c.  HypermetTOpia. 

(From  Donders,  Accommodation  and  Refraction  of  the  Eye.  i 

and  images  of  objects  the  rays  of  light  proceeding  from  which  are  parallel  are  formed 
behind  the  retina  instead  of  in  its  substance.  This  anomaly  is  known  as  hi/permetropia, 
or  far  sight.     (See  Fig.  lOS,  c.) 

To  the  second  anomaly  an  opposite  state  of  things  pertains :  the  axis  of  the  eyeball 

'  It  is  generally  believed  amongst  English,  and  is  also  supported  by  continental,  oplithalmologists 
that  in  this  country  hyperraetropia  is  of  more  frequent  occurrence  than  myopia.  It  appears  to  me 
that  the  reverse  may  obtain.  .  We  are  rarely  in  hospital  practice  consulted  about  slight  myopia,  as  it 
gives  no  inconvenience.  On  the  other  hand,  a  very  slight  degree  of  hypermetropia  may  incapacitate 
the  seamstress.  skille<l  mechanic,  or  clerk  ;  so  that,  whereas  we  get  all  degrees  of  hypermetropia.  we 
are  only  applied  to  in  the  higher  degrees  of  myopia. 

*  In  these  diagrams  o"  shows  posterior  focal  points  of  the  dioptric  system  ;  j,  in  b  and  c.  the 
abnormal  position  of  the  retina. 


262  REFRACTION. 

from  before  backward  is  too  long;  consequently,  the  retina  lies  outside  the  focus  of  the 
dioptric  system,  and  the  image  of  an  object  the  rays  of  light  coming  from  which  are  par- 
allel is  formed  in  front  of  it.  This  anomaly  is  known  as  myopia^  or  short  sight.  (See 
Fig.  lOS.  b.) 

Diagnosis  of  Anomalies  of  Refraction. —  The  diaijuoi^l^  of  anomalies  of 

refraction  can  be  made  by  trial  with  lenses,  by  direct  ophthalmoscopic  examination,  and 
by  ''  kcratoscopy."  If  we  wish  to  diagnose  and  measure  the  degree  of  anomalies  of 
refraction  by  trial  with  lenses,  we  must  be  provided  with  a  set  of  trial  glasses  and  a 
book  of  Snellen's  test  types.     (See  p.  2G5.) 

The  trial  glasses  which  have  now  come  very  generally  into  use  are  arranged  accord- 
ing to  what  is  known  as  the  "  metrical  system."  The  unit  in  this  system  is  a  lens  of  one 
metre  focal  length  ;  it  is  called  a  "  dioptric  "  (=  D).  A  lens  of  two  dioptrics  is  double 
the  strength  of  that  of  one  dioptric  and  has  a  focal  length  of  half  a  metre  (50  centimetres), 
and  so  on.  The  box  of  trial  glasses  contains  convex  and  concave  spherical  and  cylindri- 
cal lenses.      It  can  be  obtained  from  any  good  optician. 

Test  of  Refraction  by  Lenses. — We  test  refraction  with  lenses  as  follows: 
Having  placed  our  patient  at  (J  metres  from  the  sheet  on  which  are  printed  letters  from 
D  =  6'  to  D  =  60,  we  direct  him  to  look  toward  it.  Should  he  be  hypermetropic,  he  will 
be  able  to  make  out  all  or  most  of  the  letters ;  he  will  already  have  told  us  that  he  can- 
not see  to  do  near  work  or  read  for  any  length  of  time  without  the  eyes  becoming  fatigued 
and  vision  growing  misty.  We  ascertain  how  many  of  the  letters  can  be  read  by  each  • 
*eye  separately.  Should  both  eyes  read  the  same  letters,  we  hold  before  them  convex 
glas.ses,  beginning  with  + 1  D,  and  continue  the  trial  until  we  have  ascertained  the 
stron(/cst  convex  lens  with  which  the  greatest  attainable  acuteness  of  vision  is  still  main- 
tained. Thus,  supposing  our  patient  reads  D  =  6  at  6  metres,  we  find  the  strongest  con- 
vex lens  with  which  he  can  still  read  D  ;=  G ;  should  he  read  D  =  12  without  a  convex 
lens  and  D  =  6  by  the  aid  of  one,  we  find  the  strongest  with  which  he  can  still  read 
D  ^=  6  ;  if  we  cannot  improve  vision  so  that  he  reads  more  than  D  ^=  12,  we  find  the 
strongest  convex  glass  with  which  he  can  still  read  D  =  12,  and  so  on.  Should  there 
be  a  difference  between  the  two  eyes,  we  must  test  the  refraction  of  each  separately, 
keeping  one  covered  during  the  trial  of  the  other.  The  strongest  convex  lens  which  still 
allows  the  patient  to  see  as  well  at  a  distance  as  is  possible,  either  with  or  without  the 
aid  of  glasses,  shows  a  part  of  the  accoiumodative  power  which  he  was  obliged  to  exer- 
cise in  order  to  bring  parallel  rays  of  light  to  a  focus  upon  the  retina  of  his  too-short  eye. 
The  employment  of  such  a  lens  prevents  this  waste  of  accommodation  and  reserves  it  to 
be  used  when  required  for  near  work. 

Should  our  patient  be  myopic,  he  will  probably  tell  us  that  he  is  near-sighted ;  he 
will  make  out  but  few  or  none  of  the  letters  at  G  metres  ;  if  the  small  types  be  given  him 
to  read,  he  will  hold  them  near  the  eyes,  but  will  make  out  the  smallest  provided  the 
book  be  held  close  enough. 

We  notice  at  what  distance  the  small  types  can  l)e  read  by  each  eye  separately,  and,  as 
in  hypermetropia,  if  there  be  no  difference  between  the  two,  test  their  refraction  together. 

We  tell  our  patient  to  look  toward  the  sheet  on  which  are  the  letters  from  D  =  6  to 
D  —  GO,  and  hold  before  his  eyes  concave  lenses  beginning  with  that  the  negative  focal 
length  of  which  corresponds  to  the  distance  at  which  small  types  are  read. 

Thus,  if  the  small  types  can  be  read  at  20  centimetres,  we  begin  the  trial  with  a  lens 
of  5  D,  the  negative  focal  length  of  which  is  20  centimetres. 

We  continue  the  trial  until  we  have  found  the  vcakesf  concave  lens  with  which  dis- 
tant letters  can  be  most  plainly  seen.  Should  our  patient  by  the  aid  of  any  concave  lens 
be  able  to  read  D  =^  G  at  G  metres,  we  find  the  rreakcst  with  which  D  ;=  G  can  still  be  read. 
Should  he  be  able  only  to  make  out  D  =  24,  D  =  12,  etc.,  we  must  still  find  the  weakest 
concave  lens  with  which  the  best  vision  is  attainable. 

As  in  hypermetropia,  should  there  be  a  difference  between  the  two  eyes,  we  test  each 
eye  separately. 

We  must  be  careful  to  ascertain  tJie  icedkent  lens  with  which  the  best  vision  for  distant 
letters  is  attainable,  because  we  wi.sh  only  to  so  open  out  the  pencil  of  parallel  rays  of 
light  as  to  allow  of  their  being  brought  to  a  focus  in  the  retina  of  the  too-long  eyeball. 

If  we  give  too  strong  a  lens,  our  patient  will  see  ecpially  well ;  but  then  we  have 
opened  out  the  pencil  of  parallel  rays  too  much,  and  he  must  use  his  accommodative 
power  in  order  to  overcome  the  excessive  divergence. 

'  The  smaller  letters  D  =  5,  D  =  4,  D  =  3,  etc.,  placed  at  their  proper  distances,  will  do  equally 
well  if  we  have  not  a  distance  of  6  metres  at  disposal. 


Rh'J-n.K  Tff)X. 


263 


Diagnosis  by  the  Ophthalmoscope. — In  tin-  dia^tiosis  and  mfasuromont  of 
aii(tMialii>  111'  nlVailidH  hy  diirrt  uplil  iKilinuMopic  i-xaiiiiiiution  we  act  upnii  the  .same 
priiu'ijde  as  in  the  diairuosis  by  trial  with  lenses — with  this  exception,  however,  that  we 
use  uur  own  eye  as  a  t»'st,  instead  ol'  tlu-  patient's  vision. 

.\s  stated  at  p.  li")",  nntliinjr  lA'  the  details  (d"  the  I'limliis  i»t'  tin-  «iiiin<'tropic  eye  can 
he  i/nii/i/  made  out  until  we  have  approached  it  vi-ry  near.  Now,  on  the  (••mtrary,  should 
any  object  occupying;  tin-  fundus  lie  ilnirli/  srm  whilst  we  are  still  separated  fnim  the 
observed  eve  by  a  considerable  interval,  we  may  be  certain  that  we  have  to  deal  with  an 
anomaly  of  relVaction. 

The  ((uestion  now  arises,  Is  the  ea.s(!  one  of  hypernuttropia  or  myojiia  ?  W<r  answer 
the  (|uestion  by  ascertaininj;  whether  the  object  we  sec;  is  viewtid  in  an  erect  or  inverted 
j>osition.  If  till"  former,  the  eye  is  hypermetropic;  if  th(!  latter,  it  is  myopic.  We  can 
ascertain  the  position  (d'  the  imajre  l)y  moviiii:  our  head  from  side  to  side.  If  the  imajre 
be  erect  it  will  move  in  the  same,  if  invcrtcil  in  an  opposite,  direction  to  the  niovement.s 
of  the  head. 

If  wt-  wish  to  ascertain  the  amount  of  hypermetropia  or  myopia  present,  we  take  one 
of  the  ophthalmoscopes  mentioned  below,  go  a.s  close  as  possible  to  the  patient's  eye, 
revolve  the  lens  containinj;  discs  placed  at  the  back  of  the  in.strument  until  we  have 
ascertained,  in  hypermetropia  the  strongest  convex,  in  myopia  the  weakest  concave,  len.s 
with  which  we  can  still  see  clearly  the  optic  disc  and  retinal  vessels. 

The  number  of  diojUrics  of  the  strongest  convex  or  weakest  concave  lens  with  which 
the  greatest  attainable  acuteness  of  vi.sion  /or  distant  letters  is  .still  maintained  expre.sstf.s 
what  is  known  as  the  degree  of  '•  ametropia'."  Thus,  we  say  that  an  eye  which  sees  a.s 
clearly  or  more  clearly  through  a  convex  lens  of  two  dioptrics  has  a  hypermetropia  of 
2  I),  an  eye  of  which  the  acuteness  of  vision  is  most  improved  by  a  concave  len.s  of  three 
dioptrics  has  a  myopia  of  H  I),  and  so  on. 

The  same  holds  good  in  the  measurement  of  anomalies  of  refraction  by  the  ophthal- 
moscope. The  strongest  convex  lens  in  a  case  of  hypermetropia,  the  weakest  concave  in 
one  of  myopia,  through  which  a  clear  view  of  the  fundus  can  .still  be  obtained,  expresses 
the  degree  of  '"  ametropia  "  present. 

Two  very  u.seful  ophthalmoscopes  by  means  of  wliich  anomalies  of  refraction  can  not 
only  be  diagno.sed,  but  also  accurately  measured,  have  been  devised — one  (Fig.  109)  by 
3Ir.  Charles  J.  Oldham  of  Brighton  (see 

Report    of    Fourth    OpIttJialmic    Cotir/ress,  Via.  109. 

1872),  and  another  by  Mr.  W.  L.  Purves ; 
the  latter  is,  I  think,  the  more  convenient 
of  the  two.' 

The  third  method  of  ascertaining  the 
form,  and  also  the  degree,  of  ametropia  by 
'•  keratoscopy,"'  is  conducted  as  follows : 
The  patient,  being  seated,  and  the  lamp 
placed  rather  behind  the  level  of  the  face, 
is  directed  to  look  straight  forward.  The 
observer  should  stand  or  sit  at  a  distance 
of  about  a  metre  and  a  quarter,  and  with 
the  ophthalmoscope  reflect  the  light  from 
the  lamp  upon  the  patient's  eye.  As  soon 
as  the  bright  red  reflection  of  the  fundus 
is  seen  the  mirror  should  be  rotated.  If 
ametropia  be  present,  a  shadow  will  be 
seen  to  pass  across  the  illuminated  area. 
The  diagnosis  of  the  anomaly  present  is 
decided  by  the  direction  of  this  shadow. 
If  it  passes  in  the  same  direction  as  the 
rotation  of  the  mirror,  the  eye  is  myopic ; 
if  in  the  opposite  direction,  the  eye  is 
hypermetropic. 

In  slight  degrees  of  ametropia  and  emmetropia  the  shadow  is  so  faint  as  to  be  made 
out  with  difficulty  ;  if  seen  at  all,  it  moves  in  the  same  direction  as  the  mirror  in  slight 
M,  slight  H,  and  E. 

^  Many  other  refraction  ophthalmoscopes  are  in  use,  but  the  two  mentioned,  and  another  smaller 
and  cheaper  instrument  known  as  Loring's  oplulialnioscope,  will  be  found  as  useful  as  any. 


Oldham's  Ophthalmoscope. 


264  DISEASES  OF  ACCOMMODATTOX. 

We  can  ascertain  the  degree  of  anomaly  present  by  finding,  in  myopia,  the  weakest 
concave  lens  which,  held  before  the  eye,  makes  the  shadow  begin  to  move  against  the 
mirror ;  in  hypermetropia,  the  strongest  convex  lens  which  causes  the  shadow  to  begin  to 
move  with  the  mirror. 

In  the  examination  of  refraction  by  keratoscopy  it  is  well  to  have  the  pupil  and 
accommodation  fully  under  the  influence  of  atropine  or  other  mydriatic. 

The  observer  must  be  naturally  emmetropic  or  made  so  artificially. 

The  TREATMENT  of  anomalies  of  refraction  consists  mainly  in  neutralizing  the  defect 
by  suitable  spherical  lenses.  We  must,  however,  in  myopia  take  care  not  to  give  too 
strong  glasses. 

For  further  information  on  the  subject  of  refraction  the  reader  is  referred  to  works 
treating  specially  of  ophthalmic  subjects,  more  especially  to  that  on  The  Accommodation 
and  Refraction  of  the  Eye  (DondersJ. 

Accommodation. 

By  accommodation  is  meant  the  power  which  the  eye  possesses  of  altering  the  condi- 
tion of  its  refractive  media  so  as  to  form  upon  the  retina  images  of  near  objects  the  rays 
of  light  from  which  are  divergent  equally  as  distinct  as  images  of  more  distant  ones  the 
rays  of  light  from  which  are  parallel  or  nearly  so. 

The  power  of  accommodation  depends  upon  the  elasticity  of  the  crystalline  lens,  the 
curvature  of  which  can  be  increased  to  a  considerable  extent ;  the  alteration  of  curvature 
is  brought  about  by  the  action  of  a  ring  of  inorganic  muscular  fibres  situated  between 
the  sclerotic  and  choroid,  just  external  to  the  greater  circumference  of  the  iris.  This 
ring  is  known  as  the  ciliary  muscle.  The  manner  in  which  the  ciliary  muscle  acts  upon 
the  lens  is  as  yet  a  disputed  point,  one  theory  being  that  the  lens  is  m'aintained  in  a  flat- 
tened condition  by  tension  of  its  suspensory  ligament  so  long  as  the  eye  is  adjusted  for  a 
distant  object — that  upon  accommodation  for  a  near  one  the  ligament  is  relaxed  by  con- 
traction of  the  muscle  and  the  curvature  of  the  lens  (more  especially  that  of  its  anterior 
surface)  increased  by  virtue  of  its  own  elasticity.  The  other  theory  is  that  the  ciliary 
muscle  compresses  the  lens  in  some  manner  and  so  alters  its  curvature. 

Range  of  Accommodation.  . 

We  speak  of  the  range  of  accommodation,  and  by  it  we  mean  the  power  of  a  lens, 
which  we  suppose  the  crystalline  adds  to  itself  when  we  change  our  look  from  the  far- 
thest to  the  nearest  point  of  distinct  vision.  Thus,  an  eye  which  sees  clearly  at  infinite 
distance  when  its  accommodation  is  relaxed,  and  at  16  centimetres  with  greatest  ten- 
sion of  accomiuodation.  has  a  ranae  or  "  amplitude  "  of  accommodation  equal  to  a  lens  of 
iJ)_o  =  6  D,  about. 

Accommodation  is  accompanied  by  convergence  of  the  optic  axes  from  the  action  of 
the  internal  recti  muscles  and  by  contraction  of  the  pupil. 

Diseases  of  Accommodation. 

Paralysis  of  accommodation  is  met  with  in  cases  of  paralysis  of  the  third 
nerve  accompanied  by  ptosis,  divergent  strabismus,  and  more  or  less  dilatation  of  the 
pupil;  it  may  be  caused  by  injuries,  as  blows  on  the  eyeball  itself  or  in  its  vicinity; 
sometimes  it  is  met  with  without  apparent  cause,  not  unfrequently  in  persons  recovering 
from  diphtheria  or  from  any  exhausting  disease,  and  accompanied  by  no  paralysis  of  the 
external  ocular  muscles  ;  it  can  always  be  produced  artificially  by  the  use  of  atropine  or 
other  mydriatics. 

Symptoms. — Dilatation  of  the  pupil,  general  mistiness  of  vision,  and  inability  to  see 
near  objects  plainly,  the  last  condition  being  capable  of  correction  by  the  use  of  a  con- 
vex lens. 

Treatment. — This  depends  on  the  cause ;  if  the  paralysis  of  accommodation  be 
associated  with  paralysis  of  other  branches  of  the  third  nerve,  the  treatment  must  be 
directed  against  any  existing  constitutional  condition — syphilis,  rheumatism,  etc. — most 
improvement  being  brought  about  by  the  use  of  iodide  of  potassium  in  increasing  doses, 
alone  or  in  conjunction  with  bichloride  of  mercury.  If  dependent  on  injury,  the  eye 
should  be  kept  bound  up  and  inflammatory  .symptoms  treated  as  they  arise.  If  arising 
idiopathically,  without  apparent  cause,  a  solution  of  sulphate  of  eserine  should  be  used 


/•7/;/./>  OF  VISION.  265 

twii  i>r  tliroe  times  a  day  in  order  to  stiiimlate  the  oiliary  mu.scle  to  contract,  and  attfii- 
tiiiii  |i;iid  to  the  pMieral  health.      In  any  case,  a  convex  h-ns  may  he  used  if  rcfiuired. 

Spasm  of  acCOinmodation  is  met  with  in  sinm-  cases  of  liypermctropia,  and 
occasionally  in  myopia;  it  ut'ten  masks  a  cdn.sidcrahlc  amonnt  of  hypermetro|iia,  and  may 
at  times  (^ven  make  the  eye  appear  to  he  my<>]»ic.  If  it  exists  with  myopia,  tin;  de<rn;e 
of  short  siiiht  is  increased. 

Sv.Ml'To.MS. — Severe  and  constant  pain  in  the  eyehalls  and  forehead,  incrijased  on  any 
attempt  to  use  the  eyes,  and  associated  with  some  anomaly  of  refraction  T^enerally  hvper- 
metropia),  inaliility  to  see  near  or  distant  ohjects  distinctly,  these  symptoms  heiiii^  modi- 
tieil  or  entirely  removed  hy  the  use  of  atropine. 

Tkkat.MKNT. —  Paralyze  the  accommodation  hy  the  constant  use  of  a  stronj^  .solution 
of  atropiiu'  (<ir.  iv  of  sulphate  of  atrojiia  to  ^j  of  water)  and  accurately  neutralize  any 
oxistinji;  anomaly  of  refraction  hy  suitahle  lenses. 

ACUTENESS   OF   ViSION. 

By  acuteness  of  vision  we  understand  the  perceptive  and  conductive  power  of  the 
structures  concerned  in  sight :  this  may  he  ascertained  hy  the  use  of  test  types — i.  p., 
letters  of  certain  definite  proportions  which  can  he  recognized  hy  a  fairly  sharp-sighted 
eye  at  certain  distances,  which  distances  are  marked  over  each  set  of  letters. 

The  hook  of  test  types  we  use  is  that  of  Dr.  Snellen  ;  in  it  we  find  types  variously 
numhered  from  .o  to  (50,  the  former  heing  .5  of  a  metre,  or  50  centitnetres,  the  latter  <J0 
metres,  at  whi(di  distances  the  types  can  he  read  hy  an  emmetropic  eye  of  normally  acute 
vision.  The  hook  of  types  can  be  obtained  of  Williams  k  Norgate,  Henrietta  street, 
Covent  Garden  [or  of  any  optician  in  the  large  cities  of  the  United  States]. 

Field  of  Vision. 

By  the  field  of  vision  we  understand  the  area  over  which  objects  situated  in  the  same 
vertical  plane  can  be  distinguished,  the  eye  being  kejit  fixed  on  some  point.  The  limits 
of  the  field  of  vision  are  marked  by  the  most  excentrically  placed  points  of  objects  which 
can  still  be  distinguished,  the  direction  of  the  visual  axis  of  the  eye;  lieing  unaltered. 

Mode  of  Ascertaining  the  Extent  of  the  Visual  Field. — The  extent  of 

the  visual  field  is  easily  measured  by  either  of  the  two  following  methods  : 

1.  The  patient,  being  placed  at  a  distance  of  12  inches  from  a  blackboard  about  3 
feet  square  having  a  white  cross  in  the  centre,  .should  be  directed  to  look  steadily  at  the 
cross,  which  must  be  situated  on  a  level  with  the  eyes  ;  one  eye  being  closed,  the  sensi- 
bility of  the  retina  of  the  other  should  be  tested  by  moving  a  piece  of  chalk  fixed  on  a 
dark  handle  from  all  directions  toward  the  cross,  a  mark  being  made  at  the  point  where 
the  chalk  first  becomes  visible. 

The  whole  area  limited  excentrically  by  a  line  joining  the  points  at  which  the  chalk 
is  first  seen  when  approaching  from  every  direction  is  known  as  the  quantitative  field  of 
vision,  in  contradistinction  to  an  area  bounded  excentrically  by  much  narrower  limits, 
over  which  objects  are  distinctly  defined  and  letters  can  be  read,  etc.,  known  as  the  quali- 
tative field  of  viaion. 

2.  Another  very  simple  and  effectual  method  of  investigating  the  condition  of  the 
visual  field  is  conducted  as  follows  : 

Having  placed  the  patient  in  a  convenient  position,  we  stand  opposite  to  him.  at  a 
distance  of  about  2  feet,  and,  supposing  his  left  eye  to  be  examined,  we  direct  him  to 
look  steadily  at  our  right  eye,  which  is  opposite  to  his  left ;  the  patient's  right  eye  and 
our  left  being  kept  closed,  we  then  move  our  hand  in  various  directions  in  the  peripheral 
parts  of  the  field  and  notice  if  its  movements  are  perceived  by  the  patient  at  the  same 
distance  from  the  centre  as  by  our  own  healthy  retina. 

Care  must  be  taken  that  the  hand  is  moved  in  a  vertical  plane  situated  midway 
between  our  own  and  the  patient's  eye,  and  not  nearer  one  than  the  other ;  we  must  also 
take  care  that  he  keeps  his  eye  fixed. 

Supposing  that  the  eye  under  examination  distinguislies  all  movements  of  the  hand 
at  the  same  distance  from  the  centre  as  our  own.  we  decide  that  his  field  of  vision  is 
normal ;  but  if  a  falling  off  is  noticed  in  any  particular  direction,  we  infer  that  the  sen.si- 
bility  of  the  corresponding  portion  of  retina  is  impaired. 

it  must  be  remembered  that  each  part  of  the  visual  field  corresponds  to  a  part  of  the 
retina  opposite  to.  and  not  on  the  same  side  as,  the  object  seen  ;   e.  y.,  suppose  that  the 


2Q6  AFFECTIONS  OF  EYELIDS. 

movements  of  the  hand  arc  not  perceived  in  the  outer  half  of  the  fiehl,  the  inner  half  of 
the  retina  is  defective,  and  vice  versa. 

It  must  also  be  borne  in  mind  that  the  heifrht  of  the  bridge  of  the  nose  has  a  consid- 
erable influence  in  limiting  the  inner  half  of  the  visual  field.  Limitation  or  contraction 
of  the  visual  field  is  a  very  constant  accompaniment  of  retinal  changes  ;  it  is  also  one  of 
the  earliest  symptoms  of  glaucoma,  and  occurs  as  a  physiological  condition  with  advancing 
age. 

Stereoscopic  Test  for  the  Retina. — A  very  simple  and  eifectual  method  of 
testing  the  sensibility  of  the  retina  has  been  devised  by  Mr.  Joseph  Towne  of  Guy's 
Hospital :  it  consists  in  presenting  simultaneously  to  non-corresponding  halves  of  the  two 
retinaj  similar  objects. 

The  examination  is  carried  out  by  means  of  a  stereoscope  provided  with  two  slides  ; 
on  each  slide  are  two  white  semicircles  described  upon  a  red  ground,  those  on  the  one 
slide  being  so  contrived  that  when  looked  at  through  the  stereoscope  they  correspond  to 
the  nasal  halves  of  the  two  retinae,  whilst  those  on  the  other  slide  correspond  to  the  two 
malar  halves.  In  cases  of  want  of  sensibility  of  the  whole  or  any  part  of  the  retina,  from 
whatever  cause  arising,  a  part  or  the  whole  of  one  or  both  semicircles  corresponding  to 
the  affected  portion  of  retina  appears  misty  or  entirely  obscured.  The  degree  and 
extent  of  the  mistiness  or  obscurity  is  governed  by  the  degree  of  insensibility  and  extent 
of  the  impaired  portion  of  retina.  Mr.  Towne  has  made  the  stereoscopic  test  for  the 
retina  the  subject  of  some  very  interesting  papers  in  Gii^^s  Hospital  Reports,  series  iii., 
vols,  xi.,  xii.,  xiv.,  xv. 

DISEASES  AND  INJURIES  OF  THE  EYEBALL  AND  ITS 

APPENDAGES. 

Several  of  the  more  important  affections  of  the  organ  of  vision  will  be  briefly  alluded 
to  in  future  pages ;  the  present  section  is  devoted  to  a  short  description  of  those  diseases 
and  injuries  which  (with  a  few  exceptions  ;  e.(/.,  glaucoma)  do  not  call  for  operative  inter- 
ference. 

THE  EYELIDS. 

Congenital  Anomalies. — Absence  of  the  eyelids,  a  failure  of  closure  of  the  foetal 
fissure  leaving  a  cleft  in  one  or  both  lids  (coloboma),  ptosis,  complete  or  partial,  develop- 
ment of  a  third  lid,  pigment  spots,  moles,  nsevi,  and  warty  growths  have  all  been  occa- 
sionally met  with. 

Ulcers. — Simple  ulcers,  primary  venereal  sores  (chancres),  syphilitic  and  cancerous 
ulceration,  are  sometimes  met  with.  The  first  three  require  to  be  treated  on  general 
medical  pi'inciples ;  the  last  by  operation,  if  the  disease  has  not  proceeded  too  far. 

Phthiriasis. — The  pediculus  pubis  (crab  louse)  is  sometimes  found  amongst  the 
eyelashes  close  to  the  margin  of  the  lids.  The  edges  of  the  lids  appear  to  be  covered 
with  scabs  and  crusts  somewhat  resembling  tinea;  on  close  examination  the  insects  them- 
selves will  be  discovered  adhering  closely  to  the  margin  of  the  lids,  their  eggs  being 
attached  to  the  lashes  near  their  bases. 

Treatment. — The  daily  use  of  some  kind  of  mercurial  preparation,  none  being  better 
than  the  Ung.  Hydrarg.  Ammnniatum. 

Paralysis  of  the  orbicularis  muscle  occurs  in  some  cases  of  facial  paralysis : 
there  is  inability  to  close  the  eye,  the  lower  lid  falls  away  from  the  globe,  there  is  con- 
siderable collection  of  lachrymal  secretion  at  the  inner  canthus,  and  constant  watering  of 
the  eye  consequent  on  the  displacement  of  the  lower  tear  punctum. 

Treatment. — General  medical  treatment  should  be  adopted. 

Spasm  of  the  orbicularis  muscle  may  occur  from  long-continued  intolerance 
of  light  consequent  on  affections  of  the  cornea. 

Treatment  must  be  directed  against  the  corneal  affection.  (See  "  Diseases  of  the 
Cornea.") 

Spontaneous  t'witching,  more  especially  of  the  lower  lid,  popularly  known  as 
"live  blood,"  is  met  with  in  some  cases  of  hypermetropia  or  in  persons  whose  digestions 
are  out  of  order  ;  it  is  very  probably  a  symptom  of  undue  contraction  of  the  ciliary 
muscle. 

Treatment. — Correction  of  existing  hypermetropia,  instillation  of  atropine,  and 
attention   tf>  the  general   health. 

Inflammation  of  the  eyelids  niay  occur  during  or  after  acute  diseases  (measles, 


TITF  fnyjiwcTiVA.  267 

scarlatina,  etc.),  in  the  course  of  erysipelas,  as  the  result  of  injuries,  or  in  cr)iineetion  with 
severe  in  flam  mat  ion  of  uei^'hhoriiij,'  parts;  «.//.,  purulent  ophthahuia.  The  swelliiif;  and 
redness  are  usually  considerable  and  the  eye  cannot  he  opened  ;  the  inflaniiuation  gener- 
ally ends  in  resolution,  hut  may  (especially  it'  it  result  I'rom  measles,  scarlatina,  etc.)  j^o 
on  to  the  formation  uf  abscess,  or  even  to  sloujrhinjr  of  the  skin. 

'rKKAT.MK.NT. —  iiOcally.  fomentations  with  hot  water  nr  decoction  of  jxippy-heads  ;  if 
an  aliscess  form,  it  should  be  opi-ned — preferably  thmuLdi  the  conjunctiva. 

'file  patient  s  ucueral  health  shouhl  also  be  attended  to. 

Stye  (."hordeolum")  is  a  small  red  and  painful  swellin<^  situated  on  the  o\iter 
surface  of  the  lid  or  near  its  inar<.,'iii,  and  consists  in  a  circumscribed  inflammation  of  the 
lid  dependent  on  morbid  chanuc  in  the  .Meibomian  jrlands.  Styes  frenerally  occur  in 
weaklv,  delicate  persons  ;  several  may  appear  siujultaneously,  or  there  may  be  a  .succes- 
sion of  them  ;  they  <rive  rise  to  considerable  irritation  and  are  often  extremely  ftainful. 
Tlie  inflammation   usually  p^oes  on   to  suppuration. 

Tkk.vt.mknt. — Fomentations,  poultices,  the  administration  oi'  tonics,  and  good  living. 
When   pus  has  formed,  the  little  tumors  should  be  opened. 

Tinea  (ophthalmia  tarsi). — Patients  sufl"ering  from  tinea  present  themselves  with 
yellowish-brown  dry  crusts  hanging  to  the  eyelashes,  which  have  often  dropped  out  to  a 
considerable  e.vtent. 

In  old  cases  the  nuirgins  of  the  lids  are  much  thickened,  giving  rise  to  displacement 
of  the  lower  tear  punctum  and  consc((uent  watering  of  the  eye.  On  removing  the  crusts 
the  margin  of  lid  will  be  found  ulcerated,  fi.ssured,  and  easily  bleeding.  The  disease  con- 
sists in  inflammation  and  ulceration  about  the  roots  of  the  lashes;  it  runs  a  very  chronic 
course,  often  lasting  for  years  in  spite  of  remedies. 

Tre.\tmk.\t. — Slight  cases  can  generally  be  cured  by  the  use  of  a  lotion  containing 
four  to  si.\  grains  of  alum  to  the  ounce  of  a  water,  applied  three  or  four  times  a  day,  and 
of  mild  nitrate  of  mercury  ointment  (one  part  of  the  ordinary  nitrate  of  mercury  ointment 
to  eleven  of  lard')  smeared  along  the  margins  of  the  lids  night  and  morning. 

The  patient  should  be  directed  to  remove  all  the  crusts  before  applying  the  ointment. 

More  severe  ca.ses  should  be  treated  by  pulling  out  the  lashes  and  removing  the  scabs 
with  forceps,  and  then  applying  solid  nitrate  of  silver  to  the  raw  surface  left. 

In  cases  where  the  lower  tear  punctum  has  become  everted  the  punctum  and  canal- 
iculus must  be  slit  up.     (See  p.  2lMj.) 

Injuries. — Wounds  of  the  eyelids,  however  extensive  or  ragged,  should,  after  having 
been  thoroughly  cleansed,  be  brought  accurately  together;  they  will  usually  heal  readily 
enough.  Should  there  be  any  loss  of  substance,  an  endeavor  must  be  made  to  prevent 
distortion  of  the  lids  by  contraction  of  the  resulting  cicatrix. 

Ecchynaosis  of  the  lids  (black  eye)  freciuently  occurs  as  the  result  of  blows,  and 
may  be  caused  by  leech-bites  or  operations. 

Treatment. — Most  cases  may  be  left  alone  ;  but  if  it  is  desirable  to  get  quickly  rid 
of  the  eff"used  blood,  a  poultice  made  of  equal  parts  of  the  scraped  root  of  black  bryony 
and  bread  crumbs  should  be  applied.  The  poultice  should  be  kept  on  as  long  as  the  patient 
can  bear  it.     The  application  is  often  accompanied  by  a  good  deal  of  stinging  pain. 

Emphysema  of  the  lids  sometimes  occurs  from  rupture  of  the  mucous  membrane 
of  the  tiose,  air  being  forced  into  the  cellular  tissue  of  the  eyelids  on  sneezing  or  blowing 
the  nose.  Gentle  pressure  with  cotton-wool  and  a  bandage  and  avoidance  of  violent  expi- 
ratory movements,  sneezing,  etc..  is  the  only  treatment  required. 

The  Lachrymal  Apparatus. — The  principal  aflfections  of  the  tear  passages, 
etc.,  will  be  described  in  the  next  section. 

THE  CONJUNCTIVA. 

Ophthalmia. — Under  this  head  are  collected  all  the  diff"erent  forms  of  inflammation 
of  the  conjunctiva.  The  following  characters  are  common  to  all:  more  or  less  vascularity 
of  the  membrane,  uneasiness  and  stiffness  of  the  lids,  pain  of  a  smarting  character,  some 
kind  of  discharge,  and  gumming  together  of  the  lids  during  sleep. 

Inflammation  of  the  conjunctiva  has  to  be  distinguished  from  inflammation  of  the 
sclerotic  or  subconjunctival  fascia  or  the  injection  of  these  structures  which  is  present  in 
many  of  the  inflammations  of  deeper  parts  of  the  globe.  The  distinction  can  be  made  by 
paying  attention  to  the  following  points: 

'  The  ointments  employed  in  tlie  oplulialmic  department  at  Guy's  Hospital  are  now  almost 
invariably  prepared  witli  vaseline  instead  of  lard. 


268  THE  CONJUNCTIVA. 

Diagnosis. — 1.  The  inflamed  conjunctiva  is  bright  red,  the  ve'ssels  are  large  and  tor- 
tuous and  anastomose  freely,  forming  a  dense  network  ;  they  are  of  greater  calibre  about 
the  fornix  and  taper  off  toward  the  cornea. 

The  inflamed  sclerotic  or  episcleral  tissue  is  pinkish  or  bluish  in  color ;  the  vessels  are 
small  and  straight,  and  the  vascularity  is  usually  most  marked  in  a  ring  around  the  eye- 
ball just  external  to  the  corneal  margin. 

2.  The  vessels  of  the  conjunctiva  can  be  somewhat  displaced  and  made  to  glide  over 
the  surface  of  the  eyeball  by  gentle  pressure  ;  those  situated  in  deeper  parts  cannot  be 
made  to  alter  their  positions. 

3.  The  pain  in  inflammation  of  the  conjunctiva  is  of  a  smarting  character,  while  in 
inflammations  of  deeper  parts  it  is  dull  and  aching  and  often  very  severe. 

Treatment. — Inflammations  of  the  conjunctiva  are  best  treated  by  astringent  appli- 
cations. 

Any  of  the  following  formulaj  may  be  employed : 

Strong  Alum  Lotion. 

Alum,  gr.  X  ;  Water,  5J. 

Useful  in  cases  of  purulent  ophthalmia. 
Alum  Lotion. 

Alum,  grs.  iv  to  vj  ;  Water,  5J. 

Sulphate  of  Copper  Drops. 

Sulphate  of  copper,  gr.  ij  ;  Water,  5J. 

Sulphate  of  Zinc  Drops. 

Sulphate  of  zinc,  gr.  ij  ;  Water,  5j- 

Nitrate  of  Silver  Drops. 

Nitrate  of  silver,  gr.  j  ;  Water.  5J. 

Chloride  of  Zinc  Drops. 

Chloride  of  zinc,  gr.  ij  ;  Water,  Sj- 

Most  useful  in  cases  of  chronic  ophthalmia. 

Atropine  and  Astringent  Solution. 

Sulphate  of  atropia,  gr.  h  to  gr.  ij  ;  Sulphate  or  chloride  of  zinc,  gr.  ij  ;  Water,  5j- 
Useful  in  cases  where  iritis  or  corneitis  occurs  in  the  course  of  ophthalmia. 

Antiseptic  Lotion. 

Boracic  acid,  gr.  xv  ;  Water,  5J. 
U.seful  in  purulent  ophthalmia  and  sloughy  ulceration  of  the  cornea. 

Any  of  these  remedies  may  be  given  to  the  patient  to  use  himself;  they  should  be 
applied  from  three  to  six  times  a  day  or  oftener,  and  the  patient  should  be  directed  to 
wash  away  all  discharge  before  using  any  of  them,  and  to  take  care  that  the  lotion  goes 
well  between  the  lids. 

Some  kind  of  ointment  (spermaceti,  mild  nitrate  of  mercury,  etc.)  should  also  be 
ordered  to  be  smeared  on  the  margins  of  the  lids  at  night,  to  prevent  their  becoming 
gummed  together  during  sleep. 

The  condition  of  the  patient's  general  health  should  also  be  attended  to. 

Other  applications,  which  should  be  used  by  the  surgeon  himself,  are — 

The  mitigated  nitrate  of  silver  stick  (consisting  of  nitrate  of  potash  and  nitrate  of  sil- 
ver in  the  proportion  of  three  parts  of  the  former  to  one  of  the  latter. —  Green  stone — 
lapis  divinus  (consisting  of  equal  parts  of  alum,  nitrate  of  potash,  and  sulphate  of  copper, 
with  a  small  quantity  of  camphor) — and  solid  -nitrate  of  silver.  In  order  to  apply  any  of 
these  the  patient  should  be  seated  in  a  chair  and  the  surgeon,  standing  behind,  as  in  Fig. 
110,  should  evert  the  lids  and  lightly  rub  their  conjunctival  surface  with  either.  If  a 
preparation  of  nitrate  of  silver  be  employed,  the  conjunctiva  should  be  washed  with  salt 
and  water  immediately  after  the  application. 

Varieties  of  Ophthalmia. 

Catarrhal  ophthalmia  is  commonly  caused  by  draughts  of  cold  air,  is  highly 
contagious,  and  acute  in  its  course. 

The  conjunctiva,  both  ocular  and  palpebral,  is  highly  injected  and  sometimes  swollen; 
there  may  be  small  extravasations  of  blood  in  the  structure  of  the  former ;  there  is  a 
thick  yellow,  tenacious  discharge. 


VARIETIES  or  onrniALMiA.  269 

Oiii'  (»r  })utli  I'Vi's  iiiiiv  Ix"  allcctcd,  the  disease  usually  cfiniUKiiieiii^  in  (Uie,  and  sproa<l- 
iuj;  to  the  other  in  the  course  of  two  or  three  days. 

TuKAT.MKNT  in  the  early  sta<jes,  l)ef'ore  there  is  any  ;ininiiut  uT  discharfrc  Some 
sootliinj:;  ajiplicatioM  (as  deeoetion  ol"  |io)i|(y-heads)  sh(»uld  he  (Muployed  ;  later  on  an 
astrintrent  should  lie  used,  and  sonic  mild  nitrate-  of  nu-rcury  <"'  spermaceti  ointment 
sim-ared  on  the  ed<;es  of  the  lids  at  bedtime,  to  prevctnt  their  hecomiiijj;  gummed  to<rether 
during  sleep. 

Thf  /xifiiiif  (or,  in  the  ca.se  of  a  child,  its  parents)  should  he  warned  of  the  contajri'JU.s 
nature  of  tlu'  disease,  and  no  spoiijres,  towels,  etc.,  which  he  is  in  the  hahit  of  usinj.^ 
should  he  used  by  other  jteople.  Amoni;  the;  |»o<irer  classes  it  is  very  common  to  .see  a 
wliole  family  sufVerinu'  from  catarrhal  ophthalmia. 

Chronic  ophthalmia  is  usually  a  sequel  of  some  more  acute  form  ;  the  palpebral 
conjunctiva  is  redilened,  the  ocular  conjunctiva  presenting  patches  of  sli^rhtly  increased 
vascularity,  but  no  general  redness,  as  in  cases  of  catarrhal  ophthalmia  ;  the  lids  are  often 
somewhat  thickened  ami  the  caruncle  and  semilunar  fold  swollen.  There  is  slight 
mucous  discharge,  which  forms  dry  crusts  on  the  margins  of  the  lids,  and  at  the  inner 
canthus  overflow  of  tears  may  occur  from  obstruction  or  displacement  of  the  tear 
puncta. 

Thk.vtmknt,  the  same  as  that  of  catarrhal  ophthalmia.  The  disease  may  c(mtinue 
for  almost  rtny  time  ;  and  when  one  remedy  aj)})ears  to  have  lost  its  effect,  another  should 
be  trie(l. 

Phlyctenular  ophthalmia,  usually  met  with  in  children  and  young  adults, 
especially  females,  is  characterized  by  the  existence  of  small  whitish  elevations  on  the 
conjunctiva,  most  commonly  near  the  margin  of  the  cornea;  each  little  elevation  has  a 
wi.sp  of  blood  vessels  leading  to  it  if  near  the  corneal  margin,  and  is  surrounded  by  a  zone 
of  vascularity  if  situated  in  any  other  part  of  the  conjunctiva.  There  is  some  watering 
of  the  eye  and  slight  mucous  discharge. 

Patients  are  freijuently  met  with  who  suff'er  from  repeated  attacks  of  phlyctenular 
ophthalmia. 

Trkat.mknt. — In  treating  phlyctenular  ophthalmia  our  object  is  to  set  up  a  certain 
amount  of  irritation  of  the  conjunctiva,  by  which  the  phlyctenulfe  will  be  de.stroyed. 
This  can  be  attained  by  dusting  calomel  into  the  eye  daily,  or  by  ordering  a  small  qiian- 
tity  of  an  ointment  containing  two  grains  of  yellow  oxide  of  mercury  to  3j  of  lard  or 
vaseline,  to  be  applied  to  the  inner  surface  of  the  lower  lid  at  bedtime.  Either  of  these 
remedies  will  soon  cause  the  phlyctenulst;  to  disa])))ear.  The  disease,  as  aff'ecting  the  con- 
junctiva covering  the  cornea,  will  be  spoken  of  under  diseases  of  that  structure.  Tonics 
should  be  given  if  required. 

Granular  Ophthalmia. — This  disease  occurs  at  all  ages  and  is  very  common 
amongst  the  lower  classes,  especially  the  Irish  ;  it  is  highly  contagious.  Granular  oph- 
thalmia is  often  very  prevalent  where  large  numbers  of  persons  are  crowded  together  in 
workhouses,  parish  seliools,  barracks,  etc.  It  would  appear  that  in  those  who  have  lived 
for  a  considerable  time  under  unfavorable  hygienic  conditions  a  peculiar  granular  state  of 
the  palpebral  conjunctiva  becomes  developed.  Persons  thus  aff"ected  are  said  to  be  predis- 
posed to  granular  ophthalmia.  The  predisposed  eyelid  is  characterized  by  the  existence 
of  small  pale  spherical  bodies  situated  in  the  structure  of  the  conjunctiva ;  the  little 
bodies  much  resemble  and  are  known  as  sago  grains ;  they  are  most  constantly  found 
upon  the  lower  lid,  near  the  outer  canthus. 

This  predisposed  or  granular  condition  of  the  eyelids  may  remain  stationary  for  an 
unlimited  time  without  giving  rise  to  inconvenience ;  but,  on  the  otlier  hand,  attacks  of 
inflammation  are  ever  liable  to  be  set  up,  giving  rise  to  the  development  of  granular  oph- 
thalmia as  we  see  it  in  practice. 

We  meet  with  three  principal  forms  of  granular  ophthalmia,  which  may  be  distin- 
guished from  each  other  by  the  nature  of  the  granulations  present: 

One,  characterized  by  the  predominance  of  the  sago  grains,  already  alluded  to. 
around  which  inflammation  has  been  set  up,  is  known  as  "follicular  granulation." 

Another  form,  characterized  by  the  predominance  of  hypertrophied  pa]iill;\?.  by  which 
the  sago  grains,  if  they  exist,  are  obscured,  is  known  as  '"  papillary  granulation." 

A  third  form,  characterized  by  a  mixture  of  follicular  granulations  and  hypertrophied 
papilla?,  is  known  as  "  mixed  granulation  ;"'  this  is  the  most  .severe  form  of  the  three. 

In  old  cases,  and  especially  those  that  have  been  treated  by  strong  caustics,  the  con- 
junctiva may  be  found  converted  into  a  mass  of  rough  harsh  cicatrices  and  its  secreting 
power  destroyed,  the  condition  known  as  '"  xerophthalmia"  being  developed. 


270  VARIETIES  OF  OPHTHALMIA. 

Granulations  in  active  granular  ophthalmia,  unlike  the  sago  grains  which  characterize 
the  predisposed  lid,  are  always  found  most  developed  on  the  conjunctiva  covering  the 
attached  border  of  the  tarsal  cartilage  of  the  upper  lid.  Their  appearance  is  more  or 
less  altered  by  treatment ;  they  are  accompanied  by.  thick  yellow  discharge,  and  there 
may  be  more  or  less  severe  intolerance  o^  light. 

Sequelse  of  Granular  Ophthalmia. — The  cornea  may  become  more  or  less 
opacjue  and  vascular,  especially  at  its  u|)per  part;  the  condition  is  known  as  "  pannus," 
and  is  caused  by  constant  irritation  of  the  cornea  by  the  rough  surface  of  the  lid. 

The  conjunctiva  may  be  destroyed  to  a  greater  or  less  degree,  extensive  cicatrices 
being  formed,  which  by  their  contraction  cause  shrinking  of  the  membrane  and  distor- 
tion of  the  lids,  giving  rise  to  entropion  and  narrowing  of  the  palpebral  aperture.  The 
hair  bulbs  may  become  displaced,  causing  the  eyelashes  to  be  misdirected — "  trichiasis." 
(See  p.  292.)  The  results  of  granular  ophthalmia  are  frequently  aggravated  by  unskil- 
ful treatment. 

Treatment. — In  treating  granular  ophthalmia  our  object  is  to  destroy  the  granula- 
tions with  as  little  damage  as  possible  to  the  conjunctiva  itself. 

The  use  of  atrong  caustics  must  he  carefidhj  avoided,  as  they  cause  too  much  destruc- 
tion of  tissue,  followed  by  the  formation  and  subsequent  contraction  of  cicatrices. 

Slight  cases  can  be  cured  in  a  short  time  by  the  application  of  mitigated  nitrate  of 
silver  stick  twice  a  week  or  oftener,  and  the  use  of  sulphate  of  copper  drops  from  three 
to  six  times  a  day. 

More  severe  cases  will  remain  under  treatment  for  months  or  years,  but  if  persevered 
with  will  improve  greatly,  and  may  ultimately  recover.  If  the  ophthalmia  be  of  recent 
date,  the  granulations  should  be  touched  twice  a  week  with  the  mitigated  nitrate  of  silver 
stick,  or  if  possible  every  day,  sulphate-of-copper  drops  being  used  from  three  to  .'^Ix  times 
daily. 

In  chronic  cases  the  green  stone  .should  be  used  instead  of  the  nitrate  of  silver  stick. 
The  application  of  calomel  powder  or  quinine  to  the  granulations  has  also  been  found 
useful  in  some  cases. 

When  the  cornea  is  completely  opaque  and  fleshy-looking,  inoculation  with  pus  from 
a  case  of  purulent  ophthalmia  may  be  tried,  but  only  in  extreme  cases ;  otherwi.se,  we 
may  do  more  harm  than  good  by  causing  sloughing  of  the  cornea.  Should  but  one  eye 
be  affected,  care  must  be  taken  to  prevent  the  other  becoming  inoculated. 

Iritis  not  unfrequently  supervenes  in  the  course  of  granular  ophthalmia  ;  when  it 
occurs,  a  solution  of  atropine  should  be  dropped  into  the  eye  from  three  to  six  times 
daily,  in   addition  to  other  remedies. 

Pannus  requires  no  special  treatment,  and  if  not  very  dense  disappears  as  the  granu- 
lations are  cured.  In  all  cases  some  simple  ointment  should  be  applied  to  the  edges  of 
the  lids  at  night,  to  prevent  their  becoming  gummed  together. 

Purulent  Ophthalmia. — Purulent  ophthalmia  may  be  met  with  as  ''ophthalmia 
neonatorum"  in  children  soon  after  birth,  or  in  older  persons.  In  the  former  case  it  may 
be  caused  by  contact  of  acrid  vaginal  secretions,  by  want  of  cleanliness  and  fresh  air,  or 
a  combination  of  the  two  ;  in  the  latter  by  contact  with  some  form  of  specific  pus  or  by 
constant  irritation  of  the  already  inflamed  conjunctiva.     It  is  highly  contagious. 

The  worst  form  of  the  disease,  whether  occurring  in  infants  or  older  persons,  is  that 
caused  by  inoculation  with  gonorrhoeal  matter — "  gonorrhoeal  ophthalmia." 

"  Ophthalmia  neonatorum"  makes  its  appearance  a  few  days  after  birth  ;  the  eyelids 
are  found  red  or  bluish-red  and  swollen  ;  the  eyes  can  only  be  opened  with  difficulty,  and 
on  attempting  to  separate  the  lids  thick  yellow  purulent  discharge  escapes  from  between 
their  edges  ;  both  eyes  are  almost  always  affected. 

Purulent  ophthalmia  in  older  persons  may  affect  one  or  both  eyes;  it  commences  with 
intolerance  of  light,  lachrymation,  and  injection  of  the  conjunctiva,  at  first  much  resem- 
bling an  ordinary  attack  of  catarrhal  ophthalmia,  but  in  about  twelve  to  twenty-four  hours 
its  real  nature  becomes  apparent  by  thick  yellow  discharge  from  between  the  swollen,  red, 
and  sometimes  everted  lids.  The  conjunctiva  is  bright  scarlet,  traversed  by  large  dis- 
tended blood  vessels,  and  much  swollen,  especially  the  ocular  portion  (chemosis),  which 
may  overlap  the  cornea  and  protrude  in  folds  between  the  lids ;  there  is  pain  and  intol- 
erance of  light,  and  there  may  be  much  depression,  especially  if  the  attack  have  lasted 
long.  The  patient  may  be  suffering  from  gonorrhoea.  The  great  danger  to  be  feared  in 
purulent  ophthalmia  is  implication  of  the  cornea,  which  may  be  partially  or  entirely 
destroyed  by  suppuration  or  sloughing. 

Treatment. — In  all  cases  the  patients  themselves  or  their  parents  should  be  warned 


VMIIETIES   OF   orilTIIM.MIA.  271 

of  tilt'  coiitiiuinus  nature  ot'tlif  (liscasc  ;  ami  il'ttiie  eye  only  be  affected,  the  greatest  care 
slioiild  lit'  takt'n  <  jtnitt'c-t  tlu'  ntlitT.  If  ])i>s.sil)Ie,  a  fjotKl  view  of  the  cornea  should  be 
olitaiiH'd.  as  its  contlition  niaterially  iiifliienccs  the  ])ro<.MH»sis  with  rejranl  to  si^'ht.  The 
exuniinatiiin   slioiilil  l»e  made  with  eare,  as  the  cornea  may  be  rnptiired  whilst  making  it. 

In  ophthalmia  nt'oiiatornm  the  only  treatment  retjuired  is  to  wash  out  the  eyes  every 
liour  t»r  half  hour  with  stronjr  alum  lotion  (see  j).  2(i8j  until  the  diseharj^e  is  lessened; 
the  lotion  need  oidy  be  useil  thus  lVe([uently  for  twelve  hours  <Mit  of  twenty-four  (from 
S  A.  M.  to  S  i>.  .M.i,  the  chilli  beintr  allowed  to  sleep  ut  nijrht  ;  as  the  discharge  gets  less 
the  lotion  mav  be  used  less  frei|uently.  Some  simple  ointment  slmuld  bt;  applied  to  the 
margin  of  the  lids  once  or  twice  a  day  to  keep  them  from  sticking  together. 

Slight  cases  of  jiurulent  ophthalmia  in  older  persons  may  be  treated  in  the  same 
manner,  but  the  more  severe  forms  (especially  the  gonorrhtcal)  reijuire  that  much  more 
energetic  measures  be  taken. 

The  treatment  should  lie  both  local  and  constitutional. 

Local  Trrafnif'iif. — When  the  jiatieiit  is  first  seen,  the  lids  should  be  everted  and  the 
whole  conjunctiva  brusheil  over  with  a  stick  of  solid  nitrate  of  silver  or  ))ainted  witli  a 
solution  of  forty  to  si.xty  grains  of  the  salt  to  .5J  f»^'  water;  tlic  application  should  be 
repeated  in  the  course  of  two  or  three  days  if  no  improvement  have  taken  place.  The 
patient  should  be  kept  lying  down  in  a  dark  room  and  a  bag  of  ice  or  lint  kept  wetted 
with  iced  water  a])plied  over  the  closed  lids  ;  the  ice  or  lint  should  be  removed  and  the 
eves  washed  out  every  liour  or  halfhuur  with  some  astringent  or  antiseptic  lotitjn.  the 
greatest  cleanliness  Vicing  observed. 

Should  there  be  much  pain  and  the  patient  be  strong,  blood  may  be  taken  from  the 
temples  by  leedies  or  the  application  of  the  artificial  leech  ;  but,  as  before  stated,  most 
])atients  suffering  from  severe  purulent  ophthalmia  are  mucli  depressed  and  will  not  bear 
depletion. 

Omstifiifi'Hiti/  Tre'itmnit. — The  free  administration  of  tonics,  especially  iron  and 
quinine,  with  gootl  living  and  a  fair  amount  of  stimulants. 

If  perforation  of  the  cornea  threaten  or  have  taken  place,  the  eye  should  be  kept  firmly 
l)andaged.  so  as  to  prevent  as  much  as  possible  any  escape  of  the  contents  of  the  globe. 

Diphtheritic  Ophthalmia. — This  form  of  ophthalmia  is  but  rarely  met  with  \i\ 
London  [or  America]  :  it  affects  persons  of  all  ages.  At  first  sight  the  case  appears  to 
be  one  of  severe  purulent  ophthalmia  ;  its  chief  characteristic,  however,  is  a  solid  infil- 
tration of  the  substance  of  the  conjunctiva,  with  or  without  the  formation  of  diphtheritic 
membranes  on  its  surfjice.  The  affected  eye  is  frei(uently  lo.st  from  implication  of  the 
cornea.  The  disease  is  best  treated  by  sedative  applications,  as  fomentations  of  poppy- 
heads,  or  belladonna,  attention  being  paid  to  the  patient's  general  liealth. 

Injuries. — Wounds  of  the  conjunctiva  usually  heal  readily  enough,  requiring  only 
simjde  treatment. 

Biinis  are  usually  caused  by  contact  of  lime  or  hot  metals  ;  the  damage  done  may  be  only 
slight,  or  the  whole  conjunctiva  and  cornea  may  be  converted  into  a  dead  white  slough. 

Treatment. — The  conjunctiva  should  be  carefully  examined  and  all  foreign  bodies 
and  portions  of  sloughy  tissue  removed;  should  the  injury  have  been  caused  by  lime, 
the  surface  of  the  conjunctiva  must  be  carefully  cleansed  with  a  weak  solution  of  acetic 
acid  or  simple  warm  water.  Some  oil  should  be  placed  between  the  lids  and  the  eye 
bound  up  with  wet  lint  and  a  bandage.  If  any  symptoms  of  iritis  appear,  a  solution  of 
atrojiine  shotdd  be  dropped  into  the  eye  from  three  to  six  times  a  day.  Should  there  be 
much  discharge,  alum  lotion  may  be  used. 

When  the  sloughs  have  separated,  care  must  be  taken  to  prevent  adhesions  between 
the  raw  surfaces  left  by  passing  a  probe  between  the  lids  and  eyeball  once  or  twice  a  day 
and  directing  the  patient  to  draw  the  lid  away  from  the  globe  frequently. 

Fureign  bodies — small  pieces  of  coal,  iron,  etc. — are  sometimes  found  embedded  in 
the  conjunctiva,  and  must  be  removed. 

Ilemorrhiuje  into  the  substance  of  the  conjunctiva  or  beneath  it  may  occur  spon- 
taneously or  from  injury ;  no  treatment  is  necessary.  The  patient  may  be  assured  that 
no  harm  will  come  of  it.  and  that  the  blood  will  disappear  in  the  course  of  a  week  or 
longer. 

EXTERNAL  MUSCLES  OF  THE  EYEBALL. 

StraV)i>inns  will  lie  considered  in  the  next  section. 

Nystagmus  signifies  a  peculiar  involuntary  quivering  motion  of  both  eyes, 
dependent  on  rapid  contraction  of  antagonistic  pairs  of  muscles.     The  disease  is  usually 


272  THE  CORNEA. 

developed  in  infancy,  and  is  always  associated  with  considerable  impairment  of  vision, 
arising  from  congenital  cataract,  opacity  of  the  cornea  after  purulent  ophthalmia,  atrophy 
of  choroid,  etc.  Nystagmus  occurs  in  some  nervous  disorders,  as  locomotor  ataxy  ;  also 
in  persons  who  work  in  bad  light,  as  those  employed  in  mines,  when  it  is  described  as 
''  miners'    nystagmus." 

Treatment. — Nothing  can  be  done  to  remedy  nystagmus  in  the  two  first  classes  of 
cases,  but  miners'  nystagmus  may  be  entirely  cured  by  removing  the  patient  from  his 
work  and  the  administration  of  tonics. 

Paralysis  and  Paresis. — Paralysis  signifies  total  loss  of  power  of  the  affected 
muscle  ;  paresis,  only  partial  loss. 

The  symptoms  of  paralysis  and  paresis  are  double  vision  and  total  loss  or  impairment 
of  mobility  of  the  eye  in  some  particular  direction. 

The  causes  are  affections  of  the  brain  or  spinal  cord ;  disea.ses  within  the  orbit,  as 
tumors,  nodes,  or  inflammatory  exudations,  pressing  on  the  nerves  supplying  the  mus- 
cles ;  and  affections  of  the  nerves  themselves  or  of  the  muscles.  As  a  rule,  the  cause  of 
the  paralysis  or  paresis  can  only  be  conjectured,  but  very  many  cases  will  be  found  con- 
nected with  syphilis. 

Treatment. — A  careful  inquiry  should  be  made  into  the  patient's  previous  history, 
and  remedies  given  in  accordance  with  this,  those  of  an  anti-syphilitic  nature  being  gen- 
erally required.  If  the  affection  has  not  lasted  more  than  tliree  months,  a  favorable 
prognosis  may  be  given  ;  but  if,  on  the  contrary,  it  has  existed  six  months  or  more, 
recovery  is  very  improbable. 

Paralysis  of  all  the  external  muscles  of  the  eye.  "  ophthalmoplegia  externa  "  (Hutch- 
inson), is  occasionally  met  with.  The  eye  looks  nearly  straight  forward  and  is  almost 
immovable  ;  there  is  partial  ptosis. 

The  disease  is  probably  of  syphilitic  origin,  but  is  little  influenced  by  treatment  :  it  is 
often  associated  with  symptoms  of  serious  central  disease. 

Insufficiency  of  the  internal  recti  muscles  gives  rise  to  somewhat  obscure 

symptoms,  which  have  been  mistaken  for  manifestations  of  cerebral  disease. 

Patients  thus  affected  complain  that  they  cannot  do  near  work  for  any  length  of  time, 
as  objects  looked  at  become  indistinct  or  appear  double.  They  suffer  from  giddiness  and 
pain  in  the  brows  and  head  generally.  In.sufficiency  of  the  internal  recti  should  always 
be  suspected  if  in  a  case  of  hypermetropia  relief  cannot  be  given  by  the  use  of  glas.ses. 

Treatment. — Any  anomaly  of  refraction  should  be  accurately  neutralized  and  the 
weakened  muscles  assisted  by  the  use  of  prisms,  or  of  spherical  lenses  so  arranged  as  to 
have  a  prismatic  action. 

THE  CORNEA. 

Inflammation  (corneitis,  or  keratitis). — Five  different  forms  of  inflammation  of  the 
cornea  are  met  with:  (1)  Simple  corneitis;  (2)  interstitial  or  ])arenchymatous  corneitis; 
(3)  pustular  corneitis;  (4)  keratitis  punctata;  (5)  corneitis  with  sloughing  or  suppuration. 

Symptoms. — Corneitis  is  characterized  by  watering  of  the  ej'e,  impairment  of  vision, 
intolerance  of  light,  and  pain,  at  times  severe,  at  others  insignificant ;  on  examination 
more  or  less  of  the  cornea  will  be  found  cloudy  or  quite  opaque,  and  blood  vessels  may 
be  seen  in  its  substance  or  on  its  surface. 

Diagnosis. — It  is  of  importance  to  notice  the  course  and  position  of  the  blood  ves- 
sels in  any  case  where  the  cornea  has  become  vascular.  Should  the  vessels  lie  altogether 
in  the  cornea,  commencing  near  its  margin  and  passing  for  a  variable  distance  in  its 
substance,  the  case  is  probably  one  of  interstitial  keratitis ;  but  should  the  vessels  be 
continuous  with  those  of  the  conjunctiva,  pass  over  the  margin  of  the  cornea,  and  lie 
superficially  on  its  surface,  the  vascularity  is  probably  due  to  mechanical  irritation  from 
granular  lids  or  inverted  lashes,  and  the  condition  known  as  pannns  is  present. 

It  is  very  necessary  that  the  difference  between  these  two  forms  of  vascularity  should 
be  recognized,  as  their  treatment  varies  widely. 

In  the  former  case  the  treatment  of  keratitis,  to  be  presently  described,  should  be 
adopted;  in  the  latter,  treatment  must  be  directed  against  the  cause  of  the  vascularity 
(granular  lids.  etc.). 

Simple  corneitis  may  be  caused  by  injuries  or  the  lodgment  of  foreign  bodies  on 
the  surface  or  in  the  substance  of  the  cornea.  There  is  some  pain,  intolerance  of  light, 
and  lachrymation.  and  .some  part  of  the  cornea  is  found  occupied  b}'  a  halo  of  dulness. 

Interstitial  or  parenchymatous  keratitis  (corneo-iritis.  syphilitic  keratitis, 

keratitis,  diffuse  keratitis,  A'ascular  corneitis). — Interstitial   keratitis  occurs  as  a  rule  in 


consEiris.  273 

persons  will)  are  affootod  by  hereditary  sypliilis :  it  is  frequently,  but  by  no  means 
invariably,  associated  with  ehau^es  in  the  teeth,  peg^red  canines,  notched  incisors,  or 
dome  shape'of  first  molars  ;  flattened  nose,  fissures  aroiiml  tin-  angles  of"  the  nioutli.  or 
other  manifestations  of  (Congenital   syphilitic  disease. 

It  usually  first  makes  it.s  apjiearance  between  the  fifth  and  ei^diteenth  years,  but  ha.s 
been  seen  as  late  as  thirty  ;  it  always  afi'eets  both  eyes,  either  simultaneously  or  at  short 
intervals  ;  it  runs  a  very  chronic  course  and  is  most  intractable,  a  .severe  attack  often 
lasting  from   twelve  to  eighteen   months. 

Sv.Mi'ToM.-^. — Interstitial  keratitis  ])re.sents  all  the  symptoms  of  inflammation  of  the 
e(»rnea  in  a  marked  degree.  The  opacity  is  peculiar,  and  is  caused  by  iiitiltrati(»n  of  the 
substance  of  the  conu'a  with  opaipie  material. 

At  first  the  cornea  becomes  spotted  in  its  centre,  but  the  spots  .s(jon  run  together, 
forming  a  grayish  haze  ;  opacity  then  ccjmmences  at  the  up|ter  and  lower  corneal  mar- 
gins and  gradually  sprea<ls,  until  the  wliole  structure  resembles  somewhat  a  piece  of 
ground  glass,  apparently  blo(»d-staiiied  in  parts,  from  the  development  of  innumerable 
minute  blood  vessels.  There  is  always  a  well-marked  band  of  ciliary  injection.  Inter- 
stitial keratitis  is  not  unfrequently  complicated  by  iritis  ;  hence  the  name  "  corneo-iritis.' 

The  opacity,  having  reached  a  certain  point,  may  remain  .stationary  for  month.s.  but 
at  length  clearing  commences  and  the  cornea  regains  more  or  less  of  it.s  normal  trans- 
parency, recovery  always  taking  place  to  a  much  greater  extent  than  would  be  at  first 
e.\pecfe(l.      In  some  few  cases  a  choroido-iriti.s  is  set  up,  and  the  eye  eventually  shrinks. 

Pustular  COrneitis  (phlyctenular,  strumous,  vascular,  corneitis ;  strumous  <jph- 
thalmia,  fascicular  keratitis^. — Pustular  corneitis  is  met  with  in  children  and  young 
adults ;  it  often  follows  measles,  scarlatina,  or  other  acute  diseases  ;  it  is  fre<juently 
accompanied  by  eczematous  eruptions  on  the  eyelids,  about  the  nostrils  and  angles  of  the 
mouth,  and  on  the  head ;  the  patients  often  present  well-marked  strumous  diathesis  and 
are  generally  said  to  be  delicate. 

Sv.MPTOMS. — In  most  cases  there  is  profuse  lachrymation,  accompanied  by  great 
intolerance  of  light ;  the  lids  may  be  swollen,  covered  with  eczematous  eruption,  and 
tightly  screwed  up,  .so  as  to  cause  the  greatest  difficulty  in  examination. 

There  is  more  or  less  injection  of  the  ciliary  region  (ciliary  redness).  Upon  the  sur- 
face of  the  cornea  may  be  found  (1)  small  grayi.sh  elevations  (phlyetenulae) ;  (2) 
phlyctenulae  in  a  state  of  suppuration  (pustules);  (3)  small  ulcers  left  on  discharge  of 
the  contents  of  the  latter.  Any  of  the.se  are  usually  found  in  greatest  quantity  round 
the  margin  of  the  cornea,  but  its  whole  surface  may  be  found  dotted  over  with  phlyc- 
tenula;.  pustules,  or  ulcers,  or  examples  of  all  three  may  be  met  with  in  the  same  eye. 
There  is  more  or  less  haziness  and  vascularity  surrounding  the  affected  portions  of  cor- 
nea. In  some  cases  there  is  thick  mucous  or  muco-purulent  discharge  in  addition  to  the 
lachrymation. 

Cases  of  pustular  corneitis  accompanied  by  great  intolerance  of  light,  much  swelling 
of  the  eyelids,  profuse  lachrymation,  and  thick  muco-purulent  discharge,  occurring  in 
strumous  children,  are  sometimes  described  as  a  separate  di.sease  under  the  name  of 
"  .strumous  ophthalmia." 

Fascicular  keratitis  is  a  somewhat  rare  form  of  the  disease,  characterized  by  the 
existence  of  a  fasciculus  of  vessels  running  on  to  the  cornea  from  its  margin,  the 
fasciculus  terminating  in  a  .small  ulcer,  phlyctenula,  pustule,  or  small  inflamed  patch  of 
cornea. 

Pustular  corneitis  is  very  likely  to  recur. 

Keratitis  punctata  occurs,  as  a  rule,  in  young  adults,  rarely  in  children,  but 
may  be  met  with  at  all  ai:es  as  a  part  of  sympathetic  ophthalmia  ;  it  much  resembles  the 
early  stages  of  interstitial  keratitis  and  probably  arises  from  the  same  cause.  As  a  rule, 
one  eye  only  is  affected ;  there  are  the  usual  symptoms  of  corneitis,  but  the  intolerance 
of  light  is  not  very  .severe ;  the  cornea  is  dotted  over  with  small  gravish  opacities,  which 
are  collected  most  thickly  in  its  central  portion  and  on  careful  examination  will  be  found 
to  occupy  the  posterior  layers  of  the  structure.  The  disease  is  most  intractable  and  may 
be  accompanied  by  iritis. 

Corneitis  with  sloughing  or  suppuration  is  usually  the  result  of  .sharp 

blows,  a.s  flicks  from  twigs,  etc..  or  is  caused  by  the  irritation  of  foreign  bodies,  as  the 
husks  of  corn  ;  it  may  also  occur  after  operations  for  cataract. 

Symptoms. — Those  of  corneitis.  severe  pain  being,  as  a  rule,  one  of  the  most  marked ; 
some  part  of  the  cornea  will  be  found  occupied  by  a  collection  of  pus.  part  of  which  may 
have  escaped  into  the  anterior  chamber  and  collected  at  its  lower  part,  giving  rise  to  the 
IS 


274  ULCERS  OF  THE  CORSE  A. 

condition  known  as  "hypopyon,"  or  the  pus  may  have  gravitated  down  between  the 
layers  of  the  cornea  to  its  lower  margin,  forming  a  collection  much  resembling  hypopyon 
and  known  as  ••  onyx."  Suppurative  corneitis  is  met  with  in  cases  of  neuro-parnhjtic 
ophf/i((/ini(i,  a  peculiar  form  of  inflammation  associated  with  paralysis  of  the  ophthalmic 
division  of  the  fifth  nerve  and  consequent  anaesthesia  of  the  parts  supplied  by  it. 

Instead  of  a  collection  of  pus,  some  part  of  the  cornea  ma}'  be  found  occupied  by  a 
dead  white  slough  or  a  large  ulcerated  and  sloughing  surface. 

The  iris  may  also  be  inflamed  and  suppurating. 

Treatment. — The  treatment  of  corneitis  should  be  both  local  and  constitutional. 

Local  Treatment. — All  foreign  bodies  or  other  sources  of  irritation  should  be  removed  ; 
the  eyes  must  be  protected  from  light  by  a  large  shade,  protectors,  or,  better  still,  by  a 
bandage.  Sedative  applications  should  be  employed,  none  being  better  than  belladonna 
lotion  containing  from  six  to  ten  grains  of  extract  of  belladonna  to  one  ounce  of  water^ 
or,  if  preferred,  a  weak  solution  of  atropine,  gr.  A  to  a  pint  of  water,  may  be  used  instead  ; 
the  eyes  should  be  bathed  three  or  four  times  a  day  with  either  of  these  and  kept  bound 
up  with  lint  wetted  with  one  or  the  other. 

If  iritis  exist,  a  stronger  solution  of  atropine,  gr.  i  to  gr.  ij  or  iv  to  the  ounce  of 
water,  should  be  dropped  into  the  eyes  as  often  as  may  appear  necessary. 

In  corneitis  with  suppuration  warm  applications  will  be  found  most  beneficial ;  the 
eye  should  be  well  bathed  with  warm  belladonna  lotion  or  decoction  of  poppies  several 
times  a  day  and  bound  up  firmly  with  lint  soaked  in  one  or  the  other.  If  pain  be  a 
prominent  symptom,  it  may  be  greatly  relieved  by  taking  blood  from  the  temples. 
Should  a  large  area  of  the  cornea  become  infiltrated  with  pus.  a  free  incision  should  be 
made  by  transfixing  with  a  cataract  knife  and  cutting  out  obliquely  through  the  centre 
of  the  infiltrated  portion. 

In  cases  of  corneitis,  especially  of  the  pustular  form,  where  there  is  obstinate  intoler- 
ance of  light  and  the  disease  constantly  relapses  or  recurs  in  spite  of  other  treatment,  a 
seton  should  be  placed  in  the  skin  of  the  temple  on  one  or  both  sides.  (See  p.  291.)  In 
some  cases  the  spasmodic  contraction  of  the  orbicularis  may  be  kept  up  by  the  irritation 
of  small  fissures  at  the  outer  canthus ;  in  such,  a  free  division  of  the  junction  of  the  lids 
and  orbicularis  by  cutting  through  the  canthus  will  often  effect  a  speedy  cure. 

The  inhalation  of  chloroform  is  also  said  to  act  beneficially  in  some  cases. 

If  in  a  case  of  suppuration  or  sloughing  pei-foration  of  the  cornea  appear  imminent, 
iridectomy  should  be  performed.     (See  p.  304.) 

Constitutional  Treatment. — Simple  corneitis  requires  no  constitutional  treatment.  In 
the  interstitial  form  anti-syphilitic  remedies  should  be  employed.  To  older  patients  the 
bichloride  of  mercury  in  doses  of  one-sixteenth  to  one-twelfth  of  a  grain,  combined  with 
bark  or  other  tonic,  should  be  given  twice  or  three  times  a  day  ;  to  yoving  children,  hyd. 
cum  cret.  gr.  j  to  v  three  times  a  day. 

The  other  forms  of  corneitis.  especially  the  pustular,  are  best  treated  by  the  adminis- 
tration of  tonics,  as  steel  wine,  dialyzed  iron,  tincture  of  perchloride  of  iron,  quinine,  etc. ; 
and  in  strumous  children  cod-liver  oil  .should  also  be  prescribed,  with  good  living  and 
plenty  of  fresh   air. 

Ulcers  of  the  cornea  present  a  great  variety  of  forms.  They  may  be  trans- 
parent or  opiKjue  :  they  may  be  healing,  indolent,  vascular,  or  sloughing.  The  depth  to 
which  the  corneal  tissue  is  destroyed  varies  from  slight  abrasion  of  its  surface  to  destruc- 
tion of  its  whole  thickness,  causing  perforation.  The  area  of  the  cornea  which  is 
destroyed  also  varies  from  a  small  point  to  its  whole  surface. 

Ulcers  are  sometimes  described  as  marginal  or  central,  according  to  their  position. 
Ulceration  of  the  cornea  is  constantly  met  with  in  cases  of  debility,  from  whatever  cause 
arising.  It  is  very  common  in  patients  recovering  from  acute  diseases,  as  mea,sles.  scar- 
latina, and  more  especially  smallpox,  from  impaired  nutrition,  not  from  formation  of 
pustules  or  eruption  on  the  cornea.  Children  are  much  more  frequently  affected  than 
adults. 

The  SYMPTOMS  of  ulceration  are  very  similar  to  those  of  corneitis.  On  examination, 
any  kind  of  ulceration  may  be  found  (one  variety  has  been  mentioned  under  "  Pustular 
Corneitis").  There  rnay  be  one  or  more  small  transparent  vlcers.  which  can  only  be  seen 
in  certain  lights  and  are  very  likely  to  be  overlooked.  They  appear  like  small  abrasions 
of  the  epithelium  ;  sometimes  the  greater  part  of  the  surface  of  the  cornea  is  found  to  be 
aflFected  either  by  several  small  transparent  ulcers  or  one  large  one.  This  form  of  ulcera- 
tion is  most  commonly  met  with  in  adults  of  irritable,  nervous  temperament,  and  should 
always  be  carefully  looked  for  when  a  patient  of  this  description  presents  himself  suffer- 


ri.('i:i:s  or  riii:  <  ni:si:.\.  075 

iu^  from  st'Vrrc  iiitiilfiaiict'  ni"  liirlit.  watcrinj:  (it'tlif  eye  ami  smartiii;.'  pain  witlicuit  any 
wry  a|»|iareiit  caiisi-. 

(flKi</ii>  iilccin  ari'  visiltlf  t'iniu<:h  ;  they  may  l)e  ol"  any  size  or  riuinhfr.  At  tinii-s  tliey 
a|)|>i'ar  to  l»e  healing  ;  in  wliifli  ease,  the  ed^res  a|){iear  Mnooth  and  tht;  surface  of  the 
uh-er  roufrh  and  oiKKjue  or  chmdy.  At  others  they  are  indoh-nt,  and  a;.'ain  they  iiiav  he 
spreadinir.  when  their  ed;;es  are  found  to  he  elean  cut.  as  if  u  piece  iif  tlie  c«»rnea  had 
lifcn  piincheil  out  hy  some  sharj)  instrument  ;  the  surface  of  the  uh-er  appears  ^hissy  and 
is  often  deeply  excavated. 

S/i>ii>f/iiii</  ii/rir  is  nioic  or  h-ss  opa((iie.  spreads  rapidly,  hotli  in  area  and  depth,  and 
if  the  process  he  not  soon  arreste<l  the  cornea  will  he  pi'rforatcd  and  a  prolapse  of  the 
iris  of  trreater  or  less  extent  (accordinj^  to  the  size  of  the  perforation)  will  take  place. 
If  the  opeiiinLT  he  larj:e,  the  lens  or  some  of  the  vitreous  may  escape. 

In  the  irreater  mnnher  (d"  cases  oi"  perforation  of  the  cornea  the  iris  puslies  forward, 
tills  tin-  opiMiinir.  and  hecomes  adherent  to  its  marjrins,  formin<r  an  "anterior  synechia;"' 
hut  a  considerahle  prolapse  may  take  place,  forming  a  projection  or  hulge  from  the  sur- 
face of  the  cornea — "  staphyloma." 

Mun/fnit/  fir  cicsccnfic  //Av-r  (ulcus  cornias  .serpens)  is  a  somewhat  peculiar  form  of  cor- 
neal ulceration  ;  it  is  njet  with  in  persons  of  middle  age,  is  very  intractable  and  very  liahle 
to  recur  or  relapse.  This  form  of  ulceration  is  accompanied  hy  very  severe  pain,  great 
intolerance  of  light,  and  very  profuse  lachrymation.  On  examination,  a  crescentic  patch 
of  ulceration  is  found,  skirting,  generally,  the  ujtper  margin  of  the  cornea:  the  ulcer  is 
deep,  its  margin  clean  cut.  and  its  surface  glassv-looking. 

The  ulceration  spreads  rapidly  up  to  a  certain  point,  remains  stationary  fjr  a  time, 
and  then  commences  to  heal  slowly,  the  healing  process  being  frefjuently  interrupted  by 
relapses. 

The  ulcerative  process  may  involve  both  the  upper  and  lower  segments  of  the  cornea, 
but  never  pass  up  to  its  centre. 

Treatment. — The  treatment  of  ulcers  of  the  cornea  is  very  similar  to  that  of  cor- 
neitis.  In  many  cases,  however,  more  especially  those  of  marginal  ulcer,  the  instillation 
of  solutions  of  sulphate  of  eserine  (gr.  j  to  iv  to  3J  of  water)  three  times  a  day  or  oftener  will 
be  found  mo.st  beneficial.  In  all  severe  cases  the  eye  .should  be  kept  carefully  bandaged. 
Iridectomy  should  be  performed  in  anv  case  should  perforation  be  imminent.  (See 
p.  3(U.)    \ 

Opacities  of  the  cornea  are  the  result  of  inflammation,  ulceration,  or  injury. 

Thry  arc  met  with  of  all  densities  and  sizes  ;  thin  cloudy  opacities  are  known  as 
"  nebuhe."'  dense  white  ones  as  "leucomata."  A  dense  white  opacity  involving  the 
whole  cornea  is  called  a  '"total  leucoma ;"  an  opacity  of  the  same  description  occupying 
a  part  only,  a  ''partial  leucoma."  Should  a  corneal  opacity  have  been  caused  by  a'per- 
forating  iilcer  or  wound  of  the  cornea,  an  '•  anterior  synechia  "  will  probably  be  found 
associated  with  it. 

False  Pterigium. — Fleshy  opadtirx  are  sometimes  met  with  near  the  margin  of 
the  cornea  and  continuous  with  the  conjunctiva.  They  are  composed  of  granulation 
tissue,  and  are  frequently  the  result  of  burns. 

Treatment — Corneal  opacities  have  always  a  tendency  to  disappear,  especially  in 
children.  Their  removal  may  be  aided  by  the  use  of  slightly  irritating  applications 
which  set  up  a  certain  amount  of  increased  vascularity  and  thus  aid  ab.sorption.  The 
remedies  generally  employed  are  drops  of  sulphate  of  copper,  iodide  of  potassium,  or 
opium  :  turpentine,  pure,  or  mixed  in  various  proportions  with  olive  oil  ;  calomel  powder, 
or  the  yellow  oxide  of  mercury  ointment.  Any  of  these  may  be  used  for  some  considera- 
ble time.  Should  no  improvement  have  taken  place  at  the  end  of  two  or  three  months 
and  the  opacity  be  so  situated  as  to  interfere  with  vision,  an  artificial  pupil  must  be 
made:  and  if  the  opacity  be  disfiguring,  it  should  be  tinted.  (See  p.  3(t2. )  The  fleshy 
opacities  may  l>e  renioveil  by  operation.  ImU  are  very  liable  to  reappear  in  their  former  site. 

Injuries. — Abrasions  of  the  cornea  niay  be  cau.sed  by  scratches  from  thorns, 
ends  of  straw,  finger-nails,  etc.  They  give  rise  to  severe  pain,  much  intolerance  of  light, 
and  watering  of  the  eye. 

Tre.\tment. — The  eye  should  be  kept  carefully  bandaged  with  lint  soaked  in  bella- 
donna lotion  till  the  abrasion  has  healed. 

Penetrating  wounds  of  the  cornea  generally  involve  the  iris  or  lens:  in  the 
former  case  an  adhesion  of  the  iris  to  the  cornea  (anterior  synechia)  is  likely  to  be  formed, 
or  iritis  set  up  :  in  the  latter  the  lens  will  probably  become  opaijue.  a  traumatic  cataract 
being  developed. 


276  STAPHYLOMA    OF  SCLEROTIC. 

Very  extensive  wounds  of  the  cornea  may  allow  the  escape  of  the  lens  or  vitreous. 

Treatment. — The  eye  should  be  kept  carefully  bound  up  with  lint  soaked  in  bella- 
donna lotion  ;  and  in  cases  where  the  lens  has  been  wounded  or  iritis  set  up  a  solution  of 
atropine  one  grain  to  one  ounce  of  water  should  be  dropped  into  the  eye  from  four  to  six 
or  eight  times  daily. 

Should  the  lens  swell  and  cause  pain  and  increase  of  tension,  it  must  be  removed 
without  delay  or  iridectomy  must  be  performed. 

Iridectomy  may  have  to  be  performed  at  some  future  lime  for  optical  reasons  or  to 
obviate  the  irritation  caused  by  dragging  on  an  anterior  synechia.  Traumatic  cataract 
may  also  rc(|uire  to  be  treated. 

Burns  of  the  cornea  by  lime,  hot  metals,  etc.,  usually  occur  in  conjunction  with  like 
injuries  of  the  conjunctiva;  they  usually  leave  behind  them  opacities  of  greater  or  less 
extent  and  density,  according  to  the  severity  of  the  injury,  or  may  cause  sloughing  and 
destruction  of  the  whole  or  greater  part  of  the  cornea. 

Treatment,  the  same  as  that  of  burns  of  the  conjunctiva. 

THE   SCLEROTIC   AND  EPISCLERAL   TISSUE. 

Episcleritis. — Inflammation  of  the  sclerotic  or  episcleral  tissue,  or  more  commonly 
of  both  together,  is  a  somewhat  rare  disease  ;  it  is  characterized  by  the  presence  of  purple 
swollen  patches  covered  by  enlarged  conjunctival  vessels  and  situated  usually  about  the 
insertion  of  the  recti  muscles. 

The  purple  patches  often  disappear  from  one  portion  of  the  globe  and  appear  again  at 
another  ;  the  inflammation  is  chronic  in  its  course,  but  subsides  after  a  time,  leaving  some 
discoloration  of  the  afl'ected  part ;  it  is  very  liable  to  recur. 

It  occasionally  follows  operations  for  strabismus. 

Treatment. — Sedative  applications,  as  decoction  of  poppy-heads  or  belladonna  fomen- 
tation, should  be  used  three  or  four  times  a  day;  and  if  there  be  much  conjunctival  vas- 
cularity or  any  mucous  discharge,  some  astringent  lotion,  as  chloride-of-zinc  drops  (see 
Formulae,  p,  2G8),  should  also  be  employed. 

Any  constitutional  treatment  that  may  appear  called  for  should  be  adopted.  In  some 
cases  tonics  do  most  good ;  others,  again,  may  be  greatly  benefited  by  a  course  of  mer- 
cury or  iodide  of  potassium. 

This  disease  is  usually  described  as  "  episcleritis." 

Stapliyloma. — A  bulge  of  the  sclerotic  may  occur  from  softening  of  its  structure 
by  inflammatory  changes,  which  usually  commence  in  the  choroid. 

Staphyloma  may  be  met  with  in  the  ciliary  region  (ciliary  staphyloma),  about  the 
equator  (equatorial  staphyloma),  or  near  the  optic  nerve  (posterior  staphyloma).  Little 
can  be  done  in  the  way  of  treatment. 

Gummata  are  occasionally  seen  upon  the  sclerotic ;  they  occur  as  vascular,  well- 
defined  bosses,  either  singly  or  in  groups  of  two  or  three.  Their  diagnosis  is  not  easy  ; 
they  are  likely  to  be  confounded  with  sai'coma  or  patches  of  episcleritis.  From  the 
former  they  can  be  distinguished  by  their  course,  which  is,  though  slowly,  toward 
recovery;  from  the  latter,  by  being  more  aljruptly  defined  and  raised  above  the  surface 
of  the  globe. 

They  are  generally  associated  with  syphilitic  history,  and  often  with  other  manifesta- 
tions of  syphilis.     They  require  vigorous  anti-syphilitic  treatment. 

Injuries. — The  sclerotic  may  be  wounded  by  sharp  instruments  or  ruptured  by  blows  ; 
in  the  latter  case  the  lesion  usually  takes  place  in  the  ciliary  region,  near  the  upper  mar- 
gin of  the  cornea. 

The  sclerotic  (as  also  the  cornea)  may  be  pierced  by  a  .shot  or  chip  of  metal,  which 
may  be  lodged  within  the  globe  or  have  pa.ssed  clean  through  it. 

Treatment. — The  treatment  of  injuries  of  the  sclerotic  depends  much  upon  the 
extent  and  nature  of  the  damage  done. 

Small  incised  wounds  will  usually  heal  readily  enough  if  the  eye  be  kept  carefully 
bandaged.     Larger  wounds  may  require  to  be  closed  by  a  suture. 

Blows  often  cause  complete  disorganization  of  the  globe,  the  aqueous  and  vitreous 
chambers  being  filled  with  blood  and  hemorrhage  having  taken  place  between  the  sclero- 
tic and  choroid,  although  no  rupture  of  the  external  tunic  has  oceiirred. 

Such  cases  must  be  carefully  watched  and  the  eye  kept  bandaged  with  lint  soaked  in 
belladonna  lotion. 

In  cases  of  extensive  incised  wounds,  large  ruptures,  or  wounds  as.sociated  with  lodg- 


rill-:  ciiYsTM.i.isi:  less.  211 

iiii'iil  iif  ;i  tun-iLni  l)(i(ly  witliiii  llie  ;:lul)c',  rxlirpaliiui  of  tlie  ('yeliall  will  jtiulialily  hive  to 
lie  in'if'tiiim'tl.    (Si'c  i>.  iiliJ). 

THE  CRYSTALLINE   LENS. 

Congenital  Anomalies. — N'ariations  in  shape,  ubsence  of  the  wlnde  (aphakia) 
or  j.;irl  III'  I  hi-  liiis.  and  «li>|ihu(.iin'iit.s  are  met  with  as  coiifreiiital  defects. 

Presbyopia  (old  sij^ht). — I'resbyoitia  depends  on  senile  cliange  of  the  crystalline 
lens.  I»y  which  il  is  rendered  harder  than  in  youth  and  its  elasticity  is  iniitaired.  As  a 
conse(|uence,  its  curvature  can  only  be  altered  to  a  limited  extent  by  the  action  of  the 
ciliary  muscle,  and  the  power  or  raniie  of  uceonimodation  is  eorrcsj»ondin<rly  diminished. 

Persons  iri-nerally  bci:in  to  experience  the  ett'ects  of  presbyopia  about  the  ajrc  of  forty- 
five.  The  nearest  jtoint  of  distinct  vision,  which  year  by  year  has  been  receding'-  from 
the  eyes,  now  becomes  inconveniiMitly  far  off",  so  that  small  print  can  only  be  read  with 
difficulty  or  not  at  all  ;  distant  vision,  however,  still  remains  acute. 

It  has  been  arbitrarily  decided  that  a  person  shall  be  consideretl  presbyopic  as  .soon 
as  his  nearest  point  of  distinct  vision  comes  to  stand  at  'I'l  centimetres  or  fan  her  from  the 
eyes,  and  the  dej^ree  of  presbyopia  is  expressed  by  the  number  of  dioptrics  {D)  which  it  is 
necessary  to  give  the  eye  in  order  to  bring  its  near  point  up  to  tliis  di.stance,  or,  in  other 
words,  to  give  it  an  accommodative  power  equal  to  4.5  D,  which  is  tlie  power  of  the  lens 
which  the  crystalline  must  add  to  itself  in  order  to  see  di.stinctly  at  22  centimetres. 
Thus,  a  person  aged  forty-five  can  only  see  distinctly  at  28  centimetres — that  is,  he  can 
only  add  to  his  crystalline  a  lens  equal  to  3.5  D.  In  order  to  enable  him  to  see  distinctly 
at  22  centimetres,  we  mu,st  give  a  lens  which  makes  up  the  difference  between  3.5  D  and 
4.5  I) — /.  ^.,  1  D.  A  person  of  forty-five,  therefore.  re((uires  a  convex  lens  of  1  D  to 
remedy  his  presbyopia  ;  the  number  of  this  lens  also  expresses  the  degree  of  presbyopia. 

It  has  been  determined  by  observation  that  presbyopia  increases  by  one  dioptric  for 
every  period  of  five  years  from  forty  to  sixty,  sometimes  by  one  dioptric  and  sometimes 
by  a  half  only  for  each  similar  period  from  sixty  to  eighty. 

The  following  table  sliows  the  lens  required  at  each  period  of  five  years  by  the  erame- 
tropic  eye.  Sh(uild  hypermetropia  exist,  its  degree  must  be  ascertained  and  added  to  the 
number  given  in  the  table.     The  degree  of  myopia,  on  the  contrary,  must  be  subtracted : 


Age. 

Dioptrics. 

Age. 

Dioptrics. 

Age. 

Dioptrics. 

40     . 

.      .      .      (» 

oo     . 

.    .    ;■!          '< 

70     .     . 

,      .      .      5.5 

45     . 

.      .      .      1 

(ill     .     . 

.     .     4 

75     .     . 

,      .      .      0 

50"   . 

'1 

(Jo     .     . 

.     .     4.5 

80     .     . 

.     .     7 

Should  our  patient  require  to  see  at  some  particular  di.stance.  the  numbers  in  tne 
taVjle  need  not  be  adhered  to :  he  may  be  allowed  to  select  those  lenses  which  he  thinks 
suit  best.  As  a  matter  of  fact,  we  often  find  that  the  glasses  given  in  the  table  are  too 
strong,  especially  in  hypermetropic  persons  who  have  become  presbyopic  before  taking  to 
glasses.  Such  persons  have  long  been  accustomed  to  strain  their  accommodation  to  the 
utmost,  and  will  not  thank  us  for  giving  them  glasses  which  neutralize  the  whole  of  their 
hypermetropia  as  well  as  their  presbyopia.  AVe  shall  give  much  greater  .sati.sfaction  by 
orderitig  glasses  which  a  little  more  than  neutralize  the  hypermetropia,  and  so  give  a  lit- 
tle helj)  without  being  an  absolute  correction. 

Injuries. — Opacity  of  the  lens  (traumatic  cataract)  may  be  cau.sed  either  by  pene- 
trating wounds  of  the  cornea  or  simply  by  concus.sion. 

Uislocatifjii  of  the  Lens. — As  the  result  of  blows  upon  the  eyeball,  the  lens  may 
become  partially  or  entirely  displaced ;  it  may  still  retain  its  transparency,  but  often 
becomes  more  or  less  opaque. 

Displacement  of  the  lens  may  take  place  upward  or  downward,  laterally,  forward  into 
the  anterior  chamber,  backward  into  the  vitreous,  or  it  may  be  entirely  extruded  from  the 
globe  through  a  wound  in  the  sclerotic  and  lie  beneath  the  conjunctiva.  In  the  first  three 
positions  the  displacement  is  only  partial,  and  the  margin  of  the  lens  can  be  .seen  by 
obrujue  illumination  occupying  some  part  of  the  pupil. 

In  displacement  forward  the  pupil  will  be  found  dilated,  irregular  in  shape,  and  fixed  ; 
oblique  illumination  will  show  the  lens  lying  partially  or  entirely  in  the  anterior  chamber. 

In  displacement  backward  the  iris  will  be  tremulous,  the  pupil  sluggish,  and  the 
anterior  chamber  deepened.  Direct  ophthalmoscopic  examination  will  probably  detect  the 
lens  lying  in  the  ciliary  region  at  the  lower  part  of  the  eye. 


278  AFFECTIONS  OF  THE  IRIS  AND   CHOROID. 

In  displacement  beneath  the  conjunctiva  the  lens  is  found  forming  a  small  rounded 
tumor  somewhere  near  the  corneal  margin,  most  frequently  at  its  upper  part. 

Treatment.— If  the  lens  be  displaced  partially  or  into  the  anterior  chamber  and  still 
retain  its  transparency,  it  may  be  left  alone.  But  should  it  become  opaque  or  appear  to 
be  setting  up  irritation,  it  should  be  removed  by  extraction,  preferably  associated  .with 
iridectomy.  A  transparent  lens  may  remain  for  years  in  the  anterior  chamber  and,  with 
the  exception  of  impairment  of  vision,  give  rise  to  no  inconvenience.  If  its  capsule  has 
been  lacerated,  however,  it  will  become  opaque,  and  if  not  extracted  will  gradually  be 
removed  by  absorption. 

A  lens  displaced  into  the  vitreous  chamber  will  very  probably  act  as  a  foreign  body 
and  set  up  glaucomatous  changes,  in  which  case  it  should  be  removed  at  all  risks  ;  but  if 
it  produces  no  irritation,  it  is  best  left  alone. 

A  lens  displaced  beneath  the  conjunctiva  may  also  be  left  to  itself. 

Cataract  will  be  considered  in  the  section  on  operations. 

THE  IRIS  AND  CHOROID. 

Congenital  Anomalies. — Coloboma  signifies  a  cleft  condition  of  the  iris  or 
choroid  dependent  on  failure  of  closure  of  the  foetal  fissure.  In  the  iris  it  occurs  as  a 
deficiency  of  the  lower  segment,  appearing  as  if  iridectomy  had  been  performed  down- 
ward. In  the  choroid  it  is  seen  (on  examination  with  the  ophthalmoscope)  as  a  brilliant 
white  figure,  commencing  at  the  optic  disc  and  continuing  downward  and  forward  for  a 
variable  distance  toward  the  ciliary  processes,  through  which,  in  extreme  cases,  the  cleft 
may  extend,  and  be  even  continuous  with  a  similar  deficiency  of  the  iris. 

In  the  Albino  the  pigment  of  the  iris  and  choroid  is  absent  to  a  greater  or  less 
extent,  and  with  the  ophthalmoscope  the  fundus  of  the  eye  appears  of  a  yellowish-white 
color. 

Iridereniia,  or  congenital  absence  of  the  iris,  is  occasionally  observed. 
Persistency  of  the  Pupillary  Membrane. — »^mall  portions  of  the  membrane 

which  at  a  period  of  foetal  life  covered  the  pupil  occasionally  remain,  and  may  be  seen  as 
one  or  more  fine  threads,  somewhat  resembling  cobwebs,  passing  across  the  pupillary  area 
and  attached  at  either  end  to  the  anterior  surface  of  the  iris,  near  the  margin  of  the  pupil. 

Anomalies  of  Color. — The  iris  of  one  eye  may  be  brown,  that  of  its  fellow  being 
blue,  or  difterenee  in  color  may  occur  in  different  parts  of  the  same  iris. 

Tremulous  iris  (iridodonesis)  signifies  a  tremulous  condition  of  the  iris,  which 
shakes  about  as  the  eye  is  moved.  This  condition  is  met  with  when  the  iris  has  lost  the 
support  of  the  crystalline  lens,  when  the  vitreous  humor  is  abnormally  fluid  or  the  iris 
totally  paralyzed. 

The  term  jmral/ysis  should,  strictly  speaking,  be  applied  only  to  cases  where  the  iris  is 
tremulous,  all  its  proper  movements  being  destroyed  and  the  pupil  of  moderate  size ;  but 
it  is  often  used  in  the. condition  of  dilatation  of  the  pupil  met  with  in  some  eases  of  paral- 
ysis of  the  third  nerve,  in  which,  however,  only  the  circular  fibres  are  affected. 

Mydriasis  signifies  abnormal  dilatation  of  the  pupil  ;  Myosis,  abnormal  con- 
traction. 

Cases  are  occasionally  met  with  in  which  the  ciliary  muscle,  circular  and  radial  fibres 
of  the  iris  are  all  paralyzed,  the  pupil  is  of  medium  size  and  does  not  act.  The  disease 
has  been  called  "  ophthalmoplegia  interna  "  by  Mr.  Hutchinson. 

Tumors  seldom  originate  in  the  iris  itself,  but  its  structure  often  becomes  implicated 
by  growths  commencing  in  deeper  parts  of  the  globe  (see  "  Tumors  of  Eyeball ")  ; 
instances,  however,  of  malignant  growths,  dermoid  and  simple  cysts,  and  of  the  cysti- 
cercus  have  been  met  with  in  the  iris. 

Inflammation  of  the  Iris  (Iritis). 

Causes.  Locnl. — Irritation  from  foreign  bodies  in  the  conjunctival  sac  or  cornea; 
friction  of  the  cornea  by  granular  lids  or  inverted  lashes  ;  injuries  to  the  iris  itself  by 
operations  or  accidents,  with  or  without  the  lodgment  of  foreign  bodies  in  its  substance 
or  on  its  surface  ;  pressure  by  a  swollen  crystalline  lens  and  exposure  from  perforation 
of  the  cornea. 

Constltutioudl. — Debility  after  acute  disease,  overlactation,  etc.  ;  certain  specific  dis- 
eases, as  syphilis,  rheumatism,  and  gout. 

Symptoms. — The  following  symptoms  are  met  with  in  most  cases  of  iritis :   changes 


Ri'jsri/rs  or  inirrs.  279 

oi"  ciiliir.  cliimiiiit'ss  aii<l  li)>,>  (if  jMilisli  of  the  iris,  slu<^f^ishne88  or  complete  iiiiiiiol)ility 
uiul  (as  a  rule)  eoiitractioii  of  the  )Mi|iil.  iiijeetioii  of  tlic  ciliary  rej^ioii  (ciliary  reiliiess), 
wiiterinj::  of  the  eye,  and  iiiiitainiieiit  of  vision.  ()ilicr  symptoms  met  with  oceasionally 
ure  j)ain,  intolerance  of  lijrht.  irre<;ularity  in  outline  of  the  pupil,  intlammatorv  i)ro(Jucts 
— pus  or  lymph  nodules — visilile  to  the  nakt'il  eye. 

Three  varieties  of  iritis  are  commonly  nut  with:  I.  Simple  iritis;  2.  Kecnrn-nt 
or  rheumatic   iritis;    '.',.   Svphilitic  iritis. 

Simple  Iritis. — All  the  more  constant  .symptoni.s  of  iritis  are  present,  often  accom- 
panied l»y  more  or  less  severe  pain.  An  uncom])licated  attack  lasts  from  one  to  two  weeks 
or  longer,  and  usually  ends  in  resolution,  the  iris  (juite  recovering  its  normal  condition, 
but  a  few  adhesions  may  form  between  the  iris  and  lens  capsule  (posterior  synecbijc). 
In  this  as  well  as  in  the  other  forms  of  iritis,  however,  the  intiammation  may  run  on  to 
the  f<innati(iM  of  a  cnnsidcrahlc  i|uaiitity  of  new  material  or  into  suppuration. 

Recurrent  or  rheumatic  iritis  <)eeurs  in  persons  who  are  subject  to  attacks  of 
rheumatism  or  gout,  and  also  in  the  children  of  rheumatic  or  gouty  jtareiits.  An  attack 
of  this  form  of  intiammation  presents  all  the  more  constant  symjitoms  of  iritis,  and  has 
one  character  peculiar  to  itself — viz.,  its  tendency  to  recur,  some  patients  having  had  as 
many  as  twenty  or  more  separate  attacks  ;  in  some  cases  the  attacks  observe  a  remarkable 
periodicity,  recurring  regularly  at  the  same  time  of  year.  The  inflammatitjii  sometimes 
appears  in  one  eye.  sometimes  in  the  other,  or  perhaps  in  both — rarely,  however,  simultane- 
ously, but  at  short  intervals,  the  second  eye  becoming  aftected  long  before  the  first  has  begun 
to  recover.  Recurrent  iritis  is  frequently  accompanied  by  more  or  less  haziness  of  the 
cornea  and  aijueous  humor.  In  .some  cases  very  severe  pain  of  a  dull  aching  character  is 
esperienceil  in  the  eyeball,  forehead,  side  of  nose,  and  temple  ;  in  others,  the  attack  is  mo.st 
insidious,  the  patient's  attention  not  being  attracted  until  a  considerable  amount  of  new 
material  has  been  thrown  out.  extensive  adhesions  formed,  the  sight  of  one  eye  much 
impaired,  and  the  inflammatory  action  extended  to  the  other.  The  great  feature  of  this 
form  of  iritis  is  its  tendency  to  recur.  The  cause  of  the  recurrences  is  not  very  evident ; 
they  are  probably  due  primarily  to  '■  posterior  synechife,"  and  are  prevented  by  the  per- 
formance of  iridectomy. 

All  persons,  however,  who  have  "  posterior  synechitie  "  are  not  subject  to  recurrent 
iritis ;  so  that  in  all  probability  in  those  who  are  liable  to  repeated   attacks  there  is  a 
tendency  to  the  lighting  up  of  inflammation   upon  very  slight  provocation,  such  as 
dragging  of  posterior  synechij\?. 

Syphilitic  iritis  is,  perhaps,  the  most  common  of  all  the  forms. 

A  typical  case  presents  all  the  constant  symptoms  of  iritis  in  a  very  marked  degree, 
the  zone  of  ciliary  redness  being  extremely  well  defined.  There  may  be.  besides,  cer- 
tain peculiar  nodular  excrescences,  of  a  dirty  yellow  color  (known  as  Ij'mph  nodules), 
situated  on  the  surface  of  the  iris  or  at  its  pupillary  margin  and  at  times  extending  into 
the  pujiil,  which  may  be  completely  blocked  by  them.  These  excrescences  are  syphilitic 
gummata,  and  their  existence  renders  the  diagnosis  of  syphilitic  iritis  certain  ;  they  are. 
however,  only  occasionally  present,  and  in  the  greater  number  of  cases  met  with  the 
surgeon  will  have  to  take  into  consideration  the  ]>atient's  previous  history,  ascertain  the 
existence  of  other  signs  of  syi)hilis.  and  make  his  diagnosis  accordingly. 

Syithilitic  iritis  occurs  most  frequently  between  the  ages  of  fifteen  and  forty,  but  is 
occasionally  met  with  as  a  manifestation  of  congenital  syphilis  in  infants,  and  often  in 
cases  of  interstitial  keratitis. 

Results  of  Iritis. — In  many  cases,  especially  if  early  and  properly  treated,  per- 
fect recovery  takes  place ;  in  others,  permanent  signs  of  inflammation  are  left.  The 
morbid  changes  more  commonly  met  with  are — 

1.  The  iris  it.self  may  be  found  utropJiicd.  rhjitl,  or  rotten .  and  very  prone  to  bleed 
freely  on  the  slightest  wound.  These  conditions  become  mo.st  apparent  when  operating 
upon  its  structure.  On  attempting  to  perform  iridectomy  considerable  diflftculty  will  be 
experienced  in  removing  a  portion  of  the  iris,  which  may  be  so  tough  that  none  of  it 
can  be  torn  away  or  so  rotten  that  only  the  portion  included  between  the  branches  of  the 
forceps  is  removed,  or  hemorrhage  may  take  place  to  such  an  extent  as  to  prevent  the 
completion  of  the  operation. 

2.  Adhesions  to  neiijlthor!nij  parts  (••  st/nechifr  ")  may  have  formed,  those  most  com- 
monly met   with  being  between  the  iris  and  lens  capsule  ("  posterior  synechias  "). 

Posterior  synechia)  are  generally  situated  at  the  jnipillary  margin,  and  vary  in  extent  from 
a  few  adherent  tags  of  this  part  only  to  complete  adhesion  of  the  whole  posterior  surface  of 
the  iris  to  the  lens  cap.sule,  this  latter  condition  being  known  as  "total  posterior  synechia.'' 


280  RESULTS   OF  IRITIS. 

Adhesion  of  the  iris  to  the  cornea — ••  anterior  synechia  ''  (shouhl  this  occur  at  all  as 
the  result  of  iritis) — will  be  found  about  its  greater  circumference. 

3.  Closure  of  the  p\ipll  by  inflammatory  material ;  opacities  upon  the  hm-capsule  caused 
by  adhesion  of  the  •'  uvea  ""  detached  from  the  posterior  surface  of  the  iris. 

4.  Dense  inflammatory  deposits  in  or  beneath  the  capsule,  or  involving  the  superficial 
fibres  of  the  lens  itself  {capsular  cataract^,  may  also  be  met  with. 

Treatment. — In  treating  iritis  we  must  take  care,  Jirst,  to  remove  any  local  cause, 
such  as  a  foreign  body,  opaque  swollen  lens,  etc.,  and  to  cure  granular  lids  or  remove 
inverted  lashes ;  secondly/,  we  must  endeavor  to  dilate  the  pupil ;  thirdly,  to  relieve  pain  ; 
/b»/-?/i/y,  any  constitutional  treatment ,  that  may  appear  called  for  should  be  employed. 
(The  means  of  carrying  out  the  first  indication  are  detailed  elsewhere.) 

Local. — In  order  to  dilate  the  pupil  a  few  drops  of  a  strong  solution  (gr.  iv  to  5j)  of 
sulphate  of  atropine  should  be  placed  between  the  eyelids  by  the  surgeon  himself  at  each 
visit,  and  a  weaker  solution  (gr.  \  to  gr.  1  to  Sj )  should  be  used  by  the  patient  from  four 
to  eight  or  twelve  times  a  day.  If  the  case  is  treated  at  the  commencement,  more  or  less 
dilatation  of  the  pupil  will  usually  take  place;  but  should  the  iris  have  become  infiltrated 
with  inflammatory  matter  and  adhesions  formed,  little  or  no  efl^ect  will  be  produced.  The 
atropine  should,  however,  be  persevered  with. 

Some  patients  are  extremely  intolerant  of  atropine ;  in  such  it  produces  swelling  and 
inflammation  of  the  eyelids  and  face  of  an  erysipelatous  nature,  known  as  ''  atropism." 

If  atropism  occur,  a'substitute  must  be  found  for  the  atropine.  Daturine,  hyoscyamine, 
duboisine,  hematropin,  or  other  mydriatics,  may  be  tried,  or  the  atropine  may  be  used  in 
the  foi'm  of  an  ointment,  gr.  \  of  sulphate  of  atropine  to  5j  of  vaseline.  In  one  case  I 
found,  after  all  else  had  failed,  that  mixing  gr.  1  of  carbolic  acid  in  5j  of  atropine  solu- 
tion prevented  atropism. 

In  cases  of  iritis  with  suppuration  the  eye  should  be  fomented  frequently  with  hot 
belladonna  lotion  and  kept  bound  up   with  lint  soaked  in  the  lotion. 

In  cases  accompanied  by  much  pain  blood  should  be  taken  from  the  temples  by 
leeches  or  the  artificial  leech.  Atropine  may  give  rise  to  pain  by  causing  dragging  upon 
adhesions,  and  should  be  used  with  cavition  in  cases  where  its  application  is  attended  by 
much  suff"ering,  especially  if  it  have  no  efi'ect  upon  the  pupil.  The  eyes  should  be  pro- 
tected from  light  by  a  green  shade  or  protectors  until  the  inflammation  has  subsided. 

Constitutional. — Of  constitutional  remedies,  there  is  none  so  useful  in  the  treatment  of 
iritis  as  mercury.  The  drug  should  be  given,  in  some  form  or  other,  so  as  speedily  to 
aft'ect  the  system  in  all  cases  where  inflammatory  products  are  plentifully  produced, 
whether  the  inflammation  be  of  syphilitic  origin  or  not.  A  pill  containing  gr.  ij  of  pil. 
h3'drarg.  and  gr.  \  of  pulv.  opii  may  be  taken  three  times  a  day  and  is  a  very  conve- 
nient and  eff'ectnal  mode  of  administration.  Mercurial  inunction  or  vapor  baths  may 
be  employed  if  preferred. 

If  the  iritis  occur  in  debilitated  states  of  the  system  or  the  inflammation  go  on  to 
suppuration,  tonics,  as  iron  or  quinine,  should  be  prescribed,  and  a  plentiful  supply  of 
good  food  given.  Should  there  be  much  pain,  opium  must  be  given ;  and  it  is  well  to 
prescribe  the  drug  in  conjunction  with  extract  of  belladonna  or  hyoscyamus.  In  rheu- 
matic iritis  salicylate  of  soda  in  doses  of  gr.  xv  to  gr.  xxx  three  times  a  day  often  does 
much  good. 

The  reavlts  of  iritis,  should  they  seriously  interfere  with  vision,  require  the  perform- 
ance of  iridectomy  or  some  one  of  the  operations  for  artificial  pupil.  Iridectomy  should 
also  be  performed  in  cases  of  recurrent  iritis.  The  removal  of  a  portion  of  iris  in,  some 
manner — probably  by  preventing  dragging  on  adhe.sion.s — has  a  marvellous  efi'ect  in  pre- 
venting recurrences. 

Injuries. — The  iris  may  be  cut.  toi-n,  or  bruised,  prolapsed  through  or  adherent  to 
the  cornea  in  cases  of  penetrating  wounds  of  that  structure  (see  "  Wounds  of  the  Cor- 
nea"), or  it  may  be  separated  from  its  insertion  to  a  greater  or  less  extent  by  concussion 
without  external  wound.  Any  of  these  injuries  are  liable  to  set  up  iritis,  which  may  pos- 
sibly be  followed  by  suppuration. 

Treatment. — The  injured  eye  should  be  kept  carefully  bandaged  with  lint  soaked  in 
belladonna  lotion  ;  and  if  much  pain  is  complained  of  or  infiammator^'  symptoms  arise, 
blood  should  be  freel}'  taken  from  the  corresponding  temple,  either  b\-  leeches  or  the  arti- 
ficial leech. 

As  in  ii'itis  from  other  causes,  the  pupil  may  become  blocked  or  extensive  .synechite 
form,  requiring  operative  interference  at  some  later  period.     (See  "  Operations  on  Iris.") 


ciionoiniTis.  281 


Hyperemia  of  Choroid. 


TiHToasoil  vasciiliirit y  nt'  lln'  clKPrnid  is  not  iiiirrr(|iiciit  1  y  nift  with,  iiinrc  ('S|icciallv  in 
iuyi>|iir  |i('rsi)iis;  it  slimilil  Ik-  .«ii.'<|i('t'tf(l  if  a  ifcliiij:  of  t'lilncss  ami  t(ii>i(iii  of  the  eyes, 
aefdiiiiiaiiiftl  hy  wateriiit;'  an>l  iiitnU'raiiee  of  li^ht,  i.s  ciiiiiithiiiMMl  of. 

( )ii  exaiiiiiiatioii  with  the  uphthahiio.scupe  iiicrea.seil  retliie.ss  of*  tin-  choroid  (esjM'ciallv 
ot"  that  portion  nearest  tlie  outer  side  of  the  optie  dise)  and  some  enhir^eiueiit  of  the 
(dioroidal  vessels  ean  he  made  out;  these  ehaiiiics  will,  however,  very  prohahlv  he  over- 
looked hy  an  inexperienced  ohserver. 

Trk.vtmknt. — The  eyes  should  be  ke])t  carefully  at  rest,  protected  fium  li^dit,  cold 
diuu'hes  employed,  and  all  positions  (as  stoopini^  or  hangiuii-  the  head)  which  cause  con- 
gestion of  the  eyeballs  carefully  avoided;  blood  may  be  taken  from  the  temples;  and  if 
•rlasses  have  been  worn,  their  u.se  must  be  discontinued.  When  tlie  more  acute  symp- 
toms have  ])assed  otl",  any  anomaly  of  refraction  must  be  carefully  neutralized  by  suitable 
lenses. 

Inflammation  of  the  choroid,  "Choroiditis,"  occurs  uiidcr  much  the  .^ame 

conditions  as  iritis;  it  also  phiys  a  ])rominent  part  in  .sympathetic  o])htlialmia  and  is  not 
unfrt'(iuently  associated  with  inflammation  of  the  iri.s — '•  choroido-iritis.'  Two  forms  will 
be  commoidy  met  with,  simple  and  sy))hilitic. 

Sy.mI'TO.ms. — In  all  cases  of  choroiditis  more  or  less  lo.ss  of  transparency  will  be  found. 
Pain,  intolerance  of  light,  impairment  of  vision,  fulness  of  tlie  veins  emerging  from  the 
sclerotic  in  the  ciliary  region,  ciliary  redness,  dilatation  and  sluggishness  of  the  pupil,  and 
increased  tension  of  the  globe  are  symptoms  often  met  with  in  choroiditis,  but  are  by  no 
means  characteristic  of  it.  A  diagnosis  can  only  be  made  with  certainty  by  examination 
with  the  ophthalmoscope. 

The  changes  seen  in  the  choroid  with  the  ophthalmoscope  are.  grayish  or  yellowish 
patches  or  spots  of  exudation  surrounded  by  more  or  less  redness  (hyper;cmiaj,  and  at  a 
later  period  patches  of  atrophy.  The  exudation  may  occur  in  one  or  more  large  patches 
or  be  distributed  over  the  whole  or  greater  part  of  the  choroid  in  the  form  of  spots,  this 
latter  condition  being  known  as  '•  choroiditis  disseminata."'  We  know  that  the  morbid 
changes  noticed  are  in  the  choroid,  from  their  relation  to  the  retinal  vessels  which  pass  in 
front  of  and  are  not  oltscured  by  the  opacity. 

SyphiUtic  choroiditis  (in  typical  cases)  is  characterized  by  the  presence  in  the 
choroid  of  yellowish  lymph  nodules  similar  to  those  seen  in  syyjhilitic  iritis  ;  but,  as  in  the 
latter  disease,  typical  cases  are  only  occasionally  met  with,  and  we  n)ust  be  guided  by  the 
same  rules  in  forming  a  diagnosis.  Choroiditis  disseminata  is  syphilitic  ;  the  atrophic 
changes  left  by  it  are  seen  in  spots  of  white  and  dark  dotted  about  the  fundus,  often 
combined  with  an  irregular  band  of  dirty  white  extending  round  the  optic  disc.  These 
changes  are  frequently  seen  in  the  subjects  of  congenital  syphilis;  the  choroidal  disease 
is  in  many  instances  associated  with  floating  opacities  in  the  vitreous  and  may  be  looked 
upon  as  a  certain  indication  of  syphilis. 

Choroiditis  is  frequently  associated  with  inflammation  and  opacity  of  the  vitreous 
humor;  the  retina  covering  the  affected  portion  of  choroid  is  usually  involved  in  the 
inflammatory  change,  and  the  optic  disc  may  be  implicated  if  choroiditis  exist  in  its 
vicinity. 

Atrophy  of  the  choroid,  as  above  stated,  frequently  follows  inflammation.  The 
ophthalmoscope  shows  white  or  dirty  white  patches,  or  spots  corresponding  to  the  areas 
previously  occupied  by  inflammatory  exudation,  caused  by  destruction  of  the  choroid, 
allowing  the  white  sclerotic  to  show  more  or  less  plainly  through  it.  The  atrophic 
patches  are  frequently  surrounded  by  dark  bo-rders,  from  accumulation  of  pigment  which 
has  been  disjilaced  by  the  inflammatory  material. 

Inflammation  of  the  ciliary  portion  of  the  choroid  (ciliary  body)  is  known 
as  '•  cyclitis." 

Cyclitis  is  characterized  by  redness  and  swelling  of  some  part  or  the  whole  of  the 
ciliary  region,  with  considerable  eidargement  of  the  veins  of  the  retina,  choroid,  and  iris, 
and  pain  in  the  eyeball,  aggravated  by  pressure  in  the  ciliary  region.  Cyclitis  may  be 
caused  by  injury  or  may  depend  upon  syphilis,  inherited  or  ac(|uired.  Softening  and 
shrinking  of  the  globe  is  very  likely  to  follow,  from  impairment  of  nutrition,  dependent 
on  interference  with  the  circulation  of  blood.  Suppuration  may  also  take  place.  Wounds 
implicating  the  ciliary  region  of  the  sclerotic  should  always  be  looked  upon  as  much  more 
serious  than  those  of  other  portions  of  the  tunic,  as  cyclitis  is  frequently  set  up  by  such 
injuries.     Cyclitis  is  not  uncommonly  associated  with  iritis — •  irido-cyclitis." 


282  SYMPATHETIC  OPHTHALMIA. 

Treat.mext. — The  treatment  of  choroiditis  should  be  very  .similar  to  that  of  iritis. 
Iridectomy  does  good  in  some  chronic  cases  or  in  those  in  which  there  is  increase  of  ten- 
sion of  the  globe.      For  the  atrophic  changes  no  treatment  is  of  much  avail. 

Bone  upon  the  Choroid. — Deposits  of  bone  are  not  unfrequently  met  with  upon 
the  inner  surface  of  the  choroid  in  eyes  that  have  been  blind  and  shrunken  for  years. 

Tubercles  in  the  Choroid. — In  cases  of  general  tuberculosis  deposits  of  tubercle 
have  occasionally  been  met  with  in  the  choroid. 

Injuries. — The  choroid  may  be  injured  by  foreign  bodies  entering  the  eyeball  or 
ruptured  by   violence  without  perforation  of  the  tunics. 

In  the  former  case  (more  especially  if  a  foreign  body  be  lodged  in  the  structure  of  the 
choroid)  inflammation  is  very  liable  to  follow,  the  eyeball  being  eventually  lost  by  sup- 
puration or  shrinking.  A  rupture  of  the  choroid  from  external  violence  is  attended  with 
more  or  less  hemorrhage,  which  fills  the  rent  made  in  its  structure  with  blood  and  may 
cause  considerable  displacement  of  the  retina. 

Seen  with  the  ophthalmoscope  soon  after  the  receipt  of  the  injury,  a  ruptui'e  of  the 
choroid  appears  as  a  more  or  less  elongated  blood  clot  :  later  the  blood  becomes  absorbed 
and  a  white  linear  figure  is  left,  from  the  white  sclerotic  showing  through  the  rent  in  the 
choroid.     This  form  of  injury  is  not  often  followed  by  destructive  inflammation. 

Treatment. — Injuries  of  the  choroid  .should  be  treated  in  the  same  manner  as 
injuries  of  the  sclerotic,  cornea,  or  iris,  with  belladonna  lotion,  lint,  and  a  bandage. 

Sympathetic  Ophthalmia. 

'•  Sympathetic  ophthalmia  "  is  the  name  applied  to  a  peculiar  form  of  inflammation 
of  the  choroid,  ciliary  body,  and  iris  coming  on  in  one  eye  in  consequence  of  morbid 
changes  which  have  previously  existed  or  are  .still  in  operation  in  the  other. 

The  mo.st  common  cau.ses  of  sympathetic  ophthalmia  are  injuries  of  one  eye,  especially 
vxninda  implicating  the  ciliary  region,  or  associated  with  lodgment  of  a  foreign  body  in  the 
interior  of  the  globe. 

Shortly  after  the  receipt  of  an  injury  the  wounded  eye  may  become  affected  by  kera- 
titis punctata  and  choroido-iritis  of  a  marhedly  adhesive  character ;  pain  moi'e  or  less 
severe  will  be  complained  of.  sight  rapidly  lost,  extensive  synechias  form,  the  tension 
of  the  globe — at  first  .somewhat  above  par — diminish,  and  shrinking  of  the  eyeball 
follow. 

At  an_v  time  during  the  foregoing  changes  in  the  injured  eye  the  sound  one  may 
become  irritable  and  painful,  and  a  similar  inflammation  may  be  set  up  in  it,  leading 
rapidly  to  a  like  result. 

Treatment. — Where  sympathetic  ophthalmia  has  been  once  established,  in  all  proba- 
bility irreparable  damage  will  be  done  ;  the  great  point  to  bear  in  mind  is  to  prevent  its 
occurrence  by  timely  extirpation  of  the  damaged  glohe.  (See  "  Extirpation  of  the  Eye- 
ball.") Should  the  disease  have  become  fairly  establi.shed,  little  benefit  can  be  expected 
to  result  from  such  extirpation,  as  the  morbid  changes  will  probably  continue  in  the  sym- 
pathetically inflamed  globe  in  spite  of  the  removal  of  that  primarily  aflfected.  The  sym- 
pathetically aff"ected  eyeball  (or.  if  excision  have  not  been  performed,  both  eyes)  should 
be  kept  carefully  bandaged  with  lint  soaked  in  belladonna  lotion  ;  all  light  should  be 
carefully  excluded  by  using  a  black  bandage  and  keeping  the  patient  in  a  darkened  room. 
Pain  must  be  relieved  by  the  same  methods  as  in  cases  of  iritis.  Any  constitutional 
treatment  that  may  appear  necessary  .should  be  employed,  and  as  soon  as  the  acute 
inflammatory  symptoms  have  entirely  subsided  iridectomy  should  be  performed.  This 
operation  often  exerts  a  very  beneficial  influence  upon  the  nutrition  of  the  globe  (see 
"  Iridectomy  ").  and  should  be  repeated  a  second,  or  even  a  third,  time  should  the  new 
pupil  become  (as  is  very  likely  to  be  the  case)  occluded  by  inflammatory  exudations. 

Should  suppurative  inflammation  be  .set  up  in  one  eye,  sympathetic  changes  need  not 
be  feared  in  the  other  :  it  is  only  in  the  adhesive  form  of  choroido-iritis  that  sympathetic 
ophthalmia  is  likely  to  occur. 

Sympathetic   Irritation. 

It  not  unfrequently  happens  that  soon  after  the  receipt  of  an  injury  to  one  eye  its 
fellow  becomes  .slightly  painful,  intolerant  of  light,  and  irritable.  These  conditions  may 
remain  unchanged  week  after  week  and  eventually  sub.side.  They  make  up  what  is 
known  as  "  sympathetic  irritation." 


(^LAlroMA.  283 

Wlicii  sympatlit'tic  initaliim  Dcciirs,  we  iiiiisi  alwavs  watdi  tlic  iMJiircd  (>v<'  ••aref'ullv  ; 
and  if  sii^iis  of  clniroido-iiitis  or  ktTatitis  puiiclata  appt-ar  in  it,  it  should  be  ininicdiatidy 
excised.      If  no  such  symptoms  occur,  liowcvcr,  its  removal  is  not  necessary. 

THE  VITREOUS   HUMOR. 

Opacities  i"  the  vitreous  are  fretjuently  met  with  in  eases  of  niyoj»ia.  and  often  as 
the  rcsiihs  of  choroiditis. 

Inflammation  <»f  the  vitreous  occurs  occasionally  ;  it  is  generally  of  syphilitic  ori- 
gin or  causcil  liy  injuries,  especially  the  lodfjnient  of  foreijrn  bodies  within  the  globe. 
^'ision  becomes  misty,  and  on  examination  the  humor  is  found  to  l»c  more  or  less 
turbid. 

Tkkat.m  KNT. — Should  the  inflammation  be  of  syphilitic  origin,  anti-syphilitic  n-medies 
slnuild  be  emploved  ;  should  it  dejiend  tin  injury,  the  eye  must  be  kept  banrlaged  with 
lint  soaked  in  bclladoiiii;i  lotion  and  nirasures  taken  to  subdue  the  inflammation. 

Hemorrhage  into  the  Vitreous. — Occasionally  l)leeding  takes  place  into  the 
vitreous  humor  to  a  considerable  extent.  Impairment  of  vision  is  complained  of,  usually 
coming  on  suddeidy,  and  (jften  during  some  exertion.  Examination  with  the  ophthalmo- 
scope (direct  method)  shows  the  vitreous  chamber  to  be  occupied  by  a  turbid  irregular 
cloud  which  floats  about  as  the  eyeball  is  moved,  gradually  subsides  to  its  lower  part 
when  the  movements  are  discontinued,  and  is  stirred  up  again  on  the  movement.s  of  the 
globe  being  repeated.  The  blood  becomes  absorbed  to  a  greater  or  less  extent  in  the 
course  of  time,  but  very  commonly  some  permanent  opacity  is  left. 

GLAUCOMA. 

By  glaucoma  we  understand  '•  a  series  of  morl)id  changes  of  the  eyeball  ;  the  most 
prominent,  and  apparently  the  one  which  causes  all  the  others,  being  an  increa.se  of  ten- 
sion of  the  globe"'   (  Bader). 

The  cause  of  the  increase  of  tension  is  unknown,  but  is  supposed  to  result  from  undtie 
accumulation  of  the  intraocular  fluids,  dependent  on  hyper-secretion  or  deficient  removal. 
Glaucoma  is  said  to  be  simph'  when  the  increase  of  tension  progresses  slowly  and  continu- 
ously wMthout  inflammatory  outbreaks;  acute  or  chronic  when  attended  by  attacks  of 
inflammation. 

Simple  glaucoma  presents  no  very  marked  symptoms,  its  on.set  being  most  insidi- 
ous. It  is  characterized  by  gradual  decrease  of  acuteness  of  vision,  with  narrowing  of 
the  visual  field,  impairment  of  the  power  of  accommodation,  causing  rather  rapid  increase 
of  presbyopia,  sluggishness  in  the  movements  of  the  iris,  some  dilatation  of  the  pupil,  and 
some  apparent  haziness  of  the  lens.  Increase  of  tension  is  probably  one  of  the  earliest 
symptoms,  but  is  very  liable  to  be  overlooked  until  the  disease  is  far  advanced  and  con- 
siderable hardness  of  the  globe  has  taken  place.  With  the  ophthalmoscope  spontaneous 
pulsation  of  the  retinal  arteries  may  be  seen,  or  pulsation  may  l)e  produced  by  very  slight 
pressure  upon  the  globe.  The  ves.sels,  especially  the  veins,  are  thinner  on  the  surface 
of  the  optic  disc  than  in  the  surrounding  retina,  and  the  disc  itself  may  be  more  or  less 
cupped.  The  cup  of  glauconui  is  characterized  by  a  bluish  appearance  of  the  greater  por- 
tion of  the  disc ;  upon  this  blue  portion  the  vessels  appear  very  small  and  indistinct,  or 
they  may  be  quite  invisible ;  the  margin  of  the  disc  is  white,  and  the  large  tortuous  reti- 
nal vessels  are  seen  curling  up  over  its  edge  and  appearing  on  the  surface  of  the  retina 
at  a  point  not  continuous  with  their  course  upon  the  nerve  surftice.  Small  hemorrhages 
may  also  be  met  with  upon  the  retina. 

Absolute  Glaucoma. — Sooner  or  later,  in  any  form  of  glaucoma,  if  relief  be  not 
given,  the  condition  known  as  ahsohifi-  f/fduronid  is  established.  The  eyeball  becomes 
stony  hard,  the  pupil  widely  dilated  and  fixed,  the  cornea  hazy  and  anaesthetic,  the  iris 
and  acjueous  humor  discolored,  the  anterior  chaml»er  shallow,  and  the  lens  more  or  less 
opaque.  A  few  dilated  veins  are  seen  issuing  from  the  globe  in  the  ciliary  region  ;  the 
sclerotic  may  be  somewhat  bulged  in  places  and  bluish  in  color,  and  the  conjunctiva  is 
extremely  rotten,  tearing  on  any  attemjit  to  seize  it  with  forceps.  On  examination  with 
the  ophthalmoscope,  all  appears  dark  behind  the  pupil  or  a  dull-red  reflection  may  be 
returned  from  the  interior,  but  no  details  of  the  fundus  can  be  made  out.  All  perception 
of  light  is  lost. 

In  some  cases  of  acute  glaucoma,  and  almo.st  invariably  in  chronic  glaucoma,  the 
onset  of  the  disease  is  preceded  by  premonitory  symptoms. 


284  GLA  UCOMA. 

These  are,  as  in  simple  glaucoma,  rapidly-increasing  presbyopia  and  slight  increase 
of  tension  of  the  globe,  sluggishness  and  dilatation  of  the  pupil,  some  apparent  haziness 
of  the  lens,  and  narrowing  of  the  visual  field. 

Besides  these,  we  may  find  some  congestion  of  the  veins  emerging  from  the  sclerotic 
in  the  ciliary  region.  There  may  be  periodic  attacks  of  dimness  of  vision,  objects  appear- 
ing as  if  veiled  by  a  grayish  or  yellow  mist  (London  fog)  ;  in  the  later  stages  we  may 
have  a  halo  around  a  flame  or  the  appearance  of  a  rainbow,  and  at  times  attacks  of  pain 
in  and  about  the  eyeball. 

Acute  glaucoma  usually  commences  suddenly  with  well-marked  inflammatory 
symptoms.  The  ]»atient  will  state  that  he  was  seized  (frequently  during  the  night)  with 
sudden  severe  pain  in  the  eye ;  the  pain  will  be  described  as  affecting  not  only  the  eye- 
ball, but  the  whole  of  the  corresponding  side  of  the  head,  and  he  will  have  found  that 
the  sight  of  the  painful  eye  is  much  impaired  or  entirely  lost.  On  examination,  the  eye- 
lids will  be  found  slightly  reddened  and  swollen,  the  conjunctiva  somewhat  chemosed, 
and  its  vessels,  as  well  as  those  situated  more  deeply  in  the  subconjunctival  tissue, 
enlarged.  There  will  be  profuse  lachrymation,  and  often  much  intolerance  of  light; 
the  aqueous  humor  will  very  probably  be  somewhat  turbid.  The  pupil  will  be 
moderately  dilated,  somewhat  irregular  and  fixed,  and  the  tension  of  the  globe  greatly 
increased. 

On  examination  with  the  ophthalmoscope,  some  of  the  appearances  mentioned  under 
"  Simple  Glaucoma  "  may  be  found,  but  the  media  will  probably  be  so  hazy  as  to  ob.*cure 
the  parts  behind,  a  dull-red  reflection  being  all  that  can  be  made  out. 

The  acute  symptoms  may  pass  off  in  the  course  of  a  few  days  or  weeks,  leaving  the 
eye  more  or  less  permanently  damaged.  Similar  attacks  may  recur,  but  more  frequently 
the  disease  relapses  into  a  chronic  state. 

Chronic  glaucoma,  the  form  most  commonly  met  with,  is  characterized  by  the 
occurrence  of  slight  inflammatory  attacks  associated  with  temporary  increase  of  dimness 
of  vision  and  more  or  less  pain  in  and  around  the  eyeball.  On  examination,  the  field  of 
vision  will  be  found  to  be  limited,  the  tension  of  the  globe  increased ;  and  if  the  patient 
present  himself  during  an  inflammatory  attack,  the  conjunctiva  and  subconjunctival  tissue 
will  be  found  unduly  vascular,  the  pupil  somewhat  dilated,  and  the  movements  of  the 
iris  sluggish. 

The  loss  of  vision  in  cases  of  chronic  glaucoma  is  attended  by  symptoms  like  those 
of  the  premonitory  stage.  Patients  complain  that  their  sight  is  always  somewhat  misty, 
that  there  is  an  appearance  of  a  bright  halo  around  a  candle  or  other  flame,  that  they  .see 
colors  resembling  a  rainbow  and  often  of  great  beauty,  and  occasionally  flashes  of  light 
and  fiery  circles ;  the  last-mentioned  symptoms  are,  however,  common  to  all  forms  of 
retinal  irritation.  Vision  is  always  worst  during  the  inflammatory  attacks  and  recovers 
to  a  certain  extent  during  the  remission,  never,  however,  returning  to  the  same  condition 
as  before  the  attack. 

The  ophthalmoscope  shows  changes  similar  to  those  mentioned  under  '•  Simple 
Glaucoma." 

Glaucoma  Fulminans. — There  is  yet  another  form  of  glaucoma  requiring  men- 
tion— fortunately,  rarely  met  with.  Its  principal  characteristic  is  the  extreme  suddenness 
and  violence  of  its  onset ;  its  symptoms  resemble  those  of  acute  glaucoma  in  an  aggra- 
vated form.  This  variety  of  glaucoma  is  known  as  glavcoma  fidminans^  and  the  eye 
attacked  by  it  may  be  entirely  lost  in  the  course  of  a  few  hours.  The  attack  is  occasion- 
ally accompanied  by  severe  headache  and  vomiting. 

Glaucoma  is  essentially  a  disease  of  the  latter  half  of  life,  occurring  mo.st  frequently 
between  the  ages  of  forty  and  sixty,  but  occasionally  in  young  adults,  or  even  in  chil- 
dren. Glaucoma  almost  always  affects  both  eyes — not,  however,  simultaneously,  but  at 
more  or  less  considerable  intervals. 

Diagnosis. — In  order  to  diagno,se  glaucoma  we  must  be  well  acquainted  with  the 
method  of  ascertaining  the  tension  of  the  globe,  and  also  with  the  use  of  the  ophthal- 
moscope.     (See  "  I^xamination  of  Eyeball,"  etc.) 

We  must  also  remember  that  the  injurious  effects  of  pressure  are  evidenced  earliest 
in  the  peripheral  portions  of  the  retina,  and  should  therefore  very  carefully  examine  the 
condition  of  the  visual  Jiehl  in  all  suspected  cases.  (See  "  Examination  of  Field  of 
Vision.") 

Cases  are  frequently  met  with  in  which  great  contraction  of  the  visual  field  has  taken 
place,  although  central  vision  is  still  acute.  Another  symptom  which  should  lead  us  to 
suspect  glaucoma  is  the  rajnd  increase  of  presbyopia.     Patients  affected  by  the  simple  or 


Tin:   iniTlSA    AM)   (JJ'TJC  MlllVI-:.  2Ho 

pliroiiic  tonus  <if'tli»'  disrasi'  an-  fdu.staiitly  cliiin^jiiiLr  their  glasses,  as  tliL'y  find  that  tliose 
wliii'h  at  lirst  uj)])»'ar  to  suit  hi'coiiif  uscK'ss  in  the  foiirx-  of  a  few  months. 

A|i|ian'iit  ha/.iiicss  n\'  the  crystalliiif  U-ns  is  u  symiitoui  rfi|iiiriii<.'  special  attention  ; 
otiieiwise,  the  surui'on  may  tall  into  the  fatal  error  of  mistaking  clirotiic  <ir  simple  ^'lau- 
eoiiia  for  eatarart  ami  allow  the  disease  to  eonliiiiie  until  si^dit  is  irrevocahlv  lost.  In 
such  cases  opht halnioseopie  e.\amination  will  most  prcthahly  show  that  there  is  little  or 
no  nal  opacity  of  the  lens,  and  this,  aided  hy  a  careful  examination  of  the  tension  of  the 
^lolie  and  the  state  of  the  visual  litdd,  will  prevent  so  disastrous  a  mistake. 

Secondary  Glaucoma. — Uesid(!s  the  forejioinf;,  we  not  unfre(|ueiitly  meet  with 
wh.it  is  known  as  "  st'conilary  trhiucoma" — /.  '..  <rlaucoma  comiiifr  on  in  tin;  course  of 
sonic  other  disi'ase,  as  ecu'neitis.  ulceratifin  of  cornea,  iritis,  etc.  tilaiieoma  (jccurrinir  in 
younu:  per.sons  is  usually  seconilary.  (Ilauconia  following:  injury  is  spoken  of  as  "trau- 
matic <rlauc(uua.  ' 

TKK.\T.Mi;N"r. — (ilaueoma  can  he  remedied  l>;/  'ijitra/ioii  iilnui'.  Anil  it  is  our  iliity  to 
explain  to  the  patient  the  nature  of  his  case  ami  to  ur<re  ujxui  him  most  stron<.dy  the 
iinr-isi'i/  for  operativ*'  interference. 

Patients  sufVeriuir  from  <rlaueoma  often  evince  the  trreatest  uiiwillinj^uess  to  undt.-r^ro 
an  operation  :  this  unwilliimness  is  explained  hy  the  fact  that  durinj;  the  reinissionx  of  the 
disease  little  or  no  inconveiiienee  is  experiiuiced,  and,  moreover,  even  at  the  time  that  an 
attaek  of  inflammation  is  pre.sent  the  sutferer  will  he  encouraged  by  the  hope  that  the 
symptoms  will  pass  olf'  (as  they  in  all  probability  have  done  in  previous  attacks),  leaving 
the  eye  but  little  damaged.  Nevertheless,  we  must  always  bear  in  mind  that  an  opera- 
lion^  to  he  si(ccc!<!<f'tt/,  miisf  be  performed  e(xr/i/,  and  must  not  be  .satLsfied  until  we  have  con- 
vinced our  patient  of  this.  Most  patients  will  readily  submit  to  an  operation  when  one 
eye  has  been  lost  and  the  disease  has  commenced  in  the  other. 

Several  operations  have  been  practised  for  the  relief  of  glaucoma,  but  iridectomy  and 
sclerotomy  are  those  which  give  the  best  results.  Iridectomy  and  sclerotomy,  to  be 
etfectual,  should  be  performed  as  early  as  possible  ;  as  a  rule,  no  good  is  likely  to  result 
from  an  operation  in  cases  where  vision  has  been  reduced  t(j  bare  ])erception  of  light,  but 
in  acute  glaucoma  much  improvement  may  take  place  even  though  all  perception  of  light 
have  been  lost  f(jr  some  days. 

In  performing  iridectomy  for  glaucoma  we  must  take  care  to  remove  the  iris  well 
down  to  its  insertion  and  to  excise  a  good  broad  piece  (see  p.  306)  ;  merely  cutting  away 
a  portion  of  the  iris  near  the  margin  of  the  pupil  does  no  good.  The  operation  is  easy 
enough  of  performance  in  cases  of  acute  glaucoma,  but  in  those  of  old  standing,  where 
the  structures  are  rotten  or  the  pupils  so  widely  dilated  that  the  iris  has  become  a  thin 
rim  at  the  periphery  of  the  anterior  chamber,  it  is  anything  but  simple.  In  such  ca.ses 
sclerotomy  is  to  be  preferred  to  iridectomy. 

In  cases  of  glaucoma  where  for  any  reason  an  operation  does  not  seem  advisable  we 
must  do  our  best  to  give  relief  by  medical  treatment.  The  means  which  will  be  found 
most  useful  are  the  instillation  of  solutions  of  sul))hate  of  escrine  (gr.  ij  to  iv  to  water  .'^j), 
application  of  sedative  fomentations,  administration  of  opium,  and  the  local  abstraction 
of  blood  by  leeches  or  the  artificial  leech. 

Atropine  s/ioid(/  not  be  n^ed  in  glaucoma,  as  it  causes  increased  vascularity  of  the 
globe,  and  with  it  augmentation  of  tension.  Its  application  is  recommended  in  most 
works  on  ophthalmic  subjects,  but  it  do.es  more  harm  tlian  good.  Eserine,  however,  has 
a  contrary  eftect  and  is  often  of  great  benefit. 

THE  RETINA  AND   OPTIC  NERVE. 

Vision. — Space  will  not  allow  of  a  detailed  account  of  all  the  anomalies  of  vision 
which  may  be  met  with.  Before  the  introduction  of  the  ophthalmoscope  all  cases  of 
leant  o/  si'//if  occurring  without  cause  apparent  to  the  unaided  eye  were  collected  together 
into  two  classes  ])eariug  the  names  "  amblyopia"  and  "  amaurosis." 

Amblyopia  and  Amaurosis. — T<^  the  former  were  referred  all  cases  where  the 
vision  was  much  impaired,  but  not  entirely  lost  ;  to  the  latter,  ca.ses  in  which  not  even 
perception  of  light  remaineil.  But,  now  that  the  ophthalmoscope  has  come  so  generally 
into  use,  making  the  interior  of  the  globe  as  accessible  to  our  sight  as  the  exterior,  we 
have  come  to  refer  "  amblyopia"  and  ••  amaurosis'  to  their  proper  causes,  and  the  terms 
have  fallen  into  comparative  disuse.  For  instance,  if  in  a  ca.se  of  want  of  sight  we  find 
on  ophthalmoscopic  examination  that  there  is  haziness  of  the  vitreous,  inflammation  of 
the  retina,  etc.,  we  do  not  .say  (as  formerly)  that  the  patient  is  "  amblyopic."  but  that  he 


286  RETINITIS. 

is  suffering  from  opacity  of  the  vitreous,  retinitis,  etc.  Again,  in  cases  of  total  blindness, 
the  ophthalmoscope  will  in  all  probability  detect  atrophy  of  the  optic  nerve  or  other 
lesion,  and,  instead  of  saying  that  the  patient  is  '•  amaurotic,"  we  say  that  he  is  suffering 
from  atrophy  of  the  optic  nerve,  etc.  The  terms  "  amblyopia"  and  ''  amaurosis"  may,, 
however,  still  be  used  in  some  rare  cases  where  there  is  a  partial  or  complete  loss  of  sight 
associated  with  an  apparently  healthy  condition  of  all  the  ocular  structures. 

Hypersemia  of  the  retina  occurs  from  overstrain  of  the  eyes  in  doing  near  work 
(especially  in  hypermetropic  or  astigmatic  persons)  or  from  constantly  looking  at  bright 
light ;  the  disease  is  not  uncommon  amongst  engine-drivers  and  others  who  work  over  a 
blazing  fire. 

The  patient  complains  of  some  dimness  of  vision  and  a  feeling  of  fulness  and  discom- 
fort in  the  eyes.  On  examination  with  the  ophthalmoscope,  the  retinal  vessels,  both 
arteries  and  veins,  will  be  found  increased  in  size,  and  a  greater  number  of  each  will  be 
visible  than  in  the  healthy  retina. 

This  form  of  hyperaemia  may  be  described  as  "  active  ;"  another  form  of  hypertemia, 
affecting  only  the  retinal  veins,  which  become  enlarged,  tortuous,  and  sometimes  varicose, 
may  be  described  as  "  passive;"  this  condition  is  indicative  of  obstruction  to  the  return  of 
blood  from  the  eyeball.     (See  "  Ischaemia.") 

Hypercemia  of  the  retina,  especially  the  active  form,  is  not  easily  recognized,  as  the 
limits  between  health  and  disease  fade  almost  imperceptibly  into  each  other,  and  consid- 
erable experience  is  required  in  order  to  judge  with  certainty  where  one  ends  and  the 
other  begins. 

Treatment. — Active  hyperasmia  should  be  treated  by  rest,  carefully  shielding  the 
eyes  from  bright  light  by  means  of  neutral-tint  protectors  or  a  shade.  After  the  sub- 
sidence of  the  hyperemia  any  anomaly  of  refraction  should  be  carefully  neutralized. 

Passive  hypertemia  is  usually  an  indication  of  some  more  serious  disease,  and  requires 
no  special  treatment. 

Inflaniniation  of  the  Retina  (retinitis). — Retinitis  most  frequently  depends 
on  some  constitutional  condition,  as  albuminuria  or  syphilis ;  it  may  also  arise  from 
embolism  of  the  vessels  of  the  retina,  hemorrhage  into  its  substance,  or  from  cerebral 
disease ;  from  tumors  or  entozoa  within  the  globe,  exposure  to  sudden  flashes  of  bright 
light,  or  wounds  of  the  eyeball.     It  may  also  be  secondary  to  choroiditis,  iritis,  or  cyclitis. 

Retinitis  is  characterized  by  hyperaemia  of  the  retina  associated  with  more  or  less 
dense  and  extensive  opacity  of  its  structure,  and  frequently  with  extravasations  of  blood 
in  its  substance. 

Disturbance  of  vision  may  be  a  prominent  symptom,  or  the  patient  may  hardly  be 
aware  that  anything  is  amiss  with  his  eyes.  The  degree  of  impairment  of  vision  depends 
upon  the  situation  and  extent  of  the  inflamed  portion  of  the  retina  ;  for  instance,  a  small 
patch  of  inflammatory  exudation  in  the  region  of  the  yellow  spot  will  cause  much  loss  of 
sight,  whereas  a  considerable  amount  of  opacity  situated  peripherally  will  give  rise  to 
scarcely  any  symptoms. 

Pain,  photophobia,  colored  vision,  and  flashes  of  light  are  symptoms  occasionally  met 
with  in  inflammation  of  the  retina. 

Acute  retinitis  is  rarely  met  with,  and  if  it  should  occur  would  hardly  be  recognized, 
as  the  inflammatory  exudation  would  be  transparent,  and  therefore  invisible ;  conse- 
quently, the  only  appearance  revealed  by  the  ophthalmoscope  would  be  enlargement 
and  tortuosity  of  the  retinal  vessels. 

The  forms  of  retinitis  which  give  rise  to  striking  ophthalmoscopic  appearances  are 
essentially  of  a  chronic  nature  and  are  frequently  associated  with  inflammatory  changes 
in  the  choroid  and  optic  nerve. 

Retinitis  may  affect  one  or  both  eyes,  those  forms  which  are  of  constitutional  origin 
usually  affecting  both,  though  not  always  in  the  same  degree.  Several  varieties  of  reti^ 
nitis  are  described. 

Simple  Retinitis. — The  ophthalmoscope  shows  a  more  or  less  general  turbidity  of 
the  retina,  varying  from  a  scarcely  perceptible  cloudiness  (giving  the  idea  that  the  struc- 
ture is  colored  and  visible  instead  of  entirely  transparent)  to  a  uniform  grayish-white  or 
mottled  opacity,  which  appears  to  cover  the  choroid  like  a  veil. 

The  outline  of  the  optic  disc  is  indistinct.  The  retinal  veins  appear  enlarged,  dark- 
colored,  evidently  gorged  with  blood,  often  twisted  in  their  course,  and  they  may  be  in 
parts  hidden  by  the  inflammatory  exudation.  The  condition  of  the  arteries  is  nearly 
normal,  or  they  may  appear  too  thin. 

Small  hemorrhages  are  frequently  detected  in  the  course  of  the  distended  veins. 


RET  IS  IT  IS.  '2H7 

Hemorrhagic  Retinitis. — Tl"-  <'|'ti<-  nerve  will  he  IVmhkI  rcdilened,  soinewliat 
HWdlliii,  its  oiilliiif  (>l>lit(  r;it(il.  its  tr;ins|i;ir»MH'y  so  iiiiirli  aflccti-<l  tliiit  the  course  of  the 
retiliitl  vessels  ii|toii  its  siirfiiee  aiitl  in  its  sulistaiiee  caiiiiut  Ite  traced  ;  the  retinal  veins 
are  tur;;i(l  and  tfirtuous  in  their  course,  jiresenting  alternately  light  and  dark  portions, 
according  as  they  lie  deeply  in  the  eiigctrged  retina  or  more  superficially  near  its  inner  sur- 
tuee.     The  retinal  arterio.  as  in  the  simple  form  of  retinitis,  are  nearly  normal  or  too  thin. 

The  principal  characteristic  (»f  the  disease  is  the  occurrence  of  extensive  hemorrhage, 
most  marked  around  the  optic  disc,  and  fading  away  gradually  into  the  surrounding  parts. 
The  bhtod  extravasations  have  a  peculiar  striated  appearance,  and  radiate  spoke-like  from 
the  oj»tic  disc  as  a  centre.  In  snnie  cases  the  retina  iinmedi:itely  surrounding  the  disc  is 
uniformlv  soaked  with  hlood.  the  bright-red  c<dor  thus  produced  gradually  shading  off 
externally  into  the  sjioke-like  appearance  above  meiKioned. 

As  time  giies  on  the  extravasated  blood  undergoes  changes,  becoming  brown  in  color, 
and  fvciitiiallv  piirtiiillv  '>v  intirely  absorbccl. 

Retinitis  pigmentosa  i>  a  peculiar  lorm  of  degeneration  of  the  retina  met  with 
moat  fre<|uently  in  the  orts|tring  of  blood  relations;  the  sufferers  are  often  deaf  and 
dumb,  and  may  be  partially  idiotic. 

The  most  marked  symptoms  of  the  di.sea.se  are  nii/hf  hlinilneim  and  (jrinlnnl  inirroii-ing 
of  thf  ri»iiul  field  ttiffi'iiit<f/aiicoi)i(ifoii.tsi/m/j(oins.  The  ophthalmoscope  reveals  the  most 
striking  changes :  the  retina,  more  especially  about  its  peripheral  part.s.  is  dotted  more  or 
less  thickly  with  black-pigment  spots ;  these  spots  appear  somewhat  like  a  multitude  of 
small  black  spiders  with  many  legs  ;  they  have  also  been  likened  to  bone  corpuscles.  The 
spots  of  pignjent  appear  to  follow  the  course  of  the  blood  vessels  of  the  retina,  and,  as 
before  stated,  are  collected  most  thickly  in  its  peripheral  parts. 

The  blood  vessels  themselves  are  much  diminished  in  size  and  visible  number  and  the 
optic  disc  is  markedly  anivmic. 

Albuminuric  retinitis  is  a  peculiar  form  of  retinitis  met  with  in  Bright's  di.sea.se. 
The  cliaiigo  whirli  take  place  in  the  retina  are  inflammation  with  effusion  and  hemor- 
rhages, followed  by  fatty  and  fibrinous  degeneration  of  its  structure,  and  subsequent 
atrophy. 

The  ophthalmoscope  shows,  in  the  early  stages  of  the  disease,  retinal  hyperaemia 
(more  e.specially  venous)  with  increased  vascularity  and  redness  of  the  optic  disc.  Next 
the  retina  becomes  cloud}'  (more  especially  around  the  optic  disc,  the  outline  of  which 
becomes  obscured),  and  numerous  hemorrhages  in  the  form  of  streaks  and  spots  occur  in 
various  parts  of  its  structure. 

The  cloudiness  goes  on  increasing  and  obscures  the  smaller  vessels  ;  later,  in  different 
parts  of  the  fundus,  but  mostly  in  a  ring  situated  at  a  little  distance  from  the  margin  of 
the  disc,  appear  glistening  white  spots  and  patches  ;  later  the  disc  itself  becomes  gray  and 
opaf|ue. 

Whilst  the  above  changes  are  going  on  in  other  parts  of  the  retina  characteristic 
appearances  may  be  developed  in  the  region  of  the  yellow  spot.  A  number  of  small 
white  glistening  spots — which,  however,  do  not  coalesce  so  as  to  form  a  patch,  but  remain 
di.stinct — make  their  appearance.  These  glistening  spots  are  arranged  in  a  somewhat 
radiated  position  around  the  macula  as  a  centre  and  somewhat  resemble  a  constellation ;. 
the  appearance  is  quite  characteri.stic,  and.  once  seen,  is  not  likely  to  be  forgotten. 

As  the  opacity  of  the  retina  increases  the  vessels  become  more  and  more  obscured,  so 
that  when  the  disease  has  reached  its  height  only  a  few  large  venous  trunks  are  .still  visi- 
ble. Fresh  hemorrhages  may  occur  at  any  time  and  cover  over  and  obscure  the  opaque 
portions  of  retina.  After  a  time  a  retrograde  process  sets  in  :  the  hemorrhages  and 
peculiar  opacities  slowly  disappear,  the  retina  being  at  length  left  in  a  state  of  atrophy. 
Displacement  of  the  retina  may  occur. 

Albuminuric  retinitis  is  usually  associated  with  granular  kidney  ;  it  is  dependent  on 
the  blood-va.scular  disease  ''arterio-capillary-fibrosis.  Gull  and  Sutton)  of  which  the  kidney 
affection  is  only  a  part.  The  retinitis  often  appears  before  any  sign  of  the  kidne\'  mis- 
chief is  manifested,  and  it  is  the  ophthalmic  surgeon  who  first  discovers  the  nature  of  the 
case. 

Leucsemic  Retinitis. — A  peculiar  form  of  retinitis  somewhat  resembling  the 
albuminuric  has  been  described  as  occurring  in  connection  with  leucocythsemia. 

Leucajmic  retinitis  is  marked  by  pallor  of  the  optic  disc,  a  peculiar  rose-color  of  the 
retinal  vessels,  hemorrhages,  some  opacity  of  the  retina  around  the  optic  discs,  and  white 
glistening  spots  similar  to  those  met  with  in  albuminuric  retinitis,  which,  however,  are 
situated  in  the  peripheral  parts  of  the  retina. 


288  ATROPHY  OF  THE  RETINA. 

Embolism  of  the  Retina. — A  form  of  retinitis  associated  with  plugging  of  the 
central  artery  conies  on  suddenly  without  apparent  cause,  with  complete  loss  of  sight. 
Ophthalmoscopic  examination  shows  some  pallor  of  the  optic  disc  and  diminution  in  cali- 
bre of  the  vessels  emerging  from  it,  but  the  most  marked  change  is  seen  in  the  region  of 
the  yellow  spot. 

The  retina  around  the  spot  is  gray  and  oparjue,  and  numerous  blood  vessels  not  visi- 
ble under  ordinary  conditions  come  plairdy  into  view  ;  the  macula  itself  is  seen  as  a 
bright-red  spot  (which  might  be  taken  for  a  hemorrhage  by  a  careless  observer)  situated 
in  the  centre  of  the  opaque  portion  of  retina. 

The  bright-red  appearance  of  the  macula  arises  from  the  anatomical  arrangement  of 
the  parts  ;  the  retina  in  this  situation,  being  thin  and  firmly  bound  down  to  the  parts 
beneath,  does  not  become  infiltrated  with  inflammatory  exudation,  and  conseijuently  the 
normal  red  color  of  the  fundus  appears  in  striking  contrast  to  the  surrounding  opaque 
retina.      Hemorrhages  may  occur. 

Syphilitic  Retinitis. — A  form  of  inflammation  attectin'g  the  retina  immediately 
surrounding  the  optic  disc  has  been  looked  upon  by  some  as  of  syphilitic  origin,  but,  like 
syphilitic  iritis,  rarely  presents  any  very  characteristic  signs.  Should  retinitis  occur  with 
other  manifestations  of  syphilis,  congenital  or  acquired,  it  may  be  looked  upon  as 
syphilitic. 

Treatment. — Both  eyes  should  be  kept  thoroughly  at  rest  by  prohibiting  all  near 
work,  paralyzing  the  accommodation  by  atropine,  and  shielding  the  eyes  from  the  stimu- 
lus of  too  bright  light  by  neutral-tint  protectors.  Everything  that  is  likely  to  cause 
disturbance  of  the  ocular  circulation,  as  stooping  positions,  excitement,  stimulants,  too 
rapid  variations  of  temperature,  etc.,  should  be  carefully  avoided. 

In  simple  retinitis  blood  should  be  taken  from  the  temples  by  leeches,  or,  preferably, 
by  the  artificial  leech,  and  in  this  form,  as  well  as  in  retinitis  connected  with  syphilis,  mer- 
cury does  good ;  it  should  be  given  so  as  quickly  to  afiect  the  system  either  by  the 
mouth,  by  inunction,  or  in  the  form  of  vapor  baths.  In  cases  of  long  standing,  however, 
small  doses  of  the  bichloride  of  mercury,  taken  regularly  for  some  months,  may  be  bene- 
ficial. The  other  forms  of  retinitis  are  of  only  secondary  importance  to  the  disease  with 
which  they  are  associated,  and  against  which  treatment  must  be  directed.  (See  "  Causes 
of  Retinitis.")    No  treatment  is  of  much  avail  in  retinitis  pigmentosa. 

Atrophy  of  the  retina  may  be  the  sequel  of  inflammatory  changes.  Its  princi- 
pal characteristic  seen  with  the  ophthalmoscope  is  a  condition  of  bloodlessness,  in  some 
cases  associated  with  opacity  of  the  retina  and  frequently  with  atrophic  changes  in  the 
choroid.  Bloodlessness  shows  itself  in  a  diminution  of  the  visible  number,  and  also  of 
the  calibre, 'of  the  retinal  blood  vessels,  more  especially  of  the  arteries,  some  of  which 
may  appear  pervious  to  red  blood  corpuscles  in  part  of  their  course  only,  their  continua- 
tions being  marked  by  a  yellowish-white  cord.  Opacities,  if  they  occur,  are  of  a  grayish- 
white  color  and  situated  for  the  most  part  around  the  optic  disc. 

The  disc  itself  is  frequently  extremely  anaemic  or  atrophied.  (For  treatment  of  atro- 
phj'  of  the  retina,  see  "Atrophy  of  the  Optic  Disc") 

Hemorrhage  into  the  Retina. — Besides  the  form  of  hemorrhage  described  as 
.occuring  in  retinitis,  bleeding  may  take  place  into  the  structure  of  the  retina  from  rup- 
ture of  a  retinal  blood  vessel  without  previous  inflammatory  change.  The  hemorrhage  is 
usually  considerable,  and  will  be  seen  as  an  irregular  patch  of  blood  situated  somewhere 
in  the  course  of  the  ruptured  vessel,  and  often  surrounded  by  inflammatory  exudation. 

The  extravasated  blood  becomes  gradually  absorbed,  but  usually  leaves  behind  it 
some  indications  of  its  previous  existence. 

Treatment. — Rest  of  the  eyes,  protection  from  bright  light,  and  blisters  to  the 
temples. 

Displacement  of  the  retina  is  associated  with  effusion  of  serous  fluid  between 
it  and  the  choroid ;  it  may  be  caused  by  blows  on  the  eyeball  or  the  head  in  its  vicinity ; 
it  may  occur  without  apparent  cause  and  is  often  met  with  in  myopic  eyes.  Displace- 
ment of  the  retina  occurs  by  preference  at  its  lower  part,  but  may  vary  in  extent  from 
detachment  of  a  small  fold  to  total  separation  of  the  whole  retina  from  the  choroid,  the 
only  points  of  attachment  left  being  at  the  optic  disc  and  ciliary  processes. 

The  ophthalmoscope  shows  a  gray,  opaque,  movable  cloud,  over  the  surface  of  which 
the  retinal  blood  vessels  can  be  traced. 

Treatment. — Little  can  be  done  to  remedy  displacement  of  the  retina,  but  an 
attempt  should  be  made  to  procure  absorption  of  the  fluid  by  the  administration  of  such 
drugs  as  iodide  of  potassium  and  mercury,  and  by  the  application  of  blisters  to  the  tern- 


ATimriiY  or  orric  m:iivh.  289 

pli'.  ir  till'  (li>|il;iffiii('iil  iicciir  ill  (•innicrtioii  with  iiivipia,  tin-  aiioiiialv  of  rcfracliori 
shouKl  lit'  cMivfully  Ill-lit lalizi'd  l)y  siiitalilc  glasses  ;  aii<i  in  all  (lascs  rest  .should  he  ('(isurcil 
to  till'  i-yi's,  so  as  to  jiri'vciit,  as  iiiuch  us  iiossihle,  further  (letaehiiieiit. 

Inflammation  of  the  Optic  Disc  optic  neuritis,  neuro-retinitis). — The 

ojihl  lialiuoscii|)f  shows  a  icililisii-L^rav  tiirliidily  ol'  tln'  disc  and  the  suniiiindiii^'  /one  id' 
retina,  aeconipaiiied  hy  swelliiiLi  <d'  the  parts.  The  retinal  veins  are  eiijror^red,  but  their 
visihle  iiumher  is  not  increased  ;  the  arteries  are  thinner  tlian  usual,  and  all  tin;  vessels 
are  more  or  less  shnunled  and  concealed  IVoin  view  in  the  o[ta(|ue  jtortioii  of  retina  and  upon 
the  nerve  surface.      Numerous  small  hemorrha'.M's  may  occur  upon  the  disc  and  around  it. 

Ischsemia  of  the  Disc  (choked  diso. — Chokinf^  of  the  optic  disc  has  been 
(and  still  is  by  some)  looked  upon  as  distinct  from  optic  neuritis.  It  would,  however, 
appear  that  the  difference  is  one  of  degree  only.  The  ophthalmoscope  .shows  great  swell- 
ing and  an  intense  red  cobu'  of  the  disc,  its  outline  being  entirely  lo.st  ;  there  is,  however, 
but  slight  swelling  or  opacity  of  the  surrounding  retina;  small  hemorrhages  are  fre- 
quently seen  on  the  nerve  surface.  The  retinal  veins  arc  enormously  distemled,  their 
course  extremely  tortuous,  ami  they  may  be  varicose  ;  their  visible  number  i.s  also  con- 
siderably increased.  The  arteries  an;  thinner  than  natural  or  of  normal  calibre;  none  of 
the  vessels  are  shrouded  and  concealed  from  view  as  in  neuritis.  Ischa'mia  may  go  on  to 
neuritis. 

In  many  cases  of  neuritis  and  choked  disc  sight  is  unaffected  ;  in  others,  vision  is 
much  impaired  or  reduced  to  perception  of  light  oidy. 

Optic  neuritis  and  iscluvmia  may  be  looked  upon  as  indicative  of  irritation  of  the 
nerves  in  some  part  of  their  cour.se,  as  would  occur  in  meningitis,  or  of  obstruction  to  the 
venous  circulation  resulting  from  pressure  directly  on  the  main  trunks,  as  in  cerebral 
tumor,  or  from  any  form  of  disease  whatever  which  causes  overcrowding  of  the  content.s 
of  the  cranium.      Both  neuritis  and  isch;i2mia  are  usually  bilateral. 

Tkk.vt.mknt. — Optic  neuritis  and  isch;omia  of  the  disc  are  of  only  secondary  import- 
ance to  the  disease  which  gives  rise  to  them ;  they  are  of  much  greater  interest  to  the 
physician  than  to  the  oculist,  as  their  existence  enables  him  to  diagnose  cerebral  lesion 
with  great  certainty.  The  cerebral  lesion  is,  however,  often  syphilitic  ;  and  it  may  be 
laid  down  as  a  rule  seldom  to  he  departed  from  that  optic  neuritis  and  ischajmia  call  for 
the  adiniiiistratidii  oi'  iodide  of  potassium  or  mercury  in  full  doses. 

Atrophy  of  the  optic  nerve  may  be  the  result  of  preceding  neuritis,  when  it  is 
called  ••consecutive  atrophy,"  or  the  atrophy  may  have  commenced  as  such  and  slowly 
progressed  without  intiammatory  change — "  simple  atrophy." 

With  the  ophthalmoscope  the  optic  disc  will  be  seen  to  be  white  or  bluish-white  in 
color ;  frequently  its  nuirgin  appears  irregular  and  it  may  be  cupped.  The  atrophic  cup 
varies  from  the  glaucomatous  in  not  having  steep  sides,  so  that  the  ves.sels  do  not  appear 
broken  in  their  course,  as  in  the  latter  affection  ;  it  does  not  take  in  the  whole  nerve,  but 
only  its  central  part,  which  slopes  gradually  backward  ;  the  vessels  appear  curved  on  the 
surfoce  of  the  disc,  but  are  not  altered  in  calibre,  as  in  glaucoma.  Atrophy  of  the  retina 
freijuently  goes  along  with  atrophy  of  the  optic  disc. 

In  cases  of  atrophy  of  the  optic  nerve  vision  is  always  much  impaired;  some  patients 
with  extremely  white  dLscs  can  count  fingers,  distinguish  large  letters,  or  even  read  ordi- 
nary print,  but  in  the  majority  of  cases  vision  is  reduced  to  a  bare  perception  of  light. 

Treatment. — The  treatment  of  atrophy  of  the  optic  nerves,  especially  if  associated 
with  a  similar  condition  of  the  retina,  is  most  un.satisfactory,  and,  indeed,  almost  hope- 
less. Should  a  certain  amount  of  vision  still  remain  and  no  change  have  taken  place  for 
many  months,  Ave  may  safely  assure  our  patient  that  he  will  retain  what  sight  he  has. 
The  drugs  which  have  been  principally  used  are  iron,  either  alone  or  in  combination  with 
nux  vomica,  strychnia,  taken  by  the  mouth  or  injected  hypodermically,  phosphorus, 
quinine,  or  other  tonics,  and  opium  in  gradually  increasing  doses.  Galvanism  has  also 
been  employed. 
19 


290 


OPERATIONS  ON  THE  EYEBALL  AND  ITS  APPENDAGES. 


OPERATIONS  ON   THE   EYEBALE   AND   ITS   APPENDAGES. 


Position  for  Minor  Operations, 
(sitting.) 


Position  for  Major  (Jperalious. 
(Lying.) 


POSITION  OF  THE  PATIENT  AND   OPERATOR,  ETC. 

All  the  minor  operation.s,  such  a.s  slitting  the  canalieuli.  ]ias.-in<:  jirohes  down  the 
nasal  duct,  opening  tarsal  cysts,  etc.,  can  best  be  performed  when  the  patient  is  seated  in 
a  chair  and  the  operator  stands  behind  him,  the  patient's  head,  over  which  a  towel  has 
first  been  thrown,  resting  against  the  operator's  chest.     (See  Fig.  110.) 

The  more  important  operations,  as  extraction  of  cataract,  iridectomy,  squint,  etc., 
should  be  performed  whilst  the  patient   is  lying  on   a  hard  couch,  his  head  resting  on   a 

bolster  covered  by  a  towel,  which 
Fig.  110.  Fig.  111.  should  be  thrown  forward  over 

the  forehead :  the  operator  should 
sit  or  stand  behind.  (See  Fig. 
111.)  In  whichever  position  an 
operation  is  to  be  performed,  the 
chair  or  table  .should  be  placed 
in  front  of  a  large  window,  so  as 
to  ensure  a  good  light,  and  care 
be  taken  to  prevent  assistants 
and  others  from  interposing  their 
heads  or  bodies  between  the  pa- 
tient's face  and  the  source  of 
light.  It  will  be  found  whilst 
operating  that,  with  the  excep- 
tion of  occasional  pronation  and 
supination,  there  is  little  occa- 
sion to  use  the  arms,  which 
should  be  kept  with  the  elbows 
near  the  sides,  the  wrists  resting 
on  the  patient's  head  or  face  in 
a  position  which  allows  of  free  movements  of  the  hands  and  fingers. 

Every  ophthalmic  surgeon  .should  learn  to  use  his  fingers,  cultivate  his  sense  of 
touch,  and,  if  pos.sible,  become  ambidextrous. 

It  will  be  found  that  incisions  can  best  be  made  by  holding  the  knife  lightly  between 
the  thumb  and  first  two  fingers  of  whichever  hand  is  most  conveniently  situated. 

In  all  operations  incisions  commencing  at  or  situated  entirely  on  the  outer  aspect  of 
the  globe  should  be  made  with  the  hand  corresponding  to  that  side,  the  opposite  hand 
being  employed  upon  the  inner  side.  That  is  to  say,  if  the  right  eye  is  operated  on,  the  right 
hand  .-ihould  be  used  to  make  an  incision  at  its  outer  side,  the  left  at  its  inner,  and  vice  versa. 
Incisions  above  or  below  may  be  made  with  either  hand  ;  scissors  should  also  be  used 
with  whichever  hand  is  most  favorably  situated. 

In  one  operation — that  for  internal  strabismu.s — the  positions  of  patient  and  operator 
are  somewhat  different  from  those  already  described,  the  operator  standing  in  front,  at  the 
side  of  the  couch  on  the  patient's  right,  in.stead  of  behind  his  head. 

The  scissors  may  be  used  with  the  right  hand  for  both  eyes,  but  in  operating  on  the 
left  the  hands  will  have  to  be  crossed. 

Before  performing  any  operation  the  operator  should  look  carefully  to  the  condition 
of  the  instruments  he  is  about  to  use.  Knives  .'ihould  be  passed  through  a  piece  of  thin 
leather  tightly  stretched  on  a  small  metal  cylinder,  and  care  taken  to  ascertain  that  they 
have  good  points  and  that  there  are  no  notches  in  the  blades. 

Scissors  should  be  carefully  examined  and  tried ;  it  should  be  seen  that  forceps  close 
perfectly  and  are  free  from  rust  or  dirt  ;  silk  for  sutures  should  be  black,  as  fine  and 
strong  as  possible,  w^ell  waxed,  and  free  from  flaws  or  kinks.  Inattention  to  these  details 
may  very  possibly  mar  the  success  of  an  operation. 

Administration  of  Anaesthetics. — The  operator  will  find  that  he  has  much 
more  command  over  the  eye  when  the  patient  is  under  the  influence  of  an  anaesthetic 
than  when  consciousness  remains,  and  in  by  far  the  greater  number  of  cases  he  will  do 
well  to  administer  one. 

Occasionally  patients  are  met  with  who  will  bear  operations  most  quietly:  such  should 


lysEiiTiox  OF  A  sKTo.y  i\  Tin:  tkmi'i.i:.  291 

be  operatetl  nii  witlmut  aiuvsthesia ;  l»iit  if  (liirinj;  the  operation  the  patient  hcoome 
uiistoady  <>>"  l»et;iii  tn  strain,  it  is  })e.st  not  to  risk  failure,  hut  to  discontinue  the  opera- 
tion and  administer  an  an;esthetie.  If"  the  L'hihe  luis  been  opened,  it  must  he  carefully 
<;uarded  hy  a  jtad  and  handatre  duriiii:  the  administration.  If  no  aiuL'stlietic  l)e  employed, 
tlu'  operation  should  lie  ptrlornie(l  as  sim)dy  and  i|uiekly  as  jmssihle;  no  speculum  should 
he  used,  nor  should  the  eye  he  fixed  with  forceps,  hut  the  operator  should  kcr-p  the  lids 
open  and  steady  the  <;Iohe  with  the  tintrers. 

Aktkk-Tukat.MKNT. — Operations  on  the  tear  passaires.  removal  of  tarsal  cyst,  and 
strahismus  re(|uire  little  or  no  after-treatment  ;  the  parts  lu'ed  oidy  to  he  washeil  twice 
or  three  times  a  day  with  tepid  water. 

After  more  severe  operations  on  the  eyelids,  and  in  all  cases  where  an  iiu-ision  has 
heen  made  into  the  <fhd)e,  the  eye  should  he  carefully  covered  with  two  small  folds  of  lint 
wetted  with  odd  water  and  secured  hy  a  sinjrle  turn  of  handaire.  the  lint  heing  kept  wet 
aiul  the  eye  hound  up  until  the  incision  has  healed  and  all  irritation  subsided.  Wounds 
of  the  globe  made  in  operations,  as  a  rule,  heal  rapidly,  union  having  fre(|uently  taken 
place  at  the  end  of  twelve  hours. 

The  great  danger  after  operations  on  the  globe  is  the  occurrence  of  inflammation. 

Occurrence  of  Inflamraation. — Inflammation,  once  .set  up.  may  subside  shortly, 
leaving  no  trace  behind  it  ;  it  may  continue  until  more  or  less  irreparable  damage  has  been 
done,  or  may  run  on  to  suppuration  of  portions  or  the  wliole  of  the  globe.  The  cornea  is 
more  liable  to  this  change  than  any  other  structure. 

The  symptoms  of  inflammation  usually  appear  within  the  two  days  immediatelv  suc- 
ceeding an  operation,  and  little  fear  need  be  entertained  for  the  safety  of  the  eyeball  if 
all  has  gone  well  for  a  week. 

Occasionally,  after  cataract  extraction,  eyes  have  been  lost  through  inflammation,  or 
suppuration  commencing  at  a  later  period ;  but  these  cases  are  rare,  and  probably  it 
will  be  found  that  some  damage  has  been  done  to  the  eye  shortly  before  the  symptoms 
appeared. 

The  treatment  of  inflammatory  changes  consists  in  the  local  abstraction  of  blood  from 
the  temple  by  leeches  or  the  application  of  the  artificial  leech  ;  the  use  of  fomentations 
of  water,  poppy-heads,  or  belladonna  constantly  applied  ;  the  administration  of  opium  in 
full  doses,  either  alone  or  combined  with  mercury.  The  treatment  must,  of  course,  be 
varied  according  to  the  condition  of  the  patient :  should  he  be  weakly  and  ana?mic,  we 
should  be  careful  about  blood-letting,  and.  instead,  quinine  and  iron,  with  good  living  and 
a  fair  amount  of  stimulants,  should  be  prescribed. 

The  local  abstraction  of  blood,  however,  acts  most  beneficially  in  relieving  pain,  and 
should,  therefore,  be  employed  in  cases  where  pain  is  a  prominent  symptom,  even  though 
the  patient  does  not  appear  to  have  much  blood  to  lose.  Strong,  healthy  patients  should 
be  leeched  freely  and  kept  on  light  diet. 

During  the  treatment  the  eye  must  be  kept  carefully  closed  and  bandaged,  excepting 
during  the  time  that  fomentations  are  being  applied.  Moderate  pressure  by  carefully- 
applied  pads  of  lint  and  cotton-wool  secured  by  a  few  turns  of  flannel  bandage  is  said  to 
exert  considerable  influence  in  cases  where  the  cornea  is  threatened  by  suppuration  ;  it 
should  have  a  fair  trial  if  pressure  can  be  borne. 

If  the  inflammation  go  on  to  su])puration  of  the  whole  globe,  the  case  must  be  treated 
in  the  same  manner  as  abscess  in  any  other  part.      (See  •'  Ophthalmitis.") 

Insertion  of  a  Seton  in  the  Temple. — In  order  to  place  a  seton  in  the  tem- 
ple, the  i)0sition  of  patient  and  operator  should  be  as  in  Fig.  llO.  p.  290.  The  operator 
should  pinch  up  the  skin  with  the  finger  and  thumb  of  one  hand  just  in  front  of  the 
patient's  ear  and  pass  a  seton  needle  armed  with  a  double  thread  of  stout  silk  through 
the  fold  thus  produced ;  the  silk  should  be  drawn  through  and  tied  in  a  short  loop.  The 
seton  should  pass  for  about  li  inches  beneath  the  skin,  and  should  be  placed  amongst  the 
hair,  so  as  to  avoid,  as  much  as  possible,  disfigurement  from  the  subsequent  cicatrix  ;  the 
silk  should  be  drawn  backward  and  forward  through  the  wound  every  morning:  it  may  be 
left  in  as  long  as  appears  necessary. 

Care  must  be  taken  in  passing  the  needle  not  to  wound  the  temporal  artery  ;  should 
this  accident  happen,  the  seton  must  be  removed  and  firm  pressure  applied  with  a  pad  and 
bandage. 

Application  of  the  Artificial  Leech. — This  instrument  consists  of  a  small 
sharp  steel  cylinder  (worked  by  a  spring  arrangement),  with  which  a  circular  incision 
can  be  made  through  the  skin  of  the  temple,  and  a  hollow  glass  cvlinder.  which  can  be 
placed  over  the  wound  and  the  air  in  its  interior  exhausted  by  means  of  a  piston  worked 


292  OPERATIOXS  ON  THE  EYELIDS. 

by  a  screw;  as  the  air  is  removed  the  blood  flows  up  to  fill  the  vacuum.  Care  must  be 
taken  not  to  work  the  screw  too  quickly,  but  only  to  move  the  piston  at  the  same  rate  as 
the  blood  flows ;  neither  must  the  edge  of  the  cylinder  be  allowed  to  compress  the  skin 
against  the  parts  beneath,  otherwise  the  flow  of  blood  will  be  impeded. 

THE  EYELIDS. 

Tumors. — Various  small  growths  are  met  with  about  the  eyelids. 

Molluscum  occurs  as  a  small  yellowish-white  projection,  having  a  depressed  and 
often  blackened  centre,  situated  on  some  part  of  the  skin  of  the  lids ;  there  may  be  only 
one  or  many  of  these  little  growths.  They  can  be  easily  removed  by  thrusting  a  knife 
through  them  and  then  squeezing  out  the  contents  with  the  thumb-nail. 

Dermoid  cysts  are  not  unfrequently  met  with  situated  deeply  beneath  the  skin 
and  the  muscle,  often  near  the  outer  angle  of  the  orbit.  They  are  congenital,  filled  with 
sebaceous  matter,  and  often  contain  haii*.  They  must  be  carefully  dissected  out,  much 
more  trouble  being  experienced  in  so  doing  than  would  be  at  first  suspected  ;  and  they 
will  in  all  probability  be  opened  during  removal.  These  little  tumors  will  be  found 
attached  deeply  to  the  periosteum,  and  may  have  caused  a  depression  in  the  bone. 

Warts  are  not  unfrequently  met  with  about  the  eyelids ;  they  should  be  cut  off 
with  scissors. 

Tarsal  cyst  is  met  with  as  a  dusky-red  or  colorless  projection  from  the  outer  sur- 
face of  the  lid  ;  its  position  is  marked  on  the  conjunctival  surface  by  a  bluish  spot,  from 
which  a  granulation  is  occasionally  seen  growing.  The  cyst  is  formed  by  obstruction  of  a 
Meibomian  gland  and  retention  of  its  secretion;  it  is  sometimes  in  a  suppurating  condition. 

The  lid  should  be  everted,  the  cyst  freely  opened  from  the  conjunctival  surface  with 
a  small  knife,  and  its  contents  squeezed  or  scooped  out ;  it  must  be  thoroughly  emptied, 
or  it  will  in  all  probability  re-form. 

The  cavity  left  on  removal  of  the  contents  of  the  cyst  will  always  fill  with  blood,  and 
shortly  after  the  operation  the  tumor  will  be  as  large  as,  or  larger  than,  before ;  the 
patient  must  be  warned  of  this. 

The  swelling  will  most  probably  disappear  in  the  course  of  from  four  to  six  weeks ; 
if  it  remain  longer,  the  operation  should  be  repeated. 

A  tar.sal  cyst  sometimes  degenerates  into  a  hard  fibrous  little  mass,  feeling  somewhat 
like  a  large  shot  beneath  the  skin,  which  is  known  as  a  cltalazion  ;  this  should  be  dissected 
out  throvigh  an  incision  in  the  skin  of  the  lid,  which  should  afterward  be  closed  by  a  fine 
suture. 

Xanthelasma  is  often  met  with  as  a  small  yellow  patch  on  some  part  of  the  skin 
of  the  eyelids ;  its  most  frequent  site  is  the  surface  of  the  upper  lid,  near  the  inner 
canthus.     The  little  patch  may  be  excised  if  it  is  a  source  of  anxiety  to  the  patient. 

Simple  serous  cysts  occur  about  the  margins  of  the  lids ;  they  are  about  the 
size  of  small  peas  and  nearly  transparent.  A  portion  of  the  cyst  wall  should  be  cut  out 
with  scissors. 

Trichiasis  signifies  a  faulty  direction  of  the  eyelashes,  which  turn  inward  andi 
irritate  the  cornea ;  it  is  usually  caused  by  contraction  of  the  conjunctiva  (following 
granular  ophthalmia  or  its  unskilful  treatment),  producing  displacement  of  the  hair 
JoUicles. 

Treatment. — Only  a  few  lashes  may  be  misdirected,  or  the  whole  row  may  be 
inverted.  If  only  a  few  of  the  lashes  turn  inward,  it  is  sufficient  to  pull  them  out  with 
forceps  whenever  they  become  troublesome.  If  a  considerable  number  or  the  whole  row 
are  inverted,  their  roots  should  be  removed  by  operation.  The  operation  should  be  per- 
formed as  follows:  The  patient  being  placed  in  the  usual  position  (see  Fig.  Ill,  p.  290), 
the  lid  should  be  secured  by  a  compressoi'ium  forceps  (Figs.  112,  113),  by  which  means 
it  is  steadied  and  hemorrhage  prevented  ;  care  must  be  taken  not  to  screw  the  instrument 
up  too  tightly,  or  sloughing  of  the  lid  may  follow.  The  lid  being  well  secured,  the  operator 
should  make  an  incision  through  the  skin,  about  three  lines  from  the  free  margin  of  the 
lid  and  parallel  with  it,  of  such  a  length  as  to  corre.spond  to  the  lashes  which  are  mis- 
placed ;  the  incision  should  be  carried  down  to  the  outer  surface  of  the  tarsal  cartilage ; 
a  second  incision  should  then  be  made  of  the  same  length  as  the  first,  in  the  margin  of 
the  lid,  and  so  conducted  as  to  split  the  lid  and  separate  the  skin  and  hair-bulbs  from 
the  subjacent  sti-uctures ;  the  ends  of  the  two  incisions  should  then  be  joined  by  two 
short  cuts,  and  the  portion  of  skin  included  with  the  hair-bulbs  dissected  off  the  tarsal 
cartilage.     The  raw  surface  should  then   be  wiped  with  a   sponge  and  any  black  dots 


OI'EIIATIDSS   OS    THE   I.Y F.I.I DS. 


293 


Fig.  11:i. 


'r>: 


effl«?^;4p 


Coinpressoriuiu  Forceps  Applied. 


denoting  the  prcstMirc  nl"  liair-})ull>.s  carefully  rcniovfil.  Tin'  luinprcssoriuni  fnrceps 
slutuld  then  be  unsi-n-w t-tl.  wlioii  sharpish  hcii'tirrhajrt!  will  take  phn-e.  The  (•}».•  must 
lur"  ciivt-reil   Ity   two   jiicccs  of  wet   lint  securcil   l»y   a   turn   <jf  haiulafre. 

Entropion  siLMiifiis  a    ntllin^  inwanl   nf  the   whole   li<I.   the  winkle  row   oC  lashes 
lii'iuL:  cninplctclv  tiniud  toward  the  eyeball;    it  is  n»<jst   lre<|Uently  met  with  in  the  lr>wer 
liil,    more    espt'fially    in    old    people 
with     a     superabundanee     of"    loose  Fkj.  112. 

skin  about  the  laee.  It  is  often 
the  eause  of  niueh  trouble  and  an- 
noyanee,  as  well  as  oi'  dan«rer  to  the 
eye.  after  eataraet  extraetiun. 

The  inversion  may  be  caused 
cither  by  spasmodic  contraction  of 
the  orbicularis  muscle  or  by  distor- 
tion and  thickeiiinir  of  the  tarsal 
cartilaue  after  irranular  ophthalmia. 

Entr<>])ion  caused  by  contraction 
of  the  (trbicularis  is  easily  remedied 
as  follows :  The  jtatient  lyin<r  on  a 
couch  (see  Fi.ir.  Ill,  p.  "2!tO),  the 
operator  should  seize  with  forceps 
the  skin  of  the  lid  at  a  point  near 
one  or  other  canthus,  about  two  lines 
from  its  marjiin,  and  then  with  scis- 
sors remove  a  portion  in  breadth  cor- 
respondinj;  to  about  half  the  surface  compressorium  Forceps, 
of  the  lid  and  extending  along  its 
whole  length  ;  he  should  then  seize  and  remove  the  orbicularis  muscle  to  a  corresponding 
extent  :  no  suture  need  be  used ;  the  eye  should  be  bound  up  with  wet  lint  and  a  band- 
age. The  subsequent  healing  of  the  wound  and  contraction  of  the  cicatrix  will  remedy 
the  inversion. 

Entropion  depending  on  distortion  and  thickening  of  tlie  tar.sal  cartilage  is  usually 
met  with  in  the  upper  lid.  It  can  be  remedied  by  removal  of  a  wedge-shaped  piece  of 
cartilage,  including  the  more  thickened  portion,  by  the  following  operation  :  The  patient 
being  in  the  usual  position  (see  Fig.  Ill,  p.  290)  and  the  lid  fixed  by  a  compressorium 
forceps,  with  a  sharp  knife  an  incision  should  be  carried  throui:h  its  whole  thickness, 
parallel  with  and  about  two  lines  distant  from  its  margin,  along  the  whole  extent  of  the 
thickened  portion.  A  somewhat  lunated  incision  should  then  be  made  from  one  end  of 
the  first  around  the  base  of  the  thickened  portion  of  tarsus,  joining  the  first  incision  at  its 
other  extremity ;  the  second  incision  should  not  be  carried  vertically  through  the  carti- 
lage, but  obliquely,  so  as  to  meet  the  first  at  the  conjunctival  surface ;  the  portion  of 
cartilage  included  between  these  incisions  shovdd  then  be  removed,  the  wound  closed  by 
sutures,  and  the  eye  bound  up  with  lint  and  a  bandage.  The  skin  and  muscle  covering 
the  cartilage  may  be  removed  or  not.  according  to  the  fancy  of  the  surgeon.  If  their 
removal  is  not  desired,  they  should  be  dissected  back  before  making  the  second  incision. 
After  the  operation  the  margin  of  the  lid  should  appear  rightly  directed. 

Ectropion  signifies  an  everted  condition  of  the  lid  ;  the  extent  of  eversion  varies  in 
different  cases,  from  slight  falling  away  of  the  margin  of  the  lid  from  the  globe  to  ever- 
sion of  the  wliole  extent  of  the  lid  and  adjoining  fornix  of  the  conjunctiva. 

The  .slighter  forms  are  caused  by  distetision  of  the  lid  from  inflammatory  swelling, 
and  are  easily  remedied  by  slightly  narrowing  the  palpebral  aperture  by  paring  the 
edges  of  the  lids  near  the  outer  canthus,  and  bringing  the  raw  surfaces  together  by  a 
suture,  when  firm  union  will  take  place  between  the  two. 

The  more  extreme  forms  are  caused  by  the  contraction  of  cicatrices  of  burns,  wounds, 
or  inflammatory  changes,  about  the  orbit. 

No  definite  rules  can  be  laid  down  with  regard  to'  the  treatment  of  the.se  cases.  The 
surgeon  must  be  guided  by  the  conditions  as  they  present  themselves,  and  do  the  best 
he  can. 

In  any  case,  if  the  tarsal  cartilage  be  left  entire,  it  .should  be  carefully  dissected  away 
from  its  attachments  and  replaced  as  nearly  as  possible  in  its  normal  position,  in  which  it 
must  be  kept  by  paring  its  margin  and  that  of  the  opposite  lid  and  securing  extensive 
and  firm  union  between  them  by  careful  coaptation  of  their  raw  surfaces.     The  lids  must 


294  OPERATIONS  ON  THE  EYELIDS. 

not  be  opened  until  all  further  contraction  of  the  original  cicatrix  is  at  an  end,  and  it  is 
better  to  leave  the  eye  closed  for  considerably  too  long  a  period  than  to  open  it  a  day  too 
soon.  Ectropion  is  also  frequently  seen  in  the  more  severe  forms  of  ophthalmia  or  in 
cases  of  severe  intolerance  of  light,  and  is  specially  liable  to  occur  when  an  attempt  is 
made  to  open  a  firmly-closed  eye.  In  these  cases  the  eversion  requires  no  special  treat- 
ment, but  disappear.-^  as  the  affection  causing  it  is  recovered  from. 

Formation  of  a  New  Eyelid. — In  some  cases  of  burn  or  from  ulceration  of  a 
lupoid  character  more  or  less  complete  destruction  of  the  eyelids  may  take  place.  To 
remedy  this  defect,  a  flap  of  skin  from  a  neighboring  part  may  be  brought,  placed  in  the 
gap.  and  there  secured  b}'  means  of  sutures,  care  being  ahvays  taken  that  the  piece  of 
skin  is  considerably  larger  than  the  surface  it  is  intended  to  cover.  Before  removing  any 
skin  search  must  be  made  in  any  portion  of  the  eyelid  that  may  be  left  for  the  tarsal  car- 
tilage, and  if  this  be  found  it  must  be  carefully  dissected  out  and  preserved,  its  natural 
form  being  as  much  as  possible  restored ;  it  should  be  fixed  in  its  proper  position  by  unit- 
ing its  margin  to  that  of  the  opposite  lid.  Even  if  no  flap  of  .skin  be  applied  over  it,  it 
will  in  time  become  covered  with  cuticle  and  form  a  very  efliectual  covering  to  the  eye- 
ball. 

Symblepharon  signifies  adhesion  of  the  conjunctiva  of  the  eyelid  to  that  of  the 
globe.  It  is  usually  caused  by  burns  with  lime  or  hot  metal,  and  may  occur  to  any 
extent,  varying  from  a  thin  band  of  union  to  fusion  of  the  greater  part  or  whole  of  both 
lids  with  the  globe. 

This  condition  requires  to  be  remedied  by  operation.  "Where  only  a  thin  band  of 
adhesion  exists,  it  .should  be  first  carefully  secured  b}^  a  suture  passed  through  the 
extremity  nearest  the  eyeball,  and  then  be  divided  and  drawn  into  the  fornix  by  passing 
the  suture  through  the  lid  and  securing  it  to  a  small  roll  of  strapping  placed  upon  the 
cutaneous  surface.  By  this  means  the  raw  surface  left  by  removal  of  the  band  from  the 
globe  is  brought  into  contact  with  healthy  conjunctiva  and  granulates  over,  healing  with- 
out forming  adhesions. 

If  more  than  one  band  exi,st,  each  .should  be  dealt  with  separately. 

Cases  of  more  exten.sive  adhesion  give  rise  to  the  utmost  difiiculty  in  treatment,  and 
until  lately  the  operations  performed  for  their  relief  were  attended  with  only  indifferent 
succes.s.  One  plan  of  treatment  recommended  was  to  dissect  away  the  adhesion  and 
interpose  a  .shell  of  glass  between  the  raw  surfaces,  but,  as  healing  invariably  commenced 
at  a  point  remote  from  the  free  margin  of  the  lid.  the  shell  was  gradually  pushed  out  and 
the  adhesion  re-established. 

The  insertion  of  pieces  of  wire  deeply  beneath  the  adhesion,  which  were  left  in  until 
the  walls  of  the  canal  made  by  them  had  healed,  the  remainder  of  the  adhesion  being 
then  divided  with  scissors,  was  followed  by  no  more  satisfactory  results. 

Lately  an  operation  has  been  introduced  by  Mr.  P.  Teale  of  Leeds  which  has  Ijeen 
attended  with  the  best  .success.  The  operation  has  fur  its  object  the  separation  of  the 
raw  surfaces  by  a  piece  of  conjunctiva  taken  from  some  other  part  of  the  eyeball.  The 
following  is  an  extract  from  the  account  of  the  operation  given  by  Mr.  Teale  in  the 
Tro.nmctions  of  the  Fourth  Ophthalmic  Congress,  1872: 

"  The  patient  being  under  the  influence  of  an  anas.sthetic.  the  eyelid  is  freed  from  its 
attachment  to  the  lid;  next,  a  band  of  somewhat  circular  form  is  marked  out  with  a  sharp 
knife  upon  the  sound  conjunctiva  ;  the  band  commences  at  one  end  of  the  gap  left  by 
liberation  of  the  lid  and  passes  round  the  sound  side  of  the  cornea,  terminating  at  the 
opposite  extremity  of  the  gap. 

'•  Four  stitches  are  then  inserted,  two  on  each  edge  of  the  flap  thus  formed.  The  flap 
is  next  separated  on  its  under  surface,  whilst  its  extremities  are  left  continuous  with  the 
conjunctiva:  it  is  then  drawn  across  the  surface  of  the  cornea  and  fixed,  raw  surface  down- 
ward, into  the  gap  formed  by  the  liberation  of  the  eyeball  from  the  lid ;  it  is  secured  in 
its  new  position  by  the  sutures  already  alluded  to.  aided  by  as  many  others  as  may  appear 
necessary.'' 

Mr.  Teale  states  that  "  the  operation  is  most  tedious,"  and  that  he  rarely  completes  it 
within  the  hour. 

Anchyloblepharon  signifies  an  adhesion  of  the  lids  to  each  other.  The  adhesions 
must  be  divided  with  scissors,  and  if  possible  some  skin  or  conjunctiva  interposed  between 
the  raw  surfaces :  but  if  this  cannot  be  done,  reunion  mav  be  prevented  by  passing  a 
probe  between  the  lids  daily. 

Narrowing  of  the  palpebral  aperture  ("Blepharophymosis)  is  usually 

a  result  of  granular  ophthalmia,  and  is  accompanied  by  entropion,  displaced  tear  puncta, 


LACIIIIVMM.   M'l'MlATUS.  295 

and  consequent  watering;  of  the  eye.     It  rcfuiires  U)  be  remedied  by  operation,  which  can 

be  thus  iierfornied  :   Tlie  lids  bcin-r  kept  widely  open  and  ctii  the  stretch  l)y  a  wire  specu- 

hun   (  Fijr.  114),  an  incision  should  b(;  made  with  stron;^ 

scissors  throuirh  tlie  outer  canthus.      A  flap  of"  conjunc- 

tiva  of  soiuewhat   couical   shape   slutuld  tlien  be  niarke<i  ^     \f^     \; 

out  on   the  surface  of  the  ey('l)all,  the  flap  freely   (lis-  ga^^^ 

sected  from   the  subjacfnt  structures,  but  left  attached    ^»J) 

at  its  base,  which   is   toward  the  cornea,  and  then   fixed   f  jT 

by  sutures  in   the  incision  made  by  the  scissors,  in  such     "°^^^ 

a  maniu'r  as  to  kcfj)  the  raw  edges  separated  by  a  mu-  ^^^^^^^  jfc       ^s 

cons  surface.  ^^-*"-— «s^ ''W.'^^V 

U.  1  i*      I  Wire  Speculum. 

IS  sometimes  necessary  to  narrow  or  dose  entirely  ' 

the  palpebral  aj\erturc.  This  operation,  known  a.s  ttuxordphij^  can  be  performed  as  fol- 
lows:  The  lid  beint^  held  with  forceps,  a  portion  of  the  Inner  edjr  of  its  margin  should 
be  removed  with  a  small  iridectomy  knife,  care  being  taken  not  to  cut  away  any  of  the 
outer  edge  containing  the  lashes,  nor  to  wound  the  tear  puncta  or  canaliculi.  The  oppo- 
site lid  should  then  be  treated  in  the  same  manner  and  the  raw  edges  brought  together 
by  sutures  ;  firm  union  will  soon  take  place  between   them. 

Ptosis  signifies  a  drooping  of  the  upper  eyelid  to  a  greater  or  less  extent,  with 
inability  to  raise  it.  Ptosis  occurs  with  divergent  strabismus  and  more  or  le.ss  impair- 
ment of  the  mobility  of  the  eyeball  in  cases  of  paralysis  of  the  third  nerve,  and  is  gen- 
erally, but  not  invariably,  accompanied  by  dilatation  and  fixity  of  the  jtupil. 

It  is  also  met  with  as  a  congenital  defect,  and  occurs  .sometimes  after  severe  inflam- 
mation of  the  lid  or  protracted  intolerance  of  light  and  constant  spasmodic  action  of  the 
orbicularis  muscle.  Women  past  the  middle  period  of  life  with  a  superabundance  of 
loose  skin  about  the  face  are  also  subject  to  a  form  of  partial  ptosis. 

Tre.\tment. — In  ptosis  from  paralysis  of  the  third  nerve  treatment  mu.st  be  directed 
against  the  cause  of  the  paralysis,  no  operation  being  advisable  ;  other  forms  can  be 
remedied  by  the  removal  of  some  skin  and  orbicularis  mu.scle  from  the  surface  of  the  lid. 

The  operation  may  be  performed  as  follows :  The  .<kin  at  the  upper  part  of  the  lid 
should  be  pinched  up  with  forceps,  the  amount  included  between  their  blades  being  such 
as  to  rai.se  the  margin  of  the  lid  well  above  the  ujiper  border  of  the  pupil.  Then  with 
scissors  a  strip  of  skin  of  the  required  width  .should  be  removed,  along  the  whole  extent 
of  the  lid,  parallel  to  its  mai'gin  ;  the  orbicularis  muscle  should  then  be  cleanly  dissected 
off  the  tarsal  cartilage  to  about  the  same  extent,  the  wound  closed  by  one  or  two  fine 
sutures,  and  the  e3'e  bound  up  with  wet  lint  and  a  bandage. 

The  wound  will  heal  in  the  course  of  a  few  days,  and  the  shortening  caused  by  the 
removal  of  the  skin  and  muscle  and  subsef(uent  cicatrization  (possibly  aided  by  the 
entanglement  erf  some  fibres  of  the  occipito-frontalis  in  the  scar)  should  keep  the  lid  in 
the  desired  position. 

In  cases  of  congenital  ptosis  we  often  find  movement  of  the  eyes  upward  greatly 
impaired ;  it  seems  probable  that  the  superior  rectus  is  badly  developed  or  altogether 
absent. 

THE  LACHRYMAL  APPARATUS. 

The  lachrjnual  gland  is  occasionally  the  seat  of  malignant  or  other  growths  and 
may  require  extirpation. 

A  cyst  is  sometimes  met  with  caused  by  obstruction  of  one  of  the  ducts  of  the 
gland  and  accumulation  of  secretion.     The  disease  is  known  as  (facri/opis. 

Trkatment. — Its  treatment  consists  in  establishing  an  opening  into  it  from  the  sur- 
face of  the  conjunctiva;  this  is  easily  done  by  passing  a  curved  needle  armed  with  .silk 
from  beneath  the  upper  lid  through  the  wall  of  the  cyst  into  its  cavity,  and  out  again  at  a 
convenient  distance  ;  the  silk  should  then  be  drawn  through  and  the  portion  of  cy.st  wall 
included  between  the  entrance  and  exit  of  the  needle  firmly  ligatured  ;  the  ligature  will 
slough  out  and  leave  a  permanent  opening,  causing  no  inconvenience.  If  the  cyst  be 
opened  throutrh  the  skin,  it  may  leave  a  troublosonie  fistula. 

The  Tear  Puncta  and  CanalicuH. — The  tear  puncta  in  the  normal  condition 
lie  in  contact  with  the  ocular  conjunctiva  ;  they  may  be  either  everted,  as  seen  in  old  and 
neglected  cases  of  tinea,  or  rolled  .somewhat  inward  :  they  are  sometimes  found  entirely 
obliterated  either  by  disease  or  injury,  burns  of  the  evelids  being  the  most  common  cau.se. 

The  canaliculi  may  also  be  found  more  or  less  obstructed  in  any  part  of  their  cour.se, 
at  times  by  a  little  mass  of  fungus.     Any  of  these  conditions  are  accompanied  by  trou- 


296  OPERATIONS  ON  THE  TEAR  PASSAGES. 

blesome  watering  of  the  eye — "  epiphora."  They  can  be  remedied  by  slitting  tlie  tear 
puncta  and  canaliculi. 

The  lachrymal  sac  is  often  the  seat  of  acute  inflammation,  whicli  may  arise  in 
the  sac  itself,  spread  to  it  from  the  conjunctiva,  or  be  caused  by  disease  of  the  surround- 
ing bones.  It  is  characterized  by  a  dusky-red  tense  swelling  situated  at  the  side  of  the 
nose,  close  to  the  inner  canthus,  the  swelling  and  redness  often  extending  outward  alono- 
both  the  upper  and  lower  lids  ;  one  or  both  sacs  may  be  affected.  The  inflammation  may 
end  in  resolution  or  go  on  to  the  formation  of  an  abscess  ;  in  the  latter  case  the  swelling 
becomes  soft  and  fluctuating. 

^  Treatment. — At  first  hot  fomentations  and  poultices  must  be  applied  and  attention 
paid  to  the  general  health  ;  if  abscess  form,  the  pus  must  be  let  out  by  a  free  incision. 
If  an  abscess  of  the  lachrymal  sac  be  allowed  to  burst,  a  fistulous  opening  will  very  prob- 
ably be  left;  but  if  a  free  opening  be  made  so  soon  as  the  formation  of  pus  is  suspected, 
the  wound  heals  readily. 

Distension  of  the  Lachrymal  Sac  (Mucocele).— The  lachrymal  sac  not 

unfrequently  becomes  distended,  forming  a  tumor  of  varying  size  beneath  the  internal 
palpebral  ligament  (tendo  oculi) ;  pressure  on  the  tumor  'causes  the  escape  of  a  transpa- 
rent, somewhat  tenacious  fluid  consisting  of  mucus  and  tears,  in  some  cases  thickened 
from  the  admixture  of  pus  cells.  Distension  of  the  sac  is  caused  by  stricture  of  the  nasal 
duct  and  consequent  accumulation  of  secretion  ;  it  is  accompanied  by  more  or  less  water- 
ing of  the  eye  and  may  be  remedied  by  relieving  the  stricture  of  the  duct. 

Discharge  from  the  Lachrymal  Sac  (Blennorrhoea).— A  muco-purulent 

or  purulent  discharge  from  the  sac  is  often  met  with  following  inflammation,  especially 
if  disease  of  the  adjacent  bone  exist.  It  may  be  treated — 1st.  By  ensuring  a  free  exit 
for  the  discharge  by  slitting  the  canaliculus  and  passing  a  large  probe  down  the  lachry- 
mal duct ;  2d.   By  washing  out  the  sac ;  od.   By  obliteration  of  the  sac. 

Stricture  of  the  nasal  duct  may  be  met  with  in  any  part  of  its  course ;  the 
obstrucrion,  however,  is  most  frequently  found  at  its  junction  with  the  lachrymal  sac. 
Occasionally  the  duct  is  found  almost  obliterated  by  dense  bony  deposit. 

Fistula  of  the  lachrymal  sac  occurs  as  a  small,  sometimes  scarcely  perceptible 
opening  situated  at  some  point  over  the  sac ;  it  is  found  in  connection  with  obstruction 
of  the  nasal  duct.     If  the  passage  be  re-established,  the  fistula  will  probably  close. 

Operations  on  the  Tear  Passages. — The  operation  of  slitting  the  tear  puncta 
and  canaliculi  may  be  performed  thus :  The  patient  should  be  seated  ina  chair,  the  ope- 
rator standing  behind  him  (see  Fig.  110,  p.  290).  Supposing  the  lower  punctum  and 
canaliculus  on  the  right  side  to  be  operated  on,  the  small  and  ring  fingers  of  the  left  hand 
should  be  placed  upon  the  patient's  face  near  the  outer  canthus,  the  lids  drawn  tight  with 
these  two  fingers,  and  kept  so  ;  then  a  small  grooved  director  (Fig.  115)  should  be  taken 
in  the  right  hand  and  passed  at  first  verrically  to  the  margin  of  ithe  lid  through  the  tear 
punctum,  its  handle  then  depressed,  and  its  point  passed  horizontally  along  the  canaliculus 
into  the  sac.     To  ascertain  that  the  point  of  the  director  is  in  the  sac,  the  tension  of  the 

lids   mu-st   be   relaxed   and    the    director   pushed 

Fig.  115.  gently   onward.     If   there   be   any  puckering  at 

—         .    ■M^— le— — r-    ,  the    inner    canthus    when    the    director   is    thus 

Grooved  Director  for  Slitting  Canaliculus.        pushed,  its  point  has   not  entered   the   sac,  and 

a  further  attempt  must  be  made ;  if  no  pucker- 
ing occur,  the  lids  should  be  brought  again  into  a  state  of  tension  and  the  handle  of  the 
director  transferred  to  the  thumb  and  forefinger  of  the  left  hand.  A  cataract  or  any 
small  knife  that  will  cut  should  then  be  taken  in  the  right  hand  and  run  along  the  groove 
of  the  director  well  into  the  sac,  the  knife  and  director  being  then  withdrawn  together ; 
the  upper  lid  must  be  kept  out  of  the  way  by  one  of  the  fingers  of  the  right  hand.  The 
operation  can  be  performed  on  the  left  side  in  the  same  manner,  with  the  exception  that 
the  hands  are  reversed. 

The  upper  punctum  and  canaliculus  sometimes  require  to  be  slit :  this  operation  is 
not  quite  so  simple  as  that  on  the  lower  lid,  but  is  performed  in  much  the  same  way.  In 
lieu  of  the  grooved  director  and  knife,  a  small  probe-pointed  canaliculus  knife  may  be 
employed  ;  it  should  be  passed  through  the  tear  punctum  and  canaliculus  in  the  same 
manner  as  the  director,  and  will  cut  its  way  out  as  it  goes. 

The  patient  must  be  seen  at  intervals  of  two  or  three  days  for  a  week  or  longer  after 
the  operation,  and  a  probe  passed  along  the  incision  to  prevent  its  closing. 

Probing  the  Nasal  Duct. — For  the  treatment  of  stricture  ofthe  nasal  duct  a 
set  of  silver  probes  (Bowman's)  are  used  ;  there  are  three  probes  in  a  set,  the  two  extrem- 


OI'i:  HAT  IONS  ON  Till':  COSJl'SCTIVA.  297 

ities  (if  eudi  Iumiil:  nl'  iliflrri-nl  lliickmssfs,  so  tlmt  thcic  aw  six  sizes,  No.  1  heirifr  the 
sinallt'st,  No.  (I  tlu'  laru;isl. 

To  j)ass  a  prol)o  down  the  nasal  liinl,  tlic  canaliculus  slioulil  he  lirst  slit,  or,  what  is 
liettcr.  sh(»uhl  havo  hccn  slit  at  some  previous  time.  The  surgeon  shftuld  stand  behind 
the  patient  in  the  same  position  as  for  perforniinj;  the  last  (jperation.  and.  the  lids  Iteinj; 
made  tense  in  the  same  manner,  the  prohe  should  he;  pas.sed  alon<r  the  slit  canaliculus 
until  the  point  is  well  within  the  sac,  as  shown  hy  the  absence  of  puekerinj:  at  the  inner 
eaiithiis  on  relaxation  of  the  tension  of  the  lids;  th(!  opposit((  extremity  should  then  be 
raised  alon<r  the  maruiii  of  the  orbit  until  the  jirobe  has  attained  a  viu'tical  direction,  care 
beinii'  taken,  while  .so  doint;-,  to  keej)  the  end  whicdi  is  in  the  sac  ]»r(!ssed  firndy  against  its 
inner  side  ;  the  ])robe,  havinj;  been  brought  into  a  nearly  vertical  ])osition,  should  be 
pushed  <rently  but  firmly  downward  and  slightly  backward  and  outward  in  the  direction 
of  the  duet ;  when  it  has  been  passed  as  far  as  it  will  go,  it  should  be  slightly  withdrawn, 
.so  as  to  raise  its  end  off  the  fiocjr  of  the  iio.se.  If  the  probe  lias  been  properly  pa.s.sed 
down  the  duct,  its  upper  part  will  remain  firmly  in  contact  with  the  margin  of  the  orbit; 
but  if  it  moves  freely  about,  the  i)robe  is  not  in  the  duct,  but  has  been  forced  through 
its  wall.  This  little  accident  is  of  no  particular  moment,  and  needs  oidy  that  the  probe 
be  withdrawn  and  passed  afresh  in  the  right  dirih;tion. 

If  the  end  of  the  probe  is  not  well  within  the  ,sac  before  an  attempt  is  made  to  pa.s.s 
it  down  the  duct,  it  may  slip  backward  into  the  orbit  or  forward  and  downward  in  the 
cellular  tissue  of  the  cheek.  A  probe,  having  lieen  satisfactorily  pas.sed,  sliould  be  left 
in  for  about  twenty  minutes,  and  the  ojieration  be  repeated  about  twice  a  week.  The 
treatment  of  stricture  of  the  lachrymal  duct  is,  on  the  whole,  unsatisfactory,  but  the 
]trot)ing  should  be  carefully  and  perseveringly  carried  out.  It  is  well  always  to  com- 
mence with  the  largest  pr(d)e  (No.  (i),  and  try  a  smaller  one  if  thi.s  cannot  be  passed. 

Washing  out  the  Lachrymal  Sac— For  washing  out  the  lachrymal  sac  a 
good  .syringe  lifted  with  nozzles  of  different  sizes  is  re((uired.  One  of  the  nozzles  should 
be  fitted  to  the  syringe,  which  has  been  previously  filled  with  fluid  (water,  a  weak  solu- 
tion of  nitrate  of  silver,  chloride  of  zinc,  etc.)  ;  the  nozzle  should  then  be  pa.ssed  along 
the  previously  slit  canaliculus  into  the  sac  and  the  fluid  injected;  the  patients  head  must 
be  bent  forward  during  the  injection,  or  the  fluid  will  run  back  along  the  floor  of  the  nose 
into  the  jiliarynx. 

Obliteration  of  the  Lachrymal  Sac. — In  some  ca.ses  of  obstinate  discharge 
from  the  .sac.  especially  if  dependent  on  diseased  bone,  the  discharge  may  be  stopped  and 
the  ]iatient  made  more  comfortable  by  closing  up  the  sac  entirely  ;  of  course,  more  or  less 
watering  of  the  eye  will  remain  after  the  operation,  but  is  far  to  be  preferred  to  the  annoy- 
ance of  a  constant  purulent  discharge. 

Obliteration  of  the  sac  may  be  attempted  in  any  of  the  three  following  ways :  A  free 
incision  having  been  made  into  it  and  the  blood  carefully  sponged  out.  its  lining  mem- 
brane may  be  destroyed — (1)  by  filling  its  cavity  with  a  thick  paste  of  chloride  of  zinc 
and  starch,  in  equal  parts,  •enclosed  in  a  small  piece  of  lint,  (2)  by  the  application  of 
nitrate  of  silver,  or  (3)  by  the  galvanic  or  other  cautery.  By  any  of  these  procedures 
adhesive  inflammation  is  set  up,  more  or  less  obliteration  of  the  sac  following. 

Operations  for  obliteration  of  the  lachrymal  .sac  are  by  no  means  always  successful 
and  may  have  to  be  repeated,  perhaps  more  than  once,  before  a  satisfactory  result  is 
obtained. 

THE  CONJUNCTIVA. 

But  few  operations  are  performed  on  the  conjunctiva  alone;  it  is.  of  course,  cut  in 
some  of  the  operations  on  the  eyelids  and  in  that  for  strabismus,  and  some  others. 

Warts  are  occa.sionally  found  on  some  part  of  the  membrane ;  they  require  to  be 
removed   with  scissors. 

Pterygium  is  a  peculiar,  somewhat  triangular  growth,  the  base  of  which  is  situated 
in  the  ocular  conjunctiva,  generally  near  the  inner  canthus,  the  apex  encroaching  more 
or  less  upon  the  margin  of  the  cornea  or  passing  for  a  considerable  distance  upon  its  sur- 
face. The  growth  is  of  a  reddish  color  and  variable  density  ;  it  consists  of  hypertrophied 
connective  tissue. 

Pterygium  is  not  common  in  this  country,  and  when  met  with  is  usually  found  to 
occur  in  sailors  and  others  who  have  been  in  the  East.  Should  it  give  rise  to  any  incon- 
venience or  threaten  to  impair  vision,  it  must  be  removed  by  operation. 

The  patient  should  lie  on  the  couch,  the  lids  be  opened  by  a  wire  speculum,  the 
growth  seized  with  toothed  forceps,  and  with  a  cataract  knife  dissected  up  from  the  sur- 


298  STRABISMUS. 

face  of  the  cornea.  A  small  portion  of  conjunctiva  should  then  be  removed  parallel  with 
the  margin  of  the  cornea  and  the  apex  of  the  growth  fixed  by  a  suture  in  the  wound. 
The  eye  should  be  kept  bound  up  for  a  few  days  with  wet  lint  and  a  bandage. 

If  a  pterygium  is  simply  cut  off,  it  will  in  all  probability  grow  again  ;  but  if  trans- 
planted, it  will  shrivel  up  and  disappear  without  giving  further  trouble.  A  cicatrix 
always  remains  upon  the  cornea  after  removal  of  pterygium,  so  that  it  uiust  never  be 
allowed  to  grow  over  the  pupil. 

Ping"uicul8B  are  small  yellowish  growths  situated  beneath  the  conjunctiva,  gene- 
rally near  the  outer  and  inner  margins  of  the  cornea;  they  are  surrounded  by  a  few  large 
blood  vessels  and  are  occasionally  the  source  of  constant  irritation,  causing  the  eyes  to 
be  bloodshot  and  uncomfortable.  Pinguicula  can  be  removed,  if  desired,  by  making  an 
incision  over  it,  turning  back  the  conjunctiva,  then  seizing  the  little  growth  with  forceps 
and  dissecting  it  away  from  the  parts  beneath.  The  growth  having  been  removed,  ti.e 
conjunctiva  should  be  closed  over  the  wound  by  a  suture  and  the  eye  kept  bandaged  for 
two  or  three  days  after  the  operation. 

Lipoma  is  met  with  as  a  tumor  projecting  beneath  the  upper  lid,  near  the  fornix, 
and  often  between  the  superior  and  external  recti  muscles;  it  somewhat  resembles  a  third- 
lid.  If  the  tumor  gives  any  trouble,  it  must  be  removed  by  operation,  thus:  The  patient 
lying  on  the  couch,  the  lids  should  be  kept  as  widely  open  as  possible  by  a  wire  spec- 
ulum, an  incision  made  with  a  cataract  knife  through  the  conjunctiva  over  the  tumor, 
and  its  most  projecting  portion  seized  with  toothed  forceps  and  removed  with  scissors; 
care  must  be  taken  not  to  drag  upon  the  growth,  as  it  is  continuous  with  the  fat  in  the 
cavity  of  the  orbit,  a  great  portion  of  which  might  be  pulled  out.  As  much  of  the  tumor 
as  is  thought  necessary  having  been  removed,  the  conjunctiva  should  be  closed  over  it 
with  sutures  and  the  eye  bound  up. 

NSBVUS  occasionally  occurs  in  the  conjunctiva  ;  it  may  be  removed  by  the  knife  or 
destroyed  by  the  galvanic  or  other  cautery.  In  the  latter  case  due  precautions  must  be 
taken  to  guard  the  eyeball  from  injury  during  the  operation,  and  to  prevent  as  much  as 
possible  the  evils  arising  from  subsequent  cicatrization. 

Cancerous  ulcers  may  also  be  met  with ;  they  must  be  thoroughly  extirpated, 
the  eyeball  being  excised  if  neces.sary. 

Cysts  containing  a  clear  serous  fluid  are  occasionally  met  with  in  the  conjunctiva; 
they  must  be  punctured,  when  they  at  once  subside,  but  sometimes  re-form,  in  which 
case  a  portion  of  the  cyst  wall  must  be  excised  or  a  fine  seton  passed  through  it. 

CysticerCUS  also  occurs,  and  should  be  treated  by  incision  of  the  cy.st. 

EXTERNAL  MUSCLES  OF  THE  EYEBALL. 

Strabismus  (squint). — "  Strabismus  is  a  deviation  in  direction  of  the  axes  of  the 
two  eyeballs,  in  consequence  of  which  the  two  yellow  spots  receive  images  from  different 
objects.  In  convei'gent  strabismus  the  two  visual  lines  do  *not  cross  each  other  at  the 
point  it  is  desired  to  observe  ;  only  one  of  the  two — that  of  the  undeviating  eye — reaches 
it.  Under  this  deviation  not  only  does  the  expression  of  the  face  suffer  from  want  of 
symmetry  in  its  most  eloquent  parts,  but  the  power  of  vision — at  least,  in  one  of  the 
eyes — is  u.sually  disturbed,  and  the  squinter  always  loses  the  advantage  of  binocular 
vision  "   (Donders). 

Strabismus  must  not  be  looked  upon  as  a  special  form  of  disease ;  it  is  in  by  far  the 
greater  number  of  cases  a.ssociated  with  some  anomaly  of  refraction,  which,  being  the 
primary  cau.se  of  the  deviation,  gives  rise  to  the  strabismus.  Other  conditions  which 
may  induce  strabismus  will  be  subsequently  considered. 

Two  forms  of  squint  are  commonly  met  with  :  1.  Convergent;  2.  Divergent.  Other 
rare  forms  are  superior  and  inferior'  strabismus ;  these  will  receive  no  further  notice. 

Convergent  strabismus  is  the  most  common  of  all,  and  is  almost  always  the  result  of 
hypermetropia. 

Divergent  strabismus  is  usually  the  result  of  myopia. 

Convergent  strabismus,  as  just  stated,  is  nearly  always  the  result  of  hyperme- 
tropia.    The  question  naturally  ai'ises.  How  does  hypermetropia  produce  it? 

The  hypermetropic  individual  must  always  accommodate  strongly  when  looking  at 
even  a  distant  object,  and  as  the  object  is  brought  nearer  the  tension  of  accommodation 
must  be  correspondingly  increased.  As  stated  at  page  204,  accommodation  is  associated 
with  convergence  of  the  visual  lines.  Now,  the  greater  the  degree  of  convergence,  the 
more  strongly  is  the  accommodation  brought  into  play ;  consequently,  there  is  an  ever- 


CONVERGEST  STRABISMUS.  2i>9 

increasing  tendency  on  the  |i:irt  of  tlie  hypernietropic  individual  to  converge  too  much, 
in  order  to  bring  his  accnninindutiiui  into  the  highest  possihle  state  of  tension.  If  the 
convergence  of  the  visual  lines  be  excessive  or  they  do  not  meet  in  the  same  point,  con- 
vergent strabismus  results. 

Till-  (|uc?«tii>n  next  arises,  Whv  <1<>  ""t  all  livpcrnit'troj)ic  individuals  s(|uint  ?  The 
reason  is  that  if  both  eyes  are  of  the  same  refraction  and  have  e(|ual  acutencss  of  si^dit 
there  is  always  such  a  desire  to  maintain  binocular  vision  that  the  visual  lines  will  remain 
directed  to  the  same  p(»int.  even  though  the  eyes  arc  not  accurately  accommo<lated  for 
that  i>oint.  the  individual  being  content  with  ill-defined  retinal  ima;:cs  rather  than  sacri- 
tice  binocular  vision  by  increasing  his  convergence. 

l?ut  if  vision  of  one  eye  be  less  acute  than  that  of  the  other  or  if  there  be  a  differ- 
ence of  refraction  b»'tween  the  two.  the  desire  for  binocular  vision  is  lost  or  its  value  very 
much  le.s.sened,  and  the  necessity  for  a  well-defined  image  on  one  retina  is  immediately 
felt.  The  aecommodation  is  put  fully  on  the  stretch,  and  with  it  the  degree  of  converg- 
ence becomes  excessive,  both  visual  lines  being  directed  to  points  nearer  to  the  eyes  than 
that  for  which  they  are  accommodated,  the  deviation  of  the  more  defective  eye  being 
greater  than  that  of  its  fellow. 

Ordinary  convergent  or '-concomitant "  squint  has  to  be  distingui.shed  from  squint  the 
result  of  paralysis — "paralytic"  squint.  This  can  be  done  by  noticing  the  relation  of 
the  convergence  of  the  eye  which  is  observed  to  be  s((uinting — '•  primary  "  squint — to 
the  deviation — '"secotidary  8((uiiit  ' — which  occurs  in  the  properly  directed  eye  when  it 
is  covered  and  an  attempt  ina<le  to  fix  an  object  with  the  .sf|uinting  eye.  In  concomitant 
squint  the  "  primary  "'  and  "  secondary  "  deviations  are  equal  ;  in  paralytic  .squint  the  "  .sec- 
ondarv  '  deviation  is  greater  than  the  "  primary.  ' 

Thkat.mknt. — Slight  cases  of  convergent  strabismus,  especially  if  the  deviation  is 
not  constantly  present,  but  only  occasional  (periodic  squint),  may  be  cured  by  the  use  of 
glasses  which  accurately  neutralize  the  exi.sting  hypermetropia. 

In  more  severe  cases  division  of  the  internal  rectus  tendon  in  one  or  both  eyes  is 
necessary. 

It  is  often  difficult  to  decide  whether  only  one  or  both  eyes  .shall  be  operated  on. 

If  it  is  found  that  one  eye  S(|uints  habitually  and  to  no  great  extent,  the  other  being 
always  used  for  fixing  an  object,  division  of  the  internal  rectus  of  that  eye  which  habitu- 
ally deviates  alone  is  necessary. 

If  each  eye  deviates  alternately  (alternating  strabismus)  and  to  no  great  extent, 
division  of  one  internal  rectus  may  be  sufficient ;  but  if,  three  weeks  or  a  month  after 
the  operation,  the  squint  still  continues,  tenotomy  of  the  internal  rectus  of  the  other  eye 
should  be  performed. 

If  one  eye  squints  considerably  and  habitually  or  if  the  deviation  is  excessive  and 
alternating,  the  internal  rectus  in  both  eyes  must  be  divided.  In  any  case,  if  there  be 
a  doubt  as  to  whether  one  or  both  eyes  should  be  operated  on,  it  is  well  to  be  on  the  safe 
side  and  do  only  one  at  a  time. 

Operations  for  Convergent  Strabismus. — There  are  two  principal  methods 

of  operating  for  convergent  strabismus. 

1.  The  operator  .should  stand  on  the  right  side  of  the  patient,  placed  in  the  usual 
position  (Fig.  Ill,  p.  290),  and.  the  eyelids  being  kept  well  open  with  a  wire  speculum, 
should  seize  the  conjunctiva  and  subconjunctival  fascia  with  the  toothed  forceps  (Fig. 
116,  <j)  at  a  point  about  midway  between  the  margin  of  the  cornea  and  semilunar  fold 
and  just  below  the  inferior  margin  of  the  tendon  of  the  internal  rectus  muscle.  An 
incision  should  then  be  made  with  strabismus  scissors  (Fig.  IIG.  c)  through  the  conjunc- 
tiva and  subconjunctival  tascia.  well  down  to  the  sclerotic,  and  the  strabismus  hook  (Fig. 
IIG,  //)  passed  through  the  opening  and  inserted  between  the  tendon  and  the  eyeball.  If 
properly  introduced,  the  hook  will  be  brought  up  short  at  the  insertion  of  the  tendon 
into  the  sclerotic  when  it  is  pulled  forward  ;  it  should  be  held  firmly  in  position,  the  scis- 
sors passed  through  the  opening,  one  blade  following  the  hook  between  the  tendon  and 
the  eyeball,  the  other  being  kept  outside  the  tendon,  which  is  thus  included  between  the 
two  blades,  and  the  tendon  should  then  be  divided  by  one  or  two  sharp  strokes  with  the 
scissors. 

The  scissors  may  now  be  withdrawn  and  the  hook  pulled  forward ;  if  the  latter  meets 
with  no  resistance,  but  passes  freely  up  to  the  corneal  margin,  the  operation  has  been 
successfully  performed.  To  make  sure  of  this,  however,  the  hook  should  be  withdrawn, 
the  action  for  hooking  the  tendon  repeated,  and  any  fibres  that  may  have  escaped  division 
cut  throug'h. 


500 


CONVERGEXT  STRABISMUS. 


-trabismus  Hook 


On  the  division  of  the  tendon  the  muscle  retracts,  the  retraction  being  limited  by  the 
subconjunctival  fascia  with  which  it  is  intimately  connected.  If  the  eye  is  not  properly 
directed  after  simple  division  of  the  tendon,  a  greater  effect  may  be  produced  by  further 
freely  severing  the  subconjunctival  fascia. 

2.  In  the  second  operation  the  position  of  the  patient  and  surgeon  should  be  the 
same  and  the  lids  be  kept  open  with  the  wire  speculum,  as  in  the  one  already 
described. 

An  incision  should  be  made  with  scissors  through   conjunctiva  and  subconjunctival 

fascia  over  the  insertion  of  the 
tendon,  instead  of  below  its  infe- 
rior margin,  the  tendon  then  picked 
up  with  the  strabismus  hook,  and 
divided  close  to  the  sclerotic.  The 
wound  in  the  conjunctiva  should 
be  afterward  closed  with  a  fine 
suture. 

No  after-treatment  is  required 
for  strabismus  operations ;  the  pa- 
tient may  go  about  as  usual  and 
simply  keep  the  eyes  clean.  But 
if,  when  the  eyes  have  quite  re- 
covered from  the  effects  of  the 
operation,  there  should  be  any  re- 
turn of  the  squint,  the  degree  of 
hj-permetropia  must  be  carefully 
ascertained  and  glasses  which  thor- 
oughly neutralize  it  ordered  to  be 
used  for  all  purposes.  In  mo.st 
cases  this  will  be  found  sufficient  ; 
but  if,  after  the  glasses  have  been 
perseveringly  worn  for  some  weeks, 
no  effect  is  produced,  the  operation 
should  be  repeated  in  one  or  both 
eyes. 

Use  of  Anaesthetics  in 
Operations  for  Convergent 

Strabismus.  —  AVhetlier  ana?s- 
tlietics  should  be  employed  or  not 
in  squint  operations  appears  to  be 
a  matter  of  opinion,  some  eminent  oculists  never  employing  them,  others  again  rarely 
operating  without.  For  my  own  part,  I  prefer  not  to  emplo}"  an  anaesthetic  if  the  patient  is 
pretty  steady,  but  with  children  and  nervous  adults  I  always  use  one.  taking  care,  how- 
ever, that  a  full  effect  is  not  produced  ;  and  if  there  is  any  doubt  as  to  whether  one  or 
both  eyes  are  to  be  operated  on,  I  allow  the  patient  to  come  nearly  to  after  finishing  one 
eye,  so  as  to  ascertain  the  effect  produced  by  what  has  been  done.  If  an  anaesthetic  is 
given  to  such  an  extent  as  to  exert  its  fullest  influence  and  produce  thorough  muscular 
relaxation,  an  erroneous  idea  of  the  effect  of  the  operation  is  likely  to  be  formed,  and  on 
the  return  of  consciousness  the  squint  may  remain  as  bad  as  ever. 

Other  conditions  than  hypermetropia  which  may  produce  convergent  strabismus  are — 

1.  Disease  of  the  brain. 

2.  Paralysis  of  the  external  rectus  muscle. 

3.  Inflammatory  or  other  changes  in  the  internal  rectus  muscle  itself,  producing 
shortening. 

In  the  first  two  of  these  no  operation  is  advisable  ;  the  third  may  sometimes  be  rem- 
edied by  operative  interference. 

Divergent  strabismus,  as  already  stated,  is  often  the  result  of  myopia ;  it  is 
usually  consequent  on  high  degrees  of  the  anomaly  and  is  brought  about  as  follows  : 
The  highly  myopic  individual  requires  to  bring  objects  very  near  the  eyes  to  see  them 
distinctly  ;  con.sequently,  a  very  high  degree  of  convergence  is  necessary  to  keep  both 
visual  lines  directed  to  the  same  point.  Now,  not  only  has  a  high  decree  of  convergence 
to  be  maintained,  but  in  myopia  the  length  of  the  eyeball  and  the  consequent  impairment 
of  its  mobility  place  the  internal  recti  at  a  disadvantage.     Moreover,  in  order  to  direct 


Toothed  and  Fixing  Forceps. 
a,  their  points  shown  in 
side  view  ;  b,  front  view. 


i^trabismus  Scissors. 


()i'/:/:.iTin\s  nx  riii:  coiisr.A.  .'}01 

the  visual  liiii's  of  the  iiiVDpic  i-yt's  t(»  th»!  saiiu!  jmiiit,  a  ^rrcatrr  pidpiirtidMato  aiiioiiiit  of 
convcrgciuH'  is  mjuiivd  than  in  t-nmu'tropia. 

As  u  c()nsiM(UL'iicL'.  thi'  iiitcrnal  rt'ctus  of  one  eye  sooner  or  hiter  becomes  wearied  and 
gives  in  and  the  eye  deviates  outward,  hinoeuhir  vision  Iteinj;  saeriticed. 

Tkkatmknt. — Many  eases  (»f  diverj^ent  strahisiniis  may  be  remedied  by  the  use  of 
coneave  <;hisses.  whieh  enal)h(  the  individual  to  see  distinctly  at  a  distance  up  to  which 
conver^jenee  of  the  visual  lines  can  be  maintained  withitut  undue  strain  of  the  internal 
recti  muscles. 

11".  in  spite  of  the  use  of  jilasses,  the  diver<;ence  continues,  it  must  be  remedied  by 
ojteration.  In  cases  where  the  eye  oidy  deviates  outwanl  alter  an  object  has  been  lookeil 
at  for  some  considerable  time,  subconjunctival  division  of  the  external  r(?ctJis  of  the  devi- 
atiiijr  or  of  both  eyes  may  sutVice  for  a  cure  ;  but  in  cases  where  one  or  both  eyes  diverj^e 
constantly,  and  the  visual  lines  can  only  be  made  to  meet  in  one  point  by  a  ^'reat  effort, 
or  not  at  all,  the  ojieratioii  of  •' readjustment"  must  be  perfornKjd. 

This  ojteration  can  be  jterfornuul  as  follows:  The  patient  being  plaee<l  in  tlw;  usual 
position  (Kijr.  Ill,  l».  2IK>)  and  thorouirhly  an;estheti/,ed,  the  operator  should  stand 
behiiul,  fix  the  lids  open  with  a  wire  speeuiiini.  with  scissors  make  an  incision  throufjh 
the  conjunctiva  and  subconjunctival  fascia  below  the  insertion  of  the  external  rectus, 
hook  up  the  tendon,  and  divide  it  subconjunctivally  close  to  the  sclerotic. 

An  incision  should  then  be  made  through  conjunctiva  and  subconjunctival  fascia, 
about  midway  between  the  insertion  of  the  internal  rectus  and  inner  margin  of  the  cor- 
nea, of  such  a  length  as  to  reach  about  two  lines  above  and  a  like  distance  below  the  nuir- 
gins  of  its  tendon,  which  should  then  be  hooked  up  and  divided.  The  muscle  and 
subconjunctival  fascia  should  be  freely  separated  from  the  parts  beneath  and  together 
with  the  conjunctiva  turned  back  toward  the  caruncle.  Two  curved  needles  holding  fine 
silk  should  then  be  passed  through  the  tissues  next  the  margin  of  the  cornea  and  the  silks 
firmly  tied,  two  free  ends  being  left ;  the  needles  should  then  be  carried  from  within  out- 
ward through  the  muscle,  subconjunctival  fascia,  and  conjunctiva,  as  near  the  inner 
canthus  as  possible,  and  the  silk  drawn  through  ;  a  considerable  portion  of  the  mu.scle 
and  other  tissues  should  then  be  removed  with  scissors,  the  free  ends  of  the  two  fine 
pieces  of  silk  and  the  portions  to  which  the  needles  are  still  attached  then  tied  firnily 
together  (the  eye  being  rolled  well  inward  by  an  assistant  as  the  knots  are  pulled  tight j, 
and  the  ends  of  the  two  sutures  cut  off  close. 

The  eye  should  be  bound  up  \vith  wet  lint  and  a  bandage.  The  sutures  will  probably 
ref|uire  removal  in  about  four  or  five  days,  but  may  be  left  longer  if  they  cause  no 
irritation. 

Divergent  strabismus  is  met  with  in  cases  of  paralysis  of  the  third  nerve  ;  it  may  also 
occur  in  non-hy])ermetropic  eyes  if  the  sight  of  one  has  become  much  impaired  and 
binocular  vision  is  no  longer  possible,  and  may  be  caused  by  too  free  a  division  of  the 
tendon  in  the  operation  for  convergent  squint.  In  the  first  of  these  cases  no  operation 
is  advisable  ;  in  the  second,  no  improvement  of  sight  is  to  be  expected  from  readjustment, 
but  the  operation  may  be  performed  simply  to  remedy  disfigurement;  in  the  third,  read- 
justment should  be  performed. 

THE  CORNEA. 

The  affections  of  the  cornea  which  recjuire  an  operation  upon  the  structure  it.self  are 
six:  1.  Sloughing  ulcer;  2.  Conical  cornea;  3.  Corneal  opacity;  4.  Staphyloma;  5. 
Lodgment  of  foreign  bodies  :   (I.    New  growths. 

Paracentesis,  or  Tapping  the  Cornea. — Tliis  operation  is  sometimes  per- 
formed in  cases  of  sloughing  ulcer,  or  suppuration,  threatening  perforation  ;  by  the  timely 
evacuation  of  the  contents  of  the  aqueous  chamber  a  large  rupture  of  the  corneal  tissue, 
with  its  acconqianying  evils,  may  in  many  cases  be  avoided. 

Tapjting  the  cornea  may  be  done  thus:  The  patient  being  in  the  usual  position  (Fig. 
Ill,  p.  21X)),  the  operator  should  stand  behind  and  fix  the  lids  open  by  a  wire  speculum 
or  by  the  fingers.  A  broad  needle  shmild  then  be  passed  through  the  cornea  at  some 
convenient  part  of  its  margin  :  when  the  point  of  the  needle  has  fairly  entered  the 
anterior  chamber,  its  handle  should  be  rotated,  so  as  to  bring  the  breadth  of  the  blade 
across  the  incision  and  thus  open  it ;  as  soon  as  the  contents  of  the  anterior  chamber 
have  flowed  out  the  needle  should  be  withdrawn,  a  drop  of  eserine  solution  placed 
between  the  lids,  and  the  eye  bound  up  in  the  usual  manner. 

Iridectomy,  however,  is  to  be  preferred  to  paracentesis. 


302  OPERATIONS  ON  THE  CORNEA. 

Conical  cornea  ("  Staphyloma  corniae  pellucidum  "),  as  the  name  implies,  signifies 
an  alteration  in  the  curvature  of  the  cornea  of  such  a  nature  that  it  assumes  the  form  of 
a  cone.     The  origin  of  the  affection  cannot  clearly  be  traced. 

The  most  prominent  symptom  is  gradually  increasing  myopia,  which  cannot  be  reme- 
died by  concave  lenses.  On  looking  at  the  cornea  in  profile  its  conical  form  is  very 
evident. 

On  examination  with  tlie  ophthalmoscope  by  the  direct  method,  the  apex  of  the  cone, 
which  may,  however,  be  the  seat  of  some  opacity,  appears  brightly  illuminated  ;  around 
this  bright  portion  is  a  dark  ring  corresponding  to  the  sides  of  the  cone,  this  being  again 
succeeded  by  an  area  giving  a  bright  reflection  and  corresponding  to  a  portion  of  the 
cornea  which  retains  more  or  less  its  natural  curvature. 

Objects  occupying  the  fundus  of  the  eye  are  seen  through  the  apex  and  sides  of  the 
cone  near  its  base  in  an  inverted  position,  as  in  myopia,  whilst  we  obtain  a  more  or  less 
■distinct  erect  image  of  the  same  parts  through  the  portion  of  cornea  which  still  retains 
its  normal  curvature.  The  retinal  vessels  appear  to  have  a  whirl-like  motion  as  we 
change  our  point  of  view  from  side  to  side.  The  appearance  is  quite  characteristic,  and, 
once  seen,  is  not  likely  to  be  forgotten. 

Treatment. — Conical  cornea  can  only  be  remedied  by  operative  interference ;  two 
methods  of  operating  are  practised,  the  object  of  each  being  to  flatten  the  cone  and  restore 
to  the  cornea  moi'e  or  less  of  its  natural  curvature. 

In  one  operation  an  elliptical  portion  including  the  whole  thickness  of  the  cornea  is 
removed  from  the  apex  of  the  cone.  The  operation  can  be  performed  thus  (for  the  posi- 
tion of  patient  and  operator  see  Fig.  Ill,  p.  290):  An  ana\sthetic  should  be  given,  the 
lids  held  open  by  a  wire  speculum,  and  the  eyeball  fixed  by  seizing  with  the  toothea 
forceps  the  conjunctiva  and  subconjunctival  fascia  at  some  point  near  the  corneal  margin. 
A  straight  cataract  extraction  knife  (Fig.  120,  <:•)  should  then  be  thrust  through  the  cone 
from  side  to  side,  a  small  flap  formed  by  cutting  out  either  ui)ward  or  downward,  and  the 
flap  so  made  seized  with  iris  forceps  and  removed  with  scissors. 

In  this  operation  the  anterior  chamber  is  opened  and  the  cornea  collapses  as  soon  as 
the  first  incision  is  made.  Care  must  be  taken  that  the  portion  removed  includes  the 
most  prominent  part  of  the  cone,  and  that  the  opening  left  is  exactly  opposite  the  pupil. 

After  the  operation  the  speculum  must  be  very  carefully  removed,  and  the  lids  gently 
closed  and  bandaged  in  the  usual  way  ;  the  eye  must  on  no  account  be  examined  for  a 
week,  so  as  to  give  time  for  the  opening  in  the  cornea  to  fill  up.  The  wound  will  in  all 
probability  heal  in  the  course  of  ten  days,  the  anterior  chamber  being  restored. 

The  margin  of  the  pupil  is  not  unfrequently  caught  up  in  the  incision,  an  anterior 
synechia  resulting. 

The  operation  described  gives  the  most  satisfactory  results,  the  curvature  of  the 
cornea  being  greatly  improved  and  a  corresponding  amount  of  vision  regained. 

In  the  second  operation  a  superficial  portion  only  is  removed  from  the  apex  of  the 
cone  with  a  small  trephine,  a  raw  surface  being  left,  which  by  its  subsequent  cicatriza- 
tion and  contraction  causes  considerable  flattening  of  the  cone. 

Tinting  the  cornea  is  called  for  in  cases  of  dense  white  opacity  (leucoma),  caus- 
ing disfigurement.  The  operation  can  be  performed  as  follows  (for  position  of  patient 
and  operator  see  Fig.  Ill,  p.  290):  An  anaesthetic  having  been  given,  the  operator 
should  place  the  wire  .speculum  between  the  lids,  fix  the  globe  with  the  toothed  forceps, 
paint  some  Indian  ink  upon  the  opacity,  and  prick  it  thoroughly  in  with  a  bunch  of 
needles  fixed  in  an  ivory  handle ;  the  ink  should  be  sponged  away  from  time  to  time  in 
order  to  allow  the  operator  to  see  what  progress  he  has  made. 

The  opacity  having  been  thoroughly  tinted,  the  speculum  should  be  removed  ;  no 
bandage  need  be  applied,  and  no  after-treatment  is  necessary  ;  very  little  irritation  fol- 
lows. If,  after  the  lapse  of  a  week  or  ten  days,  the  opacity  do  not  appear  sufficiently 
blackened,  the  operation  may  be  repeated. 

If  the  ink  be  allowed  to  get  into  the  wound  made  in  the  conjunctiva  by  the  toothed 
forceps,  a  black  mark  will  be  left ;  care  should  therefore  be  taken  to  fix  the  globe  at  a 
point  to  which  the  ink  cannot  run.  Should  the  anterior  chamber  be  opened,  the  opera- 
tion must  be  discontinued,  as  the  lens  may  be  wounded. 

Staphyloma,  first  so  called  from  its  supposed  resemblance  to  a  grape,  has  now 
come  to  mean  a  bulge  on  any  part  of  the  eyeball.  On  the  cornea  it  is  caused  either  by 
yielding  of  its  structure  or  more  commonly  by  prolapse  of  iris  through  a  perforation  in 
it,  the  prolapsed  portion  being  firmly  coated  over  with  inflammatory  material.  Staphy- 
lonui  is  said  to  be  "  total  "  where  the  whole  of  the  cornea  is  affected,  ''  partial  "  when 


OPKRATJnSS   O.V   77//;  IRIS.  303 

hoiiu'  jmrtidii  of  it  rt'tiiiiis  its  iiortiial  ciirvatun'.  Total  staphylonia  slioiild  Itc  removed 
bv  abscission  (see  p.  27')),  or  the  eyeball  may  be  exeisetl.  Partial  staphyloma  may  sub- 
side on  the  performance  of  iridectomy  or  can  be  reniovtMl  as  follows  :  The  position  of 
jiaticiit  and  operator  should  be  as  at  l''i;;.  Ill,  p.  li'.K),  and  an  amusthetic  should  be 
administered.  The  lids  bciiiL'  ke|»t  open  by  the  wire  sj)eculum,  a  curviMJ  needle  armed 
with  tine  silk  shonlil  be  passed  tbrouirh  the  })ase  of  the  staj)hyloma,  an  elliptical  portion 
of  which  should  (hen  be  removed  with  a  straight  cataract  knii'e  ;  tin;  silk  should  then  be 
drawn  through  and  tied,  thus  brin^in;^  the  cdt^cs  of  the  ^aj»  nnide  by  the  removal  of  the 
elliptical  portion  tot::elher,  and  the  eye  bandaiied  in  the  usual  way.  The  suture  may  be 
rciMiivcd  ill  tlic  ciMirsc  of  three  or  four  days. 

Foreign  Bodies. — Small  fraj,nnents  of  metal,  chips  of  stoiut,  thorns,  etc.,  are  not 
unfreijuentlv  found  lodir,.d  in  the  coriu-a.  To  remove  them  the  jtosition  (»f  patient  and 
operator  shouhl  be  as  at  Kii;'.  1  1<(,  p.  2IK(.  As  a  rule.no  an;t\sthetic  wavA  })e  administere<l. 
The  lids  .slu)uld  be  kej)t  open  by  the  fore  and  rinii  fiii<i;ers  of  one  liand,  and  the  <:lobe 
steadied  by  irently  ])ressinj;  upon  it  with  thesecond  tinjrer ;  the  forei<rn  body  should  then 
be  carefully  lifted  ironi  its  bed  with  the  ))oint  of  a  knife  or  small  spud  held  li<i;litly  in 
the  other  Iiand.  Foreign  bodies,  especially  thorns,  are  .sometimes  so  firtnly  atid  deeply 
embcildcd  that   they  re(|uire  to  be  cut  out. 

New  growths  miiy  be  met  with  sjirinfrinir  from  the  cornea. 

Congenital  tumor  is  a  small  white  flattened  elevation  usually  situated  near  the 
corneal  maruin,  encroachini;-  on  ])oth  cornea  and  sclerotic  ;  it  lies  beneath  the  corneal  epi- 
thelium and  conjunctiva  and  appears  to  extend  pretty  deeply  into  both  cornea  and  scle- 
rotic ;  the  urowth  is  present  at  birth,  but  usually  increases  somewhat  as  the  child  grows 
up.      It  may  give  rise  to  astigmatism  by  causing  distortion  of  the  cornea. 

The  growth  may  be  single  or  there  may  be  two  or  three  little  tumors.  Their  struc- 
ture is  that  of  connective  tissue,  and  occasionally  small  hairs  grow  u])on  them. 

Should  the  little  growths  give  rise  to  inconvenience,  they  can  be  shaved  off  level  with 
the  cornea,  but,  as  a  rule,  they  cannot  be  entirely  removed. 

Round  and  spindle-celled  sarcomata  have  also  been  met  with  growing  from  the  cor- 
nea.    Such  cases  usually  call  for  extirpation  of  the  eyeball. 

THE  SCLEROTIC. 

Sclerotomy,  as  already  stated,  is  one  of  the  operations  for  the  treatment  of 
glaucoma.  In  ].erlorming  the  operation,  the  position  of  operator  and  patient  should  be 
as  in  Fig.  111.  p.  2U0.  The  instruments  required  are  a  straight  cataract  knife  (Fig. 
120,  c),  .speculum,  and  fixing  forceps.  The  lids  should  be  held  open  with  the  speculum, 
the  eyeball  fixed  with  the  forceps.  The  knife  should  be  entered  on  the  outer  side  of  the 
globe  as  far  back  in  the  sclerotic  as  is  consistent  with  the  entering  the  anterior  chamber 
quite  at  its  periphery,  pushed  across  the  chamber,  and  brought  out  at  a  corresponding 
point  on  the  inner  side.  The  transfixion  having  been  finished,  the  incisions  should  be 
eidarged  to  about  double  the  width  of  the  knife  blade,  which  .should  then  be  withdrawn, 
its  point  being  carried  round  the  margin  of  the  anterior  chaiuber  so  as  to  notch  the  parts 
bounding  it,  but  not  cut  through  the  sclerotic.  The  division  of  the  sclerotic  may  be 
made  either  upward  or  downward,  the  points  of  puncture  and  counter-puncture  be  situ- 
ated midway  between  the  ho'rizontal  meridian  of  the  cornea  and  its  upper  margin  in  the 
former  case,  midway  between  its  horizontal   meridian  and  lower   margin  in  the  latter. 

THE  IRIS. 

Iridectomy  is  called  for  in  all  cases  in  which  it  is  desirable  to  influence  the  tension 
or  nutrition  of  the  eyeball  ;  it  is  associated  with  some  operations  for  cataract,  in  a  some- 
what modified  form  is  one  of  the  methods  of  making  an  artificial  pupil,  and  is  useful  in 
some  other  conditions. 

The  operation  is  performed — 

1.  To  influence  tension. 

(rt)  In  shiuqhhi;]/  nlccrs,  or  suppuration  of  the  cornea,  accompanied  by  pain  and  threat- 
ening perforation.  In  such  cases  iridectomy  gives  almost  instant  relief  to  the  most 
severe  pain,  and  in  all  probability  will  save  the  cornea  from  rupture. 

(//)  In  injiiriex  of  the  ci/rhnU  in  which  the  crystalline  Ions,  being  wounded,  has  become 
opaque  and  swollen  and  is  pressing  on  surrounding  parts,  causing  severe  pain  and  threat- 
eniuir:  the  inteirritv  of  some  of  the  delicate  structures  within  the  iriobe.     In  these  cases 


304 


OPERATIONS  ON  THE  IRIS. 


not  only  does  iridectomy  diminish  tension,  and  so  relieve  pain,  but  gives  room  for  any 
subsequent  swelling  of  the  lens. 

(c)  In  staphyloma  of  the  cornea  iridectomy  often  causes  complete  subsidence  of  the 
projection. 

(d)  In  glaucoma  a  timely  and  well-performed  iridectomy  causes  instant  and  lasting 
diminution  of  tension  and  places  the  eye  in  comparative  safety  ;  the  operation  should  be 

performed  on  any  eye  that  can  dis- 
FiG.  117.  tinguish  bright  light,  and  to  relieve 

pain  in  any  case,  whether  there  be 
perception  of  light  or  not  ;  in  acute 
glaucoma  it  must  be  tried  even  if 
all  perception  have  been  lost  for 
some  days. 

2.  To  influence  nutrition,  iridec- 
tomy should  be  performed  in  chron- 
ic choroido-iritis,  recurrent  iritis, 
and  in  cases  of  total  exclusion  of 
the  pupil  where  there  is  no  com- 
munication between  the  anterior 
and  posterior  divisions  of  the  aque- 
ous chamber. 

3.  Associated  with  operations 
for  cataract,  iridectoni}'  should  be 
performed  previous  to  a  needle  ope- 
ration if  much  swelling  of  the  lens 
be  anticipated,  or  it  ma}-  require  to 
be  done  after  the  needle  has  been 
used  if  pain  or  increase  of  tension 
occur. 

The  operation  .should  also  be 
performed  at  some  time  previous  to 
or  simultaneously  with  small  flap  or 
linear  extraction  of  cataract. 

4.  Iridectomy  for  artificial  pupil  is  mentioned  at  another  page. 

5.  Other  conditions  in  which  iridectomy  may  be  required  are — 
(a)  Hemorrhage  into  the  vitreous  humor. 

(6)  Displacement  of  the  retina. 

(c)  As  an  aid  to  the  removal  of  foreign  bodies  from  the  globe. 

{d)  Some  peculiar  conditions  of  intraocular  circulation. 
Operation  of  Iridectomy.  Instrummtf. — A  wire  speculum  (Fig.  114),  a 
straight  or  bent  iridectomy  knife  (Fig.  117,  a),  a  pair  of  toothed  forceps  (Fig.  116,  a),  a 
pair  of  iris  forceps  (Fig.  117,  /^),  iris  scissors  (Fig.  117,  c),  and  a  curette  (Fig.  120.  «). 
For  the  position  of  patient  and  surgeon  see  Fig.  Ill,  p.  290,  The  patient  should  be 
brought  fully  under  the  influence  of  an  anesthetic,  the  lids  kept  widely  open  by  the  wire 
speculum,  and  the  eyeball  fixed  by  seizing  the  conjunctiva  and  subconjunctival  fascia 
near  the  corneal  margin  with  the  toothed  forceps ;  then,  with  a  straight  or  bent  iridectomy 
knife  of  medium  size,  an  incision  should  be  made  in  the  sclerotic  in  such  a  position  that 
the  knife  enters  the  anterior  chamber  quite  at  its  peripheral  part  and  close  to  the  anterior 
surface  of  the  iris. 

The  knife,  having  entered  the  anterior  chamber,  should  be  pu.shed  steadily  on  (care 
being  taken  to  keep  its  point  well  forward  toward  the  cornea,  so  as  not  to  wound  the 
lens)  until  the  point  is  opposite  the  centre  of  the  pupil.  The  point  should  then  be  turned 
to  one  side,  so  as  to  be  out  of  the  pupillary  area,  and  the  knife  slowly  and  gently  with- 
drawn, the  hold  of  the  forceps  being  let  go  at  the  same  time.  The  incision  thus  made 
should  be  of  such  a  length  as  to  correspond  to  a  little  more  than  one-fourth  of  the  cir- 
cumference of  the  iris. 

The  next  step  in  the  operation  is  the  removal  of  a  portion  of  the  iris.  If,  as  is  not 
unfrequently  the  case,  the  iris  has  become  prolapsed,  it  needs  only  to  be  seized  with  the 
forceps  and  a  piece  of  the  desired  size  removed  with  the  scissors.  If  the  iris  does  not 
protrude,  the  iris  forceps  should  be  introduced,  .shut,  through  the  wound  in  the  sclerotic, 
and  pushed  on  until  the  extremities  of  their  branches  are  opposite  the  nearest  portion  of 
the  pupillary  margin  ;  they  should  then  be  allowed  to  open  of  themselves,  when  the  iris 


a.  Bent  Iridectomy 
Knife. 


h.  Iris  Forceps. 


Iris  Scissors. 


Ol'EllATlnSS   O.V    77//;   IIUS.  305 

will  bf  puslicil  between  tlie  braiielie>  l>y  tlie  |ire>>ure  of  the  parts  behind  ;  no  backward 
pressure  must  l)e  made  with  the  fnreejis.  but  they  shuiiM  be  ^'ently  eh>se<l  ajraiii  and 
withdrawn,  oarryini;  the  iri>  with  them,  which  sln»uhl  tlien  l)e  cut  across  witli  the  scis- 
sors. eh)se  to  one  an;_de  of  the  wound,  drawn  over  to  the  other  an^rle.  and  a  piece  cut  off; 
the  curette  shtiuhl  be  passed  between  the  lijis  of  the  wound,  .so  as  to  pusli  back  any  por- 
tions of  iris  tlnit  may  liave  become  entan<rled  in  it.  The  eye  sliouhl  then  be  bound  up 
with  lint  and  a  banthige.  The  form  of  the  pupil  after  a  well-performed  iridectomy  should 
resemble  Fii:.  HI*.  D.' 

With  rejrard  to  the  position  of  the  portion  of  tlie  iris  to  be  removed  opinions  are  at 
variance.  If  the  surgeon  In-  a  skilful  and  experienced  operator  and  has  tin*  aid  (»f  a  com- 
petent assistant,  the  irideetomy  should  be  done  upward.  s<t  as  to  place  the  <:ap  beneath 
the  upper  lid.  and  thus  conceal  it  as  much  as  possible. 

To  perform  iridectomy  upward,  a  bent  iridectomy  knife  should  he  used  and  the  incis- 
ion made  in  the  sclerotic  above  the  upper  mar<rin  of  the  cornea;  an  assistant  should  then 
draw  the  eyeball  downward  with  forceps,  the  iris  forceps  should  be  inserted,  and  the  por- 
tion of  iris  removed  as  previously  directed. 

An  inexperienced  operator  will  find  it  much  easier  to  remove  the  portion  of  iris  from 
its  outer  and  lower  segment.  In  this  ca.se  a  straight  iridectomy  knife  can  be  u.sed  and 
no  assistant  is  required.  The  result  is  rather  an  ugly  gap,  the  disadvantage  of  which, 
however,  is  quite  counterbalanced  by  the  ease  and  safety  with  which  the  operation  can  be 
perfnrnied. 

Accidents  which  may  happen  during  the  Operation  of  Iridectomy 
and  Difficulties  which  may  be  encountered. — The  accidents  which  may  occur 

are — 

(1)  Wound  of  the  lens  from  insufficient  care  in  keejiing  the  point  of  the  knife  well 
forward  and  out  of  the  area  of  the  pupil.  This  accident  will  in  all  probability  be  followed 
by  the  formation  of  traumatic  cataract. 

(2)  Escape  of  vitreous  humor  is  very  likely  to  occur  in  hard  eyes  if  the  knife  be  too 
quickly  withdrawn  or  if  undue  pressure  be  exerted  on  the  globe  with  the  fixing  forceps. 

(8)  The  iris  may  be  torn  away  from  its  insertion  at  a  point  opposite  to  the  incision  If 
undue  triictimi  be  exerci.<ed  upon  it  with  the  iris  forceps. 

Difficulties. — The  iris  may  be  found  so  rigid  that  it  cannot  be  seized  with  the 
forceps,  or  so  rotten  that  only  very  small  portions  can  be  brought  away ;  sometimes  it 
bleeds  profusely  when  touched,  filling  the  anterior  chamber  with  blood  and  considerably 
hindering  the  ojteration. 

Artificial  Pupil. — The  operation  for  artificial  pupil  is  performed  to  open  a  new 
path  for  ray>  y<\'  liirht  to  the  retina,  the  natural  passage  being  obstructed. 

It  is  indicated  in  the  following  cases:  (\)  In  opacity  of  the  cornea,  with  or  without 
anterior  synechi;e :  ('!)  In  closure  of  the  pupil :  (3)  In  extensive  posterior  synechias ; 
;4)  In  central  opacity  of  the  lens  or  its  capsule. 

The  artificial  pupil  must  be  small,  as  nearly  central  and  as  well  defined  as  possible. 
Care  must  be  taken  to  make  it  behind  that  portion  of  the  cornea  which  is  mo.st  trans- 
parent and  least  altered  in  curvature,  the  best  situation  being  ascertained  by  oblique 
illumination.  The  new  pupil  must  not  be  made  upward,  or  it  will  be  covered  by  the 
upper  lid. 

An  artijirial pupH  can  be  made  in  any  of  the  following  ways:  (1)  By  incision  of  the 
iris ;  (2)  By  tearing  it  away  from  its  insertion  ;  (3)  By  excision  of  a  portion  (iridectomy 
for  artificial  pupil)  ;  (4)  By  ligature. 

In  operations  for  artificial  pupil  the  position  of  patient  and  surgeon  should  be  the 
same  as  in  ••  iridectomy."  and  an  anaesthetic  should  be  administered. 

1.  (a)  Incision  TFig.  119  A). — This  operation  is  called  for  in  cases  of  complete  closure 
of  the  pupil  t'i>ll..\ving  removal  of  the  lens  either  by  operation  or  injury,  but  is  not  advis- 
able unless  the  lens  be  absent.  In  these  cases  the  iris  may  be  found  changed  intw  a  tense, 
unyielding  membrane  which  cannot  be  seized  with  forceps. 

The  operation  of  "  incision  "  may  be  performed  either  by  thrusting  a  broad  needle 
through  the  cornea  near  its  margin  and  then  incising  the  iris,  so  as  to  cut  across  its  radial 
fibres,  or.  an  incision  having  been  made  with  an  iridectomy  knife  in  the  sclero-corneal 
margin,  a  pair  of  scissors  (having  one  sharp  and  one  blunt-pointed  blade)  may  be  intro- 
duced through  the  wound,  one  blade  being  thrust  through  the  iris  at  its  nearest  point  and 
passed  behind  it.  the  other  carried  along  its  anterior  surface,  and  the  iris  then  cut  fairly 
across  from  one  side  to  the  other. 

Whichever  plan  of  incision  is  adopted,  the  vitreous  humor  pushes  forward  into 
20 


306 


OPERATIONS  ON  THE  IRIS. 


the  wound  and  keeps  its  edges  widely  separated,  a  pupil  resembling  Fig.  119  A,  being 
formed. 

Two  other  methods  of  making  an  artificial  pupil  by  •'  incision  "  have  been  lately  intro- 
duced ;  they  are  known  as  single  and  double  "iridotomy." 

For  the  positions  of  patient  and  surgeon  in  performing  either  of  these  operations  sec 
Fig.  Ill,  p-  290. 

(h)  Single  iridotomy  should  be  thus  performed  :  The  eyelids  being  kept  open  with  the 
wire  speculum  and  the  eyeball  fixed  by  seizing  the  conjunctiva  and  subconjunctival  fascia 

close  to  the  margin  of  the  cornea 
Fig.  118.  at  its  inner  side,  an  incision  should 

be  made  with  an  iridectomy  knife 
in  the  cornea  about  midway  be- 
tween its  margin  and  the  pupil  and 
opposite  to  the  point  of  fixation 
with  the  forceps.  The  forceps 
scissors  (Wecker's,  Fig.  118)  must  be  then  introduced,  closed,  through  the  wound  into 
the  anterior  chamber,  the  blades  opened,  one  passed  through  the  pupil  behind  the  iris,  the 
other  on  its  anterior  surface,  and  the  sphincter  of  the  pupil  be  divided  with  one  sharp 
cut.  The  scissors  should  then  be  withdrawn,  any  prolapse  of  iris  that  follows  replaced 
with  the  curette,  a  drop  of  atropine  placed  between  the  lids,  and  the  eye  lightly  bandaged. 
This  operation  is  applicable  to  cases  where  the  lens  is  present,  its  centre  being  opaque 
and  its  peripheral  portion  clear. 

(c)  Douhle  iridotomy  is  applicable  to  cases  of  closed  pupil  after  cataract  extractitm. 
An  incision  should  be  made  through  the  upper  part  of  the  cornea,  the  knife  carried 
through  the  iris  and  along  its  po.sterior  surface,  so  as  to  make  a  fair-sized  wound  in  it ; 
the  incision  being  finished,  the  knife  should  be  carefully  withdrawn,  and  very  possibly 
some  vitreous  humor  will  follow  it. 


Wecker's  Scissors. 


Fig.  119. 


A.  Pupil  after  Iiici^nm 


/<ij?7lFir?x. 


'iipil  after  Excision.    C.  Pupil  aftei  Ligature. 


D.  Iridectomy  for  Glaucoma,  etc. 


The  next  step  in  the  operation  is  to  pass  the  forceps  scissors,  closed,  through  the 
wound  in  the  cornea  into  the  interior  chamber,  open  them,  pass  one  blade  behind  the  iris, 
the  other  in  front  of  it.  make  an  incision  in  a  direction  downward  and  inward;  then 
change  the  direction  of  the  scissor  blades  and  make  a  cut  downward  and  outward.  Thus 
a  small  piece  of  iris  is  enclosed  by  a  V-shaped  incision,  the  apex  of  the  V  being  upward. 
The  small  portion  of  iris  contracts  up  and  a  somewhat  triangular  pupil  is  left.  The  eye 
should  be  bound  up  as  usual. 

2.  Tearing  away   the  Iris   from  its  Insertion   flridodialysisX — An 

incision  having  been  made  through  the  cornea  on  the  side  opposite  to  that  on  which 
the  iris  is  to  be  removed,  a  pair  of  iris  forceps  should  be  pas.sed  through  the  wound  and 
across  the  anterior  chamber,  the  iris  seized  close  to  its  greater  circumference  and  torn 
forcibly  away  from  its  insertion ;  the  instrument  should  then  be  carefully  withdrawn  and 
the  eye  bound  up.  If  necessary,  the  whole  iris  may  be  removed  in  this  way.  This  opera- 
tion is  applicable  to  cases  of  dense  corneal  opacity  (leucoma)  occupying  the  whole  of  its 
central  part,  some  transparent  cornea  being  left  at  the  margin. 

3.  Excision ;  Iridectomy  for  Artificial  Pupil. — An  incision  .should  be  made 

of  the  requisite  size  through  some  part  of  the  sclero-corneal  margin,  the  iris  forceps  intro- 
duced through  the  wound,  the  ends  of  their  branches  passed  fairly  up  to  the  margin  of 
the  pupil,  the  iris  seized  and  drawn  out  through  the  wound,  and  a  small  portion  removed 
with  scissors.  The  curette  should  then  be  passed  between  the  lips  of  the  wound,  so  as 
to  push  back  any  portion  of  iris  that  may  have  become  entangled  in  it ;  a  pupil  resem- 
bling Fig.  119,  B,  should  be  formed. 

4.  By  Ligature  (Iridodesis,  or  Iridesis). — An  incision  should  be  made  with 
a  broad  needle  near  the  margin  of  the  cornea,  a  small  noose  of  silk  laid  upon  the  surface 
of  the  eyeball  so  as  to  encircle  the  incision,  an  iris  hook  or  canular  forceps  then  passed 
through  the  noose  and  wound,  and  the  iris  drawn  gently  out ;  an  assistant  with  two  pairs 


(•ATM:  ACT.  .307 

of  ln();ul-('ii(l((l  rurccps  ^lioiild  sci/c  lacli  ciiil  nf  tlus  noo.se  and  firmly  ligature  the  includf-d 
portion  of  iris;  tlu-  iijiiitiirt'  will  drop  oil  in  tin'  course  of  a  few  days,  a  pupil  resenibling 
in  shape  Fig.   ll:>,  (\  being  left. 

THE  CRYSTALLINE  L^NS. 
Cataract. 

Hv  eataraet  we  understand  an  opacity  of  tlie  crystalline  lens. 

The  causes  of  this  opacity  arc  .snnunvhat  obscure,  but  it  probably  depends  on  impair- 
ment of  nutrition  of  the  lens  consc((uent  on  senile  decay  or  constitutional  condition." 
(r.  y.,  diabetes). 

It  also  (tecurs  in  cdunection  with  inHanimatory  changes  in  adjacent  parts — the  choroid, 
ciliary  body,  vitreous,  and  iris — is  met  with  as  a  congenital  defect,  and  very  frequently 
results   frnni   injury. 

Forms  of  Cataract. 

There  are  two  principal  forms  of  cataract: 

1.  77//'  cortiad  or  soft  aifaracf. 

2.  The  nucJi'((r  or  Jiard  cataracf. 

In  the  first  form  the  cortical  substance  of  the  lens  is  primarily  affected,  the  nucleus 
afterward  becoming  opaque,  the  whole  being  soft,  or  even  fluid. 

In  the  second  the  nucleus  of  the  lens  first  becomes  hard,  yellowish,  and  opaque,  the 
cortical  substance  being  subsequently  affected. 

The  cortical  cataract  is  met  with  as  an  idiopathic  disease  in  childhood  and  early  adult 
life,  and  as  the  result  of  iujury  at  all  ages. 

There  are  several  varieties  of  cataract. 

(a)  ZonuJar  or  JnmrU<(r  catorxct  is  either  congenital  or  commences  soon  after  birth; 
it  is  characterized  by  an  opacity  of  circular  form  and  well-defined  outline,  situated  in  the 
cortical  substance  of  the  lens,  but  at  some  distance  fr,?m  its  surface;  the  margin,  nucleus, 
and  superficial  layers  of  the  lens  are  transparent. 

(6)  Ordinar)/  congenital  cataract  is  a  bluish-white  opacity  of  the  whole  lens. 

(c)  Traumatic  cataract  is  an  opacity  of  the  lens  often  accompanied  by  swelling  and 
caused  by  rupture  of  its  capsule  from  injury  and  the  subsequent  action  of  the  aqueous 
humor  upon  its  substance. 

(ff)  Posterior  polar  cataract,  an  opacity  situated  at  the  posterior  pole  of  the  lens  ;  and — 

(e)  Entircl//  fluid  or  diffluent  cataract.,  caused  by  changes  in  the  lens  secondary  to 
inflammation  of  adjacent  parts. 

The  variety  of  cataract  met  with  in  diabetes  is  composed  principally  of  soft  material ; 
but  if  the  patient  be  advanced  in  years,  there  is  usually  a  hard  nucleus. 

Xnclear  cataracf  occurs  in  persons  who  have  passed  the  middle  period  of  life  and  is 
characterized  by  the  presence  of  a  hard  yellowish  central  portion  or  nucleus  of  varying 
size  and  density  ;  the  nucleus  is  surrounded  by  moi;e  or  less  soft  cortical  substance  and  is 
occasionally  of  a  greenish  or  almost  black  color,  giving  rise  to  what  is  known  a.?,  green  or 
hhtrk  cataracf. 

Diagnosis. — The  existence  of  cataract  is  easijy  ascertained  by  oblique  illumination, 
the  pupil  having  been  dilated  with  atropine  previous  to  making  the  examination. 

Treatment. — The  treatment  of  cataract  is  entirely  operative,  no  kind  of  medication 
being  of  the  least  use. 

Our  object  in  performing  an  operation  is  to  open  a  path  for  rays  of  light  to  pass  t<> 
the  retina.  This  can  be  attained  in  one  of  two  ways,  the  method  adopted  depending  on 
the  kind  of  opacity  present. 

1.  In  cases  (as  lamellar  cataract)  where  the  bulk  of  the  lens  is  clear,  the  opacity 
being  situated  in  the  axis  of  the  normal  pupil,  very  useful  vision  is  procured  by  making 
an  artificial  pu]iil  opposite  a  transparent  portion  of  the  lens.     (See  ''Artificial  Pupil.') 

2.  When  tile  whole  lens  is  opa(ine.  its  entire  removal  must  be  accomplished. 
Varieties  of  Operation. — Three  varieties  of  operation  are  performed  to  secure 

the  removal  of  the  whole  lens : 

1.  The  operation  for  solution   or  absorption. 

2.  Extraction. 

3.  Suction. 

Forms  of  Cataract  to  which  each  Operation  is  Applicable. — As  a 


308 


CATARACT. 


broad  rule,  cataract  occurring  in  persons  below  20  is  of  the  soft  or  cortical  form  and 
should  be  removed  by  sofiition  or  suction;  cataract  occurring  in  persons  above  30  (except 
traumatic  cataract)  is  of  the  hard  or  nuclear  form  and  must  be  removed  by  extraction. 

In  the  intermediate  decade  a  doubt  may  arise  as  to  what  is  the  best  plan  of  procedure  ; 
in  these  cases  the  surgeon  must  be  guided  by  the  general  appearance  of  the  cataract.  If 
it  appears  bluish  in  color  and  somewhat  swollen,  it  is  probably  soft  and  can  be  removed 
by  solution  or  suction;  if  there  is  a  distinct  yellow  reflection  from  its  centre,  denoting  the 
presence  of  a  hard  nucleus,  it  should  be  removed  by  extniction.  It  must  also  be  borne 
in  mind  that  loss  of  time  is  a  very  serious  consideration  with  most  patients;  consequently, 
a  preference  must  always  be  given  to  that  operation  which  will  allow  them  to  resume  their 
occupations  as  early  as  possible. 

Solution,  though  perhaps  somewhat  safer  than  extraction,  is  always  a  tedious  process, 
and  the  more  so  the  older  the  patient ;  consequently,  preference  must  be  given  to  extrac- 
tion in  all  cases  where  the  condition  of  the  patient's  sight  is  such  as  to  prevent  him  fol- 
lowing his  occupation,  even  though  there  be  no  appearance  of  a  hard  nucleus.  In  cases 
where  the  cataract  is  evidently  soft  and  one  eye  retains  useful  vision  solution  is  to  be 
preferred  to  extraction,  as  the  patient  can  continue  at  his  work  during  the  time  that 
absorption  is  going  on. 

Before  performing  any  operation  for  cataract  we  must  take  care  to  ascertain  that  the 
eye  has  good  perception  to  light,  indicating  that  the  retina  is  in  a  normal  condition ; 
otherwise,  no  improvement  in  vision  will  result  from  removal  of  the  lens. 

Oper.ations  for  Removal  of  Cataract. 

Solution. — In  the  operation  for  solution  the  capsule  of  the  lens  is  opened,  and  its 
substance  thus  allowed  to  be  acted  upon  by  the  aqueous  humor,  by  which  it  is  broken  up 
and  softened,  absorption  finally  taking  place. 

The  operation  can  be  performed  as  follows  (for  the  positions  of  patient  and  operator 
see  Fig.  Ill,  p.  290):  No  anaesthetic  is  needed;  the  pupil  should  be  well  dilated  with 
atropine;  the  operator,  keeping  the  eyelids  separated  by  the  fore-  and  ring-fingers  of 
one  hand  and  steadying  the  globe  by  pressing  the  second  finger  gently  upon  it,  should 
take  a  cataract  needle  in  the  other  hand  and  pass  it  obliquely  through  the  cornea  at  such 
a  distance  from  its  centre  that  any  resulting  cicatrix  will  not  interfere  with  vision  ;  the 
needle  should  then  be  pushed  on  across  the  anterior  chamber  into  the  area  of  the  pupil, 
its  point  then  depressed  and  three  or  four  incisions  made  with  it  in  the  lens  capsule,  so  as 
to  divide  it  freely.     Care  must  be  taken  to  use  the  needle  very  gently  and  not  to  pass  it 

too  deeply  into  the  lens ;    otherwise, 
Fig.  120.  the  suspensory  ligament  nuiy  be  torn 

and  the  lens  displaced. 

The  capsule  having  been  freely  di- 
vided, the  needle  should  be  carefully 
withdrawn  and  a  drop  of  solution  of 
atropine  placed  between  the  lids ;  the 
only  after-treatment  required  is  the 
constant  use  of  atropine,  so  as  to  keep 
the  pupil  widely  dilated. 

If  the  eye  be  examined  in  the 
course  of  a  few  days,  white  flocculent 
lens  matter  will  be  seen  protruding 
through  the  opening  in  the  capsule 
into  the  anterior  chamber,  showing 
that  the  lens  is  swelling  and  under- 
going solution. 

The  operation  will  probably  re- 
quire to  be  repeated  in  about  a  month 
or  six  weeks,  and  possibly  on  one  or 
two  subsequent  occasions,  before  the 
whole  lens  is  absorbed.  Care  must 
be  taken  not  to  do  too  much  at  one  sitting,  or  the  lens  may  swell  too  rapidly  and  press 
upon  the  surrounding  parts,  giving  rise  to  severe  pain,  increased  tension  of  the  globe, 
iritis,  cyclitis,  etc. 

Extraction  of  Cataract. — The  object  of  operations  for  extraction  of  cataract  is 


Instruments  for  Extraction  of  Cataract. 

a.  Curette  and  pricker.    6,  Triangular  cataract  knife,    c,  Straight 

cataract  knife  (Graefe's).    d,  Sharp  hook.    >-,  .Scooj). 


CATAnAf'T. 


.'}09 


the  rciimval  of  tin-  lens  tlimutrli  ;iii  iiirisiun  altup-tlicr  in  tin-  (•«»riK'a,  the  sclcrD-coriieal 
maiiriii.  partlv  in  tlic  .scliiotic  and  partly  in  the  sclfro-cfuiical  iiiarfrin,  or  wlidlly  iti  the 
sfltTiitic,  tlu'  incision  lifini:  I'itlicr  siiM|)I«'  or  asso('iat«Ml  with  excision  of  a  portion  of  iris. 

Kxtraction  can  hi-  hcst  pirfornicd  hy  oiii'  of  the  five  fuMowinj;  methods:  (\)  I'Map 
extraction;  (li)  Small  flap  with  iridectomy:  ('A)  Kxtraction  }»y  ohli(|U(!  corneal  section  ; 
(4)  Ijnear  extraction  ;  (."))  Kxtraction  hy  means  of  a  fraction  instrnmerit.  In  the  first 
and  third  methods  no  iris  is  removed;  in  the  second,  fonrth.  and  last,  iridectomy  should 
be  performed  either  at  the  time  of  removal  of  the  lens  or  sonu'  weeks  or  months  previ- 
ously. All  entirely  opacpie  lenses  (mature  cataracts)  may  he  removed  hy  the  first  or  third 
methods  ;  all  partiallv  npa(|ue  lenses  (immature  cataracts)  must  ho  extract erj  hy  the  .second 
or  fnurtli.  a  fraction  instrument  hein^  used  in  any  case;  where  ^^reaf  difticulty  i«  encoun- 
tered or  where  escape  nf  vitreous  has  taken  place  hefore  the  lens  has  been  extracted. 

We  shall,  however,  lind  that  in  all  cases  we  obtain  mo.st  uniform  success  by  extrac- 
tion a.ssoeiated  with  iridect<»my  ;  we  should  never  attempt  to  extract  an  immature  cata- 
ract without  first  excisinir  a  portion  of  iris,  and  it  is  well  to  do  so  as  a  preliminary  soma 
Weeks  ln'fure  the  lens  is  removed. 

Flap  Extraction. — The  instruments  re(|uired  for  flap  extraction  are  a  triangular 
cataract  kiiit'c.  sharp  hunk,  and  curette  (Fig.  120,  /y,  if,  a). 

For  the  p(»siti<iiis  of  patient  and  operator  see  Fig.  Ill,  p.  2JM(.  Xo  anjcsthetic  is 
re(|uired;  the  jtatient  should  Ite  requested  to  look  downward,  the  lid.s  kept  open  and  the 
eyeball  steadied  Ity  the  operator's  fingers  as  in  tlie  operation  for  sf)lution. 

The  incision  should  be  made  by  passing  a  triangular  cataract  knife  through  the  outer 
margin  of  the  cornea  at  a  point  just  above  its  horizontal  meridian,  into  and  across  *he 
anterior  chamber,  bringing  it  out  through  the  cornea  at  a  corresponding  point  on  the  inner 
side,  ami  completing  the  section  by  pushing  the  knife  onward  until  its  heel  cuts  out  along 
the  upper  margin  of  the  cornea  (Fig.  121,  A). 

Fig.  121. 


A 

A,  Flap.  B,  Oblique  corneal  section.        C,  Lineal  incision. 

Incisions  for  Extraction  of  Cataract. 


This  simple  onward  movement  of  the  knife  is  sufficient  if  the  inci.sion  has  been 
properly  planned ;  but  should  the  cornea  have  been  entered  too  low  down,  the  knife  will 
not  be  wide  enough  to  cut  out,  and  then  the  section  mu.st  be  completed  by  slightly  with- 
drawing the  blade  or  by  a  sawing  movement.  Care  must  be  taken  not  to  withdraw  the 
knife  until  it  has  passed  some  distance  through  the  opposite  side  of  the  cornea,  or  the 
aqueous  humor  will  escape  too  soon  and  the  iris  fold  over  the  edge  of  the  knife  and  be 
wounded. 

If  the  incision  has  been  properly  made,  it  will  lie  within  the  corneal  margin,  and  a 
semicircular  flap,  including  a  little  less  than  half  the  cornea,  will  be  formed. 

The  section  having  been  finished,  the  patient  should  close  the  eyes  gently  and  be 
allowed  to  rest  for  a  moment. 

The  next  step  in  the  operation  is  the  removal  of  the  opaque  lens.  The  upper  lid 
being  drawn  gently  upward  and  the  patient  directed  to  look  downward,  the  sharp  hook 
must  be  introduced  through  the  wound  and  the  lens  capsule  lacerated  by  gently  scratch- 
ing it :  the  hook  should  then  be  withdrawn  and  the  patient  allowed  to  close  the  eyes  for 
a  short  time. 

The  eyes  should  then  be  gently  opened  and  the  lens  removed  by  lightly  pressing,  the 
lower  lid  against  the  globe,  just  below  the  inferior  margin  of  the  cornea,  with  the  thumb 
of  one  hand,  counter-pressure  being  similarly  applied  with  the  forefinger  of  the  other 
hand  at  a  corresponding  point  above.  If  the  manoeuvre  be  properly  executed,  the  pupil 
gradually  dilates,  the  lens  slips  gently  through  it  into  the  anterior  chamber,  and  then 
escapes  by  the  corneal  wound.  Any  prolapse  of  iris  that  may  occur  must  be  carefully 
returned  with  the  curette  :  each  eye  should  then  be  covered  with  two  pieces  of  wet  lint 
and  a  light  bandage  applied. 

Small  Flap  with  Iridectomy. — A  flap  section  should  be  made  by  transfixing 


310  CATARACT. 

the  eyeball  through  the  sclero-eorneal  margin  with  the  straight  extraction  (Graefe's) 
knife  (Fig.  120,  c),  and  then  cutting  out  in  the  line  of  the  sclero-eorneal  junction. 

The  section  may  be  made  either  upward  or  downward,  and  the  point  of  transfixion 
should  be  about  one-third  of  the  distance  from  the  horizontal  corneal  meridian  to  the 
upper  or  lower  margin  of  the  cornea.  The  steps  of  the  operation,  with  the  exception  of 
the  incision,  are  exactly  similar  to  those  of  linear  extraction  (see  below)  ;  but  should  it 
be  thought  fit  to  perform  the  operation  without  anaesthesia,  no  speculum  or  fixing  forceps 
should  be  used. 

Oblique  Corneal  Section.— This  operation  often  goes  by  the  name  of  Bader's 
or  Liebreich's  operation,  when  the  section  is  made  downward ;  Lebrun's  '•  extraction  by 
small  median  flap,"  when  the  section  is  made  upward.  It  seems  to  me  that  the  term 
"  oblique  corneal  section  "  expresses  all  and  dispenses  with  much  unnecessary  prolixity. 

The  instruments  required  are  a  thin  straight  cataract  knife,  a  sharp  hook,  and  curette 
(Fig.  120,  i\  d,  a).  (For  the  position  of  patient  and  surgeon  see  Fig.  Ill,  p.  290).  Xo 
anaesthetic  is  required,  and,  with  the  exception  of  the  incision,  the  steps  of  the  operation 
are  much  the  same  as  in  flap  extraction. 

The  incision  may  be  made  either  upward  or  downward  (Fig.  120,  B),  by  passing  the 
straight  knife  through  the  sclero-eorneal  margin  on  the  outer  side  at  a  point  (puncture) 
corresponding  to  the  horizontal  corneal  meridian  into  and  across  the  anterior  chamber, 
out  at  a  corresponding  point  on  the  inner  side  (counter-puncture),  and  then  cutting  for- 
ward by  a  sawing  movement,  ohUqmlij,  through  the  cornea,  midway  between  the  pupil 
and  upper  or  lower  corneal  margin — the  former  if  the  incision  is  made  upward,  the  latter 
if  it  is  made  downward.  In  entering  the  knife  and  pas.sing  it  across  the  anterior  chamber 
care  must  be  taken  to  keep  its  edge  directed  forward  toward  that  part  of  the  cornea  which 
it  is  desired  to  incise ;  if  the  knife  be  rotated  in  any  wa}'  after  the  anterior  chamber  has 
been  opened,  the  aqueous  humor  will  escape  and  the  blade  become  entangled  in  the  iris. 

The  capsule  should  be  lacerated  and  the  lens  removed  in  the  .same  way  as  in  flap 
extraction  ;  the  position  of  the  incision  near  the  centre  of  the  cornea,  however,  will  not 
allow  the  lens  to  be  pressed  out  immediately,  as  is  done  in  the  flap  opei"ation. 

Before  attempting  to  squeeze  out  the  cataract  its  margin  must  be  brought  opposite 
the  incision  by  gently  pressing  upon  the  globe  above  or  below,  according  as  the  section 
has  been  made  upward  or  downward. 

The  bulk  of  the  cataract  having  been  removed,  care  must  be  taken  to  get  away  any 
soft  cortical  substance  or  fragments  of  lens  that  may  be  left.  The  soft  matter  can  be 
removed  by  gently  rubbing  the  cornea  ;  small  hard  fragments  must  be  drawn  out  by  the 
curette  or  a  small  scoop.  The  whole  of  the  cataract  having  been  removed,  the  iris — 
which  will  in  all  probability  have  somewhat  prolapsed — must  be  replaced  with  the  curette, 
some  solution  of  eserine  dropped  into  the  eye  to  keep  the  pupil  contracted  and  so  reduce 
the  risk  of  recurrence  of  the  prolapse,  and  both  eyes  carefully  bandaged. 

Linear  Extraction. — In  this  operation  the  cataract  is  removed  through  a  linear 
incision,  partly  in  the  sclerotic  and  partly  in  the  cornea,  or  altogether  in  the  former; 
usually  associated  with  iridectomy,  performed  at  the  time  of  extraction  of  the  cataract 
or  some  months  pi'eviously. 

By  linear  incision  is  generally  understood  an  incision  made  in  the  same  direction  as  a 
straight  line  drawn  from  the  centre  of  curvature  of  the  cornea  to  its  circumference  (one 
of  its  radii).  Many  modifications  of  linear  incision  are  practised,  but  only  one  will  be 
described  here.  The  instruments  required  for  linear  extraction  are  a  wire  speculum  (Fig. 
114),  toothed  forceps  (Fig.  IIG,  «),  a  straight  cataract  knife,  a  curette,  sharp  hook  (Fig. 

120,  c,  «,  fZ),  iris  scissors,  and  iris  forceps  (Fig.  117,  6,  c). 

The  operation  should  be  performed  thus,  and,  as  in  the  other  forms  of  extraction,  the 
incision  may  bemade  either  upward  or  downward  (for  position  of  patient  and  operator 
see  Fig.  Ill,  page  290):  The  patient  should  be  thoroughly  ana?sthetized,  the  lids  kept 
open  by  a  wire  speculum,  and,  supposing  the  incision  to  be  made  upward,  the  globe  must 
be  drawn  gently  downward  with  the  toothed  forceps,  holding  the  conjunctiva  and  sub- 
conjunctival fascia  close  to  the  lower  margin  of  the  cornea ;  then  with  the  straight  cata- 
ract knife  puncture  and  counter-puncture  should  be  made  in  the  schrotic.  just  beyond  the 
sclero-eorneal  margin,  the  knife  entering  at  a  point  on  the  outer  side  of  the  globe,  situ- 
ated about  two-thirds  of  the  way  between  the  horizontal  meridian  of  the  cornea  and  its 
upper  margin,  and  emerging  at  a  correspuiiding  point  on  the  inner  side;  the  edge  of  the 
knife  should  then  be  directed  nearly  straight  forward,  and  by  a  sawing  movement  made 
to  cut  its  way  out  through  the  cornea   at   a   short  distance  from   its  upper  margin  (Fig. 

121,  C). 


CATAJLWT. 


'Ml 


If  iriili'ctiiiiiy  lias  not  Ih'imi  previously  perforiiMMl,  a  piece  of  tlic  iris  sIkhiM  next  be 
oxciseil   t'nini   the   upper  seiinient.      (See  ''  Iriileetoniy.'"^ 

The  next  step  is  t(»  laeerate  the  capsule.  'I'he  operator  should  fix  the  eve  anu  draw  it 
jjently  downwaril  with  the  toothed  loreeps,  tiien  introduce  the  sharp  hook  throufrh  the 
incision  and  freely  lacerate  the  capsule  with  it.  The  cataract  can  then  he  removed  by 
niakinu:  trentle  ]>ressure  with  the  curette  upon  the  eyeball,  n(!ar  the  lower  margin  (»f"  the 
cornea,  tlu;  globe  being  steadied  and  held  in  position  by  fixing  the  conjunctiva  with  the 
toothed   forceps. 

The  nucleus  and  bulk  of  the  catarart  having  escaped,  the  curette  slntuld  be  passed 
gently  over  the  surl'ace  of  the  cfUiiea  IVoni  all  directions  toward  the  incision,  so  as  to 
press  out  any  cortical  substance  that  may  be  left,  and  if  any  bh^od  or  portions  of  lens 
remain  in  the  incision  they  must  be  carefully  removed,  .so  as  to  ensure  perfect  coaptation 
of  its  margins  ;  the  s])eculum  should  then  be  removed  and  both  eyes  bandaged  in  the 
usual   way. 

The  incision  for  linear  extraction,  as  already  stated,  may  be  made  downward  as  well 
as  upward,  the  Ibrmer  method  of  operating  being  much  the  easier  and  not  requiring  the 
aid  of  an  assistant. 

The  same  objections  apply  to  extraction  downward  as  to  iridectomy  in  the  same  direc- 
tion, but  the  results  obtained  are  eijually  good  as  from  upward  sections,  and  the  ease  with 
which  the  operation  can  be  performed  quite  counterbalances  any  objections  which  may 
be  made  lui  tlie  score  of  disfiuMrcnicnt. 

Extraction  of  Cataract  by  a  Traction  Instrument. — Cataract  can  be 


Fig.  122. 


"removed  by^a  traction  instrument,  either  through  a 
flap  section  or  a  linear  incision  peri])herally  situated, 
iridectmny  being  performed  in  either  ca.se. 

The  patient  should  be  thoroughly  anae.sthetized, 
and.  whichever  incision  is  made,  the  eyelids  should 
be  kejit  open  with  the  speculum  and  the  globe  fixed 
Avith  the  toothed  forceps  while  the  section  is  made 
and  during  the  subseciuent  removal  of  the  lens. 

The  traction  instrument  employed  is  either  a  scoop 
or  a  sharp  hook   (Fig.  12l).  r.  (/). 

Removal    of  Cataract   by   the   Scoop 

(scoop  extraction). — Scoop  extraction  can  be 
accomplishL'<l  thus :  The  section  having  been  made 
and  iridectomy  performed,  the  convex  surface  of  the 
scoop  .should  be  pressed  gently  upon  the  more  periph- 
eral margin  of  the  incision,  so  as  to  cause  it  to  gape 
somewhat ;  the  instrument  should  then  be  pasiied  with 
the  utmost  gentleness  through  the  incision,  beneath 
the  margin  of  the  lens,  along  its  posterior  surface  and 
beyond  its  posterior  pole,  until  the  lens  lies  well  in  its 
concavity,  and  it  should  then  be  carefully  withdrawn, 
carrying  the  cataract  with  it.  the  removal  being  as- 
sisted by  gentle  pressure  on  the  exterior  of  the  globe. 

Removal  of  Cataract  with  the  Sharp 
Hook    sharp-hook    extraction). — The  hook 

sliMiiM  be  passed   well    behind    the  lens  in  the   same 

manner  as  the  scoop,  fixed  into  its  posterior  surface, 

and  then  carefully  withdrawn,  carrying  the  lens  with 

it.     Two  sharp  hooks  may  1>e  used  instead  of  one.  and  should  be  fixed  into  the  lens  at 

different  points,  so  as  to  prevent  it  rolling  round  (as  sometimes  happens  when  only  one 

hook  is  used),  instead  of  passing  in  the  desired  direction. 

After  removal  of  the  lens  by  either  method  both  eyes  should  be  bound  up  in  the 
usual   way. 

Suction. — The  removal  of  cataract  by  suction  is  indicated  in  cases  where  the  lens 
has  beoome  nearly  or  entirely  fluid,  as  occurs  in  many  instances  of  traumatic  cataract, 
and  frequently  after  a  needle  operation  has  been  performed. 

The  instruments  required  are  a  wire  speculum,  toothed  forceps,  broad  needle,  and 
suction  tube  (Figs.  114,  11(5  ./.  122  u,  b).  Before  operating,  the  pupil  should  be  well 
dilated  with  atropine.     (For  position  of  patient  and  surgeon  see  Fig.  Ill,  p.  290.) 

It  is  best,  but  not  absolutely  neces.sary,  to  place  the  patient  under  the  influence  of  an 


a,  Needle  for  making 
iticisioD  in  suction 
operation. 


b,  Suction  tul)e. 


312  CATARACT. 

anaosthetic.  The  lids  should  be  kept  open  by  a  wire  speculum,  the  eyeball  fixed  by  the 
toothed  forceps,  and  a  small  linear  incision  made  in  the  cornea  with  the  broad  needle, 
about  midway  between  its  summit  and  margin,  in  any  convenient  position. 

The  operator  should  then  place  the  mouthpiece  of  the  suction  tube  in  his  mouth,  pass 
its  nozzle  through  the  incision  and  behind  the  softened  lens,  and  by  sucking  gently  remove 
as  much  lens  matter  as  will  come  away  easily.  No  force  must  be  used  ;  and  if  any  por- 
tion of  the  lens  be  too  hard  to  pass  easily  into  the  tube,  it  may  be  left  to  become  absorbed 
or  be  dealt  with  on  a  future  occasion.  When  as  much  lens  as  will  easily  come  away  has 
been  extracted,  the  suction  tube  should  be  removed,  the  speculum  taken  out,  a  drop  of 
solution  of  atropine  placed  between  the  lids,  and  the  eyes  bandaged  in  the  usual  way.  Th.e 
bandage  should  be  continued  and  the  pupil  kept  dilated  with  atropine  until  all  irritation 
has  subsided. 

Accidents  during  Extraction  of  Cataract. 
Premature  Escape  of  Aqueous  Humor, — If  care  be  not  taken  in  making 

the  section,  the  a((ueous  humor  may  escape  too  soon  and  the  movements  of  the  knife  be 
hampered  by  the  iris  falling  forward.  Should  this  happen,  the  knife  must  be  carefully 
withdrawn  and  the  section  completed  with  scissors. 

Bleeding  into  the  Anterior  Chamber. — In  some  cases  hemorrhage  from  the 
cut  iris  or  conjunctiva  takes  place  to  such  an  extent  as  to  fill  the  anterior  chamber  with 
blood  and  hide  the  cataract  entirely  from  view. 

If  the  blood  does  not  flow  out  easily  on  placing  the  curette  between  tjie  lips  of  the 
incision  and  making  gentle  pressure  on  the  cornea,  the  operation  should  be  discontinued, 
the  eye  bound  up  and  left  till  the  blood  has  become  absorbed,  unless  the  lens  capsule  has 
been  lacerated,  in  which  case  the  lens  must  he  removed  at  all  risks,  or  it  may  swell,  press 
upon  surrounding  parts,  set  up  inflammatory  action,  cause  increase  of  tension  of  the  globe, 
and  very  probably  lead  to  destruction  of  the  eye. 

Prolapse  of  Vitreous  Humor. — If  any  undue  pressure  be  exerted  on  the  globe 
during  extraction,  the  suspensory  ligament  of  the  lens  gives  way  and  a  prolapse  of  vit- 
reous follows.  Should  the  prolapse  of  vitreous  occur  before  the  escape  of  the  lens,  the 
cataract  .should  be  removed  as  quickly  and  gently  as  pos.sible  by  the  aid  of  a  scoop  or 
sharp  hook. 

Prolapse  of  vitreous  is  more  likely  to  occur  if  the  humor  is  abnormally  fluid.  The 
accident  may  give  rise  to  no  bad  results,  but  is  .sometimes  followed  by  a  form  of  chronic 
choroiditis  which  ultimately  destroys  the  eye. 

If  vitreous  has  been  lost,  great  care  must  be  taken  to  bandage  the  eye  so  as  to  keep  the 
lids  immovable  and  prevent  them  pressing  upon  the  globe  and  cau.sing  further  prolapse. 

Displacement  of  the  Cataract.  — In  some  cases,  on  an  attempt  being  made  to 
press  out  the  lens,  the  suspensory  ligament  gives  way,  and  the  cataract,  instead  of  coming 
forward  into  the  anterior  chamber,  passes  behind  the  iris  or  sinks  backward  into  the  vit- 
reous chamber ;  it  should,  if  possible,  be  removed  by  the  scoop  or  sharp  hook.  If  left 
within  the  globe,  it  will  probably  act  as  a  foreign  body,  set  up  inflammation,  and  destroy 
the  eye. 

After-Treatment  of  Extraction  of  Cataract. 

Immediately  after  the  operation  each  eye  should  be  covered  with  two  folds  of  wet 
lint  secured  by  a  bandage  which  has  been  contrived  for  the  purpose  by  the  late  Mr. 
Dunnage '  of  the  Central  London  Ophthalmic  Hospital.  The  patient  should  then  be  put 
to  bed,  where  he  should  remain  for  three  or  four  days. 

The  lint  must  be  kept  constantly  wet  for  the  first  week,  and  fresh  pieces  should  be 
applied  every  two  or  three  days. 

On  no  account  should  the  eye  be  examined  until  the  end  of  the  first  week  ;  if  the  lids 
remain  in  a  normal  condition,  we  may  rest  assured  that  all  is  going  on  well,  and  opening 
the  eye  too  early  can  do  no  good  and  may  do  a  great  deal  of  harm. 

At  the  end  of  a  week  the  eye  may  be  opened  and  its  condition  ascertained.  Should 
the  section  be  healed,  the  anterior  chamber  re-established,  and  no  .signs  of  inflammatory 
action  present,  the  sound  eye  can  be  safely  left  uncovered,  the  one  that  has  been  operated 
on  being  kept  bandaged  with  dry  lint  and  a  large  green  shade  worn  over  both.     At  the  end 

'  Duunasje's  bandage  consists  of  a  [liece  of  material  of  an  open  texture,  througli  which  water  will 
easily  run.  of  such  a  length  as  to  cover  botli  eyes  and  leave  some  to  spare.  To  each  end  of  this  piece 
are  attached  tapes,  by  which  the  bandage  is  secured. 


i:xrii:r Ai'ios  of  rili:  i:yi:i'.  \li.. 


:n3 


of  three  week^  I  lie  lnill(l;iL;e  lii;iV  lie  removed  iVniil  (lie  eye  on  wlliell  ext  racf  inn  lias  lieell  |i(!r- 
foniiud,  liut  tlic  sliade  nr  iiidtectnrs  slKiiild  lie  worn  iiiil  il  aU  imdiie  vascularity  li:is  siiltsideil. 

At  the  end  <>!'  aliout  two  months  (if  then'  he  no  intolerance  ol"  li;.dit  or  irritahility  of 
the  I'Vt' )  Jilassi'S  should  he  ordered,  two  jiairs  heiiij;  jrivcn.  one  for  ;:nin{r  ahoiit  and  one 
for  reiulin«r ;  convex  1.'5  1)  will  usually  he  found  most  suitahle  for  the  former  |>urpose, 
convex  1<>  l>  for  the  latter.  Hut  should  the  jiatient  have  been  inynpie  or  hypermetropic 
before  the  ojieration,  i:lasses  weaker  or  stroiiiicr  than  these  may  lie  re<(iiired. 

Tllis  is  the  usual  cniirse  of  cases  of  ext ract ion  of  cataract  ;  all  do  not.  however.  ;:<»  on 
SO  favorably. 

A  dav  ">r  two  (lavs  after  the  oiieratioii  the  jiatient  may  coin|ihtin  of  severe  |iaiii  in  the; 
eyeball,  temph\  and  brow,  and  on  removinti  the  bandaLit'  the  lids  may  be  found  Jiiiffy  and 
red,  or  perhaps  niueh  swollen. 

These  .symptoms  always  indicate  inflammatory  chan^'^es  in  some  of  the  ocular  struc- 
tures ;  the  inflammation  may  be  simply  an  attack  of  iritis,  which  will  probably  proceed  to 
a  favorable  termimition,  but  may  subse(|uently  aflect  the  choroid,  a  chronic  form  of 
ehoroido-iritis  beint;-  set  up,  which  leatls  to  softening,  and  eventually  to  shrinking,  of  the 
globe;  the  cornea  may  be  inflamed  or  sujipurating,  or  inflammation  and  suppuration  of 
all  the  ocular  structures  (panophthalmitis)  may  have  set  in.  (For  the  treatment  of  these 
cases  see  "  Iritis,"  ''  Corneitis,"  etc.) 

A  not  uncommon  cause  of  pain  and  irritation  is  the  occurrence  of  entropion  of  the 
lower  lids ;  this  must  be  remedied  by  operation.     (See  "  Operations  on  the  Eyelids.") 

Causes  of  Unsatisfactory  Results  of  Cataract  Extraction. 

The  result  of  an  ojieration  for  extraction  of  cataract  may  be  marred  by  closure  of  the 
pupil  consequent  on  iritis,  by  obstruction  of  its  area  with  opa(|ue  lens  capsule,  or  by 
opacity'  of  the  vitreous  luimor. 

Occlusion  of  the  pupil  should  be  remedied  by  making  an  artificial  one  (.see  "  Artificial 
Pupil  ")  ;  capsular  obstructions  should  be  torn  through  with  cataract  needles,  cut  across 
•with  scissors,  or  removed  bodily  with  forceps. 

The  greatest  caution  must  always  be  exercised  in  meddling  with  opaque  capsule,  as 
an  operation  upon  it,  especially  an  attempt  to  tear  it  forcibly  away,  is  very  likely  to  be 
followed  by  increase  of  tension,  inflammation,  or  even  suppuration  of  the  eyeball. 

For  opacity  of  the  vitreous  humor  nothing  can  be  done. 


EXTIRPATION  OF  THE  EYEBALL. 

Removal  of  the  eyeball  is  called  for  under.the  following  conditions : 

1.  In  all  cases  of  injury  causing  complete  disorganization,  with  collapse  of  the  globe 
and  escape  of  its  contents. 

2.  In  cases  where  one  eye,  having  been  damaged  by  injury  or  disease  to  such  an 
extent  as  to  render  it  jiractkalh/  usefriss,  becomes  irritable  or  painful  and  the  sound  eye 
appears  threatened  by  sympathetic  ophthalmia. 

3.  In  cases  where  an  eye  lost  from  injury  or  disease,  and  qinte  hUiuI,  is  a  source  of 
annoyance,  even  though  the  other  eye  be  not  threatened. 

4.  In  cases  where  the  globe  has  become  the  seat  of  malignant  disease. 
p]xtirpation   of  the  eyeball   should  be  thus  performed  (for  position   of  patient  and 

operator  see  Fig.  Ill,  p.  290):    The  instruments  recjuired  are  a  wire  speculum,  toothed 
forceps,  a  pair  of  blunt-pointed 

scissors  curved  on  the  flat  (  Fig.  Fig.  123. 

123),  and  a  strabi.smus  hook. 
The  patient  being  thoroughly 
,  under  the  influence  of  an  an- 
aesthetic, the  operator  should 
place  the  wire  speculum  be- 
tween the  lids,  then  by  the  aid 
of  the  forceps  and  scissors  cut 
through  the  conjunctiva  all 
round  the   cornea    as    close   to 

its      margin      as     possible;      he  Extirpation  Scissors. 

should  tlfen  with    the    strabis- 
mus hook  take  up  the  four  recti  muscles,  one  after  the  other,  and  divide  them  with  the 


314  AFFECTIONS  OF  THE  ORBIT. 

scissors,  either  the  external  or  internal  rectus  being  cut  at  a  little  distance  from  the  globe, 
so  as  to  afford  a  hold  for  the  furcejis  in  the  subsequent  steps  of  the  operation,  and  the 
other  three  muscles  as  close  to  it  as  possible. 

The  muscles  having  been  divided,  the  hook  should  be  made  to  sweep  round  the  globe, 
so  as  to  be  sure  that  nothing  is  left  uncut.  By  pressing  the  speculum  backward  the 
eyeball  will  become  dislocated  in  front  of  the  lids,  and  then,  being  steadied  by  holding  the 
piece  of  muscle  purposely  left  with  the  forceps,  the  scissors  should  be  passed  behind  it 
until  their  points  are  found  to  be  in  contact  with  the  optic  nerve,  then  slightly  with- 
drawn, opened  widely,  pressed  forward  again,  and  the  nerve  divided  by  a  single  cut. 

As  soon  as  the  nerve  has  been  cut  through,  the  eyeball  will  be  almost  free,  being  held 
only  by  the  oblique  muscles,  which  should  be  divided  close  to  the  sclerotic.  Should 
there  be  free  hemorrhage,  the  speculum  may  be  left  between  the  lids,  a  piece  of  sponge 
pressed  firmly  into  the  orbit  and  secured  by  a  turn  of  bandage ;  when  all  bleeding  has 
ceased,  the  sponge  should  be  removed  with  the  speculum  and  two  small  pads  of  wet  lint 
and  a  bandage  applied.  Should  the  hemorrhage  be  but  slight,  two  or  three  small  pads 
of  wet  lint  must  be  laid  over  the  closed  lids  and  secured  by  a  bandage  in  the  same  man- 
ner as  in  other  operations  on  the  eye.  In  about  a  month  or  six  weeks  an  artificial  eye 
may  be  ordered. 

ABSCISSION. 

Abscission  is  the  removal  of  that  portion  of  the  eyeball  (including  the  ciliary  region) 
situated  in  front  of  the  attachments  of  the  recti  m-uscles.  these  being  left  intact.  The 
object  of  this  operation  is  to  leave  a  movable  stump  on  which  an  artificial  eye  can  rest 
and  be  moved  in  harmony  with  the  movements  of  the  sound  one. 

Abscission  is  indicated  in  staphyloma  occupying  the  whole  or  greater  part  of  the 
former  situation  of  the  cornea,  the  remainder  of  the  globe  retaining  its  normal  curvature. 

The  opei'ation  should  be  thus  performed  (for  position  of  patient  and  operator  see  Fig. 
Ill,  p.  290)  :  The  instruments  required  are  a  wire  speculum,  toothed  forceps,  strabismus 
scissors,  a  triangular  cataract  knife,  a  curved  needle,  and  silk.  The  patient  being  thor- 
oughly under  the  influence  of  an  anftsthetic,  the  wire  speculum  should  be  placed  between 
the  lids,  the  conjunctiva  divided  all  round  close  to  the  corneal  margin  (as  for  extirpation) 
and  dissected  back  to  the  desired  extent.  Then  with  the  curved  needle  a  single  suture 
should  be  passed  through  the  edge  of  the  divided  conjunctiva  at  five  or  six  different 
points,  so  as  to  surround  the  wound  in  it  in  much  the  same  manner  as  the  string  sur- 
rounds the  mouth  of  an  ordinary  bag,  and  the  ends  of  the  silk  left  hanging  on  the 
patient's  face. 

The  staphyloma,  the  whole  of  the  ciliary  body,  and  sclerotic  corresponding  to  it, 
should  then  be  removed  by  transfixing  the  globe  with  the  triangular  knife  just  in  front 
of  the  insertions  of  the  internal  and  external  recti  muscles,  cutting  out  upward  in  front 
of  the  insertion  of  the  superior  rectus  and  finishing  the  removal  by  a  sweep  of  the  knife 
in  the  opposite  direction. 

The  silk  should  be  then  drawn  up  and  tied,  by  which  means  the  conjunctiva  will  be 
made  to  cover  the  wound  in  the  globe,  and  wet  lint  and  a  bandage  applied.  As  soon  as 
the  parts  have  firmly  healed  an  artificial  eye  may  be  worn. 

Abscission  should  be  performed  in  preference  to  excision  of  the  globe  in  children  ;  the 
presence  of  the  stump  left  prevents  to  a  great  extent  the  shrinking  or  non-development 
of  the  orbit  which  will  occur  if  the  eyeball  be  removed  entirely. 

In  older  persons  excision  is  generally  to  be  preferred,  as'  the  stump  left  after  abscis- 
sion is  very  liable  to  become  troublesome,  and  in  the  very  old  is  prone  to  suppurate. 

AFFECTIONS   OF  THE  ORBIT. 

Protrusion  of  the  Eyeball. — As  many  of  the  diseases  of  the  orbit,  and  to  a 
considerable  extent  tumors  of  the  eyeball  itself,  cause  more  or  less  protrusion  of  the 
globe,  it  will  be  w^ell  to  say  a  few  words  on  the  subject  before  describing  the  morbid 
changes  which  may  give  rise  to  it. 

The  symptoms  are  obvious  enough  and  do  not  require  description.  The  causes  are 
the  following : 

1.  Inflammation  within  the  orbit,  either  with  or  without  the  formation  of  abscess. 

2.  Hemorrhage  into  the  orbit. 

3.  Vascular  protrusion  of  the  eyeball.  » 

4.  Exophthalmic  goitre. 


AFFEOTTOy^   OF  TIIF  OJllllT.  .'315 

;').   Tumors  within  tlic  oiliit,  iindcs,  exnstoscs,  iiiali^'iiant  <;rowtli.s,  cysts,  rucvi,  etc. 

(1.  Kiilar^M'int'iit  ^A'  tin-  ey»'liall  itsclt'  tVtuii  ('/)  jrnnvtli.s,  iiiali^'iiant  or  .simple;  (J)) 
iiiflaiiimatinii  ami  sii|i]iuratioii  nf  tlie  whole  eyehail  (oiihlhalmitisj. 

7.  I'aralysis  of  its  muscles,  allowiuir  the  jrlohe  to  (lru|i  jurwanl  and  thus  assume  an 
iiiuisual  ju'omineiicc. 

l)(MiltIe  visiiui  is  i/i  n>  niUi/  eniii|ilaine(l  of  in  jirotrusion  of  the  eyehail.  'I'lie  ill-effeCtH 
of  tlie  aluHU-mal  position  are  seen  hoth  in  the  jrlohe  itself  and  in  the  lids.  Shuuhl  the 
protrusion  he  so  ureat  that  the  lids  cannot  he  closed  over  the  eyehail,  the  eornc^u  will  he 
left  unprotected,  and  may  hi'come  opa(|ue  and  afterward  ulcerate  or  slou^rh.  If  the  pro- 
trusion continue  for  lonjr.  the  lids  hecome  distended  and  tlaccid.  their  inovemttnts  heinp 
much  iujpaired  ;  the  tear  puncta  may  also  hecome  displaced,  Lrivinjr  rise  to  continual 
wateriiiL'^  of  the  eye. 

Tkkat.MKNT. —  In  all  eases  where  the  eyehail  is  healthy  care  shouhl  he  taken  to  pro- 
tect the  cornea  from  injurious  expo.sure  hy  drawinji  the  li<ls  over  it  an<l  keepin<,'  them  fixed 
by  a  compress  and  handa<;e,  hut  in  extreme  cases  the  edj;es  of  the  outer  third  of  the  lids 
must  l)e  jtared.  unite<l  hy  sutures,  and  allowed  to  heal  firmly  together. 

Inflammation  within  the  Orbit. — Inflammation  may  affect  the  .soft  ti.ssues 
within  tile  orhit.  the  periosteum,  or  the  hone  itself;  it  may  end  in  resolution,  the  part.s 
returning  to  tiieir  natural  condition  ;  chronic  thickening  may  result,  causing  more  or  less 
permanent  protrusion  and  impairment  of  the  movements  of  the  eyeball,  or  abscess  may 
form,  and  in  the  case  of  periostitis  or  ostitis  caries  and  necrosis  of  the  bony  walls  may 
supervene. 

8v.MPT0.MS. — Inflammation  within  the  orljit  is  accompanied  by  more  or  less  febrile 
disturbance,  pain  of  a  throl)bing  ch.aracter,  much  increased  by  pressure,  swelling  of  the 
conjunctiva  and  lids,  more  or  less  prominence  and  inijtaired  movement  of  the  eyeball, 
intolerance  of  light,  and  watering  of  the  eye;  it  may  be  the  result  of  cold,  injuries,  or 
general  diseases,  as  erysipelas  and  (in  the  case  of  periostitis)  of  syphilis,  or  may  come  on 
in  debilitated  states  of  the  system,  during  recovery  from  acute  disea.ses  (scarlet  fever, 
measles,  etc.).  or  from  over-lactation.  It  is  not  easy  to  distinguish  inflammation  affecting 
the  soft  parts  only  from  inflanunation  of  the  periosteum  or  bone. 

Treat.mext  should  consist  in  allaying  pain  and  inflammation  by  means  of  opium 
internally,  fomentations  of  poppy-heads  to  the  affected  part,  leeches  to  the  corresponding 
temple  (two  to  six  in  number),  and  rest  in  bed  in  a  darkened  room  ;  any  general  medical 
treatment  which  may  appear  most  applicable  should  also  be  employed. 

For  instance,  if  the  patient  be  strong  and  healthy,  low  diet,  purgatives,  etc.  should 
be  had  recourse  to ;  if  weakly,  as  during  recovery  from  some  acute  disease,  tonics  and 
good  diet  should  be  prescribed.  Should  the  patient  be  the  subject  of  syphilis,  this 
should  be  treated. 

Abscess. — Should  the  inflammation  go  on  to  the  formation  of  abscess,  the  symp- 
toms are  aggravated,  the  conjunctiva  becomes  more  swollen  and  in  some  cases  almost 
covers  the  cornea,  the  lids  are  greatly  swollen  and  red,  the  prominence  and  impairment 
of  movement  of  the  eyeball  increase,  and  rigors  may  occur.  Vision  becomes  misty,  and 
in  some  cases  all  perception  of  light  is  entirely  lost.  After  a  time  fluctuation  may  be 
detected ;  if  left  to  itself,  the  abscess  will  burst,  the  pus  being  discharged  either  through 
the. skin  or  conjunctiva.  The  abscess  having  been  emptied,  in  favorable  cases  the  swell- 
ing will  disappear,  the  eyeball  resume  its  natural  position,  and  the  opening  heal.  But  in 
some  cases,  especially  if  the  suppuration  be  associated  with  caries  and  necrosis  of  the 
bone,  the  abscess  will  remain  open  or  the  orifice  alone  heal,  the  sac  again  becoming  filled 
with  pus. 

TuEATME.VT. — As  Soon  as  the  surgeon  feels  satisfied  of  the  existence  of  pus  in  the 
orbit  it  should  be  evacuated.  If  fluctuation  can  be  detected,  the  diagnosis  is  easy 
enough,  but  even  if  this  cannot  be  done  and  suppuration  is  suspected,  an  exploratory  punc- 
ture should  be  made,  when  the  escape  of  pus  will  clear  up  any  doubt. 

The  best  method  of  opening  an  abscess  in  the  orbit  is  that  recommended  by  Mr.  Hil- 
ton for  evacuating  pus  situated  at  a  depth  from  the  surface  amongst  important  structures. 
1  he  operation  should  be  performed  as  follows :  An  incision  having  been  made,  either 
through  the  skin  or  conjunctiva,  at  that  part  w^here  the  eyeball  appears  most  thrust  away 
from  the  wall  of  the  orbit,  a  grooved  director  should  be  thrust  in  (the  surgeon  bearing 
in  mind  the  direction  of  the  wall  along  which  he  is  passing  the  instrument  and  the  depth 
of  the  orbit).  As  soon  as  pus  is  seen  escaping  along  the  groove  of  the  director  a  pair  of 
small  dressing  forceps  .should  be  passed  along  it  until  their  points  are  within  the  abscess : 
the  blades  should  then  be  .separated  slightly,  and  drawn  out  whilst  so  separated  ;  a  ragged 


316  AFFECTIONS  OF  THE  ORBIT. 

opening  will  thus  be  left,  which  is  nnt  likely  to  close  too  soon,  and  the  danfror  of  cutting 
important  structures  will  be  obviated. 

The  greatest  care  must  always  be  taken  not  to  injure  the  eyeball.  As  the  operation 
is  very  painful,  an  anaesthetic  should  be  given. 

Immediately  after  the  operation  search  should  be  made  by  means  of  a  probe  for  dis- 
eased bone  or  foreign  bodies.  If  a  foreign  body  or  loose  sequestrum  be  detected,  it  should 
be  at  once  removed  ;  diseased  bone,  if  still  tirm,  may  be  left  to  itself,  and  will  either 
come  away  spontaneously  or  may  require  removal  at  a  later  period.  If  the  opening 
appear  inclined  to  close  too  soon,  it  should  be  kept  open  by  means  of  a  piece  of  lint 
passed  intd  it  ;  (inly  light  water  dressings  need  be  applied. 

Periostitis  or  Ostitis  followed  by  Caries  and  Necrosis  of  the  Walls 

of  the  Orbit. — The  symptoms  of  periostitis  or  ostitis  going  on  to  caries  or  necrosis  are 
similar  to  those  above  described,  excepting,  perhaps,  that  the  pain  is  more  severe  and 
often  aggravated  at  night.  This  form  of  inflammation  should  always  be  .suspected  in 
persons  suffering  from  syphilis,  and  occasionally  nodes  may  be  met  with  at  the  margin  of 
the  orbit  or  on  the  forehead ;  their  existence  should  always  lead  the  surgeon  to  suspect 
that  the  inflammation  within  the  orbit  is  periosteal.  When  the  abscess  has  formed  and 
burst  or  has  been  opened,  the  seat  of  inflammation  becomes  evident  from  the  character 
of  the  pus,  which  is  of  that  peculiar  unhealthy  and  bad-smelling  variety  met  with  in 
abscesses  connected  with  diseased  bone,  as  well  as  from  the  condition  of  the  opening, 
which  remains  patent  and  is  surrounded  by  large  unhealthy  granulations,  and  from  the 
fact  that  the  bare  bone  can  be  felt  with  a  probe  passed  through  the  opening. 

Caries  and  necrosis  usually  end  in  recovery  after  a  time,  the  diseased  bone  being- 
thrown  off"  and  the  sinus  becoming  closed.  The  disease  generally  attacks  the  margin  of 
the  orbit  and  often  leaves  cicatrices,  which  cause  great  disfigurement  and  deformity  of 
the  eyelid.  Should  caries  or  necrosis  occur  deeply  in  the  orbit,  the  results  may  be  most 
serious,  the  optic  nerve  becoming  aff"ected  and  vision  lost,  or  the  disease  may  spread  to 
the  interior  of  the  skull,  set  up  meningitis,  and  cause  death. 

Treatment. — In  the  earlier  stages  the  treatment  should  be  the  same  as  that  described 
under  inflammation  and  abscess  of  the  orbit ;  but  when  the  abscess  has  burst  or  been 
opened,  its  cavity  should  be  syringed  out  daily  with  some  mild  disinfecting  solution  ;  care 
must  be  taken  to  prevent  its  too  early  closure,  by  means  of  a  piece  of  lint  pushed  into 
the  sinus;  exuberant  granulations  should  be  kept  down  by  the  application  of  nitrate  of 
silver,  and  distortion  of  the  lids,  if  likely  to  occur,  must  be  prevented  by  uniting  their 
edges.    (See  "  Operations  on  the  Eyelids.") 

If  any  pieces  of  bone  are  found  loose,  they  should  be  removed  by  operation. 

Hemorrhage  into  the  Orbit. — Orbital  hemorrhage  may  depend  upon  the  spon- 
taneous rupture  of  a  vessel  within  the  orbit,  and,  should  it  be  considerable,  may  produce 
displacement  of  the  eyeball.  The  blood  may  become  diffused  and  appear  beneath  the 
conjunctiva,  being  subse(juently  gradually  removed  by  absorption  ;  occasionally,  how- 
ever, the  clot  becomes  encysted,  and  permanent  displacement  of  the  eyeball  results. 
Hemorrhage  into  the  orbit  also  occurs  in  fracture  of  its  walls,  frequently  to  a  consider- 
able extent,  subconjunctival  ecchymosis  being  a  prominent  symptom  in  some  cases  of 
fracture  of  the  base  of  the  skull  extending  through  the  roof  of  the  orbit. 

Hemorrhage  sufficient  to  cause  displacement  of  the  eyeball  has  occurred  after  the 
operation  for  strabismus. 

Treatment. — In  cases  of  spontaneous  hemorrhage  light  pressure  should  be  applied 
to  the  eye  by  a  pad  of  lint  or  cotton-wool  and  a  bandage.  Where  excessive  hemorrhage 
occurs  after  operations  for  strabismus,  a  large  pad  of  lint  should  be  placed  on  the  closed 
lids  and  firm  pressure  by  means  of  a  bandage  kept  up  for  a  few  hours  after  the  opera- 
tion. Hemorrhage  from  fracture  of  the  orbital  walls  is  only  of  secondary  importance  to 
the  injury  which  caused  it.  and  may  be  left  to  itself;  it  is  of  more  interest  to  the  general 
surgeon  than  to  the  specialist. 

Vascular  Protrusion  of  the  Eyeball. — This  is  the  name  applied,  and  very 
justly,  by  Mr.  Thomas  Nunneley  (3Ierlico-Chir.  Trans.,  vol.  xlviii.)  to  a  set  of  cases 
formerly  considered  to  belong  to  the  class  of  "  aneurism  by  anastomosis,"  but  which,  Mr. 
Nunneley  .shows,  differ  in  many  essentials  from  the  latter  affection,  both  in  their  clinical 
aspect  and  history.  He  has  also  had  opportunities  of  verifying  his  diagnosis  by  post- 
mortem examination,  and  in  no  case  has  he  met  with  an  instance  of  the  above-mentioned 
affection  due  to  this  cause.  Mr.  Nunneley  has  reported  in  all  seven  cases,  and  mentions 
some  ten  or  twelve  others  described  by  various  writers.  The  cases  reported  are  chiefly 
either  instances  of  traumatic  aneurism  or  aneurism  arising  spontaneously  from  rupture 


r.i.sv77..i/;  i'i:nriirsi()S  nr  rur:  j:yi:n.iLL.  317 

III'  a  ilix'a.M'il  aiinv  in  an  cMrrly  imTmiii,  Imt  in  one  cax-  a  immcltdus  f^ruwtli  was  tuiiiKl 
iiivulviiiu;  tlu-  (nliit  ami  ollirr  |iarls. 

Till'  sviiiptuiiis  fdinplaiiii'il  ol"  \i\  tin-  |iati<'Mt  art-  nuiM-  in  the  licail  ami  fcclinjr  uf  It-n- 
Hion,  siiiirin^  in  tlio  cars,  pain  in  the  mhit  an<l  rycball,  all  of  which  arc  utr;iravate<i  by 
stoopin;;,  or  cxcrtiim,  but  arc.  nevertheless,  most  aniioyinj;  at  ni^ht.  These  .syinptoiiis 
arc  aecoinpanii'tl  by  more  or  less  jtrotnisioii  and  iinpaireil  ino))ility  of  the  eyeball, 
dimness  of  vision,  much  conj;estioii,  principally  venous,  of  the  eyeliils  and  conjunc- 
tiva, and  chemosis,  pulsati(»n  (  which  may  be  controlled  l»y  pressure  on  the  carotid  of 
the  .same  si(K')  in  any  |)art  of  the  orbit  and  communicated  to  the  eyeball,  and  often 
a  bruit  heard  on  auscultation  over  the  lirovv  or  otln'r  parts  immediately  adjuining  the 
orbit. 

In  most  ca.ses  these  symptoms  have  come  on  at  a  varying;  time  after  some  injury  to 
the  head,  or  liave  occurred  spontaneously  :ind  suddenly. 

The  nu)rbid  chanires  met  with  in  tlie  three  cases  examined  after  death  by  Mr.  Nuii- 
neley  were,  in  one  (in  which  the  disease  commenceil  spontaneously,  and  tlie  patient  died 
sixteen  days  after  liijature  of  the  carotid),  a  dilatation  of  the  carotid  at  tlie  point  of  giv- 
ing  oft'  tlie  oplitlialmic  branch,  the  dilatation  lieing  tilled  with  and  surrounded  by  coagu- 
lum  ;  the  oplitlialmic  artery  itself  was  somewhat  dilated,  its  coats  thickened,  and  athero- 
nuitous  in  parts  ;  two  of  its  branches  were  much  dilated  and  filled  with  clot.  In  another 
case,  also  of  s])ontaneous  origin,  a  circumscribed  aneurism  of  the  ophthalmic  artery  clo.se 
to  its  origin  was  discovered.  The  third  case  was  found  to  be  one  of  cancerous  disease 
within  the  orbit  associated  with  cancerous  tumors  in  other  parts  of  the  body. 

In  the  majority  of  cases  of  "  vascular  protrusion  "  of  the  eyeball  the  disea.se  is  not 
"within  the  orbit,  but  intracranial,  the  protrusion  being  dependent  on  obstruction  to  the 
return  of  venous  blood  and  analogous  to  the  swelling  and  congestion  seen  in  the  limbs 
when  the  main  artery  is  aifected  by  aneurism. 

It  is  easy  to  understand  how  in  a  small  and  firmly-bound  space  like  the  cavernous 
sinus  a  very  insignificant  dilatation  of  the  commencement  of  the  ophthalmic  artery,  or  of 
the  carotid  itself  at  any  point  within  the  sinus,  or  a  small  hemorrhage  from  either,  may 
prove  a  most  serious  impediment  to  the  return  of  venous  blood — much  more  so  than  the 
same  amount  of  disease  situated  in  the  cavity  of  the  orbit  it.self. 

Nicvus,  as  is  well  known,  is  not  unfrequently  met  with  in  the  orbit,  but  is  usually 
easily  enough  diagnosed.     (See  p.  310.) 

A  case  of  traumatic  aneurism  of  the  orbit — which  is,  I  believe,  unique — came  under 
7ny  observation  in  September,  1873. 

The  patient,  a  young  gentleman,  was  some  two  months  previou.sly  opening  a  hamper 
in  which  were  some  bottles  of  soda-water;  one  of  these  burst,  and  a  large  piece  of  glass 
was  driven  with  considerable  force  into  the  left  orbit,  inflicting  a  wound  in  the  upper  eye- 
lid just  external  to  the  internal  angular  process  of  the  frontal  bone  ;  the  glass  dropped 
out;  sharp  arterial  hemorrhage  occurred,  which  was  stopped  by  pressure;  much  swelling 
and  ecchyniosis  of  the  lids  followed.  The  wound  healed,  the  swelling  and  ecchymosis 
disa])peared,  and  all  seemed  to  be  going  on  well ;  but  shortly  before  being  seen  by  me  the 
eyeball  .seemed  to  be  somewhat  protruded  and  considerable  congestion  of  the  eyelids  and 
conjunctiva  was  noticed.  When  first  seen  by  me,  there  was  much  venous  congestion  of 
the  eyelids  and  conjunctiva  (no  chemosis),  marked  protrusion  of  the  eyeball  in  a  direction 
somewhat  outward  :  a  small  pulsating  tumor  could  be  distinctly  felt  near  the  inner  angle 
of  the  orbit ;  a  marked  thrill  was  communicated  to  the  eyeball,  which  could  be  felt  on 
placing  the  hand  upon  the  closed  lids  ;  a  buzzing  in  the  head  was  complained  of,  especially 
on  stooping ;  there  was  a  small  linear  cicatrix  over  the  pulsating  tumor,  marking  the  seat 
of  the  original  injury. 

Ophthalmoscopic  examination  showed  an  extremely  dilated  and  tortuous  condition  of 
the  retinal  veins,  but  detected  no  pulsation  ;  there  was  no  impairment  of  vision. 

Pressure  on  the  left  carotid  at  once  stopped  the  pulsation  and  caused  considerable 
decrease  of  the  venous  congestion. 

Aneurismal  varix  was  diagnosed.  Perfect  rest  and  pressure  applied  directly  to  the 
part  were  tried  for  some  months  without  benefit.  It  was  at  length  determined  by  the 
patient's  medical  attendant  to  perform  an  operation  ;  accordingly,  an  incision  was  made 
over  the  tumor,  and  several  fair-sized  vessels  which  appeared  to  communicate  with  it  were 
tied.     The  wound  healed  kindly. 

I  saw  the  patient  again  at  the  beginning  of  the  summer  of  1S74.  The  congestion 
had  disappeared,  the  pulsation  ceased,  and  the  eyeball  had  returned  to  its  natural  po.sition. 
the  only  sign  of  the  disease  remaining  being  a  small  linear  cicatrix  in  the  upper  eyelid 


318  TUMORS   OF  THE   ORBIT. 

and  a  slight  thickening  near  the  inner  angle  of  the  orbit  in  the  position  previously  occu 
pied  by  the  pulsating  tumor. 

Treatment. — Rest,  low  diet,  with  depressing  remedies,  as  cold  applied  locally  and 
the  administration  of  digitalis  or  antimony,  should  always  have  a  fair  trial.  Pressure 
applied  locally  by  means  of  a  pad  and  bandage  should  also  be  employed  if  it  can  be 
borne. 

These  means  failing,  recourse  must  be  had  to  digital  pressure  of  the  carotid,  kept  up 
for  .some  hours,  the  patient  being  under  the  influence  of  an  anaesthetic,  as  pressure  in  the 
neck  gives  rise  to  such  intolerable  pain  that  even  the  most  resolute  can  only  bear  it  for 
a  few  minutes  at  a  time. 

As  a  last  resource  a  ligature  must  be  applied  to  the  common  carotid  on  the  same  .side 
as  the  disease. 

This  operation  was  performed  in  all  but  one  of  ^Ir.  Xunneley's  cases  with  the  best 
results. 

Should  a  case  similar  to  that  reported  in  this  article  occur,  the  operation  which  proved 
so  successful  in  it  sliould  be  performed. 

ExoPHTKALivnc  Goitre  (Basedow's  Disease). 

This  disease  is  characterized  by  protrusion  of  the  eyeball,  impairment  of  the  move- 
ments of  the  lids,  and  diminished  sensibility  of  the  cornea  and  conjunctiva,  accompanied 
by  disturbance  of  the  hearts  action  and  sy.stolic  murmurs  in  the  heart  and  great  blood 
vessels  of  the  neck,  together  with  dyspncea  and  enlargement  of  the  thyroid  body. 

Treatment. —  Should  the  protrusion  of  the  eyeballs  be  very  extreme,  ulceration  and 
perforation  of  the  cornea  may  occur ;  this  may  be  guarded  against  by  protecting  the  cor- 
nea with  a  small  pad  and  light  bandage  applied  over  the  closed  lids,  or  the  outer  third 
of  the  palpebral  aperture  may  be  closed  by  operation.  These  patients  are,  however, 
extremely  intolerant  of  anaesthetics.  General  medical  treatment  should  also  be  employed; 
for  this  the  reader  is  referred  to  works  on  general  medicine. 

Tumors  of  the  Orbit,  Orbit  and  Eyeball,  and  Eyeball  alon^e. 

Tumors  of  the  orbit  alone  are :  exostoses,  naevi.  cysts,  nodes,  and  malignant  growths.. 
Those  of  both  orbit  and  eyeball  are  usually  malitrnant  and  commence  primarily  either  in 
the  eveball  or  some  of  the  other  structures  within  the  orbit ;  those  of  the  eyeball  alone 
are  also  for  the  most  part  malignant,  but  simple  sarcomatous  and  cystic  growths  are  occa- 
sionally met  with. 

Tumors  of  the  Orbit  alone. 

Exostoses. — These  are  of  two  kinds,  either  hard,  ivory-like  masses  consisting  of 
compact  bonv  tissue,  or  soft  spongy  growths  of  an  open  cancellated  .structure. 

Bonv  tumors  are  generally  met  with  as  hard  more  or  less  circumscribed  outgrowths 
of  varving  size,  growing  either  from  the  bone  itself  or  from  the  periosteum.  They  aifect 
the  orbit  alone  or  mav  project  into  neighboring  cavities — a  fact  which  should  be  borne  in 
mind  when  attempting  their  removal. 

Treatment. — Should  exostosis  of  the  orbit  give  rise  tr>  inconvenience,  it  may  be 
removed  by  operation.  An  inci.sion  .should  be  made,  parallel  with  the  margin  of  the 
orbit,  over  the  most  prominent  part  of  the  growth,  which,  having  been  thoroughly  exposed, 
should  be  removed  in  any  way  which  may  appear  the  most  effectual,  the  greatest  care 
being  taken  to  guard  the  eyeball  from  injury,  and.  if  possible,  to  preserve  the  continuity 
of  the  lachrymal  canaliculi  and  position  of  the  tear  puncta.  In  the  removal  of  the  hard 
ivory  exosto.sis  the  greatest  difficulty  will  be  experienced,  some  hours'  patient  work  with 
chisel  and  mallet  being  occasionally  required.  The  operation  can.  however,  be  greatly 
facilitated  by  boring  through  the  base  of  the  tumor  with  a  drill  worked  by  a  "  dental 
engine."  The  surgeon  who  undertakes  the  removal  of  such  a  growth  should  be  aware 
of  the  extreme  difficulty  to  be  surmounted,  and  arm  himself  with  a  corresponding  amount 
of  patience  and  perseverance  before  commencing  the  operation.  The  soft,  spongy  growths 
are  much  more  easilv  removed  :  the  tumor,  having  been  thoroughly  exposed,  can  usually 
be  broken  off  with  .^tronir  forceps.  Should  the  ^rrowth  be  on  the  inner  side  of  the  orbit 
and  much  force  be  used  in  its  removal,  the  cavity  of  the  nose  may  be  opened,  and  the 
operator  may  be  rather  alarmed  at  seeing  large  Vjuantities  of  air  blown  out  with  the  blood 
This  accident.however,  need  occasion  no  uneasiness,  as  it  makes  no  difference  to  the  prog- 


rvMoiis  OF  (iiir.ir  A.\n  i:yi:ii.\ll.  319 

ress  <»1'  the  case;  in'VcrllifU'ss,  care  slioiild  always  l)c  taki-ii  not  Id  rractiiri'  the  urhital 
'walls.  Sliuuld  the  IVactuif  taki'  |ilac-t'  in  tla*  nnif  iiistt-atl  of  in  tliu  inner  wall,  the  t-on.sc- 
(|iU'nc('s  would  Ik'  most  disastrous,  as  the  cavity  <d'  the  cTaniuiii  would  lie  t»|K'nod. 

N£evi  ;H'e  not  imcoiMinonly  nu-t  with  in  or  ahout  the  orltit.  situate<l  ^reiierally  near  its 
niaiLiiii.  or  in  tlie  eyelids,  hut  sonn'times  jrrowin^'  deeply  in  the  orliital  eavity.  They  pre- 
sent niueh  the  same  characters  as  in  other  situations,  heinjr  soft  to  the  tou<di.  of  a  lilnish 
color,  and  hecominir  hanlcr  an<l  more  tense  durinjr  cryinfr  or  straining;. 

Tkk.vtmknt. — The  n:eviis  should,  if  possilile,  he  excised.  Suhcutaneous  ligature  is 
most  applicahle  in  some  cases,  hut  care  should  be  taken  t(»  prevent,  as  much  as  possible, 
subsei|uent  cicatrization,  in  conse<(uence  of  the  deformity  it  may  jiroduce  in  or  about  the 
eyelids.  Other  cases  may  be  treated  by  setting  ujt  adhesive  inflammation  within  the 
growth,  by  the  use  of  the  galvanic  or  other  cautery,  or  by  passing  a  number  of  small 
setons  soaked  in  perchloride  of  iron  through  its  sulistance.  The  setons  should  be  left  in 
until  they  have  set  up  a  slight  amount  of  sujipuration.  Injection  of  the  growth  with 
perchloride  of  iron,  solution  of  tannin,  or  chloride  of  zinc  may  also  be  tried  ;  but  the 
greatest  caution  is  necessary,  as  the  operation  has  occasionally  been  followed  by  the 
sudden   death   of  tlie   patient. 

Cysts. — Various  kinds  of  cysts  are  met  with  in  and  about  the  orbit,  the  most  com- 
mon being  the  congenital  dermoid  cyst.  (See  '•  Operations  on  the  Eyelids. ')  Simple 
cysts,  probably  the  reniains  of  hemorrhages,  and  cysts  connected  with  the  lachrymal 
gland,  are  also  met  with.      Hydatids  have  occasionally  been  seen. 

Nodes. — Periosteal  nodes  are  not  unfrequently  met  with  ;  they  occur  as  hard,  and 
sometimes  painful,  tumors,  usually  situated  somewhere  about  the  margin  of  the  orbit,  but 
sometimes  deep  in  its  cavity.  The  existence  of  a  node  deep  in  the  orbit  should  always 
be  suspected  in  cases  of  paralysis  of  any  of  the  ocular  muscles,  displacement  of  the  eye- 
ball, etc..  if  these  symptoms  be  associated  with  nodes  on  the  forehead  or  margin  of  the 
orbit  and  other  symptoms  of  syphilis.  Nodes  gradually  disappear  under  anti-syphilitic 
treatment. 

Sarcomatous  or  cancerous  growths  may  be  met  with  ;  and  when  pos,sible, 
they  should  be  removed  by  operation. 

Tumors  of  Orbit  and  Eyeball. 

The  tumors  affecting  the  orbit  and  eyeball  are  malignant  growths  which  have  usually 
commenced  within  the  eyeball  and  afterward  perforated  the  tunics  and  implicated  the 
tissues  of  the  orbit.     They  are  generally  of  the  variety  known  as  melanotic  sarcoma. 

The  appearance  of  the  tumor  varies  according  to  the  .stage  of  growth  at  which  it  has 
arrived.  In  an  advanced  case  a  large  fungoid  mass,  of  a  dirty  grayish  or  browni.sh  color, 
having  a  foul  surface  covered  in  parts  with  dark  scabs,  in  others  discharging  thin 
unhealthy  matter  occasionally  mixed  with  blood,  will  be  seen  protruding  between  the 
swollen  and  distended  lids.  On  clo.ser  examination  the  eyeball  (as  such)  will  be  found 
nearly  destroyed,  portions  of  the  sclerotic  abme  remaining  in  their  proper  position.  The 
movements  of  the  globe  are  much  impaired  or  altogether  wanting,  the  growth  having 
implicated  the  whole  of  the  tissues  of  the  orbit  in  one  malignant  mass.  It  is  curious  how 
the  growth,  as  it  advances  beyond  the  limits  of  the  eyeball,  loses  its  melanotic  character 
and  becomes  lighter-colored. 

The  constitutional  disturbance  in  these  cases  is  often  severe,  especially  when  the 
disease  is  fitr  advanced. 

Treatment. — The  treatment  of  these  growths  depends  much  on  the  extent  to  which 
the  tissues  of  the  orbit  are  implicated  and  the  state  of  the  patient's  health. 

If  the  tumor  is  fairly  circum.scribed.  so  that  there  appears  to  be  a  reasonable  hope  of 
removing  the  whole,  and  the  patient  is  in  such  a  state  of  health  as  to  preclude  the  like- 
lihood of  similar  deposits  in  other  parts,  extirpatien  of  the  eyeball  and  other  diseased 
tissues  should  be  performed,  any  portions  of  growth  that  may  be  left  being  afterward 
destroyed  by  some  escharotic.  But  should  the  orbit  be  so  filled  by  cancerous  depo.sit 
that  there  appears  to  be  little  hope  of  removing  the  whole  growth,  more  especially  if  the 
patient  is  in  a  cachectic  condition,  no  operation  should  be  thought  of.  and  the  surgeon 
must  content  himself  with  palliative  treatment,  as  opiates  to  relieve  pain  and  attention  to 
the  general  health. 


320  TUMORS  OF  THE  EYEBALL. 

Tumors  of  the  Eyeball. 

1.  Glioma. 

2.  Sarcomata,  melanotic,  round,  and  spindle-celled. 

3.  Carcinoma. 

4.  Tubercular  deposit. 

5.  Pseudo-glioma. 

Glionia  is  most  commonly  met  with  in  children,  but  occasionally  in  older  persons. 

Sarcomata,  melanotic,  round,  or  spindle-celled,  are  usually  met  with  in  persons  of 
from  fifty  to  sixty  years  old,  and  occasionally  in  early  adult  life.  The  melanotic  is  the 
most  common  form. 

Carcinom.a  has  been  met  with  in  persons  past  the  middle  period  of  life,  but  its 
occurrence  is  rare. 

Glioma  occurs  mo,st  commonly  in  children  ;  it  commences  in  the  retina  and  presents 
the  following  appearance ;  The  patient  will  generally  be  healthy-looking  and  present  no 
signs  of  cachexia  ;  attention  has  been  drawn  to  the  eye  from  a  peculiar  glistening  appear- 
ance of  the  pupil  (cat's  eye).  On  examination,  the  surgeon  will  notice  the  peculiar  reflec- 
tion through  the  pupil,  which  is  generally  somewhat  dilated,  but  movable,  in  the  earlier 
stages.  Examination  both  by  means  of  the  ophthalmoscope  and  by  lateral  illumination 
will  show  a  whitish  growth  projecting  into  the  vitreous  chamber,  either  as  a  single  prom- 
inence or  in  nodules ;  the  growth  will  gradually  increase,  its  surface  become  covered  with 
blood  vessels,  the  retina  be  displaced,  and  sight  soon  entirely  lost. 

As  the  disease  progresses  the  tension  of  the  globe  increases ;  the  pupil  becomes 
widely  dilated  and  fixed,  the  iris  pushed  forward  and  nearly  in  contact  with  the  cornea, 
and  the  lens  opaque,  preventing  a  view  of  the  interior  of  the  eye.  The  whole  globe  now 
gradually  enlarges,  frequent  inflammatory  attacks  occur,  the  sclerotic  becomes  thinned, 
and  at  last,  if  the  growth  is  allowed  to  remain,  a  slough  forms  near  the  centre  of  the 
cornea,  which  ruptures,  and  a  fungoid  bleeding  mass  protrudes. 

The  increase  of  the  growth  now  becomes  much  more  rapid,  and  it  may  grow  to  a 
considerable  size  in  a  short  time. 

As  soon  as  the  growth  becomes  exposed  to  the  air  it  commences  to  discharge  thin 
sanious  pus  and  blood  and  becomes  more  or  less  coated  with  a  dirty  yellow  scab.  The 
eyelids  become  inflamed  and  swollen,  sharp  attacks  of  hemorrhage  may  take  place,  the 
general  health  suff'ers,  and  the  patient  dies  from  exhaustion  or  from  extension  of  the 
disease  to  the  brain. 

Glioma  in  its  early  stages  is  likely  to  be  confounded  with  tubercular  deposit  within 
the  eyeball  or  pseudo-glioma,  but  it  is  not  likely  to  be  thus  mistaken  after  perforation 
has  occurred. 

Treatment. — The  only  treatment  of  glioma  is  extirpation  of  the  globe,  and  this 
should  be  done  as  soon  as  the  nature  of  the  disease  has  been  made  out ;  but,  however 
early  the  operation  may  be  performed,  the  disease  is  almost  certain  to  return  either  in 
the  optic  nerve  or  in  the  brain. 

Melanotic  sarcoma,  or  black  cancer,  affects  persons  of  advanced  age  ;  it  is  a 
variety  of  soft  cancer,  characterized  by  the  development  of  black  pigment-cells ;  it  may 
grow  either  from  the  interior  or  exterior  of  the  eyeball,  but  generally  commences  in  the 
choroid.  It  is  said  not  to  be  so  liable  to  recur  as  glioma.  Round-  and  spindle-celled 
sarcomata  also  commence  most  commonly  in  the  choroid. 

Treatment. — Early  extirpation.  In  all  cases  of  excision  for  malignant  growths  the 
optic  nerve  must  be  cut  back  as  far  as  possible. 

Carcinoma,  as  above  stated,  is  rarely  met  with. 

Tubercular  Deposit. — The  appearance  of  this  deposit  within  the  eyeball  closely 
resembles  that  met  with  in  the  early  stages  of  glioma.  The  patients  are  usually  children. 
The  deposit  is  in  the  choroid;  there,  is  the  peculiar  glistening  appearance  of  the  pupil 
noticed  in  glioma,  and  blood  vessels  may  be  seen  upon  the  surface  of  the  growth  ;  the 
retina  is  more  or  less  displaced  by  fluid  between  it  and  the  choroid  and  floats  in  the 
vitreous  chamber.  The  growth  goes  on  increasing ;  the  pupil  becomes  dilated,  its  mobil- 
ity is  destroyed  ;  the  lens  becomes  opaque,  the  sclerotic  thinned,  the  whole  eyeball  some- 
what enlarged,  and  suppuration  may  occur;  supposing  the  disease  to  have  gone  on  up  to 
this  point,  there  is  nothing  by  which  it  can  be  distinguished  from  glioma. 

Diagnosis. — Now,  however,  the  difl"erence  becomes  manifest :  the  growth,  instead  of 
increasing,  destroying  the  cornea,  and  projecting  from  the  eyeball,  commences  to  shrink, 
and  with  it  the  eyeball,  which  becomes  soft  and  is  at  length  reduced  to  a  small  irregular 


IM-I.AMMATlnS  AM)  sri'l'lllArinS   OF  Till-:   EY KHALI..  :V1\ 

mass.  The  jirowth  of  tubercular  deposit  may  lje<'ome  arrested  at  any  time,  and  tlie  shrink- 
in;:  of  the  eyeball  commence;  in  this,  a^ain,  it  ditt'ers  from  f^lii^ma. 

Ajtpearances  somewhat  similar  to  glioma  are  also  produced  by  inflammatory  deposit 
in  the  vitreous;  the  disease  has  received  the  name  of  '' Pseudo-glioma."  It  is  possible 
to  distiniruish  the  two  by  the  fact  that  in  glioma  the  anterior  chamber  is  in  the  early 
statues  of  irood  depth  ;  in  pseudo-i^lioina  it  exists  only  at  the  periphery.  More<n'er,  in 
pseiido-irlioma  there  are  often  evident  siirns  of  past  iritis  and  the  tension  of  the  globe  is 
below  par. 

Tkk.vt.mknt. — Tonics  and  udod  ofiieroiis  diet.  In  all  doubtful  ca.seH  and  in  tho.se  in 
whiiii  there  is  inuch  pain  the  eye  should  be  incised. 

Inflammation  and  Suppuration  of  the  Eyeball  (" Ophthalmitis,'. 

Ophthalmitis  is  usually  the  result  of  injuries,  especially  of  those  complicated  by  the 
lodgment  of  a  foreign  body  within  the  globe ;  it  unfortunately  not  infrequently  follows 
operations  for  cataract,  and  is  occasionally  met  with  during  erysipelas,  pyajmia,  .scarlet 
fever,  etc.,  and  sometimes  in  women  after  confinement,  especially  if  the  strength  is  low- 
ered by  over-lactation.  The  disease  may  begin  in  any  of  the  structures  of  the  eyeball. 
Should  it  commence  in  the  cornea  and  iris,  the  former  will  become  cloudy,  and  soon 
ab.scesses  will  form  in  its  substance,  the  iris  likewise  becoming  discolored  and  covered 
with  pus.  The  suppuration  may  stop  short  here,  the  cornea  and  iris  being  alone 
destroyed,  and  the  eyeball  left  with  some  perception  of  light.  (See  '•  Suppuration  of 
Cornea  "  and  ••  Iris." )  Should  the  di.sease,  however,  commence  in  the  deeper  structures 
of  the  eyeball,  rapid  impairment  of  vision  will  take  place,  all  perception  of  light  being 
lost  in  perhaps  a  few  hours. 

If  the  pupil  be  clear,  pus  may  be  seen  behind  it,  but  in  most  cases  all  appears  dark  ; 
the  movements  of  the  eyeball  are  much  impaired  and  the  lids  and  conjunctiva  consider- 
ably swollen.  As  the  disease  advances  the  eyeball  becomes  enlarged  and  its  tension 
increa.sed,  and  if  left  to  itself  will  rupture  and  discharge  its  contents,  much  to  the 
patient's  relief.  The  globe  afterward  shrinks  to  a  small  button-like  stump.  Pain  is 
very  severe  in  many  cases,  but  occasionally  is  altogether  wanting.  Suppuration  of  the 
eyeball  rarely  sets  up  sympathetic  changes  in  the  fellow-eye. 

Treatment. — This  depends  upon  the  cause  of  the  disease  and  whether  one  or  both 
eyes  are  affected.  Should  the  inflammation  depend  upon  the  lodgment  of  a  foreign  body, 
this  should  be  removed  without  any  reference  to  its  position  or  the  state  of  vision  ;  if  the 
eye  have  still  good  perception  of  light,  it  will  certainly  be  destroyed,  and,  whatever  diffi- 
culties the  surgeon  may  encounter,  he  cannot  possibly  make  matters  wor.se,  and  he  should 
not  hesitate  an  instant  or  he  will  lo.se  his  chance  of  preserving  any  sight  that  may  be 
left.  Any  foreign  body  having  been  removed,  the  surgeon's  next  care  should  be  to 
relieve  pain,  and,  if  possible,  check  the  progress  of  the  inflammation. 

The.se  indications  are  best  carried  out  by  the  application  of  leeches  (if  the  patient  be 
strong  and  can  bear  blood-letting),  by  opium  internally,  and  by  the  constant  use  of  sed- 
ative fomentations,  the  best  being  the  Fotus  Belladonnae  (made  by  dissolving  a  drachm  of 
extract  of  belladonna  in  a  pint  of  warm  water)  mixed  with  an  equal  quantity  of  Fotus 
Papaveris  (made  by  boiling  an  ounce  of  poppy-heads  in  a  pint  of  water)  ;  a  piece  of  rag 
or  lint  soaked  in  this  mixture  as  hot  as  it  can  be  borne  should  be  kept  con.stantly  applied 
to  the  affected  eye.  Poultices  may  also  be  employed.  Most  patients  will  require  the  admin- 
istration of  a  fair  amount  of  stimulant,  good  fjod,  with  iron  and  quinine. 

AVhen  suppuration  has  V)een  fairly  e.stablished  and  all  perception  of  light  lost,  the  eye 
ball  must  be  treated  as  an  ordinary  abscess  and  the  pus  let  out  by  incision. 

21 


322 


AFFECTIONS  OF  THE  EXTERNAL  EAR. 


CHAPTEK    IX. 


AFFECTIONS    OF    THE    EAR. 


By  Mr.  LAIDLAW    PURVES. 


:^ 


V- 


AFFECTIONS  OF  THE  EXTERNAL  EAR. 

Malformations. — The  malformations  of  the  external  ear  which  are  met  with  are 
very  varied,  extending  from  cases  in  which  there  occurs  an  entire  want  of  the  auricle  to 
those  in  which  the  possession  of  a  double  set  is  seen.  In  cases  where  the  hearing  is  not 
affected  by  the  malformation  the  surgeon  may  be  consulted  as  to  the  propi'iety  of  an  ope- 
ration with  a  cosmetic  view.  He  must  in  these  regulate  his  opinion  by  the  usual  surgical 
rules,  having  regard  to  any  possible  interference  with  the  acuteness  of  hearing  which  an 
operation  might  entail.  The  most  common  malformation  is  a  congenital,  either  partial  or 
entire,  want  of  the  auricle,  with  a  failure  of  the  meatus  auditorius  externus  or  an  occluded 
meatus,  the  lobules  of  the  ear  occasionally  being  displaced  either  on  to  the  neck  or  cheeks 
P   ,   J24  '       (i^V/cFig.  124).    But  the  auri- 

cle may  be  absent  from  injuries 
and  the  meatus  closed  fiom 
otitis,  lupus,  etc.  Such  defects 
do  not  necessarily  occasion  an 
absence  of  the  hearing-power, 
and  cases  are  on  record  in 
which  patients  with  this  de- 
fect could  hear  sufficiently 
well  to  hold  conversations 
with  those  to  whose  voices 
they  were  accustomed.  Be- 
fore deciding  to  operate  in 
such  congenital  cases  it  is 
advisable  to  keep  the  child 
under  observation  for  some 
time  for  the  purpose  of  not- 
ing if  anj'  signs  of  hearing 
are  developed. 

Treatment. — Should  it  be  determined  to  operate,  the  .point  of  operation  may  now 
and  again  be  fixed  by  passing  a  current  of  air  through  the  Eustachian  tube  and  noting 
the  point  at  which  the  impingement  of  air  at  the  end  of  the  rvJ-dr-Ritc  is  heard  best.  Tliis 
is  accomplished  by  using  what  is  generally  called  "  Politzer's  method"  (Fig.  125),  which 

consists  in  passing  the  soft  nozzle  of  a  caout- 
chouc bag  filled  with  air  into  one  or  other  nos- 
tril of  the  patient,  and  while  he  swallows  a 
mouthful   of  water   compressing   the    nostrils 
with  the    fingers    of  the    left    hand,  so  as  to 
prevent   the    exit  of  air    through    them.     At 
the    same    moment    the    right    hand    forcibly 
?^>-'     expels   the   air  from   the   bag  •  in  such  a  way 
'^^'      that,  finding  no  passage  open  except  the  Eus- 
tachian tubes,  it  rushes  up  them,  passes  into 
the  tympanic  cavit3^  and  pushes  out  the  mem- 
brana  tympani.     It  is  this  sudden  rush  of  air 
against  the  external  wall  of  the  cavity  which 
the  surgeon  listens  for  by  means  of  a  tube  of 
india-rubber  passing  from   the  meatus  of  the 
patient  to  that  of  the  surgeon.     In  cases  of 
ab.sence  of  the  meatus  a  stethoscope  may  be 
used,  by  which  the  surgeon   determines  at  which   point  the  air  impinges  most  forcibly, 
and  at  this  point  he  makes  his  opening.     If  hard  and  bony  at  this  spot,  the  trephine  will 


dulous  outgrowth  on  left  nostril. 


(Taken^  from  a  female  patient  of  Mr.  Bryant's, 

'  ''  "      than  left,  and  more  defoimed. 

The  child  had  likewise  a  jien- 


Drawing  of  Occluded  Ears, 
aged  three  months.)     Right  auricle  smaller  than  left,  and  more  deformed. 
The  pendulous  bodies  contained  cartilage. 


Fig.  125. 


Politzer's  Method  of  Inflating  the  Middle  Ear. 


AFFIXATIONS  OF  THF  EXTERNAL  EAR.  32:3 

be  necessary  ;  it'  soft,  tin-  knife  will  siifVicc,  niakini:  ;i  cnuial  (ijicniri;.'  and  keeping  tlie 
openinj;  patent  by  means  ui'  tents  or  dllicr  luivi<.'n  lnnlii-s.  In  (•un;ienital  eases  tlie  open- 
inj;  (intxlit  tn  bi-  made  very  earet'ully,  watcliin^-  for  the  niembrana  tympani;  l)Ut  sbonld 
there  be  nii  membrane  (uiind  un  enttinj.'  down  tn  the  nsual  ]ii)sition  of  sneli,  it  is  advisa- 
ble to  allow  the  arlilicial  opening;-  to  close  a;j:ain.  If  the  deafness  before  operatinfr  is  very 
^reat,  it  is  pr(d)ably  better  to  diseoimtenanee  any  operation,  as  the  results  of  interference 
with  congenital   malformations  of  the  ear  have   <renerally  bet-n  by  no  means  satisfactory. 

Cutaneous  Affections  of  the  External  Ear.— Hypertrophy  from  chronic 

intlaiiini.ilinii.  ee/enia  (miite  and  elinmic  i,  lierpo.  iiiipetiL;n,  pemphigus,  <;rysipelas,  affect 
tlie  auricle  and  have  nundi  the  same  appearances,  follow  the  same  course,  and  are  amen- 
able to  the  same  treatment,  as  in  other  parts  of  the  body. 

TKKAT>tK.\T. — Particular  attention  ought  to  be  paid  to  any  skin  affection  which  may 
be  present  in  the  neighborhood  id'  the  auricle,  es]»ecially  in  the  hair,  careful  note  being 
paid  to  the  sort  of  pomade  or  other  application  the  patient  uses  for  cosmetic  purposes. 
The  meatus  auditorius  e.xternus  ought  to  be  cleared  once  daily  by  a  lukewarm  water 
injection  of  any  collection  of  epidermis  or  cerumen,  which  is  apt  to  be  of  a  greater  quan- 
tity than  niinnal  iluring  the  progri'ss  of  the  skin  affection. 

Injuries  to  the  External  Ear. 

Injuries  to  the  external  ear  are  by  no  means  rare,  but,  hajipily,  if  confined  to  the  auricle, 
they  affect   the  hearing  of  the  sufferer  but  slightly,      l^ider  the  usual   treatment  they 
generally  do  well,  care  being  had  to  make  as  perfect  an   adjustment  of  the 
parts  as  possible.      In   lS(i(i,  Mr.  Bryant  treated  a  girl  of  twelve  years  of  *^'    ^^' 

age  for  the  effects  of  an  ulceration  of  the  external  ear  some  years  previously. 
The  condition  of  the  ear  i.s  indicated  in  the  accompanying  engraving  (Fig. 
120).  By  paring  the  edges  of  the  pendulous  portions  of  the  auricle  and  the 
skin  covering  over  the  parts  behind,  a  good-looking  entire  ear  was  made,  with 
great  addition  to  her  comfort. 

The  tumors  of  which  the  auricle  may  be  the  seat  are  the 
oth;omatoiiiatoiis,  gouty,  fibru-plastic,  fibro-cartilaginous.  sebaceous,  erectile, 
epitholiomatous,  and  sarcomatous.  The  tibro-plastic  or  cheloid  has  been 
already  alluded  to  as  occurring  in  the  lobulus  of  the  ear  after  the  operation 
of  puncture.  I  have  seen  many  such,  the  largest  having  been  the  size  of  a 
walnut  (Fig.  12S).  They  generally  do  well  after  excision,  but  if  not 
thoroughly  removed  will  grow  again.  The  otba?matomatous  requires  special  '"^'^'"e  224  \ 
mention,  but  the  others  are  to  be  recognized  and  treated  as  in  other  parts  of  the  body. 

Hsematoma. — Idiopathic  hjematoma  auris,  or  vascular  tumor  of  the  ear,  consists, 
according  to  the  latest  trustworthy  authorities,  of  a  degenerative  morbid  process  induced 
by  general  disturbances  of  nutrition.  The  cartilage  of  the  auricle  is  its  seat,  but  the 
pathological  appearances  differ,  as  some  bave  found  the  perichondrium  separated  from 
the  cartilage,  while  others  have  found  "  pieces  of  the  cartilage  attached  to  the  perichon- 
drium." In  other  cases  the  cartilage  has  been  found  thicker  but  no  harder  than  natural, 
the  thickened  part  presenting  no  appearance  of  a  cyst,  but  under  the  microscope  showing 
hypertrnphied  cartilage  cells  and  intercellular  matter.  This  idiopathic  hfomatoma  com- 
mences by  a  flushing  of  the  auricle,  which  becomes  hot  and  painful.  In  a  few  hours  an 
effusion  of  blood  takes  place,  which,  generally  commencing  in  the  concha,  gradually 
spreads  over  the  auricle,  feeling  firm  to  the  touch,  but  allowing  of  fluctuation  being 
detected  if  looked  for  with  care  (Fig.  127).  It  is  believed  to  be  peculiar  to  patients 
suffering  from  dift'erent  forms  of  insanity,  general  paralysis  having  the  largest  share, 
melancholia,  acute  and  chronic  mania,  and  dementia  following  in  the  order  named.  Dr. 
Hun  thinks  that  the  affection  obtains  such  an  exclusive  position  amongst  the  in.sane  that 
any  one  suffering  from  ha?matoma  auris,  although  sane  at  the  time  of  observation,  ought 
to  be  suspected  of  insanity. 

That  the  aft'ection  occurs  in  persons  Avho  bave  no  hereditary  history'  and  show  no 
symptoms  of  insanity  is  undoubted,  but  whether  the  pathological  changes  at  the  seat  of 
the  tumor  are  the  same  in  those*ca.«;es  or  differ  in  the  other  cases  in  which  there  is  a  his- 
tory of  traumatic  injury  is  yet  undetermined,  though  I  am  inclined  to  believe,  from  the 
ca.^es  which  have  come  under  my  own  notice,  that  those  resulting  from  injur}-  do  not 
arise  from  the  same  pathological  changes. 

Treat.aient. — The  modes  of  treatment  recommended  by  different  authorities  vary. 
Grul)er  recommends  evacuation  of  the  fluid  and  coagula  and  the  after-use  of  a  compress 


324 


AFFECTIONS  OF  THE  EXTERNAL  EAR. 


bandage,  while  Wendt  relates  a  case  where  vascular  tumor  recurred  twice  after  incision 
but  passed  off  under  lead-water  applications  and  compression.  I  have  tried  the  different 
methods  proposed,  once  passing  a  seton  through  the  tumor  and  keeping  up  a  slight  dis- 
charge from  it,  and  find  them  get  well  under  all  the  different  methods.  'Since  the  appli- 
cation of  a.stringent  lotions  and  a  compress  is  less  alarming  to  the  patient  and  .seems  as 
effectual,  I  am  inclined  to  follow  it  in  future  cases,  keeping  up  the  compression  by  a 
modified  letter  clip  applied  to  the  ear,  padding  the  arms  of  the  clip,  so  as  to  prevent 
injury  to  the  skin  of  the  auricle. 


Report  by  Dr.  Goodhart  on  Ciieloid  Tlmor.s  of  the  Ear. 

The  small  tumors  or  thickenings  of  the  skin  which  usually  go  by  the  name  of  che- 
loid  (Alibert),  are  of  inflammatory  nature,  with  more  or  less  tendency  to  become  fibrous. 


Fig.  127. 


Fig.  1-29. 


Hfenialoma  Aiiris. 


Fig.  126. 


Cheloid  1  i,.,,.j,  .j,  ]:ar. 


Fig.  128  gives  the  microscopical  appear- 
ances of  one  of  those  cheloid  tumors, 
from  the  pencil  of  Dr.  Goodhart. 


Q-       Horny  layer  of  epidermis. 
Q^  '       Its  limit. 

- h  Cutis  vera. 

Limiting  layer  of  epithelial  cells. 


Corium  of  fibrous  tissue  with 
nuclear  elements  scattered 
■through  it.  They  are  appar- 
ently inflammatory,  for  they 
do  not  alter  the  ti.ssue  in  any 
way;  they  merely  lie  in  the 
sjjaces. 


Hyaline  bands  of  fibrous  tissue, 
taking  the  carmine  stain  well, 
iiut  having  no  definite  struc- 
ture. 


These  drawings  (Figs.  128,  129),  made  from  a  section  of  one  of  these  growths  in  the 
lobule  of  an  ear  which  had  been  pierced  for  an  earring,  show  the  microscopical  character- 
istics. Its  macroscopical  appearance  was  that  of  a  fibrous  tumor.  It  will  be  .seen  that, 
in  addition  to  newly-formed  tissue,  there  is  also  a  great  deal  of  nuclear  germination 
going  on. 

Affections  of  the  External  Meatus. 

To  examine  the  external  meatus,  it  is  usually  necessary  to  employ  a  .speculum  for  the 
purpose  of  straightening  and  widening  the  canal,  and  so  allowing  of  the  pas.sage  of  rays 
from  a  natural  or  artificial  light.  The  specula  are  formed  of  silver  or  caoutchouc  and  are 
of  various  forms.  The  silver  speculum  of  Wilde  with  a  round  aperture  at  the  narrow 
end  will  be  found  as  convenient  as  any,  it  being  necessary  to  have  three  or  four  different 
sizes.  If  available,  sunlight,  either  direct  or  reflected  from  a  white  cloud,  is.  I  think, 
the  best  mode  of  illumination,  as  it  gives  different  tints  of  the  meatus  and  tympanic  mem- 
brane more  truly  than  any  artificial  light.  Seating  the  patient  near  a  window,  with  the 
ear  to  be  examined  away  from  the  window,  you  receive  the  rays  on  a  mirror  either  held 
in  the  hand  or  placed  on  the  forehead,  and  reflect  them  into  the  meatus  by  inclining  the 
mirror  to  the  required  angle.     If  you  use  the  rays  direct  from  the  sun  itself,  it  is  neces- 


AFFKCTlnSS   nF   TIH:   FXTFUXAf.    AM  A'.  ;j'Jo 

sarv  that  a  i>laiic  iiiirror  slioiiM  lie  tisfd,  tin-  ii-<iial  concave  mirror  soon  causinp;  such  an 
aniiMiiil  of  Ileal  to  Ik-  l«'lt  at  tlic  spot  on  which  tiic  reflected  rays  are  tlirown  that  tlie  patient 
cannot  endnre  a  hdij;  examination.  Shoiihl  sntVn-ienf  daylijrht  n(»t  be  olitainalde.  an  ar;^'and 
burner,  with  or  witliont  a  bnll's-eye  hintern  placed  over  it,  will  act  as  a  jrood  sulistitute. 
llavinir  arraiiL'ed  your  flood  of  li^ht  so  tliat  it  falls  on  the  auri<de  and  external  meatus, 
yon  take  the  superior  ami  posterior  part  ol'  the  auricle  between  tlie  middle  and  index  fin- 
ders of  the  left  hainl.  and,  puUinu  the  auricle  backward  and  upward,  you  widen  more  fully 
the  lumen  ol"  the  meatus,  into  which  you  introduce,  by  the  rij.'ht  hand,  the  small  rouml 
end  of  the  spe<-ulum.  Passinir  it  irently  in  by  a  slii;htly  rotating  motion,  you  reach  a 
spot  where,  there  being  no  foreign  body  to  occlude  the  view,  if  the  meatus  is  fif  a  mjrmal 
width,  the  tympanic  menibrain>  will  be  expo.sed  t<»  view.  On  aceomjtlishing  this,  the 
external  edge  of  the  speculum  is  passed  to  the  care  of  the  thuml)  and  index  fingers  of  the 
left  hand,  which  move  it  in  diflerent  directions,  so  as  to  throw  rays  on  the  different  por- 
tions of  the  canal  and  the  tympanic  membrane,  while  the  right  hand  is  left  free  to  u.se  the 
mirror,  or.  placing  the  mirror  on  the  forehead,  to  use  any  instruments  which  may  be 
necessary. 

The  most  freipient  change  in  the  external  meatus  which  comes  befiu'e  the  surgeon  on 
thus  looking  into  the  canal  is  an  accumulation  of  cerumen,  known  by  its  position,  form, 
color,  and  light  reflecti<ui.  It  occurs  on  account  of  some  hypenemia  of  the  ear,  of  which 
a  very  common  cause  is  the  irritation  arising  from  .scratching  the  meatus  with  pencils, 
pins,  etc.;  but  anvthing  which  causes  an  increased  flow  of  blood  to  the  lining  membrane 
of  the  meatus  will  cause  a  greater  accumulation  of  cerumen  than  normal.  It  also  occurs 
in  those  much  exposed  to  the  sun  and  dust,  in  those  who  perspire  freely,  and  in  the  old, 
in  whom  the  cerumen  is  denser  and  stiff'er  than  in  the  young. 

Symptoms. — The  subjective  symptoms  caused  by  such  accumulations  are  pain,  vertigo, 
confusion  of  ideas,  tinnitus  aurium,  and  deafness,  the  latter  .symptom  being  often  character- 
ized by  its  sudden  entrance  and  departure. 

PRO(iNOSls. — The  prognosis  is  not  so  favorable  as  is  generally  supposed.  If,  in  the 
affected  ear,  a  vibrating  tuning-fork  placed  on  one  of  the  incisors  or  on  the  middle  line  of 
the  vertex  is  not  heard  better  than,  or  so  well  as,  in  the  non-affected,  you  may  expect 
some  complication,  and  the  mere  removal  of  the  cerumen  will  not  probably  be  followed 
by  much  beneficial  result  to  the  deafness.  Toynbee  gives,  as  the  results  of  his  removal 
of  accumulations  of  cerumen  from  the  meatus  causing  deafness,  a  table  of  165  cases,  of 
which  (iO  were  cured,  43  were  improved,  and  the  remaining  62  were  '•  either  but  slightly 
or  not  at  all  improved.''  Mr.  Ilinton  gives  one  in  six  as  his  proportions  of  recovery  in  the 
same.  It  will  thus  be  seen  that  in  a  large  pro])ortion  of  eases  of  accumulation  of  cerumen 
in  the  external  auditory  meatus  there  is  a  complication  present  which  does  not  give  way 
on  the  removal  of  the  cerumen  and  which  clouds  the  prognosis  considerably. 

Treatment. — If  you  can  easily  lay  hold  of  the  accumulation  by  means  of  the  forceps 
without  risk  of  pushing  it  against  the  membrane  and  without  causing  pain,  it  is  well  to 
remove  it  in  that  way,  e.specially  if  you  are  removing  it  for  the  purpose  of  obtaining  a 
view  of  the  parts  behind  which  you  wish  to  examine  on  account  of  some  affection  pres- 
ent, as,  should  there  be  some  abnormality  of  the  parts  behind,  the  passage  of  a  strong 
current  of  water  might  prejudice  them.  But  should  it  not  be  practicable  to  remove  the 
accumulation  by  the  forceps  without  causing  irritation,  the  syringe  must  be  used  in  the 
manner  described  in  treating  of  f(U-eign  bodies  in  the  meatus. 

A  lessening  of  the  secretion  is  sometimes  seen  in  acute  aflfections  of  the  middle  ear 
and  in  nervous  deafness,  but  before  making  3"our  diagnosis  in  such.  in(|uiry  of  the  patient 
as  to  what  he  has  done  to  the  ear  before  coming  to  you  is  useful  in  eliciting  a  good  rea- 
son for  the  condition  found.  The  use  of  some  slight  emollient  and  attention  to  the  pri- 
mary cause,  if  any  such  is  detected,  comprise  the  treatment. 

Foreign  Bodies. 

In  no  department  of  surgery  is  the  aphorism  that  "  blind  zeal  only  hurts  "  more  neces- 
sary to  be  remembered  than  in  that  relating  to  foreign  bodies  in  the  ear.  The  form  of 
the  canal  is  so  peculiar,  being  that  of  a  s})iral  turning  anteriorly  inward  and  downward 
and  having  expansions  at  either  extremity,  and  the  forms  of  the  foreign  bodies  which 
enter  or  are  placed  in  the  meatus  are  so  varied,  that  the  cflForts  to  remove  them  by  any 
other  means  than  a  current  of  water  must  be  used  only  where  the  practitioner  is  guided 
by  an  accurate  knowledge  of  the  anatomy  of  the  external  meatus  if  damage  to  the  deli- 
cate structures  which  limit  the  inner  end  of  the  meatus  is  to  be  avoided.     So  common 


326  AFFECTTOyS   OF  THE  EXTERXAL   EAR. 

are  forcible  attempts  to  extract  by  those  unaccustomed  to  meet  such  cases  thai  it  is 
exceptional  that  a  case  is  seen  by  the  surgeon  before  such  efforts  have  been  made  as 
have  caused  a  certain  amount  of  inflammation  of  the  canal  and  its  consequent  lessening 
in  calibre.  In  such,  where  the  calibre  has  been  rendered  too  narrow  to  admit  of  the  pas- 
sage of  the  foreign  body  without  consideral>le  force,  the  first  indication  is  to  allav  the 
inflammation  by  rest,  leeches,  and  fomentations.  The  exudation  having  been  absorbed 
and  the  canal  having  nearly  or  wholly  resumed  its  normal  size,  the  surgeon  ought  to 
determine  whether  there  is  a  foreign  body  present,  and,  if  possible,  its  .size.  form,  and 
position  ;  for  cases  continually  occur  in  which  a  patient  sufiering  from  chronic  disease  of 
the  middle  ear  has  the  feeling  of  a  foreign  body  being  present,  while  others  are  either  the 
subjects  of  delusion  from  other  causes  or  are  attempting  to  delude  you.  This  information 
is  obtained  by  means  of  the  usual  mirror,  speculum,  and  probe.  Vjy  the  last  of  which  30U 
can  determine  if  the  body  is  hard  or  soft  or  moves  easily. 

Treatment. — If  the  last  is  the  case,  you  may  by  inclining  the  head  to  the  side  of  the 
ear  affected  shake  it  out.  or  by  laying  the  one  hand  on  the  ear  a  sharp  percussion  on  the 

hand  so  placed  may  remove  it.     But  the  persevering  use 
Fig.  130.  of  an  injection  of  lukewarm  water  from  a  four-  or  five- 

ounce  syringe,  the  point  of  the  nozzle  of  which  has  a 
calibre  of  from  one  to  two  millimetres,  is  the  method 
which  ought  to  be  used  above  all  others,  which  carries 
with  it  the  least  danger,  and  is  by  far  the  most  successful. 
A  bowl  being  held  by  the  patient  .so  that  the  rim  is 
pressed  against  the  skin  close  under  the  lobule  of  the  ear. 
the  surgeon  draws  the  auricle  upward  and  backward  so  as 
to  straighten  the  external  meatus,  and.  the  nozzle  being 
pas.sed  slightly  within  the  external  opening  and  pressed 
against  the  upper  wall,  a  moderately  forcible  current  is 
made  to  pass  along  the  upper  wall,  sweep  across  the 
menibrana  tynipani.  and  \)\  it  is  directed  outward,  in 
which  latter  course  it  meets  with  the  foreign  body,  and, 
carrying  it  with  it.  forces  it  along  the  lower  wall  of  the 
Svringing  Ear  *'       Canal  and  out  at  the  external  opening.     It  may  be  neces- 

sary so  to  change  the  position  of  the  patients  head  as  to 
give  the  stream  a  different  direction,  according  to  the  po.sition  of  the  foreijrn  body  in  the 
canal,  the  endeavor  being  always  to  pass  the  inward  current  beyond  the  body,  which 
ought  to  be  influenced  only  by  the  outward  rush.  Should  the  body  be  impacted,  it  may 
be  necessary  to  loosen  it  by  the  probe  before  you  can  remove  it  by  the  syringe ;  but  the 
first  injections  generally  suffice  to  do  this.  This  failing,  which  is  extremely  rare,  and 
the  body  being  soft,  you  ma}"  pa.ss  a  hook  into  it  from  the  side  and  so  extract  it ;  or 
should  it  be  too  large  for  this,  vou  may.  having  fixed  it  with  the  hook  so  as  to  prevent  it 
passing  farther  in  by  your  manipulations,  pull  pieces  out  of  it  by  means  of  small  kneed 
forceps  and  so  reduce  its  bulk  sufficiently  to  extract  by  the  hook.  When  the  body  is 
hard  and  .so  formed  that  the  current  cannot  have  much  influence  upon  it  and  a  hold  by 
forceps  or  hook  cannot  be  obtained.  Lowenberg's  method  of  bringing  the  point  of  a  camel's- 
hair  pencil  armed  with  joiner's  glue  or  other  glutinous  material  into  contact  with  the 
body,  allowing  the  viscous  substance  to  harden,  and  thus  binding  the  pencil  and  the 
foreign  body  together  and  .so  extracting  them,  is  sometimes  useful.  Many  other  instru- 
ments have  been  proposed  to  remove  foreign  bodies,  most  of  which  are  not  worthy  of  a 
place  in  the  surgeon's  armamentarium  :  but  mention  must  be  made  of  Wilde's  wire  snare, 
which  may  be  found  very  useful  and  has  the  advantage  of  being  very  safe,  and  Mr. 
Durham's  ear  forceps,  which  allows  of  the  passage  of  the  instrument  through  a  narrow 
speculum — a  very  great  desideratum. 

It  may  happen  that  none  of  the  above-mentioned  means  will  enable  you  to  extract 
the  body,  and  yet  the  symptoms  of  pressure  on  the  nervous  structures — giddiness,  confu- 
sion, delirium,  etc. — are  so  urgent  that  removal  is  imperative.  In  such  you  may  be 
compelled  to  place  the  patient  under  chloroform,  enter  the  meatus  by  loosening  the 
auricle  from  its  superior  attachments  or  throuirh  the  mastoid  process,  and  so  reach  the 
offending  body  and  extract.  But  resort  to  such  serious  measures  will  only  be  called  for 
b}-  the  most  pressing  symptoms,  and  then  probably  in  cases  where  violent  unsuccessful 
efforts  to  extract  have  been  made,  os  tlip  mffc  jjreseuce  of  a  foreign  body  in  tlu   external 

Modes  of  Softening  Foreign  Bodies. — Before  attempting  to  remove  certain 


AJThCTFOXS  OF  TIIF.    EXTERSAL   EAR.  ;J27 

Imdu's  it  is  iicci'ssary  t(i  |il;ic»'  tliciii  in  a  coiiditioii  favorahli-  tn  tlicir  rt'iimval  or  to  allay 
till-  uiilicaralde  irritation  causfil  l»y  .some  of  tlieiii.  For  examplf,  a  liall  of  ccruineii  may 
lit'  so  liaril  that  no  iiistriimciit  will  pierce  it  sufticieiitly  to  j:ivc;  the  surgeon  suflicieiit 
l»urchase  upon  it  to  extract  it,  or  it  may  he  too  large  to  ])ass  the  isthmus  of  the  external 
meatus  without  the  use  of  undue  lorce.  in  sueh  you  are  eompelied  to  soften  it  hy 
repeated  soakings  in  hot  water  or  a  solution  of  glycerine  or  some  alkaline  solution  before 
endeavoring  to  break  it  up.  Again,  wlien  some  small  animal  has  passed  into  the  ear  and 
its  movements  are  causing  great  annoyance  by  irritating  the  excessively  sensitive  tym- 
panic meml)rane,  it  is  necessary  to  introduce  toba<-co-smoke  or  water,  (»r  a  little  spirit  and 
water,  or  <iil.  to  kill  it.  and  at  oni-c  allay  tlic  inilatimi  licturc  attempts  at  removal  are 
undertaken. 

Maggots  are  sometimes  found  in  the  external  meatus  and  tympanic  cavitv.  especially 
in  cases  of  otorrluea.  and  are  generally  dittieult  to  remove.  Should  the  membrane  iifjt  be 
perforated,  the  syringe  will  suffice;  but,  as  in  the  eases  in  which  they  are  mostly  found 
the  meml»rane  is  ))erforated,  the  force{)s  is  found  more  effectual.  To  allay  the  pain  gen- 
erally occasioned  by  their  presence,  the  itijection  of  ten  drops  three  or  four  times  daily 
of  a  lukewarm  solution  of  a  grain  of  acetate  of  lead  and  a  grain  of  acetate  of  morphia  in 
an  ounce  of  water  will  be  found  of  service.  \'arious  kinds  of  as])ergilli  are  met  with, 
especially  in  climates  warmer  than  that  of  England;  but  even  in  Kngland  they  are  more 
Cfimmon  than  is  generally  believed,  judging  from  the  cases  reported  in  the  medical  jour- 
nals as  rarities  and  worthy  of  notice.  The  ap])earance  on  examining  the  meatus  with  the 
speculum  is  as  if  fine  meal  had  been  blown  into  the  ear,  or  as  if  "coal-dust  had  been 
blown  on  to  white  sand."  The  true  diagnosis  can  be  made  certain  by  the  microscope 
only.  The  parasiticides  pro])osed  are  many,  but  warm  water  often  used  or  a  mixture  of 
spirit  and  water  will  suffice  in  all  cases. 

Should  it  be  found,  after  the  removal  of  any  foreign  body,  that  the  tymj)anic  mem- 
brane has  changed  its  jiosition  and  does  not  of  itself  recover  its  normal  situation,  the  air- 
bag  or  catheter  or  the  vacuum  speculum  may  be  of  benefit  in  assisting  you  to  replace  it. 

A  piece  of  wadding  should  l>o  lightly  inserted  in  the  meatus  after  the  removal  of  the 
foreign  body  and  kept  there  for  some  hours,  so  as  to  protect  the  irritated  parts  from  cold, 
strong  noises,  etc. 

It  ought  to  be  remembered  that  foreign  bodies  in  the  ear  may  cause  many  reflex 
actions,  such  as  tickling  in  the  throat,  giddiness,  pain  and  heaviness  in  the  head,  vomit- 
ing, cough  and  expectoration,  sneezing,  an;vsthesia  of  side,  epilep.sy.  etc. 

Furuncles  of  the  external  meatus  originate  generally  in  one  of  the  hair  folli- 
cles or  in  one  of  the  ceruminous  glands.  They  occur  mostly  as  the  symptom  of  some 
constitutional  affection,  in  which  case  they  are  as.sociated  with  boils  on  other  parts,  or  of 
some  deeper  local  chronic  inflammatory  lesion,  and  are  considered  in  such  as  a  favorable 
sign.  The  long-continued  use  of  astringent  lotions,  especially  of  alum  solutions,  seems 
to  place  the  meatus  in  a  condition  favorable  to  their  formation,  if  it  be  not  the  actual 
cause  in  some  cases.  The  symptoms  they  occasion  are  great  throbbing  and  pain,  conse- 
quent on  the  unyielding  condition  of  the  skin  and  connective  ti.ssue  of  the  external  meatus 
to  the  pressure  from  the  accumulating  pus,  fever  (especially  during  the  evening),  some- 
times tinnitus,  a  feeling  of  tension  in  the  ear,  and  more  or  less  deafness,  according  to  the 
position  and  extent  of  the  inflammation.  They  occur  at  all  ages  and  in  all  constitutions, 
but  middle  age  obtains  by  far  the  majority  of  cases.  The  prognosis  is  favorable,  though 
you  may  be  unable  to  check  the  fornuxtion  of  new  crops,  which  go  on  for  months,  even 
in  the  most  robust  people. 

Treatment. — The  treatment  is  conducted  either  with  a  view  to  arrest  the  develop- 
ment of  the  abscess,  or,  the  formation  being  complete,  to  give  the  pus  free  exit.  The 
former  may  be  brought  about  by  painting  the  swelling  with  a  strong  solution  of  nitrate 
of  silver  (3ss— 5j  to  5J  of  water)  or  a  solution  of  sulphate  of  zinc  of  the  same  strength. 
The  latter  is  best  accomplished  by  a  small  narrow  knife — so  narrow  in  the  blade  and 
handle  that  it  does  not  exclude  your  view  of  the  part  while  nuiking  a  free  incision 
through  the  boil.  After  making  tlie  incision  I  found  it  useful  to  apply  a  vacuum  specu- 
lum (Siegle's ;  see  article  on  '"Affections  of  the  Membrana  Tympani ")  to  the  meatus  and 
by  suction  empty  the  abscess  as  much  as  possible  of  pus  and  at  the  same  time  obtain  a 
free  flow  of  blood  from  the  wound.  The  application  of  moist  heat  afterward  by  fre- 
quently filling  the  ear  with  warm  water,  and  laying  for  half  an  hour  or  so  a  cataplasm 
over  the  whole  ear  so  filled,  of  leeches  in  front  of  the  tragus  if  there  is  much  pain,  or  of 
a  plug  of  cotton  which  has  been  saturated  with  glycerine  (Fisher),  changed  twice  daily, 
for  the  same  purpose,  and  the  judicious  use  of  purgatives,  result   in  a  favorable  termina- 


328  AFFECTIONS  OF  THE  EXTERNAL  EAR. 

tion  to  the  particular  boil  in  question  ;  but  the  constitutional  treatment  must  follov/,  to 
prevent,  if  possible,  the  development  of  others.  As  a  local  preventive  Mr.  Hinton  con- 
sidered that  the  application  to  the  meatus  of  red  or  white  precipitate  ointn)ent  was  of 
service. 

Narrowing  of  the  meatus  in  the  cartilaginous  portion  occurs  not  unfrequently 
in  the  aged,  on  account  of  the  tense  tissue  bundles  of  the  posterior  and  upper  walls  hav- 
ing become  loosened  and  sunk  forward  against  the  anterior  wall.  This  narrowing  seldom 
leads  to  complete  closure,  and  therefore  does  not  influence  the  hearing-power  to  any 
extent ;  but  its  presence  prevents  the  normal  exit  of  the  cerumen,  and  so  tends  to  the 
formation  of  cerumen  balls  beyond  the  narrowed  part  of  the  meatus,  and  their  results. 
Other  narrowings  besides  those  which  are  congenital  arise  from  thickening  of  the  skin 
after  frequent  attacks  of  inflammation  of  the  meatus,  after  furuncle  and  other  tumors, 
eczema,  and  the  long  use  of  astringent  lotions  or  ointments.  Except  in  the  case  of 
tumors,  you  may  widen  the  canal  by  the  use  of  the  laminarla  (liyitdfa^  or  sponge  dila- 
tors, sufficiently  to  form  your  diagnosis  and  apply  remedies. 

Treatment. — Treat  any  aff"ection  of  the  tympanic  cavity  which  may  be  present. 
Keep  the  canal  clear  of  cerumen  and  epidermis  by  injections  of  lukewarm  water  or  the 
passage  of  a  dry  camel's-hair  pencil,  and  by  the  use  of  small  ivory  bougies  gradually 
increased  in  size,  so  that  the  amount  of  pressure  may  be  kept  up,  promote  absorption. 

Exostoses  of  the  meatus  are  found  in  individuals  of  the  gouty,  rheumatic,  and 
syphilitic  diatheses,  though  their  connection  with  this  last  diathesis  is  not  well  estab- 
lished. They  are  certainly  frequent  in  the  meatus  of  good  livers,  who  are  likely  to  have 
their  mucous  membranes  frequently  congested.  On  looking  into  the  meatus  an  elevation 
is  seen,  generally  about  the  middle  third,  the  skin  over  which  is  reddened  and  moist  and 
pressure  on  which  by  the  sound  causes  pain. 

Treatment. — The  treatment  is  not  sati.sfactory  unless  the  exostosis  has  a  pedicle,  in 
which  case  it  may  be  broken  off".  In  other  cases,  having  paid  attention  to  any  aff'ection 
causing  congestion  of  the  mucous  membrane  of  the  tympanic  cavity,  the  application  of 
iodine  to  the  growth  itself,  and  behind  the  ear,  so  as  to  keep  up  a  slight  counter-irritation 
for  a  lengthened  time,  and  the  exhibition  of  it  internally,  offer  the  best  hopes  of  resolu- 
tion. Should,  however,  the  exostosis  prevent  the  exit  of  pus  from  the  parts  internal  to 
it,  the  formation  of  a  channel  by  a  hammer  and  chisel,  trephine,  dentist's  drill,  or  elec- 
trolysis, and  the  maintaining  of  it  by  tents,  may  be  imperative  for  the  purpose  of  keeping 
the  parts  clean  and  the  application  of  medicaments  to  the  parts  beyond. 

Hyperostosis  of  the  bony  meatus  is  seen  after  a  chronic  otorrhoea,  and  gen- 
erally extends  through  the  whole  of  the  bony  canal.  It  is  caused  by  inflammation  of  the 
periosteum,  which  results  in  a  well-developed  bony  formation.  The  skin  along  the 
narrowed  portion  of  the  canal  is  more  or  less  congested.  The  treatment  is  that  of  exos- 
tosis. 

Molluscous  tumors  of  the  meatus  consist  of  accumulated  laminae  of  epidermis 
and  sebaceous  matter  enveloped  in  a  thick  membrane.  Though  thus  composed  of  com- 
paratively innocuous  material,  they  have  the  power  of  causing  absorption  of  the  bone 
lying  in  contact  with  it,  passing  through  it  by  a  clean-cut  aperture  without  affecting  the 
bony  sides  of  the  canal  thus  caused,  and  so  pursuing  their  course  pass  to  and  press  on 
the  parts  beyond,  causing  symptoms  varying  according  to  the  parts  implicated.  The 
diagnosis  of  this  molluscous  tumor  from  exostosis  is  made  by  pressing  a  probe  on  the 
skin  over  the  tumor  and  noting  the  hardness  of  the  enlargement.  Laying  open  the 
tumor,  washing  out  the  accumulated  epidermis  by  the  syringe,  and  withdrawing  by  the 
forceps  the  lining  membrane  is  the  treatment  recommended. 

Syphilitic  affections  of  the  meatus  occur  as  fissures  and  ulcerations  near  the 
orifice,  condylomata,  and  exostoses.  The  ulcerations  exhibit  the  usual  punched-out- 
irregular  contour  and  discharging  surface.  The  treatment  is  the  usual — general  and 
local. 

Inflammation  of  the  external  auditory  meatus,  or  otitis  externa,  is 

an  inflammatory  affection  of  the  cutaneous  tissues  of  that  canal,  involving  more  or  less, 
according  to  the  violence  of  the  attack,  the  periosteum  of  the  osseous  part  of  the  canal 
and  the  membrana  tympani. 

Symptoms. — The  patient  complains  of  a  continual  itching  sensation,  with  a  feeling  of 
heat  and  dryness,  in  the  canal,  which  compels  him  to  pass  any  suitable  instrument  which 
may  be  at  hand  into  the  meatus  for  the  purpose  of  scratching  the  part  implicated.  This 
irritation  may  pass  off  without  forcing  the  patient  to  seek  advice,  or  it  may  pass  on  to 
one  of  pain  shooting  over  all  the  affected  side  of  the  head,  increased  by  every  motion  of 


AFFECTIOSS   <>!■'   Till:   nXTlHiXA  L    I'.M:.  •  329 

the  li(';i(l  or  liv  iii:i>tii-;iliiiii.  ami  ;ici-niii|i;mic(|  liy  a  I'l'diiiLr  '»!"  lulni',-:-  in  llic  car.  Iiy  fever 
1111(1  ilt'iifncss.  Alter  this  cdii^ested  state  lias  lasted  tor  t\V(t  or  tlir l:i}s.  that  (if  exu- 
dation ('liters — at.  first  as  a  hrijrht  watery  disehurire.  \vlii<di  ^rradiially  asHiiiiies  ii  iiiueoiis 
character;  and  this  in  its  turn  <;ives  way  t(i  a  yellow  jturiilent  a|i|ieararice.  Tlu;  pain, 
which  till  now  has  heeii  usually  severe,  suhsides  when  the  |iiirulent  diseharjre  shown 
itself,  or  soon  afterward,  and  the  jiatieiit  feels  litihtcr  and  fre(!r  (d'  the  sensation  of  '•  nunih- 
ness  "  or  '' fulness  "  of  wliicdi  he  hefore  coni|iIainc(l.  A  favorahli!  terniinatioii  without  any 
treatment  mav  now  take  jilacc,  thoiiirh  more  fn'(|uently  the  attccti(»n  Itecoines  (dironic  and 
the  patient  sutlers  from  recurrent  attacks  on  Keiiii:'  affected  hy  any  excitin;r  cause. 

Al'PKAU.VNCKS. — In  e.xamiiiiiiir  the  ear  it  is  not  always  easy  to  arrive  at  a  satisfactory 
diagnosis,  on  account  of  tln^  painful  swcllin;^  ol"  the  canal,  wliicdi  is  particularly  sensitive 
about  the  middle  third  and  resents  the  introduction  of  a  .speculum.  When  you  are  able 
to  introduce  the  specuhun  sufficiently  well  to  sei;  the  inner  part  of  the  nieatu.s,  you  may 
find  a  mass  of  moist  or  macerated  white  epidermal  lanielhc  obstructing  your  view  of  the 
membrane,  necessitating  the  careful  use  (d'  the  forceps  or  injection  of  warm  water  for 
their  removal.  Having  removed  the.se  and  obtained  a  view  of  the  mcmbrana  tympani, 
you  find,  in  those  ca.se.s  in  which  that  iiHimliraiie  is  aff"(!cte(l  (and  it  is  rare  that  you  are 
consulted  before  it  is  so),  the  vessels  of  the  membrane  increased  in  number  and  size  and 
fullv  injected  ;  or  if  the  case  has  reached  a  i'urther  stage,  the  single  vessels  are  no  longer 
visible  and  the  whole  has  a  resemblance  to  a  red  blennorrlneic  conjunctiva.  The  natural 
angle  formed  by  the  skin  of  the  external  meatus  and  its  continuation  with  the  deniKjid 
layer  of  the  meinbrana  tympani  is  obliterated,  or  nearly  so,  by  the  pressure  of  the  exu- 
dation inside  the  cutaneous  tissues.  But  the  exudation  may  be  so  great  and  may  have 
so  narrowed  the  canal  of  the  meatus  that  only  a  small  part  of  the  membrane  can  be  seen, 
its  appearance  depending  upon  the  part  seen  and  the  stage  of  the  afiection.  The  acute 
stage  being  neglected,  it  passes  gradually  into  the  chronic  form,  in  which  there  is  gener- 
ally little  swelling  of  the  meatus,  possibly  here  and  there  slightly  macerated  or  pus- 
covered  spots,  which  bleed  easily  on  being  acted  on  by  the  speculum,  or  brown,  badly- 
smelling  crusts  standing  upon  half-dried  secretions.  The  amount  of  secretions  vary  from 
a  moisture  discerniltle  at  the  external  opening  of  the  meatus  to  three  or  four  ounces 
daily  of  a  high-smelling  yellow  discharge,  and  changes  by  the  seasons  and  other  influences. 
The  alarming  results  of  the  affection  are  dependent  upon  the  continuance  of  this  otor- 
rh(x?a.  which,  if  of  long  standing,  may  cause  opacity  or  thickening  of  the  membrane, 
polypi,  maceration  of  the  surrounding  tissues,  with  ulceration  of  the  niemlirane  and  its 
conse(|uences.  inflammatory  and  purulent  processes  in  the  dura  mater  and  its  sinuses. 
These  latter  are  especially  frecjuent  in  children,  in  whom  the  conditions  for  the  transmi.s- 
sion  of  such  processes  are  easy. 

The  diagnosis  of  this  diffuse  inflammation  of  the  meatus  from  that  of  furuncle  of 
the  meatus  is  made  by  means  of  a  speculum  in  which  a  small  mirror  placed  at  the  end 
of  the  instrument  may  be  revolved,  so  as  to  give  the  observer  a  reflected  image  of  the 
different  parts  of  the  meatus  in  succession,  or  by  means  of  Blake's  small  mirrors ;  or 
should  neither  of  these  be  admissible,  by  the  contraction  of  the  meatus,  by  the  moist 
appearance  of  the  dermoid  covering  of  the  membrana  tympani  in  furuncle,  the  same  layer 
in  otitis  externa  having  the  appearance  of  the  re.st  of  the  meatus. 

Causes. — The  causes  of  inflammation  are  the  passing  of  any  acute  or  chronic  exan- 
themata to  the  meatus,  irritation  or  injuries  to  the  ear,  as  by  the  application  of  heat  or 
spirits  to  the  meatus,  the  prolonged  use  of  injections,  the  pressure  of  foreign  bodies,  the 
passage  of  cold  currents  of  air  or  water,  the  non-drving  of  the  ear  and  hair  round  it 
thoroughly  after  washing,  the  presence  of  fungi,  and,  in  short,  anychiiig  causing  a  con- 
gestion and  irritation  of  the  lining  membranes  of  the  meatus. 

The  affection  may  run  its  course  in  ten  or  fourteen  days  if  the  purulent  stage  has 
not  been  reached,  but,  that  stage  having  supervened,  it  lasts  from  five  to  eight  weeks 
generally. 

Pro<}N()sis. — The  prognosis  in  a  usual  primary  case  under  treatment  is  favorable,  but 
relapses  are  common.  The  form  following  an  acute  exanthem  is  very  different,  as,  should 
the  middle  ear  inflammatory  process  be  well  developed  and  the  membrane  much  affected, 
the  chances  of  saving  an  entire  membrane  are  les.sened. 

Treatment. — The  treatment  is  etiological.  If  there  are  foreign  bodies  present,  their 
removal  demands  your  first  attention  :  and  after  this  the  prevention  of  any  purulent 
accumulation  and  the  use  of  frequent  injections  of  warm  water  are  the  chief  treatment. 
Should  the  swelling  be  great,  scarification  of  the  meatus  or  an  incision  and  ab.straction  of 
blood  by  the  vacuum  speculum  seems  to  be  of  more  use  than  any  other  means  in  causing 


330  AFFECTIOXS   OF  THE  MIDDLE  EAR. 

a  speedy  subsidence  of  the  thickened  membranes,  which  you  may  also  assist  by  keeping 
up  a  pressure  on  the  circuniference  of  the  canal  b}-  charpie  gently  pressed  into  the 
meatus,  being  careful  that  the  charpie  is  frequently  renewed  and  the  meatus  cleared  of 
discharge.  Wliat  is  called  "  Wilde's  incision."'  from  its  having  been  first  brought  into 
notice  by  Sir  William  Wilde,  is  a  favorite  means  of  remedy  with  some,  and  in  the  relief 
of  pain  or  as  a  means  of  giving  exit  to  any  exudation  which  may  have  passed  toward  the 
mastoid  process  is  very  useful.  It  con.sists  in  making  an  incision  down  to  the  bone  over 
the  mastoid  process  at  a  distance  of  from  half  to  three-quarters  of  an  inch  from  the 
auricle,  carefully  avoiding,  if  possible,  severing  the  posterior  auricular  artery.  The  appli- 
cation of  leeches  in  front  of  the  tragus  (should  the  patient  be  too  timid  to  allow  of  the 
abstraction  of  blood  b}'  incision  or  scarification)  is  advisable  where  the  pain  is  severe. 
During  the  painful  stage  no  strong  astringent  lotions  must  be  used,  those  of  a  .sedative 
nature  being  preferred,  as  morphia  in  the  strength  of  gr.  j  to  aq.  dest.  oSS,  or  sulphate  of 
of  atropine  gr.  ij.  to  ^j.  This  stage  being  passed,  the  use  of  the  customary  astringent 
lotions — alum,  sulphate  of  copper,  sulphate  of  zinc,  in  solutions  of  from  one  to  four 
grains  to  the  ounce,  or  nitrate  of  silver  of  from  ten  to  twenty  grains  to  the  ounce — are, 
with  attention  to  any  complication  of  the  middle-ear  apparatus  and  to  the  diathesis  pres' 
ent,  sufficient  to  ensure  a  favorable  course.  Should  the  affection  have  assumed  the 
chronic  form,  .stronger  solutions  of  the  astringents  mentioned  ought  to  be  employed  ;  and 
the  keeping  up  of  a  counter-irritation  behind  the  mastoid  by  tincture  of  iodine,  cantha- 
rides  ointment,  or  other  irritant,  will  be  found  serviceable. 

Polypus. 

Aural  polypi  generally  show  themselves  during  a  chronic  purulent  discharge  from  the 
tvnipanic  cavity  or  external  meatus,  and  are  not  only  caused  by  such  a  discharge,  but  are 
themselves  a  means  of  increasing  it  by  furnishing  an  additional  secreting  surface,  and.  by 
preventing  the  exit  of  the  discharge,  keeping  the  parts  pressed  upon  by  the  pus  in  an 
unhealthy  irritable  condition.  They  are  of  different  forms  and  appearances,  being  of  a 
lively  red,  rich  in  blood,  soft,  and  easily  bled  by  touching,  or  firm  and  solid  with  a  glan- 
cing surface,  grape-like  or  ragged,  so  small  that  their  presence  can  be  determined  only  by 
a  careful  inspection  of  the  deeper  parts  or  so  large  that  they  protrude  from  the  meatus. 
Their  po.sitions  are  as  varied  as  their  forms,  as  they  arise  from  any  part  of  the  meatus  or 
tvmpanic  cavitv  or  membrane,  the  different  authorities  not  being  agi'eed  as  to  which  are 
the  most  frequent  sites.  Happily,  their  diagnosis  and  treatment  are  the  same,  the  former 
being  their  capability  of  displacement  by  the  sound,  and  the  latter  their  removal  either 
by  caustics,  a.stringents.  the  forceps,  scissors,  knife,  hooks,  the  galvanic  cautery,  or  Wilde's 
snare. 

Treatment. — If  the  polypus  is  sensitive,  which  is  not  usually  the  case,  and  the 
patient  will  not  suffer  the  removal  by  instruments,  the  application  of  undiluted  liquor 
plumbi  or  alum  or  tannin  powder  regularly  for  a  time,  care  being  taken  that  each  new 
application  meets  with  a  clean  surface,  will  suffice :  but  the  treatment  above  all  others  is 
the  immediate  removal  by  in.struments  as  far  as  possible  and  the  application  thereafter  to 
the  root  of  some  caustic,  such  as  acetic,  nitric,  or  chromic  acid,  by  means  of  a  glass  rod 
or  piece  of  wood.  The  in.struments  employed  for  the  purpose  are  numerous,  those  which 
I  find  most  useful  being  Wildes  snare.  Durham's  forceps,  and  Hinton"s  forceps.  Wilde's 
snare  is  especially  valuable,  as  by  its  means  you  are  capable  of  reducing  a  polypus  to  a 
considerable  extent  without  endangering  any  of  the  structures  near  it.  while  the  others 
have  the  advantage  of  easier  adaptation  to  an  excrescence  which  is  difficult  of  reaching. 
Should  the  polvpus  be  very  snlall  or  .so  situated  that  you  cannot  use  a  cutting  or  tearing 
instrument,  the  application  of  a  thin  layer  of  nitrate  of  silver,  obtained  by  heating  a 
cry.stal  of  the  caustic  over  the  flame  of  a  spirit-lamp  and  placing  a  probe  or  piece  of 
stout  silver  wire  against  the  heated  crystal,  will  be  found  useful  in  cauterizing  it.  and  at 
the  same  time  limiting  the  application  to  the  desired  spot,  which  is  not  so  easy  when  solu- 
tions are  employed.  After  the  removal  of  the  polypus,  the  disease  of  which  the  growth 
was  only  a  .symptom  must  be  attended  to. 

Affections  of  the  Middle  Ear. 
Injuries  to  the  Membrana  Tympani. — Eupture  of  a  healthy  tympanic 

membrane  is  usually  caused  by  the  introduction  of  some  sharp  instrument  through  the 
external  meatus,  the  efforts  to  extract  some  foreign  bodv  from  that  canal,  or  by  a  sudden 


Mi'iX'TioNs  or  Tin:  middle  i:ml 


331 


concussion  over  tlic  auricle,  us  l>y  a  blow  from  tin-  liaiid.  tlie  unexpected  explosion  of 
artillery,  or  such  like.  Tlie  (liu<rnosis  of  rupture  in  .mu«-1i  is  easily  ascertaine<l.  hut  nic<l- 
ico-lei;al  (juestinns  sonu-tiines  arise  in  which  it  is  nec»'ssary  to  ileterniiiie  whether  a  rup- 
ture was  caused  l)y  a  hlow  on  the  ear  or  was  present  hefore  the  hlow  was  <:iv<'n,  or  whether 
the  nieinhrane  was  in  such  an  unhealthy  condition  that  it  would  he  easily  injured.  The 
rupture  of  a  healthy  ineinhrane  caused  liy  a  hlow  is  usually  a  lon;r  j-'apin;^  tear — the 
jrapiui:  dependinu:  on  the  action  (d"  the  railiatini:  fihres  of  the  middle  layer — the  edj:es  of 
which  have  a  eoatini;  of  hlood  upon  them.  The  rest  ot"  the  mendjrane  is  healtliy,  free 
(d"  thickeniuir,  opacities,  cretaceous  or  other  deposits,  tlnuiirli  jiossihlv  hvper;«Miiic.  On 
]>a>sinu:  a  current  td"  air  throuirh  the  Kiistaidiian  you  hear  a  continuous  hroatl  .soft  sound, 
unlike  the  broken  hiss  from  the  perl'oratir)n  of  a  <liseased  mcmhianc,  unless  some  time 
has  elapsed  since  the  rupture  was  made,  in  which  case  infiltration  and  exudation  nuiy 
have  occurred,  <riviii<r  the  appearances  and  .sounds  (d'  a  di.seased  membrane. 

Prouniksi.'s. — The  profrnosis,  unless  pus  has  formed  to  some  extent  and  deafness  to  a 
considerable  extent  is  present,  is  very  favorable,  and  the  perforation  will  be  (juickly 
healed  without  further  treatment  than  keepin<r  the  membrane  jtrotected  from  cold. 
Should,  however,  considerable  deafness  and  tinnitus  have  i>ccurred  fnnn  a  blow,  either 
with  or  without  rupture  of  the  membrane,  the  j)roj:iiosis  is  unfavorable,  as  probably  the 
stapes  has  been  driven  into  the  labyrinth,  tearinir  the  nerve  fibres  and  jmssibly  remaining 
fixed  there  ;   and  you   must  keej)  the  j»atient  a  leniitliened  time  under  observation  before 


giviMLT  any  oj. 


if  what  the  results  will  be. 


Fig.  131. 


Appearance  of  Meiiibrana 
Tyiiipani.  showine  the 
relation  of  Parts  lo  each 
other.    ^Kighi  ear.) 


Inflammation  of  the  membrana  tympani,  or  myringitis,  is  probably 

always  associated  with  some  affection  of  the  internal  or  external  parts  eonti^'nous  to  it. 
The  diasrnosis  and  treatment  will  be  found  in  the  description  of  inflammation  of  the 
external   meatus. 

In  examinin<i  the  membrana  tympani  the  point.^  to  be  noted  are  its  color,  transparency, 
lustre,  light  cone,  inclination,  curvature,  entirety,  tension,  whether  adhesions  are  present 
or  not,  and  the  position  of  the  malleus,  especially  of  its  short  pro- 
cess. For  a  full  description  of  these  we  must  refer  the  reader 
to  Politzer's  Beleuclitungs/jihfrf  (/rs  Trommeljilh  !m  Gexundeit  kid/ 
Kilt  liken  Znatiriule  (Wien,  18G5),  but  the  following  short  note  of 
changes  seen  in  the  nu)st  common  affections  in  which  it  is  impli- 
cated may  be  found  useful  in  diagiujsis.  In  acute  inflammation  the 
membrane  is  smooth  and  glistening,  and  more  or  less  red  according 
to  the  amount  of  hyjtenvnjia  present.  When  the  mucous  layer  is 
hypertrophied.  and  accordingly  a  greater  amount  of  secretion  pres- 
ent than  in  the  normal  state,  the  memljrane  is  less  .shining  than 
natural  and  has  a  whitish-gray  parchment  look.  If  there  is  a  con- 
siderable accumulation  of  mucus  which  has  lain  in  contact  with  the 
membrane  for  some  time,  it  assumes  a  sodden  appearance,  as  if  the 
parchment  had  been  .steeped  in  fluid.  The  changes  of  inclination  and  curvature  of  the 
membrane  depend  upon  closure  of  the  Eustachian  tube,  adhesions  to  the  other  walls  of 
the  cavity,  accumulations  of  pus.  mucus,  or  tumors,  internal  or  external  to  the  cavity, 
and  perforations  or  thinnings  of  the  membrane,  and  can  only  be  diagnosed  by  seeing 
numerous  cases  at  an  aural  clini(|ue.  The  fact  that  usually  only  one  eye  is  brought  to 
bear  at  a  time  on  the  meml)rane  makes  it  difficult  for  the  observer  to  judge  of  displace- 
ment, protrusions,  or  any  changes  in  which  the  judging  of  distance  is  reijuired  till  he 
has  accustomed  himself  to  the  use  of  one  eve  only. 

Chronic  perforation  of  the  membrana  tympani  is  one  of  the  most  com- 
mon affections  of  tlie  ear  on  whicli  yijii  will  l)e  consulted.  The  diagnosis  of  the  affection 
is  easy,  either  by  the  speculum,  by  asking  the  patient  to  drive  a  current  of  air  by  a  for- 
cible expiration  through  the  Eustachian  tubes,  the  nostrils  and  lips  being  held  firndy 
together — this  method  being  called  Valsalva's  method — by  passing  a  current  of  air  from 
Politzers  bag.  as  described  under  malformations  of  the  external  ear.  or  by  passing  the 
Eustachian  catheter  and  forcing  a  current  of  air  from  the  mouth  or  from  an  india-rubber 
bag  through  the  catheter.  By  the.se  three  last  methods  you  will  obtain,  the  Eustachian 
tubes  being  open,  a  sound  more  or  less  of  a  hissing  character,  depending  upon  the  rush 
of  a  column  of  air  through  a  small  orifice.  The  usual  causes  of  the  perforation  of  the 
membrane,  apart  from  those  of  a  traumatic  origin,  are  scarlet  fever,  measles,  tuberculosis, 
and  any  greatly  debilitating  affection  in  which  the  mucous  membranes  are  affected. 

Prooxosis. — The  prognosis  is  regulated  greatly  by  the  dy.scrasia  present,  but  it  ought 
always  to  be  remembered  that   a  perforation    may  heal  without   leaving  anv'  discernible 


332  AFFECTIONS  OF  THE  MIDDLE  EAR. 

pathological  changes  and  without  in  the  slightest  recognizable  degree  lessening  the  power 
of  hearing.  The  hopes  for  such  a  happy  result  are  the  greater  the  shorter  the  acute 
attack  which  has  caused  the  perforation,  while  it  is  rare  after  a  chronic  affection  accom- 
panied by  otorrhcjea  ;  but  no  opinion  ought  to  be  hazarded  till  you  have  carefully  washed 
out  the  ear  and  seen  the  extent  of  the  perforation  and  losses  which  have  already  resulted 
therefrom.  The  process  of  healing  is  known  by  a  gradual  diminution  of  the  secretion 
and  of  the  perforation,  the  cicatrix  being  formed  by  the  dermoid  and  mucous  layers,  but 
of  a  much  more  delicate  structure  than  the  natural  layers  and  not  separable  into  laminae. 
The  hopes  of  cicatrization  are  at  an  end  for  the  time  when  the  edges  of  the  perforation 
become  cicatrized  and  a  gap  still  remains,  but  a  new  impetus  may  be  given  to  the  regen- 
eration by  any  future  affection  which  causes  a  hyperaemia  in  the  part  and  a  softening  of 
the  cicatricial  edges  of  the  perforation. 

Treatment. — In  the  treatment  of  a  perforation  the  rule  is  to  close  it  if  possible,  on 
account  of  the  exposure  caused  by  the  perforation  of  the  tender  mucous  membrane  of 
the  tympanic  cavity  to  cold  air  or  water,  dust,  and  other  foreign  bodies.  These  by  their 
irritation  may  cause  a  purulent  discharge,  and  that,  being  once  present,  may  lead  to  results 
of  the  most  disastrous  nature.  But  if  the  perforation  have  existed  some  time  and  be  of  a 
considerable  extent,  the  question  arises  whether  the  closing  of  the  perforation  will  not 
impair  the  patient's  hearing-power ;  and  before  doing  anything  to  close  such  it  is  advis- 
able to  temporarily  close  the  gap  by  a  drop  (jf  glycerine  or  other  thick  fluid  and  note  the 
effects.  Should  the  result  be  to  lessen  the  hearing-power  to  any  considerable  extent,  you 
must  carefully  consider  the  probabilities  before  determining  upon  your  action.  While 
the  affection  is  still  in  the  acute  stage,  the  keeping  of  the  parts  clean  by  gentle  injections, 
and  the  use  of  some  slight  astringents,  for  the  purpose  of  reducing  the  secretion  of  the 
membrane  and  bringing  it  into  a  more  normal  condition,  are  all  that  are  required,  with 
the  use  of  a  little  wadding  in  the  ear  when  the  patient  goes  out,  unless  the  weather  is 
very  mild,  when  the  latter  may  be  dispensed  with.  Should  discharge  be  present  which 
by  some  means  has  become  thickened,  and  by  its  presence  closes  or  tends  to  close  the 
p]ustachian  tube,  Politzer's  operation  ought  to  be  done  now  and  again  ;  and  if  this  is  not 
sufficient  of  itself,  the  softening  of  such  an  accumulation  by  an  alkaline  solution,  as  bicar- 
bonate of  soda  3ss-.5j  to  an  ounce  of  water,  and  then  the  Politzeration,  will  suffice  to 
remove  it.  Should  you  determine  to  try  to  close  a  large  perforation,  you  carefully  and 
gently  stimulate  the  edges  of  the  perforation  by  the  application  to  them  of  nitrate  of 
silver  or  other  irritant,  either  in  solution  or  by  touching  the  moistened  edges  with  a  thin 
layer  of  the  crystals  placed  on  a  probe,  as  mentioned  in  the  treatment  of  granulations,  or 
by  abrading  the  edges  with  a  knife,  conical  file,  or  plug  of  wadding  turned  in  the  perfor- 
ation. But  if  you  fail  to  close  it  by  the  growth  of  new  cicatricial  tissue,  and  yet  believe 
that  its  closure  would  improve,  or  at  least  not  impair,  the  hearing  capability,  you  may 
resort  to  the  artificial  drum,  the  success  of  which  in  some  cases  is  very  great.  Numerous 
modifications  of  artificial  drums  have  been  proposed,  but  the  most  simple,  the  most  easily 
applied,  and  one  that  is  as  successful  as  any  other  is  a  piece  of  cotton-wadding  moistened 
in  water  or  some  antiseptic  solution  and  applied  over  the  perforation  and  lapping  consider- 
ably over  the  edges.  The  difficulty  of  its  use  is  its  first  adaptation  ;  but  if  once  applied 
successfully,  the  patient  can  adapt  it  in  future  for  himself  more  truly  and  quickly  than 
his  medical  attendant.  The  conclusion  as  to  whether  it  will  be  of  benefit  or  not  must 
only  be  arrived  at  after  several  attempts  have  been  made,  changing  the  point  of  pressure 
and  adapting  it  more  closely  to  the  remnant  of  natural  membrane  at  different  points  at 
each  attempt.  When  it  has  been  used  for  some  time  with  success,  the  patient  feels  it  very 
inconvenient  to  be  without  it.  If  found  of  service,  it  ought  not  to  be  worn  above  an  hour 
or  two  at  a  time  for  some  days,  gradually  increasing  the  duration  of  its  application,  but 
always  removing  it  at  night,  and  the  patient  should  be  directed  to  attend  to  the  most  per- 
fect cleanliness  at  each  renewal  of  the  wadding.  How  the  artificial  membrane  acts  is  still 
a  matter  of  doubt.  It  is  considered  that  it  is  a  support  to  the  ossicles  and  membranes, 
and  this  is  probably  its  action  in  the  majority  of  cases.  From  observations  at  the  differ- 
ent positions  in  which  it  increases  the  hearing-power,  I  think  it  may  have  also  a  reso- 
nating action. 

Artificial  Perforation  of  the  Tympanic  Membrane. — Having  spoken  of 

the  means  of  closing  a  perforation,  it  is  convenient  here  to  speak  of  artificial  perfora- 
tion of  the  membrane.  The  operation  is  recommended  in  cases  of  accumulations  of  pus 
or  mucus  within  the  tympanic  cavity,  of  impassable  .stricture  of  the  p]ustachian,  of  thick- 
ening of  the  membrane,  of  adhesions  of  the  membrane  to  the  tympanic  walls,  in  case  of 
tinnitus,  and  in  cases  where  no  benefit  is  derived  after  prolonged  use  of  other  curative 


AFFEcTKiSS   or   Till-:   MI />/>/. !■:   EAR.  333 

nu':iii>  ami  the  (liauiiusis  is  iml  drar.  Iiiit  I  lie  acoustic  i.s  intl  iiiiirl,  aflcctcd.  That  licricfit 
may  he  tli-iivt'd  in  all  such  cases  cannot  he  denied,  hut  unha|i|(ily  we  are  not  yet  in  a  posi- 
tii>n  to  say  that  |)erroration  will  henetit  this  or  that  case.  <'xcc|)t  in  ca.ses  of  accumulation. 
The  |niint  of  operation  is  th'termineil  in  ea.se.s  of  accumulation  hy  the  point  of  the  meni- 
lM"ane  at  which  huliriii.ir  i"<  present,  while  in  other  cases  a  spot  hehind  the  maiiuhrium  is 
usually  chosen.  Hrinuing  the  nu-mhrano  well  into  view  hy  the  usual  niethoil.  the  opera- 
tion is  made  hy  means  oi'  one  of  the  numerous  instruments  which  have  heen  proposed 
for  t lie  pur]tose.  If  it  is  merely  as  an  experimental  proi-eedinjr  to  determine  whether  an 
openiiii;  will  he  of  hiiutit  to  the  hearini:.  or  for  the  [(urpose  of  allowin<r  the  exit  of  pu.s 
or  mucus,  a  small  jilain  duuhle-edjicd  scalpel  is  all  that  is  required.  Having  made  the 
openin<:  sufficiently  large,  you  renntve  all  impediments  to  the  passage  <if  soutid  by  caus- 
ing an  air  douclie  to  be  pas.sed  through  the  cavity  by  one  of  the  usual  methods,  having, 
if  necessary,  previously  softened  any  accumulations.  It  being  thus  empirically  determined 
that  a  permanent  opening  in  the  mend)rane  would  be  desirable,  you  attempt  to  keep  the 
opening  irom  closing  by  a  bougie  or  l^ditzers  eyelet,  l»y  making  the  perforation  by  the 
galvano-cautery.  by  removing  a  j)art  of  the  nuilleus  with  a  ])ortion  of  the  membrane,  by 
the  constant  use  of  the  air  douche,  by  repeated  renicnals  of  the  cicatricial  membram.',  by 
digestion  with  popsine.  acids,  etc.  But  as  yet  no  method  has  been  proposed  which  act.s 
with  certainty  <>f  success. 

Catarrh  of  the  Middle  Ear. — The  ordinary  nffcctlons  <>/ the  niidjllt  car  which 
tlie  general  practitioner  will  be  called  upon  to  treat  are  included  under  tlie  title  of 
"catarrhal  affections,"  and  may  be  of  an  acute  or  clironic  character.  The  principal 
objective  .symptoms  of  acute  catarrh  are  a  liypertiemic  swelling  of  the  mucous  membrane, 
with  an  increased  secretion  therefrom,  the  pharytigeal  mucous  membrane  near  the  orifice 
of  the  Eustachian  tube  leading  to  the  affected  ear  being  nearly  always  implicated.  This 
state  of  the  mucous  membrane  gives  to  the  observer  who  passes  a  current  of  air  through 
the  Eustachian  tube  and  listens  by  means  of  an  otoscope,  one  end  of  which  is  placed  in 
the  meatus  of  the  patient  and  the  other  in  his  own,  sounds  ranging  from  a  harsh  dry 
sound,  like  that  caused  by  distending  a  dry  bladder,  to  a  mucous  rale.  The  tympanic 
membrane  varies  in  appearance,  according  to  the  stage  of  the  affection,  from  that  of  a 
glancing  polished  copper  plate  to  that  of  a  dull  wet  bladder  from  which  all  bright  reflex 
has  gone,  corresponding  to  the  dry  and  infiltrated  states  of  the  tissues.  A  more  or  less 
obliteration  of  the  malleus  may  be  present,  depending  upon  the  passage  of  the  exudation 
between  the  layers  of  the  membrane.  A  bulging  of  the  membrane  will  be  observed 
should  an  accumulation  of  fluid  have  taken  place  to  a  considerable  extent.  The  chief 
subjective  symptoms  are  a  pain  in  the  depth  of  the  ear,  which  is  increased  by  every 
motion  of  the  parts,  such  as  by  coughing  or  swallowing,  an  impairment  of  hearing,  a 
feeling  of  heaviness,  fulness,  or  pressure  in  the  ear — often  described  as  "  a  drop  of  water 
in  the  ear" — tinnitus  of  various  characters,  as  singing,  knocking,  or  surging,  the  position 
of  which,  whether  outside  or  inside  the  head,  the  patient  cannot  always  tell,  giddiness, 
confusion  of  thought,  and  other  symptoms  of  pressure.  The  subacute  form  is  merely  a 
combination  of  the  same  symptoms  in  a  milder  degree.  If  the  case  is  properly  attended 
to  while  in  the  acute  stage,  no  grayer  disturbances  of  the  organism  ought  to  arise ;  but 
it  must  always  be  remembered  that,  the  tendency  of  the  affection  being  to  thickening  and 
swelling  of  the  membranes  implicated,  adhesions  and  solderings  are  apt  to  take  place 
between  the  closely-situated  delicate  structures  of  the  tympanic  cavity.  The  general 
position  of  such  adhesions  is  between  the  manubrium  and  promontory,  the  tympanic 
membrane  and  incus  or  stapes,  the  tendon  of  the  tensor  tympani  and  stapes,  and  especially 
often  in  the  niches  of  the  two  fencstrcB,  binding  the  walls  together  or  to  the  stapes. 

But  should  the  acute  stage  be  neglected,  the  acute  passes  into  the  chronic  form,  gen- 
erally, like  the  acute,  implicating  both  tube  and  cavity.  It  may,  however,  be  localized, 
and  consist  in  repeated  swellings  with  gradual  condensations  and  thickenings  of  the 
mucous  membrane,  which  becomes  gradually  less  elastic,  and  by  proliferation  form  bands 
in  the  cavity.  These  by  their  physical  (|ualities  as  well  as  by  their  interference  with  the 
swinging  faculty  of  the  sound-conducting  apparatus  materially  interfere  with  the  hearing 
capabilities.  This  chronic  form,  once  established,  is  most  obstinate  to  treatment  and  leads 
to  increase  of  the  deafness,  which  depends  more  on  the  locality  of  the  changes  than  on 
their  extent.  It  also  causes  an  increase  of  the  .symptoms  of  pressure,  the  tinnitus  possi- 
bly becoming  so  harassing  that  persons  have  been  known  to  have  committed  suicide  to 
escape  from  it,  and  often  causing  such  dej)ression  by  the  effects  of  the  vertigo  and  vomit- 
ing which  it  occasions  that  an  inclination  to  resort  to  intoxicating  fluids  is  thereby 
aroused. 


334  AFFECTIONS  OF  THE  MIDDLE  EAR. 

Prognosis. — The  prognosis  is  generally  favorable,  but  the  treatment  is  prolonged 
over  such'  an  extent  of  time  that  the  patient  frequently  ceases  to  attend  before 
restoration  is  accomplished,  or  aid  is  not  sought  in  time  to  prevent  changes  which, 
having  once  occurred,  cannot  be  undone.  In  these  cases  we  must  endeavor  to  stay  the 
course  of  the  disease-,  which,  if  left  to  itself,  will  certainly  lead  to  total  deafness.  The 
older  the  patient  the  more  chronic  the  affection  ;  and  the  greater  the  changes  formed  in 
the  tympanic  cavity,  the  less  hope  is  there  of  a  good  result.  If  the  tinnitus  is  continuous 
and  has  been  present  for  some  time,  the  prognosis  is  unfavorable,  even  although  under 
treatment  the  hearing-power  is  improved  ;  while  if  nearly  total  obliteration  of  the  cavity 
has  occurred,  especially  if  chalky  deposits  are  present  on  the  tympanic  membrane,  a 
favorable  prognosis  is  almost  negatived. 

TREATiMENT. — The  treatment,  besides  the  constitutional  and  hygienic,  consists  in  local 
blood-letting  while  the  pain  and  hyper^emia  are  present,  the  application  of  the  air  douche, 
the  injection  of  medicaments  to  the  Eustachian  tube  and  tympanic  cavity,  the  treatment 
of  any  naso-pharyngeal  aff'ection  which  may  be  present,  and  the  performance  of  diff"erent 
operations  on  the  sound-conducting  apparatus.  Two  methods  of  passing  a  current  of  air 
into  the  tympanic  cavity  through  the  Eustachian  tube  have  been  already  described 
(p.  322).  The  passage  of  the  Eustachian  catheter,  used  either  for  the  conveyance  of  air, 
fluids,  or  vapors  or  for  the  better  guidance  into  and  tlu'ough  the  tube  of  bougies,  elastic 
catheters,  or  instruments  for  electrical  purposes,  is  by  no  means  so  difficult  as  is  generally 
believed.  The  silver  catheter  with  an  obtuse  angle  of  from  110°  to  120°  is,  I  find,  the 
most  generally  useful  in  the  hands  of  those  accustomed  to  pass  it.  The  caoutchouc  ones 
are  apt  to  break  after  being  used  some  time,  and  do  not  convey  to  the  operator  such 
accurate  knowledge  of  the  position  of  the  beak  in  relation  to  the  structures  over  which  it 
passes  as  those  composed  of  metal,  although  the  caoutchouc  are  less  likely  to  make  a  false 
passage  in  the  hands  of  an  inexperienced  operator.  The  patient  ought  to  be  placed  with 
the  external  openings  of  the  nares  horizontal  and  oppo.site  to  the  right  shoulder  of  the 
operator,  Avho,  tilting  the  point  of  the  nose  upw^ard  by  the  fingers  of  the  left  hand,  dis- 
closes the  cavity  of  the  nares  more  fully,  upon  the  floor  of  one  of  which  he  places  the 
beak  of  the  catheter.  Keeping  the  beak  on  the  floor,  he  passes  it  through  the  cavity  and 
onward  across  the  pharyngeal  space  till  it  comes  against  the  posterior  pharyngeal  wall, 
which  in  its  normal  condition  gives  him  much  the  same  feeling  of  resistance  as  he  receives 
on  pressing  the  catheter  against  the  tense  open  palm  of  the  hand.  Drawing  the  catheter 
toward  him,  and  at  the  same  time  elevating  the  end  which  he  holds  in  his  hand,  he  brings 
the  concave  curvature  of  the  opposite  end  against  the  po.sterior  edge  of  the  nasal  floor, 
and  then,  turning  the  beak  outward  and  upward,  keeping  it  at  the  same  time  against  the 
external  lateral  wall  of  the  pharj-nx,  he  will  feel  it  make  a  slight  dip  into  the  pharyngeal 
opening  of  the  p]ustachian  tube. 

The  above  method  is  the  one  usually  adopted,  but  there  is  that  proposed  by  Bonne- 
font,  which  consists  in  turning  the  beak  of  the  catheter  from  the  posterior  pharyngeal 
wall  outward  into  Midler's  depression  and  drawing  it  then  toward  you  till  you  feel  that 
it  has  passed  over  a  swelling  and  then  fallen  into  a  depression  ;  or  Lowenberg's,  consist- 
ing of  turning  the  catheter  beak  inward  after  reaching  the  post-pharyngeal  wall,  drawing 
it  toward  you  till  the  curve  catches  on  the  posterior  edge  of  the  nasal  septum,  and  then 
revolving  it  upward  or  downward  toward  the  lateral  pharyngeal  wall,  when  it  will  proba- 
bly pass  into  the  tube.  If  there  is  a  difficulty  in  passing  the  catheter  through  the  nasal 
cavity,  it  is  generally  most  easily  overcome  by  keeping  the  beak  toward  the  external  wall 
and  passing  along  it.  But  should  you  fail  in  passing  it  through  the  nostril  correspond- 
ing to  the  Eustachian  tube  into  which  you  desire  to  introduce  it,  by  using  a  catheter  with 
a  longer  curve  you  can  reach  the  mouth  of  the  Eustachian  tube  from  the  other  nostril,  or 
you  ma}'^  pass  it  into  the  tube  from  the  mouth.  You  know  that  the  nozzle  has  passed 
well  into  the  mouth  of  the  tube  by  the  position  of  the  catheter  not  being  disturbed  when 
the  patient  speaks  or  swallows,  by  the  fact  that  the  nozzle  will  not  pass  further  upward, 
and  especially  by  the  fact  that  on  blowing  air  into  the  catheter,  either  by  mouth  or  india- 
rubber  bag,  you  recognize  its  passage  into  the  tympanic  cavity  of  the  jiatient  by  having 
placed  a  tube  of  communication  from  his  meatus  to  your  own.  In  children  the  outward 
turn  of  the  catheter  is  usually  more  limited  in  extent  than  in  the  adult,  in  whom  it  is 
generally  from  a  fourth  to  three-eighths ;  but  a  latitude  must  be  allowed,  as  the  forma- 
tion of  the  part  varies.  In  a  new  patient,  if  you  wish  to  pass  the  catheter  into  the 
Eustachian  tube,  it  is  advisable  to  try  the  right  side  first,  as  it  will  be  found  usually 
easier  to  pass  on  that  side,  on  account  of  the  septum  gently  inclining  toward  the  left. 
The  mistake  generally  made  is  that  the  catheter  is  not  brought  sufficiently  forward  after 


Ari'i:<ri()ss  of  tiii:  Minnu-:  ear.  335 

liaviiii:  ri'McliciI  ilic  |iii-liTinr  |ili;irvMi:c;il  \V:ill.  xi  tli;it  tlic  liciik  falls  info  the  depression 
posterior  to  the  opeiiiiij:  rif  tiie  tiilie.  Hut  tliis  may  l)e  easily  averted  liy  attending  to 
the  directions  ahove  ;:iven  as  to  feeling  pressure  of  the  curve  on  the  hack  of  the  septum 
or  soft  palate  hefore  turninir  the  heak  outward. 

Dr.  Wchcr-Liel  ol"  lierlin  has  lately  introduced  a  small  elastic  catheter  for  the  jnir- 
pose  of  socurinu:  the  jiassa^e  of  injections  directly  into,  or  the  removal  of  accumulations 
irom.  the  tympanic  cavity.  This  is  passed  throuL'h  tin-  usual  silver  catheter  as  a  director 
to  the  tuhe,  and  having-  thus,  on  its  exit  from  the  silvti-  catheter,  obtained  a  positioti  in 
the  tuhe,  it  is  passed  on  with  a  little  care  throutrh  the  tuhe  and  into  the  tympanic  cavity. 

The  injecticuis  ]>assed  throuirh  the  catheter  consist  (d'  preparations  of  potass,  amnioida, 
iodine,  mercury,  silver,  zinc,  atropine,  chloral,  etc.,  in  solution,  care  heinir  taken  that  the 
tiuiil  is  lukewarm  at  the  time  of  entrance. 

The  fidlowlnt;  solutions  may  he  found  useful :  Sul|)liate  of  zinc  in  varyin<r  strcntrtlis  from 
one  to  ten  jrrains,  of  muriate  »d' ammonia  five  to  twenty  <:rains.  of  iodide  of  potassium  ten 
t<»  si.\ty  grains,  iodine  one  to  five  grains,  chlorate  of  soda  live  grains,  to  the  ounce  of  dis- 
tilled water.  Before  using  them  always  see  that  the  tube  is  pervious  and  cleared  of  mucu.s 
or  other  removable  obstruction  to  their  entrance.  They  are  proVjably  mo.st  useful  when 
employed  every  second  or  third  day  for  from  three  to  eight  weeks,  after  which  an  interval 
of  a  month  or  more  of  rest  is  advisable  before  continuing  their  application.  The  injec- 
tions through  the  elastic  catheter,  passing  directly  to  the  tympanic  cavity,  ought  to  be 
much  weaker. 

Siiould  objections  be  made  to  the  passing  of  the  catheter,  so  that  you  cannot  use  it  in 
passing  fluids  or  vapors  to  the  ear,  the  instruction  of  the  patient  in  doing  Valsalva'.s 
method  of  inflating  the  tympanum,  by  which  he  may  drive  steam  impregnated  with  a 
little  iodine  and  acetic  ether,  will  serve  the  purpose.  The  method  of  doing  .so  is  as  fol- 
lows:  Having  placed  from  ten  to  twenty  drops  of  a  solution  consisting  of  e(|ual  parts  of 
tincture  of  iodine  and  acetic  ether  in  a  pint  of  hot  water,  the  patient  inhales  a  mouthful 
of  the  steam,  and,  having  closed  the  nostrils  with  the  fingers,  makes  a  violent  expiration, 
keeping  the  mouth  and  nostrils  firmly  closed.  The  .steam  by  this  forcible  expiration  is 
driven  against  the  walls  of  the  naso-pharyngeal  space  and  month,  and,  the  Eustachian 
tubes  being  the  only  spots  for  exit,  rushes  up  these  and  fills  the  tympanic  cavity,  a  sensa- 
tion of  fulness,  and  po-ssibly  warmth,  being  felt  in  the  ear  by  the  patient  if  the  operation 
has  succeeded.  This  ought  to  be  done  several  times  at  a  sitting,  the  patient  swallowing 
between  each  inhalation.  But  should  the  Eustachian  tubes  be  not  rendered  pervious  by 
the  force  used,  as  is  not  unfrequently  the  case  when  the  mucous  membrane  is  consider- 
ably swollen,  the  catheter  must  be  resorted  to,  as  by  the  passage  of  a  current  from  an 
india-rubber  bag  directly  through  the  catheter  to  the  tube  an  obstruction  which  will  not 
give  way  to  Valsalva's  method  will  be  overcome. 

The  treatment  of  the  naso-pharyngeal  space  consists  in  topical  application  to  the 
mucous  membrane  of  the  space  of  astringents  such  as  alum,  tannin,  or  nitrate  of  silver. 
A  very  useful  form  is  the  drawing  of  a  solution  of  alum  up  the  nostrils,  allowing  it  to 
pass  back  into  the  pharyngeal  space,  expectorating  it,  and  then  blow^ing  the  nose  violently. 
When  the  alum  is  thought  not  sufiicient  for  the  condition  present  in  the  pharynx,  a  nitrate- 
of-silver  solution  of  from  5ss-3j  to  the  o  of  water  applied  to  the  pharynx,  and  especially 
to  the  membrane  round  the  Eustachian  regions,  will  be  found  a  valuable  agent.  The 
patient  being  seated  so  that  good  light  is  thrown  into  the  mouth,  and  the  tongue  being 
depressed  by  a  tongue  spatula  or  the  index  finger  covered  by  a  stall,  he  is  desired  to  take 
a  deep  in.spiration,  at  which  moment  the  surgeon  takes  the  opportunity  to  pass  the  brush, 
which  has  been  dipped  in  the  solution,  to  one  of  the  Eustachian  regions,  and.  making  a 
half  revolution  upward,  passes  over  the  whole  roof  of  the  space  to  the  Eustachian  region 
of  the  opposite  side.  The  use  of  gargles  at  home  between  the  applications  of  the  caustic 
is  to  be  recommended. 

Professor  Gruber  and  others  use  what  is  called  the  nasal  douche  by  driving  from  a 
syringe  the  nozzle  of  which  fills  one  nostril,  the  other  being  closed  by  the  fingers  of  the 
operator,  a  current  of  some  astringent  solution  up  one  nostril  and  so  into  the  other,  the 
obstruction  to  its  exit  from  the  other  nostril  by  the  fingers  regulating  the  force  with 
which  it  acts  on  the  pharyngeal  walls.  But  it  is  so  diflicult  to  regulate  that  force  with 
the  resistance  of  the  p]ustachian  tubes  that  the  fluid  may  pass  into  the  tympanic  cavity 
with  such  a  rush  as  sometimes  to  do  serious  damage,  and  accordingly  I  would  not  advise 
its  being  applied  by  those  unaccustomed  to  its  use 

The  operations  on  the  tympanic  membrane  and  structures  of  the  cavity  are  perfora- 
tion, division  of  adhesions,  and  tenotomy  of  the  tensor  tympani.     The  perforation  of  the 


336  AFFECTIONS  OF  THE  INTERNAL  EAR. 

membrane  has  been  spoken  of  at  p.  332.  The  division  of  adhesions  and  of  the  tensor 
tympani  is  made  by  small  curved  bistouries  or  by  revolving  cutting  hooks  made  for  the 
purpose.  Those  of  Weber-Liel  and  (jruber  will  be  found  most  useful.  The  determina- 
tion of  adhesions,  with  their  exact  positions,  is  best  made  by  using  Siegles  pneumatic 
speculum,  by  which,  on  creating  a  vacuum  in  the  meatus,  you  are  able  to  note  what  part 
of  the  membrane  is  bound  down  and  does  not  fall  into  the  vacuum  with  the  rest  of  the 
membrane.  It  requires  a  considerably  lengthened  experience  in  aural  diagnosis  to  be 
certain  of  the  necessity  for  or  advantage  to  be  derived  from  such  operations. 

Otitis  media  or  purulent  catarrh  is  merely  a  higher  grade  of  inflammatory 
mucous  discharge,  but  it  has  always  a  much  more  unfavorable  prognosis  than  simple 
catarrh.  The  symptoms  are  much  the  same  as  in  simple  catarrh,  but  more  violent,  being 
accompanied  with  severe,  pain,  fever,  and  nearly  always  leading  to  perforation.  This, 
should  there  be  an  accumulation  of  considerable  extent  in  the  cavity,  is  to  be  desired 
rather  than  feared;  because,  should  the  membrane  not  give  way,  as  is  apt  to  be  the  case 
in  a  thickened  membrane  from  chronic  catarrh,  the  pus  is  apt  to  find  its  way  through 
some  of  the  many  passages  which  often  exist  between  the  tympanic  and  cerebral  cavities, 
and  so  cau.se  meningitis. 

Treatment. — The  treatment  is  conducted  on  the  usual  principles.  Give  the  pus 
every  opportunity  of  free  exit,  either  by  natural  or  artificial  channels,  and  thus  allay 
fever  and  pain  and  save  time  and  tissue.  Leeches,  opiates,  purgatives,  and  warm-water 
injections  into  the  meatus,  keeping  the  Eustachian  open  so  as  to  have  a  natural  drain,  if 
necessary  perforation  of  the  membrane  at  the  point  of  bulging,  and  when  otorrhoea  has 
occurred  regular  syringing  of  the  ear  with  lukewarm  water  to  which  an  aiitiseptic  or 
astringent  has  been  added,  are  what  are  generally  found  successful.  To  make  the  astringent 
employed  pass  into  the  cavity  and  through  the  Eustachian  tube,  it  is  useful  to  fill  both 
canals  with  the  astringent,  causing  the  patient  to  keep  it  there  till  you  pass  a  current  of 
air  through  the  Eustachian,  on  which  the  fluid  in  the  external  canals  will  rush  into  the 
cavity  and  Eustachian,  or  by  driving  a  current  of  fluid  with  or  without  medicaments 
through  the  Eustachian  tube  and  tympanic  cavity  from  one  side  or  other.  In  addition 
to  the  local  treatment,  that  of  the  constitution  must  be  attended  to.  the  residence  of  the 
patient  in  such  chronic  discharges  being  of  especial  importance. 

The  pus  catarrh  of  children  is  often  most  insidious  in  its  progress  and  may 
cause  great  injury  before  its  presence  is  suspected.  Till  a  discharge  appears,  probably 
the  ear  has  not  been  looked  upon  as  the  seat  of  any  disease,  on  account  of  the  child's 
inability  to  localize  its  pain  or  tell  of  its  deafness.  The  screaming  of  the  child  when  pus 
has  formed  is  loud  and  persevering,  especially  at  night,  is  increased  by  every  movement 
or  concussion  of  the  body,  especially  by  movement  of  the  head,  and,  above  all,  by  suck- 
ing at  the  breast,  which  at  last  becomes  so  painful  that  the  child  refuses  to  take  the 
breast  entirely,  preferring  to  be  fed  by  the  spoon. 

Treatment  before  Perforation. — In  nearly  all  the  cases  of  suppuration  in  the 
tympanic  cavity  which  come  before  the  surgeon  the  pus  has  already  made  its  way 
through  the  membrane,  and  the  child  is  brought  to  you  on  account  of  the  discharge 
from  the  ear.  Should  you,  however,  see  the  child  before  the  pain  is  relieved,  you  may, 
by  the  timely  use  of  the  remedies  mentioned  as  useful  in  otitis  media  and  the  free  open- 
ing of  any  enlargement  over  the  mastoid  process,  with,  if  necessary,  opening  into  the 
mastoid  itself  if  there  be  indications  of  pus-accumulation  there,  prevent  the  destruction 
of  valuable  structures.  The  great  cause  of  the  aff"ection  is  scarlet  fever,  though  measles 
and  typhoid  fever  contribute  largely  to  the  number  of  cases. 

Treatment  after  Perforation. — When  the  acute  purulent  has  become  chronic, 
there  is  a  widespread  prejudice  amongst  both  the  laity  and  professional  men  against  the 
stopping  of  such  a  discharge  by  treatment.  This  prejudice  cannot  be  too  strongly  com- 
bated, as,  though  in  such  chronic  cases  there  are  generally  present  slight  deafness  and 
only  occasionally  pain,  we  can  never  be  certain  that  complications  arising  from  the  con- 
stant otorrhoea,  such  as  polypi,  paralysis  of  the  facial,  ulceration,  caries  and  its  results, 
will  not  occur. 

Affections  of  the  Labyrinth. — The  chief  symptoms  of  this  class  of  cases  are 
great  deafness,  gradually  or  suddenly  acquired,  diagnosed  by  the  patient's  inability  to 
hear  the  vibrating-fork  when  placed  on  the  bones  of  the  skull,  vertigo,  tinnitus,  with  pos- 
sibly nausea,  vomiting,  and  pain.  The  conditions  causing  such  aff"ections  are  believed  to 
be  hyperaemia  of  the  labyrinth  or  hemorrhage  into  it,  inflammation  of  the  labyrinth — 
wliich  is  generally  in  children  considered  under  the  term  of  "  meningitis" — and  malignant 
affections.     But  aff"ections  of  the   internal  ear  are  much  more  numerous  as  secondary 


AFFh'CTFOyS   OF   TIIF   ISTFIISM.    FAR.  337 

aff<'ctiiiii>  rt'sultinjr  I'loiii  an  cxti'iisioii  nt'  ilisrasi-  (if  tin-  mnlilli'  car,  iiicniii^ritis,  fevers, 
tuiiKirs,  aneurism,  aiiii'inia,  livstt-ria,  cliililltirtli.  or  syphilis.  Witli  tlu;  latter,  arisirijr  from 
luMvtlitary  syphilis,  are  ;;eiierally  seen  tlu;  syphilitic  physioj^tioiny  ;  and  in  all  the  cases 
wliii'li  have  yet  eoiiM'  liefore  me  in  whieh  the  acoustic  was  considerably  impaired,  cliaiiges 
ill  the  <lioroid  wen'  iiivariahly  ioiind  il'  tlie  media  were  .sufficiently  dear  to  allow  of  a 
view  ol"  the  retina  heinj;  ohtained. 

Tkkatmknt. — The  treatment,  sliniild  syphilis  lie  the  cause,  is  not  eiitiiclv  liopeless, 
liut  if  from  other  causes  is  almost  nil.  Strytdmia,  (juinine,  morphia,  and  local  remedies 
have  their  ditferent  advocates.  Khu-tricity  may  he  tried,  but  a  suilicicMit  nu:nb(;r  of 
earrfiillv  recorded  cases  is  still  re(|uire<l  liefore  an  opinion  of  its  value  can  be  given. 

Deaf-Mutism. — Hy  I'ar  the  majority  (above  three-fourths)  of  the  eases  of  deaf- 
mutism  arise  from  congenital  affections,  tlu;  n-maiiider  resulting  from  fevers,  teething, 
hvdidct'phalus,  convulsions,  etc.  The  hereditary  influt-nces  are  undoubt(!d  ;  and  when 
such  are  jire.sent  it  is  often  .seen  combined  with  retinitis  [tigjiientosa.  The  pathological 
conditions  found  in  such  are  changes  in  the  tympanic  cavity  with  defects  in  the  sound- 
conveying  apparatus,  abnormalities  in  the  labyrinth  or  cerebrum,  especially  near  the 
fourth  ventricle.  But  the  inner  ear  or  cerebrum  may  have  no  perceptible  changes  suf- 
ficient to  account  for  such  a  high  degree  of  deafness  as  is  present.  The  treatment  is  the 
careful  cultivation  of  any  remnant  of  hearing  which  may  be  present  and  the  placing  of 
the  child  in  an  institution  for  the  education  of  deaf  mutes,  where  by  the  careful  watch- 
ing of  the  lips  of  tlie  speaker  tliey  are  able  to  follow  him  in  conversation,  and  by  a  labor- 
ious teaching  of  tlie  positions  in  which  the  organs  of  speech  are  to  be  placed  in  forming 
the  different  syllables  they  are  rendered  capable  of  answering. 


SURGERY  OF  THE  CIRCULATORY  SYSTEM. 


CHAPTER    X. 

WOUNDS   OF   THE  HEART    AND   ARTERIES— HEMORRHAGE   AND   ITS 

TREATMENT. 

Wounds  of  the  Heart. 

Although  it  is  quite  possible  for  the  anterior  mediastinum  to  be  traversed  from  side 
to  side  by  a  foreign  body  without  any  important  structure  being  wounded,  it  is  far  more 
common  for  some  severe  lesion  to  be  the  result,  such  as  a  wound  of  the  pericardium, 
heart,  lung,  or  of  the  great  vessels.  A  wound  of  the  pericardium  aloue  may  occur  and 
not  prove  fatal.  Dr.  G.  Fischer  has  collected  fifty-two  reputed  cases  of  this  nature, 
including  punctured,  incised,  gun.shot,  and  lacerated  wounds,  of  which  twenty-two  recov- 
ered. The  chief  danger  of  this  local  injury  lies  in  secondary  inflammation  of  che  mem- 
brane. From  a  unique  preparation  shown  by  Mr.  Morrant  Baker  in  May.  1877.  at  the 
Pathological  Societ}',  it  would  seem  that  an  omental  or  other  hernia  may  take  place  from 
the  abdominal  cavity  through  the  diaphragm  into  the  pericardium  by  an  aperture  the 
result  of  some  antecedent  stab. 

The  operation  of  "  paracentesis  pericardii '"  has  been  performed  with  advantage,  and 
generally  with  the  aspirator.  The  best  point  for  puncture  is  probably  the  left  fifth  inter- 
costal space  nearer  the  rib  below  than  the  one  above,  and  about  two  or  two  and  a  quarter 
inches  from  the  median  line  of  the  sternum.  Dr.  J.  Roberts'  of  Philadelphia,  has  tabu- 
lated sixty  cases  of  the  operation,  of  which  twenty-four  recovered.  When  pus  exists  and 
can  be  diagnosed,  it  may  be  evacuated  by  an  incision  in  the  left  intercostal  space  below 
the  nipple,  and  the  pericardium  drained,  as  proved  by  the  case  of  Dr.  .S.  West,  read  at  the 
Roy.  Med.  and  Chir.  Society,  April.  isSo. 

W^OIinds  of  the  heart  itself  are  generally  mortal,  rare  instances  only  recover- 
ing. Death  takes  place  immediately  in  about  one-fourth  of  the  cases,  and  in  the  bulk 
of  the  remainder  after  a  few  days.  The  symptoms  of  a  wound  of  the  heart  are  very 
uncertain,  but  the  most  important,  sa3\s  Poland,  '"is  the  presence  of  a  lesion  in  the  neigh- 
borhood of  the  heart,  with  extenuil  hleeding.  followed  by  all  the  signs  of  sudden  internal 
hemorrhage."  Sudden  collapse  is  a  very  general  consequence  of  the  injury  ;  when  it 
comes  on  some  time  afterwai'd,  it  is  probably  due  to  secondary  hemorrhage  from  the 
giving  way  of  the  clot  in  the  wounded  heart.  Dyspnoea^  according  to  Fischer's  analysis, 
is  not  con.stant ;  in  some  cases  it  is  immediate  and  intense.  It  seems  to  be  due  to  com- 
pression of  the  heart  by  the  eifusion  of  blood  into  the  pericardium  and  pleura.  The  puhe 
is  often  unequal,  small,  and  intermitting.  Pain  is  uncertain.  The  position  of  the  exter- 
nal wound  is  a  valuable  aid  to  diagnosis,  and  it  is  well  to  remember  that  the  sternal  end 
of  the  second  left  intercostal  space  corresponds  to  the  left  side  of  the  base  of  the  heart, 
and  the  lower  margin  of  the  fifth  rib  to  the  apex.  In  a  medico-legal  sense  it  should  also 
be  known  that  "  when  a  person  is  found  dead  with  a  wound  in  the  heart,  attended  with 
abundant  hemorrhage,  it  must  not  be  supposed  that  the  flow  of  blood  took  place  in  an 
instant  or  that  the  person  died  immediatel}'  and  was  utterly  incapable  of  exercising  any 
power"  (Taylor).  The  symptoms  as  well  as  the  duration  of  life  are  much  influenced  by 
the  direction  and  size  of  the  wound.  Thus,  if  made  in  the  cour.se  of  the  muscular  fibres, 
there  will  be  little  or  no  hemorrhage,  and  consequently  less  collapse  and  dyspnoea  ;  but 
if  the  heart  be  cut  across,  the  edges  will  separate  to  a  great  extent  and  sudden  death 
ensue  from  the  immediate  gush  of  blood.     In  oblique  wounds  there  will  be  le.ss  gaping 

23S  1   7»v'7(x.  Amer.  Mffl.  Akkoc,  18S0. 


H'or.\7>.v  or  rni:  .\irn:i:ii:s.  ;;;}9 

c»t"  the  I'dj^fs.  With  ri'sjtfct  to  tlic  cuso  of  rt-covci y,  S:m.»oii  has  recorded  an  iristaiicc  in 
whifli  :i  cicatrix  in  the  heart  was  found  some  h-n;rthencd  |)eriod  after  the  receipt  of  a 
wound  from  which  the  patient  liad  recovered  in  twenty-ei;_'ht  days.  Velpeau  has  cited  a 
second,  of  a  man  aj:ed  ."»(>.  who  died  nine  years  after  having'  received  a  wound  in  the  left 
side  of  the  chest  from  a  tahh'  knife,  and  in  whom  the  jierieardium  was  found  hirjrely 
opened  and  adherent  to  the  parietal  cicatrix,  while  fihrous  lines  traversed  the  wlnde  thick- 
ness of  the  riirht  auricli-  at  a  point  corresponding  to  the  hreach  of  surface  in  tluj  [)eri- 
cardiiini.      In   the  Maiicni  Tini>s  nml  (in:.,  of  April  4.  1S74,  a  case  is  also  reported  of  a 

Captain    H .  set.  4(1.  who  died  from  dysentery,  and  after  death  a  leailen  bullet,  which 

had  (-ntered  tlie  chest  above  the  nipple  eleven  years  previously,  was  found  encysted  out- 
side the  pericardium,  between  the  orijrin  of  the  juilmonary  artery  in  front  and  the  a.scend- 
ing  part  of  the  arch  of  the  aorta  behind.  The  heart  may  also  be  lacerated  by  a  severe 
contusion  or  pressure  upon  the  chest  without  external  wound  or  fracture  of  the  ribs. 
(Thus  at  (luys  there  is  ii  prep.,  140(P,  in  which  both  auricles  of  the  heart  are  lacerated 
with  the  pulmonary  veins,  which  was  taken  from  a  child  aged  four,  over  who.se  back  tlie 
wheel  of  a  cart  had  passed.  There  is  also  another  in  the  Koyal  College  of  .Surgeons  of 
Edinburgh  which  demonstrates  this  {loint.j.  The  diagnosis  and  treatment  of  thi.s  form 
of  injury  are  the  same  as  in  ca.ses  of  wounds. 

Tkkatment. — As  hemorrliagc  after  a  wound  of  the  heart  is  the  main  fear,  .so  to  pre- 
vent and  arrest  it  should  be  the  chief  aim.  With  this  object  absolute  repose  is  essential, 
and  the  local  and  general  employment  of  cold  should  be  maintained  throughout  the  case. 
To  calm  the  excited  action  of  the  heart,  belladonna  and  digitalis  have  been  recommended, 
and  so,  even,  has  venesection.  The  diet  should  be  nutritious,  but  unstimulating.  W^hen 
the  pericardium  is  full  of  blood,  it  has  been  suggested  to  lay  open  the  cavity  to  let  it 
out ;  but  the  uncertainty  of  diagnosis  is  sufficient  to  forbid  the  attempt.  For  further 
information  on  the  subject  I  may  refer  to  Poland's  article  in  HolmeiCs  Snrgnnj.,  which  con- 
tains an   admirable  analysis   of  Fischer's  paper;  also  to  a  paper  by  West  in   the   »SV. 

T/lonnls's    Ifnsj,.    Rr/...   ISTO. 

Wounds  of  the  large  vessels  of  the  chest  are  generally  fatal,  death  being 
immediate  in  most  cases  from  internal  hemorrhage.  Dr.  Heil,  however,  records  a  ca.se  in 
which  a  man.  after  receiving  a  stab  which  penetrated  the  aorta,  recovered  and  lived  a 
year.  Pelletan  also  cites  another,  in  which  a  man  was  run  through  with  a  foil,  which 
entered  the  chest  above  the  right  nipple  and  came  out  at  the  left  loin  ;  yet  no  violent  or 
marked  .symptoms  followed  the  accident  beyond  constant  pain  in  the  loins.  Two  months 
later  he  suddenly  died  in  great  agony  from  hemorrhage  into  tlie  right  side  of  his  chest, 
and  after  death  an  opening  the  size  of  a  quill  was  found  in  the  aorta  above  the  diaphragm. 
The  Hunterian  Mu.seum  (No.  1565a)  contains  a  specimen  of  the  a.scending  aorta  of  a 
sailor,  in  which  was  lodged  a  bullet  in  a  piece  of  integument  surrounded  by  lymph.  The 
wound  was  produced  by  a  rau.sket-ball  pas.sing  through  the  diaphragm  and  pericardium 
into  the  aorta  ;  it  entered  the  chest  between  the  eighth  and  ninth  ribs  and  was  followed 
by  a  rush  of  blood.  All  hemorrhage,  however,  very  soon  ceased.  The  man  lived  three 
days  after  the  injury. 

Wounds  of  the  Arteries. 

When  an  artery  is  romphtclj/  cut  acrosx,  bleeding  takes  place  and  the  blood  jets  forth 
per  .saltuni,  as  it  is  called,  with  each  pulsation  of  the  heart.  Pulsation  in  the  ves.sel 
below  the  seat  of  injury  is  likewise  lost.  The  blood  is  usually  of  a  bright-red  color 
unless  the  patient  be  asphyxiated  or  fully  under  the  influence  of  some  anaesthetic,  when 
it  is  often  as  black  as  venous  blood.  Pressure  upon  the  artery  above  the  wounds  arrests 
or  diminishes  the  hemorrhage.  When  an  artery  is  ouli/  p(u-tiuUi/  wounded,  either  trans- 
versely, obliquely,  or  longitudinally,  the  bleeding  will  probably  be  less  profuse  ;  and  the 
blood  rarely  jets  out  as  from  a  divided  vessel,  but  wells  up  in  a  deep  wound  or  flows  in  a 
continuous  stream,  after  the  manner  of  venous  blood.  When  the  blood  is  red,  its  arterial 
nature  can  easily  be  recognized  ;  but  when  black,  its  recognition  is  more  difficult.  Should 
pressure,  however,  above  the  wound  arrest  the  flow  and  pulsation  in  the  vessel  below  the 
wound  be  lost,  the  probabilities  of  the  blood  being  arterial  are  strengthened.  It  is  an 
important  fact  to  bear  in  mind  that  when  a  large  artery  is  partially  divided  just  befow  a 
large  anastomotic  branch,  bleeding  will  take  place  from  the  lower  end  of  the  wounded 
artery,  as  well  as  from  the  upper,  and  pulsati«m  in  the  vessel  below  will  only  be  dimin- 
ished. 

When  hemorrhage  takes  place  from  a  large  vessel,  it  is  generally,  unless  instantly 
checked.  ?.o  profuse  as  to  destroy  life  rajiidly.     When  from  a  small,  it  is  less  copious  and 


340 


NA  TURA  L  -H.EMOSTA  TICS. 


has  a  natural  tendency  to  stop — at  any  rate,  for  a  time — and  to  give  an  opportunity  for 
natural  haemostatics  to  take  effect. 

Whatever  favors  retraction  of  a  divided  artery  and  its  contraction  tends  to  arre.st  bleed- 
ing ;  whatever  hinders  these  processes  prolongs  and  increases  it.  Thus,  vessels  that 
traverse  loose  textures  cease  bleeding  more  readily  than  others  circulating  through  those 
that  are  close  and  compact,  such  as  the  integument  of  the  head  and  sole  of  the  foot ;  and 
bleeding  from  an  inflamed  or  rapidly-growing  part  is  checked  with  greater  difficulty  than 
that  from  other  tissues. 

The  size  and  form  of  the  wound  in  the  vessel  have  also  inucli  to  iId  with  the  result. 
A  puncture  in  the  axis  of  a  large  artery  may  heal  by  natural  processes  and  be  unattended 
by  much  bleeding ;  a  small  vertical  wound  may  likewise  close,  whereas  an  ohlique  wound 
will  gape,  and  is  consequently  attended  with  copious  bleeding  ;  while  a  transverse  wound 
is  of  all  others  the  most  dangerous,  on  account  of  the  difficulty  of  controlling  hemorrhage 
and  the  improbability  of  natural  hfemostatics  unassisted  by  art  acting  with  any  perma- 
nent advantage.  The  retracting  power  of  the  vessel  tends  to  cause  gaping  of  th'e  wound 
rather  than  closure,  and  encourages  rather  than  checks  bleeding. 

It  is  well,  therefore,  to  consider  now  how  wounded  arteries  heal  and  by  what  means 
bleeding  can  naturally  be  arrested. 

Repair  of  Wounded  Arteries.— Small  wounds  of  arteries  may  heal  by 
immediate  union  or  primary  adhesion,  and  larger  may  likewise  for  a  time  be' closed  by 
the  clot  of  blood  that  covers  the  wound,  or  even  by  .some  .stronger  reparative  material ; 
but  "  the  closure  of  a  wound  in  an  artery  is  often  ineffectual  or  only  for  a  time,  and  fresh 
bleedings  ensue,  either  increasing  the  accumulation  of  extravasated  blood  or  pushing  out 
the  clots  already  formed.  In  this  manner,  with  repeated  hemorrhages  at  uncertain  inter- 
vals, the  wound  in  an  artery  is  often  kept  open,  and  at  the  end  of  two  or  three  weeks 
may  show  no  trace  of  healing,  but  rather  appear  widened  and  with  softened  everted  edges. 
In  such  a  case  it  is  possible  that  the  wound  in  an  artery  may  still  heal  by  granulations, 
either  rising  from  its  edges  or  coalescing  over  it  from  adjacent  parts,  but  the  event  is  too 
unlikely  to  justify  the  icaitinrj  for  its  occurrence  if  there  be  opportunity  for  surgical  inter- 
ference ;  and  even  if  healing  should  go  so  far  as  to  close  the  opening  in  the  artery,  yet 
is  it  likely  to  be  insecure,  for  both  the  elastic  tissue  and  the  smooth-fibred  muscle  on 
which  its  strength  largely  depends  are  very  .slowly  formed  in  scars.  Hence,  a  form  of 
traumatic  aneurism  seems  not  very  rare  in  which  the  sac  is  chiefly  formed  of  scar  tissue 
which  closed  the  wound  in  the  artery  and  then  yielded  to  the  pressure  of  the  blood." 

Thus  a  partial  is  a  more  serious  injury  than  a  complete  division  of  an  artery,  and 
requires  as  prompt  surgical  treatment,  because  the  means  adopted  by  nature  for  the 
permanent  arrest  of  bleeding  in  a  divided  vessel  are  acting  at  a  disadvantage,  and  are 
rarely  effectual  in  one  only  partially  wounded.  In  practice,  therefore,  the  surgeon,  by 
the  complete  division  of  a  partly  divided  vessel,  often  gives  natural  haemostatics  a  fair 
chance  of  effecting  a  cure.  Hemorrhage  from  vessels  of  small  size,  as  a  rule,  ceases 
after  the  first  rush,  or,  at  any  rate,  as  soon  as  nature's  proces.ses  for  controlling  bleeding 
have  had  time  to  act.  Indeed,  "  gradually,  with  or  without  surgical  help,  all  the  vessels, 
divided  by  a  wound  are  clo-sed  and  cease  to  bleed,  the  larger  being  often  aided  to  this  end 
by  their  retraction  among  the  looser  textures,  by  the  coagulation  of  the  blood  within  or 
over  their  orifices,  and  by  the  diminution  of  the  heart's  force  with 
the  increasing  loss  of  blood.  Coincidently  the  flowing  blood  becomes 
gradually  brighter  and  paler.  And  if  the  wound  be  left  open  after 
■  pure  blood  has  ceased  to  flow,  there  is  an  oozing  of  blood-tinged 
serous-looking  fluid,  and  this  is  gradually  succeeded  by  a  paler  fluid, 
some  of  which  collects  like  a  whitish  film  on  the  surface  of  the  wound  " 
(Paget). 

Natural  Hemostatics. 


Fig.  13-2. 


In  a  Divided  Artery. —  When  an  artery  is  divided  across,  five 
things  happen  :  (1)  The  divided  ends  (Fig.  132  (?)  retract  within  the 
.sheath  (a),  and  (2)  by  contracting  diminish  the  calibre  of  the  canal ; 
(3)  Blood  coagulates  in  the  sheath  (a)  around  the  orifice  of  the  divided 
vessel,  and  (4)  in  the  artery  itself  (b)  up  to  the  first  large  branch  (e)  ; 
and,  lastly  (5).  plaxtic  lymph  is  poured  out  from  the  divided  coats  of 
Natural  Hieuiusiatics.  ^'^^  vessel,  and  by  its  organization  the  permanent  closure  of  the  vessel 
takes  place.  The  clot  subsequently  becomes  organized  and  contracts. 
In  a  large  proportion  of   the  cases  of   divided  arteries  these  natural   haemostatic  pro- 


.S7  IK! K  :  I  /.    ll.KM'isr.  I  TK  'S. 


;ui 


cesses  arc  aiiij  'c  >>{'  tliciiisflvfs   lar  the  arrest  of  hlecdiiiL'.  wliile   it  is  only  in   the  lar^rcr 
arteries  tliat  aiiv  siirL'ieal  or  artilieial  aids  are  re(|iiired. 

In  Torn  Artery. —  W'Jhh  oh  arfin/  is  torn  across,  t\ni  saiiie  eliaiijres  take  place  ; 
hut  titii/  itrt  vtirrinl  out  to  (in  mliuintatjf,  as  the  streteliiii;:  or  t<trsioii  <»!'  the  vessel  hel'ore 
it  <rives  way  eiifourages  itn  ^^  ntriirtion '^  and  '■'■  rout ror.l Ion  ^'  atid  the  hieerated  ed^cs  <if* 
the  vessel  help  the  eoa^Mjlatioii  (if  the  hlond.  It  thus  happens  often  that  siieli  large 
arteries  as  the  femoral  and  hrachial  may  lie  torn  asunder  and  ii<t  l(lee(liri<r  follow, 
and  whole  limits  avulsed  from  the  trunk  without  hemorrhage.  The  lacerated  ves.sel 
apjH'ars  under  these  circumstances  as  if  drawn  out,  with  its  external  elastic  tunic 
stretched    into   a    conical    form    ovt'r   the    imicr 

coats  that  have  been  divided  and  ri'tractcd.     An  Vu;.  V.V.',.  Vm    I."4. 

artery,  however  large,  divided  l»y  laceration 
or  torsi(»n  conser|uently  rarely  bleeds ;  and  it 
was  the  oliservatiun  of  this  fact  that  suggested 
to  Anuissat  the  idea  of  practising  torsion  of  an 
artery. 

In  a  Stretched  and  Contused  Ar- 
tery.—  117/' /(  (III  iirti  11/  /.s-  cnii/HS'i/  or  so 
.stretched  as  to  .suffer  s(unething  less  than 
complete  rupture  of  all  its  coats,  it  may  be- 
come obstructed  ;  and  this  obstruction  is  proba- 
bly caused  by  a  more  or  less  complete  circular 
laceration  or  breaking  up  of  its  inner  tunics, 
for  the  different  museums  contain  prejiara- 
tions  which  prove  that  an  artery  so  treated, 
when  apparently  maintaining  its  continuity, 
may  have  a  complete  circular  laceration  of  its 
inner  coats,  a  separation  of  these  coats  from 
the  external  cellular  one,  or  an  incurvation  of 
these  tunics  into  the  lumen   of  the  artery,  as 

in    torsion    f  B.   Figs.    Vo.j.     13-i),  the    deposition  Laceration  und   Recurvation  of  Intprnal  Cats  of  an 

of    clot    subscouentlv    taking    place    within    the  -V'^^^'fr^'V  Kx'ernal  injury    (Takeiifron.  prepara- 

i     .    .   '                                1  tions  now  in  the  Museum  ot  th'>  .Middlesex   lios- 

meshes    of    the    divided    coats,    and,    as    a    COnse-  pital  by  the  kind  permission  of  the  surgeons.) 

quence,  the  complete  occlu.sion  of  the  vessel. 

I  have  known  this  obstruction  to  follow  many  injuries,  and  have  seen  the  external 
iliac  artery  obstructed  in  a  case  of  a  broken  pelvis,  in  one  instance  followed  by  gangrene 
of  the  lower  extremity,  and  in  a  second  by  cure.  I  have  also  known  the  common  and 
the  superficial  femoral  artery,  the  axillary  and  the  brachial  arteries,  to  become  perma- 
nently closed  in  a  similar  manner.  It  is  a  question,  indeed,  whether,  as  a  result  of  con- 
tu.sion,  adhesive  inflammation  ever  takes  place  in  an  artery  to  cause  its  occlusion  without 
some  such  laceration  of  its  inner  tunics  as  has  been  described. 

Sometimes  a  vessel  will  rupture,  some  days  after  the  injury,  at  a  part  that  has  been 
severely  contused,  causing  a  secondary  subcutaneous  hemorrhage  and  the  sensation  of 
something  giving  way.  Such  a  result,  however,  is  rare  in  civil  practice,  although  in 
military,  from  gunshot  wounds,  it  is  more  frequent.  The  bleeding,  under  such  circum- 
stances, occurs  after  the  fifth  day.  Cold  lotions  will  generallv  suffice  to  induce  aV).sorption 
of  the  Vjlood  when  the  hemorrhage  is  slight,  although  in  some  cases  the  fluid  blood  may 
be  drawn  off  with  a  good  result.  In  exceptional  ca.ses  an  aneurism  may  form  and  require 
treatment. 

Surgical  Hemostatics. 

It  has  been  asserted  that  by  natural  processes  alone  divided  vessels  are  permanently 
sealed  and  arteries  in  continuity  occluded  ;  it  will  be  well,  therefore,  to  in(|uire  into  the 
modes  of  action  of  the  different  means  which  the  surgeon  has  at  his  disposal  to  bring 
about  these  results,  since  it  may  be  stated  in  limine  that  the  means  are  to  be  regarded  as 
good  in  so  far  as  they  aid  and  turn  to  account  the  natural  proces.ses  that  have  been 
described. 

Thus,  the  exposure  of,  and  the  appJirntion  of  cold  to,  a  divided  artery  favor  its 
'•contraction.''  this  physiological  explaining  the  practical  fact  that  on  the  free  opening 
of  a  wound  hemorrhage  often  ceases,   never  to  return. 

Pressure  upon  the  end  of  a  wounded  artery  favors  '•  coagulation"'  in  the  vessel,  and 
the  value  of  acupressure  rests  mainly  upon  this  j>rinciple,  the  pins  and  pressure  mechan- 


342 


5  UR  GICA  L  HjEMOSTA  TICS. 


ically  arresting  the  flow  of  blood,  wliilst  coagulation  is  taking  place  in  the  vessel  up  to 
the  first  branch. 

When  (I  lujatnrc  is  applied  firmly  to  an  artery,  the  inner  coats  are  usually  more  or  less 
regularly   divided  and    the  outer  is    so   constricted   as   to   arrest   the  current    of  blood 

through  the  vessel.  The  blood  thus  arrested  consetjuently 
coagulates  and  forms  a  clot  or  thrombus,  which  is,  as  a  rule, 
conical,  with  its  base  toward  the  ligature  and  apex  pointing 
to  and  reaching  the  first  branch  (Fig.  135,  h).  This  clot  sub- 
AK'J^Jiy/iiH.-s  sequently  contracts  and  becomes  organized.      The  inner  and 

7      ''l^P     1^^,  \  middle  coats,  from  their  divided  edges,  pour  out  (f)  plastic 

lf!3i.-.  -V     \  lymph,  which  heals  the  wound  and   eventually  cements  to- 

gether the  outer  and  inner  coats  and  the  clot  into  one  homo- 
geneous mass  ;  and  if  in  the  sequence  of  events  nothing  (oc- 
curred to  interfere  with  the  steady  evolution  of  this  reparative 
process,  all  would  indeed  be  well,  but  unfortunately  such  is  not 
always  the  case,  ftr  the  ligature  has  often  to  come  awav.  To 
this  end  the  outer  coat  of  the  artery,  where  constricted,  must 
slough  or  ulcerate,  and  the  vessel  itself,  in  either  case,  at  the 
line  of  ligature  thus  becomes  divided.  By  such  action,  there- 
fore, what  nature  by  the  processes  already  described  might 
have  well  done  too  frequently  becomes  undone  ;  and  unless  a 
firm  clot  has  filled  both  ends  of  the  artery  or  plastic  lymph 
become  organized  around  the  divided  coats,  the  risks  of  secon- 
dary hemorrhage  are  very  great.  It  is  this  fact  which  makes 
the  practice  of  arresting  hemorrhage  by  means  of  the  silk, 
hemp,  or  wire  ligature  so  unsatisfactory.  To  Stilling  and  Dr. 
J.  F.  D.  Jones,  1805,  we  are  indebted  for  most  of  our  know- 
ledge on  these  points. 

When  the  carbolized  prepared  catgut  ligatures  are  em- 
ployed, the  primary  eifects  of  the  ligature  are  the  same  as 
with  the  permanent  (wu/e  Fig.  135  ;  Trans,  of  Clin.  Soc.  1878), 
but  the  secondary  changes  which  have  been  described  do  not 
of  necessity  follow.  The  prepared  catgut  ligatures,  conse- 
quently, may  be  regarded  as  temporary  ligatures  which  may 
either  dissolve  within  a  few  days  of  their  application  or  be- 
come loose.  If,  therefore,  an  aj-tery  to  which  such  a  ligature 
has  been  applied  does  not  become  permanently  closed  by  natural  haemostatic  processes 
before  the  ligature  has  dissolved  or  become  loose,  the  circulation  through  the  vessel  may 
be  restored  or  secondary  hemorrhage  may  ensue  ;  and  this  accident  has  occurred.     The 

prepared  catgut  ligature  is  not,  therefore,  so  safe  as 
torsion  for  divided  arteries.  It  is,  however,  a  safer 
ligature  than  the  silk  or  hempen,  as  it  does  not,  like 
the  latter,  of  necessity  require  an  ulcerative  process 
for  its  discharge. 

Barwell's  flat  ox-aorta  ligature  occludes  an  artery 
by  mechanically  holding  its  coats  together,  and  its 
safety  depends  upon  the  coagulation  of  the  blood  in 
the  artery  and  its  power  of  holding  long  enough  to 
give  time  for  the  organization  of  the  clot.  With  it 
there  is  no  division  of  the  inner  coats  of  the  artery. 
I  do  not,  therefore,  believe  it  to  be  as  safe  as  the  pre- 
pared gut  or  silk  ligature. 

The  Effects  of  Torsion  on  an  Artery.— 

Wlien  an  artery  is  closed  hy  what  i<  termed  torsion,  the 
Effects  of  Torsion  upon  an  Artery,  showing  i^^er  coats  are  ruptured  (Fig.  13(),  B  and  c),  and  the 

the    Incurvation    and    Laceration   of    the   outer  (a),  when  not  twisted  off",  closed  by  the  tWlStS  tO 
Inner  Coats.     (From  paper  bv  the  author,       i  •    i     -^    i         i  i.-      ^    j         t>    ^  j.\       •  „,.,*„    4„ 

Med-ciiir.  Ti-ans.,  is6s!)         "  which  it  has  been  subjected.     But  the  inner  coats,  in- 

stead of  being  simply  divided  in  a  linear  manner,  as 
occurs  when  the  ligature  is  used,  become  ruptured,  separated  from  the  outer  coat,  and 
incurved,  their  divided  ends  turning  into  the  vessel  and  in  the  most  perfect  examples 
forming  complete  vessels  not  unlike  the  semilunar  valves  of  the  heart.  The  blood,  which 
is  consequently  arrested  by  this  valvular  incurvation  of  the  inner  tunic,  undergoes  changes 


Effects  of  Carbolized  Catgut  Liga- 
ture on  Common  Femoral  Ar- 
tery. (Taken  from  a  girl  tet.  19, 
who  died  on  the  twentieth  day, 
from  gangrenous  leg,  after  the 
application  of  the  ligature  to  the 
arterj'  for  elephas.  The  ligature 
in  this  case  was  firmly  attached 
to  the  vessel  and  had  acted  upon 
its  coats  as  a  permanent  liga- 
ture.) 


Fig.  136. 


oy  Ji F.MnnnuMii:  .\\/>  //s  treatmkst.  343 

pn'cist'ly  MJinilar  to  tliosi'  alrcaily  ih'scrihcd.  I'la.stic  lynipli  Ih  poured  out  by  tho  divided 
tuuic's  ill  the  sunie  way  as  has  been  shown  in  the  application  of  the  lijjature,  and  it  acts 
the  same  part  in  cementing  all  the  arterial  tunies  and  clot  together.  Between  the  two 
forms  of  practice.  hi>wever,  there  is  this  difference — that  where  the  pi;rmanent  ligature 
has  hi'cn  use<l  ulceration  of  tlie  vessel  is  prone  to  occur  to  allow  of  its  escape,  and  thus 
may  undo  all  that  nature  has  floiie  to  seal  the  artery  and  prevent  hemorrhage;  when'aH, 
when  torsion  has  been  effieiently  perfnrnieil  and  the  heinrjrrhage  arrested,  no  sub- 
se(|Ui'nt  action  is  lialjle  to  undo  the  good  work  that  has  been  done  or  to  hinder  the 
permanent  closure  of  the  vessel.  With  both  ligature  and  torsion  natural  luemostatics 
are  aiiled  in  their  work,  but  with  the  former  the  ulceration  set  up  by  the  ligature  may 
materially  interfere  with  the  perfection  of  the  jtrocess,  while  with  the  latter  there  is 
n(»thing  to  jirevent   the  proces.s  going  on   to  its  completion. 

On  Hemorrhage  and  its  Treatment. 

When  bleeding  takes  place  rapidly  from  a  wound  after  an  injury  or  operation,  it  is 
called  primary;  when  it  occurs  on  reaction  from  shock  within  twenty-four  hours,  or  in 
rare  cases  within  two  days,  it  is  called  recurring  or  intermediary;  and  when  after 
a  lajtse  of  a  longer  period,  secondary. 

The  /in'iiiiiri/  is  due  to  tlie  ilin-et  injury  of  the  vessel  ;  the  recurrin;/,  to  the  increa.sed 
force  of  the  circulation  during  reaction  and  the  displacement  of  clots  that  were  sufficient 
to  seal  vessels  when  the  circulation  was  feeble,  to  the  overlooking  of  a  ves.sel  during  the 
dressing  of  a  wound,  or  to  some  imperfection  in  the  mode  of  securing  it  at  the  time  of 
operation.  The  seromfdn/  is  caused  by  the  giving  way  of  an  artery  or  vein,  by  ulceration 
of  the  ligature,  by  slouirhing  of  the  vessel  alone  or  with  the  tissues  around  by  the  acci- 
dental separation  of  a  ligature,  injury,  or  owing  to  the  hemorrhagic  diathesis. 

When  blood  escapes  from  a  wound  externally  or  into  a  cavity,  the  term  hemorrhage 
is  applied;  when  it  is  effused  beneath  the  integuments  or  amongst  tissues,  extravasation 
or  e(f'iis{on  is  said  to  occur. 

The  SYMPTOMS  of  external  hemorrhage  require  no  de.scription,  the  slow  flow  or  the 
stidden  gush  of  the  lifes  blood  being  recognizable  by  all.  Tho.se  of  concealed  inter- 
nal hemorrhage  or  extrava.sation  require,  however,  .some  attention.  They  are  those  of 
local  injury  pfus  those  general  symptoms  which  denote  hemorrhage  generally. 

'•  In  slow  and  in  sudden  hemorrhages."  wrote  John  Bell  .seventy  years  ago,  "  the 
symptoms  are  very  different.  In  the  former  the  patient  is  very  slowly  exhausted  ;  at 
each  return  of  bleeding  the  patient  faints  and  is  laid  in  bed  and  the  cold  applications  and 
the  fainting  save  his  life.  He  rises,  after  some  days.  pale,  languid,  and  giddy.  The 
pulse  flutters  and  is  hardly  to  be  felt  ;  the  breathing  is  quick  and  anxious,  accompanied 
with  sighing  and  great  oppression  :  the  heart  palpitates  on  the  .slightest  motion,  and  the 
slightest  inclination  of  the  head  or  rising  suddenly  from  the  couch  endangers  fainting. 
The  voice  is  low  ;  the  eye  is  languid,  colorless,  and  of  a  pearly  white  ;  the  flesh  feels  soft 
and  woolly,  and  the  skin  is  pale,  yellow,  gelatinous,  and,  as  it  were,  tran.sparent,  like 
modelled  wax.  After  this  stage  of  weakness  the  blood  loses  its  color ;  from  this  time 
forward  it  is  a  bloody  serum  only  that  distils  from  the  vessels ;  dropsv  appears  and  the 
slightest  loss  of  blood  proves  fatal.  But  when  the  patient  expires  suddenly  bv  an  impet- 
uous bleeding  from  some  great  artery,  when  he  dies  of  the  bleeding  from  a  femoral 
aneurism,  when  he  is  wounded  among  the  vLscera  and  some  great  vessel  is  pouring  out 
blood,  the  blood  in  the  general  circulation,  in  place  of  being  forced  onward  by  the  con- 
tractions of  the  arteries,  runs  backward  toward  the  wound  from  all  parts  of  the 
body.  The  arteries  no  longer  push  on  the  contents  of  the  veins ;  the  blood  cea.ses  to 
"flow  toward  the  heart  :  the  heart  ceases  to  act,  and  the  countenance  assumes,  as  in 
asphyxia,  a  livid  hue.  from  want  of  circulation.  The  face  becomes  all  at  once  deadly 
pale;  the  circle  round  the  eyes  is  livid,  the  lips  are  black,  and  the  extremities  are  cold. 
The  patient  faints,  revives,  and  faints  again,  with  a  low  and  quivering  pulse ;  he  is  sick 
and  his  voice  is  lost.  There  is  an  anxious  and  incessant  tossing  of  the  arms,  with  rest- 
lessness, which  is  the  most  fatal  sign  of  all.  He  tosses  continually  from  side  to  side :  his 
head  fiills  down  in  the  bed  ;  he  raises  his  head  at  times  suddenly,  gasping,  as  it  were,  for 
breath,  with  inexpressible  anxiety  ;  the  tossing  of  the  limbs  continues ;  he  draws  long 
convulsive  sighs  :  the  pulse  flutters  and  intermits  from  time  to  time,  and  he  expires.  The 
countenance  is  not  of  a  transparent  paleness,  but  that  of  that  clayey  and  leaden  color 
which  the  painter  represents  in  assassinati<tns  and  battles  ;  and  this  tossing  of  the  limbs, 
"which  is  commonly  represented  as  the  sign  of  a  fatal  wound,  is,  indeed,  so  infallible  a 


344  ON  HEMORRHAGE  AND  ITS  TREATMENT. 

sign  of  death  that  I  have  never  known  any  one  to  recover  who  had  faHen  into  this  con- 
dition "  (^Principles  of  Siirgeri/,  voh  i.  p.  143). 

This  sketch  is  so  graphic  that  I  have  extracted  it  as  a  whole.  Since  my  student 
days,  when  I  first  read  it,  it  has  been  fixed  in  my  memory.  It  is,  however,  only  a  page 
out  of  the  work  of  a  master-surgeon  which  still  deserves  close  study. 

A  patient  may  lose  a  large  quantity  of  blood  and  yet  rally.  Children  bear  the  loss 
of  blood  badly,  yet  rally  quickly.  In  old  age  a  small  hemorrhage  is  of  grave  importance, 
the  rallying-po-wer  being  very  small. 

Treatment. — To  treat  a  case  of  arterial  hemorrhage  successfully,  the  surgeon,  wrote 
Robert  Liston,  "  must  learn  to  look  boldly  on  the  open  mouths  of  arteries."  He  must 
know,  moreover,  that  hemorrhage  from  any  vessel,  however  large,  is  readily  controlled 
by  the  application  of  well-applied  direct  pressure  upon  the  tvoundrd  pxtrt ;  conse(|uently, 
any  surgeon  on  being  called  to  a  case  of  wounded  artery,  having  cleansed  the  wound  and 
exposed  the  vessel,  should  put  his  thumb  or  finger  on  the  bleeding  orifice  and  check  the 
flow  until  more  permanent  hajmostatic  methods  can  be  adopted.  When  moderate  bleed- 
ing comes  from  a  wound  and  its  source  is  unknown,  whether  arterial  or  venous,  the  mere 
act  of  cleansing  the  ivound  and  removing  clots  is  often  sufficient  of  itself  to  arrest  bleeding, 
not  only  for  the  time,  but  permanently.  When  the  bleeding  is  venous,  the  elevation  of  the 
limb  has  always  a  most  beneficial  and  rapid  action.  When  direct  pressttre  is  employed  to 
check  bleeding,  it  should  be  well  applied  ;  a  small  and  compact  pad  corresponding  in  size 
to  the  last  joint  of  the  thumb  should  first  be  applied  to  the  bleeding  part,  and  over  this 
a  larger  one  .should  be  carefully  adjusted,  a  third  covering  in  the  whole.  These  are  to  be 
firmly  bound  down  over  the  bleeding  ves.sel  with  a  1)andage  or  some  unyielding  strapping, 
care  being  taken  that  the  pressure  employed  is  sufficient  to  control  the  bleeding,  but  not 
enough  to  arrest  wholly  the  circulation  through  a  limb,  thereby  producing  gangrene  of 
the  parts  below. 

When  direct  pressure  is  inapplicable,  indirect  pressun-^  as  it  is  called,  may  be  applied 
to  the  main  artery  of  a  limb  above  the  wound,  and  for  temporary  purposes  this  may  be 
efficiently  performed  by  the  thumb  or  finger  of  the  .surgeon  or  of  a  skilled  assistant ;  but 
for  a  lengthened  period  this  method  is  untrustworthy,  it  being  impossible  for  any  ordinary 
man  to  maintain  firm  pressure  upon  a  vessel  for  more  than  a  few  minutes  consecutively. 
As  a  temporary  means  of  arresting  bleeding,  however,  manual  pressure  is  of  immense 
value  and  should  be  applied  to  the  femoral  artery  below  Poupart's  ligament  for  the  lower 
extremity,  and  on  the  inner  side  of  the  biceps  muscle  for  the  upper,  the  fingers  or  thumb 
of  the  surgeon  being  employed,  according  to  convenience.  In  some  cases  the  use  of  the 
weight,  as  shown  in  Fig.  149,  may  be  recommended. 

What  is  known  as  Esmarch's  method  of  arresting  hemorrhage  has  in  recent  times  met 
with  considerable  support.  It  consists,  first,  in  the  application  of  an  elastic  bandage  from 
the  extremity  of  the  limb  to  be  operated  on  to  a  point  above  the  site  of  the  operation  ; 
and  secondly,  in  the  adjustment  of  an  india-rubber  band  or  tube  tightly  above  the  upper 
border  of  the  elastic  bandage,  which  can  then  be  removed.  By  this  method  the  parts 
below  the  band  have  been  rendered  bloodless,  and  the  surgeon  may  explore  a  limb,  excise 
a  tumor,  joint,  or  bone,  and  even  amputate,  with  the  loss  at  the  time  of  a  spoonful  of 
blood.  The  method  has,  however,  one  objection  ;  which  is,  that  when  the  band  is  removed 
blood  oozes  from  the  soft  parts  to  a  far  greater  extent  than  it  does  under  other  circum- 
stances, the  smaller  vessels  apparently  becoming  paralyzed  by  the  compressing  bandage 
or  from  having  been  completely  emptied.  The  operation,  which  is  bloodless  during  the 
cutting  process,  is,  on  the  whole,  therefore,  followed  by  the  loss  of  as  much  blood  as  gen- 
erally follows  other  methods.  All  the  good  of  this  method,  without  the  evil,  may,  how- 
ever, be  obtained  in  an  amputation  by  raising  the  limb  for  a  few  minutes  before  the  appli- 
cation of  the  elastic  tourniquet  and  smoothing  heartward  with  the  hand  the  soft  parts,  to 
empty  the  veins.  I  feel  bound  to  add  that  this  method  of  emptying  a  limb  of  venous 
blood  before  amputation  was  practised  at  Guy's  by  the  late  Mr.  Aston  Key  in  1849,  when 
I  was  his  dresser,  in  a  case  of  compound  fracture  which  re((uired  amputation,  and  in 
which  it  was  necessary  that  the  loss  of  blood  should  be  reduced  to  a  minimum.  The  ca.se 
did  well.  The  late  Mr.  Hilton  subsequently  often  adopted  the  practice.  For  exploratory 
operations  and  the  removal  of  small  foreign  bodies,  excision  of  joints,  and  removal  of 
necrosed  bone,  the  compressing  bandage  has.  however,  great  advantages. 

Tlie  tourniquet  is  doubtless  an  excellent  instrument  for  the  compression  of  an  artery, 
and  J.  L.  Petit's  is  probably  the  best  for  the  extremities.  It  should  be  applied  to  the 
limb  directly  over  the  vessel  to  be  compressed,  the  pad  being  adjusted  in  the  axis  of  the 
vessel.     The  ends  of  the  band  are  then  made  to  pass  round  the  limb  and  are  secured 


ox  iLKM()iii'Ji.\<:i-:  .i.\7>  /7'.v  Tiii:.\rMi:sr. 


345 


either  h\  a  Imcklf  or  :i  knot,  the  innncr  liciii;^  preferaJde.  TIk'  fwn  plates  can  then  he 
Heparated  hv  the  rotafidii  nt'  the  ^cnw  and  a  sufiieient  amount  of  jiressurc  cmpluyed  to 
stop  the  current  of  hhxid.  and  iki  more  {vidr  Kifr.  137).     Jiister  ha.s  invented  an  adniirahlo 

Vic.  VM. 


tourniquet  for  compressinir  the  ahdominal  aorta,  and  many  others  liave  heen  constructed; 
hut  these  are  ample  for  all  ordinary  purposes  of  arresting  or  preventing  hemorrhage. 

When  a  tourniquet  is  not  at  hand,  as  in  the  field,  a  stone  or  any  hard  substance  may 
be  rolled  up  in  a  handkerchief,  applied  over  a  ve.ssel,  and  bound  round  the  limb;  the  ends 
of  the  handkerchief,  too,  should  be  attached  to  a  stick  or  sword,  any  amount  of  com- 
pression being  obtained  by  simply  twisting  them. 

As  temporary  means  of  arresting  hemorrhage,  therefore,  the  surgeon  may  employ 
digital  or  instrumental  pressure  either  upon  the  bleeding  spot — *',  e.,  direct ;  or  upon  the 
main  artery  of  the  part — i.e.,  indirect.  The  wound  in  both  ca.ses  should  be  well  exposed 
and  cleansed  and  all  coagula  removed  preparatory  to  the  application  of  such  permanent 
means  as  may  be  at  command.  Of  these,  the  lirfoture,  torsion,  and  acnpreasKre  are  the 
chief.  Styptics  and  the  cautery  are  only  employed  when  the  three  means  mentioned  are 
either  inapplicable  or  have  proved  unsuccessful. 

On  the  Use  of  the  Ligature. 

Since  Ambrose  Pare  reintroduced  the  use  of  the  ligature  (1550)  it  has  been  the  favor- 
ite means  for  the  arrest  of  hemorrhage,  the  speedy  way  in  which  bleeding  from  an  artery, 
however  large,  is  checked  by  its  application,  and  the  feeling  of  relief  experienced  on  know- 
ing that  for  a  time  at  least  all  fear  of  bleeding  has  been  removed,  having  so  influenced 
the  majority  of  practitioners  in  its  favor  as  to  induce  them  to  put  aside  untried  all  other 
suggested  means  as  being  unnecessary.  It  took,  however,  nuire  than  two  centuries  for 
the  ligature  to  become  established  in  practice  ;  in  fact,  its  adoption  was  not  general  till 
Dr.  J.  F.  I).  Jones  had  demonstrated  by  his  experiments,  already  alluded  to  (p.  342),  the 
physiological  processes  by  which  hemorrhage  is  naturally  arrested  in  a  bleeding  vessel, 
and  that  by  the  ligature  these  were  utilized. 

To  tie  an  artery  efficiently,  the  vessel  should  be  taken  up  cleanly,  drawn  out.  and  tied 
with  a  smooth  cord  of  prepared  silk  or  catgut  with  sufficient  force  to  rupture  the  inner 
coats  of  the  vessel  (such  a  result,  although  desirable,  does  not  appear,  however,  to  be  con- 
stant) and  occlude  the  outer  coat ;  the  ligature  should  be  made  secure  by  what  is  called 
the  sailors  reef-knot ;  the  surgeons  doultle-knot  should  not  be  used.  Tn  forming  the 
loop  the  ligature  should  be  pressed  down  to  the  artery  by  the  finger  or  thumb,  as  indi- 
cated in  the  drawing  (Fig.  137);  otherwise,  the  extremity  of  the  artery  will,  if  diseased, 
be  liable  to  be  broken  ofi". 


346  ACUPRESSURE. 

When  the  vessel  is  deeply  phiced  and  cannot  be  isolated,  it  must  be  ligatured  with 
some  of  the  adjacent  tissues.  When  it  is  so  embedded  that  its  free  end  cannot  be  taken 
up  with  forceps,  a  tenaculum  may  be  passed  beneath  the  bleeding  vessel,  and  all  the 
tissues  taken  up  by  the  instrument  should  be  strangled  by  the  ligature.  The  ends  of  the 
ligature  used  to  be  left  hanging  out  of  the  wound,  but  at  the  present  time  the  practice  of 
the  late  Mr.  de  Morgan,  which  is  a  revival  of  that  of  the  last  century,  of  cutting  off  both 
ends  of  the  ligature,  leaving  the  knot  //(  sifO.,  and  closing  the  wound,  has  become  general. 

When  the  vessels  are  diseased  and  brittle,  extra  care  is  needed  in  the  application  of 
the  ligature.  The  vessel  should  not  be  tied  too  tightly  lest  too  much  of  the  artery  be 
torn  and  the  ligature  be  made  to  .separate  before  natural  haemostatics  have  closed  it. 
Some  have  suggested  the  use  of  a  flat  ligature  under  these  circumstances,  but  it  seems 
scarcely  needed.  In  1865  I  was  called  upon  to  apply  a  ligature  to  the  femoral  artery  of 
a  man  over  seventy  years  of  age  for  femoral  aneurism.  The  vessel  was  so  brittle  that  I 
felt  the  coats  give  way  on  the  application  of  the  ligature ;  the  included  tissue,  too, 
seemed  so  thin  that  I  expected  to  find  the  ligature  come  away  in  my  hatid,  which  did 
not  occur.     The  case  ultimately  did  well,  and  no  bleeding  ensued. 

When  a  vessel  is  wounded,  the  artery  is  to  be  secured  at  the  seat  of  injury  by  a  liga- 
ture applied  above  and  below  the  wound.  Some  surgeons  then  advise  the  division  of  the 
vessel  between  the  ligatures.  Dr.  J.  A.  Lidel  of  New  York,  in  his  able  article  on 
"  Injuries  of  Blood  Vessels,"  in  the  International  Cycloj)sedia  of  Surgery  (vol.  iii.  p. 
81),  speaks  decidedly  upon  this  point,  giving  as  his  reason,  '-so  that  both  ends  of  the 
divided  vessel  may  be  able  to  retract." 

Acupressure. 

The  late  Sir  James  Simpson  brought  this  method  of  arresting  hemorrhage  before  the 
profession   in   1860,  and  on  his  authority  many  resorted  to  the  practice.     The  late  Mr. 

Pirrie  of  Aberdeen  gave  it  his 
Fig.  138.  warmest  support,  but  since  his 

death  the  practice  has  been 
given  up  except  in  rare  cases. 
The  principle  of  the  practice  is 
very  simple — viz.,  the  occlusion 
of  the  artery  by  the  temporary 
pressure  of  a  pin  without  lacer- 
ating the  vessel  or  setting  up 
inflammatory  and  suppurative 
action,  as  in  the  ligature.     The 

Difterent  Modes  of  Applying  Acupressure.  pin  is  removed  on  the  seCOnd  Or 

third  day.  according  to  the  size 
of  the  artery.  The  advantages  thus  claimed  for  it  are  very  great,  but  experience  has  not 
decided  in  its  favor.     There  are  three  leading  forms  of  acupressure. 

In  i\ie  first  the  artery  is  directly  compressed  between  the  pin,  which  crosses  its  free 
end,  and  the  muscle  beneath  (Fig.  138,  1). 

In  the  Hecond  the  same  result  takes  place,  the  pin  being  made  to  give  a  half  twist 
through  the  tissues  between  its  first  and  second  insertions  (Fig.  138,  2). 

In  the  third  the  pin  is  simply  passed  beneath  the  vessel  and  pressure  applied  to  the 
artery  by  means  of  a  loop  of  wire  or  silk  looped  over  its  point  and  made  to  cross  the 
vessel,  the  ends  of  the  loop  being  secured  upon  the  shaft  of  the  pin  (Fig.  138,  3). 

The  good  point  in  acupressure  is  the  absence  of  any  foreign  body  for  more  than  a  few 
hours  or  days.  Its  disadvantage  lies  in  the  fact  that  its  success  depewds  upon  the  coagu- 
lation of  the  blood  in  the  vessel  down  to  the  first  branch— one  of  nature's  temporary 
hfemostatic  processes — and  not  upon  the  permanent  closure  of  the  coats  of  the  vessel. 
As  a  consequence,  it  is  not  so  secure  as  the  ligature,  or  physiologically  so  sound  as  the 
practice  of  torsion.  As  a  mode  of  temporarily  arresting  hemorrhage  in  certain  cases 
where  the  ligature  and  torsion  are  inapplicable,  as  in  wounds  of  the  palm  or  the  sole  of 
the  foot,  it  is  indeed  valuable,  and  particularly,  also,  as  a  means  of  arresting  the  flow  of 
blood  from  a  leech  bite  or  other  bleeding  point,  the  passage  of  a  needle  through  the  skin 
and  a  figure-of-8  ligature  over  being  of  great  service. 

An  ingenious  modification  of  this  process  has  been  devised  and  successfully  used  by 
Mr.  Dix  of  Hull.  A  wire  passed  through  the  flaps  by  means  of  two  needles  and  twisted 
over  a  cork  outside  compresses  the  bleeding  vessel  in  the  same  way  as  the  needles.     It  is 


o.v  mnsio.y. 


347 


called  l»v  its  author  '  tlu'  wire  coiiiiirt'ss."  and  is  liilly  dt-scribcd  in  ili,'  h'i/iiiliiir(//t  Afrt/inil 
Jniiniii/,  Si'pti'inhcr,  ISllJ.  It  scfiiis,  ImweviT,  to  he  more  ada|itc<|  for  scruriiijr  an  artery 
in  its  continuitv,  us  in  the  treatment  of  aneurism,  under  wlii(  h   head  it  will   he  described 


•tail. 


On  Torsion. 


Fi«.  i.w. 


livnh: 


In  a  |>hvsi(doirical  ]K)int  of  view,  there  is  no  method  mori'  pi-rfeet  at  eommaixl  for  the 
eoutrol  of  liemorrha.L'e  than  that  of  torsion,  heeause,  uidike  acupressure,  wliieh  u.ses  one 
only  ol"  nature's  ha'niostatie  processes,  or  the  li<;ature,  which  is  a  forei<rii  body  in  a  wound 
and  becomes  ii  source  of  dan;;er  by  undoing  at  a  later  what  has  been   done  at  an  earlier 

period  of  the  ease,  it  utilizes  to  the  utmost  all  the  physio- 
logical processes  emj)loyed  by  nature  to  prevent  and  arrest 
bleeding  and  places  the  vessel  in  the  most  favorable  position 
for  them  to  take  effect  (vide  page  ?>M)). 

For  the  application  of  torsion  a  good   pair  of  forceps  is 

re([uired  {ri<li'  Fig.  i:J7)  that  will  hold  the  end  of  the  artery 

Vrlr/fri/       ti"""'!}'^  th'it  'I'l^  "'^  lateral  motion,  and  with  serrations  blunt 

enough   to  obviate  any   laceration   or  cutting  of  the   parts 

seized  by   the   blades.      The   vessel    should    then    be    drawn 

out.  as  in  the  application  of  the  ligature,  and  three  or  four 

,     ■    m  -         sharp  rotations  of  the  forceps  made.      In  large  arteries,  such 

j;t.crfca..ir/o/'mnrrG,ats  j^^  the  femoral,  the  rotation  should  be  repeated  till  the  >^emp 

effects  of  Torsion  on  Fen.oral        ^^j.  ,.,,,.j-,^^„^,,  J^,^^  p^,,,,,,/       The  ends  should  not  be  twisted  off. 

In  small  arteries  the  number  of  rotations  is  of  no  importance, 
and  their  ends  may  be  twisted  off  or  not  as  may  be  preferred.  In  Fig.  139  the  appear- 
ance of  a  femoral  artery  sufficiently  twisted  is  well  shown. 

When  the  vessels  are  diseased,  fewer  rotations  of  the  forceps  are  required,  the  inner 
tunics  of  the  vessels  being  .so  brittle  as  to  break  up  at  once  and  incurve.  If  the  surgeon, 
therefore,  twi.st  more,  he  will  break  away  the  external  or  cellular  coat,  which  is  of  essen- 
tial importance  not  only  in  maintaining  the  lacerated  inner  coats  in  position,  but  in  allow- 
ing blood  to  coagulate  and  lymph  to  organize  between  them.  AVith  this  caution,  diseased 
arteries  appear  to  be  as  amenable  to  the  treatment  as  the  healthy  ;  and  torsion  requires 
no  more  care  under  these  or  any  circumstances  than  the  application  of  a  ligature. 

The  physiological  arguments  in  tavor  of  torsion  are  numerous,  while  the  practical 
advantages  seem  to  be  not  less.     After  fifteen   years'  experience  of  the  practice  among 

Fig.  140, 


1.  An  artery  taken  up  I)_v  the  constrictor.    2.  Artery  constricted.    3.  Effects  of  cnstriction  upon  vessel.    4.  As  seen 

wlien  laid  open. 

vessels  of  all  sizes  (the  femoral  being  the  largest^  I  have  had  no  mi.shap.  I  have  further 
observed  that  wounds  have  united  more  rapidly  and  kindly,  primary  union  being  the  rule; 
there  has  been  less  constitutional  disturbance  after  operation,  and  consequently  less  lia- 
bility to  traumatic  fever,  pyj^mia,  and  other  complications  such  as  we  are  all  too  familiar 


348  ON  HAEMORRHAGE  AND  ITS   TREATMENT. 

with  in  the  practice  of  surgery.  Stumps  have  healed  in  a  week  and  patients  been  up  in 
two  without  one  single  drawVjack,  rapid  and  uninterrupted  convalescence  following  the 
operation.  In  other  ca.ses  equally  good  success  can  be  recorded.  At  Guy  s  Hospital  we 
have  had  two  hundred  consecutive  cases  of  amputation  of  the  thigh,  leg,  arm.  and  fore- 
arm, in  all  which  the  arteries  had  been  twisted  (one  hundred  and  ten  of  them  having  been 
of  the  femoral  artery),  and  no  case  of  secondary  hemorrhage. 

The  Artery  Constrictor. 

Dr.  Fleet  Speir  of  Brooklyn,  New  York,  has  had  an  artery  constrictor  made  (Fig.  140) 
which,  as  he  has  demonstrated  upon  both  the  living  and  the  dead,  has  the  power  of  divid- 
ing the  inner  coats  of  an  artery  and  allowing  them  to  recurve  as  in  tor.sion.  He  has  used 
it  on  all  the  larger  vessels  except  the  iliac  and  subclavian,  and  has  never  had  any  trouble, 
union  chiefly  by  first  intention  having  followed  (^Med.  Mirror,  ^e'w  York,  April.  1871,  and 
Archives  of  Clinical  Snrgcri/^  SeptemVjer,  1876). 

The  instrument  he  recommends  (Fig.  140)  should  be  "  tight-fitting  enough  to  con- 
strict thoroughly,  and  yet  grooved  and  smooth  enough  not  to  lacerate  the  external  coats, 
while  it  makes  a  complete  invagination  of  the  inner  coats.  For  operating  upon  vessels  in 
continuity,  as  for  aneurism,  I  prefer  to  place  the  limb,  after  constriction,  in  a  relaxed 
position,  so  as  not  to  stretch  the  vessel  after  being  constricted." 

In  Fig.  140  the  instrument  is  shown  applied  to  an  artery,  and  in  Fig.  140  ("4)  a  sec- 
tion of  the  artery  subsequent  to  its  constriction.  I  have  tested  this  instrument  on  the 
living  and  have  made  a  large  number  of  experiments  on  the  dead,  and  find  it  does  all  that 
Dr.  8peir  asserts.  I  believe  it  to  be  of  value  for  obstructing  arteries  in  continuity,  as  it 
does  for  such  precisely  what  torsion  does  for  divided  vessels.  In  May.  1882.  I  employed 
the  instrument  with  encouraging  success  in  the  case  of  a  man  set.  48  with  popliteal  aneu- 
rism.'     The  wound  healed  by  '"quick  union,"'  and  the  aneurism  was  cured. 

Other  Methods. 

Astringents  or  styptics  are  valuable  agents  in  the  arrest  of  bleeding  when  the 
means  pi-eviously  mentioned  are  inapplicable,  their  value  being  much  increased  when 
combined  with  pressure.  The  perchloride  or  persulphate  of  iron,  pounded  matico,  alum 
in  powder  or  solution,  applied  to  a  bleeding  surface  on  a  pad  of  lint  or  dossil  of  cotton- 
wool and  bound  on,  are  the  best  applications,  though  tannic  acid.  Ruspini's  styptic,  or  oil 
of  turpentine  is  also  serviceable.  Before  applying  any  of  these  the  bleeding  part  should 
be  wiped  as  dry  as  possible  and  all  coagula  removed.  In  uterine  surgery  injections  of 
some  of  these  astringents  are  much  used.  In  rectal  surgery  the  bowel  may  be  plugged 
with  lint  or  sponge  saturated  with  a  styptic,  and  in  epistaxis  the  nose  ma}'  be  plugged  in 
a  like  way. 

"  Cold  "  is  a  powerful  .styptic,  cold  air  often  permanently  arresting  even  copious  hem- 
orrhage on  laying  open  a  wound.  A  .stream  of  cold  water  directed  to  a  bleeding  part,  or 
ice  pounded  and  placed  in  bladders  or  bags  and  laid  on  bleeding  wounds,  is  at  times  of 
great  assistance.  '•  Heat,"  also,  is  equally  good,  and  when  applied  in  the  form  of  a  hot 
sponge  wrung  out  of  an  iodine  or  antiseptic  lotion  is  enough  to  stop  all  capillary  oozing. 
I  have  adopted  this  practice  after  operations  for  some  years  with  excellent  success. 

Cauterization,  which  was  the  common  mode  of  arresting  bleeding  by  the  ancients, 
is  now  seldom  employed  ;  yet  it  is  a  valuable  agent  in  ca.ses  where  neither  torsion,  liga- 
ture, nor  acupressure  is  available.  In  spongy  tissues  from  which  blood  is  oozing,  and 
also  in  other  cases,  the  hot  iron  will  often  act  most  beneficially.  It  may  be  applied 
through  iron  buttons  or  cones  brought  to  a  black  heat  by  means  of  fire,  or  through  plati- 
num or  porcelain  instruments  heated  by  means  of  benzoline  vapor  or  the  galvanic  battery. 
In  any  case  the  heat  should  be  enough  to  cause  a  dry  eschar  upon  the  bleeding  part, 
while  care  should  be  exercised  subsequently  not  to  remove  this  too  soon  ;  indeed,  the 
eschar  scab  should  be  left  for  natural  proces.ses  to  throw  oif.  In  no  case  should  the  cau- 
tery be  too  hot^ — that  is.  red  hot — as  it  destroys  the  vessels  too  much.  It  should  be 
merely  of  a  htack  lieat. 

Capillary  Hemorrhage. — Hemorrhage  from  the  capillaries  or  small  vessels 
rarely  takes  place  to  any  dangerous  extent  unless  it  occurs  in  "  bleeders  "  or  such  as 
labor  under  the  hemorrhagic  diathesis.  It  has  always  a  tendency  to  stop  by  it.self 
through  such  natural  haemostatic  processes  as  have  been  described,      [f,  however,  it  be 

^Brii.  Med.  Journal,  vol.  li.,  1882. 


O.V  ll.i:MnniillM;i:  am,  its  trkatmest.  310 

too  porsistt'iit,  tilt!  siirl'iK'f  ol'  tlic  woimd  >li()ulil  lie  »'xp(»s('(l  :iiiii  cleansed,  tlit;  stimulus  of 
the  air  being  ol'teu  siitlieieiit  to  excite  cliisure  of  the  ve.H.sels.  Moderate  pressure  upon 
the  surf'aee  of  the  wcnind  or  u  stream  of  cold  water  over  it  is  also  a  valuable  auxiliary. 

Summary  of  Treatment  of  Hemorrhage. 

All  divided  or  wuiiiidcd  artcrio  fmni  \vlii(di  MihmI  thiws  arc.  11"  piosibjc.  to  l)c  t\vi>lcd 
or  tied  at  the  seat  of  injin y  ;  and  to  aeeomplish  this,  when  room  is  nM|uired,  the  wound 
may  be  eidar<;ed.  When  an  artery  is  lUvlilnl.  hull,  nuh  are  to  be  dealt  with  separat»dy. 
When  an  artery  is  wutiiiilnl.  John  Hunter's  advice  is  still  sitund  :  "  Tirst  apply  the  tour- 
nicjuet.  then  lay  the  artery  siitlieicntly  bare,  and  tie  the  ves.sel  above  and  below  the 
wounded  ]iart  '  (.MS.  Lect..  1T><7).  In  some  eases  the  vessel  had  better  be  (■<)mpletelv 
divitled  ;  with  the  brachial  I  have  tollowe<l  this  praetiee  on  three  (tccasirjns,  and  twisted 
its  two  emls.  with  i^ood  nvsult.  and  advise  its  adoption  as  a  rule  of  practice  in  arteries  of 
less  calibre.      In  lar<;er  arteries  it  is  also  j)robably  good. 

When  there  is  no  bleeding  pre.sent.  an  operation  is  not  required,  although,  in  excep- 
tional ea.-<es,  when  a  renewal  of  the  liemorrhage  may  endanger  life,  this  rule  may  be  devi- 
ated from. 

When  moderate  arterial  hemorrhage  exists  and  the  artery  cannot  be  taken  up  in 
the  wound  without  an  operation,  the  graduated  comj)rcss  may  be  employed  with  a  fair 
chance  of  success  ;  but  should  it  fail,  the  vessel  must  be  secured. 

When  arterial  hemorrhage  endangers  life  and  the  artery  cannot  be  treated  at  the 
wound,  the  trunk  of  the  vessel  is  to  be  secured  above  the  wound. 

When  recurring  hemorrhage  is  severe,  the  wound  is  to  be  reopened  or  erdarged,  all 
clots  turned  out,  and  the  vessel  tied  or  twisted.  When  moderate,  it  can  be  treated  hy 
elevating  the  part,  by  pressure  over  either  the  main  trunk  of  the  ves.sel  or  the  wound, 
and  l)y  tlu'  aiiplication  of  cold,  such  as  the  ice-bag. 

At  times  all  bleeding  ceases  on  the  mere  exposure  of  the  open  wound  ;  at  others  there 
is  merely  a  general  oozing.  Uuder  these  circumstances,  if  exposure  of  the  wound  to  the 
air  or  to  a  stream  of  cold  water  fails  to  check  it,  well-applied  pressure  will  often  suffice. 
In  exceptional  ca.ses  styptics  may  be  required. 

Secondary  hemorrhages  are  to  be  dealt  with  in  the  wound  as  primary — that 
is.  when  bleeding  is  profuse,  the  artery  is  to  be  religatured'or  twisted  at  the  bleeding 
point  ;  when  not  severe,  it  will  probably  be  restrained  by  pressure  and  the  elevation  of 
the  part,  .since  in  a  general  way,  when  secondary  hemorrhage  takes  ])lace  after  the  appli- 
cation of  a  ligature  to  a  wounded  artery,  the  bleeding  comes  from  the  lower  end  of  the 
vessel.  Guthrie  has  clearly  shown  that  in  the  lower  end  of  a  divided  vessel  repair  is  less 
perfect  than  in  the  upper,  that  there  is  less  contraction  and  retraction  of  the  ves.><el,  less 
perfect  coagulation  of  blood,  and  less  effusion  of  plastic  lymph. 

Venous  Hemorrhage,  unless  from  the  trunks  of  large  veins,  quickly  ceases, 
usually  from  the  collapse  of  the  veins.  Where  any  impediment  exist.s.to  the  return  of 
the  blood  from  the  wounded  part,  it  may,  however,  prove  troublesome,  yet  its  arrest  will 
probably  be  secured  on  the  removal  of  the  obstruction.  The  elevation  of  the  wounded 
part  will  tend  much  toward  this  end,  as  will  also  the  application  of  cold  or  firm  pressure 
upon  the  spot. 

When  large  veins  are  divided  and  the  bleeding  is  copious,  they  must  be  tied  or  twisted. 
When  veins  are  wounded,  they  .should  be  divided  and  tied  ;  to  close  a  small  opening  into 
a  large  trunk  with  a  fine  ligature  is  not  safe  practice.  Wounds  of  veins  heal  rapidly,  as 
is  .seen  after  venesection. 

Injuries  of  the  large  venous  trunks,  however,  are  of  grave  importance,  and  any  wound 
or  injury  that  induces,  directly  or  indirectly,  the  complete  arrest  of  the  venous  circulation 
through  one  of  these  is  probably  of  greater  consequence  than  the  wound  of  an  artery. 
The  internal  jugular  vein  has,  however,  often   been   tied   with   success. 

A  vein  is  known  to  be  opened  when  black  blood  flows  from  the  wound  in  a  steady 
stream  and  from  its  distal  part,  when  pressure  above  the  wound  increases  the  flow  and 
pressure  below  retards  or  stops  it. 

Phlebitis  is  the  chief  evil  to  be  feared  from  an  injury  to  a  vein  ;  and  when  it 
occurs,  it  is  very  fatal.  Veins,  however,  will  doubtless  bear  much  more  manipulation 
without  any  such  danger  ensuing  than  our  forefathers  believed. 

The  entrance  of  air  into  a  wounded  vein  is  a  source  of  great  danger; 

but   the   subject   will  receive   attention   in   a   succeeiling  chapter. 

Ulceration  of  arteries  in  contact  with  pus  occasionally  occurs  in  feeble  subjects; 


350  TRANSFUSION. 

and  when  the  artery  is  large,  death  may  follow.  I  have  lost  a  case  of  iliac  abscess  from 
this  cause,  the  deep  circumflex  iliac  artery  having  been  opened ;  many  similar  examples 
are  on  record.  When  the  hemorrhage  is  recognized  and  the  source  of  bleeding  known, 
an  exploratory  incision  is  called  for ;  the  opened  artery  should  be  treated  as  a  wounded 
one. 

The  General  Treatment  of  Hemorrhage, 

though  of  importance,  is  subsidiary  to  the  locaf.  When  syncope  has  taken  place  from  loss 
of  blood,  the  surgeon  should  not  be  too  hasty  to  overcome  it,  since  it  is,  without  doubt, 
one  of  the  most  valuable  means  nature  employs  to  check  bleeding  and  to  assist  natural 
haemostatics ;  but,  at  the  same  time,  great  care  is  needed  that  the  syncope  be  not  fatal. 
If  such  an  event  appears  imminent,  the  patient  should  be  kept  in  the  horizontal  posture 
with  the  head  low ;  cool  air  should  be  allowed  to  blow  upon  the  face  or  cold  water  sprin- 
kled over  it;  some  diifusible  stimulant,  such  as  ammonia,  ether,  chloroform,  or  the  nitrate 
of  amyl,  may  be  inhaled,  or  brandy  given  in  small  quantities.  In  extreme  cases  some 
surgeons  advise  pressure  being  made  upon  the  abdominal  aorta  or  large  arteries,  to  con- 
fine the  blood  to  the  nerve-centres,  or  even  transfusion  may  be  employed.  This  operation, 
however,  has  never  been  in  high  favor  with  surgeons,  though  from  accoucheurs  it  has 
received  considerable  support,  the  late  Dr.  James  Blundell  having  given  it  his  energetic 
advocacy.  When  attempted,  it  should  not  be  delayed  until  too  late — ('.  f.,  till  the  hope 
of  rousing  the  nervous  and  circulating  system  has  become  almost  forlorn.  Under  all  cir- 
cumstances plenty  of  bland  liquid  nourishment  should  be  given,  such  as  milk,  eggs, 
broths,  etc.,  and  stimulants  in  moderation.  When  there  is  a  prospect  of  a  recurring 
hemorrhage,  all  food  should  be  given  cold.  In  the  convalescing  stage  iron  and  quinine, 
ammonia,  and  bark  are  of  the  greatest  value.  Opium  is  a  drug  that  must  not  be  forgot- 
ten, as  in  the  restless  stage  of  bloodlessness  its  action  is  most  beneficial.  It  must,  how- 
ever, be  administered  with  caution  ;  for  with  a  feeble  heart  large  doses  are  apt  to  depress. 
Half-grain  doses  repeated  at  intervals  are  probably  the  safest ;  larger,  however,  may  at 
times  be  given.  When  capillary  bleeding  takes  place  to  any  extent  after  an  operation,  a 
full  dose  of  opium,  say  a  grain,  is  often  very  valuable. 

When  the  hemorrhagic  diathesis  exists,  iron  in  full  doses  is  of  great  service,  the  tinc- 
ture of  the  acetate  or  perchloride  in  half-drachm  doses  being  the  best.  Oil  of  turpentine 
is  likewise  a  valuable  remedy,  twenty-minim  doses  being  sufficient  for  an  adult.  Gallic 
acid  in  ten-grain  doses  and  acetate  of  lead  in  one-gi'ain  doses  are  also  beneficial.  All 
these  act  upon  the  blood  and  dispose  it  to  coagulate. 

Transfusion. 

When  Dr.  Lower  of  Oxford,  with  .Sir  E.  King,  in  16G5.  first  practised  transfusion, 
blood  was  drawn  from  an  artery  and  conducted  directly  by  means  of  a  tube  into  the  vein 
of  the  patient,  the  blood  being  propelled  simply  by  the  force  of  the  circulation  of  the 
emitter.  As  time  progressed  the  inexpediency  of  opening  an  artery  was  felt,  and  the 
plan  of  transmitting  blood  from  vein  to  vein  came  into  use.  In  1785  this  plan  was  also 
warmly  advocated  by  Dr.  Harwood  of  Cambridge.  With  this  change  of  practice  the 
mode  of  operating  had  to  be  altered,  because  the  force  of  the  venous  circulation  was 
found  to  be  insufficient  to  propel  the  blood.  The  indirect  or  mediate  mode  of  operating 
consequently  came  into  use,  the  blood  of  the  emitter  being  received  into  a  vessel  and 
transmitted  by  a  tube  or  syringe  into  the  vein  of  the  patient.  To  James  Blundell  is  due, 
undoubtedly,  the  credit  of  having  devised  an  apparatus  by  which  the  operation  can  be 
efficiently  performed.  He  called  it  first  an  "  impeller,"  and  when  improved  a  "  gravita- 
ter."'  Since  his  time  Drs.  Aveling,  Hewitt.-  Braxton  Hicks,^  and  particularly  Roussel, 
have  done  much  toward  rendering  the  practice  more  safe  and  certain.  The  object  of  the 
surgeon  in  the  operation  is  to  transfuse  blood  from  a  healthy  into  a  bloodless  patient,  and 
his  aim  should  be  to  prevent  the  coagulation  of  the  healthy  blood  during  the  operation,  as 
well  as  to  guard  against  the  introduction  of  air  into  the  veins.  This  operation  should  only 
be  undertaken  when  a  trustworthy  apparatus  is  at  hand,  and  of  these  Dr.  Roussel's  is.  with- 
out doubt,  the  most  complete.     Aveling's,  however,  is  excellent. 

Dr.  Roussel's  instrument  is  made  of  hardened  pure  caoutchouc  ;  it  is  composed  of  a 

tube  with  a  Higginson's  syringe  large  enough  to  contain  two  and  a  half  drachms  of  fluid 

(Fig.  141,  14)  in  its  course.     One  end  of  the  tube  is  attached  to  a  rigid  cjdinder  (10) 

open  at  each  end  and  applied  over  the  seat  of  the  vein  required  to  be  punctured  (3), 

1  Lancet,  1829.  ^  obMet.  Tram.,  1865.  ^  Guy's  Rep.,  1868. 


DISEASES  OF    III  I-:   AinKIiHiS. 


351 


which  has  het'ii  dhhtructed  by  the  huiul  (1).  Tlic  t-ylinder  is  fixcil  in  ponition  by  beinp 
surroniuled  by  a  ri;;i(l  fu|>,  which  can  be  exhauster!  by  an  elastic  puinp  CJ)  in  connection 
with  it.  The  exliaustion  oJ"  this  cup  nut  (»rily  fixes  the  ajiparatiis  to  the  arm.  l»ut  also 
increases  tlie  tur^'idity  of  the  vein  over  which  it  is  appliol.  The  cyliruh-r  witliin  it  (11  ) 
is  then  closed  by  the  introduction  at  its  upper  extremity  of  a  lancet  (12;.  the  exact  depth 
of  which  can  be  re;.Milated  (l.'>).  Before  opcratin*:  the  air  should  be  driven  out  of  the 
cylinder  and  tube  by  filling:  them  with  tepid  water  (»>),  in  which  a  little  bicarbonate  of 
soda  may  be  dissolved,  by  means  of  the  syrin;.'e  (!(;  an<l  the  tube  (H  and  7j.  which  i.s 
attached  to  the  cylinder  opposite  to  the  conducting  tube  ( ITj.  When  about  to  operate, 
the  lancet  (lli)  is  depressed  into  the  vein. 

To  the  extremity  <d"  the  cotiductiuL'  tube  a  stopcock  (17)  with  two  canuhe  (lt»  and 
18)  is  attached,  the  stopcock  being  inserted  to  direct  the  flow  of  flui<l  into  one  or  other 
of  the  caiiuht*.  One  «d"  thc.-e  canuhe  is  introduced  into  the  vein  of  the  recipient  (:}). 
The  apparatus  (10)  being  filled  with  water,  the  vein  is  opened  by  the  lancet  and  the  con- 
tents of  the  cylinder  and  tube  are  pumped  out  through  the  free  canula  (18;  until  blood 
only  flows  through  it.  The  stopcock  (17)  is  then  turned,  and  the  blood  is  injected  into 
the  patients  arm  through  an  opening  in  the  vein  (4).  The  syringe  by  this  apparatus 
forces  "the  blood  into  the  vein  of  the  recipient  by  degrees  as  it  draws  it  from  the  vein 

Fk;.  141. 


Dr   Ron 


Injecting  Apparatus. 


of  the  donor,  every  particle  of  it  having  remained  less  than  a  second  out  of  the  human 
vessel,  enclosed  in  a  full  tube,  and  the  blood  conducted  by  an  artificial  vein  and  heart 
hermetically  closed,  damp,  warm,  and  soft  as  are  the  human  vessels.  The  blood  is  not 
modified  as  regards  its  fibrine.  globules,  gas.  temperature,  or  density  :  it  passes  from  one 
system  to  another  with  all  its  primitive  vitality,  and  continues  to  live  on." 

Not  more  than   six  to  nine  ounces  of  blood  should  be  transfused  at  one  time  ;   the 
injection,  too,  should  be  gradual — that  is.  about  six  .syringefuls  a  minute. 


DISEASES  OF  THE  ARTERIES. 

Arteritis. — Under  this  heading.  Vx'sides  the  rarer  forms  of  disease,  we  shall  include 
atheroma,  as  there  is  no  longer  any  question  of  its  inflammatory  nature.  Of  this  Vir- 
chow.  Billroth.  Wilks.  and  Moxon  have  given  sufficient  evidence,  though  in  modern  text- 
books the  old  view  is  still  taught  and  the  weight  of  Gulliver's  investigations  ( Mefl.-Chir. 
Truns.  vol.  xxvi.)  has  not  yet  lost  its  influence.  We  by  no  means  think  that  Gulliver 
was  altogether  in  error  in  holding  that  atheroma  was  a  fatty  and  calcareous  degeneration 
of  the  inner  and  middle  arterial  coats,  with  subsequent  thickening  of  the  adventitia :  on 
the  contrary,  it  is  not  improbable  that  atheroma  may  sometimes  be  a  simple  retrograde 
metamorphosis  of  the  arterial  tissues  :  but  there  can  be  no  doubt  that  it  more  often 
begins  as  a  subinflammatorv  process.  This  conclusion  has  been  reached  partly  upon 
histological  grounds  and  from  the  fact  that  the  disease  is  most  prone  to  occur  where  the 
wear  and  tear  is  greatest,  and  inflammation,  consequently,  most  likely.  Syphilis  has 
doubtless  much  to  do  with  arterial  disease,  and,  as  a  consequence,  with  aneurism  :  and 
the  frequent  association  of  syphilis  and  aneurism  in  the  army  has  been  adduced  as  strong 


352  DISEASES   (jF  the  A I  ITER  I ES. 

evidence  in  favor  of  the  conclusion.  Mr.  Myer.s  ha.s.  however,  shown  (Path.  Tram.,  vol. 
XX.  p.  13-t)  by  comparing  the  array  with  the  navy,  where  .syphilis  and  overexertion  are 
about  the  same,  that  in  the  former  aneurism  is  fifteen  times  as  common  as  it  i.s  in  the  lat- 
ter; and  he  believes  that  the  constriction  of  the  collar  and  coat  of  the  soldier,  bv  obstruct- 
ing the  blood  stream,  favors  arterial  disease  more  than  syphilis. 

Arteritis  is  usually  described  as  -  acute  "  and  '•  chronic."  and  it  will  be  well  for  us  to 
adopt  the  terms  in  general  u.sage.  But  the  student  must  remember  that  the  pathologist 
applies  the  one  to  a  process  the  product  of  which  i.s  cellular  or  nuclear,  the  other  to 
that  which  shows  organized  or  tissue  product  or  some  degenerative  change  such  as  the 
calcareous,  which  must  necessarily  have  taken  some  time  in  its  production.  From  a  clini- 
cal point  of  view,  both  terms  are  more  arbitrary  than  exact ;  and  there  is  other  evidence 
than  pathological  to  .show  that  changes  judged  by  such  a  standard  to  be  chronic  are 
rapid  in  their  course,  and,  in  the  .same  way.  others  which  must  be  called  acute,  in  that 
micro.scopically  they  are  cellular,  are  not  necessarily  of  short  duration.  If  we.  then,  con- 
tinue to  describe  arteritis  as  acute  and  chronic,  it  is  evident  that  no  strictly  histological 
basis  is  broad  enough  for  accuracy ;  and  we  have  therefore  adopted  that  classification  of 
acute  arteritis  which  accords  best  with  our  own  experience. 

Acute  arteritis  is  found  under  four  conditions : 

l.-t.  As  -li-litly  raised  grayi.sh  or  piellucid  patches  on  the  lining  membrane  of  the 
artery,  which  when  examined  microscopically  .show  a  multiplication  of  the  cells  of  the 
superficial  layers  of  the  inner  coat.  It  is  a  disea.se  which  is  not.  perhaps,  of  much  impor- 
tance when  attacking  the  aorta  or  larger  vessels  :  but  when  it  affects  the  visceral  arteries, - 
it  may  lead  to  a  considerable  diminution  of  their  calibre,  to  thrombosis,  and  thus  to  all 
those  changes  which  ensue  when  the  circulation  becomes  arrested.  It  is  a  change  of  this 
kind  which  Heubner  lately  described  in  the  vessels  of  the  brain  as  particularly  liable  to 
occur  in  the  subjects  of  syphilis,  and  it  is  probable  that  a  similar  result  may  be  induced 
in  the  larger  arteries  from  the  .same  cause. 

2d.  As  a  general  affection  of  the  arch  of  the  aorta  in  wliir-li  that  vessel  is  grayi.sh, 
softened,  thinned,  and  dilated,  but  without  any  strictly  atheromatous  or  calcareous  change 
in  it.  It  would  be  better,  perhaps,  to  call  this  state  "  acute  softening."  though  the  nature 
of  the  process  is  essentially  inflammatory. 

3d.  As  a  local  disease  in  the  arch  of  the  aorta  in  cases  of  acute  rheumatism.  This  is 
rare,  sometimes  originating  in  the  friction  produced  by  large  valvular  vegetations  which 
are  washed  backward  and  forward  in  the  blood  .stream,  and  sometimes  without  any  such 
cause,  and  apparently  as  a  spontaneous  arteritis.  In  either  ca.se  it  is  liable  to  lead  to 
aneurism  or  imperfection  of  the  aortic  valves. 

•ith.  As  a  local  disea.se  in  the  arteries  secondary  to  the  lodgment  of  emboli,  which  by 
their  presence  set  up  an  arteritis. 

Chronic  arteritis  niay  occur  as  a  wide.spread  and  continuous  disea.se  in  mo.st  of 
the  arteries  of  the  body  or  as  one  which  is  localized  to  various  parts,  .specially  the  larger 
vessels.  Of  the  former — a  very  rare  di.sease — examples  have  been  published  by  Wilks 
(Guys  Rej>..  1869)  and  Savory  ( MefJ.-Chir.  Troas..  1856).  In  Wilks  s  case  the  principal 
arteries  of  the  body  were  thickened  and  obstructed,  the  vessels  being  filled  with  old  clot 
that  was  "  so  closely  adherent  that  the  wall  of  the  vessel  would  split  rather  than  part 
from  the  clot.  At  both  the  ending  and  commencing  parts  the  clot  was  white  and  like 
fibrous  tissue  and  could  not  be  distinguished  from  the  coats,  which  here  were  swollen  and 
atheromatous.  The  atheroma,  indeed,  appeared  to  be  here  in  the  clot  also  as  well  as  in 
the  arterial  clot." 

There  seems  little  doubt  also  as  to  the  fact  that  a  vessel  may  become  completely 
obstructed  by  a  strictly  local  arteritis. 

It  may  be  noted  in  passing  that  the  descriptions  of  the  naked-eye  appearances  in 
these  cases  exactly  correspond  with  that  of  the  .so-called  syphilitic  disease  of  the  cerebral 
arteries  just  alluded  to  as  having  been  described  by  Heubner.  and  which  has  been  classed 
by  us  as  acute  arteritis,  inasmuch  as  it  is  a  disease  purely  cellular. 

Such  cases  as  the  last,  however,  are  rare  compared  with  those  of  local  chronic  aneritis 
such  as  is  met  with  in  the  arch  of  the  aorta  at  its  bifurcation  and  other  parts.  It  is 
indicated  by  thickening  of  the  vessel  and  lo.ss  of  its  elasticity,  by  the  external  coat 
changing  into  a  tough  fibrous  tissue,  and  the  affected  parts.  in.stead  of  feeling  thin  and 
pliaVile.  becoming  hard  and  leathery.  "  Xow.  such  changes  as  these  are  commonly  present 
along  with  the  atheromatous  pulp  in  the  deep  inner  coat,  and  these  are  the  part  of  the 
changes  that  go  by  the  term  -atheroma"  as  commonly  accepted.  Changes  of  a  kind  that 
cannot  be  regarded  as  other  than  inflammatory  are  present  in  nearly  all  bad  examples  of 


ijisj:asj-:s  or  riii:  a!:ti:i:ii:s. 


353 


atluToiiia  ;  the  oxtciit  of  the  iiiHaiiiiiiatdry  cliaiijris  L'liicrally  surpasses  that  of  the  atheru- 
iniituiis,  and  these  iiiHaiiMiiatory  ehaii-res  oeeur  often  witlioiit  any  atlieroina,  ami  e.>j»eciallv 
ill  vouiif.'er  suhjeets,  ahoiit  or  uiitler  middle  a;re.  The  more  inflammatory  chan^reK  tend 
more  to  prodiiee  aneurisms  than  <lo  the  atheromatous  jiatehes.  When  atheroma  is  thor- 
ouL'hlv  i>talili>hed,  so  that  a  pulpy  mass  is  formed  in  the  coats  at  any  spot,  this  is  j.'en- 
erally  thiek  and  hard  and  unyielding,  and  does  not  ^ive  way  to  pressure  so  as  to  form  an 
aneurism.  The  disease  that  leads  to  aneurism  is  the  same  disease  as  leads  to  atheroma, 
and  I  think  it  is  a  eorreet  way  of  describin*:  these  relations  to  say  that  they  are  alterna- 
tive results  of  tlie  disease  of  the  coats.  I  mean  so  that  if  the  suhinflammation  is  geverer, 
then  the  eoats  are  softened  and  yield  early,  before  tlie  thiekeniiifr  and  stiffening  ehronic 
process  that  leads  to  the  atheroma  patch  has  had  time  to  occur.  On  the  other  hand,  if 
the  subiniiammation  is  lower  and  slower,  then  there  is  not  such  s(»ftenin<r  at  any  time  in 
its  course  as  to  lead  to  aiieurismal  yielding;  but  the  result  is  a  slow  thickening,  which 
reaches  a  considerable  and  a  sufficient  degree  before  any  fatty  degeneration  occurs  within 
it.  and  then  always  the  thickening  goes  farther  than  the  granular  change,  so  that  the;  wall 
of  the  artery  is  rather  .stronger  there  than  weaker;  and  if  the  suhinflammation  be  yet 
slower  and  slower,  the  fatty  or  granular  change  in  the  coat  goes  on  to  an  accumulation 
of  lime  salts  or  petrifaction  of  the  spot,  the  stone  in  the  wall  showing  sometimes  some 
rude  bone  cells,  so  that  ossification  may  be  thought  really  to  occur,  though  the  bone  is 
truly  a  very  rough  production,  if  it  be  bone  at  all.  Now,  if,  instead  of  being  thus  slow, 
so  as  to  give  time  for  the  calcareous  change  of  its  products,  the  suhinflammation  be  very 
acute,  then  the  arterial  wall  may  rupture  and  either  sudden  death  or  a  false  aneuri.sm  be 
the  result."  •'  I  might."  adds  Moxon,  ''  give  practically  any  number  of  ca.ses  and  draw- 
ings showing  the  active  cell  formation  in  cases  of  atheroma,  this  cell  formation  found  in 
the  deep  layer  of  the  inner  coat  especially  and  causing  the  production  of  little  nests  of 
cells  in  which  fat  and  lime  soon  accumulate.  In  severer  cases  the  middle  and  outer 
coats  and  the  deep  layer  of  the  inner  coat  are  seen  to  be  charged  with  lymph  cells  in 
enormous  numbers,  crowded  together  and  separating  the  proper  elastic  and  the  muscular 
fibres  into  little  patches  and  shreds,  while  both  elastic  and  muscular  fibres  fall  into  a  state 
of  fatty  degeneration  "  (Moxon,  Guy's  Ifoxp.  R< p.,  18711-71). 

In  Figs.  14li  and  1-13,  taken  from  drawings  kindly  made  for  me  by  Dr.  Moxon.  these 
changes  can  be  seen.     His  description  is  appended. 

Dr.  Moxon  and  others  believe — and  I  think  rightly — that  mechanical  strain  is  the 
main  cause  of  atheroma  of  the  arteries.     It  is  chiefly  found  at  points  where  the  strain 

Fifi.  142. 


Fig.  142  shows  the  incipient  inflammatory  stage  of  the  change  in  an  arterv  which  leads  to  atheroma,  and  in  which 
aneurism  usually  o<-cur~. 

Fig.  14;i  shows  the  final  degenerative  stage  of  the  same  change  in  the  artery  which  constitutes  atheroma. 

Fig.  142  is  a  small  portion  of  a  fine  section  of  an  artery  from  the  neighborho<Kl  of  an  aneurism;  the  arterv  was  here 
soft  and  swollen  and  had  a  more  pellucid  and  bliiish  api>earaiice  th.in  natural.  \  small  and  earlv  patch  of  the 
disease  is  represented.  The  cells  of  the  artery  wall  are  found  enlanied,  their  nuclei  multiplied,  and  at  the  centre 
of  the  patch  they  burst  toward  each  other  to  make  a  cluster  of  cells  derived  from  the  nuiltii>lied  nuclei. 

Fig.  143  is  taken  from  the  same  artery  at  another  spot,  where  the  coat  had  the  well-known  vellow  appearance  of 
atheroma.  Here  the  patch  of  multiplied  cells  has  degenerated  to  a  heap  of  oilv  and  earthv  matter  with  some 
plates  of  cholesterine.  The  individual  cells  around  are  seen  to  be  degenerated  in  the  same  wav.  Some  of  those 
at  the  upi»er  part  of  the  figure  are.  on  the  other  hand,  developing  into  elastic  fibrils.  This  is  a'  frequent  accom- 
paniment of  the  atheromatous  process,  and  its  etiect  is  to  ultimately  strengthen  the  arterial  wall  at  the  diseased 
spot. 

upon  the  coats  is  greatest  and  in  men  who  follow  laborious  occupations.  Gulliver 
originally  described  it  as  a  disease  of  the  larger  arteries,  but  it  is  now  known  to  involve 
the  whole  arterial  system. 

23 


354  EMBOLISM. 

In  advanced  disease  calcareous  plates  are  found  in  the  larger  arteries,  while  the 
smaller  are  converted  into  completely  solid  tubes.  The  vessels,  moreover,  alter  in  shape 
and  become  tuberous  as  well  as  tortuous,  dilatation  taking  place  at  the  points  of  bifurca- 
tion. When  the  disease  is  very  extensive  or  advanced,  the  inner  coats  become  destroyed 
and  undermined  with  blood.  When  this  undermining  takes  place  to  any  extent,  what  is 
known  as  a  dissectinc/  (nieurism  may  be  produced  ;  but  in  other  cases  the  inner  coat  is  so 
raised  by  the  clot  of  blood  behind  it  that  the  arterial  canal  becomes  closed  and  gangrene 
of  the  parts  supplied  by  the  occluded  vessel  may  ensue.  In  a  preparation  in  Guy's 
Museum  (1465)  the  aorta  was  thus  aifected,  causing  gangrene  of  the  extremities.  In 
others  the  vessel  may  rupture  and  cause  death  from  hemorrhage.  In  rarer  cases  the 
vessel  may  be  completely  closed  by  the  calcareous  disease  ;  in  some  the  roughened  raised 
patches  become  the  centres  of  fibrinous  adhesions  which  may  either  cause  occlusion  of  the 
vessel  directly  by  their  size  or  indirectly  by  being  carried  into  more  distant  arteries  as 
emboli.  In  both  cases  gangrene  of  the  parts  thus  deprived  of  blood  will  be  produced. 
Senile  (jangrene  doubtless  is  occasionally  caused  in  this  manner.  Thus  it  is  seen  that  this 
atheromatous  disease  of  the  arteries  is  often  the  cause  of  gangrene  of  a  part  by  direct 
occlusion  of  the  vessel  as  well  as  by  embolism.  As  a  general  rule,  however,  in  those 
instances  in  which  portions  of  the  artery  are  found  to  be  withered  and  converted  into 
fibrous  cords,  evidence  is  wanting  of  arteritis  being  the  cause,  recent  investigations 
having  tended  to  show  that  such  changes  are  the  natural  result  of  an  obstruction  of  the 
vessel,  and  that  this  obstruction  is  probably  due  to  the  plugging  of  a  canal  by  a  clot  or 
to  what  is  now  known  as  an  embolus. 

Fatty  degeneration  of  the  inner  and  a  primary  calcareous  change  in  the  muscular  or 
middle  coat  of  medium-sized  vessels  must  also  be  mentioned.  These  may  be,  and  no 
doubt  are.  mostly  associated  Avith  chronic  inflammatory  changes  in  the  arterial  system  ; 
but  there  is  also  reason  to  believe  that  sometimes  they  are  essentially  primary  degenera- 
tions which  lead  to  contraction  of  the  vessels  and  senile  gangrene,  as  do  atheromatous 
changes. 

Embolism 

is  a  somewhat  common  affection,  and  consists  in  the  occlusion  of  a  vessel,  large  or  small, 
by  a  plug  of  fibrin  or  calcareous  matter  carried  by  the  blood  from  some  diseased  artery 
or  distant  part,  and  generally  from  the  heart.  The  physician  meets  with  it  in  cases  of 
paralysis  more  or  less  complete  associated  with  valvular  disease  of  the  heart,  acute  rheu- 
matism, or  aortic  disease  caused  by  a  thrombus  formed  in  an  atheromatous  vessel  and 
carried  forward  into  a  cerebral  vessel,  or  by  the  plugging  of  a  capillary  by  the  oily  or 
fatty  debris  derived  from  the  disintegration  of  an  atheromatous  patch.  The  surgeon 
meets  with  it  in  certain  forms  of  amaurosis  and  local  gangrene  and  as  a  precursor  of 
aneurism.  The  pathologist  sees  it  in  the  fibrinous  clots  (infarcta)  found  frequently  in 
the  lungs,  spleen,  kidneys,  or  other  organs. 

The  SYMPTOMS  of  embolic  occlusion  of  an  artery  are  sudden  and  severe  pain  in  the 
part  from  which  the  circulation  is  cut  off,  the  pain  in  some  cases  extending  down  the 
whole  course  of  the  artery;  in  others  it  is  a  local  numbness;  tenderness  is  usually  present 
in  the  course  of  the  vessel.  Symptoms  of  a  deficient  circulation  in  the  part  soon  appear, 
such  as  coldness  and  pallor  of  the  skin,  which  may  go  on  to  complete  gangrene.  All  cases 
of  embolic  occlusion  of  an  artery,  however,  do  not  end  in  death  of  the  part,  since  in 
patients  of  good  power  the  collateral  circulation  may  become  subsequently  established 
and  a  recovery  follow.  In  patients  of  feeble  power  gangrene  is  to  be  feared.  In  not  a 
few  cases  embolism  leads  to  the  formation  of  an  aneurism  (vide  page  357). 

A  woman  set.  47  who  never  had  any  illness  was  seized  in  June,  1868,  with  a  mild 
attack  of  hemiplegia  on  the  left  side,  from  which  she  perfectly  recovered  in  three  weeks. 
She  remained  well  and  returned  to  her  ordinary  duties — those  of  a  laundress — for  three 
months,  when,  whilst  kneeling,  she  suddenly  felt  a  severe  pain  in  the  right  leg,  extending 
down  the  calf.  This  was  rapidly  followed  by  numbness  and  coldness  of  the  leg  and  dis- 
coloration. She  was  admitted  into  Guy's  under  my  care,  three  days  subsequently,  with 
gangrene  of  the  foot  and  lower  two-thirds  of  the  leg.  The  pulsation  in  the  femoral  artery 
was  normal,  but  no  vessel  could  be  felt  below  the  thigh.  I  amputated  the  limb  at  the 
knee-joint  on  October  13,  twisting  the  popliteal  and  other  arteries.  Some  sloughing  of 
the  stump  followed,  but  recovery  appeared  probable,  when  acute  bronchitis  set  in,  fol- 
lowed by  delirium  and  death.  Dr.  Fagge  kindly  examined  this  patient's  heart  before  the 
operation  and  reported :  "  There  is  scarcely  any  evidence  of  cardiac  disease,  but  I  think 
that  I  discover  a  short  presystolic  bruit.     If  this  is  so,  the  mitral  orifice  is  probably  con- 


i>is/:.\si:s  or  riii:  Airrrnih'S.  3/35 

truc'ttMl  ;  :iinl  a  clni  I'liniH'il  on  tlir  valvi-  ur  in  mir  of  tlic  licurt's  oavitics  iiia}'  have  Ihtmi 
carritMl  iiitd  tin-  artcrv  of  the  Idwcr  liiiili."  After  di-atli  tin-  mitral  was  iournl  tin-  size  of 
a  biittnii-holi'.  Anmiwl  its  (mIitc  witc  rfcciit  vcixt'latimis,  ami  uiic  of  tlifiii,  doubtlfss.  lia«l 
hoi'ii  carrit'il  into  tin-  circulatidii,  caiisiiii^  tin;  L'aiiirrfiif.  as  aimtlitr  liail  rausi-d  the  paral- 
vsis  three  iiiniitiis  |irevii»iisl y. 

Maiiv  cases  nt'  senile  L;aii;^rene  are  doiihtless  eniliolic.  tVoin  tlic  washing'  away  oC  snine 
eali-areniis  t'rairnieiit  fVniii  an  atlieniniatmis  vessel. 

In  some  eases  of  oeelnsion  of  an  artery  Ity  an  emholus,  after  the  application  of  a  liir- 
atiire  hvper.Tsthesia  and  increased  tcmpcratnre  of  the  part  Itelow  the  seat  of  ohstniction 
mav  he  met  with.  These  .symptoms  arc  clearly  due  to  the  infiiieiice  oi'  the  nervous  sys- 
tem and  tlie  eoiiiicstion  of  the  smaller  collateral  vessels. 

Arterial  Pyaemia. — l>r.  W'ilks  has  also  shown  (Oui/n  Unsp.  Rrp.^  1870)  that  as 
in  phlehitis  niorhid  matters  may  he  taken  up  by  a  vein  and  carried  into  tlie  circulation 
throiiiih  the  riuht  side  of  the  heart,  thcrel)y  f;iviii<i  rise  to  vennKs  jn/ftmitt,  no  disintegrated 
tihrin  of  the  hlood  may  l»e  carrii-d  into  the  arterial  systi;m  from  the  left  side  of  the  heart 
and  give  rise  to  (irtirinl  jti/friin'tt.  Kehrile  symptoms  with  joint-]iains  and  rigors  associated 
with  aiu-tic  and  mitral  limit  ought  to  excite  suspicion  of  this  latter  affection  ;  hut  when 
the  liver  or  s])leen  is  I'ound  enlarged,  the  diagnosii^  is  confirmed.  He  also  points  out  how 
this  occurs  in  a  secondary  fever  of  the  nature  of  ])yivmia  after  scarlatina,  which  is  often 
followed  by  ioint-])ains,  and  not  uiifre(|uently  hy  endocarditis.  In  confirmation  of  the.se 
views  I  may  mention  that  it  lias  twice  fallen  to  my  lot,  in  the  case  of  lemale  patients 
aged  respectively  fifti'en  and  twenty  years,  to  amputate  a  leg  for  gangrene  the  result  of 
occluded  femoral  artery  after  scarlet  fever.  In  neither  of  these  cases  had  any  ves.sel  to 
he  secured,  while  in  hotli  a  good  result  rapidly  ensued. 

Pulmonary  embolism,  remains  to  be  considered — a  form  which  is  important  to 
tlie  surgeon  not  so  mucli  as  a  disease  of  the  lung  as  because  it  is  generally  a  sequence 
of  some  clotting — or  tlirombosis,  as  it  is  called — in  the  veins.  This  clotting  is  very  com- 
mon in  all  kinds  of  cases  under  treatment  in  surgical  wards.  We  can  hardly  represent 
the  case  too  strongly,  and  we  know  of  no  more  important  subject  than  this  relation  of 
thrombosis  to  pulmonary  emlxilism.  Whenever  a  patient  undergoes  prolonged  rest  in 
bed,  especially  if  he  be  naturally  weak,  bloodless,  or  debilitated  from  any  cause  what- 
ever, if  the  blood  be  overfibrinous,  as  in  lying-in  women,  whenever  there  is  any  surgical 
fever,  and  in  other  states  too  numerous  to  mention,  there  is  a  risk  of  clotting  occurring 
in  the  qniit  parts  of  the  circulation,  especially  in  the  veins  of  the  lower  limbs  and  in  tho.se 
of  the  pelvis.  The  symptoms  are  often  slight.  If  the  clot  be  due  to  phlebitis,  then  there 
may  be  pain  ;  if  not,  there  may  be  no  more  than  the  slightest  oedema  about  one  ankle. 
This,  however,  is  sufficient  to  put  the  surgeon  on  his  guard,  and  by  the  subsequent 
enforcement  of  prolonged  rest  time  is  given  for  the  adhesion  of  the  plug  to  the  vein  wall, 
and  pulmonary  embolism  is  arrested.  It  should  be  remembered,  too,  that  clot  forming 
in  contact  with  a  comparatively  healthy  vein  wall,  as  is  the  ca.se  in  many  instances,  takes 
time,  and  sometimes  a  very  long  time,  before  adliering  to  the  wall ;  and  until  it  does  there 
is  the  risk  of  its  detachment  when  the  patient  moves.  There  can  be  no  doubt  that  many 
have  died  of  pulmonary  embolism  wlien  with  a  little  more  vigilance  on  the  part  of  the 
attendants  they  might  liave  been  saved. 

These  remarks  ap])ly  to  embolism  of  the  larger  branches  of  the  pulmonary  arteries, 
which  never  give  rise  to  furtlier  changes  in  the  lungs,  and  the  patient  dies  from  asphy.xia. 
If  the  smaller  branches,  liowever,  become  plugged,  then  arise  those  secondary  inlarcta 
already  mentioned,  and  in  the  case  of  septic  embolism  the  lobular  pneumonia  of  pyivmia 
and  gangrene  of  the  lung. 

Pathology. — The  changes  which  take  place  when  an  artery  becomes  plugged  differ 
according  to  the  size  of  the  afl'ected  vessel.  If  it  be  a  tenniital  vessel,  the  immediate 
result  is  congestion  of  the  vascular  area  concerned,  with  sub.sequent  hemorrhage  and 
atrophy  of  the  tissue.  The  various  stages  may  be  studied  with  great  precision  by  the 
ophthalmoscope  in  occasional  cases  of  embolism  of  the  arteria  centralis  retinjv.  It  i.s 
unnecessary  to  discuss  whether  the  process  is  due  to  vasomotor  paralysis  or  alteration  of 
blood  pressure,  since  it  is  of  pathological  rather  than  of  surgical  interest,  and  the  ques- 
tions involved  are  fully  stated  in  all  pathological  works.  We  shall,  therefore,  only  remark 
further  that  em])olism  of  the  small  vessels  is  important  or  otherwise  according  as  the 
source  from  wlience  tlie  plug  is  derived  is  healthy  or  not.  If  the  clot  be  septic,  then  the 
resulting  infection  will  probably  lead  to  an  abscess  ;  and  hence  the  probable  connection 
of  abscesses  in  the  pelvis  with  those  in  other  parts  after  labor  or  after  operations  in  the 
viscera  or  connective  tissue  of  the  body.      But  embolism  of  the  medium  size  and  larger 


356  DISEASES  OF  THE  ARTERIES. 

arteries  is  followed  by  chano;es  of  the  very  greatest  iiioinent  in  the  walls  of  the  affected 
vessels.  Unfortunately,  they  have  up  to  the  present  time  not  been  fully  worked  out  as 
regards  embolism,  though  we  can  obtain  considerable  aid  toward  understanding  what 
takes  place  by  availing  ourselves  of  the  exp«^riments  which  have  been  made  for  us  by  the 
ligature  of  vessels.  When  an  artery  of  any  size  becomes  closed  by  an  embolism,  the 
canal  may,  of  course,  be  gradually  restored  by  the  disintegration  and  washing  away  of 
the  plug  ;  if  not,  the  presence  of  the  clot  acts  as  an  irritant,  inflammation  is  set  up.  and 
the  clot  becomes  adherent  to  the  wall  of  the  vessel.  It  is  a  disputed  point  whether  the 
next  stage  is  one  of  organization  and  vascularization  of  the  clot,  or  of  absorption  of  the 
clot  by  vascular  granulations  which  spring  up  from  the  wall  of  the  vessel.  Weber  holds 
the  former,  but  Cornil  and  Ranvier  the  latter,  view.  This  difference,  however,  does  not 
matter,  as  all  that  is  important  would  be  granted  by  either — viz.,  that  embolism  leads 
sooner  or  later  to  a  local  inflammation  of  the  arterial  walls.  But  if  arteritis  is  thus  pro- 
duced by  a  simple  and  healthy  clot,  the  intensity  of  the  local  disease  will  be  gi-eater  when 
the  clot  is  septic,  the  plugs  so  exciting  the  component  elements  of  the  surrounding  arte- 
rial coat  that  its  tissues  will  become  disorganized,  its  cellular  elements  multiply  rapidly, 
and  the  coats,  as  a  consequence,  give  way.  Indeed,  we  know  that  these  changes  do 
actually  occur  in  small  vessels  and  abscesses  follow  ;  so,  without  doubt,  also — though  the 
fact  is  less  generally  recognized — the  same  changes  occur  in  the  larger  arteries  and  lead 
occasionally  to  aneurism.  I  shall  revert  to  this  subject  in  the  chapter  on  "  Aneurism," 
and  will  add  no  more  here,  since  what  has  been  already  said,  together  with  the  subjoined 
woodcut  of  the  state  of  the  arterial  coats  after  embolism,  may  sufficiently  explain  the 
morbid  processes  set  up  in  the  larger  vessels. 

Treatment. — The  objects  which  surgeons  should  have  in  view  in  the  treatment  of  a 
vessel  occluded  by  an  embolus  are  to  favor  the  venous  circulation  through  the  limb  by 
its  elevation  and  to  establish  the  arterial  collateral  circulation  by  maintaining  the  warmth 
of  the  limb  by  means  of  cotton-wool  carefully  wrapped  round  it  over  oiled  lint.  Pain  can 
be  relieved  by  sedatives,  such  as  chloral  or  opium,  given  by  the  mouth,  or  morphia  injected 
subcutaneously,  while  the  powers  of  the  patient  are  to  be  maintained  by  nutritious  diet, 
by  stimulants  carefully  administered,  and  by  tonics. 

When  gangrene  has  taken  place,  the  parts  may  be  covered  with  some  antiseptic  mate- 
rial, as  carbolic  acid  in  a  watery  or  oily  solution,  one  part  to  thirty,  or  with  powdered 


Fig.  144. 


.,t^\> 


Transverse  Section  of  the  Upper  Part  of  the  Radul  Arter\  plugged  b\  an  Embolus  of  "^cptic  Oiigin  some  Days  before 
I)eath.  (From  a  ease  of  ulcerative  endocarditis,  boy  set.  19.  Drawn  by  Dr.  J.  !■'.  Uoodtiart,  to  show  the  condition 
of  the  aclventitia.) 

a,  Clot.  /,  Adventitia  crowded  with  abnormal   nuclei  and  propor- 

(*,  Internal  coat.  tionately  thickened. 

c,  Internal  elastic  or  fenestrated  membrane.  /',  Region  of  vasa  vasorum. 

(I,  ^liddle  muscular  coat.  g,  Fat. 

e,  Outer  elastic  membrane. 

charcoal,  chloralum,  terebene,  or  MacDougal's  disinfecting  powder ;  but  if  the  odor  is  not 
very  offensive,  simple  oakum  surrounding  the  part  may  be  sufficient. 

When  the  line  of  demarcation  has  formed  and  the  gangrenous  part  can  be  removed 
by  amputation,  such  an  operation  may  bo  performed ;  but  the  surgeon  should  always  be 
cautious  in  interfering  with  these  cases.  He  should  at  the  same  time  take  every  precau- 
tion that  any  necessary  or  desirable  operation  is  not  unduly  postponed. 


I'.\rilnlj)(;Y  OF  AXEl'lilsM. 


357 


Fig.  14o. 


ANEURISM. 

All  aiK'iirisiii  is  cither  :i  suniilntiil  hinnn-  (•(iiitaiiiiii;,^  IiImmiI  cijiiiiiiiiiiif'atiiiL'^  witli  the 
caiiul  dt"  ail  arti'i  V  and  loniu;<l  iiKire  or  h;s.s  tVoiii  its  walls,  or  a  /'nsi/'t/nii  illlntntinn  »{'  an 
artory.  \\  lu'ii  all  tin-  coats  arc  involved  in  the  saccnlatcd  dilatation,  it  has  h(.'cn  the  cu.s- 
tttni  to  describe  it  as  hi-inji;  true ;  and  wluui  tlic  two  inner  coats  liave  <;iven  way  and  the 
external  or  cellular  alone  remains,  as  /(thr.  I  a<rree  witli  Holmes,  however,  that  it  is 
impossihlc  clinically  to  perceive  any  difi'erence  hetween  true  and  false  aneurisms  at  tlie 
time  they  jfcnerally  come  under  ohservation,  inasmuch  as  tlie  true  become  false  a.s  they 
«j:row  ami  the  false  an;  liy  far  the  more  common.  I  hohl,  moreover,  with  Moxon,  that 
pathoIo<j;ically,  ''  when  an  aneurism  has  readied  any  size,  and  often  before  it  ha.s  well 
started,  the  several  coats  of  the  vessel  have  lost  by  inflammation  their  di.stinctive  cha- 
racter, and  that  the  sooner  the  division  of  aneurisms  into  varieties  by  the  supposed  behav- 
ior of  the  several  coats  becomes  purely  a  matter  of  history  the  better." 

When  the  distension  of  a  vessel  involves  its  whole  CiiWhra^-ji  fusiform  or  tnljidiir  ontnr- 
is»i  or  aneurisnial  dilatation  is  said  to  exist,  whether  the  enlarfrement 
be  or  be  not  due  to  an  inflammatory  disease  of  the  arterial  coats. 

What  is  described  as  a  (fijfnsrd^  spurious,  or  consrcntirr  aneurism  is 
where  the  sac  of  the  aneurism  is  I'ovmed  by  the  muscles  and  conden.sed 
cellular  tissue  of  the  part  into  which  the  blood  has  been  extra vasated 
from  a  ruptured  aneurism  or  a  ruptured  artery  rather  than  by  the 
arterial  coats.  These  terms  should  not  be  applied  to  cases  in  which 
there  is  diffused  extravasatioii  of  jjlood. 

.1  (fissecn'iiff  nneiiri'sm  is  one  in  which  the  inner  is  separated  from 
the  middle  coat,  or  where  blood  is  extravasated  into  the  thickness  of 
the  middle  coat  itself  or  between  the  middle  and  external  coats,  the 
blood  re-entering  the  cavity  of  the  artery  at  some  distant  spot.  The 
aorta  is  the  part  usually  affected,  and  even  its  whole  length  may  be 
involved.  An  excellent  example  of  this  affection  has  been  recorded 
by  Dr.  Fagge  {MtnL-Chir.  Trans.,  vol.  Hi.).  These  cases,  however, 
rarely  come  under  the  hands  of  the  surgeon.  There  are  also  cirsoid 
and  arterio-venous  aneurisms,  to  which  attention  will  be  drawn.  To 
show  what  an  aneurism  may  do.  the  following  figure  (Fig.  146)  is 
given.  It  was  taken  from  a  drawing  in  Guy's  Hospital  Museum. 
The  aneurism  of  the  innominata  has  involved  the  left  carotid  and  root  of  the  subclavian, 
a  second  aneurism  of  the  left  carotid  existing;  above. 


SaciMihitnl  Ti.inMiatic 
Aneurism.  .T'lawing 
44'8,(;uy's  IIosp.  Mus., 
Mr.  Poland's  case.) 


Pathology  of  Aneurism. 

A  low  form  of  inflammation  of  the  arterial  walls  is,  without  doubt,  the  most  common 
predisposing  cause,  while  overaction  of  the  heart  and  circulation  is  the  exciting  cause  of 
aneurism.  Direct  injury  to  an  artery  is  an  occasional  cau.se  (traumatic),  although  more 
frequently  the  injury  sets  up  the  disease  that  produces  the  aneurism.  Whenever  the  coats 
of  an  artery  are  weakened  by  accident,  disease  (suppurative  or  otherwise),  or  the  loss  of 
their  natural  support,  they  become  liable  to  dilate  under  any  .sudden  or  prolonged  increase 
in  the  force  of  the  circulation.  Dr.  Rendle  of  the  Queen's  Prison,  Brixton,  has  recorded 
two  cases  in  which  abdominal  aneurism  could  be  traced  to  the  .shock  caused  by  a  .sentence 
of  transportation.  Aneurisms  are  more  common  in  the  aorta,  where  chronic  inflammatory 
changes  are  so  likely  to  appear  and  the  heart's  action  is  more  directly  felt ;  at  the  bifur- 
cation of  an  artery,  where  the  force  of  the  circulation  is  always  more  powerful ;  or  at  the 
flexure  of  joints,  where  muscular  action  is  the  most  liable  to  tell  by  overstretching  or 
bending. 

That  aneurism  is  a  disease  of  the  arterial  system  and  not  always  of  traumatic  origin  is 
proved  from  the  fact  that  a  man  may  have  an  aneurism  form  when  in  bed  and  that  the 
whole  arterial  system  may  be  involved  in  the  disease.  Broca  has  mentioned  a  case  of 
Pelletan's  in  which  sixty-three  aneurisms  were  found  in  one  body.  It  is  also  a  disease 
of  middle  age,  half  the  cases  occurring  between  the  ages  of  thirty  and  forty-five.  It  is 
not  uncommon,  however,  to  find  it  in  young  persons.  Dr.  X.  Moore  exhibited  one  of  the 
external  iliac  artery  in  a  child  aet.  7  (Path.  Soc,  October  17,  18S2).  Syme  has  recorded 
an  instance  in  a  child  of  nine.  My  colleague.  Dr.  Habershon.  reported  an  example  of 
femoral  aneurism  in  a  boy  of  ten  with  heart  disease.  Cerebral  aneurism  in  early  life  is 
still  more  common.     But  such  ca.ses,  almost  without  exception,  are  associated  with  vege- 


558  AXEUEISM. 

tations  on  the  valves  of  the  heart,  and  often  with   ulceration  of  the  valves,  and  are  prob- 
ably due  to  embolism.     The  symptoms  are  those  which  Dr.  Wilks  has  described  under  the 
term  '•  arterial  pyaemia  ;'  they  are,  mainly,  considerable  pyrexia  and 
Fid.  14H.  enlargement  of  the  spleen.     Many  such   are  now  on   record,  and, 

besides  the  parts  above  mentioned,  they  have  been  found  situated  on 
the  brachial,  ulnar,  popliteal,  axillary,  mesenteric,  and  many  other 
smaller  vessels.  Indeed,  the  frequency  of  their  occurrence  can  only 
be  estimated  by  looking  into  the  literature  of  visceral  aneurisms. 
It  will  then  be  "found  that,  though  the  relation  between  heart  disease 
and  aneurism  has  not  till  of  late  years  been  studied,  very  many  cases 
of  aneurism  associated  with  endocarditis  and  emboli  in  the  solid  vis- 
cera have  been  recorded  at  diiferent  times.  Among  the  earliest 
writers  on  the  subject  are  Joliffe  Tufnell  in  the  Duhlin  Journal^  vol. 
XV.  p.  371  ;  Dr.  Ogle,  Futli.  Trans.,  vol.  viii.;  Dr.  AVilks.  do.,  vol.  xi.; 
Mr.  Holmes,  do.,  vol.  xii.  Other  cases  have  been  recorded  in  the 
same  Transact ion.f  more  recently  by  Drs.  Church,  Goodhart,  Gowers. 
Murchison,  Semple.  and  myself.  Similar  cases  may  also  be  found 
in  various  medical  publications  (viWe  Brigld's  Medical  Reports,  vol. 
Drawing  4^«.J-'U.Vs  Ho.p.  ji  ^  266  ;  Gull,  Guys  Hasp.  Rep.,  3d  series,  vol.  v.  p.  299  ;  Ponfick, 
Virch.  Arcldv,  Bd.  58,  1873.  See  also  Wilks  and  Moxon,  Path. 
Anaf.,  pp.  158,  159;  Holmes,  Si/st.  Surg.,  etc.). 

Various  explanations  have  been  given  of  the  occurrence  of  aneurism  under  such  con- 
ditions. It  has  been  maintained  by  some  that  the  plug  leads  to  sudden  obstruction  and 
afterward  to  dilatation  of  the  vessel  behind  it.  But  a  look  at  preparations  of  such  aneur- 
isms shows  that  the  dilatation  is  not  behind  the  embolus,  but  actually  at  the  plugged  spot. 
Moreover,  if  the  local  obstruction  leads  to  dilatation  behind  it,  we  ought  to  find  aneurism 
a  more  common  result  of  ligature  than  is  the  fact ;  we  ought  to  find  it  more  frequently 
after  embolism  than  we  do,  because  embolism  is  a  very  common  aflPection  in  one  part  or 
another  of  the  body.  Other  ingenious  though  somewhat  labored  explanations  have  been 
offered,  which  need  not  be  mentioned  here  ;  and  the  only  one  of  any  importance  is  that 
recently  ably  argued  by  Dr.  Goodhart,  attributing  the  aneurism  to  a  "local  arteritis  which 
in  its  turn  has  been  caused  by  the  embolism.  It  has  been  already  asserted  that  when  an 
artery  becomes  blocked,  the  clot,  unless  it  softens  and  breaks  down,  becomes  adherent  to 
the  wall  and  subsequently  becomes  vascular.  If  this  be  true — and  that  it  is  so  is  allowed 
by  nearly  all  observers — then  there  must  have  been  some  preceding  inflammation  of  the 
wall  of  the  vessel  to  allow  of  this  new  formation  of  capillaries.  That  embolism  causes  a 
local  arteritis  is  admitted,  but  how  it  is  that  under  these  circumstances  an  aneurism  is  so 
rare  a  result  has  yet  to  be  explained,  and  the  explanation  is  probably  to  be  found  in  an 
examination  of  the  cases  in  which  emboli  exist.  They  are,  almost  without  exception, 
examples  of  ulcerative  endocarditis  in  which  there  is  a  very  severe  local  inflammation 
attended  with  symptoms  of  blood  poisoning  which  is  supposed — and  we  think  rightly  so 
— to  be  due  to  the  septic  nature  of  the  emboli  which  are  detached  from  the  ulcer  and 
carried  to  all  parts  of  the  body.  When  this  septic  clot  becomes  lodged  in  some  part  of 
an  artery,  in  proportion  to  its  septicity  the  artery  will  inflame,  and  as  a  consequence,  in 
the  more  severe  cases,  there  will  be  the  rapid  formation  of  an  abscess  and  perhaps  a  false 
aneurism,  whilst  in  those  somewhat  less  severe  cases  there  will  be  acute  softening  and 
cellular  infiltration  of  the  arterial  coats,  with  probably  the  formation  of  a  true  aneurism. 
In  the  majority  of  cases,  however,  as  the  embolism  is  not  caused  by  septic  clots,  there 
will  be  neither  aneurism  nor  abscess. 

In  June,  1883,  through  the  kindness  of  my  colleague.  Dr.  Pye-Smith.  I  saw  a  man 
set.  25  who  had  been  admitted  under  his  care  at  Guy's  with  heart  disease  and  symptoms 
of  embolism  of  the  spleen,  kidney,  and  right  brachial  artery  at  its  bifurcation.  The 
arterial  obstruction  had  taken  place  the  day  before  his  admission,  when  he  was  at  work, 
with  sudden  severe  throbbing  pain  in  the  bend  of  the  elbow,  soon  followed  by  swelling. 
On  admission  there  was  a  local  swelling  at  the  point  corresponding  to  the  bifurcation  of 
the  vessel,  pulsation  in  the  brachial  artery  down  to  this  spot,  but  not  at  it,  no  pulsation 
in  the  right  ulnar  artery,  and  very  feeble  pulsation  in  the  radial.  On  the  second  day  a 
hard  lump  was  felt  at  the  bifurcation  of  the  brachial.  On  the  fourth  day  the  pulsation 
in  the  lower  ves.sels  had  improved.  On  the  sixth  the  collateral  vessels  about  the  elbow 
were  enlarged.  On  the  thirtieth  day  where  the  lump  had  been  at  the  bifurcation  of  the 
brachial  artery  strong  pulsation  was  felt.  On  the  thirty-fourth  day  an  aneurismal  sac 
■was  clearly  to  be  felt,  with  a  marked  bruit  over  it.     On  the  forty-sixth  it  was  as  large  as 


A.\/:ii;isM. 


359 


a  nut.  Tlic  |(uls;itiniis  in  the  ratlicK'  ulnar  artrrics  were  Cull.  In  lliis  case  tlir  whole 
ooiirst'  di"  fViMits  may  In-  >,i\(\  to  havi-  lu-cn  lUKlcr  uhM-rvation.  and  tlie  fact  fit  tin-  iornia- 
tiuii  of  an  anrurisni  tiilhiwinu  an  (•inlMili.><in  was  ck-aily  ilcinonstrated. 


Progress  and  Natural  Cure  of  Aneurism. 

An  aniMirism.  wlu'n  nm-e  tunnL-d,  has  a  natural  teink'ncy  tci  increase — the  "  saccu- 
latrd  '  more  so  than  tlie  "  I'lisif'orm  ;  "  and  the  "  sacculated '"  eommiinicatiiig  by  a  small 
oin'iiinLr  witli  tin'  cavity  of  an  artery  has  a  tendency  to  increase  more  rapidly  than 
another  in  which  the  openin<r  is  free,  the  force  of  the  circulation  l>cin<r  more  concentrated 
upon  one  point  of  the  aneurismal  sac  in  the  former  case  than  in  the  latter.  Hence  sac- 
culated aneurisms  attain  a  much  larger  size  than  the  fusiform,  and  are  much  more  liable 
to  rujiture. 

When  an  aneurism  is  cured,  it  is  so  by  its  cavity  becomint:  tilled  with  blood  clot, 
which  subse([nently  contracts,  and  in  the  best  cases  l)y  the  occlusion  of  the  arterial  trunk 
upon  which  the  aneurism  is  placed  ;  the  .sacculated  aneurism  is 
more  capable  of  a  natural  cure  than  the  fusii'orm.  When  the 
arterial  coats  are  rou':;hened  by  disease  and  weakened,  the  fusiform 
is  as  likc'ly  to  iiu'rease  as  the  .sacculated  and  is  as  capable  of  a 
spontaneous  cure.  In  any  case  of  sacculated  aneurism,  as  well  as 
in  some  of  fusiform,  a  sjxnitaneous  cure  may  take  place  by  the 
coajjulation  of  the  lilood  in  the  sac  and  the  subsecjuent  consolida- 
tion of  the  clot.  When  this  process  is  slow,  the  fibrin  of  the 
blood  is  deposited  in  layers  or  lamina)  (Fig.  147)  ;  the  external 
layer  in  contact  with  the  walls  of  the  sac  becomes  at  times  more  or 
less  united  with  them,  and  so  strengthens  them  as  to  prevent  their 
dilatation:  the  clot  also  becomes  dense  by  contraction  and  decolor- 
ized.    Subsequent  layers  form  in  the  same  maimer  as  the  process  Ja'i>>"atH    Coafnihini    re- 

n  '  1  •  t-i     4.1  11  •        au     ^  1     £       11  "loved  Irom  Axillary  An- 

01  recovery  proceeds,  until  the  wlioie  sac  is  nlled  and  nnally  eurism  twelve  years  after 
obliterated.  A  section  of  an  aneurismal  sac  thus  cured  much  ,^|,bcl^fvL'n''Uierv''^%^''- 
resembles  that  of  an  onion,  the  outer  lamin*  of  fibrin  being  thin,*  ration  performed  i><2:i. 
fibrous,  firm,  and  bloodless,  each  successive  layer  toward  the  centre  7achmeru"'""o  'The ""sac' 
approaching  more  to  the  color  and  consistency  of  newly-coagulated  Prep.  <;uy's  Hosp.  Mus., 
blood.    The  laminated  coagulum  lining  the  sac  is  frequently  called, 

after  Broca,  ''  active  clot,"  and  the  soft  coagulum  in  the  centre  "  passive  clot,"  from  the 
idea  that  this  latter  is  a  mere  post-mortem  and  not  a  vital  deposit.  This  view,  however, 
can  scarcely  be  correct,  as  there  can  be  little  doubt  tliat  in  all  cases  of  aneurism  that  are 
rapidly  cured  by  pressure,  digital  or  otherwise,  the  consolidation  of  the  aneurism  must 
be  due  to  the  simple  coagulation  of  the  blood  in  the  sac  and  its  subse(|uent  induration 
and  contraction,  inasmuch  as  a  few  hours  are  evidently  too  .short  a  period  for  the  coagu- 
lum to  form  in  any  other  way.  In  the  following  beautiful  drawing  (Fig.  148)  by  Dr. 
Moxon,  taken  from  a  specimen  of  popliteal  aneurism,  which  was  cured,  in  a  man  under 
my  care  two  years  before  death,  by  digital  compression  applied  for  four  and  a  half  hours 
(see  Gii}/'s  Ihisj).  Rip.,  18t!il),  the  whole  pathology  of  aneurism  is  .shown,  with  the  con- 
solidation of  the  aneurism  and  occlusion  of  its  supplying  artery. 

Colles  of  Dublin,  and  some  older  pathologists,  believed  that  tlie  fibrin  which  lines  the 
sac  was  the  product  of  an  exudation  from  the  lining  membrane  of  the  sac.  and  that  suc- 
cessive exudation  of  this  material  formed  the  lamina?.  This  view,  however,  is  now  almost 
exploded.  Le  Fort  also  accounts  for  the  cure  of  the  fusiform  aneurism  by  inflammation 
of  the  inner  lining  of  the  sac,  and  he  regards  the  fusiform  as  a  simple  dilatation,  which 
it  is  not  in  all  eases.  Most  pathologists,  however,  now  admit  that  where  the  inner  tunic 
of  an  artery  exists  in  a  healthy  state  in  an  aneurism,  coagulation  of  the  blood  does  )iot 
take  place  within  the  sac,  and  conse((uently  that  a  spontaneous  cure  is  impossible,  and 
that  in  the  sacculated  or  fusiform  aneurism  successive  deposits  of  fibrinous  lamime  only 
take  place  when  the  internal  membrane  is  absent,  from  the  contact  of  tlie  blood  with  the 
rough  walls  of  the  sac. 

Mr.  Poland  has  recorded  a  case,  probably  uniiiue,  occurring  in  the  practice  of  Dr. 
Adams  of  Dublin,  of  fusiform  aneurism  of  the  subclavian,  which  tends  to  support  this 
theory   {Mcd.-Chir.    Trans.,  vol.   Hi.    18t)!>). 

An  aneurism  may  also  be  cured  by  the  "  distal  occlusion  "  or  plugging  of  the  artery 
beyond  the  sac  with  a  clot  that  has  been  dislodged  by  the  force  of  the  circulation,  acci- 
dent, or  design.     The  vessel  at   first  may  be  only  partially  clo.sed  by  the  clot,  yet  fresh 


360 


AXEURrSM. 


fibrin  will  soon  be  deposited  upon  the  "  embolic  plug  "  and  com])lete  obstruction  be  pro- 
duced. This  natural  mode  of  cure  is  utilized  in  the  distal  operation  for  the  cure  of 
aneurism,  and  in  the  cure  by  manipulation.  Recover}-  may  also  be  caused  by  the 
"sloughing  of  the  tumor"  (suggesting  the  treatment   by  caustics).     It   is  likewise  on 

Fig.  148. 

o,  The  section  edge  of 
the  arterial  coats  where 
healthy. 

(ta,  The  coats  in  the 
diseased  and  occluded 
part  of  the  artery.  Their 
sulxstauce  is  dispersed 
and  lilended  with  the 
new  tibrous  tissue,  b, 
whicli  fills  the  vessel. 
yet  not  so  much  difJ'used 
but  that  they  can  still 
be  traced  to  the  mouth 
of  the  aneurysm  (opposite 
the  upper  c). 

e,  The  aneurism  .  sac, 
composed  of  laminated 
clot  and  compressed  tis- 
sue welded  together  in- 
definitely. 

<1,  Scarcely  laminated 
clot,  filling  "the  hollow 
of  the  sac. 

The  vein,  with  two 
valves  in  its  lower  part, 
is  seen  close  behind  the 
artery. 

Section  through  an  Aneurism  of  the  Popliteal  Artery,  cured  nearly  two  years  before  by  Digital  Pressure.  (The 
aneurism  is  not  dissected  out,  but  left  embedded'  in  the  popliteal  fat,'f,  e.  The  artery  is  occluded  with  the 
aneurism.) 

record  that  the  artery  with  which  the  aneurism  is  connected  may  be  obstructed  either 
above  or  below  the  sat  by  the  pressure  of  the  aneurism  itself,  from  its  being  bound  down 
by  a  strong  fascia  or  from  the  pressure  caused  by  effused  blood  following  its  rupture,  and 
in  the  treatment  by  flexion  this  natural  mode  of  cure  is  made  use  of.  As  an  aneur- 
ism increases  and  encroaches  on  the  neighboring  parts,  tissues  are  separated,  and  even 
absorbed ;  bone  may  even  be  gradually  worn  away  by  the  steady  pressure  of  the  pulsa- 
ting tumor,  so  that  in  thoracic  aneurism  the  sternum  may  be  perforated  or  the  bodies  of 
the  vertebrae  eaten  away  and  the  spinal  canal  opened  (Prep.  1489'*",  Guy's  Hosp.  Mus.). 
During  this  increase  the  tissues  surrounding  the  sac  may  inflame,  though  they  rarely 
suppurate,  and  by  becoming  condensed  give  the  aneurism  some  support  and  tend  to 
retard  its  growth.  In  rare  cases  this  inflammatory  action  may  involve  the  sac  itself 
and  cause  sloughing ;  but  when  the  aneurism  increases  unchecked,  it  will  eventually 
give  way.  A  thoracic  or  abdominal  aneurism  may  burst  into  a  mucous  tract  such  as  the 
trachea,  phar3'nx,  oesophagus,  or  intestine;  and,  when  it  does,  Dr.  Gairdner  (Med.-Chir. 
Trans.,  vol.  xlii.)  has  shown  that  it  proves  fatal  by  a  recurrent  hemorrhage  through  a 
s7n(iU  orifice.  When  it  bursts  into  a  serous  cavity,  such  as  the  pleura,  pericardium,  or 
peritoneum,  it  de.stroys  by  a  sudden  hemorrhage  through  a  /aiyf  aperture.  Cases  are 
also  on  record  where  it  discharged  itself  into  a  vein  or  the  pulmonary  artery.  External 
or  surgical  aneurisms  burst  by  the  formation  and  giving  way  of  a  slough.  Aneurism 
of  the  extremities,  or  surgical  aneurism,  may  give  way  into  a  joint  or  cellular  tissue.  It 
may  bur.st  externally,  but  only  in  rare  instances.  An  aneurism  may  be  fairly  filled  with 
clot  and  yet  increase,  the  blood  making  its  way  round  the  clot  and  thus  dilating  its  walls. 
This  is  prevented  only  when  the  artery  connected  with  the  sac  as  well  as  the  aneurism  is 
filled  with  clot. 

The  surgeon,  however,  has  more  to  do  with  external  than  internal  aneurisms,  and, 
although  the  pathology  of  both  forms  is  alike,  the  treatment  diff'ers.  It  is  to  surgical 
aneurisms,  therefore,  that  the  following  remarks  may  specially  apply,  and  first  of  all  as 
to  their  symptoms  and  diagnosis. 


Symptoms  and  Diagnosis. 

An  aneurism  has  no  pathognomonic    symptoms,  and  its   early  symptoms  are  very 
uncertain.     It  often  happens  that  the  patient's  attention  is  first  directed  to  some  sv:elling, 


/>/.u;.vo,s7\  oi'  Asr.rinsM.  361 

alt  liiMiLili  it  may  In-  nnly  tliat  t\\'  Imul  lliiDhliiiiij — soiiii'  wcakm-ss  ur  -tiHricss  ufaii  cxtrcin- 
ity,  nr  some  m  rvc  iinin  |(it'C(Mliii<;  the  discnvcry  (tf  tlic  iliscasc  ;  yet  siicli  sytii|»t()iii.s  arf, 
not  cdiistaiit.  Whi'ii,  liowi'Vcr,  tlin  surj^cuii  is  consiiltcil  \'nv  pain  that  sIhidIs  down  the 
roiirsc  of  a  luTVi?  runiiiiii;  in  contact  with  a  hir^'c  artery,  he  shouhl  alhiw  the  tliou^'ht  of 
ani'urisnial  jiressurc  to  pass  tliroii^rli  his  mind  ;  and  when  tlii.s  is  asso(riafed  with  the  j)res- 
ence  of  a  tumor  connected  with  the  vessel,  the  suspicion  ot"  its  heiiifr  aneurismal  shouhl 
he  excited.  It"  tliis  tumor  he  si)/(,  rxjxnisi/r^  and  pu/sufini/.  if  it  Ijccome  tense  on  the 
application  of  pressure  to  the  trunk  of  tht;  arttsry  on  the  distal  side  ami  flaccid,  non-pulsa- 
tile, and  vanishiut;  on  pressure  on  the  cardiac  side,  and  shouhl  pressun;  on  the  tumor 
modify  the  ]»ulse  in  the  vess(d  helow,  the  chances  of  its  heinj:;  aneurismal  amount  almost 
to  certainty.  Shouhl  it  expand  aj^ain  readily  on  the  removal  of  the  ])ressure,  and  this 
expansion  he  accompanied  with  a  ])(M!uliar  thrill  on  the  readmission  of  hlood  into  the  sac, 
with  a  bellows  murmur  or  aneurismal  bruit  synchronous  with  the  pulse — audible,  too,  on 
the  application  of  the  ear  to  the  tumor — the  diagnosis  is  com])lete. 

The  pulse  of  the  extremity  l)elow  the  swellinj;  is  frenerally  afl'ected  ;  it  is  weaker  and 
slower  than  its  fellow,  and  as  the  disea.se  progresses  it  may  cease  altogether.  The  blood 
will  then  flow  in  a  "'  venous  stream"  or  cease  to  flow,  either  from  the  obstruction  of  the 
arterial  trunk  by  the  pressuri;  of  tlie  aneurism  or  the  eml)olie  occlusion  of  the  ve.s.sel 
below  from  a  dislodged  coagulum.  Under  tlu>se  circumstances,  fulness  of  the  veins  with 
tedema  of  the  ])arts  supjdicd  by  the  artery  will  soon  appear,  and  at  times  excruciating 
pain  from  stretching  of  the  nerves  will  arise.  If  the  aneurism  be  cervical  and  the  circu- 
lation through  the  brain  be  interfered  with,  giddiness  and  loss  of  consciousness  may  be 
present :  and  where  any  pressure  is  made  upon  the  recurrent  laryngeal  nerve,  a  peculiar 
and  characteristic  hoarseness  will  be  produced.  This  hoarseness  i.s  sometimes  as.sociated 
with  loss  of  voice  and  laryngeal  .spasms  simulating  laryngeal  disease.  In  the  case  of  a 
women  ;et.  22  under  my  care,  in  whom  an  aneurism  existed  involving  the  aorta  below 
the  opening  of  the  left  subclavian  and  pressing  upon  the  left  bronchus  and  trachea,  this 
symptom  was  so  severe  as  to  call  for  tracheotomy.  When  the  cervical  sympathetic  gan- 
glia are  pres.sed  upon,  the  pupil  of  tlie  affected  side  may  be  permanently  contracted,  and 
nerve  pains  will  be  present  according  to  the  amount  of  pressure  applied. 

When  an  aneurism  luis  partially  consolidated  and  has  either  so.  enlarged  or  become  so 
diffused  as  to  press  upon  the  soft  parts,  so  as  no  longer  to  exhibit  any  pulsation — for 
there  are  aneurisms  that  do  not  pulsate — when  it  feels  firm,  with  po.ssibly  a  soft  point 
here  and  there,  some  difticulty  may  be  felt  in  forming  a  diagnosis,  and  the  surgeon,  under 
these  circumstances,  will  have  to  depend  as  much  upon  the  history  of  the  case  as  upon 
the  pliysical  symptoms.  When  external  signs  of  inflammation  or  suppuration  are  present, 
the  difficulty  will  be  enhanced  ;  for  it  must  be  recorded  that  aneurisms,  under  these  cir- 
cumstances, have  been  opened  for  abscesses.  I  remember  a  popliteal  aneurism  having  been 
so  maltreated  with  a  fatal  result.  Such  mistakes  of  diagnosis,  however,  ought  not  to 
occur,  as  they  are  due  to  carelessness.  The  diagnosis  of  an  aneurism  may  generally  be 
made  by  attending  to  the  history  of  the  case  and  to  the  existing  symptoms.  An  abscess 
in  contact  with  an  artery  may  receive  pulsation  from  it,  as  may  any  cyst,  or  even  solid 
tumor  ;  but  in  all  these  the  pulsation  will  cea.se  on  the  application  of  pressure  to  the 
artery  above  the  tumor  without  any  change  whatever  taking  place  in  the  tumor  itself. 
I  have  seen  a  case  of  lumbar  abscess  which  pulsated  freely  from  aortic  contact.  It  is 
also  rare  for  such  tumors  to  cause  a  bruit.  Cases  are  on  record  in  which  an  artery  in 
contact  with  an  abscess  or  suppurating  hydatid  cyst  has  been  opened  by  ulceration  and 
given  rise  to  the  idea  of  an  aneurism.  Pulsatile  tumors  of  bone  may  also  be  mistaken 
for  aneurism,  but  from  the  former  being  in  bone  and  more  or  less  ossific,  from  the  bone 
being  expanded — although,  perhaps,  irregularly — and  from  a  bruit  rarely  existing  in  it, 
the  diagnosis  ought  not  to  be  difficult.  Tumors  lying  near  large  arteries  and  receiving 
pulsation  from  them  may  likewise  be  mistaken  for  aneurism,  but.  from  the  pulsation  not 
being  expansile  and  the  tumor  being  capable  of  being  drawn  away  from  the  vessel,  a  cor- 
rect diagnosis  should  be  made.  It  must  be  admitted,  notwithstanding,  that  men  of  the 
greatest  skill  and  experience  have  mistaken  such  cases  for  aneurism. 

Treatment. 

There  is  probably  no  disease  a  surgeon  has  to  treat  which  requires  to  be  dealt  with 
more  on  scientific  principles  than  aneurism,  since  all  treatment,  to  be  effective,  must  be 
based  upon  the  physiological  processes  of  a  natural  cure  ;  and  this  natural  cure  is  brought 
al)out  by  the  coagulation  and  subsequent  consolidation  of  the  blood  in  the  aneurismal 
sac,  and  in  the  best  examples  in  the  artery  upon  which  the  sac  is  placed  (vide  Fig.  148). 


362  TEEATMEXT  OF  ANEUBJSM. 

To  induce  coagulation  of  the  blood  in  the  sac  and  artery  by  natural  processes  becomes, 
consequently,  the  chief  object  of  treatment,  and  this  is  to  be  brought  about  by  general 
as  well  as  local  means.  For  this  purpose  it  is  necessary  to  have  a  feeble  circulation 
through  the  sac-;  and  to  this  end  r^st  in  the  recumheut  position  is  an  essential  point  to  be 
ohyerved.  and  it  ought  to  be  maintained  in  every  case ;  indeed,  there  is  every  reason  to 
believe  that  by  it  alone  aneurisms  have  been  cured.  Luke  (^Lond.  Med.  Gaz.,  May,  1845), 
Bellingham,  Tufnell.  Stanley  (Path.  Soc.  Trans.,  vol.  v.  p.  107).  and  others  have  recorded 
in.stances  of  this  nature.  Tufnell  allowing  for  diet  about  ten  ounces  of  solid  and  eight 
ounces  of  fluid  food  in  the  twenty-four  hours.  As  a  preliminary  to  all  otJier  treatment, 
'■'•  abaohite  rest^'  is.  therefore,  most  essential. 

With  the  .same  object  "  bleeding  "  has  been  employed,  and  was  at  one  time  largely 
practised  on  the  authority  of  Valsalva,  who  powerfull}-  advocated  it,  and  probably  to 
excess.  There  seems  no  reason  why  it  should  not  be  adopted  when  the  force  of  the  circu- 
lation is  strong  and  the  powers  of  the  patient  ai*e  good,  as  bleeding  not  only  lowers  the 
force  of  the  circulation,  but  at  the  same  time  tends  to  render  the  blood  more  fibrinous. 
In  internal  aneurism  it  is  calculated  to  be  of  more  service  than  in  external,  but,  practised 
with  caution,  it  is  doubtless  of  value  in  both.  Medicines  do  not  seem  to  have  much  influ- 
ence in  encouraging  the  coagulating  process,  though  the  acetate  of  lead  gave  some  prom- 
ise of  value  in  the  hands  of  m^'  former  colleague.  Dr.  G.  0.  Rees,  but  more  extended 
experience  has  not  confirmed  the  hope  held  out ;  the  iodide  of  potassium  or  sodium  has 
been  also  much  vaunted,  more  particularh'  when  syphilis  is  su.?pected.  2Cnfritions,  but 
unstimnlating.  food  .should  be  given  in  all  instances  to  maintain  the  powers  of  the  patient, 
though  not  to  increase  the  force  of  the  circulation.  All  mental  excitement  should  be 
positively  forbidden. 

The  object  of  the  local  treatment  of  aneurism  is  to  arrest  or  diminish  the  circulation 
through  the  sac,  and  the  success  which  is  to  be  expected  from  whatever  practice  may  be 
adopted  will  depend  as  much  upon  the  shape  of  the  aneurism  as  upon  the  size  and  po.si- 
tion  of  the  opening  into  the  sac.  The  surgeon  has  for  this  purpose  a  variety  of  means 
at  his  disposal,  which  may  be  divided  as  follows : 

1.  Compression  of  the  artery  above  the  aneurism — "  indirect  pressure." 

2.  Compression  of  the  aneurism  itself — '"direct  pressure." 

3.  Compression  of  the  artery  as  it  leaves  the  aneurism — "  distal  pressure." 

4.  The  Hunterian  operation  of  applying  a  ligature  to  the  artery  on  the  cardiac  side 
of  the  aneurism  or  the  occlusion  of  the  afferent  vessels  by  other  means. 

5.  The  application  of  a  ligature  to  the  artery  within  the  aneurism  itself — operation 
operation  of  Ant^^llus. 

6.  The  application  of  a  ligature  to  the  artery  on  the  distal  side  of  the  aneurism — 
"  di.stal  operation."  < 

There  are  likewise  other  means  which  may  be  justifiably  employed  in  exceptional 
cases — such  as  the  treatment  by  manipulation,  galvanic  puncture,  and  the  introduction 
of  some  foreign  body  into  the  sac — to  which  attention  will  be  drawn.  At  Guy's  Ho.s- 
pital  in  the  fifteen  years  ending  1880,  42  aneurisms  were  treated  by  compression  alone, 
and  19  by  the  Hunterian  operation  when  compres.sion  had  failed.  In  13  cases  the 
Hunterian  operation  was  primarily  employed.  In  3  the  operation  of  Antyllus  was  per- 
formed. In  3  the  distal  ligature  was  used.  In  1  primary  amputation  was  called  for,  and 
in  1  the  aneurismal  sac  was  plugged  with  horsehair.  In  all,  82  cases  were  treated.  For 
full  details  ride  valuable  paper  by  Charles  Symonds  (Gut/'s  Rep.,  vol.  xxv.,  1881,  p.  447). 

Treatment  by  Compression. 

1.  Indirect  Pressure. — This  plan  of  treatment,  to  which  the  term  "  Dublin 
method  "  may  fairly  be  given,  has  now  found  a  lasting  place  in  surgery  :  Todd.  Hutton, 
Bellingham.  Tufnell,  and  Carte,  though  not  originating  the  practice,  having  adduced  ample 
evidence  of  its  scientific  and  practical  value.  It  consists  essentially  in  the  more  or  less 
complete  cutting  off"  the  supply  of  blood  from  the  aneurismal  sac  by  the  application  of 
pressure  to  the  artery  on  its  cardiac  side  ;  and  the  more  completely  the  current  of  the 
blood  is  arrested,  the  more  rapid  appears  to  be  the  cure,  modern  experience  having  fairly 
proved  the  soundness  of  Dr.  W.  Murray's  observation  in  1871,  that  the  principle  on 
which  the  rapid  method  rests  is  clearly  ••  the  complete  stagnation  of  a  mass  of  blood  in 
the  aneurism  until  it  coagulates."  Whether  this  is  to  be  done  under  the  influence  of  an 
anaesthetic  or  without,  whether  by  pressure  both  above  and  below  or  only  above  the  sac, 
and  whether  the  pressure  is  to  be  made  by   the   hand,  by  flexion,  by  a  weight,  or  by  a 


Tni:.\TMi:sT  nv  (•(fMi'ni-:ssi().\.  363 

touriii(|Uot,  arc  (iiu'stimis  wliicli  in  no  wav  (micli  ilic  {iriiici|il(;  nii  wliidi  tlic  treatment 
is  based.  The  |>ractiee  is  tlutirelieallv  Mtiiinl  aii<l  jiraetieally  safe,  ami  is  ea|ialile  by 
itself  hI"  ciiriiit^  tlic  iiiaj(trity  of  surfrical  aiieiirisnis,  and  even  some  that  are  internal.  At 
least  I'oiir  eases  i>l'  aneurism  of  the  neelc  have  l»een  cimMl  l»y  dijrital  eompression  ol'  the 
eoinmon  eamtid,  and  .Nl.  Kuiii^e  of  Lau.sanne  re|Mirts  a  fifth,  in  which  a  man  iet.  (!H  had 
a  earnti<l  ain-iirism  cured  in  seventeen  days  by  lateral  jiressure  between  the  thumb,  in 
IVont  (if  the  sternu-masloid  mu.M'le,  and  the  fin<rers  behiiul  (Hull,  dr  In  Sue.  ih  Chlr..  IHdK, 
]i.  Kil).  .Mr.  (iay  has  al^i  a|i|parctitly  cured  ;i  sixth  case  by  tin-  same  process  {Lnuirt^ 
Hcdmes's  lect.,  ISTo). 

('(impression  should  not  be  altem|ite(l  where  evid(Mice  exists  of  jiressure  ujion  the 
main  vein  of  the  limb,  as  indicate<l  by  (edema,  or  where  the  aneurism  is  rapidly  increa.s- 
intr  or  a  rupture  ol'  the  aneurism  appears  immim-nt,  because  in  sucIj  cases  a  lifrature 
should  be  a|)plied  to  the  arterial  trunk.  It  should  not  be  persevered  with  when  slouph- 
inj:  of  the  skin  has  been  induced,  nor  ouffht  it  when,  from  some  constitutional  irritability, 
indocility,  or  stupidity,  the  patient  fails  to  second  the  surgeon's  aim;  for  to  make  the 
patient  understand  the  objects  which  the  surgeon  has  in  view  is  doubtless  a  valuable 
means  of  guaranteeing  their  successful  accomplishment.  Tt  mu.st  be  known,  however, 
that  when  compression  has  failed  to  cure,  "the  patient  is  in  a  worse,  and  not  a  better, 
state  for  subscMpient  operation."'  Mr.  Holmes  has  demonstrated  this  fact  (Lanrit.  Octo- 
ber 12,  1S74). 

This  treatment  can  be  carried  out  by  "  digital  "  or  "  instrumental  "  compression  or  by 
means  of  ''  Esmarchs  bandage,"  a  form  of  pressure  which  differs  from  the  other  in  some 
es.sential  points,  to  which  attention  will  be  drawn. 

l)ii/if(il  prrs.tiirt\t(>  be  successful,  must  be  well  applied;  when  indifferently  carried  out, 
it  is  probaldy  less  to  be  relied  upon  than  instrumental  pressure.  To  keep  up  a  steady  pres- 
sure u])on  the  trunk  of  an  artery  for  any  tiuie  consecutively  is  a  difficult  task,  and  few  men 
could  do  it  for  more  than  ten  uiinutes.  AVhat  is  wanted  is  the  steady  equal  pressure  of  a 
finger  or  thumb  applied  directly  over  the  vessel  which  is  to  be  compressed,  such  pressure 
being  .so  adjusted  as  to  be  suflScient  to  arrest  the  flow  of  blood  through  the  artery,  but  no 
more.  Greater  pressure  than  this  is  a  waste  of  power  on  the  part  of  the  surgeon  and  a 
cause  of  needless  distress  to  the  patient.  Neither  vein  nor  nerve  need  be  much  pres.sed 
upon,  as  a  rule,  nor  much  pain  produced.  To  carry  out  this  treatment  three  good  men 
should  be  employed  for  four  or  five  hours  consecutively,  each  in  rotation  carefully  apply- 
ing pressure  for  ten  minutes  at  a  time.  By  ado|iting  this  practice  1  have  cured  an  aneur- 
ism of  the  thigh  in  twenty-four  hours,  and  in  other  ca.ses  even  less  time  has  sufficed. 
In  a  case  I  recorded  in  Guys  I/o.y>.  R<p.  for  iStiO  a  patient  act.  32  cured  himself  of  a 
popliteal  aneurism  by  pressure  in  four  and  a  half  hours.  In  one  more  recent  a  man  net. 
4(1  cured  himself  in  eighteen  hours,  after  flexion  and  prolonged  surgical  treatment  by 
instrumental  pressure  had  utterly  failed.  M.  Vanzetti  in  1855  records  a  case  in  which 
digital  compression  cured  a  popliteal  aneurism  in  four  hours. 

When  digital  pressure  can  be  employed  and  is  successful,  it  is  more  rapid  than  any 
other,  and,  as  a  rule,  less  painful.  It  can  also  be  used  where  instrumental  pressure  is 
inapplicable,  as  in  the  case  of  the  carotid.  In  fact,  when  admis.sible,  it  should  always  be 
primarily  employed  in  preference  to  any  other  form  of  treatment. 

I)i>itri(menfal  Compnssiou.  —  W/ien  (ligltcd  eompresaion  cannot  he  applied,  flif  nc.rf  best 
is  instrumental  pressure,  and  for  this  purpose  there  is  nothing  equal  to  a  conical  weight  of 
lead  (Fig.  149,  a)  covered  with  leather  and  perforated  with  an  iron  axle  (b),  upon  which 
extra  pieces  of  lead  (c)  can  be  dropped  (Bellingham's  method),  the  weights  being  so 
adjusted  as  to  arrest  the  circulation  through  the  artery,  and  no  more.  This  weight  can 
be  slung  to  a  cradle  placed  over  the  limb,  held  by  an  assistant  or  left  to  the  intelligent 
patient.  It  can  be  shifted  gently  from  one  spot  to  another  when  pressure  causes  pain, 
and  is  far  less  painful  than  any  other  instrument.  In  popliteal  aneurism  the  weight  may 
be  adjusted  to  the  upper  part  of  the  groin,  and  it  is  an  excellent  plan  to  apply  a  semicir- 
cular tourniquet  lower  down,  by  which  means  pressure  can  be  applied  alternately.  The 
instruments  of  Signorini,  Bellingham  (Fig.  149,  d),  Skey.  Crampton,  Carte,  or  any  other 
that  allows  the  pad  to  press  upon  the  vessel  and  not  otherwise  interfere  with  the  circula- 
tion through  the  limb,  may  be  used  for  this  purpose.  All  of  these  consist  of  a  circle  or 
semicircle  of  steel,  a  fixed  pad  being  attached  on  one  side  for  counter-pressure,  and  a 
movable  pad,  adjusted  by  a  screw,  for  direct  pressure.  Indeed,  with  these  instruments 
carefully  adjusted  by  the  aid  of  a  trustworthy  a.ssistant  w'ho  will  see  that  pressure  is  well 
applied,  maintained,  and  shifted  only  when  required,  most  cases  of  aneurism  of  an  extrem- 
ity may  be  treated.     In  Fig.  150  is  depicted  an  ingenious  contrivance  made  by  Weiss,  on 


364 


INSTRUMENTAL   COMPRESSION. 


the  principle  suggested  by  Mr.  F.  Bulley,  for  the  application  of  pressure  to  an  artery  by 
means  of  pads  which  may  be  used  alternately  and  adapted  to  Bellingham's  instrument  (d, 
Fig.  149),  either  by  the  rigid  screw  or  elastic  pressure  of  Coles's  pa"d  ;  and  in  Fig.  151  is 
shown  a  very  valuable  arrangement  suggested  by  Mr.  George  C.  Coles— the  pressure  being 


JBar  of  cradle 


Fig.  150. 


Weiss's  Double  Pad. 


Mode  of  applying  Pressure  to  the  P^emoral  Artery  for  the  Cure  of  Aneurism. 

elastic — which  may  be  used  as  hand  pressure  or  adapted  to  any  of  the  tourniquets.  The 
treatment  by  compression  requires  intelligent  supervision,  and  then  is  very  successful,  but 
without  such  it  is  uncertain  in  its  effects. 

My  friend  and  colleague,  Mr.  Davies-Colley,  who  happened  to  have  been  my  dresser 
when  a  case  of  popliteal  aneurism  was  under  treatment  by  digital  compression,  informed 
me  that  he  proved  by  experiment  that  he  could  readily  arrest  the  circulation  through 
the  femoral  artery  for  six  or  eight  hours  at  a  time  with  his  finger  applied  directly  over  the 
vessel  and  the  weight  adjusted  upon  his  finger,  the  weight  acting  in  lieu  of  the  muscular 
power  that  would  otherwise  have  been  required  as  the  compressing  force. 

To  neutralize  the  effects  of  the  local  irritation  of  the  skin  by  the  pressure,  free  use 
may  be  made  of  French  chalk,  starch,  or  violet  powder.     To  allay  pain  opiates  or  chloral 

in   full  doses  may  be  given, 
Fig.  151.  and  in  some  cases  even  chlo- 

rofonii  may  be  used  and  its 
influence  kept  up  for  several 
hours,  to  allow  of  complete 
compression  being  main- 
tained. Dr.  Mapother  did 
this  for  twelve  hours.  There 
seems  little  doubt  that  in  a 
general  way  complete  obstruc- 
tion to  the  circulation  is  more 
likely  to  be  followed  by  a 
rapid  cure  than  is  incomplete, 
and  that  next  to  completely 
stopping  the  flow  of  blood 
till  the  aneurism  has  consol- 
idated the  application  of  the  intermittent  complete  compressing  force  is  to  be  advocated, 
or,  in  other  words,  complete  compression  may  be  maintained  for  a  certain  time  and  then 
given  up,  to  be  returned  to  as  soon  as  the  condition  of  the  patient  will  permit.  The  total 
suppression  of  the  circulation  is  doubtless  the  most  rapid  plan  of  curing  an  aneurism,  but 


JMMMfil 


llus  instrument  consists  of  a  trephine  handle,  to  which  is  attached  a 
straight  rod  telescopically  arranged.  The  two  upper  segments  of  this 
rod  are  hollow  tubes,  each  containing  a  spiral  spring;  the  lower  segment 
IS  a  solid  brass  rod  fitting  into  the  upper,  having  at  its  extremity  a  screw 
at  an  ol)tuse  angle.  To  the  end  of  this  is  adjusted  a  pad  composed  of 
cotton-wool  and  horsehair. 


ti'j:.\tmi:st  nv  i:a.\1)A<;i:.  ;iG5 

tlu'  partial  .supprossion  is  likewise  successful,  altliou}.'li  slowiT.  On  all  these  points,  liow- 
ever,  I  shouUl  like  the  l)uliliii  surjjeoiis  to  speak.  Dr.  Kawiloii  Maciiaiiiara  has  clone  so 
ill  an  able  paper  (lirlt.  Mnl.  ./mtr.,  August  VJ,  1871),  IVoin  which  the  following  extract 
has  heen  taken.      It  epitomizes  the  whole: 

"A  ca.sc  of  ]iopliteal  ane.iirisni  presents  itself  for  treatment.  We  determine  to  use 
(•(impression.  We  first  carefully  ascertain  the  ccjiitlition  of  the  patient's  general  health. 
If  an;iMiiic  or  hypenemic,  we  take  appropriate  measures;  and  when  we  are  satisfied  upon 
this  point,  we  ap])ly  snine  one  or  other  of  the  most  improved  compressors — tho.se  in 
which  the  comjtressing  power  is  modified  elasticity.  With  this  we  compress  the  artery 
ill  the  upper  ])ortioii  nf  its  course,  having  previously  arranged,  some  three  or  four  inches 
lower  down,  the  aiixiliarv  instrument  by  means  of  which  we  propo.se  to  alternate  the 
pri'ssure.  The  upper  instrument  is  now  made  to  control  the  artery,  so  as  hut  just  to 
arrest  the  pulsation  in  the  sac.  This  is  the  most  delicate  step  in  all  the  procedure,  and 
is  regulated  by  the  hand  of  an  intelligent  assistant,  who  at  once  informs  us  when  the 
pulsation  is  arrested  ;  and  then  and  there  the  further  application  of  pressure  is  arrested. 
A  roster  of  intelligent  students  is  now  organized,  and  to  them  is  entrusted  the  manage- 
ment of  the  case.  Two  are  appointed  to  take  charge  of  the  patient  for  one  hour,  when 
tliev  arc  relieved  by  two  others,  and  so  on  during  the  day,  whereby  we  secure  unwearied 
attention  during  the  period  that  pressure  is  kept  up  ;  and.  as  in  Dublin  we  visit  our  ho.s- 
pital  at  1)  o'clock  A.  M.,  the  treatment  generally  commences  about  that  hour  and  is 
continued  up  to  nine  o'clock  P.  >[.,  when  all  pressure  is  rem<jved  and  the  patient  is 
encouraged  to  take  his  night's  rest  undisturbed.  Next  morning  the  treatment  is  resumed, 
and  so  on  until  the  cure  is  perfected.  At  the  commencement  of  the  ca.se  we  take  the 
patient  into  our  confidence,  explain  to  him  the  nature  of  his  case  and  the  method  we  are 
about  to  adopt  for  his  cure,  placing  clearly  before  him  the  alternative,  with  all  its  possi- 
ble dangers,  which  we  should  have  to  adopt  in  case  compression  should  fail.  The  value 
of  this  procedure  is  very  frequently  demonstrated  by  the  intelligent  interest  exhibited  by 
our  patients  in  the  management  of  their  own  cases — so  intelligent  as  in  protracted  cases 
to  supplement,  if  not  altogether  to  supersede,  the  supervision  of  them  by  our  students. 
In  the  selection  of  our  compressing  force  we  adopt  in  its  widest  sense  the  maxim  'Nullius 
addictus  jurare  in  verba  magistri.'  Should  one  compressor  prove  irksome,  we  try  another; 
if  all  should  fail,  we  have  recourse  to  digital  compression  or  to  compression  by  means  of 
weights ;  but  in  every  instance,  convinced  of  the  soundness  of  this  plan  of  treatment,  we 
leave  no  stone  unturned  to  .secure  its  success." 

Compression  by  (he  Elasdc  Bdinhige  of  Esmardi. — The  treatment  of  an  aneurism  by 
this  method  differs  from  all  other  forms  of  treatment  by  compression  in  that  in  it  the 
blood  is  totally  arrested  in  all  the  vessels  of  the  extremity  to  which  it  is  applied  and  iKit 
in  the  main  artery  alone,  as  in  other  forms  of  compression.  Under  such  circumstances, 
the  method  has  its  own  dangers,  in  addition  to  those  it  shares  with  others ;  and  the  chief 
I  believe  to  be  gangrene,  due,  apparently,  to  the  clotting  of  the  blood  in  the  collateral 
vessels  of  the  limb  upon  which  its  vitality  depends.  The  following  case  illustrates  the 
point. 

The  case  was  that  of  a  man  fet.  45,  who  was  admitted  into  Guy's,  under  my  care,  in 
March,  1877,  with  a  po])liteal  aneurism,  which  was  increasing  so  rapidly  that  active 
treatment  was  called  for.  The  man  could  bear  neither  digital  nor  instrumental  pressure 
upon  the  afferent  artery.  I  consequently  applied  the  elastic  bandage  to  the  limb  below 
the  aneurism,  using  moderate  pressure,  allowed  the  aneurism  to  fill  with  blood,  and  then 
so  compressed  the  thigh  above  the  sac  as  to  entirely  check  all  pulsation  in  it.  these  three 
being  apparently  the  essential  points  to  observe.  A  subcutaneous  injection  of  morphia 
was  also  given.  The  pressure  was  maintained  for  three  hours  consecutively  and  a  second 
dose  of  morphia  injected;  but  when  the  bandage  was  removed,  the  aneurism  was  decidedly 
harder,  although  pulsation  still  existed  in  it.  Four  days  later  all  clot  .seemed  to  have  dis- 
appeared, and.  as  the  aneurism  was  as  big  as  ever,  the  elastic  bandage  was  again  applied, 
only  on  this  occasion,  to  soothe  the  man,  an  antvsthetic  was  used.  This  treatment  was 
continued  on  this  occasion  for  three  hours,  and  at  the  end  little  had  been  gained  from  it. 
A  fortnight  was  then  allowed  to  elapse  to  allow  the  parts  thoroughly  to  recover  them- 
selves, when  a  carbolized  catgut  ligature  was  applied  to  the  artery,  and  within  one  week 
the  wound  had  completely  healed  by  immediate  union,  not  a  drop  of  pus  having  been 
exuded  ;  indeed,  the  patient  had  no  idea  that  any  operation  had  been  performed  upon 
his  thigh. 

The  foot,  however,  soon  became  the  seat  of  anaemic  gangrene,  and  a  fortnight  after 
the  application  of  the  ligature  amputation   in   the  middle  of  the  leg  \\as  required  and  a 


366  TREATMENT  BY  DIRECT  PRESSURE. 

good  recovery  followed.  At  the  amputation  every  arterial  trunk  was  found  obstructed. 
No  vessel  required  torsion   or  ligature. 

In  this  case  I  am  disposed  to  attribute  the  gangrene  to  the  employment  of  the  elastic 
bandage,  and  fear  that  from  its  two  applications  the  collateral  vessels  that  would  have 
carried  on  the  circulation  through  the  foot  after  the  ligature  of  the  femoral  had  become 
blocked,  and,  as  a  consequence,  gangrene  followed. 

This  plan  of  treatment  was  first  suggested  and  carried  out  by  Staif  Surgeon  "\V.  Reid, 
R.  N.  {Lancet,  1875),  and  it  has  since  been  practised  in  more  than  7<l  cases.  I  have 
employed  it  in  3.  Mr.  Pearce  Gould,  an  able  assistant  surgeon  of  the  Middlesex  Hospital, 
has  in  an  interesting  paper '  tabulated  72  examples,  35  of  which  or  half  the  cases  were 
cured.  In  2  the  treatment  was  doubtful;  in  20  a  cure  followed  the  ligature  of  the  artery; 
3  were  cured  by  compression  and  1  spontaneously,  and  1  (of  bracheal  artery)  by  the 
introduction  of  catgut  into  the  .sac.  In  3  the  artery  was  ligatured  without  success ;  in  3 
death  took  place  whilst  under  treatment,  and  in  1  the  limb  was  amputated  with  a  fatal 
result.  Of  the  whole  number  of  72  cases — omitting  the  3  of  which  no  subsequent  his- 
tory was  known  after  the  failure  of  the  method  and  the  2  doubtful — G  died.  35  were 
cured,  and  25  were  successfully  treated  by  other  means  after  the  failure  of  Esmarch's 
bandage,  in  my  own  case  after  amputation — a  result  which  is  certainly  encouraging. 
The  method  is  most  applicable  to  small  sacculated  aneurisms  in  fairly  healthy  subjects, 
and  ought  not  to  be  practised  when  the  aneurysm  seems  thin  and  likely  to  rupture,  and 
when  by  pressure  it  materially  interferes  with  the  venous  circulation  of  the  limb. 

When  employed,  the  bandage  .should  be  so  applied  as  to  secure  complete  blood  stasis 
in  the  aneurismal  sac  and  its  atljacent  artery,  and  this  stasis  should  not  in  the  majority  of 
cases  be  maintained  for  inore  than  one  hour,  or  for  more  than  two  in  any.  The  bandage 
should  primarily  be  applied  below  the  aneurism  with  sufficient  firmness  to  arrest  the  cir- 
culation through  the  limb.  It  should  be  passed  lightly  over  the  aneurism,  so  as  to  sup- 
port but  not  compress  it ;  and  when  carried  fairly  above  the  tumor,  which  should  be  allowed 
to  become  well  filled  with  blood,  it  should  so  constrict  the  limb  above  as  to  prevent  any- 
thing like  a  circulation  being  carried  out.  In  irritable  subjects  a  subcutaneous  injection 
of  morphia  should  be  given  before  the  treatment  is  commenced,  and  in  others  an  anaes- 
thetic may  be  used.  When  the  sac  appears  to  have  been  filled  with  clot  and  pulsation  in 
it  has  ceased,  it  is  wise  to  have  digital  or  instrumental  pressure  kept  up  upon  the  aflferent 
artery  for  ten  or  twelve  hours,  and  even  when  a  doubtful  cure  has  taken  place  a  like 
treatment  may  bring  about  a  good  result.  Indeed,  in  all  cases  of  rapid  cure  of  aneurism 
by  this  or  other  modes  of  compression  this  treatment  should  be  pursued,  because  the  clot 
that  has  filled  the  sac  must  of  necessity  be  soft,  and  a  very  little  may  cause  its  displace- 
ment, and  thus  interfere  with  that  natural  contraction  of  the  fibrin  of  the  blood  that  is  to 
fill  the  sac  permanently,  prevent  its  dilatation,  and  cure  the  disease.  At  Guy's  Hospital, 
out  of  17  cases  of  popliteal  aneurism  consecutively  treated  b}'  pressure,  11  were  cured; 
and  Mr.  Holmes  informed  us  in  his  college  lectures  that  out  of  124  cases  so  treated  in 
different  hospitals,  66  were  treated  with  and  58  without  success.  Of  the  latter,  in  44, 
the  femoral  artery  was  afterward  tied,  and  in  8  amputation  was  practised,  5  dying.  Death 
occurred  in  1  case  and  in  4  there  was  no  evidence  of  subsequent  treatment  (^Lancet, 
December  19, 1874).  In  the  majority  of  these  cases  instrumental  pressure  was  employed, 
and  in  some  the  treatment  was  imperfectly  carried  out. 

2.  Treatment  by  Direct  Pressure. — The  treatment  of  aneurism  by  direct 
compresiiirm  next  claims  attention,  and  in  modern  times  it  is  known  as  that  hx  flexion  ;  for 
there  can  be  little  doubt  that  the  modus  operandi  of  flexion  in  the  cure  of  aneurism  is 
mainly  due  to  three  conditions  :  first,  to  direct  compression  of  the  aneurismal  tumor  itself: 
secondly^  to  indirect  compression  through  the  medium  of  the  tumor,  intercepting  either 
wholly  or  partially  the  supply  of  blood  to  the  sac:  and.  thirdlij.  to  displacement  of  the 
clot,  as  suggested  by  Holmes,  and  the  consequent  obliteration  of  the  mouth  of  the  aneur- 
ismal tumor.  This  mouth  may  likewise  be  so  situated  as  to  be  closed  by  the  bending  of 
the  artery,  an  aneurism  in  the  posterior  wall  of  the  popliteal  artery  being  in  a  far  more 
favorable  position  for  cure  than  one  on  the  anterior.  At  the  same  time  we  know  that 
forced  flexion  of  a  limb  is  capable  of  arresting  the  flow  of  blood  through  the  healthy 
artery.  In  England.  Mr.  E.  Hart  demonstrated  the  success  of  this  method  of  treatment 
in  the  year  1858.^  although  in  1857,  Dr.  Maunoir  of  Geneva  recorded  the  first  successful 
case  in  U Echo  Medicate  (Neufchatel),  and  since  that  time  many  surgeons  have  success- 
fully applied  the  practice.     To  carry  it  out.  the  limb  must  be  carefully  bandaged  from 

'  Trans,  of  Internat.  Congress,  1881,  vol.  ii.  p.  209. 
^  Med.-Chir.  Trann.,  vol.  xlii.;  Pvoceediny.*,  vol.  iv. 


ri'J'.ATMKST  nV   DISTAL    PRF-^.^mE.  367 

helow  upwanl  to  the  am-urisiii.  and  in  the  case  of  the  pnjjliteal  artery  the  knee  shouhl 
l»e  hent,  sutticient  force  l)einji;  ein|ih»yL'd  to  iliininish  or  arrest  the  pulsation  of  the  tumor, 
hut  no  more,  some  turns  of  the  roller  maintaininj;  the  limh  in  this  p(jsition.  The  tliij^h 
shouUl  then  he  flexed  upon  the  pelvis  and  the  patient  turned  on  his  side  with  tlie  linih 
restintr  o.i  a  pillow.  My  this  plan  tlie  arrest  of  the  cireulation  throujrh  the  aneurism  may 
freiierally  he  efl'ected  and  a  cure  expected.  When  the  flexion  is  forced,  the  jiatient  is  too 
often  unahle  to  endun'  the  sufVerin;;  cause<l  hy  the  jiosition.  To  lar<re  and  rapidly  }rrow- 
inir  aneurisms  this  method  is  inapplicahle,  and  jtrohahly  dangerous,  as  it  may  induce  rup- 
ture ;  and  when  any  iuHammation  or  other  complication  exists,  it  ought  not  to  he  em[»loyed, 
nor  ought  it  he  persisted  in  when  it  is  not  lihviously  doing  go(jd.  The  plan,  however,  in 
small  ant'urisms  is  .so  simple,  and  when  liearahle  is  so  successful,  that  it  should  always  be 
attem]>tcd  where  it  can  he  applicil  ;  and  when  unsuccessful,  it  is  almost  harmless. 

Pressure  may  likewise  he  used  with  riexion  where  the  latter  is  insufficient,  many  ca.se.s 
having  been  reported  in  which  success  followed  the  conjoint  means.  In  one  under  my 
care  in  1S71  I  cured  aneurisui  helow  the  popliteal  space  in  eighteen  hours  by  alternating 
the  flexion  of  the  leg  with  digital  pressure  in  the  groin. 

M.  Liegoi.s  in  an  interesting  paper  (^IJ  Utiian  Med.,  August,  18G9)  gives  11  ca.ses  in 
which  flexion  alone  proved  successful  in  popliteal  aneurism,  and  also  11  in  which  it  wa.s 
successful  in  combination  with  other  measures.  In  4  it  succeeded  after  other  means 
had  failed.  On  the  other  hand,  it  failed  in  23  eases,  or  nearly  half  the  whole  number, 
and  of  the.se  7  are  stated  to  have  suffered  rupture  and  1  had  inflammation  of  the  .sac. 
Holmes's  statistics  show  nearly  the  same  results. 

3.  Distal  Pressure. — The  compression  of  an  artery  on  the  distal  side  of  an  aneur- 
ism for  purjKiscs  of  cure  claims  a  notice  as  a  resource  open  to  the  surgeon  when  all  others 
are  ina]>](lical)le,  since  there  is  enough  evidence  to  show  that  by  such  means  an  aneurism 
may  be  cured.  In  my  own  practice,  in  1S72.  I  treated  a  case  of  abdominal  aneurism  on 
this  principle,  and  kept  up  pressure  for  sixteen  hours;  and,  although  the  patient  died 
from  peritonitis,  bi'ought  on  by  the  pressure,  the  condition  of  the  sac  filled  with  clot  was 
enough  to  prove  the  pos.sibility  of  a  cure  being  brought  about.  In  the  Tmnsorfions  of 
the  Royal  Med.  and  Chir.  Society,  vol.  Iv.,  the  ca.se  is  published  in  detail,  with  some 
remarks  on  distal  treatment  which  need  not  be  repeated  in  the.se  pages,  although  it  may 
be  stated,  from  my  own  cases,  from  Edwards's  case  of  the  innominate  (Lancet,  January 
9,  1858),  from  Porter's  (DuhUn  Quart.  Jonrtiaf,  November,  1867).  and  others,  that  the 
distal  treatment  of  aneurism  by  compression  or  ligature,  whereby  the  efferent  artery  of 
an  aneurism  can  be  obstructed,  claims  the  surgeon's  close  attention  when  other  means  are 
ina]i))licable. 

Tiwporary  Occlusion  nf  Artery. —  The  wire  compress  of  Mr.  Die  of  Hull,  already 
alluded  to  (see  p.  34(3).  requires  naming  as  a  means  of  dealing  with  aneurism.  It  is  a 
method  that  has  been  advocated  by  Porter  of  Dublin  (Di(h.  Quart.  Jfntm.,  November, 
1867).  Hilliard,  and  others  (vide  Mr.  Dix's  paper  in  the  British  Medical  Journ..,  October 
30.  1875,  p.  551).  It  is  in  reality  treatment  by  compression,  and  not  by  strangulation. 
It  does  not  cut  the  artery  nor  obliterate  it  at  the  seat  of  operation  ;  therefore  in  principle 
and  methodus  medendi  it  ranks  not  with  the  ligature,  but  with  the  tourniquet  and  other 
modes  of  pressure.  But,  forasmuch  as  the  application  of  the  wire  requires  exposure  of 
the  artery  by  a  cutting  operation,  this  process  cannot  enter  into  surgical  competition  with 
the  simpler  methods  of  compres.sion  and  flexion  ;  yet  where  these  have  failed  or  are  inap- 
plicable, and  operative  procedure  is  inevitable,  "then,"  says  the  author,  '•  I  back  my  ope- 
ration, for  certainty,  rapidity,  and  .safety,  against  any  form  of  ligature — silk,  hemp,  or 
catgut — or  against  any  kind  of  forceps,  '  artery  constrictor."  or  compressor  applied  in  or 
through  a  wound.  " 

The  operation  is  as  follows,  and  it  seems  to  be  specially  necessary  to  follow  out  the 
exact  details  with  care  and  attention : 

The  artery  is  exposed  by  incision  and  the  aneurism  needle  passed  in  the  usual  way. 
A  piece  of  surgical  wire  about  9  inches  long  is  threaded  through  the  eye  of  the  aneurism 
needle  and  carried  beneath  the  artery  by  the  withdrawal  of  the  needle,  which  is  then 
separated  from  the  wire.  A  straight  surgical  needle  is  then  attached  to  either  end  of  the 
wire  and  the  two  needles  (first  one  and  then  the  other)  are  passed  through  the  ti.ssues  to 
the  surface,  so  that  they  emerge  on  the  skin,  one  about  a  quarter  of  an  inch  and  the  other 
three-quarters  of  an  inch  from  the  edge  of  the  wound,  on  whichever  side  of  it  may  seem 
most  convenient,  hut  loth  on  the  same  side  (Fig.  152).  By  drawing  them  through 
together  the  wire  forms  a  loop  over  the  artery  and  the  intervening  tissues,  and  the  needles 
are  then  detached  from  the  wire.     The  half  of  a  vial  cork,  flat  side  downward,  is  now 


368 


TREATMENT  BY   WIRE  COMPRESS. 


Fig.  152. 


U/XT*- 


t tL  ourtc Tit ~        ~; 
Dix's  Mode  of  Compressing  Artery. 


placed  on  the  skin  between  the  ends  of  the  protruding  wire  and  firmly  pressed  down  by 
the  fingers  of  an  assistant  in  the  exact  line  of  the  urteri/,  the  wire  being  at  the  same  time 
drawn  tightly  upward  and  sharply  twisted  over  the  cork  till  the  current  through  the  artery 

is  effectually  stopped  and  the  pulsation  of 
the  aneurism  ceases.  It  Is  of  great  import- 
ance that  the  po.sition  of  the  cork  should 
be  longitudinally  over  the  course  of  the 
artery,  so  that  the  blood  current  is  checked 
as  much  by  the  downward  pressure  of  the 
cork  as  by  the  upward  tension  of  the  wire, 
the  intervening  tissues  forming  a  firm  com- 
pressed pad.  The  superfluous  ends  of  wire 
are  then  cut  off"  and  the  wound  closed  and 
dressed  according  to  the  predilections  of  the 
surgeon. 

"When  the  depression  of  anaesthesia  goes 
off"  and  the  circulation  revives,  it  will  be 
found  that  a  feeble  pulsation  returns  in  the 
aneurism.  This,  according  to  the  author  (who  strongly  advocates  the  gradnal  rather  than 
the  rrqnd  method  of  producing  coagulation  in  the  sac),  should  be  allowed  to  go  on  for  two, 
or  even  three,  days,  when  the  wire  is  to  be  tightened  in  the  following  manner : 

The  cork  being  firmly  pressed  down  over  the  artery,  the  wire  is  drawn  uj)ward  by 
gentle  traction  on  its  twisted  ends,  and  two  or  three  small  wooden  wedges  are  pushed  in 
hy  an  assistant  between  the  cork  and  the  wire,  so  that  sufficient  tension  is  caused  to 
entirely  stop  all  pulsation  in  the  aneurism.  If  the  wire  has  been  sufficiently  drawn 
tightly,  at  fir.st  very  small  wedges  are  required,  such  as  two  or  three  bits  of  a  lucifer 
match,  for  instance.  The  wire  is  on  no  account  to  be  twisted  afresh,  lest  it  break-. 
Meanwhile,  by  the  action  of  the  two  or  three  days'  feeble  current  the  .sac  has  been  pre- 
pared, as  it  were,  for  the  coagulation  of  sudden  sfft  clot  which  is  now  formed,  whilst  the 
collateral  circulation  has  also  by  the  same  means  been  encouraged,  the  result  being  that 
in  from  twenty-four  to  forty-eight  hours  consolidation  is  perfect ;  thus  about  the  fifth  or 
sixth  day  the  cure  is  complete  and  the  compress  may  be  removed,  which  is  thus  done : 
Untwist  the  wire  and  remove  the  cork ;  separate  widely  the  two  ends  of  the  wire,  to 
lessen  the  curve  as  much  as  possible ;  clip  off"  one  end  close  to  the  skin  ;  make  gentle 
pressure  with  one  finger  where  the  cork  has  been,  and  by  steady  traction  on  the  other 
end  of  the  wire  it  is  readily  withdrawn.  If  it  should  seem  to  adhere,  leave  it  till  next 
day.  when  it  must  have  becom'^  loosened  in  the  tissues  and  will  be  easily  removable. 
The  advantages  of  this  ruethod  are  thus  summarized  by  Mr.  Dix  : 

I.  The  wire  does  not  cause  ulceration  or  any  damage  to  the  coats  of  the  artery,  either 
external  or  internal ;  therefore,  the  blood  channel  being  unopened,  bleeding — one  of  the 
chief  dangers  of  the  old  operation — is  impossible. 

II.  By  causing  at  first  a  retarded  circulation  and  a  diminished  current  it  most  accu- 
rately imitates  the  natural  cure  of  aneurism,  and  by  allowing  time  for  the  establishment 
of  the  collateral  circulation  the  risk  of  gangrene — the  second  great  danger  of  the  ligature 
— is  very  much  diminished. 

If,  nevertheless,  there  be  coldness  of  the  limb  and  a  threatening  of  gangrene,  the 
wire  can  be  at  once  untwisted  and  relaxed,  or  even  removed. 

III.  Ultimately  the  current  through  the  artery  and  the  sac  is  entirely  obstructed,  so 
as  to  produce  the  needful  clot.  Of  course  this  complete  obstruction  can  be  effected  at 
first  if  desired,  and  therefore  this  operation  does  what  an  operation  by  ligature  or  forceps 
cannot  do — viz.,  it  gives  the  surgeon  a  choice  between  the  rapid  and  the  gradual  method 
of  treatment. 

It  will  be  seen  that  in  the  opinion  of  the  author  the  gradual  method  is  much  to  be 
preferred,  and  he. considers  it  one  of  the  chief  merits  of  his  operation  that  this  effect  can 
be  produced. 

lA^.  The  -jvire  does  not  act  as  a  foreign  body  in  the  wound,  setting  up  suppuration 
and  impeding  the  healing  process,  as  a  ligature  does. 

V.  It  is  not  a  fixture  upon  the  artery  remaining  for  an  indefinite  period,  but,  its  work 
being  done,  it  can  be  at  on<:-e  got  rid  of. 

VI.  The  clot  produced  by  this  concurrence  of  the  gradual  and  rapid  method  is  less 
likely  to  break  down  and  suppurate  than  the  soft  sudden  clot,  which  is  the  eff'ect  of  the 
ligature. 


TRKATMhWr   I'.Y    I.IC ATrilE. 


;ifj9 


Fio.  153. 


Anol's.       Hunter's. 


Wardrop's. 


\'II.  .\n(l  lastly.  .\.'h  tlicrt'  i>  no  |Mis.sil)ilit y  nl'  lilciMlini:;  rrmii  tlic  artery,  the  Hiirj.'(!(»n 
ha.s  a  wider  elioiee  dI"  loeality  fnr  u|ierati(iii.  I"'(ir  in.staiice,  tlie  <<iiiiiiiiiii  leiriorul  rir  the 
external  eamtid,  whieh  dm  iiecimiit  of  heiiiorrliai^ic  ri.sk.s  i.s  usually  avditJeil  hy  the  (ipe- 
rutDr.  may  he  .safely  treated  on  this  plan,  which  is,  indeed,  applieahle  to  all  arteries  alike. 

N.  U.  InasMMudi  as  it  i\y)vs  not  idditerate  tlit!  artery  at  the  site  oC  the  application  of 
tlie  wire,  this  procedure,  in  ifs  /msi nf  ('unn.  is  not  suitahhr  for  tin;  distal  operation  ;  hut 
it  is  prohahhf  that  complete  ot-clusion  and  ohlitiMution  may  he  clh-eted  hy  tin;  simple  nnjdi- 
ticalion  of  applyinir  '"'"  wires  upon  the  vessel  ahoiil  Imli'  an  inch  a]iart,  lielween  whieh  a 
clot  would  iorm  and  hecome  or<;anizeil. 

This  nu'thod  is  (|uite  trustworthy  in  trainnalic  aiMuri^in  and  in  a  wounded  artery, 
where  a  wire  should  he  applied  on  either  side  of  the  orilice  in  llie  artery  and  the  ves.sel 
divided  hetwei-n  them.      It  has  also  proved  succe.ssful  in  amputution,  etc. 

4.  The  Treatment  by  Ligature. — When  the  treatment  of  an  aneurism  hy  com- 
pression in  one  of  its  forms  is  inappli(;ilile  either  from  the  position  of  the  antMirism  or  from 
the  unsatisfactory  comlition  of  the  ])atient,  or 
when  su(di  treatment  has  proved  unsuccessful, 
then  the  treatment  hy  li<j;ature  should  he  enter- 
tained ;  and  this  should  he  carried  out  hy  the 
Hunterian  method  (Fijr.  !'>;}) — that  is,  hy  the 
application  of  a  ligature  at  some  distance  from 
the  sac,  ratlier  than  hy  the  "  methode  d'Anel," 
in  which  the  li<rature  is  ap])lied  close  to  the 
aneurism.  The  advantages  of  the  Hunterian 
operation  are  the  slight  flow  of  blood  through 
the  aneurism  when  the  main  flow  is  arrested,  the 
maintenance  of  the  collateral  circulation,  and  the 
probability  of  the  artery  being  more  healthy  at 
some  distance  from  than  clo.se  to  the  seat  of  dis- 
ease. The  operation  is  also,  as  a  rule,  less  diffi- 
cult. 

The  ligature  employed  should  be  of  either 
carbolized  silk,  ox  aorta,  kangaroo  tendon,  or 
prepared  catgut.  The  ends  of  the  ligature  should 
be  cut  ort"  short  after  the  band  has  been  tied,  and 
an  attemj)!  should  be  made  to  get  quick  union  of 
the  wound.  To  leave  the  ends  of  the  ligature 
long  encourages  suppuration  and  ulceration  of  the  artery  at  the  point  of  ligature  ;  the 
vessel  may  ulcerate  through  or  a  portion  of  the  artery  may  slough  away  with  it — a  pro- 
cess which  takes  from  nine  to  twenty  days,  or  more  in  large  vessels.  With  the  prepared 
catgut  ligature  now  en)ployed,  some  ulceration  of  the  vessel  at  the  seat  of  ligature  may 
likewise  follow,  but  a  complete  division  of  the  artery  by  ulceration  need  not  take  place. 
On  that  account  the  catgut  ligature  is  preferable. 

Causes  of  Death  after  Llijatiir' . — When  the  ligature  fails  and  death  ensues,  it  is  from 
gangrene  of  the  parts  below  the  seat  of  disease  or  from  secondary  hemorrhage.  The 
former  is  the  more  fre(|uent  cause  of  death,  and,  according  to  Dr.  Norris,  out  of  fifty 
fatal  eases  of  ligature  of  the  femoral  artery,  twenty-three  died  of  gangrene  and  only  eight 
of  hemorrhage.  To  lessen  the  risk  of  hemorrhage  some  excellent  surgeons  have  within 
the  last  lew  years  returned  to  the  old  practice  of  ligating  the  artery  in  two  places  and 
dividing  it  between  the  ligatures.  They  have  done  this  under  the  idea  that  by  such  a 
practice  the  tension  of  the  vessel  is  lessened,  and,  as  a  con.sequence,  the  risks  of  bleeding 
are  diminished.  Signor  Corradi  of  Florence  follows  this  method,  as  a  rule,'  and  Dr.  J. 
Lidell  advises  it. 

When  a  ligature  is  ap))lied  to  the  main  artery  of  a  limb,  the  circulation  is  for  a  time 

more  or  less  cut  off";  conse(niently.  coldness  of  the  part,  and  even  gangrene,  may  ensue. 

Congestion,  however,  generally  takes  place  gradually  in  the  extremity,  from  the  blood 

being  forced  into  the  collateral  vessels,  and  with  this  some  increase  of  temperature  may 

be  felt,  with   hypenxjsthesia.     This  point  has  been   already  noticed  in   my  remarks  on 

embolic  arterial  obstruction.      Brown-8e<|uard  explains  the  elevation  of  temperature  that 

is  often   observed  in  a  part   after  the  application  of  a  ligature  to  its  main  artery  l)y  the 

paralysis  of  the   vaso-motor   nerves  that   ramify  on   or  in   the   coats   of  the  vessel,  this 

paralysis  producing  a  corresponding  paralysis  of  the  ramifications  of  the  vessels,  and,  as 

*  Ashhurst's  Internat.  Eiiciiclon.  of  Sun/.,  vol.  iii. 
24  J     I     J         J' 


Diagram  showing  the  DifTerent  Operatiou.s  for 
Aneurism. 


370  TREATMENT  BY  LIGATURE. 

a  consequence,  the  blood  finds  its  way  freely  through  the  collateral  branches  into  the  part 
below  the  seat  of  the  ligature  ;  this  increased  activity  of  the  collateral  circulation  produces 
the  congestion  of  the  part  as  well  as  the  concomitant  elevation  of  temperature  (Arc/iives 
de  Physiolotjie,  1851).  The  surgeon  should,  however,  after  the  application  of  a  ligature 
do  what  he  can  to  maintain  the  temperature  of  the  limb,  which  is  best  effected  by  cover- 
ing it  thickly  with  cotton-wool,  at  the  same  time  keeping  the  part  raised,  to  encourage 
the  venous  circulation.  Simple  nutritiou.s  food  should  be  allowed,  but  stimulants  only 
with  great  caution,  and  in  quantity  merely  enough  to  help  digestion  and  maintain  the 
force  of  the  heart's  action,  the  habits  of  the  patient  forming  the  best  guide  as  to  quantity. 
Should  pain  be  present,  opium,  morphia,  or  chloral  must  be  prescribed,  either  by  the 
mouth  or  subcutaneously. 

When  the  ligature  has  separated,  the  wound  healed,  and  the  aneurism  consolidated, 
no  forcible  or  prolonged  exercise  of  the  limb  must  be  allowed  for  some  weeks,  although 
gentle  exercise  is  beneficial.  The  limb  should  also  be  kept  warm,  for  it  has  happened 
that  the  circulation  through  it  has  failed  to  become  full  or  even  sufficient  after  the  opera- 
tion, and  some  permanent  weakness  and  loss  of  sensation  has  been  left.  A  patient  may, 
however,  live  a  long  life  even  after  a  double  operation.  In  1864  I  saw  a  man  aet.  51 
upon  whom  Mr.  B.  Cooper  had  operated  twenty-three  years  before  (1841)  for  popliteal 
aneurism  of  the  left  leg,  and  of  the  right  in  1843.  He  had  been  an  orange-porter,  and 
subsequently  followed  his  work.  When  gangrene  takes  place,  it  is  generally  as  a  direct 
result  of  the  cutting  off  of  arterial  supply  from  a  limb  and  of  the  ensuing  blood  stasis. 
As  a  consequence,  it  occurs  within  a  few  days  of  the  ojieration.  It  may,  however,  be 
produced  by  the  presence  of  an  inflamed  or  rapidly  increasing  aneurism,  and  has  then 
little  or  nothing  to  do  with  the  operation.  It  should  be  dealt  with  energetically.  If  it 
spread  rapidly  and  threaten  life,  amputation  of  the  limb  about  the  line  of  ligature  should 
be  performed  without  delay.  Should  it,  however,  be  limited  in  its  nature  and  slowly  pro- 
gressive, the  expectant  treatment  must  be  employed.  The  warmth  of  the  limb  at  the 
same  time  should  be  carefully  looked  to,  the  sloughing  or  dying  parts  covered  with  well- 
oiled  lint,  the  venpus  circulation  assisted  by  the  elevated  position  and  by  gentle  friction, 
and  the  powers  of  the  patient  stimulated  by  food  and  wine,  opiates  being  administered  for 
the  alleviation  of  pain. 

When  the  sac  of  the  aneurism  inflames  and  suppurates  after  the  application  of  a  liga- 
ture, the  case  may  be  regarded  as  one  of  local  gangrene  the  result  of  the  operation  ;  it  is 
a  dangerous  complication  and  no  definite  rules  can  be  laid  down  for  its  treatment. 
Hemorrhage  is  occasionally  a  result  of  this  action,  the  blood  coming  from  the  lower  end 
of  the  vessel ;  pyaemia  or  blood  poisoning  is  another.  In  general,  when  an  aneurismal 
sac  suppurates,  amputation  is  the  best  practice  when  it  can  be  performed,  and  where  it 
cannot  the  operation  of  Antyllus  may  be  successful,  as  in  a  case  of  carotid  aneurism 
reported  by  Mr.  H.  Morris,  Med.  Chir.  Tram.,  vol.  Ixiv.  In  August,  1871,  I  applied  a 
ligature  to  the  left  carotid  artery  of  a  man  set.  29  for  a  large  aneurism,  and  death  ensued 
on  the  thirty-fourth  day  from  suppuration  of  the  sac  and  sloughing  of  nearly  the  whole 
aneurism.  This  process  had  been  preceded  by  some  hemorrhage  on  the  thirteenth  day 
after  the  operation.  The  same  result  may  take  place  after  the  cure  by  compression^ 
rapid  or  slow.  It  is  an  open  question,  however,  whether  aneurismal  sacs  that  have  been 
suddenly  filled  with  coagula  are  not  more  liable  to  break  up  and  suppurate  than  others  in 
which  the  process  has  been  more  gradual. 

In  rare  instances  after  the  Hunterian  operation  the  pulsation  of  an  aneurism  reap- 
pears, and  a  passing  feeble  pulsation  in  the  sac  a  day  or  two  after  the  application  of  the 
ligature  is  by  no  means  a  rare  occurrence,  nor  need  it  excite  any  alarm,  as  it  is  doubtless 
due  to  the  passage  of  a  feeble  current  of  blood  through  the  sac  by  means  of  a  collateral 
branch.  This  is  more  likely  to  occur  when  a  cure  by  pressure  has  been,  previously 
attempted  and  failed,  the  collateral  circulation  having  been  enlarged  by  the  pressure. 
Should,  however,  the  pnhnflon  continue  peraisfenf,  even  after  the  application  of  a  ligature 
to  the  main  trunk,  it  will  be  fair  to  infer  that  a  "  vas  aberrans  "  exists,  by  which  the 
blood  is  brought  direct  to  the  aneurism,  and  which  must  be  ligatured  before  a  cure  can 
be  expected.  At  times  the  existence  of  this  vas  aberrans  may  be  made  out  at  the  time 
of  operation,  when  the  vessel  must  be  looked  for  when  the  main  trunk  is  tied  ;  indeed,  it 
may  be  possible  that  no  necessity  will  be  found  to  tie  the  main  trunk,  as  the  operation  for 
aneurism  is  to  tie  the  vessel  that  supplies  the  sac,  and  this  may  be  connected  only  with 
the  vas  aberrans. 

Operation  of  Antyllus. — Should  it  not  be  possible  to  apply  a  ligature  to  the  efferent 
vessel,  and  the  case  is  one  in  which  other  means  are  inapplicable  or  the  aneurism   is 


TREATMF.ST  HY   M  [SIl'H.ATIOS.  371 

clearly  the  result  ni'  a  wounded  artery,  the  formidable  original  operation  for  aneurism — 
that  of  Antyllus.  practised  more  recently  l)y  Synie — may  he  re(|uircd.  which  is  the  layiti;; 
open  of  the  sac  of  the  aneurism,  llu'  reujoval  of  its  contents,  and  the  apftlication  of  a  lifra- 
ture  ahove  and  lielow  its  connection  with  the  artery.  To  do  this,  however,  much  bold- 
ness and  operative  skill  are  neci-ssary  to  prevent  a  fatal  hemorrhage.  With  this  object, 
in  a  case  of  axillary  aneurism.  .^Ir.  Syme  made  an  incision  above  the  clavicle  aion^'  the 
border  of  the  stcrno-mastoid  muscle,  to  enable  an  assistant  to  compress  the  subclavian 
artery  airainst  the  first  rib.'  acting.:  upon  the  sann-  principle  as  he  adopted  thirty  years 
bef«>re,  when  he  nnnle  an  incision  behind  the  anj:le  of  the  jaw  to  enal)le  an  assistant  to 
compress  the  internal  ma.xillary  artery  before  the  removal  of  the  upper  jaw.  In  IHdl  he 
laid  open  a  <;luteal  aneurism,  havinj;  previously  thrust  a  bistoury  into  the  tumor  over  the 
situaticui  of  the  gluteal  artery  and  introduced  a  fin<!:er,  .so  as  to  prevent  the  blood  from 
flowinji;  except  l)y  occasional  <rushes.  He  eventually  thrust  his  hand  into  the  .sac,  rapidly 
turned  out  the  clot,  and  had  the  bleeding  orifice  at  onee  under  subjection  by  the  pressure 
of  the  hand.  Both  cases  did  well.  Still,  this  practice  i.s  only  applicable  to  desperate 
cases  where  all  other  modes  of  treatment  have  failed  or  are  out  of  the  question.  In 
aneurisms  of  small  arteries,  however,  it  is  very  applicable.  I  have  successfully  employed 
it  in  many  cases  of  aneurism  of  the  radial  and  ulnar  arteries  for  traumatic  aneurism  with 
good  results,  and  in  several  cases  I  divided  the  ve.s.sel  completely  and  twisted  both  end.s, 
a  rapid  recovery  followinL^ 

Diafnf  Litjii'iii'. — WIkmi  a  ligature  cannitt  be  applied  to  the  cardiac  .side  of  an 
aneurism  and  the  treatment  by  compression  has  failed  or  is  inapplicalde.  the  distal  opera- 
tion of  Brasdor  or  the  a|iplicati(in  (»f  a  ligature  to  the  vessel  as  it  leaves  the  aneurism 
(Fig.  \h'.^)  may  be  entertained,  with  the  view  of  assisting  coagulation  of  blood  in  the 
aneurism  by  "slowing"  the  blood  current;  for  it  may  fairly  be  accepted,  as  proved  by 
the  cases  of  C.  Heath.  Annandale.  Holmes,  and  Barwelk  that  the  application  of  a  ligature 
to  the  left  carotid  artery  in  aneurism  of  the  aorta  is  of  benefit.  The  credit  of  the  sug- 
gestion, however,  mu.st  be  given  to  Dr.  Cockle,  who  wrote  on  the  subject  (^Lmnef,  1869), 
although  three  or  four  ca.ses  had  previou.sly  been  recorded  in  which  the  operation  had 
been  performed  with  success  for  supposed  carotid  aneurism.  Evidence  likewi.se  exists  to 
show  that  the  application  of  a  ligature  to  the  right  carotid  artery  in  ca.ses  of  innominate 
or  mixed  innominate  and  aortic  aneurism  may  do  good.  This  practice  is  to  be  followed 
up.  if  needs  be,  by  the  application  of  a  ligature  to  the  subclavian  vessel,  Mr.  Fearn's 
ca.se  ajid  others  having  made  the  repetition  of  the  operation  justifiable.  In  Augu.st,  1871, 
I  performed  Wardrop  s  operation  on  a  man  xi.  33  for  innominate  aneurism.  The  sub- 
clavian was  ligatured  with  a  carbolized  catgut  ligature  ;  the  wound  was  closed  and  sealed 
with  lint  saturated  with  the  compound  tincture  of  benzoin.  A  good  recovery  ensued, 
and  considerable  consolidation  of  the  aneurism.  The  man  left  the  hospital  thirty-six 
days  after  the  operation  so  well  satisfied  with  the  success  of  the  treatment  that  he  did 
not  return  to  have  the  carotid  ligatured ;  indeed,  he  went  on  so  well  up  to  about  six 
weeks  Vjcfore  his  death  that  he  thought  nothing  of  his  trouble.  He  died  from  dyspnoea, 
the  result  of  pressure,  in  August,  1874,  three  years  after  the  operation.  After  death  the 
aneurism  was  found  to  be  full  of  solid  clot,  and  there  was  a  passage  through  it  to  the 
carotid,  with  a  smooth  lining.  T'nfortunately,  the  gentleman  who  took  out  the  prepara- 
tion threw  away  the  bulk  of  the  clot  that  filled  the  sac,  which  was  as  big  as  a  fist.  The 
success  of  the  operation,  however,  was  encouraging. 

The  Treatment  by  Manipulation. 

This  method  was  introduced  into  surgery  in  1852  by  Sir  W.  Fergusson,*  and  it  is  based 
on  natural  although  exceptional  processes — viz.,  the  embolic  occlusion  of  the  distal  end 
of  an  artery  by  a  dislodged  clot.  It  is  practically  to  be  carried  out  by  the  manipulation 
of  the  sac  of  an  aneurism  with  the  view  o^i  dislodging  the  blood  clot  it  may  contain,  with 
the  chance  of  such  being  carried-  by  the  circulation  into  the  afferent  artery.  It  may 
likewi.se  be  employed  "  to  alter  the  relations  of  the  laminated  fibrine  in  the  cavity  of  the 
aneurism,  so  as  to  bring  about  a  further  deposition  of  fibrine  on  the  projecting  surfaces 
of  the  di.splaced  lamina?  "  (Oliver  Pembertons  Aildress  on  Snrgfri/,  Brit.  Med.  Assoc). 
Sir  W.  Fergusson  practised  it  in  two  cases,  and  in  both  the  success  was  sufficient  to  sanc- 
tion the  repetition  of  the  means  in  appropriate  cases  and  when  all  other  treatment  is  out 
of  the  question.  Holmes  told  us  {Lanat,  vol.  i..  1873.  p.  159)  that  it  had  been  used  in 
five  cases  of  subclavian  and  two  of  femoral  aneurism.  In  two  cases  a  cure  was  obtained, 
'  Med.-Chir.  Trans.,  vol.  xliii.  *  Ibid.,  vol.  xl. 


372  OTHER  METHODS. 

and  in  a  third  it  was  probable.     In  cervical  aneurism  the  practice   is  not  applicable,  on 
account  of  the  dangers  of  embolism  of  the  cerebral  arteries. 

Galvano-Puncture,  or  Electrolysis. 

To  induce  or  assist  coagulation  of  the  blood  in  the  sac  other  means  have  been  sug- 
gested, and  of  these  tlce  treatinenf  hy  galvcuio-puncture^  as  advocated  by  Abeille  in  1849 
(J /■'■//.  Qin.  de  Medecine)  and  by  Ciniselli  in  IHolJ,  is  one  of  the  mo.st  promising  in  theory, 
though  the  practical  results  have  not  been  equally  satisfactory.  In  consists  in  the  intro- 
duction of  the  two  needles  of  a  constant-current  battery  into  the  sac,  witli  the  view  of 
coagulating  the  blood  into  a  firm  clot.  The  practice  is  one  that  can  be  entertained  only 
in  exceptional  cases — i.  e.,  in  those  which  cannot  from  their  position  be  submitted  to  other 
forms  of  operation.  It  is,  however,  well  adapted  for  the  treatment  of  aneurisms  at  the  root 
of  the  neck  and  the  thoracic  aorta,  and  possibly  for  some  forms  of  abdominal  aneurisms. 

The  constant-current  battery  should  be  used,  and  a  moderate  current,  say  of  five  cells, 
be  first  employed,  its  strength  being  increased  gradually,  but  never  to  cause  pain.  The 
battery  may  be  used  for  half  an  hour  at  a  time,  about  twice  a  week,  yet  this  will  depend 
upon  its  eifects.  The  needles  should  be  of  steel  gilt,  sharp,  very  fine,  and  about  three 
inches  long,  and  should  be  insulated  to  within  half  an  inch  of  the  point.  They  are  to 
be  introduced  and  removed  with  a  rotatory  motion,  and  may  be  attached  to  either  pole 
of  the  battery.  The  dangers  of  the  operation  are,  as  stated  by  Holmes,  principally  from 
two  causes,  "  the  inflammatory  action  produced  in  the  sac  and  the  cellular  tissue  which 
surrounds  it,  and  the  gangrene  or  ulceration  of  the  skin  at  the  points  of  entrance  of  the 
needles." 

Other  Methods. 

The  treatment  by  injection  is  a  mode  that  demands  notice,  although  hitherto 
it  has  not  been  satisfactory.  Alcohol,  tannin,  acetic  acid,  and  the  perchloride  of  iron 
have  all  been  used  as  coagulating  agents,  but  the  last  is  the  drug  for  which  the  most  can 
be  said.  That  it  has  a  powerful  influence  in  causing  the  coagulation  of  the  blood  is  well 
known,  but  to  produce  this  in  the  sac  of  an  aneurism  is  a  dangerous  proceeding.  The 
most  dangerous  result  is  embolism,  and  the  next  inflammation  and  suppuration  of  the 
sac.  A  solution  of  the  perchloride  diluted  to  one-twentieth  the  strength  of  the  British 
Pharmacopoeia  preparation  is  strong  enough,  and  not  more  than  about  twenty  drops  of 
the  solution  ought  to  be  dropped  into  a  large  sac.  The  graduated  glass  syringe  with 
screw  piston  should  be  employed,  such  as  is  generally  used  for  subcutaneous  injections. 
Care  should  be  taken  that  the  perforated  trocar  be  well  introduced  into  the  cavity  of  the 
tumor,  and  that  the  afferent  as  well  as  eflerent  artery  be  well  compressed.  The  escape 
of  arterial  blood  is  the  only  test  of  the  trocar  having  entered  the  sac.  The  fluid  should 
then  be  injected,  and  by  manipulation  mixed  with  the  blood.  When  the  sac  seems  solid, 
the  canula  should  be  withdrawn  ;  but  the  pressure  upon  the  cardiac  side  of  the  sac 
should  be  maintained  subseqiiently  for  a  full  hour,  to  prevent  the  consolidating  mixture 
of  blood  and  iron  being  sent  onward  into  the  circulation. 

With  objects  similar  to  the  above,  the  late  Mr.  Moore  inserted  twenty-six  yards  of  iron 
wire  into  an  aortic  aneurism  through  a  canula,  his  object  being  merely  to  detain  the  fibrine 
of  the  fluid  blood  {Med.-Chir.  Trans.,  vol.  xlvii.).  Dr.  J.  Levis  of  Philadelphia  in  Octo- 
ber, 1873,  inserted  twenty -four  feet  of  horsehair  into  a  thoracic  aneurism  in  a  man  xt.  41 
with  some  advantage,  and  on  November  25,  1873,  I  adopted  a  like  practice,  introducing 
into  the  sac  of  a  rapidly-increasing  popliteal  aneurism  due  to  embolism  twenty  feet  of 
horsehair  through  a  fine  canula,  with  the  eft'ect  of  causing  almost  complete  consolidation 
of  the  tumor.  The  patient  was  a  man  aet.  33,  admitted  with  ulcerative  endocarditis,  who 
survived  the  operation  five  days.  Mr.  Gould  records  a  case  in  which  a  Dutch  surgeon. 
Van  der  Meulen,  cured  a  brachial  aneurism  in  a  woman  xt.  22  by  the  introduction  of  cat- 
gut into  the  sac.  The  results  thus  obtained  are  quite  sufiicient,  therefore,  to  justify  a 
repetition  of  the  operation  under  circumstances  in  which  all  other  plans  of  treatment  are 
unjustifiable  or  have  failed. 

In  recent  times  Langenbeck,  with  the  view  of  causing  contraction  of  the  walls  of  an 
aneurism,  has  been  led  to  inject  the  parts  surrounding  the  sac  with  a  solution  of  ergotin. 
Dr.  Dutoit  of  Berne  relates  in  Lcnu/cnbcck's  Arcln'v  (Band  xii..  No.  3)  a  case  in  which  he 
successfully  adopted  the  practice  ;  the  man  was  forty  years  old  and  the  aneurism  was  sup- 
posed to  be  subclavian.  Fifteen  injections  were  made  at  intervals  of  two  or  three  days 
over  the  tumor,  which  gradually  diminished.  To  render  the  cure  certain,  however,  digital 
compression  was  subsequently  employed. 


'n:.\rM.\ric  .\\/:ri:isM.  ;}7;] 


Traumatic  Aneurism. 


All  ailtrv  rt'ccivfs  a  |Miii(t  iirctl  or  an  iiicisi'd  wound;  Mccflinj;  fakes  place;  pressure 
is  applied  to  eontnd  it,  and  tlie  wound  lieals.  In  course  of  time  a  pulsatint:  sw(dlin^'  is 
discovered  at  the  seat  td"  injury,  and  a  traumatic  aiu-urism  is  said  to  exist. 

A  man  in  wrestling'  or  after  niakiii';  some  sudden  unprepared-lor  muscular  exertion 
finds  something  irive  way  in  his  lej;  or  fancies  he  has  sprainetl  his  knee.  In  a  shorter  or 
loiif^er  period  a  swellintr  ajijtears  in  the  popliteal  space,  which  steadily  increases  and  is 
pulsatile:  he  has  heconie  the  subject  of  an  aneurism.  In  the  former  case,  doulitless,  the 
injury  was  the  direct  cause  of  the  aneurism:  in  \\\v  hittir  \t  produced  it  indirectly  hy 
actinjr  upon  a  diseased  vessel.  And  yet.  if  tlii'  former  aneurism  is  sacculate<l  cither  hy 
the  expansion  of  the  reparative  material  with  which  tlu!  wound  of  tlie  artery  had  hecri 
closed  or  l»v  the  hernial  protrusion  of  one  or  more  of  the  coats  of  the  artery  throu<rh  a 
rupture  or  wouiul  ol"  the  outer  (tr  l»y  the  condensation  of  the  cellular  tissue  intr)  which  the 
blood  has  escaped,  it  diflers  in  no  sin<,de  practical  j)oiiit  from  the  latter  or  any  other  aneu- 
rism that  has  been  alreaily  considered;  and,  what  is  more,  it  must  be  treated  on  the  .same 
principles,  although,  as  the  artery  of  a  traumatic  is  healthier  than  that  of  a  si)oritaiieously 
formed  aneurism,  the  traumatic  may  be  more  readily  cured. 

When,  however,  an  aneurism  caused  by  an  injury  is  vaguely  or  not  encysted,  when 
either  from  the  first  it  is  "  diffused"  or  it  becomes  so  from  the  rupture  of  its  sac,  or  when 
atiij  onlimirj/  (tiicKrixni  nij>fiiris,  a  different  condition  presents  itself  to  the  surgeon,  and 
the  case  ajiproaches  that  of  a  ruptured  artery  and  is  to  be  treated  accordingly — that  is, 
the  artery  is  to  bo  cut  down  upon,  if  possible,  at  the  scat  of  rupture,  and  its  two  ends 
ligatured  or  twisted,  or  the  aneurismal  sac  is  to  be  opened  and  the  operation  of  Antyllus 
performed.      Amputation  may  be  called  for. 

Wlu'ii  with  a  sprain,  fracture,  or  dislocation  there  is  evidence  by  want  of  pulsation 
and  other  symptoms  that  the  main  artery  (d"  the  part  is  obstructed,  it  is  not  to  be  assumed 
that  the  vessel  is  lacerated  and  should  be  cut  down  upon  and  tied,  because  a  large  propor- 
tion of  such  cases  as  these  recover  without  any  such  proceeding  being  called  for.  Indeed, 
in  one  where  the  extravasation  is  severe  and  no  pulsation  exists,  it  is  impossible  to  make 
out  with  any  clearness  the  true  condition  of  affairs.  A  limb  either  with  or  without  a 
fracture  may  be  greatly  distended,  and  this  from  effused  blood;  but  whether  the  blood 
has  been  poured  out  from  the  rupture  of  a  large  artery  or  vein  or  some  smaller  vessel 
there  can  be  no  means  of  knowing,  .since  even  the  pulsation  in  the  vessels  below  may  be 
indistinguishable  on  account  of  the  effusion.  Under  these  circumstances  no  active  pro- 
ceeding can  be  carried  out.  The  limb  should  be  elevated,  cold  applied,  and  the  ca.se  left 
to  nature,  and  in  a  large  number  of  instances  a  beneficial  result  will  ensue.  I  can  recall 
several  such  cases  where  I  anticipated  bad  results,  but  witnessed  good.  If  the  effusion  is 
so  severe  as  to  be  followed  by  evidence  of  arrest  of  circulation  in  the  limb,  the  surgeon 
will  be  justified  in  cutting  down  upon  the  vessel  at  the  point  where  the  history  of  the  case 
indicates  that  it  is  wounded,  and  in  tying  both  ends  after  having  turned  out  all  clot,  etc. 
In  other  cases  the  main  artery  may  be  tied,  but  too  often  there  will  be  nothing  to  be  done 
but  amputation,  as  gangrene  may  set  in.  This  operation,  however,  must  be  postponed  till 
the  line  of  demarcation  is  ftiirly  indicated.  No  general  rule  can,  however,  be  laid  down 
for  the  treatment  of  all  these  cases,  as  each  one  must  be  treated  on  its  own  merits. 

But  the  student  .should  remember — 

1.  That  every  encysted  aneurism,  however  caused,  is  to  be  treated  upon  the  previously 
described  general  principles. 

2.  That   ruptured  traumatic  aneurisms  arc  to  be  regarded  as  ruptured  arteries. 

H.  That  the  rupture  of  an  artery  when  bound  down  by  a  dense  fascia,  such  as  the 
popliteal,  is  generally  followed  by  the  complete  arrest  of  both  the  arterial  and  venous 
circulation  in  the  liinb,  and,  as  a  result,  by  gangrene,  which  requires  to  be  treated  by 
amputation. 

4.  That  in  cases  of  partial  rupture  there  may  be  less  extravasation,  and  consequently 
less  severe  effects  ;  under  such  circumstances  pressure  upon  the  main  trunk  above  may 
suffice  to  bring  about  a  cure,  or,  if  this  fail,  the  application  of  a  ligature  to  the  wounded 
vessel  may  be  required. 

5.  That  a  ruptured  artery  in  parts  less  fascia-bound  than  the  leg  (as,  for  instance,  the 
arm)  may  be  treated  more  as  in  the  case  of  injuries  to  arteries,  by  the  application  of  a 
ligature  to  the  wounded  vessel. 

Collateral  Circulation.— When  an  artery  is  obstructed,  the  circulation  is  carried 
on  bv  what  is  called  the  collateral  circulation,  in  which  the  vessels  coming  off  above  the 


374 


ARTERIO  -  VENO  US  ANE URISM. 


obstructed  part  communicate  with  those  which  arise  below  it.     At  first  the  vessels  are 
very  numerous,  but  as  time  goes  on  their  number  diminishes,  and  only  those  most  con- 

FiG.  154.  Fig.  155. 

Anterior  View.  Posterior  View. 


Sf^~  tt 


Fig.  154. — a,  Common  iliac  artery,  ft,  External  iliac,  r,  Internal  iliac.  </,  Femoral,  e,  I'rofunJa.  f,  External  circum- 
flex, g,  Internal  circumflex,  h.  Iliac  artery,  which  had  been  tied  and  had  shrivelled  into  a  cord.  i,  Kemains  of 
aneurismal  sac.  A,  Anastomosing  branches  of  the  circumflex  ilii.  /..Anastomosing  branches  of  the  circumflex 
externa,    m,  Obturator  artery,  anastomosing  with,  n,  circuniflexa  interna. 

Fig.  155. — o.  Gluteal  artery.  6,  Ischiatic  artery,  c,  Anastomosing  branches  of  gluteal  with  the  circumflex,  rf,  .Anas- 
tomosing branches  of  the  ischiatic  with  the  perforating  branches  of  the  profunda.      (Prep.  15191'-,  Guy's  Museum.) 

veniently  situated  for  carrying  on  the  circulation  become  rajjidly  or  gradually  and  per- 
manently enlarged. 

To  illustrate  this  beautiful  compensatory  natural  act  I  submit  two  drawings  (Figs. 
154,  155)  taken  from  a  preparation  in  Guy's  Museum,  made  by  Mr.  Cock  in  the  year 
1826,  from  a  patient  £et.  58,  in  whom  Sir  A.  Cooper  had  applied  a  ligature  to  the  external 
iliac  artery  for  femoral  aneurism  eighteen  years  and  a  half  previously. 

A  full  description  and  preparation  of  the  case  is  to  be  found  in  the  first  volume  (first 
series)  of  the  Guys  Reports,  by  Mr.  Cock.  The  drawings  need  no  lengthy  description, 
as  they  explain  themselves. 

Arterio- Venous  Aneurism. 

When  an  artery  and  a  vein  communicate  with  each  other,  the  arterial  blood  passing 
directly  into  the  vein  without  the  intervention  of  a  sac,  an   aneiiri»mal  vari.i:  is  said  to 

exist  (a,  Fig.  156)  ;  and  when 
a  sac  exists  into  which  the 
arterial  blood  flows  in  its  pas- 
sage to  the  vein,  this  condi- 
tion is  called  a  varicose  aneu- 
rism (b,  c,  and  D,  Fig.  156). 
Both  these  varieties  of  ai"te- 
rio-venous  aneurisms  are  now 
rare ;  but  when  venesection 
was  a  common  operation,  they 
were  far  more  frequent,  as 
they  are  usually  produced  by 
the  perforation  or  division  of 
an  artery  through  a  vein,  the 
opening  between  the  vessels 
remaining  permanent.  Both 
forms  may  originate  sponta- 
Goupil   (Paris,  1855)  recorded  the  fact  that  out  of  fifty-seven 


Illustrating  the  Difterent  Forms  of  Varicose  Aneurism.  A,  'I'ho  artery  and 
vein  directly  communicating.  B  and  C,  The  dilatation  being  more  in 
the  vein.    I),  Aneurism  laid  open. 


neously  from  disease. 


.\irri:nii) -  \  i:\oi 's  . i .\i:i  l'/s.u. 


375 


Aneurisnial  Varix. 


cases  iif  tills  jitVcclinii.  tliiity-niif  wcif  tlic  icmiIi  dl'  lilrcdiii;.^  Cases  are  on  reeonl  wliere 
the  anita  ami  siijierior  or  iiilerior  vena  cava  eoiiimunieateil.  Wade  (  Duhlin  Mnl.  J'rixg, 
IStil  )  has  leeordeil  a  ease  in  wliieli  an  openiii};  existe<l  hetween  the  aorta  and  jmlinoiiary 
artery;  in  1SS2  1  suw  a  ease  with  my  coliea^rue,  Mr.  |)avies-('()ney.  in  which  this  condi- 
tion existed  hetwoen  the  snperlieiai  femoral  artery  and  t'einorul  vein,  the  result  of"  a  f^un- 
shot  wound,  and  my  friend  Mr.  Morris  informs  nie  that  hu  lias  seen  a  like  ease  in  the 
femoral  reiiion.  the  result  ot"  a  jtistol-shot  received  hy  a  s|)ortsm.iii  in  America.  Indeed, 
all  the  lar<ie  arteries  and  v«'iiis  may  he  similarly  affected. 

In  an  aneurismal  varix  the  vein  assumi-s  in  some  de;:ree  the  i»ro|Mrties  of  an 
artery  and  liecoim-  riil:ir.:til  I'mm  the  arterial  impulse,  liesides  hein;;  irrejrularly  <lilated 
and  tiu-tuous,  the  dilatation  assumes  a  fusiform  or  sacculated  ajipearance,  while  it  also 
hecomes  thickened  and  pulsates,  the  mixe(l  hlood  currents  iriviiiLT  rise  to  a  peculiar  thou<jjh 
characteristic  "  huzziu;^"  murmur  which  when  once  heard  is  not  likely  to  he  mistaken. 

In  some  instances  the  condition  is  conj^eiiital  ;  it  was  so  in  the  one  illustrated  (Fig. 
157).  in  which  the  st>at  of  commiinicatioM  of  the  ves.sels  was  ahmit  the  axilla.  The  boy, 
ait.  14,  was  admitted  under  my 

care  at  Guy's  in  1  S7!»  f<ir  hleed-  I''u;.  l'>7. 

in^  from  an  opi-u  ulcer  on  his 
loft  intlex  fiiii:er,  the  ulcer  hav- 
iiiLT  followed  an  injury  eifi'hteen 
mouths  previously.  The  in- 
jured fiuirer  was  spoiiiiv  from 
vascular  tissue,  and  the  palm 
of  the  haiul  had  the  apjicar- 
ance  of  a  cutaneous  ua'vus. 
TIk^  veins  of  the  whole  limb 
were  immen.scly  distended  and 
thrilled  very  markedly  ;  the 
buzzing-  murmur  so  generally  present  in  these  case.s  was  very  characteristic.  The  case 
was  treated  by  elevation  of  the  limb  after  it  had  been  firmly  fixed  to  a  splint  ;  under  such 
care  there  was  no  recurrence  of  blee«jiiig,  and  a  rapid  healing  of  the  ulcer  on  the  finger 
followed.      It  was  not  thought  expedient  to  interfere  with  the  disease. 

In  the  varicose  aneurism  the  sac  may  or  may  not  freely  communicate  with  the 
artery  or  vein.  In  some  case.s  it  will  involve  the  whole  calibre  of  both  vessels,  or  the 
vein  may  be  hypertrophied  and  enlarged,  as  in  the  aneurismal  varix.  In  a  unifjue  case 
(Fig.  158).  recorded  by  Mr.  Cock  ( Mn/.-Chir.  Tnnis.,  1851),  of  atraumatic  varicose 
aneurism  of  the  popliteal  artery,  the  sac  was  small,  but  involved  the  whole  calibre  of  the 
artery  and  vein,  and  the  whole  of  the  arterial  l)lood  passed  through  it.  The  secondary 
effects  of  the  disease  were  also  shown  with  singular  clearness.  It  occurred  in  a  man  set. 
28  who  eleven  years  previously  had  received  a  punctured  wound  in  the  popliteal  artery 
for  which  two  weeks  subsequently,  on  account  of  secondary  hemorrhage,  the  femoral  was 
ligatured.  He  convalesced  and  returned  to  his  work,  but  two  years  afterward  became  the 
subject  of  •'  varicose  veins."  He  remained  well  until  three  or  four  months  before  hia 
admission  into  Guy's,  when  he  had  fever,  and  on  convalescing  and  trying  to  walk  discov- 
ered his  leg  was  stiff,  painfid.  and  swollen.  He  was  admitted  with  what  was  supposed 
to  be  a  large  collection  of  pus  beneath  the  superficial  mu.scles  of  the  calf.  The  femoral 
artery  below  Poupart's  ligament  and  the  anterior  and  posterior  tibial  arteries  were  pul- 
sating freely.  The  cavity  was  opened;  .some  ounces  of  dark  grumous,  pitchy,  non-eoag- 
ulaltle  blood  escaped.  The  next  day  a  ((uantity  of  offensive  pus  flowed  away  mixed  with 
coairula.  For  a  fortnight  everything  went  well,  when  arterial  hemorrhage  took  place,  and 
he  lost  nearly  three  ])ints  of  blood.  After  due  consultation,  amputation  was  performed, 
from  which  an  excellent  recovery  ensued. 

On  dis.secting  the  limb  ]Mr.  Poland  found  connected  with  the  popliteal  artery  an 
aneurismal  sac  (Fig.  158,  .s)  the  size  of  a  pigeons  e'J!:p:.  which  w'as  of  cartilaginous  hard- 
ness and  lined  with  fibrine.  The  artery  ( ^4)  freely  entered  the  sac  from  above.  The 
vein  (  F)  was  obstructed  above  with  coagulated  blood,  and  below  was  lost  in  the  walls 
of  the  sac  as  a  fibrous  cord.  From  the  lower  part  of  the  sac  two  vessels  issued  ;  the 
smaller  one  (o)  was  the  continuation  of  the  popliteal  artery,  c/i-fafli/  iJimiimhifl  in  size, 
which  divided  as  usual  to  the  leg.  The  larger  (  Va)  was  the  popliteal  vein  greatly  hyper- 
tro])hied,  pouched,  and  puckered.  It  was  quite  pervious  and  pas.sed  down  for  about  two 
inclies,  when  it  divided  into  two  trunks  :  one,  which  accompanied  the  anterior  tibial  artery, 
was  quite  ohl iterated,  the  other  led  directly  into  a  second  aneurismal  sac  (s^)  the  size  of  a 


376 


ARTERIO -VENOUS  ANEURISM. 


Fig.  158. 


Mr.  Cock"s  Case  of  Arte- 
rio-Venous  Aneurism. 


duck'.s  effg.  witli  th*^  walls  of  which  its  coats  became  identifiod.  It  was  this  that  had  been 
opened.  From  the  lower  part  of  this  venous  .wc  emerged  three  or  four  large  impervious 
branches  that  were  clearly  veins  accompanying  the  posterior  tibial 
and  peroneal  arteries.  The  contents  of  these  veins  could  be  washed 
out  and  the  valve-s  seen. 

It  should  be  added  that  the  cutaneous  veins  above  described  as 
varicose  were  greatly  hypertrophied.  and  it  was  evident  that  the 
whole  of  the  blood  from  the  leg  was  returned  through  them. 

It  would  appear  also  that  in  this  case,  as  a  dtrect  result  of  an 
injury,  a  varicose  aneurism  formed,  into  which  the  whole  of  the  arte- 
rial blood  flowed.     Moreover — 

That  the  arterial  blood  subsequently  found  a  more  direct  course 
through  the  popliteal  vein  than  through  the  artery,  and  as  a  result 
the  vein  became  hypertrophied  and  the  artery  atrophied.     Also — 

That  the  force  of  the  arterial  blood  current  upon  the  thin  coats 
of  the  vein  caused  the  gradual  dilatation  of  the  vein  and  the  subse- 
quent formation  of  an  aneurism  in  its  course,  and  that  by  the  giving 
way  of  this  aneurism  bleeding  had  taken  place. 

The  wasting  of  the  femoral  vein  ahore  and  the  hypertrophy  of  the 
same  vein  hehnc  the  upper  sac,  from  its  taking  on  the  functions  of  an 
artery,  are  points  of  interest ;  and  not  the  least  important  change  was 
the  great  hypertrophy  of  the  cutaneous  veins  through  which  the  whole 
of  the  venous  circulation  of  the  leg  must  have  been  carried  on. 

I  have  given  this  case  at  some  length  because  it  illustrates  better 
than  any  general  description  the  whole  effects,  primary  as  w^ell  as  secondary,  of  a  varicose 
aneurism. 

With  reference  to  diagnosis,  it  may  be  stated  that  at  the  point  of  junction  of  the  arte- 
rial and  venous  streams  a  peculiar  burring  bruit  is  often  felt  and  heard,  and  this  bruit  fre- 
quently extends  along  the  course  of  the  dilated  veins.  Where  a  sac  exists  in  which  the 
two  blood  currents  meet  between  the  artery  and  the  vein,  there  is  likewise  a  soft  bruit. 
The  sac  is  rarely  very  large,  and  is  made  up  of  .condensed  cellular  tissue  and  plastic 
matter. 

Treatment. — In  these  cases  surgical  intei'ference  is  not  generally  required.  Should, 
however,  the  disease  be  extensive  and  either  from  pain,  mechanical  causes,  or  chances  of 
rupture  of  the  vessels  require  treatment,  a  cure  may  be  attempted  by  the  occlu.sinn  of 
the  artery  above  and  below  the  point  of  communication  between  the  artery  and  the  vein. 
The  case  should  be  treated  as  one  of  wounded  artery.  The  vein  need  not  be  interfered 
with,  as  it  will  gradually  wither  so  soon  as  its  arterial  communication  has  been  cut  off. 

Pulsating  exophthalniOS,  or  vascular  protrusion  of  the  eyeball,  associated  with 
a  marked  swelling  and  enlargement  of  the  vessels,  a  peculiar  rushing  bruit,  and  arterial 
pulsation,  is  an  affection  of  much  interest  and  of  some  ob-scurit}-,  since  it  may  be  due  to 
intraorbital  aneurism,  to  rupture  of  the  internal  carotid  artery  into  the  cavernous  sinus, 
or  to  some  condition  of  vessels  apparently  independent  of  arterial  disease.  Mr.  Bowman's 
dissections  have  fairly  demonstrated  that  this  affection  may  exist  during  life  and  after 
death  show  no  patholog}'.  3Ir.  W.  Rivington  has  written  an  excellent  article  upon  this 
subject  (Med.-Chir.  Trans..  Iviii.),  and  has  proved  that  in  many  cases  this  affection  has 
been  preceded  by  some  fracture  of  the  base  of  the  skull,  complicated,  probably,  with 
laceration  of  the  venous  sinus  and  obstruction  or  laceration  of  the  internal  carotid  artery, 
and  in  idiopathic  cases  the  like  changes  probably  exist ;  in  fact,  some  of  these  cases  of 
pulsating  exophthalmos  had  better  be  looked  upon  as  examples  of  arterio-venous  aneuri.sm. 
Treat.aiext. — Some  of  the.se  cases  do  well  without  treatment;  but  when  they  show 
evidence  of  steady  progress.  Rivington's  facts  clearly  prove  the  propriety  of  apph'ing  a 
ligature  to  the  common  carotid  artery,  success  having  followed  this  practice  in  fifteen  out 
of  eighteen  idiopathic  and  twenty-three  out  of  twenty-.six  traumatic  cases. 


Cirsoid  Aneurism,  Erectile  Tumors,  and  Aneurism  by  Anastomosis. 

These  have  nothing  in  common  with  the  spontaneous  and  traumatic  aneurisms  that 
have  been  already  described  beyond  the  fact  that  they  are  diseases  of  the  arterial  system. 
They  are  vascular  tumors  made  up  of  arterial  tissue  and  formed  by  a  dilatation  and  elon- 
gation of  arteries,  the  term  cirsoid  anruri>im  being  employed  when  the  trunks  of  the  larger 
vessels  are  involved  (vide  Fig.  159),  and  aneurism  hy  anastomosis,  or  cirsoid  arterial  tumors, 


CIRSOID  .\si:ritisMS. 


377 


l-K..    1. ■)'.». 


wlifii  tlic   siiijillcr   vessels  (ir  ciiiiillaries   are   afleeted.      In    tlie  eirsoid  aiii-urisiii  (irie  vessel 

or   iiiaiiy    vessels  may  Ik-  diseased,  tlie  disease  sli(t\vin<:  itself  liv  tiie  arterv  lii'coniiiiL:  tur- 

tiKiiis,  dilated  into  jioiudies,  and  ciinvuluted.      When  (trie  vessel 

aldiie  is  atl'eeted,  (Insseliu    ealled    it    itrtiriitl   nirix.       Wlien    lln' 

disease  is  on    the   sealp  (its   most    (Mimiiion    seat),  three;   or   I'luir 

larL'e   idrtimiis   arteries   may  lie  seen   eonver<rin<_'  to  the  eentre. 

where   a    eonireries   ol"  dilated  arteries   will  he   found,  prohahlv 

of"  new  growth.      It    may,   however,   affect   the  arteries  of  the 

extremity.      I    have   seen    it    in    the   foot    fFiir.  Iiid).  and   Crii- 

veilhier  has   reported  a  case  in  which   the   external    iliac   arterv 

was  so  af!'eeti'd.      Cirsoid  aneurism  is  i;<'nerally  found  in  youn<: 

jieojde  dnrinir  the  period  (d' <:rowth,  and  in  the  majority  of  eases 

can  he  traced  to  local  injury.      It   can   he  ri-adily  made  out  liy 

its  pulsatiufi;  nature  ami   the   jieculiar   tortuous  and  convoluted 

appearance  of  the  diseased  ves.sels,  not  only  of  the  vessels  form- 

inii"  the  tumor,  hut  of  the  arteries  hy  which  it  is  supplied. 

Tkk.vtmknt. — All   forms  id'  treatment   have  been   tried   in 
these  cases,  such  as  direct  pressure,  injection,  the  application       Artery.   (Taken  from  a  man 
of  lijratures  to  the  vessels  that  converge  toward  the  arowth,      *t.«"who  was  under  my  care 

,  ^  ^  m  1881.) 

and  to  the  main  artery  that  goes  to  the  part;  the  tumor  has, 

moreover,  been  laid  open  and  treated  by  pressure,  with  the  view  of  causing  its  ohditeration 
by  inflammatory  exudation  ;  Grlif,  Bell,  Arnott,  and  Lawrence  have  each  recorded  suc- 
cessful instances  of  this  form  of  practice,  but  no  good  success  in  the  majority  of  cases 
has  been  achieved. 

The  best  success  has.  however,  follow'ed  the  removal  of  the  growth,  either  by  the 
application  of  the  ligature  or  by  excision.  In  1S70  I  excised  a  cirsoid  aneurism,  situated 
below  the  jaw  in  connection  with  the  facial  artery,  from  a  lady,  set.  25,  with  success.     In 


Fig.  IfiO. 


pluniur    u.rUTif 


This  drawing  was  taken  from  a  patient  of  Mr.  Poland's,  a  girl  xX.  19.    The  di.sea.se  followed  an  injurv,  and  was  treated 
by  amputation,  other  nieasuies  having  failed  {Gin/s  Hosp.  Rep.,  18r>9). 

1867  I  treated  a  boy  aet.  14  for  a  large  cirsoid  aneurism  of  four  years'  growth,  situated 
on  the  right  temple.  It  was  supplied  with  blood  by  tortuous  vessels  converging  from  all 
quarters,  and  pulsated  freely.  I  applied  acupressure  pins  to  all  these  vessels,  even  to 
their  division,  without  success ;  the  growth  for  the  time  became  flaccid,  but  quickly  reap- 
peared and  increased.  Under  the.se  circumstances  I  exci.sed  the  tumor,  making  my  incis- 
ions at  some  distance  from  its  margin,  and  ligatured  about  twenty  large  vessels  a.s  I  pro- 
ceeded ;  a  rapid  recovery  followed,  and  the  boy  was  well  three  years  later.  In  this  case 
it  was  remarkable  to  see  how  rapidly  the  tortuous  convoluted  arteries  that  supplied  the 
tumor  withered  and  became  of  their  normal  size  so  soon  as  the  central  disease  was 
removed.  This  process  illustrates  John  Hunter's  opinion  that  "  vessels  have  a  power 
of  increase  within  themselves,  both  in  diameter  and  in  length,  according  to  the  ncces.sity 
of  the  tissues,  whether  natural  or  diseased,"  and  indicates  that  the  attracting  power  had 
its  centre  in  the  growth,  and  not  in  the  afferent  arteries.  In  a  third  case,  that  of  a  girl 
aet.  12,  I  removed  the  aneurism  by  a  subcutaneous  ligature  with  like  success,  and  more 
recently  in  a  man  who  had  such  a  vascular  pulsatile  growth  in  his  left  cheek,  which 
appeared  to  have  had  all  the  afferent  arteries  tied  without  succe.ss  before  he  came  into 
my  hands.     I  ligatured  the  whole  mass  subcutaneously,  and  a  recovery  followed.     Four 


378 


NuEVUS. 


years  later,  however,  tlie  disease  returned,  and  in  June,  1S77,  I  excised  it,  tlie  wound  heal- 
ing rapidly.  Indeed,  the  only  successful  cases  of  treatment  of  cirsoid  aneurism  that  1 
have  dealt  with  or  seen  have  been  those  in  which  the  growth  itself  was  treated  by 
removal. 

Cases  of  aneurism  by  anastomosis  are  very  amenable  to  treatment  by  styptic  injection, 
the  galvano-cautery,  or  the  ligature. 


N^VUS. 

Telangeiectasis,  erectile  tumor,  or  angeioma,  is  essentially  a  disease  of  the  capillaries, 
appearing  in  a  general  way  to  be  made  up  of  a  mass  of  vascular  tissue,  the  tubes  freely 
intercommunicating  with  each  other.  It  is  true  the  walls  of  the  vessels  are  indistinguish- 
able in  an  advanced  case  of  the  disease,  the  nsevus  appearing  as  a  collection  of  cells  or 
spaces  opening  widely  into  one  another,  through  which  blood  flows.  When  the  arterial 
supply  is  very  free,  the  growth  appears  florid,  warm,  and  pulsatile,  and  is  then  called  an 
arterial  rixoits ;  when  the  venous  element  predominates,  the  growth  is  less  florid,  has  a 
congested  bluLsh  appearance,  and  does  not  pulsate,  and  is  termed  a  venous  ttaevus. 

These  growths  for  the  .most  part  appear  in  the  skin  or  subcutaneous  tissue,  are  fre- 
quent on  the  head  and  often  multiple.  Rare  examples  are  on  record  where  they  affected 
deeper  parts,  even  the  viscera  and  the  brain  (ride  Wilks  and  3Ioxon,  Path.  Aiuif.,  and 
Morris,  rofh.  Tram.,  vol  xxii.).  In  a  clinical  point  of  view  they  may  be  divided  into  the 
ciifaneoiis  or  pure  skin  naevus,  the  suhcutaneous  or  cellular  tissue  najvus.  and  the  mixed 
form,  where  both  tissues  are  involved ;  which  distinction  has  an  important  practical 
bearing.  Nrevi  are,  as  a  rule,  diffused — that  is,  they  have  no  distinct  capsule  ;  but  in 
many  cases  they  are  encysted  and  may  be  treated  accordingly.  A^enous  subcutaneous 
n^vi  appear  to  be  more  frequently  encapsuled  than  the  cutaneous  and  arterial. 

Najvi.  moreover,  are  generally  congenital  or  make  their  appearance  soon  after  birth. 
They  occur,  however,  at  a  later  period  of  life,  and  then  seem  to  be  due  to  some  injury  or 
wound.  These  n^vi  at  times  grow  quickly,  the  cutaneous  form  rapidly  .spreading;  the 
more  florid  and  arterial  the  growth,  the  greater  is  its  tendency  to  spread  ;  the  venous 
najvus  is  less  progressive.  They  may  grow  also  for  a  time  and  then  stop ;  indeed,  they 
all  have  a  tendency  to  become  stationary  after  a  period,  and  even  to  degenerate.  It  is 
not  uncommon  to  meet  with  na?vi  that  have  begun  to  undergo  this  process  before  the 
birth  of  the  child,  and   I  could  adduce  many  cases  in  which  the  njevus  was  ulcerated,  or 

even  sloughing,  at  birth.  In  feeble  or  cachectic  children  it 
is  not  uncommon  for  these  ''  marks"  to  ulcerate  or  slough, 
and  after  measles,  fever,  or  other  depressing  illness  the  de- 
struction of  the  growth  is  sometimes  very  rapid.  These 
facts  show  that  njevi.  although  blood  tumors,  are  not  long- 
lived  growths  and  have  a  tendency  toward  early  death. 
When  they  do  not  ulcerate  or  slough,  they  undergo  degen- 
erative changes,  and  the  most  characteristic  is  the  cystic 
form  (Fig.  161).  When  the  skin  undergoes  this  cy.stic 
change,  the  surface  becomes  warty  and  vesicular,  the  ves- 
icle.-* containing  more  or  less  blood-stained  serum.  When 
the  cellular  tissue  is  the  part  involved,  cysts  will  still  ap- 
pear of  a  like  nature,  but  occasional!}'  the  whole  growth 
passes  into  a  mass  of  cysts  of  diff'erent  sizes  bound  together 
by  fibrous  tissue.  This  degenerative  change  is  very  typical.  To  accoutit  for  the  forma- 
tion of  these  cysts  is  no  easy  matter;  no  satisfactory  explanation,  indeed,  of  their  pro- 
duction has  }'et  been  given. 

Some  na3vi  are  pigmentary,  and  are  then  termed  '•  moles."  They  are  fiar  less  vascular 
than  the  forms  already  alluded  to  and  have  no  tendency  to  spread.  They  grow,  it  is 
true,  with  the  growth  of  the  subject,  but  as  a  rule  in  no  greater  proportion  ;  in  excep- 
tional instances  their  increase  is  rapid.  They  do  not  appear  to  have  a  tendency  to  ulcer- 
ate, slough,  or  undergo  the  cystic  degeneration  like  the  vascular  nfevi,  but  have  a  .special 
tendency  to  become  the  seat  of  disease,  and  particularly  of  the  melanotic  form  of  sarcoma 
or  cancer — that  is,  subjects  who  become  the  victims  of  cancer  and  have  moles  are  often 
attacked  primarily  in  .such  structures,  and,  as  the  cancer  originates  in  a  pigmentary 
growth,  it  takes  on  its  character  and  becomes  melanotic.  I  have  seen  many  such  cases, 
and  so  many  others  have  been  now  recorded  as  to  place  the  question  beyond  doubt. 

Treatment. — Unless  a  noevus  is  so  situated  as  to  be  an  eyesore  or  an  inconvenience, 


Fig.  161. 


Drawing  of  J)egei]eratintr  X;evus. 
(Guy's  Mils.,  Iti054.      Hilton's  case 


TREATMKSr  OF  S.KVUS. 


.'i79 


or  unless  it  show  a  (IccicK-d  toiidoncy  td  rupiil  incn-iisf,  tlicre  is  no  necessity  fur  operative 
iiitorfcrcnco.  Fur  a  certainty,  after  a  tinn-,  it  will  cease  to  jrrow,  and  also  as  certainly 
(IcLjeneratc  or  waste;  and  nnder  sneli  eirennistanees  it  is  not  necessary  to  interfere. 
Should,  however,  the  n;evus  he  so  situ.ited  as  to  he  an  inconvenience  or  a  deforniitv.  <jr 
should  it  Ljrow  so  rapidly  as  to  threaten  t<i  heconie  either,  soniethin^^  must  he  atteinpte<l; 
and  this  suniethiiiu  is  to  he  dett'rinined  hy  the  nature  of  the  n:evus  and  of  the  tissue  in 
which  it  is  ])laced.  If  jiiinli/  tii/inirtnis  and  not  involvin<;  deeper  tissues,  it  may  he 
destroyed  hy  some  external  application,  such  as  caustic,  nitric  acid,  or  ]»otassa  fusa, 
chhu'lde  of  zinc,  ethylate  of  sodium,  or  tartarized  antimony,  the  former  two  heinir  applied 
directly  to  the  part,  the  latter  two  in  the  form  of  \'icnMa  paste  or  otherwi.se.  The  hot 
iron  and  the  pis  or  <::alvanic  cautery  are  also  very  valuahle  destructive  aj.M'iits,  one  touch 
of  either  of  these  latter,  steadily  ap]tlied  to  the  surface  or  as  multiple  punctures,  de.stroy- 
inir  the  <;rowth.  and  with  hut  little  pain. 

In  the  piiir/i/  siiliritftiiitiiiis  lufriia  the  treatment   hy  caustics  or  cautery  ap[)licd  as  a 
caustic  is  clearly  inapplicahle.      When  encysted,  as  very  often 
it  is,  rxciKioii  is  the  hest  remedy  ;   !)nt  care  should  he  taken  to  Via.  ]iV2. 

save  the  skin.      When  such  treatment  cannot   he  adopted,  the 
n:evus  may  he  straniiled  hy  a  liuature  applied  suhcutaneously. 
as  illustrated  in  the  drawini;-,  Fig.  1()2,  or  it   may  he  injected 
with  the  perchloride  of  iron   of  the  pharmacopeia  strentrth, 
with  a  .solution  of  tannin  in  water  in  the  pro]tortion  of  ."j  to    C'\^/ ^ 
5j,  or  of  the  chloride  of  zinc  grs.  xij   to   .^j   of  water,  about    ^i:::^:""^ 
twenty  drops   heinii   thrown    into  the  centre  of  fhe  growth,       -^ 
care   being  taken   beforehand  to  tear  up  the  texture  of  the 
tumor   with   a   needle.     The   object   of  this   treatment   is  to 
coagulate    the    blood    in    the    tissue,  and    thus    promote   its    Mixed  Xavus,  with  the  Ligatures 
consolidation   and  cure.     In  many  cases  injection  causes  in-      netfiL*ry  Sre  I'eln^^Ued"*^*^"'*' 
flammation,  suppuration,  or  even   sloughing  of  the  growth  ; 
and  though  in  this  manner  a  cure  may  be  obtained,  it  is  often  by  deformity. 

The  treatment  by  injection  when  the  nanus  is  on  the  head  or  trunk  is,  however, 
attended  with  great  danger,  more  particularly  from  embolism.  I  lost  a  patient  where 
the  n:vvus  was  on  the  cheek  from  this  cause  in  a  few  minutes  after  the  operation.  For 
the  above  reason  it  is  well  to  apply  a  ligature  to  the  base  of  the  growth  and  then  inject, 
or  to  isolate  the  growth  by  means  of  the  pressure  of  a  metallic  ring  hi/ore  injecting. 

In  the  mixe(/  rnn'rfi/,  when  the  skin  appears  to  have  been  involved  secondarily  by  the 
extension  of  the  disease  from  the  cellular  tissue,  the  nj\?vus  may  be  treated  by  excision, 
igni]iuncture.  subcutaneous  ligature,  or  injection. 

When  the  skin,  with  the  cellular  tissue,  is  extensively  involved  and  the  naevus 
defined,  the  whole  may  be  removed  by  excision  ;  but  when  otherwise,  by  ignipuncture  or 
ligature.  AVhen  the  nsevus  is  pendulous  or  when  it  can  be  isolated  from  the  parts 
beneath,  exci-sion  is  most  suitable ;  and  when  hemorrhage  is  dreaded,  the  base  of  the 
growth  may  be  previously  held  in  a  flat  clamp.  In  several  instances  I  have  excised  the 
naevus  by  cutting  on  pins  that  have  been  inserted  beneath  its  base,  keeping  the  pins  as 
points  round  which  a  ligature  might  be  applied,- and  by  which  the  edges  of  the  wound 
might  be  brought  together.  When  the  thickness  of  the  lip  is  involved  in  the  disease  and 
the  disease  is  limited,  a  V-piece  may  be  taken  out  with  the  growth  advantageously  ;  but 
when  the  whole  lip  is  involved,  the  growth  may  be  dis.sected  out,  leaving  the  skin.  The 
drawing  below  is  of  a  case  in  which  this  operation  was  successfully  practised  (Fig.  163), 

Within  the  last  few  years  I   have 
successfully     treated     maiuy     of     the  Fk*.  H>3. 

mixed  varieties  of  na?vi  with  the 
ar-tual  or  galvanic  cautery  by  simply 
perforating  them  with  the  heated 
needle  in  many  points  (ignipuncture). 
introducing  the  needle  at  a  l)lack  heat 
into  the  healthy  margin  of  the  growth 
down  to  its  base.  The  cautery  de- 
stroys the    subcutaneous  growth,  and 

with  it  the  skin.  l-  Xitvus  involvinc  the  whole  of  the  upper  lip.    2.  After  removal 

rni  ^  . .  .      f>       T<r         i  ;i.  Flatteiiinsof  the  teeth  from  the  pressureof  the  niBvus.   (From 

ine  treatment  oi  a  diffused  nanus      Om/s  R'-pm-ts.) 
by  means  of  setons  is  a  practice  that 
can  also   be  strongly  recommended.     Several  setons  steeped  in  the  solution  of  the  per- 


380 


THE  LIGATURE  OF  ARTERIES. 


chloride  of  iron  are  often  sufficient  to  coagulate  the  blood  or  to  set  up  enough  inflamma- 
tory action  to  cure  the  growth.  When  a  njevus  is  extensive  and  is  to  be  treated  by  the 
ligature,  it  may  be  dealt  with  piecemeal  (Fig.  16-1).     It  occasionally  happens  that  the 


Fig.  164. 


Fu; 


Illustrating  the  method  of  ligaturing  a  large 
mixed  ntev  us  in  sections  around  pins.  At 
one  end  the  pin  has  been  removed  and  the 
knot  completed  (/i. 

ligaturing  of  half  a  nasvus  cures  the  whole  by  the  extension  of  the  inflammatory  action. 
In  naevi  involving  the  eyelids  this  suggestion  is  of  value,  and  in  my  own  practice  several 
instances  of  cure  have  followed  the  application  of  a  ligature  to  half  the  growth. 

In  a  mixed  n^evus  of  moderate  size,  when  the  cure  by  ligature  is  to  be  carried  out,  a 
pin  may  be  pa.ssed  beneath  the  growth,  and  also  a  needle  at  right  angles  to  the  pin, 
armed  with  a  double  ligature  (Fig.  165).  The  naevus  is  then  strangled  in  halves  by  the 
ligatures  tightly  drawn  beneath  the  pin,  but  before  the  ligatures  are  finally  tightened  it 
is  well  to  puncture  it  to  let  out  the  serum  and  blood,  to  relieve  tension,  and  to  allow  of 
the  more  perfect  strangulation  of  the  growth.  When  this  act  is  completed,  the  pin  may 
generally  be  removed. 

Small  naevi  may  be  vaccinated,  although  the  chances  of  a  cure  by  such  means  are 
very  small.     The  same  also  must  be  said  for  compression. 

Fig.  166. 


The  best  needle  for  the  application  of  a  subcutaneous  ligature  to  a  nrevus  is  shown 
above. 

RiCHET,  "Aneurism"  in  Did.  de  Med.  el  de  Chir.  Prat.,  vol.  ii. — Leox  de  Fort,  Diction.  Ency- 
clopediqne  des  Sciences  Medicakfi,  1866. — Broca,  Traiie  des  Aueurysmes,  1856. — Lisfranc,  Des  differens 
Methndc!',  etc.  pour  I' Obliteration  rfe.s  Arteres,  1834. — Scarpa,  On  Aneurism,  Wishart's  Translation. — 
Bellingham,  On  Aneurism,  1857. — Tufnell,  On  Treatment  of  Aneurism  by  Compression,  1851. — 
Holmes,  System  of  Surgery,  3d  ed.,  1883. — Hodgson,  On  Arteries  and  Veins,  1815.— Dr.  Norris, 
American  Journal. — Dr.  Stephen  Smith,  ditto. — Erichsen's  Cooper's  Sun/ical  Diet.,  1861. — War- 
prop,  Cyclop,  of  Surgery. — Syme,  Obaerv.  in  Clinical  Surgery,  1861. — Fergupson,  Sir  W.,  Med.-Chir. 
Trans.,  vol.  xl. — Dr.  Jones,  On  Hemorrhage. — Bryant,  Lancet,  April  4,  1874. — Gould,  Trans.  Inter- 
national Congress,  1881. — Holmes,  St.  George's  Hasp.  Rep.,  vol.  vii. — Ashhur.st's  International  Ency- 
dop.,  vol.  iii.,  1883. 


THE  LIGATURE  OF  ARTERIES.— SPECIAL  ANEURISMS,  Etc. 

John  Bell  wrote  seventy  years  ago  ''that  the  right  way  of  securing  a  great  artery  is 
perhaps  one  of  the  most  important  points  in  practical  surgery;"  and  I  may  add  that  to  do 
this  with  nicety  and  precision  requires  a  sounder  and  more  accurate  knowledge  of  anatomy 
than  any  other  operation. 

"  Before  undertaking  to  tie  an  artery  the  surgeon  ought  to  know  its  general  course 


Tin:  iJi:.\Triii:  of  arteriks.  381 

and  its  rflaliuns.  ami  cspcciall  v  tin-  pnniiiiiiiit  |iait  or  )iarl>  wliii-li  arc  to  ^iiiilf  liiin  lu  the 
])ositi(iii  111"  the  vi's.sel  ;  he  oiij^ht  to  liavi'  raiiiiliari/.ctl  liiiiisidt'  by  t'rt'ijiuMit  tlis.sectioii  with 
tlu'  thickness  of  the  parts  eoverint;  it.  and  their  appcaranee  as  far  as  that  can  he  judjred 
of  in  the  (h-ad  l)ody;  and  tinally.  he  onirht  to  know  tlie  usual  position  of  its  principal 
hranehcs  and  the  anastoinosi>  l»y  whicli  the  circulation  may  he  exp(;ctcd  to  he  restored. 
It  is  advisalih'  also  to  he  aware  of  the  lea<linLr  peculiarities  in  course,  relations,  hifurca- 
tion,  etc..  which  the  operator  may  jK-rhaps  nn-et  with,  and  for  whicdi  lu;  ou^ht  to  he  pre- 
pared" ( /Ill/ill is' K  ,Si/sfiiii.  \iA.  iii.  p.  !•'.*).  In  I'act,  without  anatomical  knowledge,  any 
attempt  to  tie  the  trunk  of  a  lar^t;  artery  must  he  surrounded  with  difficulties  and  fraught 
with  danger,  whilst  with  it  the  operation  l>ecoine.s  in  the  hand  of  an  experienced  surgeon 
an  act  of  precision  ami  apparent  simjtlicity. 

1m  a  former  chapter  the  mode  <if  applying  a  ligature  to  a  divided  artery  after  operation 
was  discussed  and  illustrated,  and  in  the  ])resent  attention  will  be  directed  to  the  applica- 
tion of  a  ligature  to  an  nrfcri/  in  con  fin  in'///,  as  in  the  operation  for  aneurism  or  the  arrest 
of  hemorrhage  from  a  puiicture<l  wound.  To  acccjmplish  this,  the  surg(!on  has  to  go 
through  several  stages  of  thought  as  well  as  of  action.  He  haajirsf  of  all  to  make  out 
with  ])reeision  the  rxacf  coiirsi-  o/' /he  nssrf  /o  h<'  li(f(i/nrt'.il,  which  may  be  d(jne  by  the  arti- 
ficial linear  guides  with  which  he  ought  to  be  familiar,  the  muscular  guides  to  its  position, 
and  the  recollection  of  the  anatomical  relations  of  the  vessel. 

He  has,  seroniJ///,  to  decide  on  f/w  point  at  zvhic/i  the  fii/atiire  shon/i/  Ix-  (ipplied.  When 
for  a  xoounil  in  the  vessel,  this  point  is  already  settled,  it  having  been  laid  down  as  a  rule 
that  whenever  jiossible  a  wounded  artery  is  to  be  exposed  at  the  seat  of  iujury  and  two 
ligatures  applit'il.  one  al)0ve  and  one  below  the  seat  of  lesion. 

Point  of  Selection. — When  for  aneurism,  the  question  is  more  open,  the  '•  point 
for  ligature"  having  to  be  determined  by  the  surgeon.  In  deciding  this  important  (jues- 
tion  it  should  be  remembered  that  if  the  ligature  be  applied  too  near  the  aneurism,  there 
is  a  risk  of  the  ligatured  vessel  partaking  of  the  disea.se  for  which  the  operation  is 
required  ;  and  if  too  far  ojf,  the  circulation  through  the  aneurismal  sac  may  be  too  free 
on  account  of  the  collateral  circulation  of  the  part. 

But,  above  all,  the  surgeon  should  avoid  selecting  a  spot  n:here  an  artery  Itifnrcatea  or 
gives  off  larije  //ranches,  as  under  these  circumstances  the  clot  that  is  required  to  plug  the 
vessel  behind  the  ligature  must  be  absent  and  one  of  Nature's  most  important  haemostatic 
agents  become  lost. 

With  the  decision  of  these  primar}^  and  important  points  the  operation  itself  has  to  be 
considered,  which  resolves  itself  into  the  exposure  of  the  artery,  its  isolation,  the  application 
of  the  ligature  around  it,  and  the  after-treatment,  the  position  of  the  patient  for  the  opera- 
tion being  previously  determined. 

The  position  of  the  patient  should  be  such  as  to  render  prominent  the  anatom- 
ical guides  to  the  course  of  the  artery,  to  make  the  skin  tense,  and  to  facilitate  its  division. 
It  should,  moreover,  he  one  of  extension  ;  yet,  after  the  artery  has  been  exposed,  it  is  well 
to  remember  that  the  muscles  of  the  part  luust  be  relaxed,  as  the  artery  is  thus  better 
brought  into  view  and  the  subsequent  steps  of  the  operation  are  rendered  more  easy. 

The  exposure  of  the  artery  is  to  be  made  by  incision,  its  course  having  been 
clearly  made  nut.  and  the  point  di'termined  on  beforehand  for  the  application  of  the  liga- 
ture. The  incision  should  be  in  the  course  of  the  vessel,  its  centre  corresponding  to  the 
point  where  the  ligature  is  to  be  applied,  an  occasional  obliquity  being  .sometimes  prac- 
tised when  the  exact  position  of  an  intermuscular  interspace  in  which  the  vessel  lies  is 
uncertain  and  when  the  artery  lies  deep.  It  should,  moreover,  be  free.  It  need  not  be 
so  long  in  a  thin  as  in  a  fat  subject,  nor  in  the  case  of  a  superficial  artery  as  in  that  of  a 
deep  vessel ;  but  under  all  circum.stances  the  skin  wound  should  be  enough  to  allow  room 
for  manipulation. 

The  first  incision  .should  include  the  skin  and  superficial  fascia  down  to  the  deep  fascia, 
and  in  making  it  the  operator  has  only  to  avoid  the  division  of  any  large  vein,  such  as  the 
external  jugular  in  operations  on  the  neck,  or  saphena  in  operations  on  the  thigh.  He 
should,  consequently,  mark  out  their  position  by  arresting  the  circulation  through  them 
on  their  c^xrdiac  side  and  make  his  incision  parallel  with  them  when  they  lie  in  his 
course. 

When  the  deep  fascia  is  exposed,  it  should  be  laid  open,  and  in  this  step  the  use  of  a 
director  is  .sometimes  valuable;  the  fascia,  moreover,  should  always  be  divided  to  the  full 
extent  of  the  external  incision.  The  student  .should  renieml)er  that  the  trunks  of  all  arte- 
ries except  the  cutaneous  are  covered  in  by  fascia.  With  the  division  of  the  fascia  the 
use  of  the  knife  can  for  a  time  be  dispensed  with,  as  the  intermuscular  septa  and  cellular 


382 


THE  LIGATURE  OF  ARTERIES. 


tissue  are  readily  separated  by  the  handle  of  the  instruinent  or  finger,  so  that  the  sheath 
of  the  vessel  can  be  thus  well  exposed. 

"  If,"  writes  Malgaigne,  "  immediately  after  the  first  incision,  the  surgeon  attempts  to 
find  the  artery,  he  tries  an  impossibility,  since  he  cannot  reach  it  till  after  the  last  incis- 
ion." He  will  then  proceed  uncertainly  and  at  random  ;  hence  the  following  rule  of  the 
guiding  points :  "  The  surgeon  should  not  at  the  commencement  occupy  himself  with 
looking  for  the  artery,  but  should  seek  the  first  marked  point  of  guidance,  then  the  sec- 
ond, then  the  third,  and  so  on  to  the  end.  ' 

In  looking  for  the  sheath  every  anatomical  guide  is  to  be  made  use  of,  to  prevent 
undue  manipulation  or  separation  of  parts. 

When  the  sheath  is  found  and  the  pulsating  artery  is  felt  within,  the  end  of  the 
operation  is  not  distant.     Yet  many  errors  may  be  committed.     Every  possible  mistake 

should    consequently    be    thought    over 
Fig.  167.  Fig.  168.  beforehand  in  order  to  be  avoided.      The 

operator  must  ask  himself  as  to  the  posi- 
tion of  the  nerves  and  veins  about  the 
part,  so  as  to  avoid  them.  He  need  not 
look  for  them  as  in  a  dissection,  for  this 
would  necessitate  superfluous  manipula- 
tion, but  their  existence  ought  to  be 
present  in  his  mind.  He  should  only 
remember  their  relative  position  to  the 
vessel  where  the  ligature  is  to  be  ap- 
plied, and  then  guard  against  their  being 
injured.  The  sheath  having  been  found, 
it  must  be  raised  by  the  forceps  and  care- 
fully opened  (Fig.  167,  A),  such  opening 
being  only  sufficient  to  admit  a  probe  or 
aneurism  needle  ;  and  the  less  the  sheath 
is  separated  from  its  vessel  the  better. 
The  needle  (Fig.  168)  with  the  ligature 
is  then  to  be  passed  (Fig.  167,  B),  and  it 
should  be  introduced  between  the  artery 
and  the  vein,  because  when  it  is  passed  the 
other  way  the  vein  may  be  perforated  or 
mistaken  for  fascia  ;  yet  in  the  hands  of 
a  careful  surgeon  this  point  need  not  weigh  against  convenience.  With  the  exposure  of 
the  artery  all  anxiety  ceases,  for  to  put  an  ordinary  silk,  wire,  or  catgut  ligature  around 
it  is  a  comparatively  easy  task  with  the  majority  of  arteries ;  so  when  this  is  accom- 
plished, the  operation,  as  such,  is  all  but  completed.  To  do  this,  however,  the  surgeon 
must  be  careful  not  to  elevate  the  artery  from  its  bed  by  the  ligature,  but  to  tie  the  knot 
with  his  fingers  well  passed  down  to  the  vessel  {vid<'  Fig.  167,  C).  He  should  also  sat- 
isfy himself,  when  the  vessel  is  on  the  needle,  that  pulsation  exists  and  that  pressure 
arrests  pulsation  in  the  aneurism.  When  the  ligature  has  been  applied,  the  displaced 
parts  must  be  readjusted,  the  wound  cleansed,  its  edges  brought  together,  and 
some  light  application  employed,  such  as  dry  lint  or  water  dressing.  Where  the  artery 
of  an  extremity  has  been  tied,  the  limb  should  be  raised,  to  facilitate  the  venous  circula- 
tion, and  cotton-wool  wrapped  round  the  part,  to  maintain  its  heat ;  but  beyond  this  no 
local  treatment  is  required.  It  need  hardly  be  stated  that  an  anaesthetic  should  invaria- 
bly be  given  in  these  operations,  and  that  the  subsequent  treatment  of  the  case  should  be 
based  on  general  principles.  When  veins  bleed  or  large  venous  trunks  require  to  be 
divided,  they  may  be  tied  or  twisted,  though  gentle  pressure  often  arrests  bleeding  from 
small  vessels.  The  wound  should  be  carefully  cleaned  during  the  operation  by  the  firm 
pressure  of  a  well-squeezed  sponge  ;  the  edges  should  be  held  apart  after  the  sheath  has 
been  exposed  by  hooked  directors,  but  the  surgeon  on  no  account  should  allow  his  assist- 
ants to  draw  the  parts  so  far  asunder  as  to  make  them  lose  their  relative  positions.  With 
these  general  remarks,  the  application  of  a  ligature  to  special  arteries  will  now  claim 
attention. 

Ligature  of  the  Abdominal  Aorta. 

In  1817,  Sir  A.  Cooper  tied  the  abdominal  aorta,  having  failed  to  find  the  communi- 
cation between  the  common  iliac  artery  and  an  aneurismal  tumor,  after  the  introduction 


This  diagram  represents  three  distinct  operations: 
A,  Opening  of  the  Sheath.  B,  Drawing  ligature 
round  the  artery.    C,  Tying  artery. 


77//;  i.idArriu'.  of  Airn:i:n:s. 


383 


of  his  tiiiL'^cr  tlin>ui:li  a  small  (i|pciiiii^'  in  tin-  ni|itiirc(l  sue.  lie  iuikIc  his  iiicisinii  ilirou;_'li 
the  liiica  all»a  In  the  Icl't  of  tin-  iiiiiliilicus,  ilircrtly  (iVi-r  thf  a(»ita.  'I'hc  paiifiit  liv('(l  forty 
hours.  James  of  Kxeti-r  (  IS:?!*),  ami  Murray  of  tlie  ('a|»('  (if  (JcxmI  I|(»|.<-.  fullowcd  his 
cxaiuplo  with  no  lu'ttcr  success,  tlie  patients  surviviiifr  three  and  a  half  and  twenty-three 
hours  resjK'ctively.  In  isili  (Lidinf,  y.  '.V.Vl)  Dr.  ('.  li.  Moiiteiro  <if  Kio  Janeiro  ree(»rdcd 
H  ease  in  whieli  the  patient  died  from  hemorrhage  on  the  tenth  (hiy.  In  1H5«).  Mr.  South 
{/jiiiiccf,  vol.  ii.)  operated  on  a  patient  who  lived  forty-three  hours.  In  lH(iK  ( Ayiim'raii 
Jiinniitl  (if  Mcdlrnl  Svifiivi)  \)i\  .Alcduirc  ol'  llichmond,  X'irjrinia,  recorded  a  si.\th  ca.se, 
in  which  the  patient  lived  twelve  hours.  In  iStiM,  J)r.  I'.  H.  Watson  of  Edinhurgh 
(^lin'f.  Mrti.  Joiini.,  18(j*J)  i.s  .said  to  have  performed  the  operation  on  a  man  who  survived 
it  sixty-five  hours;  and  in  the  Diihlin  Qiiurf.  lor  IS'ID  Mr.  Stokes,  Jr.,  has  recorded  an 
eifrhth  ca.se,  in  which  a  temporary  ligature  was  applied,  but  without  success. 

In  all  these  the  operation  was  perfornu'd  for  aneurism  <»f  the  common  iliac  arterv,  hut 
the  results  u)»  to  the  present  offer  little  eiieourajrement  for  its  repetitioti,  more  particularly 
when  we  have  (»ther  means  at  our  command  holding  out  a  hetter  pntmise  of  success,  such 
as  pressure  by  the  abdominal  tournii(uet  while  the  patient  is  uiuler  the  influence  of  chhiro- 
form.  Cures  of  abdominal  aneurism  by  this  uieans  have  been  recorded  by  Dr.  .^Iurray  of 
Newcastle-on-Tyne  (Rapiif  Citrc  a/  Aiienn's»i  hi/  JWssin-f\  1S71),  Dr.  Heath  of  Sun<li'rland 
(Jh-if.  Mr, I  ./,.,ini.,  IStlT.  p.  L\S7),*Mr.  Ilolden  (Sf.  Burthol.  llo^p.  Rrp.,  IHOtl),  Dr.  Mox(»n 
and  Mr.  Durham  {M(<f.-('/iir.   7V(uis.,  187-^,  and  Dr.  Greenhow  (ihid.^  187^:$). 

I  believe,  nevertheless,  the  operation  of  placing  a  ligature  upon  the  abdominal  aorta 
to  be  justifiable  under  exceptional  circumstances,  such  as  in  cases  of  aneurism  of  the 
coninion  iliac  artery  when  all  other  means  are  inapplicable. 

The  best  incision  by  which  to  reach  the  abdominal  aorta  is  the  hidirecf,  a  modification 
of  that  adopted  by  Sir  P.  Crampton  ^  in  the  case  of  the  common  iliac  artery  (Fig.  IG'J) — 

Fig.  169. 


Incision  for  the  .\pplication  of  a  Ligature  to  the  .Aorta  or  Common  Iliac  .Artery. 

viz.,  one  extending  from  the  anterior  superior  spinous  process  of  the  ilium  of  the  left  side 
to  the  cartilage  of  the  tenth  rib,  the  peritoneum  being  reflected.  The  great  difficulty  in 
this  operation  is  in  the  application  of  the  ligature  to  the  vessel. 


Ligature  of  the  Arteria  Innominata. 

The  first  operation  was  by  V.  Mott  of  New  York  in  1818,  and  since  then  this  artery 
has  been  tied  eighteen  times,  but  only  once  with  success  (by  Dr.  Smyth  of  New  Orleans 
in  1864,  the  patient  living  ten  years),  and  in  that  case  the  carotid  and  vertebral  arteries 
were  likewise  ligatured,  the  former  at  the  same  time  as  the  innominata,  the  latter  on  the 
fifty-fourth  day,  for  secondary  hemorrhage.  Dr.  Smyth  accomplished  this  on  the  sug- 
gestion made  by  Mott  in  1818,  when  he  wrote  .  "  By  thus  intercepting  the  retrograde 
current  through  the  primitive  carotid  there  would  be  less  chance  of  any  reflux  hemor- 
rhage in  the  event  of  a  phagedjvnic  ulceration  taking  place  in  the  wound."  In  all  the 
other  cases  a  fatal  result  rapidly  ensued.     Graafe's  case  lived  sixty-seven  and  Thomson's 

^  Med.-Chir.  Irfin.".,  vol.  xvi. 


384-  THE  LIGATURE  OF  ARTERIES. 

forty-two  days  {Brit.  Med.  ,/oinu.,  October  14,  1882).  It  can  only  be  entertained,  there- 
fore, in  cases  of  injury  to  the  carotid  or  subclavian  near  their  origin  or  in  exceptional 
cases  of  disease.      When  decided  on,  the  ojieration  should  be  proceeded  with  as  follows : 

Operation. — The  head  being  thrown  back  to  the  left  and  the  shoulder  depressed, 
the  vessel  may  be  secured  by  making  an  incision  along  the  anterior  border  and  .sternal 
origin  of  the  sterno-mastoid  muscle,  or  by  a  transverse  one  over  the  upper  border  of  the 
clavicle,  making  its  centre  correspond  to  the  upper  border  of  the  sterno-clavicular  joint, 
or  by  both  combined.  Under  all  circum.stances  the  sternal,  and  sometimes  a  part  of  the 
clavicular,  origin  of  the  muscle  will  recjuire  division.  The  sheath  of  the  cervical  vessels 
will  then  come  into  view,  with  the  internal  jugular  vein  on  the  outer  side  of  the  carotid 
artery  and  the  vagus  nerve  between  them.  On  tracing  these  downward  the  innominate 
vessel  will  be  reached.  In  a  healthy  subject  the  artery  is  always  to  be  found  behind  the 
right  sterno-clavicular  joint,  but  in  disease  its  relative  position  may  be  altered  by  mechan- 
ical displacement.  Dr.  Cooper  of  San  Francisco  has  reached  the  artery  on  two  occasions 
by  removing  the  sterno-clavicular  articulation.     A  stout  animal  ligature  should  be  used. 

In  aneurism  of  the  innominate  there  is  no  possibility  of  applying  a  ligature 
to  its  cardiac  side,  even  if  the  disease  involves  only  the  upper  part  of  the  artery  ;  yet,  as 
a  rule,  this  form  of  aneurism  is  almost  sure  to  be  associated  with  dilatation  of  the  aorta. 
The  distal  operation,  however,  may  be  thought  of,  the  carotid  and  subclavian  arteries 
being  ligatured  simultaneously  or  consecutively.  Of  five  instances  in  which  the  former 
practice  was  followed,  one  (Ensor's  case.  Lancet,  July  31,  1875)  lived  sixty-five  days 
and  one  recovered ;  while  out  of  three  of  the  latter  an  equal  success  may  be  recorded. 

The  credit  of  the  successful  case  in  the  former  clas.s — for  a  success  I  take  it  to  have 
been — belongs  to  Mr.  C.  Heath,  who  tied  the  subclavian  artery  in  the  third  part  of  its 
course  as  well  as  the  common  carotid  simultaneously  in  18G5.  The  operation  was  fol- 
lowed by  marked  relief  and  the  diminution  of  the  tumor;  the  woman,  get.  30.  survived 
the  operation  four  years,  and  died  from  rupture  of  the  aneurism.  After  death  the  aneu- 
rism was  found  to  be  of  the  aorta,  the  innominate  being  only  slightly  involved.  (  Vit/e 
Prep,  in  Mus.  of  Royal  Coll.  of  Surgeons,  and  Path.  Tran>(.,  vol.  xxi.) 

The  successful  issue  to  the  case  in  the  latter  class  belongs  to  Mr.  Fearn  of  Derby,  who 
tied  the  carotid  in  1836,  and  the  subclavian  in  the  third  part  of  its  course  two  years  later, 
for  innominate  aneurism.  The  patient  died  four  months  after  the  second  operation,  from 
pleurisy.  I  had  an  opportunity  in  186(3  (Patli.  Soc.  Trans..  \o\.  xviii.)  of  carefully  exam- 
ining and  reporting  on  this  preparation,  which  is  now  in  the  College  of  Surgeons'  Museum, 
and  a  better  specimen  of  a  cured  small  sacculated  aneurism  could  not  possibly  be  seen. 

Aneurism  of  the  innominate  has  likewise  been  treated  by  ligature  of  the  subclavian 
or  of  the  common  carotid  alone,  Wardrop's  operation  ;  and  in  Wyeth's  prize  essay  (New 
York,  1879)  and  Hulmens  ISnrgery  &  most  interesting  list  of  references  to  such  cases  can 
be  found.  Out  of  eighteen,  Evans's  case,  as  recorded  by  Wardrop,  was  cured  ;  his  own 
lived  tAvo  years.  Morrison's  case  lived  twenty  months,  two  others  lived  six  months,  and 
the  remainder  lived  only  a  few  days  or  weeks. 

In  August,  1871,  I  ligatured  the  subclavian  in  a  man  aet.  33  for  this  affection,  and  a 
rapid  convalescence  followed,  with  great  diminution  and  consolidation  of  the  aneurism. 
The  man  lived  three  years  after  the  operation  {r,ide  page  371).  This  result,  therefore,  is 
not  so  discouraging  as  to  preclude  the  question  of  operation  in  favorable  cases.  It  should 
only  be  entertained,  hoAvever,  under  exceptional  circumstances,  and  more  as  a  palliative 
than  as  a  curative  remedy. 

Ligature  of  the  Common  Carotid  Artery. 

This  operation  was  first  performed  for  aneurism  by  Sir  A.  Cooper  in  1805,  but  unsuc- 
cessfully. The  same  surgeon,  however,  had  a  successful  case  in  1808,  the  man  surviving 
thirteen  years  (C^^^'.s  Hosp.  Rep.,  vol.  i.).  The  operation  may  be  demanded  for  aneurism 
of  the  trunk  itself  or  one  of  its  branches,  for  erectile  tumors  of  the  orbit  or  of  the  scalp, 
etc.,  and  for  wounds  or  hemorrhage.  It  mav  also  be  called  for  as  a  distal  operation  in 
aortic  aneurism.  It  is  a  dangerous,  and  sometimes  a  difiicult,  operation  ;  but  in  a  mod- 
erately thin  subject  it  may  be  performed  with  facility.  It  .should  only  be  resorted  to 
when  all  other  means  of  treatment  are  inapplicable  or  have  been  found  inefiectual ;  for 
aneurism  it  ought  not  to  be  performed  unless  the  treatment  by  digital  compression  has 
been  rejected.  Holmes  well  sums  up  the  matter  in  his  College  Licfures  (1873)  as  follows: 
"  That  the  experience  of  surgeons  hitherto  leads  to  the  conclusion  that  aneurism  of  the 
trunk  of  the  carotid  artery  may  be  very  often  treated  succes.sfully  by  compression,  and 


77//;  lk; AT! •/:!■:  or  mitkiuf.s.  p>85 

tliat  tlu-  fiirc  liv  fnin|iri's.-itiii  tV<'(|iiciitly  liavcs  tlic  iirtrry  uriohlitcratcd,  and  tlicrcfore 
exposes  till'  [»ati«.'iit  to  a  far  less  risk  of  (•LTcl)ral  iiiiscliicr  tliaii  tlic  lifratiirc  ;  that  the  lifr- 
ature  of  the  rarotid  for  siu-li  tumors  is  oxtrciiicly  (hiiijrcroiis  and  oiifrht  not  to  he;  under- 
taken until  attempts  well  devised  and  perseverinjrly  carried  (tut  have  failed  (o  efleet  the 
cure  1)V  eompression  ;  and  that  when  the  surjreori  has  heen  eompelled  l»y  the  position  of 
tlie  tum(»r  to  place  his  liirature  close  to  the  proximal  side  of  the  sac,  it  is  worth  very 
^'reat  consideration  whether  it  would  not  he  hetter  to  evacuate  the  tumor  and  tie  the 
distal  part  of  the  artery  also;  limilly,  that  cases  d(»  occur  in  whi<di  lirasdor's  method 
l>ulds  out  a  ratiftiial  h(»pc  of  cure,  hut  that  this  operation  oujrht  not  to  he  jiractised 
except  in  cases  cd"  <:rowin>r  Jtncurism  when  ditrital  pressure  checks  the  pulsation  u\'  the 
tumor,  yet  has  failed  to  effect  a  cure"  (/>a//fy/,  June,  187.i).  The  vessel  may  he  lijr- 
atured  in  the  upper  part  of  its  course  at  the  apex  of  the  carotid  trianjrle,  in  a  line  witli 
the  cricoid  cartila<:e,  or  lower  down  than  this;  the  former  yiosition  is  the  preferahle  and 
the  operation  there  is  more  easy,  and  for  disease  of  any  of  the  hranches  of  the  vessel  it 
should  he  selected.  The  latter  should  he  rcs(»rted  to  only  for  disease  of  the  U|)pfcr  part 
of  the  trunk  itself.  The  course  of  the  artery  can  always  he  made  out,  correspondiiifr,.  as 
it  does,  with  a  Hne  drawn  from  the  sterno-davicular  joint  to  the  anjrle  of  the  jaw  ;  the 
vessel  divides  on  a  level  with  the  u[)pcr  part  of  the  thyroid  cartilage  and  .should  he  tied 
opposite  the  cricoid.  The  centre  of  the  incision  made  to  expose  it  should  he  opposite  to 
the  cricoid,  and  should  extend  ahout  three  inches  alonir  the  anterior  marjLMn  of  the  sterno- 
mastoid  muscle.  The  position  of  the  patient  should  therefore  he  such  as  to  render  this 
muscle  prominent,  which  is  ensured  by  the  extension  of  the  head  Itackward,  the  face 
beintr  turned  to  the  opposite  side. 

Operation. — Before  makinp:  the  first  incision  throujrh  the  skin,  platysma.  and  super- 
ficial fascia  the  surgeon  should  assure  himself  that  no  large  vein,  such  as  the  anterior 
jugular,  is  likely  to  be  divided;  gentle  pressure  below,  enough  to  interfere  with  the 
venous  cir(;ulation  of  the  part,  readily  supplies  this  information.  The  deep  fa.scia  cover- 
ing in  the  sheath  of  the  vessel  may  then  be  divided,  care  being  taken  to  do  this  to  the 
whole  extent  of  the  external  wound.  The  sheath  of  the  artery  will  then  come  into  view, 
lying  between  the  trachea  and  sterno-ma.stoid  muscle ;  the  piilsation  of  the  vessel  likewi.se 
can  be  detected.  The  head  of  the  patient  at  this  stage  of  the  operation  .should  be  slightly 
raised,  so  as  to  relax  the  sterno-mastoid  muscle  and  allow  its  being  gently  drawn  outward 
by  means  of  the  retractor,  as  well  as  to  permit  of  the  separation  of  the  cellular  connective 
tissue  of  the  part.  The  anterior  belly  of  the  omo-hyoid  muscle  will  then  probably  be  at 
once  visible  with  its  fibres  passing  downward  and  outward;  and  when  this  muscle  is 
broad,  it  will  cover  in  a  great  part  of  the  vessel.  The  desccndens  noni  nerve  may  like- 
wise be  seen  lying  upon,  or  sometimes  within,  the  sheath  ;  due  care  should  be  taken  that 
it  is  not  wounded  or  included  in  the  ligature ;  and  if  it  be  in  the  way,  it  must  be  gently 
held  aside  by  a  retractor,  as  should  be,  also,  any  large  vein  that  crosses  the  sheath.  The 
inner  border  of  the  .sheath  is  then  to  be  taken  up  and  firmly  held  with  forceps,  and  a  suf- 
ficient opening  made  in  it  by  the  knife,  held  with  its  flat  surface  toward  the  artery,  to 
allow  of  the  introduction  of  the  aneurism  needle.  The  needle  is  then,  as  generally  rec- 
ommended, passed  (inntd,  though  this  is  not  a  point  of  importance,  for  nnnrmid  it  is 
passed  with  greater  facility.  By  a  little  manijtulation  the  needle  may  be  passed  round 
the  artery  from  without  inward,  introducing  it  between  the  vein  and  vessel  and  keeping 
its  point  close  to  the  artery.  The  sheath  may  be  dropped  from  the  forceps  and  the  loop 
of  the  ligature  seized,  or  the  needle  may  be  threaded  and  withdrawn.  The  surgeon  must, 
however,  satisfy  himself  beforehand  that  the  right  vessel  has  been  exposed  and  that  the 
vagus  nerve  is  not  included.  The  ves.sel  can  now  be  tied,  great  caVe  being  observed  that 
it  is  not  raised  from  its  bed  or  manipulated  more  than  is  necessary  ;  the  knot  should  be 
tightened  by  the  index  fingers  pa.s.sed  well  into  the  wound.  The  wound  should  then  be 
adjusted  and  the  patient  put  to  bed,  the  mo.st  perfect  quiet  being  enjoined.  The  surgeon 
ought  to  remember  all  through  this  operation  that  the  jugular  vein  is  on  the  outer  .side 
of  the  artery  and  often  overlaps  it,  while  the  vagus  nerve  is  behind  and  the  descendens 
noni  in  front  (Fig.  170).  None  of  these  parts  need  be  looked  for.  however,  so  long  as 
care  is  observed  that  they  are  neither  wounded  nor  included  in  the  ligature. 

The  operation  for  ligaturing  the  hnnr  part  of  the  cnrofi'/  is  .somewhat  similar  to  the 
above ;  the  operation  is,  however,  more  diSicult  from  the  vessel  being  deeper,  particularly 
on  the  left  side.  The  incision  should  in  this  instance  extend  lower  down  over  the  sterno- 
clavicular articulation.  The  muscles  will  also  require  more  retraction,  and  probably  some 
division. 

Mr.  Cock  related  to  me  a  case  which  he  authorizes  me  to  quote,  in  which  Mr.  Aston 
25 


386 


THE  LIGATURE  OF  ARTERIES. 


Key  applied  a  ligature  to  the  left  carotid  for  aneurism  and  the  man  died  on  the  table — 
indeed,  died  on  the  application  of  the  ligature.  After  death  it  was  found  that  the  right 
carotid  had  been  previously  obliterated,  and  the  operator  had  by  ligaturing  the  left  so 
interfered  with  the  supply  of  blood  to  the  brain  as  to  cause  death. 


Fig,  170. 


jint.''  herder  cf  jSternO 


(This  figure,  with  many  others  in  this  chapter,  is  based  upon  tliose  given  in  Sedillot's  work.) 


With  respect  to  the  prognosis  after  this  operation,  much  depends  on  the  object  for 
which  it  is  performed.  Dr.  Pilz  of  Breslau  (^LangenhecJcs  Arclilvts,  1868)  makes  out 
that  48  out  of  every  100  die;  Dr.  J.  Wyeth  of  New  York,  in  a  careful  analysis  of  789 
cases,  gives  41  per  cent.  Pilz  says  that  of  228  cases  in  which  the  operation  was  per- 
formed for  hemorrhage,  128,  or  56  per  cent,  were  fatal;  of  87  for  aneurism,  31,  or  35 
per  cent.,  died;  of  142  for  tumors,  49,  or  34  per  cent.,  died;  of  71  for  extirpations,  25 
died,  or  nearly  34  per  cent. ;  of  34  for  affections  of  the  nervous  sy.stem,  only  1  died,  or 
3  per  cent. ;  and  of  38  for  aneurism  on  the  distal  or  Brasdor's  method,  25  died,  or  65 
per  cent. 

Secondary  hemorrhage  is  a  common  cause  of  death,  but  brain  complications  are  the 
more  frequent,  abscess  in  the  brain  and  atrophic  softening  from  want  of  arterial  supply 
being  the  usual  form — local  gangrene,  as  it  were,  of  the  brain.  Brain  symptoms  in  some 
of  their  forms  also  occur  frequently  after  the  operation,  when  death  does  not  take  place 
simply  from  altered  cerebral  circulation.  Suppuration  of  the  aneurismal  sac  is  not 
unfrequent,  and  in  a  case  of  my  own  it  was  the  cause  of  death. 

Ligature  of  the  external  or  internal  carotid  artery  has  been  rarely  per- 
formed, the  ligature  of  the  common  trunk  being  preferred ;  but  the  wisdom  of  this  prac- 
tice is  not  very  clear.  INIr.  Cripps  has  shown,  in  a  valuable  paper  upon  the  treatment 
of  hemorrhage  from  punctured  wounds  of  the  throat  and  neck,  that  the  application  of  a 
ligature  to  the  exteiiidl  carotid  above  the  superior  thyroid  artery  or  one  inch  above  the 
bifurcation  of  the  common  carotid  is  the  "  point  of  selection  "  for  the  application  of  a 
ligature.  The  incision  for  the  operation  should  be  made  in  front  of  the  sterno-mastoid 
muscle  from  behind  the  angle  of  the  jaw  downward  to  a  point  below  the  level  of  the 
thyroid  cartilage.  The  deep  fascia  and  parts  over  it  having  been  divided,  the  i'acial  and 
lingual  veins  will  be  seen.  These  may  be  turned  aside  or  ligatured  and  divided  if  in  the 
way.  The  artery  will  be  found  behind  the  stylo-hyoid  and  the  posterior  belly  of  the 
digastric  muscle,  crossed  by  the  hypo-glossal  nerve,  with  the  internal  jugular  vein  and 
internal  carotid  artery  along  its  outer  side. 

The  same  incision  is  required  for  the  application  of  a  ligature  to  the  internal  carotid 
artery. 


LIHATVRK   OF   THK  Sl'JiCLA  VIAX.  387 

Dr.  .lolm  A.  NVvctli  of  New  Vmk  in  an  alilf  ]iiize  essay  (\H'H)  advocated  tliis  view. 
Ill'  slniws  that  nut  of  IH  cases  (if  ligature  of  tiie  external  carotid  only  4i  per  cent,  died, 
anil  asserts  that  the  eoininon  carotid  artery  should  lu'vcr  he  tied  lor  a  wound  of  the  exter- 
nal or  one  id"  its  hranchi's  when  then-  is  room  enoutrh  hctween  tlie  wound  and  the  hifur- 
eation  of  the  common  carotid  to  allow  of  the  application  tA'  a  lii^ature  to  tlie  external. 

in  the  Xnr  Yinh-  Mai.  ./oiinin/,  (January.  1S74)  a  case  is  recorded  hy  J>r.  H.  1*. 
Sands  of  New  York  of  successful  ligature  of  the  infmial  carotid  artery  ahove  and  l)elow 
the  bleeding  point  for  secondary  hemorrhage  occurring  ten  days  after  the  removal  of  a 
cancerous  tumor.     This  oi)eration  has  been  ))erformed  four  times. 

Cervical  aneurisms  situated  on  one  of  the  secondary  carotids  should  he  diligently 
treated  hy  com])ression.  and  the  Ilunterian  o])eration  performed  oidy  when  treatment  liy 
eoni])ression  has  lailed. 

The  lingual  artery  has  been  ligatured  lor  wounds  of  the  tongue  and  of  the 
arterv  itself,  to  cluck  the  growth  of  cancerous  tumors,  or  to  arrest  heinorrliage  from 
their  substance.  The  operation  is  difficult.  The  trunk  of  the  vessel  is  always  to  be 
found  at  a  point  abare  tlic  (jrcat  rtirnn  of  tlie.  hjjoid  hoar.,  and  this  point  must  be  rendered 
prominent  by  the  head  being  well  drawn  over  to  the  S(»und  side  and  there  held.  The  best 
incision  is  horizontal,  on  a  level  with  the  hyoid  bone,  its  centre  c(jrresponding  to  the  end 
of  the  greater  cornu.  The  skin  and  fascia  having  been  divided,  the  submaxillary  gland 
will  become  exposed.  On  hooking  this  upward  and  dividing  the  border  of  the  mylo- 
hyoid muscle  the  hypoglossal  nerve  will  be  seen  resting  on  the  hyoglossus  muscle. 
Beneath  this  muscle,  and  at  a  lower  level  than  the  nerve,  the  artery  will  be  found.  It  is 
in  close  contact  with  the  tendon  of  the  digastric  muscle.  The  fibres  of  the  hyoglossus 
will  always  require  division  to  admit  of  the  ligature  l^eing  applied.  Fig.  171  illustrates 
these  points. 

An  excellent  paper  on  this  subject  by  M.  I)emar(|uay  may  be  referred  to  (6V/.:.  Mid. 
de  Pans,  18(57). 

The  facial  artery  is  always  to  be  found  in  the  greater  part  of  its  course  close  to 
the  anterior  border  of  the  masseter  muscle,  where  it  is  only  covered  in  by  skin,  platy.sma, 
and  fascia  ;  and  at  this  part  a  transverse  or  oblique  incision  at  the  lower  insertion  of  the 
muscle  will  expose  the  artery,  where  it  can  be  ligatured  (n'lfc  Fig.  170).  It  is  difficult  to 
understand  under  what  circumstances  this  operation  can  be  called  for.  as  the  artery  can 
be  so  readily  controlled  by  pressure,  an  acupressure  needle  and  twisted  suture  over  it 
being  the  best  form  to  employ.  But  where  the  artery  comes  off  from  the  external  caro- 
tid and  lies  in  the  submaxillary  gland  beneath  the  jaw,  it  is  somewhat  deep  and  an  ope- 
ration for  its  ligature  by  no  means  easy.  I  have,  however,  had  only  one  opportunity  of 
practising  this  operation,  and  it  was  on  a  lady  a?t.  25  who  was  suffering  from  a  cirsoid 
aneurism  of  the  vessel  as  it  passed  through  the  submaxillary  gland.  The  operation  was 
successful.      T  saw  the  case  with  Dr.  Hehsham  of  Brixton. 

The  teraporal  artery  can  always  be  found  and  pressed  upon  in  front  of  the  pinna 
of  the  ear,  over  the  zygoma.  It  lies  buried  in  the  dense  cellular  tissue  which  exists  in 
this  spot  beneath  the  skin  and  fascia,  and  can  readily  be  exposed  by  a  vertical  or  oblique 
incision  an  inch  long,  one-third  of  an  inch  in  front  of  the  tragus. 

The  occipital  artery  can  be  traced  by  a  line  drawn  from  the  mastoid  process  to 
the  occipital  ])rotuberance,  and  lies  beneath  the  skin  and  cranial  aponeurotic  origins  of 
the  sterno-mastoid,  splenius  trachelo-mastoid,  and  digastric  muscles,  which  must  be  divided 
to  reach  the  vessel  in  the  deep  part  of  its  course.  The  artery  can  be  felt  about  the  centre 
of  the  line  mentioned. 

Ligature  of  the  Subclavian  Artery. 

This  operation  in  the  Jjrst  part  of  the  vessel's  cour.se  has  been  performed  twelve  times, 
but  never  with  success.  It  is  an  unscientific  as  well  as  an  unsuccessful  operation,  and, 
for  disease  it  is  scarcely  a  justifiable  proceeding,  though  for  a  wound  it  may  perhaps  be 
entertained.     The  incision  for  the  ojteration  would  be  similar  to  that  for  the  innominate. 

The  point  usually  selected  for  the  application  of  a  ligature  to  the  subclavian  is  in  the 
third  part  of  its  course,  where  the  artery  emerges  from  behind  the  scalenus  muscle.  This 
operation  may  be  demanded  for  aneurism  of  the  axillary  artery  or  for  a  wounded  vessel. 

Aneurism  may  affect  the  subclavian  artery  in  any  part  of  its  course ;  it  may  involve 
the  whole  of  the  artery  or  be  confined  to  its  first  or  third  portion.  When  situated  on  the 
artery  to  the  inner  side  of  the  scaleni  muscles,  it  may  be  mistaken  for  an  innominate  or 
aortic  aneurism,  or  a  common  aneurism  may  involve  all  these  vessels  on  the  right  side  of 


388  LIGATURE  OF  THE  SUBCLAVIAN. 

the  body.  AVhen  affecting  the  artery  external  to  the  scaleni,  it  is  most  frequently  asso- 
ciated with  disease  of  the  axillary  artery. 

The  DIAGNOSIS  of  subclavian  aneurism  is  by  no  means  easy,  and  is  thus  referred  to 
by  Nekton  : 

"  In  subclavian  aneurism  the  tumor  extends,  generally  externally,  to  the  clavicular 
origin  of  the  sterno-mastoid  muscle,  reaching  the  posterior  and  inferior  triangle  of  the 
neck ;  becomes  more  elongated  transversely  than  vertically  ;  the  bruit  is  propagated  more 
toward  the  axilla  than  the  neck,  and  remains  the  same  on  compressing  the  carotid  ;  the 
the  radial  pulse  enfeebled  ;  the  limb  painful  and  oedematous  and  incommoded  in  its  move- 
ments. In  carotid  aneurism  the  tumor  is  seated  between  the  sternal  and  clavicular  origins 
of  the  sterno-mastoid  muscle,  becomes  more  elongated  in  a  vertical  direction  than  in  a 
transverse  one,  and  on  auscultation  gives  to  the  ear  a  hruit  de  souffle,  which  is  propagated 
more  toward  the  side  of  the  neck  than  the  arm,  with  diminution  of  the  arterial  pulsation 
in  the  corresponding  side  of  the  face  and  cranium,  and  without  weakening  the  radial  pulse 
on  the  same  side.  In  innominate  aneurism  the  tumor  is  placed  under  the  sternum  or  at 
the  inner  border  of  the  sternal  portion  of  the  sterno-mastoid  muscle,  with  weakening  of 
the  pulse  in  the  subclavian  and  carotid  arteries,  and  with  absence  of  the  other  signs  pecu- 
liar to  the  two  other  forms."  When  a  cervical  rib  is  present  and  the  subclavian  artery 
passes  over  it,  the  existence  of  aneurism  may  be  simulated;  but  the  knowledge  of  the  fal- 
lacy should  prevent  such  an  error  of  diagnosis  being  made. 

The  PROGNOSIS  must  always  be  regarded  as  unfavorable,  for  these  aneurisms  are  pecu- 
liarly liable  to  become  diffused  even  in  the  early  stage  of  their  development  as  a  visible 
tumor ;  yet  there  are  several  instances  on  record  of  their  slow  progress,  and  some  for- 
tunate examples  of  their  ultimate  cure  by  natural  efforts. 

The  TREATMENT  of  these  aneurisms  is  most  unsatisfactory,  the  space  at  the  disposal 
of  the  surgeon  being  so  limited  that  he  is  at  a  loss  to  know  where  he  can  attack  the  dis- 
ease by  the  few  means  that  are  at  command.  Ligature  of  the  first  portion  of  the  subcla- 
vian, ligature  of  the  innominate,  the  distal  ligature  of  the  subclavian  and  axillary  arte- 
ries, and  ligature  of  the  carotid  have  all  been  performed,  and,  with  one  exception,  been 
attended  with  fatal  results.  The  exceptional  case  is  that  of  Pr.  Smyth  of  New  Orleans, 
who  tied  the  innominate  and  carotid,  and  subsequently  the  vertebral  artery  on  the  fifty- 
fourth  day.  It  is  only  in  small  aneurisms  occupying  the  third  portion  of  the  artery  and 
the  commencement  of  the  axillary  that  the  operation  of  tying  the  subclavian  external  to 
the  scaleni  has  been  successfully  performed,  and  in  some  of  these  instances  the  outer  fibres 
of  the  scalenus  anticus  muscle  have  been  obliged  to  be  divided. 

The  amjndation  at  the  shouMer-Jfrijif  on  the  distal  side  of  the  aneurism  has  been  sug- 
gested by  surgeons  for  the  cure  of  the  disease.  It  has,  too,  been  successfully  performed 
by  Professor  Spence  of  Edinburgh. 

Galvano-pimctiire  has  been  successful  in  one  case  by  Abeille,  and  escharofics  in  another 
by  Bonnet.  Manipulation  has  been  employed  by  Fergusson  in  two  cases  and  by  Lidell  in 
one  case,  with  satisfactory  results  in  the  latter  one  only.  A  case  of  Porter's  may  also  be 
accepted  as  successful.  Direct  compression  of  the  aneurism  has  been  tried  by  Warren 
with  a  favorable  issue,  although  much  danger  was  risked  in  the  proceeding.  Corner's  case 
(^Med.-Chir.  Trans. ^  vol.  Hi.),  though  one  not  actually  of  the  same  kind,  was  a  very  good 
instance  of  the  value  of  preventing  an  aneurism  from  enlarging  and  exerting  such  mod- 
erate compression  as  to  incite  fibrinous  deposition  in  the  interior  of  the  sac.  Poland's 
case  of  successful  7J?-e.ss!(?'e  on  the  artery  on  the  cardiac  side  of  the  aneurism  is  quite  excep- 
tional. Gay  also  has  recently  met  with  success.  The  use  of  acupressnre  by  Porter, 
though  successful  on  the  distal  side  of  the  aneurism,  proved  fatal  when  applied  on  the 
cardiac  side  to  the  innominate  artery,  and  injection  into  the  sac  was  performed  in  one  case 
with  a  fatal  result.  Langenbeck  has  recently  injected  the  parts  over  the  aneurism  with  a 
.solution  ofergotin,  the  object  being  to  cause  contraction  of  the  aneurismal  sac.  Such  is  a 
list  of  the  means  which  have  been  resorted  to,  but  the  success  has  never  been  great.  The 
question  naturally  arises,  therefore,  whether  we  should  not  discard  such  measures  and 
treat  these  aneurisms  on  the  ordinary  principles  of  internal  aneurisms,  by  rest,  attention 
to  diet,  and  medicinal  remedies. 

Mr.  Poland,  in  an  admirable  essay  in  the  Gny's  Rejwrts  for  1870,  gives  a  very  favor- 
able return  of  cases  which  he  has  been  able  to  collect  in  reference  to  this  question  of 
treatment.  It  stands  thus  :  Out  of  13  that  underwent  general  and  local  treatment^  7  recov- 
ered, 1  was  relieved,  and  5  died  ;  out  of  22  cases  in  which  an  expectant  treatment  only 
was  pursued,  4  recovered  and  18  died  ;  thereby  giving  a  total  of  11  recoveries  and  23 
deaths,  1  being  relieved.     Of  the  23  fatal  cases,  the  duration  of  life  was  noticed  in  17. 


LinAi'rni:  of  riir.  sri:ci..\vi.\s. 


389 


111  21  i-ast's  in  wliidi  tin-  siilichiviun  artt^ry  was  liiiat un-il  in  iIm;  thinl  fHtrt  uf  I'fs  course 
for  aiuMirisiii,  !)  recovcri'tl  (in  0  of  tlu'so  it  wa.s  tlio  left  aitfiy  tliat  wa.s  li^aturtMlj.anfl  12 
dioil  ;  S  (if  till'  (U'atlis  wi-ro  due  to  lu'niorrliaj^c  and  4  to  hraiii  complications  or  rjtlicr  .symp- 
toms, rnland's  facts  thus  accord  well  with  Koch's,  who  gives  'M')  recoveries  out  of  (;.'> 
eases,  somcthinii'  less  than  half  dyin;:; — a  success  which  is  in  a  dej^ree  encouratrintr  to  sur- 
geons to  uiulertakc  the  operation. 

Ol'KUATION. — It  has  heen  already  stated  that  the  ajiplication  of  a  ligature  to  the  suh- 
elavian  in  the  first  part  of  its  eour.se  is  scarcely  a  justifiable  operation,  hut  when  under- 
taken the  ineisioii  on  the  right  side  would  be  similar  to  that  for  the  innominate  ;  on  the 
left  side  it  is  scarcely  practicable,  on  account  of  the  depth  and  relations  of  the  artery. 

In  the  tfiinf  jxirt  of  i.ts  course  the  operation  should  be  performed  as  follows  Tthe 
method  being  similar  for  both  sides):  The  patient  should  be  raised  on  a  ])illow  with  his 
head  thrown  back  and  face  turned  to  the  opposite  side,  an  assistant  drawing  the  arm 
down  as  much  as  jxissible,  to  depress  tlie  shoulder.  An  iilcision  three  or  fi>ur  inches 
long  should  then  l)e  made  on  the  upper  surface  of  the  miildl(>  of  the  clavicle  (Fig.  171) — 

Fig.  171. 


Ligature  of  Suliclavian  .iiid  Lingual  Arteries. 

not  above  the  bone,  as  the  external  jugular  vein  might  then  be  wounded.  Some  surgeons 
advise  the  skin  to  be  drawn  down  from  the  neck  upon  the  clavicle,  so  as  to  diminish  this 
risk.  In  this  incision  the  skin  with  the  superficial  fascia  and  platysma  will  be  divided. 
The  deep  fascia  is  then  seen  with  the  extei'nal  jugular  vein  coursing  over  it;  this  must 
be  held  aside  with  a  retractor.  When  its  division  is  a  necessity,  it  should  be  done  after 
the  application  of  two  ligatures,  one  above  and  another  below  the  line  of  section.  The 
cervical  fascia  can  then  be  divided  in  the  whole  extent  of  the  wound,  and  this  must  be 
done  with  care  on  a  director.  Should  more  room  be  wanted,  a  portion  of  the  sterno-mas- 
toid  or  trapezius  muscle  may  be  divided.  The  knife  is  now  to  be  laid  aside  and  the 
artery  looked  for  in  the  space  exposed,  the  parts  being  separated  by  a  director  or  the 
handle  of  the  scalpel.  The  vessel  will  be  found  just  on  the  outer  side  of  tlie  scalenus 
anticus  muscle  (the  edge  of  which  can  generally  be  felt)  and  behind  the  tubercle  on  the 
first  rib,  a  point  which  can  almost  always  be  made  out.  Several  arteries  of  large  size  will 
probably  be  found  cro.ssing  this  space,  as  well  as  many  veins.  The  supra-scapular  artery 
and  vein  will  always  be  seen  behind  the  clavicle.  The  brachial  plexus  lies  above  and 
behind  and  the  subclavian  vein  in  front  and  below  the  subclavian  artery.  When  the 
vessel  is  seen  or  felt,  the  sheath  is  to  be  opened  and  the  aneurism  needle  passed  around  it 
from  above  downward,  care  being  taken  not  to  injure  the  vein  or  include  a  nerve. 


390 


LIGATURE   OF  THE  AXILLARY  ARTERY. 


Ligature  of  the  Axillary  Artery. 

This  is  a  rare  operation,  although  it  may  be  demanded  for  some  wound  of  the  vessel 
or  for  aneurism  of  the  Vjrachial.  It  may  be  performed  in  one  of  two  positions — either 
immediately  below  the  clavicle  or  in  the  axilla. 

The  subclavicular  operation  is  carried  out  by  an  incision  made  immediately 
below  the  bone  from  the  coracoid  process  to  the  sternal  end  of  the  clavicle,  dividing 
integument  and  fascia  and  carefully  avoiding  the  cephalic  vein  that  runs  along  the 
anterior  border  of  the  deltoid  to  join  the  axillary.  The  clavicular  origin  of  the  ftectoral 
muscle  will  be  divided,  and  the  deep  fascia  or  costo-coracoid  membrane  covering  in  the 
sheaths  of  the  vessels  will  be  then  exposed  and  divided.  In  this  step  of  the  operation 
some  of  the  branches  of  the  thoracic  acromial  artery  will  come  into  view,  and  if  wounded 
must  be  secured.  The  coracoid  insertion  of  the  pectoralis  minor  can  also  be  seen.  The 
fascia  covering  in  the  vessels  will  be  exposed,  and  on  laying  it  open  the  greatest  care  is 
necessary,  as  the  axillary  vein  lies  immediately  beneath  it.  while  above  will  be  found  the 
vessel  resting  on  the  first  intercostal  muscle.  The  brachial  plexus  is  above  and  behind. 
The  axillary  vein  should  be  drawn  downward  and  the  aneurism  needle  passed  from  below 
upward,  care  being  taken  not  to  include  the  external  respiratory  nerve  of  Bell  that  pas.ses 
behind  the  artery.  When  the  vessel  has  been  expo.sed.  the  passage  of  the  ligature  will 
be  facilitated  by  bringing  the  arm  down  to  the  side  of  the  body.  On  the  dead  subject 
this  operation  is  not  difficult,  but  the  number  of  veins  and  arteries  that  exist  in  the  space 
must  ever  render  the  operation  on  the  living  far  from  easy. 

To  tie  the  axillary  artery  in  the  axilla,  the  aim  should  be  well  raised 

upward  and  the  course  of  the 
vessel  marked  out  slightly  pos- 
terior to  the  middle  line  of 
the  axilla.  An  incision  should 
then  be  made  along  the  inner 
margin  of  the  coraco-brachialis 
muscle  through  the  skin  and 
fascia  for  about  two  or  three 
inches  and  the  deep  fascia  ex- 
posed. This  .should  be  carefully 
divided  to  the  whole  extent  of 
the  wound,  when  the  artery  with 
its  attendant  nerves  and  veins 
will  come  into  view.  In  this 
.stage  of  the  operation  the  fore- 
arm should  be  flexed  on  the  arm, 
to  relax  the  parts.  The  vessel, 
as  a  rule,  has  the  median  nerve 
on  its  outer  side  and  nearer  to 
The  internal 


Fifi.  172. 

f areata  -  In-a  eiial 


■ccle 


Ligature  of  A.xillary  Artery. 


pectoralis  major  muscle,  and  the  vein  and  ulnar  nerve  to  its  inner  side, 
ineous  nerve  is  in  front.     {VkU  Fig.  172.) 


the 
cutaneous 


Fig.  173. 


jiledian  nerve 

Ligature  of  Brachial  Artery. 


Mr.  Guthrie  condemned  the  subclavicular  operation  altogether,  and  advised  the  sur- 
geon to  expose  the  artery  by  an   incision   three  inches   long,  carried  upward  along  its 


LKiATi'iu:  or  Tin-:  iihaciiim.  Airri:iiY 


391 


course,  coiiiiiicnciiit;- at  the  Inurr  lidnlcr  nl"  the  iiccioriil  iiiiisclc  ;  yet  few  liavc;  f'nllowod 
this  advice,  most  siirueinis  |in'l'eniii;i  tlie  ii|ieratiiiii  named  siilx-lavieiilar,  one  of"  its  riiodi- 
tieatiiiiis,  or  the  lit^atiire  uftlie  siiheiaviaii.  l-'nr  the  superior  o|ieratioti  Mr.  Kriidiseti  j»re- 
li'rs  all  incision  iiiaih'  IVoiii  the  cent  re  of  t  lie  da vich- downward  in  the  course  of"  the  vessel 


Vu..  171. 
Tendinous .  Ilioneurofis 
(III  itietl 


I.inaluii:  ni    l;i,u  hi.il  Ailcry. 

to  the  michllc  of  tlio  anterior  fohl  of  the  axiHa,  sucdi  incision  necessitating:  tlie  divi.sion  of 
the  great  pectoral  muscle,  and  often  of  the  small.  He  says  "  that  this  division  need  not 
leave  any  permanent  weakness  of  the  limb,  as  by  proper  position  ready  unicm  may  be 
effected  between  the  parts." 

In  all  these  operations  on  the  axillary  artery  the  surgeon  must  ever  be  on  the  out- 
look for  almormal  division  and  relations  of  the  vessel. 

Ligature  of  the  brachial  artery  is  a  very  successful  operation,  and  may  be 
demanded  for  direct  injury  to  the  vessel,  lieinorrhage  from  a  wound  of  one  of  its  divisions 
in  the  hand  or  fore-arm  which  cannot  be  treated  locally,  aneurism,  etc.  It  can  be  per- 
formed readily  in  any  part  of  its  course.  The  middle  of  the  arm  is  the  best  point  to 
choose.  The  course  of  the  vessel  is  indicated  })y  a  line  drawn  from  the  middle  of  the 
axilla  to  the  inner  side  of  the  biceps  tendon  at  the  bend  of  the  elbow,  while  the  inner 
border  of  the  biceps  muscle  is  the  guide  to  the  incision. 

Operation. — The  vessel  may  be  exposed  by  a  cut,  two  or  three  inches  long,  made  in 
this  position,  with  the  arm  extended  and  supinated.  The  skin,  which  is  always  thin,  and 
the  fiiscia  should  be  carefully  divided,  and  the  deep  fascia  which  is  thus  exposed  ought 
then  to  be  laid  open,  but  with  care,  for  the  basilic  vein  lies  immediately  below  it  on  the 
inner  side  of  the  brachial  artery.  The  ulnar  nerve  will  be  found  on  the  inner  side  of  the 
vein  and  the  median  in  front  of  the  artery,  but  there  is  no  regularity  in  these  relations ; 
consequently,  much  care  is  required  in  finding  the  vessel  and  discretion  in  trying  it,  for  a 
high  division  of  the  vessel  or  the  existence  of  some  vas  aberrans  may  mi.slead  and  con- 
fu.se.  When  the  right  vessel  has  been  found,  the  application  of  a  ligature  is  readily 
concluded.  In  performing  this  operation  care  must  be  taken  not  to  open  the  sheath  of 
the  biceps  muscle,  and  it  should  be  remembered  to  flex  the  fore-arm  on  the  arm  after  the 
division  of  the  deep  fascia  has  taken  place.  In  several  cases  in  which  the  occlusion  of 
this  artery  was  required  I  have  divided  it  and  tor.sed  both  ends  with     excellent  results. 

Ligature  of  the  brachial  in  its  lower  third  is  now  rarely  performed.  In 
the  days  of  bleeding  it  was  by  no  means  unfrequently  required  for  traumatic  aneurysm, 
though  it  has  never  fallen  to  my  lot  to  witness  its  perfornnince  for  such  a  cause.  The 
operation  may  be  performed  with  the  fore-arm  extended  by  making  an  incision  tw^o  and  a 
half  inches  long  on  the  inner  side  of  the  tendon  of  the  biceps,  care  being  taken  to  avoid 
the  large  veins  that  ramify  in  the  superficial  fascia.  The  tendinous  apOneurosis  of  the 
biceps  will  then  come  into  view,  and  on  its  division  the  artery  will  be  exposed  with  its 
venae  comites.  the  tendon  of  the  biceps  being  on  its  outer  and  the  median  nerve  on  its 
inner  side.  The  fore-arm  should  then  be  flexed  after  the  artery  has  been  expo.sed.  when 
a  ligature  can  be  passed  without  trouble. 

Ligature  of  the  Radial  Artery. — A  line  drawn  frojn  the  outer  side  of  the 
biceps  tendon  at  the  bend  of  the  elbow  to  half  an  inch  internal  to  the  styloid  process  of 
the  radius  at  the  wrist  marks  out  with  sufiicient  clearness  the  course  of  the  radial  artery, 
and  the  vessel  may  be  tied  in  any  part  of  it.  In  the  upper  third  of  the  fore-arm 
(Fig.  175),  between  the  supinator  longus  on  the  outer  and  pronator  teres  on  the  inner 
side,  it  can  be  found  by  an  incision  two  inches  long  made  in  the  line  above  mentioned, 
dividing  the  integument  and  deep  fascia,  care  being  taken  not  to  divide  the  large  cuta- 


392 


LIGATURE  OF  THE   ULNAR  ARTERY. 


neous  veins  unnecessarily.  On  separating  the  muscles  with  the  hanJle  of  the  knife,  the 
fore-arm  being  partially  flexed,  the  artery  will  be  brought  into  view  with  its  venfe 
comites,  the  nerve  being  to  its  outer  side.  A  ligature  can'  then  be  easily  passed  round 
the  vessel.     1  have  had  to  cut  down  upon  the  radial  artery  in  this  part  of  its  course  for 

Fig.  175 
Su/iinato?-  hnrfUS 


i.iganirf  of  liatUal  Artery. 

a  traumatic  aneurism  the  result  of  a  punctured  wound  ;   I  divided  the  vessel  and  twisted 
both  ends,  convalescence  speedily  following. 

At  the  lower  third  the  vessel  may  be  found  external  to  the  flexor  carpi  radialis 
muscle,  but  internal  to  the  supinator  longus.  It  lies  beneath  the  deep  fascia,  and  on  the 
division  of  this  the  artery  can  readily  be  found  (Fig.  17U).  On  the  dead  subject  the 
principal  cause  of  difiiculty  in  applying  the  ligature'lies  in  the  fact  that  students  look 
for  the  artery  too  superficially,  mistaking  the  .superficial  radial  vein  for  the  deep.  I  have 
had  to  ligature  or  twist  the  radial  on  seven  occasions  for  aneurism — in  six  for  traumatic 


Fig.  176. 


Bcefijftscta 


aneurism  .situated  above  the  wrist,  and  in  one  for  aneurism  at  the  back  of  the  wrist.  In 
all  a  good  result  ensued. 

Ligature  of  the  Ulnar  Artery.— This  vessel  lies  beneath  the  superficial  layer 
of  muscles  in  tlic  upper  half  of  its  course,  and  in  the  lower  between  the  tendons  of  the 
flexor  carpi  ulnaris  on  the  inner  side  and  flexor  sublimis  digitorum  on  the  outer,  being 
covered  with  integument  and  deep  fascia.  Its  position  is  roughly  indicated  by  a  line 
drawn  from  the  inner  side  of  the  biceps  tendon  to  the  radial  side  of  the  pisiform  bone, 
the  upper  part  of  the  vessel  describing  a  curve  with  the  concavity  outward. 

To  ligature  the  artery  in  the  upper  half  of  its  course,  an  oblique  incision  must  be 
made  crossing  the  line  above  indicated,  and  the  radial  border  of  the  flexor  carpi  ulnaris 
should  be  found.  Through  this  the  incision  must  be  made,  when  the  artery  will  be  .seen 
between  the  two  layers  of  muscles.  This  operation  is  very  difiicult  and  uncertain,  and  it 
is  an  open  question  whether  it  ought  to  be  performed.  I  am  disposed  to  think  that  the 
brachial,  under  all  circumstances,  except  for  wound,  ought  to  be  tied  rather  than  have 
recourse  to  it. 

To  tie  the  ulnar  above  the  wrist  is  not  more  difficult  than  to  tie  the  radial 
(Fig.  176).  An  incision  along  the  outer  side  of  the  flexor  carpi  ulnaris.  dividing  skin, 
superficial  and  deep  fascia,  exposes  the  vessel,  with  its  venae  comites.  and  the  nerve  on 
its  inner  side.  A  ligature  can  easily  be  passed  round  it.  The  drawings  well  illustrate 
these  points. 

Hemorrhage  from  the  palm  of  the  hand  is  always  alarming  and  trouble- 
some, more  particularly  when  caused  by  a  punctured  wound.  In  a  superficial  incised 
wound  the  vessel  may  generally  be  found  and  ligatured  or  twisted,  but  in  the  case  of  a 
deep  wound  it  is  rarely  expedient  to  cut  into  and  explore  for  such  a  purpose. 

When  the  vessel  cannot  be  tied,  a  graduated  compress  may  be  applied  over  the  wound 


i.icM'riu'.  or  Miri:i:!i:s  of  iiii:  i.nwi.n  r.srnF.Miry 


;{l>3 


ami  llii'  fiiiLTi'i's  l);iiiil:iLrt'il,  IK-xctl.  ami  lnniml  ilnwii  uvcr  a  hall  ur  l.ldck  u\'  wood,  ilir  arm 
lu'iii!^  wi'll  raisi'd  in  u  vortical  juisitinii.  'I'liis  ilrcssiiiir  should  not  In-  undnni'  for  at  Ica.st 
live  or  six  days.  If  tlitvsi-  iiifaiis  fail — which  they  rarely  do  when  crticiently  c*iii|iloved — 
the  radial  and  ulnar  arteries  may  tie  <'om]»ressed  with  aciipressnre  needles;  and  Hhonld 
this  ])rove  unsuecessliil.  the  a|)|ilication  <if  a  ligature  to  the  hraehial  artery  inav  he 
re<|nired.  In  ne<;lected  cases,  where  the  parts  are  all  inliltraled  and  ho^riry.  this  practice 
mav  he  called  for  at  once.  It  is  well,  licnvever,  hefore  resorting:  to  this  practice,  to  try 
«'.\tronie  He.xion  <d'  the  fore-arm  upon  the  arm,  with  forctid  supination  <d"  the  hand,  with 
or  without  a  pad  at  the  hi'iid  of  the  arm,  as  it  is  now  well  known  that  hy  this  positi(jti  the 
eircuhition  throui^h  the  l)ra(diial  artery  can  be  com])letely  arrested  ;  indeed,  under  all  cir- 
eiimstanees,  whether  for  injury  or  di.sease  of  the  arteries  of  the  liand  and  fore-arm  in 
which  surji:ieal  iutt^rfereme  is  rtMniisite.  it  wouhl  Ije  well  to  remember  this  treatment,  it 
beiui;  uu)st  effective.  It  should  be  known,  how(!ver.  that  repeated  liemorrha<re  may  take 
place  from  the  palm  of  the  hand  from  the  presiuice  (»f  a  slouLHiini.'  tendon.  In  illustra- 
tion of  this  I  may  mention  a  very  interesting;  case  I  had  with  j)r.  Hunny  of  Newbury, 
where  a  <i;entlemau  ;et.  '.V.\  had  his  middle  Hnicer  bent  back  .so  forcibly  by  a  cricket-ball  as 
to  cau.se  ru])ture  of  the  intei^ument  in  iVout  of  the  extreme  joint  and  laceration  of  the 
flexor  tendons  of  the  Hnirer  about  the  wrist.  Suppuration  and  sIouLchin;;  (jf  the  tendons 
followi'd,  attended  by  repeated  attacks  of  jialmar  lieuKjrrhaLre,  which  ceased  at  once  on 
the  riMuoval  of  the  di'ad  tendons. 


I'friteneam. 
S/terma^i'c  Cord 


LIGATURE   OF   ARTERIES   OF  THE  LOWER  EXTREMITY. 

The  External  Iliac  Artery. 

This  operation  may  be  reipiired  for  aneurism  of  the  common  femoral  artery,  or  for 
any  other  affection  in  which  it  is  necessary  to  arrest  the  flow  of  blood  tlirouuh  the  lower 
extremity.  It  should  not,  how- 
ever, be  performed  for  any  disease 
unless  pressure  of  the  artery,  digi- 
tal or  instrumental,  has  proved 
ineft'ectual  or  is  inapplicable,  for 
Mapother  {D\ih,  Med.  Fress^  18G5). 
Eck  (.SV.  Barthol.  Hosp.  Rep., 
18(J0),  and  Hilton  (Med.-Chir. 
Traii.^.,  18G9)  have  all  recorded 
instances  of  cure  of  inguinal  an- 
eurism by  these  means.  The 
operation  of  ligature  is,  however, 
a  successful  one,  and  Norris  and 
Cutter  give  47  fatal  cases  out 
of  153  (Am.  Journ.  Mid.  Sci.. 
1847  and  18G4).  I  have  performed 
it  on  six  occasions,  and  in  all  with 
success.  The  course  of  the  vessel 
is  clearly  indicated  by  a  line  drawn 
from  the  left  side  of  the  navel 
where  the  aorta  bifurcates  to  the 
middle  of  Poupart's  ligament,  the 
upper  third  of  this  line  correspond- 
ing to  the  common  iliac  and  the 
lower  two-thirds  to  the  external. 

Abernethy.  in  1796,  was  the 
first  to  ligature  the  vessel.  The 
incision  he  practised  was  vertical 
in  the  course  of  the  artery,  begin- 
ning an  inch  above  Poupart's  liga- 
ment. The  peritoneum,  however, 
is  too  much  disturbed  by  this  pro- 
ceeding, as  well  as  the  abdominal 
walls  weakened.  The  best  incision  Ligature  of  External  iliac  and  Superficial  Femoral  Arteries.  (In  this 
is  that  employed  by  Sir  A.  Cooper.  "S»re  the  incision  for  the  femoral  artery  is  placed  too  low., 

a  slightly  curved  one,  about  half  an  inch  above  Poupart's  ligament,  commencing  on  the 


Def/t  fasfia 


SarUrtus  inusrlc 


Xieny  Sa/i/iena 


394  LIGATURE   OF  THE  COMMON  ILIAC  ARTERY. 

inner  side  of  its  centre,  curvint;  upward  and  outward  for  about  three  inclies  toward  the 
anterior  superior  spine  of  the  ilium  (Fig.  177).  This  incision  should  divide  all  the  soft 
parts  superficial  to  the  external  oblique  muscle.  All  vessels  that  are  divided  should  be 
secured. 

The  tendon  of  the  external  oblique  muscle  should  then  be  divided  the  whole  length  of 
the  skin  wound,  together  with  the  internal  oblique  and  transversalis  muscle  when  they 
cannot  be  drawn  outward,  and  care  should  be  taken  not  to  injure  the  peritoneum  ;  the 
cord  which  then  comes  into  view  should  be  drawn  inward  and  the  parts  held  well  aside 
by  hooked  retractors.  With  the  fingers  the  transversalis  fascia  should  be  separated  from 
Poupart's  ligament  and  raised  upward  with  the  peritoneum  and  the  sheath  of  the  vessel 
exposed,  the  vein  being  to  the  inner  side  of  the  artery.  The  sheath  can  then  readily  be 
opened  and  a  ligature  passed,  the  needle  being  introduced  between  the  vein  and  artery. 
To  divide  the  transversalis  fascia  the  whole  length  of  the  wound  is  an  unnecessary  pro- 
ceeding, but  to  deal  with  it  as  suggested  above  is  an  extra  protection  to  the  peritoneum 
and  in  no  way  renders  the  operation  more  difficult  ;  indeed,  I  have  been  led  to  believe 
that  it  facilitates  the  operation.  It  certainly  does  this  on  the  dead  subject,  and  in  the 
eight  cases  in  which  I  have  been  called  upon  to  perform  it  on  the  living,  this  opinion  was 
confirmed.  The  genito-crural  nerv.e,  which  lies  upon  the  vessel,  should  not  be  included 
in  the  ligature.  The  operation  is  only  applicable  for  tumors  situated  below  Poupart's 
ligament ;  for  others,  Abernethy's  operation  or  that  suggested  for  the  common  iliac  should 
be  selected. 

Ligature  of  the  COmniOn  iliac  artery  has  been  performed  about  thirty-nine 
times,  but  only  ten  times  with  success.  It  was  first  successfully  performed  by  Mott  of 
New  York  in  1827.  I  have  seen  it  done  but  once,  and  then  by  my  colleague,  Mr.  Cock, 
in  1863,  on  a  man  aet.  27,  with  success. 

To  expose  the  vessel,  the  incision  must  be  long,  its  length  being  determined  bv  the 
size  of  the  aneurism  and  the  depth  of  the  artery.  A  curved  incision  commencing  outside 
the  internal  ring  and  passing  upward  and  outward,  as  if  for  the  external  iliac  artery, 
appears  to  be  the  best,  the  muscles  being  divided  to  an  equal  extent.  The  transversalis 
fascia  must  be  laid  open  or  torn  through  and  the  peritoneum  turned  upward.  It  is  at 
this  part  of  the  operation  that  the  greatest  difficulties  arise,  for  as  soon  as  the  transver- 
salis fascia  is  divided  the  peritoneum  covering  the  intestine  bulges  into  the  wound.  This 
membrane  also  is  frequently  found  adhering  to  the  aneurismal  sac,  and  much  difficulty  is 
felt  in  separating  it.  This  was  markedly  so  in  Mr.  Cock's  case.  The  oozing  of  blood 
into  the  wound  also  masks  the  vessel.  The  depth  of  the  wound  likewise  renders  the 
application  of  the  ligature  a  matter  of  great  difficulty.  Xevertheless.  these  difficulties 
can  be  ovei'come  by  care  and  good  aids.  The  operation  is  similar  to  that  last  described, 
though  more  difficult.  In  1846,  Mr.  Stanley  ligatured  the  common  iliac  artery  by  an 
operation  suggested  by  Sir  P.  Crampton  and  described  by  Skey.  The  patient  was  placed 
upon  his  side  and  an  incision  made  from  the  end  of  the  last  rib  downward  and  forward  in 
front  of  the  iliac  crest;  the  transversalis  fascia  was  divided  and  the  peritoneum  rolled  up. 
The  common  iliac  artery  was  then  found  and  tied  with  apparent  facility.  On  the  dead 
body  this  operation  is  far  from  difficult,  and  promises  to  be  of  service  to  the  living  when 
the  aneurismal  tumor  is  large  and  high  up.  Indeed,  it  is  probably  the  better  operation 
of  the  two  given.  The  abdominal  aorta,  too,  could,  be  ligatured  by  the  same  means 
(Fig.  169,  page  383). 

Ligature  of  the  Internal  Iliac. — Stevens  of  Vera  Cruz,  in  1812.  was  the  first 
to  perform  this  operation  in  a  case  of  gluteal  aneurism,  occurring  in  a  negress.  and  the 
operation  proved  successful.  Since  his  time  the  operation  has  been  repeated  eleven 
times,  and  in  six  with  success.  The  incision  and  steps  of  the  operation  are  the  same  as 
for  the  common  iliac.  Stevens,  however,  cut  down  through  the  anterior  abdominal  walls, 
similar  to  Abernethy's  operation  for  the  external  iliac.  It  should  not,  however,  be  per- 
formed for  gluteal  aneurisms  unless  rapidly  increasing  till  other  means  of  cure  have 
been  tried  and  failed,  such  as  pressure  upon  the  aorta  or  common  iliac,  or  even  galvano- 
puncture.  Besides,  Holmes  has  clearly  shown  in  his  College  Lecture!^  that  in  cases  of 
imperfect  or  ruptured  sacs  either  the  operation  of  Anel  or  that  in  which  the  sac  itself  is 
opened  should  be  practised. 

In  operating  upon  any  of  the  iliac  vessels  it  should  be  remembered  that  great  variety 
exists  as  to  their  length.  When  the  common  iliac  is  long,  its  branches  are  short,  and 
vice  versa. 


Lit;Arri:i:  of  riii-:  ri.MouAL  Anii.nv.  liijo 

Ligature  of  the  Femoral  Artery. 

This  vi'sscl  i-aii  be  tied  in  iiiiy  part  nC  its  course  ;  and  whrn  llir  tliiirli  is  straij:lit,  a 
lino  drawn  from  the  ct'iitrc  ol'  Poiipart's  liframcnt  to  the  iiiner  side  ot"  the  jiatcila  will 
mark  out  its  position  with  tok-raltic  accuracy.  When  the  thi<:h  is  ahdnctcd  and  rotated 
outward,  a  line  drawn  from  the  same  point  ahove  to  the  inner  side  of  tlu;  inner  eondyhj 
indicates  the  upper  half  of  its  c(»urse.  In  tlu?  upper  third  it  is  tolerahly  superficial  ;  in 
the  middle  and  lower,  it  is  covered  by  the  sartorius  muscle,  which  varies  much  in  its 
width,  and  hy  the  mendtrane  formiiif;  the  roof  of  Hunter's  canal.  At  the  present  day  it 
is  an  exceptional  act  to  li<:;ature  the  vessel  in  llunt(!r"s  canal.  F(M'  popliteal  aneurism  the 
artery  is  <reiu'rally  ligatured  in  the  middles  third  of  its  course,  at  tlie  ape.x  of  Scarpa's 
trianj;le.  ^^)r  aneurism  of  the  femoral  itself  the  common  femoral  niay  In;  tie»l  helow 
Poupart's   liiiameiil. 

'flu-  COmmOIl  femoral  is  usually  ahout  an  inch  and  a  half  in  Icn^'th  ;  it  doi-s  not 
exceed  one  inch  in  one  case  in  four,  while  in  oiu;  in  four  it  is  between  an  inch  and  a  half 
and  two  inches  (  Xunn.).  It  is  from  these  facts  that  surtreons  have  <^enerally  preferred  to 
ligature  the  external  iliac  rather  tluin  the  common  femoral.  The  two  Porters,  however, 
as  well  as  Macnamara  of  l)ul)lin,  have  adduced  sufficient  evidence  to  prove  that  succe.ss 
may  attend  the  ])ractice,  giving  thirteen  eases  between  them,  and  eleven  proving  success- 
ful.     (  Vide  Dnhlin  Qiutrf.  Jouni.,  1800,  and  Brit.  Med.  Joiirii.,  October,  1<S()7.) 

The  operation,  moreover,  is  not  difficult,  the  ves.sel  being  readily  exposed  by  a  ver- 
tical, oblique,  or  transverse  (Porter's)  incision.  The  sheath  of  the  artery  is  then  to  be 
opened  without  touching  the  vein — indeed,  the  vein  should  never  be  exposed — care  being 
taken  not  to  enclose  the  crural  branch  of  the  genito-crural  nerve  running  down  in  front 
of  the  vessel  in  the  ligature. 

The  main  arguments  against  the  operation  are  founded  on  the  uncertain  length  of  the 
artery,  the  proximity  of  the  ligature  to  large  branches,  and  the  lial)ility  to  gangrene 
from  the  occlusion  of  the  main  nutrient  arteries  of  the  limb.  On  the  other  hand,  there 
are  the  success  of  the  operation  and  the  facility  with  which  it  can  be  performed.  More 
experience,  however,  is  recjuired  before  the  operation  can  be  recommended,  though  it 
should  not  be  dismissed   without  due  consideration. 

Ligature  of  the  femoral  artery  in  the  middle  third  of  its  course  is  a 

capital  ojtcratioii,  an(l,^moreover,  a  successful  one.  Norris  gives  40  fatal  out  of  188 
operations  for  aneurism,  or  one-fourth  of  the  cases  collected  from  all  sources,  from  John 
Hunter's  first  operation  in  1785  down  to  1848,  and  undertaken,  too,  under  many  different 
conditions.  Syme  informs  us  that  he  has  had  23  successful  cases  consecutively,  and  at 
Guy's  Hospital,  during  fourteen  years,  the  femoral  artery  was  tied  for  aneurism  24  times, 
with  only  1  death  from  py;emia  and  1  failure,  these  cases  including  G  in  which  pressure 
had  been  tried  and  failed.  Pressure  had  been  employed  in  17,  and  in  11  with  success. 
During  the  fourteen  years  ending  1880  the  results  have  not  been  so  good.  Mr.  Charles 
Symonds  having  shown  in  his  interesting  paper  (Gin/s  Rep. ^  vol.  xxv.,  1881)  that  6  cases 
died  out  of  20,  or,  eliminating  2  which  died  from  causes  quite  unconnected  with  the 
operation,  4  out  of  20  ;  but  in  considering  these  figures  it  must  be  remembered  that  the 
ligature  of  the  femoral  artery  is  resorted  to  in  the  bad  cases  alone,  in  which  the  treat- 
ment by  compression  is  inapplicable  or  has  failed.  Mr.  Holmes,  in  his  lectures  at  the 
Royal  College  of  Surgeons  in  1874,  moreover,  gives  some  statistics  of  recent  hospital 
practice  which  possibly  place  the  operation  in  even  a  better  light,  inasmuch  as  out  of  77 
cases  of  popliteal  aneurism  treated  by  ligature  at  once  the  deaths  were  11,  or  14  per 
cent.,  and  the  failures  15,  or  19  per  cent.  ;  while,  in  44  other  cases  in  which  the  ligature 
was  applied  after  the  treatment  by  pressure  had  failed.  31  succeeded  and  13  ftiiled,  or  29 
per  cent.,  the  mortality  in  the  latter  class  of  cases,  as  might  have  been  expected,  being 
larger  than  in  the  former. 

I  may  add  that,  of  124  cases  of  popliteal  aneurism  collected  by  Mr.  Holmes,  pressure 
succeeded  in  60  and  failed  in  58.  In  44  of  the  58  ca.ses  the  artery  was  tied,  as  seen 
above,  13  of  these  dying,  and.  of  the  remaining  14,  amputation  was  practised  in  8,  death 
occurred  in  1,  while  in  4  there  was  no  evidence  of  subse((uent  treatment. 

Oper.vtion. — To  tie  the  vessel  the  limb  of  the  patient  should  be  slightly  abducted 
and  rotated  outward,  the  leg  being  partially  flexed  and  the  knee  supported  on  a  pillow. 
The  line  of  the  vessel  should  then  be  marked  by  the  eye  and  the  point  at  which  the  liga- 
ture is  to  be  applied  determined,  the  lower  part  of  Scarpa's  triangle  being  the  "  point  of 
selection"  (Fig.  177).  An  incision  about  three  inches  in  length  must  then  be  made 
parallel  to  the  vessel  dividing  the  integument  and  superficial  fascia  down  to  the  deep 


596 


LIGATURE  OF  THE  POSTERIOR   TIBIAL  ARTERY. 


parts,  the  course  of  the  superficial  veins  having  previously  been  ascertained  by  making 
pressure  upon  the  saphena  vein  where  it  joins  the  deep  femoral,  in  order  to  avoid  it.  If 
the  vein  be  in  the  way,  the  incision  can  be  made  by  its  side ;  but  generally  it  is  on  the 
inner  side  of  the  wound.  The  deep  fascia  may  then  be  divided  and  the  inner  border  of 
the  main  guide  to  the  artery,  the  sartorius  muscle,  looked  for.  This  is  readily  recogniza- 
ble by  the  course  of  its  fibres  dou-mcard  and  imcard,  and  underneath  this  the  sheath  of 
the  vessel  is  certain  to  be  found.  The  muscle  having  then  been  gently  separated  from  its 
attachments  by  means  of  the  finger  and  held  outn-urd  with  a  retractor,  the  sheath  will  be 
exposed  with  the  artery  in  front  and  vein  behind,  the  long  saphenous  nerve  generally, 
and  sometimes  a  nerve  to  the  vastus  internus,  lying  upon  the  vessel.  The  sheath  should 
then  be  opened  with  caution  and  its  inner  side  held  tense,  an  opening  being  made  suffi- 
cient to  expose  the  vessel  and  admit  the  aneurism  needle  ;  moreover,  care  should  be  taken 
to  keep  the  end  of  the  needle  close  to  the  artery,  in  order  that  the  vein  may  not  be 
injured  or  included  in  the  ligature.  The  needle  ought  to  be  passed  from  within  outward. 
The  ligature  having  been  passed,  the  surgeon  must  satisfy  himself  that  nothing  but  the 
artery  is  surrounded  and  that  the  vessel  sought  for  has  been  exposed  ;  he  may  then  tie  it, 
readjust  the  parts,  and  close  the  wound,  covering  the  limb  with  cotton-wool  and  raising  it  on 
a  pillow.  Should  the  vein  be  wounded  by  the  needle,  it  must  be  ligatured  below  the  wound. 
A  silk  ligature  may  separate  from  the  femoral  artery  in  nine  or  ten,  or  not  even  for 
thirty,  days,  a  wide  diiference  existing  on  this  point,  an  analysis  of  cases  decisively 
proving  that  no  general  rule  can  be  laid  down  as  to  when  its  separation  may  be  expected. 


Ligature  of  the  Popliteal  Artery. 

I  hardly  know  under  what  circumstances  the  popliteal  artery  may  require  the  applica- 
tion of  a  ligature,  except  for  a  wound,  as  for  rupture  of  an  ai'tery  or  for  aneurism  the 
operation  is  as  inapplicable  as  it  would  be  unsuccessful.  Mr.  Poland  has  pointed  out 
how  the  posterior  ligament  of  the  knee-joint  is  frequently  involved  in  the  laceration  of 
the  vessel.  Some  years  ago  I  was  called  upon  to  cut  down  upon  a  large  needle  that  had 
perforated  the  popliteal  space  and  become  lost  in  its  tissues,  all  movements  of  the  joint 
being  impossible  by  the  pricking  pain  occasioned.  I  discovered  the  foreign  body  lying 
obliquely  across  the  popliteal  artery  with  its  point  fixed  in  the  posterior  ligament  of  the 
knee-joint.  The  artery  was  exposed  without  difficulty  by  an  incision  made  along  the 
outer  edge  of  the  semimembranous  muscle,  the  leg  being  extended.  The  vein  is  more 
superficial  than  the  artery  and  can  always  be  found  to  its  outer  side  above ;  the  nerve  is 
still  more  superficial,  and  above  still  farther  out,  but  it  lies  over  the  artery  at  the  back 
of  the  knee  and  to  its  inner  side  where  covered  by  gastrocnemius. 

Ligature  op  the  Posterior  Tibial  Artery. 
Guthrie  brought  the  weight  of  his  great  authority  to  support  the  recognized  practice 

Fig.  178. 


Ligature  of  Posterior  Tibial  Artery. 

of  tying  a  wounded  vessel  at  the  wounded  part  even  in  the  case  of  the  deeply  placed 
posterior  tibial  and  peroneal  arteries,  and  practically  carried  it  out  in  a  supposed  wound 
of  the  latter  vessel  by  making  a  free  incision  through  the  muscles  of  the  calf  of  the  leg 
down  to  the  wounded  artery.     Arnott,  also,  acting  on  Guthrie's  suggestion,  tied  the  pos- 


LicATi'iiE  OF  Tin:  A.\Th'i:/>)/:   TIl:/.\L   AnTl.'l:)'. 


:V.i7 


Vui.  179. 


toriur  tiliial  \>\  tliis  method,  thoufrli  lu-itlicr  tli<'  n'|i(>rt  of  tlif  case  (M'd.-C/iir.  Tnmn.^ 
vol.  xxix.)  nor  Mr.  Arni»tt  s  remarks  are  encoura;:iii;r  in  any  way  in  favor  of  its  repeti- 
liiin  ;  intleetl,  modern  surjrediis  have  universally  rejeeted  the  method  in  lavor  of  that 
which  has  now  }>een  deserilied. 

It  must  he  ])remised  that  tlie  vessel  lies  beneath  the  sujterfieial  layer  of  muscles  form- 
inj;  the  ealf  and  heneath  the  deep  fascia,  the  nerve  being  toward  the  inner  side  above, 
but  to  its  outer  side,  in  the  greater  part  of  its  course.  Its  course,  too.  is  indicated  by  a 
line  drawn  lV(»m  the  centre  of  the  popliteal  Hpacc  to  a  point  midway  ))etweeii  the  inner 
malleolus  and  the  tendo  Aehillis. 

In  order  to  tie  the  artery,  the  leg  must  be  partially  flexed  upon  the  thigh  and  made 
to  rest  ujion  a  ]»illow  on  its  outer  side,  the  heel  being  raised,  to  relax  the  mu.seles.  An 
incision  about  four  inches  in  length  should  then  be  made  about  half  an  inch  from  the 
edge  nf  the  tibia  and  parallel  with  it,  through  the  integument,  down  to  the  deep  fascia, 
avoiding,  if  possible,  any  largo  suj)crficial  veins. ^  The  deep  fascia  can  then  be  divided 
and  the  muscles  ex]»osed.  The  lower  border  of  the 
tibial  origin  of  the  .soleus  muscle  should  then  be 
lonked  fur,  and  l)eneath  it  a  director  introduced;  the 
til>ial  iirigin  of  this  muscle  should  then  be  divided 
the  wlnde  extent  of  the  wound.  The  glistening  ten- 
dinous covering  of  the  deep  surface  of  the  muscle  is 
an  excellent  guide  to  the  vessel  and  should  not  be 
mistaken  for  the  deep  fascia,  which  lies  deeper  and 
beneath  which  is  found  the  vessel.  To  search  for 
the  artery,  the  leg  must  be  well  flexed,  the  heel 
drawn  up,  and  the  muscles  retracted.  The  ligature 
can  then  be  pa.«^sed  in  the  most  convenient  way. 

On  the  dead  subject  this  operation  is  not  diffi- 
cult, and  on  the  living,  more  particularly  when  per- 
formed with  the  aid  of  Esmarch  s  bandage,  it  can 
hardly  be  -so  '•  difiicult,  tedious,  bloody,  and  danger- 
ous "    as    Mr.    Guthrie    has    described,    and     as    is    his    Ligature  of    Posterior   Tibial   Artery   behind 

luuer  -Malleolus. 

own  operation. 

The  operator  .should  be  careful,  however,  not  to  divide  the  tibial  origin  of  the  soleus 
too  near  the  tibia,  as  in  doing  so  he  may  penetrate  the  deep  fascia  and  thus  Icse  his  best 
guide — viz.,  the  glistening  tendinous  tibial  origin  of  the  soleus. 

To  tie  the  artery  at  the  loicer  third  of  the  leg  behind  tin-  inner  malleohta  is  a  simple 
operation.  It  lies  with  its  venae  comites  at  the  junction  of  the  anterior  with  the  middle 
third  of  the  space  between  the  malleolus  and  the  heel,  the  nerve  being  behind.  It  can 
readily  be  exposed  by  a  curved  incision  two  inches  long  over  the  course  of  the  vessel, 
dividing  integument  and  deep  fa.scia,  which  is  thick  from  receiving  many  fibres  from  the 
internal  lateral  ligament.  The  relative  position  of  the  vessel  can  easily  be  seen  in  the 
drawing  (Fig.  17D). 


Ligature  of  the  Anterior  Tibial  Artery. 

This  operation  is  far  from  simple,  inasmuch  as  the  vessel  lies  buried  in  the  upper  two- 
thirds  of  its  course  between  the  muscles  on    the  interosseous  membrane ;    its  course 

Fig.  180. 
IibiaJis   anticus 


Ejctensor  /onj/us 
tiiaitorum 

Ligature  of  the  Anterior  Tibial  Artery. 

is  indicated  by  a  line  drawn  from  the  inner  side  of  the  head  of  the  fibula  to  the  ba.se  of 


398 


INJURIES  AND  DISEASES  OF  THE    VEINS. 


the  great  toe.     The  surgical  guide  to  the  vessel  is  the  tibialis  anticus  muscle,  which  lies 
to  its  inner  side  throughout  its  course. 

To  reach  the  vessel  in  the  upper  two-thirds  of  its  extent,  it  is  important  to  expose  the 
intermuscular  space  separating  the  tibial  muscle  from  the  extensors  communis  digitorum 
and  proprius  poUicis;  and  the  best  way  to  accomplish  this  is  to  make  an  oblique  incision 
ibur  inches  long,  commencing  at  the  outer  edge  of  the  tibia  and  directed  downward  and 
outward  toward  the  external  malleolus,  dividing  the  integument  and  superficial  fascia. 
The  deep  fascia  will  then  be  exposed,  and  the  first  white  line  external  to  the  tibia  will  be 

found  to  mark  the  intermuscular  space  outside 
Fig.  181.  the  tibialis  anticus  muscle  in  which  the  anterior 

..  n  tibial  artery  is  to  be  found.    The  fascia  over  this 

I  :|  line  may  then  be  opened  and  the  muscles  sepa- 

rated, the  foot  being  well  flexed  to  facilitate  this 
measure.  The  anterior  tibial  nerve  will  then 
come  into  view,  and  beneath  it  the  artery  will 
be  found.  The  ligature  may  be  passed  as  best 
can  be  done. 


J^jctensor 
or f vis  dig  I  torum\ 
muscle 


Trnr7on  n/^ 
T.y/cn-sor 
/iro/iriiis 
/lollicis 


Ligature  of  Dorsal  Arteries  of  the 
Foot. 


The  dorsalis  pedis  artery  should  be 

ligatured  to  the  outer  side  of  the  extensor  pro- 
prius pollicis  muscle,  by  the  side  of  which  it  lies. 
The  vessel  can  readily  be  exposed  by  an  incision 
made  along  its  course,  the  integument  and  deep 
fascia  being  divided  (Fig.  181).  It  is  crossed 
at  its  lower  part  by  the  tendon  of  the  extensor 
brevis  digitorum  muscle,  and  the  nerve  lies  out- 
side the  vessel,  while  venae  comites  attend  the 
artery.  The  tendon  of  the  last-named  muscle 
is  an  infallible  guide  to  the  artery,  as  it  crosses 

it,  whilst  the  tendon  of  the  extensor  proprius  pollicis  muscle  is  the  guide  to  the  incision. 

The  surface  line  of  this  vessel  extends  from  the  middle  of  the  joint  of  the  ankle  to  the 

base  of  the  first  metatarsal  space. 


Ligature  of  Dorsalis  Pedis  Artery. 


CHAPTER     XI 


INJURIES    AND    DISEASES    OF    THE    VEINS. 

The  blood  from  a  wounded  vein  is  black,  flows  in  a  steady  stream,  and  never  jets  out 
as  from  an  artery.  When  mixed  with  arterial  blood,  as  occurs  when  both  artery  and  vein 
are  punctured,  it  appears  as  a  dark  band  streaming  through  a  red,  or  vice  versa,  the  rela- 
tive thickness  of  black  or  red  band  indicating  the  extent  of  the  wound  in  the  artery  and 
the  vein.  Pressure  on  the  distal  side  of  a  wounded  vein  controls  bleeding,  whilst  pressure 
on  the  cardiac  side  increases  it. 

Wounds  of  veins  unite  as  do  wounds  of  arteries,  the  reparative  process  being  alike  in 
both.  After  a  clean  incision  into  a  vein  repair  may  be  so  perfect  in  a  few  days  as  to 
leave  no  trace  of  injury  behind.  The  lips  of  a  wound  in  a  vein  readily  unite — as  after 
venesection — when  kept  together  by  gentle  pressure  or  the  application  of  a  ligature. 

A  completely  divided  vein  contmcts,  though  somewhat  less  than  an  artery  ;  it 
also  re/nic/s  into  its  sheath,  and  the  natural  arrest  of  hemorrhage  is  helped  by  these 
actions,  together  with  the  coagulation  of  the  blood  in  the  vein  and  around  its  orifice. 
But  these  processes  are  slow  in  their  action,  very  feeble,  and  practically  insufficient. 
Fortunately,  however,  hemorrhage  from  a  divided  vein  is  easily  arrested  by  well-adjusted 
pressure  and  by  elevation  of  the  limb.  After  amputations,  if  venous  bleeding  persist  on 
the  removal  of  the  tourniquet,  and  should  the  means  just  indicated  have  failed,  the  bleed- 
ing vein  may  be  acupressed,  ligatured,  or,  what  is  better,  twisted. 


L\.n'i:ii:s  .wd  Dishwsi.s  or  rur:  viciys.  309 

A  partially  divided  vein  of'tcn  ^rivt-s  inmli  in.ulplr,  altlnm^'li  not  wIh-h  s^yMv- 

/('<•/<*/,  ln'caiisc  tlu'  I'lovalioii  ol"  tlic  liiiili  and  a  f(»iii|»n'ss  carclully  .strapped  (ir  l)uiida<;tMj 
over  the  wnmided  jiart  are  i^eiierully  .siillieieiit  tn  clieck  the  hh-edin^r,  and  in  tliree  (tr  four 
davs  repair  may  he  enniideted. 

W^OUlldS  of  deep  veins,  however,  an-  ol"  urave  importance;  and  when  tin'  veins 
are  hirL'e,  lln-v  are  as  si'rious  as  wounds  id'  hirire  arteries,  ami  iiniiealthy  inflammation  of 
tin-  vein  witli  all  its  dangers  may  loUow. 

'I'kkat.mkn  T. — In  wounds  (dany  of  the  veins  of  the  extremities  \vell-applie»l  pros.suru 
is,  a>  a  rule,  sulVieient  to  arrest  hleedinjr  and  jiive  time  for  repair;  when  the  trunk  of  the 
femoral  vein  is  wounded  in  o]ieration,  as  in  lij;ature  of  the  femoral  art(!ry.  the;  vein  should 
be  divided  and  tied  with  a  tine  prepared  eat<;ut  lij^ature.  The  .same  should  he  done  to  a 
punetured  wound  of  the  internal  juf:;ular  or  any  larj^e  vein.  To  tie  the  operiiiij;  in  the 
vein  is  now  known  to  be  an  error.  Wounded  vein.s,  indeed,  should  be  treated  on  the 
same  prineijdes  as  wounded  arteries.  When  pressure  i.s  enoufrh  to  arrest  hemorrhage 
from  a  vein,  however  lar^e,  the  liirature  is  not  retpiired  ;  but  when  it  fails  or  is  inappli- 
oal)le.  the  ligature  may  ))e  fearlessly  em))loyed.  The  dread  of  setting  uj)  ])hlehitis  by 
liuaturing  veins  is  ba.sed  on  prejudice,  and  not  on  experience;  it  is  doubtless  due  to  the 
intlm^nce  of  authorities  who  have  pronounced  against  it.  It  cannot,  however,  be  disputed 
that  )>hlebitis  occasionally  i'oUows  the  surgical  treatment  of  veins.  When  it  occurs,  the 
afteetion  is  serious,  and  takes  jdace  oidy  in  the  enfeebled  and  cachectic. 

Wounds  of  the  internal  jugular  and  subclavian  veins  are  as  fatal  as,  and 

probably  more  so  than,  wounds  of  the  carotid  or  subclavian  arti-ries.  When  the  internal 
jugular  is  wounded  near  the  base  of  the  skull,  life  is  speedily  destroyed  ;  and  when  near 
its  cardiac  end,  to  the  danger  of  hemorrhage  is  added  that  of  the  introduction  of  air  into 
the  heart.  When  the  internal  jugular  is  divided  above  the  clavicle,  the  orifice  remains 
open,  the  walls  not  collapsing,  as  they  would  at  a  greater  distance,  owing  to  their  connec- 
tions with  the  deep  cervical  fascia;  reflux  bleeding  consequently  takes  place  from  the 
cardiac  end,  and  during  some  violent  inspiratory  act  air  may  be  drawn  into  the  circula- 
tion and  into  the  heart,  causing  death.  Hence  great  care  is  always  required  in  operating 
about  the  root  of  the  neck  to  avoid  large  veins,  and  to  compress  or  ligature  them  when 
wounded. 

When  death  takes  place  from  primary  hemorrhage  from  the  internal  jugular,  it  is 
generally  within  an  hour.  I  recorded  in  the  Trans,  of  Path.  Soc.  in  1857  such  a  case, 
which  occurred  in  the  practice  of  Mr.  Birkett  ;  a  second  was  recorded  by  !Mr  Henry 
Gray  in  Holmes  s  S^irijcri/,  and  a  third  by  Mr.  Sanuiel  Cooper  in  his  First  Lines  of  Snr- 

When  death  does  not  supervene  from  either  of  these  two  causes,  it  may  occur  from 
secondary  hemorrhage  or  from  }>ya!mia. 

A  vertical  incision  into  the  internal  jugular  vein  is  not  necessarily  attended  with  a 
fatal  hemorrhage.  When  bleeding  occurs,  it  will  be  recurrent.  This  was  well  illustrated 
in  a  case  recorded  by  Mr.  Woodman  of  ICxeter  {^Bn't.  Med.  Journ.,  1873),  in  which  the 
internal  jugular  vein  was  ligatured  with  a  successful  result. 

Coagulation  in  Veins. 

Adhesive  Phlebitis. — When  a  vein  was  found  by  the  older  surgeons  obstructed 
by  a  fibrinous  clot,  the  suspicion  of  phlebitis  was  excited  ;  and  when  this  clot  contained 
in  its  centre  a  "  puriform  "  fluid,  the  evidence  of  inflammatory  action  was  considered  to 
be  strong.  When  the  clot  was  nu)re  or  less  adherent  to  the  inner  membrane  of  the  vein 
and  this  membrane  presented  a  pink  appearance,  the  evidence  was  thought  to  be  com- 
plete. At  the  present  day,  however,  none  of  these  phenomena  are  accepted  as  true 
indications  of  an  inflamed  vein,  as  it  is  known  that  blood  coagulates  spontaneously  in  a 
wounded,  lacerated,  or  bruised  vein,  that  it  does  so  when  the  venous  blood  is  stopped 
circulating  from  pressure  upon  its  walls  or  from  inflammatory  or  ulcerative  changes  in 
the  parts  around,  and  that  in  ill-nourished  and  cachectic  subjects  there  is  a  renuirkable 
tendency  for  the  fibrin  of  the  blood  to  become  de])0sited  upon  the  serous  lining  of  the 
veins,  either  idiopathically  from  some  altered  condition  of  the  blood  or  on  the  .slightest 
injury,  without  the  existence  of  inflammatory  action. 

The  supposed  pus  found  in  the  centre  of  the  fi})rinous  mass  is  known  to  be  made  up 
of  the  white  blood  corpuscles  present  in  all  coagula,  while  the  pinkish  tint  upon  the 
serous  lining  of  the  vein  is  due  to  the  mere  imbibition  of  coloring  matter  from  the  blood, 
and  not  to  inflammatory  injection. 


400  IS  JURIES  AND  DISEASES  OF  THE   VEINS. 

A  clot  once  formed  in  the  vein  rapidly  increases,  the  stream  of  blood  as  it  flows  over 
it  depositing  fresh  layers,  until  the  whole  calibre  of  the  vein  is  obstructed.  When  the 
process  is  slow,  regular  layers  of  fibrin  may  be  seen  in  section  ;  but  when  rapid,  the 
clotting  is  irregular.  At  the  extremities  of  the  clot,  also,  like  accretions  are  deposited  ; 
the  coagula  increase  more  or  less  rapidly  in  all  directions  and  into  all  branches,  till  com- 
plete obstruction  or  thrombosis,  takes  place.  This  clotting  of  blood  in  the  vein  becomes 
arrested  only  by  the  blood  stream  of  a  junction  trunk.  These  coagula  can  readily  be 
removed  by  washing ;  and  when  removed,  the  lining  membrane  of  the  vein  will  generally 
be  found  natural  and  the  valves  visible.  The  coat  of  the  veins  at  times  may  appear 
thickened  from  contraction,  but  Mr.  Callender  has  shown  that  this  is  not  a  real,  but  only 
an  apparent,  condition,  the  coats  of  the  veins  readily  yielding  to  pressure  under  water. 
[n  the  process  of  cure  sometimes  the  clot  will  contract  toward  one  side  of  the  vein,  thus 
allowing  the  blood  to  pass  and  the  circulation  to  become  re-established.  In  rarer  cases 
the  blood  "'may  drill  for  itself  a  passage  through  the  centre  of  the  clot."  In  many, 
again,  the  clot  will  eventually  disappear  and  the  vein  become  patent.  Ordinarily,  how- 
ever, a  different  result  takes  place  ;  the  vein  becomes  permanently  obliterated,  the  clot  and 
vein  ultimately  contracting  so  as  to  form  a  firm  and  shrunken  cord.  In  rare  cases  the 
clot  may  subsequently  organize.  Authors  have  described  these  as  instances  of  ci(l/iesive 
phlebitis.  In  feeble  and  cachectic  subjects,  however,  these  curative  changes  cannot  take 
place.  The  clot,  instead  of  organizing,  will  soften  and  disintegrate,  giving  place  to  blood- 
stained puriform  fluid  that  may  be  carried  into  the  pulmonary  circulation,  cau.sing  a 
lobular  pneumonia  such  as  is  found  in  pyaemia  from  embolism  of  the  pulmonary  artery. 
This  was  well  illustrated  in  the  following  case,  extracted  from  the  catalogue  of  the  Guy's 
Museum,  No.  1521"":  Jugular  vein  exhibiting  a  wound  occupying  about  half  its  circum- 
ference and  situated  about  half  an  inch  above  the  subclavian,  the  neighboring  branches 

showing    the    effects    of  phlebitis.      James    F ,    aet.    30,    under    3Ir.    Birkett.      He 

received- a  stab  with  a  knife  in  the  left  side  of  the  neck  which  wounded  the  jugular 
vein  ;  much  hemorrhage  followed,  and  continued  for  some  days,  when  symptoms  of 
phlebitis,  .set  in,  and  he  died  of  pneumonia  twenty  days  after  the  accident.  The  vein 
was  found  to  be  wounded,  as  seen  in  the  preparation,  its  coats  infiltrated  with  lymph,  and 
its  interior  filled  with  fibrin.     The  lungs  were  filled  with  abscesses. 

Results  such  as  these,  however,  do  not  occur  under  all  circumstances,  but  only  in  the 
feeble  and  cachectic  ;  for  ''the  clot,  when  softened,  is  usuall}-  shut  off"  in  an  upward-and- 
downward  direction  by  newly-added  coagula.  The  softening  begins  in  the  coagula  last 
formed,  and  not.  as  Virchow  states,  in  those  first  depo.sited ;  for  in  the  advance  of  the 
malady  the  patients  health  fails  and  the  fibrin  becomes  more  and  more  prone  to  disinte- 
grate and  soften  into  a  puriform  fluid"  (Callender).  The  clot  softens  also  in  the  centre, 
and  not  at  its  periphery;  and  such  cases  have  been  described  as  examples  of  suppurative 
pJdehifis. 

Symptoms. — The  most  prominent  symptoms  of  an  obstructed  vein  are  cedema  of  the 
parts  below  the  obstruction,  some  fulness  of  the  superficial  veins,  with  local  pain  and 
tenderness,  constitutional  disturbance  of  variable  degrees  of  severity  generally  preceding. 
When  superficial  veins  are  involved,  the  symptoms  ma}'  be  chiefly  local,  but  in  the  case 
of  deep  veins  constitutional  disturbance  is  sure  to  accompany  local  action.  Among  the 
superficial  veins  the  saphena  of  the  leg  and  thigh  is  most  commonly  aff"ected,  and  is  often 
a  sequela  of  a  varicose  condition.  Under  these  circumstances,  the  tortuous,  dilated, 
indurated  vein  becomes  a  marked  object,  set.  as  it  were,  in  a  frame  of  hardened,  inflamed 
skin  and  cellular  tissue.  The  parts  themselves  will  to  a  certainty  be  painful,  and  the  pain 
and  tenderness  probably  extend  up  the  thigh  as  far  as  the  groin.  Among  the  deep  veins 
the  common  femoral  or  iliac  is  more  frequently  involved  than  any  other,  and  what  is 
known  as  a  "  white  leg  "  is  due  to  this  aff"ection.  it  being  an  oedema  of  the  leg  from  an 
obstruction  to  the  femoral  or  iliac  vein,  with  local  pain  and  tenderness  and  more  or  less 
constitutional  disturbance.  In  some  cases  the  phlebitis  is  of  a  very  mild  character,  and 
then  a  good  result  may  be  anticipated  ;  but  in  others  it  is  very  severe,  and  in  such  sup- 
purative changes  will  probably  take  place. 

It  sometimes  happens  that  a  limb  becomes  much  enlarged  and  solid  in  the  deeper  but 
not  in  the  superficial  parts — that  is,  no  cedema  of  the  cellular  tissue  beneath  the  skin 
will  be  present,  although  the  superficial  veins  may  be  turgid.  The  absence  of  this 
symptom,  however,  must  not  mislead,  as  it  simply  indicates  that  the  superficial  circula- 
tion is  efficiently  carried  on  and  that  no  stagnation  exists  sufficient  to  allow  of  passive 
serous  exudation. 

When  these  cases  proceed  favorably,  the  swelling  will  gradually  subside,  as  will  also 


i.\ji/:ii:s  AM)  nisj:.\si:s  of  tiih  veins.  loi 

every  ntlirr  syiii|itiiiii,  tlic  vein  cillicr  nvovcrinir  its  normal  cuiKlitioii  or  tli(!  l)loorl  tiniliti;^ 
its  way  tliroiiirli  otlu-r  cliaiiin'ls  Wlicii  they  j^o  on  iiiifiivoriihly,  suppiirutiori  will  take 
placi'  ;  and  it'  tlic  tlfcp  parts  are  involve<|.  the  case  ussuiues  u  very  serious  aspect,  as  a 
local  or  a  dittused  abscess  may  result  (the  hitter  condition  bein<^  the  more  cutiiinon),  and 
then  Ii1(mk1  poisoniu":  too  fre<|uently  ensues  with  its  usual  consecjuences. 

TliKATMKNT. — The  two  f^reat  indications  for  treatuieut  in  these  cases  are  (1)  to 
faviir  thr  rniaiis  rlrciiltilii)n  of  fli<'  jxn't,  and  ('!)  I"  iiiii>rorr  f/ir  i/inirn/  loin/ifion  uf  lite 
piifirii/. 

The  first  can  Itc  attaine<l  l>y  elevation  of  the  limit,  the  foot  hcin;;  rais»;d  higher  than 
the  hip,  and  hy  the  a|)plication   of  warmth   to  the  part    in  the  shape  of  fonunitations  or 

COttoM-Wool. 

The  second  can  lie  carried  out  liv  the  administration  of  a  simple  nutritious  diet,  tonics, 
such  as  (|uiniiM',  hark,  or  iron,  and  stimulants  caref'ullv  adjustecl  to  the  wants  of  the 
individual  case. 

I'ain  must  he  allayed  hy  both  local  and  general  means,  as  poppy  fomentations  and  the 
internal  use  of  ojtiuin,  mctrphia,  or  chloral. 

Leecliini;  should  never  be  resorted  to,  nor  mercury  in  any  of  its  forms,  as  the  prac- 
tice was  based  on  a  mistaken  pathology,  and  therefore  should  be  discarded. 

When  suppuration  appears,  it  must  be  dealt  with  on  ordinary  principles,  as  it  is  wise, 
as  a  rule,  to  evacuate  it  as  soon  as  it  has  declared  itself. 

Gouty  Phlebitis. — Subjects  who  are  gouty  from  hereditary  or  acquired  causes  are 
likewise  liable  to  (t<fh'siiv'  jtldchllla.  Sir  J.  Paget  has  well  described  tlie  affection  in  his 
Cliniad  Lectures  (1875),  and  IMr.  (jay  has  also  written  ably  upon  it  {Luiicrl^  May  19, 
1877):  '"In  such  cases  the  phlebitis  may  have  no  intrinsic  characters  by  which  to  dis- 
tinguish it,  yet  not  rarely  it  has  peculiar  marks,  especially  in  its  symmetry,  apparent 
metastases,  and  fre(|uent  recurrences." 

Like  other  forms  of  phlebitis,  it  is  more  common  in  the  lower  than  in  the  upper 
extremities,  yet  it  may  be  found  anywhere.  It  affects,  however,  the  superficial  rather 
than  the  deep  veins  and  often  occurs  in  patches,  affecting  on  one  day  (for  example)  a 
short  piece  of  the  saphenous  vein,  and  the  next  another  piece  of  the  same,  some  other 
distinct  vein,  or  a  corresponding  piece  of  the  opposite  vein. 

The  inflamed  portions  of  vein  usually  feel  hard  and  are  painful  to  the  touch.  The 
soft  parts  coveriixg  the  vein  become  slightly  thickened  and  often  have  a  dusky  reddish 
tint.  When  the  deep  veins  are  involved,  oedema  appears,  with  the  well-recognized  results 
of  venous  obstnu^tion  :  "the  limb  becomes  big.  clumsy,  featureless,  heavy,  and  stiff:  its 
skin  is  cool  and  may  be  pale,  but  more  often  it  has  a  partial  slight  livid  tint,  which  might 
be  discerned  by  comparison  with  the  other  limb,  and  has  mottlings  from  small  cutaneous 
veins  visibly  distended."  The  limb  thus  enlarged  feels  uidematous  throughout,  but  firm 
and  tight-skinned,  not  yielding  easily  to  pressure,  and  not  pitting  very  deeplv. 

By  almost  this  .state  alone  the  disease  can  sometimes  be  recognized. 

The  coNsTiTiTio.NAL  svMi'TOMs  associated  with  this  local  affection  vary  from  some 
slight  febrile  condition  to  those  met  with  in  acute  gout.  Complete  recovery  may 
take  place  in  this  as  in  other  forms  of  phlebitis,  the  veins  becoming  pervious  in  some 
ea.ses  and  obstructed  in  others,  the  limb  rea.ssuming  its  healthy  condition  or  becoming 
permanently  enlarged,  cumbrous,  and  heavy.  The  risks  of  embolism  are  also  the 
same. 

Tre.\tmknt. — Nothing  special  can  be  recommended,  as  the  so-called  gout  remedies  do 
not  appear  to  have  much  influence  on  the  local  di.sease.  Rest,  elevation  of  the  limb,  lead 
lotion  to  the  inflameil  vein  when  superficial  and  fomentations  when  deep,  are  tlie  chief 
points  to  be  attended  to  in  the  local  treatment,  and  a  lower  diet,  abstention  from  stimu- 
lants, and  saline  drinks  in  general.  When  feebleness  exists,  the  li(|Uor  ammonia  in  doses 
of  five  to  ten  drops  with  Itark  is  an  excellent  remedy,  but  at  others  quinine  is  called  for. 

Suppurative  Phlebitis.. — There  is.  however,  another  form  of  phlebitis  that  must 
be  mentioned,  and  which  is  by  far  the  most  .serious — viz.,  the  uuhadtlii/  <li(f'use  or  siippu- 
rativt  phlihitis.  It  is  an  affection  of  the  cellular  tissue  around  the  veins,  these  veins 
themselves  being  secondarily  involved.  It  is  a  species  of  erysipelatous  inflammation  of  a 
low  type,  and  it  is  only  found  in  the  feeble  and  cachectic.  It  comes  after  a  severe  injury 
to  or  operation  on  bone ;  after  a  slight  contusion  or  a  severe  wound  ;  it  may  supervene 
on  the  puncture,  division,  or  ligature  of  a  vein,  or  chronic  suppurative  disease,  more  par- 
ticularly of  the  bones  of  the  cranium.  It  occurs  also  in  the  puerperal  state.  Dejiending 
upon  a  vitiated  condition  of  the  blood. "  we  are  able  to  appreciate  how  it  is  that  the  many 
different  forms  of  jthlebitis  may  follow  various  dissimilar  injuries,  arid  reconcile  the  fre- 
26 


402  INJURIES  AND  DISEASES  OF  THE   VEINS. 

quency  of  their  occurrence  after  operations  involving  the  venous  system.  The  dangers  are 
not  to  be  looked  for  when  the  general  condition  of  the  system  of  the  individual  is  good 
and  when  the  walls  of  the  vessels  are  in  a  healthy  state,  but  they  may  be  anticipated  in 
enfeebled  and  broken-down  constitutions,  more  particularly  when  the  coats  of  the  vessels 
are  abnormally  changed.  Upon  such  a  class  of  persons  operative  procedure  should,  there- 
fore, if  possible,  be  avoided"  (Dr.  8.  W.  Gross,  1867). 

Local  Symptoms. — The  disease  shows  itself  as  a  purulent  infiltration  of  the  cellular 
tissue  surrounding  the  vein  with  a  thickening  and  softening  of  the  coats  of  the  vein  itself. 
As  the  disease  progresses  abscesses  form  around  the  vein,  whilst  the  circulation  through 
it  is  arrested  by  the  formation  of  coagula  in  one  spot  and  a  sloughing  abscess  in  another. 
In  superficial  veins,  such  as  in  the  leg,  all  these  changes  can  be  well  observed,  but  in  the 
deep  they  are  difficult  to  diagnose.  In  the  superficial  the  external  signs  of  inflammation 
are  well  marked,  local  redness  and  brawniness  of  skin  around  a  dilated,  thickened,  and 
tortuous  vein  being  the  chief  symptoms.  As  the  disease  progresses  local  abscesses  appear 
in  the  vein  itself,  which  yield  blood  and  pus  on  being  opened,  these  contents  being,  doulit- 
less,  broken-down  coagula. 

Constitutional  Symptoms. — The  constitutional  symptoms  vary  with  the  extent 
and  severity  of  the  disease,  marked  depression  of  the  general  powers  always  being  pres- 
ent, while  rigors  not  only  usher  in  the  attack,  but  attend  its  progress,  each  one  probably 
indicating  some  suppurative  change.  Local  pain  and  sleeplessness  are  common  accom- 
paniments, and  in  cases  that  cease  to  be  local  and  have  an  infective  tendency  those  known 
as  typhoid  symptoms  occur.  When  blood  poisoning  or  pyaemia  appears,  the  symptoms 
are  such  as  have  been  described  in  an  early  chapter. 

On  the  Presence  of  Air  in  Veins. 

That  air  may  find  its  way  to  the  heart  through  an  open  vein  and  cause  sudden  death 
is  a  clinical  fact  with  which  all  surgeons  should  be  familiar,  also  that  this  entrance  gen- 
erally occurs  during  the  removal  of  tumors  about  the  neck  and  axilla,  amputations  at  the 
shoulder-joint,  and  operations  or  wounds  involving  the  cervical  or  other  veins.  It  has 
likewise  occurred  in  uterine  surgery  from  the  injection  of  air  or  gas,  etc.  Two-thirds 
of  the  patients  affected  die  from  the  accident,  half  within  a  few  minutes,  others  living 
hours  or  a  few  days.  The  accident  is  favored  by  a  thickened  state  of  the  vein,  and  is 
generally  indicated  during  the  progress  of  an  operation  by  a  sudden  gurgling,  hissing,  or 
bubbling  sound  in  the  wound,  associated  with  venous  bleeding,  sudden  faintness,  and 
insensibility  of  the  patient,  or  convulsions,  probably  terminating  in  death.  When  this 
result  does  not  at  once  transpire,  there  will  be  labored  and  irregular  respiration,  tumul- 
tuous action  of  the  heart,  and  feeble  pulse,  the  lividity  of  the  patient  gradually  disap- 
pearing, the  heart  then  regaining  its  natural  action,  and  the  patient  recovering.  Bubbles 
of  air  may  at  times  be  seen  in  the  wound.  In  some  cases  the  patient  will  give  a  sudden 
cry  with  the  first  onset  of  the  symptoms. 

After  death  evidence  of  the  admixture  of  air  with  the  blood  has  been  found  in  the 
form  of  bubbles  in  the  vessels  of  the  brain  or  in  the  large  venous  trunks  and  arteries. 
In  some  cases  air  has  been  found  in  the  right  cavities  of  the  heart.  Where  a  suspicion 
of  this  cause  of  death  exists,  the  heart  and  large  vessels  should  be  opened  under  water, 
to  make  manifest  the  escape  of  air-bubbles,  one  single  bubble  indicating  air  in  the  heart, 
and  many  bubbles  air  in  the  vessels.  Experiments  on  animals  by  Erichsen  and  by  a 
French  commission  tend  to  confirm  this  observation. 

Treatment. — How  to  deal  with  these  cases  has  now  to  be  considered,  and,  witliout 
doubt,  preventive  are  more  important  than  curative  measures.  In  dealing  with  large 
veins,  or,  indeed,  any  veins  near  their  cardiac  ends,  the  surgeon  should  be  careful  to  apply 
pressure  and  to  maintain  it  during  the  operation,  while  in  some  instances  it  is  more  expe- 
dient to  ligature  before  dividing  or  twisting  them.  When  the  bubbling  sound  has  been 
heard,  pressure  must  at  once  be  applied  to  the  spot  where  the  bubbles  appear.  When  a 
large  vein  has  been  wounded  by  accident,  it  should  be  tied  ;  and  when  this  cannot  be  done, 
the  opening  must  be  taken  up  by  forceps  and  carefully  closed  with  a  fine  silk  ligature. 

When  air  has  been  admitted  into  the  heart  and  its  action  interfered  with, the  surgeon's 
aim  should  be  to  keep  up  its  action  and  help  the  respiratory  act  by  artificial  means,  such  as 
by  cold  water  on  the  face  and  thorax,  stimulants,  as  ammonia  to  the  nostril,  etc.  Amus- 
sat  ascribed  recovery  in  one  of  his  cases  to  pressure  upon  the  chest,  leaving  the  opening  in 
the  vein  free,  so  as  to  allow  of  the  escape  of  the  admitted  air  ;  but  in  adopting  this  prac- 
tice care  must  be  observed  to  close  the  orifice  of  the  vein  in  the  inspiratory  act.    Brandy 


INJUKIKS   .\.\n    I  USE  ASKS   O/'   77//;    I'AVAW. 


40;i 


rcuin.stanoes  as 
tinn  iii'  ;i  part 


Kir:.  IS". 


and  (liHu.^ililo  stiiniilatits  .><h(iul»l  also  \>v  iVccly  ^'ivcii,  to  sustain  and  .stiinulato  tlio  vital 
t.r<:ans.' 

Hypertrophy  and  atrophy  <•*'  vt-ins  occm-  in  incciscly  similar  fire 
hypiTtropliv  and  atrophy  (tf  other  structurt's.  Thu.s  where  increase  ol'  fuiie 
exists,  or  increased  p;rowth,  (he  veins  will  elonfjate,  dilate, 
and  thicken.  When  decrease  of  I'linctioii  or  di.soase  of  a 
part  takes  place,  the  veins  waste  or  hec(tnie  atrophied  with 
other  structures.  Hence,  after  auiputattun  of  the  thi<;h, 
the  femoral  artery  and  vein  lieeonie  as  small  as  the  ante- 
rior tihial  ;  and  in  Mr.  Cock's  ease  of  arterial  varix,  re- 
lated in  pa<;e  liT'),  the  vein  ahove  the  varix  withered  to  a 
mere  cord.  On  the  other  hand,  in  the  same  case  of  arte- 
rial varix,  the  popliteal  vein  helow  the  varix,  when  takin*r 
on  the  action  of  an  artery,  heconie  miieh  eidarjred  and 
thickened — in  fact,  hyportrophied — simply  on  account  of 
the  increase  of  work  it  had  to  jierform  under  its  new  con- 
dition, and  the  superficial  cutaneous  veins  through  which 
the  whole  of  the  returning  blood  must  have  jjassed  be- 
came enormously  enlarged.  An  equally  good  instance  of 
hypertrophy  of  veins  can  be  seen  when  any  obstruction 
occtirs  to  one  of  the  cava3  or  any  large  venous  trunk,  the 
venous  circulation  making  its  way  through  other  channels, 
which  consequently  enlarge.  Thus,  in  Fig.  182  the  skin 
veins  of  the  abdonu'u  and  chest  are  seen  to  be  enormously 
distended  and  hypertrophied  to  carry  on  the  circulation 
from  the  lower  part  of  the  body  to  the  heart,  the  lower 
vena  cava  having  been  completely  obstructed  from  cancer- 
disease.  The  woman,  fet.  47,  a  patient  of  Sir  W.  W.  (lull, 
had  no  oedema  of  the  lower  extremities  all  through  the 
case,  thus  proving  the  perfection  of  the  compensatory 
venous  collateral  circulation,  and  probably  indicating  the 
gradual  progress  of  the  obstruction. 

Calcareous  and  atheromatous  diseases  of  the  coats  of  veins  may 

occur,  but  are  rare  afeetions  when  compared  with  their  frequency  in  the  arteries.  In 
Guys  Museum  (1588'^)  there  is  a  good  specimen  of  ossified  saphena  vein,  and  at  St. 
Thomas's  Hospital  and  the  College  of  Surgeons'  Museums  may  be  found  examples  of 
calcareous  degeneration  of  other  veins.  Gay  has  also  described  a  dissection  of  a  varix 
which  "  appears  to  have  been  occasioned  by  disease,  originally  atheromatous,  followed  by 
softening  and  ulceration  of  the  inner  and  middle  tunics  of  the  vessel,"  and  3Ir.  Pick  of 
St.  Georges  Hospital  (^Faf/t.  Tnain.,  18(37)  has  given  a  somewhat  similar  example.  How 
far,  however,  this  atheromatous  and  calcareous  degeneration  is  a  distinct  disease,  or  an 
"after-change  in  some  local  deposit  of  fibrin,''   is  an  open  question. 


Collateral  Veuous  Circulation.  (^Taken 
from  a  woman  iet.  47.  under  the  care 
of  .Sir  W.  W.  (iull,  in  whom  the  in- 
ferior vena  cava  was  completely  ob- 
structed from  cancer.  Guy's  Hosp. 
Mus.,  Iirawing  44''0.) 


Varex. — Varicose  Disease  of  the  Veins  and  Phlebolithes. 

The  term  "  varicose  vein  "  is  unfortunate,  as  it  is  applied  to  any  enlarged  tortuous 
vessel,  to  such  as  have  been  already  described  as  hypertrophied  veins,  and  to  others  that 
are  clearly  due  to  some  diseased  action  resulting  in  hypertrophy  with  dilatation.  In  the 
sequel  the  term  will  be  confined  to  the  latter  condition.  A'^arix  is  commonly  an  affection 
of  the  veins  in  the  lower  extremities,  and  mainly  of  the  branches  of  the  saphena  vein. 
When  it  involves  the  submucous  veins  of  the  rectum  it  is  called  a  hemorrhoid,  and  when 
the  veins  of  the  spermatic  cord  a  varicocele.  But  '■  all  the  veins  of  the  body  may  become 
varicose,'  said  M.  Bri(|uet  in  1824.  In  18(!9  a  child  aet.  4  was  brought  to  me  with  a  sac- 
culated varix  the  size  of  a  nut  connected  with  a  vein  on  the  outer  side  of  the  right  fore- 
arm ;  it  had  been  coming  on  for  a  year  and  a  half.  Taking  varix  of  the  lower  extreiuity 
as  a  type  of  the  affection,  it  appears  as  a  disease  involving  one  or  more,  and  in  extreme 
cases  all,  of  the  branches  of  the  saphena  vein.  In  most  instances  it  is  confined  to  the 
larger  trunks ;   in  some  it  spreads  to  the  smaller  tributaries. 

In  some,  however,  the  affection  appears  to  begin  in  the  capillaries  of  the  skin  and  to 
spread  toward  the  larger  trunks,  and  such  cases  are  most  common  in  women.    They  appear 

^  The  reader  may  refer  to  an  admirable  paper  on  this  subject  by  Dr.  J.  S.  Green  of  Massacliusetta, 
Amfr.  Med.  Journ.,  1864. 


404 


INJURIES  AND  DISEASES  OF  THE   VEINS. 


as  '■  clusters  of  diseased  venous  radicles  "  (Gay)  and  rarely  involve  other  than  the  smaller 
branches. 

It  must  not  be  thought,  however,  that  this  affection  is  one  of  the  superficial  veins 
alone,  for  such  is  not  the  case.  Boyer  asserted  this  many  years  ago,  and  on  his  authority 
the  opinion  has  been  accepted.  Verneuil  corrected  the  error,  and  in  the  Gazette  Hehdo- 
madaire  e,t  Medicale,  1855,  showed  that  varix  is  as  often  a  disease  of  the  deep  veins  as 
of  the  subcutaneous,  the  latter  often  indicating  the  existence  of  the  former.  He  believed, 
moreover,  that  the  intramuscular  veins  are  sometimes  aftected  without  the  subcutaneous. 
Hilton,  and  more  recently  Callender,  have  told  us  that  the  varix  of  a  subcutaneous  vein 
is  found  wherever  the  intramuscular  veins  pass  into  the  subcutaneous,  mentioning  that 
"  the  valves  obstruct  below  and  the  column  of  obstructed,  slow-moving  blood  resist 
above."  Callender  has  failed,  however,  to  confirm  Verneuil's  remarks,  that  varix  of  the 
intramuscular  branches  is  constant. 

Mr.  Gay,  an  able  author  on  varicose  veins  (1868),  concludes  from  his  experience  of 
many  dissections  that  "  with  superficial  varicosity  there  are  other  serious  lesions  affecting 
both  arteries  and  veins,  deep  and  superficial,  such  as  would  lead  to  the  conclusion  that  the 
genei'al  circulation  has  been  subject  to  a  very  considerable  and  long-standing  embarrass- 
ment, some  incompetency  of  the  arterial  system  or  impediment  to  the  venous,  or  both 
combined;"  and  these  conclusions  are  probably  correct. 

The  CAUSES  of  varicose  disease  of  the  vein  are  obscure.  Surgeons  of  the  past 
regarded  such  affections  as  the  invariable  result  of  some  obstruction  to  the  venous  cir- 
culation, such  as  prolonged  standing,  the  presence  of  abdominal  or  pelvic  tumors,  patho- 
logical, fecal,  or  foetal,  patients  of  a  relaxed  and  feeble  habit  naturally  suffering  more  than 
the  robust ;  and  in  a  measure,  doubtless,  their  opinions  were  correct.  Mr.  Herapath  of 
Bristol  maintained  that  the  cause  of  varix  was  the  narrowing  of  the  saphenous  opening 
of  the  thigh,  and  cases  are  on  record  where  its  enlargement  seemed  of  value  ;  facts,  how- 
ever, are  wanting  to  support  this  view.  General  testimony  also  admits  that  this  disease 
is  as  common  in  the  higher  as  in  the  lower  ranks  of  life  and  in  women  as  in  men  ;  that  it 
is  as  frequent  on  the  right  as  the  left  side,  and  more  frequently  on  both  ;  that  it  is  a  dis- 
ease of  the  young  as  much  as  of  the  middle-aged ;  that  it  is  met  with  in  the  strong  and 
healthy  as  well  as  in  the  feeble  and  cachectic ;  in  fact,  it  is  found  under  every  condition 
of  life  and  in  every  variety  of  subject.  Some  evidence  exists  that  gout  and  hereditary 
predisposition  are  efficient  causes,  with  local  injuries  and  prolonged  muscular  exertion. 

The  SYMPTOMS  vary  according  to  the  place  of  its  origin.  When  it  commences  in  the 
venous  capillaries — its  common  seat  in  women — it  appears  as  a  fine  capillary  injection 
giving  an  arborescent  appearance  to  the  skin,  with  more  or  less  congestion,  and  as  it 
extends  the  larger  venous  trunks  become  involved,  the  main  trunks  being  rarely  affected. 
When  it  originates  in  a  large  trunk,  the  varix  may  appear  as  a  fusiform  enlargement 
or  a  .simple  dilatation  of  the  whole  length  of  the  vein.  In  some  there  will  be  thinning 
of  the  venous  coats,  in  others  a  thickening,  whilst  in  a  third  class  one  part  will  appear 
thin   and  another  thick. 

Again,  the  affected  vein  becomes  tortuous  and  knotted  to  an  extreme  degree,  and  it  is 
far  Irom  unusual  to  find  it  the  diameter  of  a  finger  (Fig.  183).  The  valves  of  the  veins 
under  these  circumstances  are  clearly  lost — not,  however,  from  a  yielding 
due  to  backward  pressure  of  the  column,  but  from  their  action  being  ren- 
dered imperfect  by  the  dilatation  of  the  vein  behind ;  the  '•  valve  cusps, 
being  unable  to  meet  and  close  the  canal,  shrink  and  atrophy." 

As  the  disease  progresses  the  tissues  around  the  affected  vein  become 
gradually  absorbed ;  the  skin  is  thinned,  and  even  the  bone  grooved,  the 
skin,  indeed,  becoming  so  thin  as  even  to  rupture  ;  and  a  fatal  hemor- 
rhage is  far  from  being  a  rare  result.  At  Guy's  during  the  last  few  years 
several  cases  of  this  sort  have  taken  place.  Subcutaneous  rupture  of  the 
vein  may  at  times  occur,  of  which  I  saw  a  severe  instance  in  a  man,  set 
G2,  in  1858.  More  frequently,  however,  the  soft  parts  around  the  dis- 
eased vein  thicken  or  inflame.  They  thicken  from  a  kind  of  passive  exu- 
dation into  the  cellular  tissue,  the  result  of  impeded  venous  circulation, 
and  give  rise  to  a  slightly  anasarcous  condition  of  the  part,  which  in 
chronic  cases  becomes  somewhat  permanent,  producing  what  Liston  so 
well  described  as  a  "  solid  oedema."  In  extreme  instances  this  solid 
(edema  is  so  marked  as  to  give  rise  to  appearances  similar  to  the  dis- 
Varicose  Veins,  easc  called  "  elephas,"  or  Arabian  elephantiasis. 
oOh'^jtcobson/  On  the  other  hand,  it  is  a  very  common  result  for  the  cellular  tissue 


Fig.  183. 


IXjrnihS  AM)   DISEASES   OF   THE    VEIXS  405 

ari)iiti(l  till'  vein,  ami  |ir<il>atily  tin-  vein  itscH",  to  inflatiu'.  The  parts  armiml  the  varix 
or  tortuous  vi'iii  Itocoim"  iiMluratrd,  ml.  ami  |iiiiiil"iil.  In  licaltliy  sultjcct.s  tliis  iiiHaiii- 
inatioii  may  end  as  an  adlirsivf  (tno  (local  ailhcsivc  phli'liitis )  and  in  the  f'celiU-  as  a 
sujtpurative,  local  or  difluscd  alisccsscs  sul»sc<|ni'ntly  sliowini;  tlicnisclvcs.  When  the 
powers  of  the  patient  are  very  low  or  blood  poisoning:  takes  place,  that  terrible  disease 
iinhealthv  suppurative  phlebitis,  previously  described,  may  ensue. 

In  the  early  period  of  the  di.sease  an  aehinj;  of  the  limb.s  on  standitig  or  after  exer- 
cise may  be  the  only  .symptom,  a  local  pain  occasionally  indicatinjr  the  seat.  In  a  more 
advanced  period  ledema  around  the  ankle  may  be  ob.served. 

When  the  femoral  vein  becomes  dilated  where  the  f^rand  venous  junetion  takes  p'.aoe 
at  the  saphenous  openin<r.  the  swellinj^;  may  <tn  a  careless  examination  be  mistaken  for  a 
femnrnl  h>  ruhi  ;  for  both  will  disappear  on  the  patient  assuminir  the  recumbent  posture, 
and  reappear  on  his  couL'hinir.  There  is.  however,  this  point  of  distinction — that,  while 
by  loeal  pressure  on  the  crural  rinjr  a  femoral  hernia  can  be  kept  in  its  position,  a  femoral 
varix  can  be  made  to  enlar<re. 

As  a  secondary  result  of  varicose  disease  the  blood  iti  the  vein  may  coagulate,  gi\  ing 
rise  to  t/iromfiosis  ;  and  this  coatrulum  may  break  up.  causing  a  local  ab.scess,  or  it  may 
wither  and  organize,  causing  occlusion  of  the  vein,  and  consequently  a  partial  cure. 
There  is  reason,  also,  to  believe  that  this  may  dry  up  and  become  so  altered  as  to  form 
what  are  known  as  phleboiif/i' x,  as  these  have  a  laminated  character,  and  in  Dr.  Franklin's 
analysis  are  ."aid  to  be  composed  of  protein  matter  and  phosphate  of  lime,  with  a  little 
sulphate  of  potash  and  lime. 

With  varicose  disease  of  the  veins  there  is  very  frequently  associated  an  eczematous 
condition  of  the  leg.  the  eczema  being  apparently  due  to  the  feeble  venous  circulation  of 
the  part.  If  this  eczema  be  neglected,  a  superficial  ulceration  of  the  skin  may  ensue; 
and  if  no  attention  be  paid  to  this  condition,  the  ulcer  becomes  chronic.  But  beyond 
this  no  special  form  of  ulcer  can  be  said  to  exist  as  a  result  of  varico.se  veins ;  in  fact, 
there  are  no  "•  varicose  ulcers."  In  practice  every  variety  of  ulcer  is  found  associated 
with  varicose  disease,  and  the  existence  of  the  latter  doubtless  renders  the  repair  of  the 
former  somewhat  more  difficult.  Thus  it  appears  that  chronic  indolent  sores  associated 
with  varicose  diseases  have  been  termed  "  varicose  ulcers."' 

Treatment. — Varicose  disease  of  the  veins  in  its  early  stage  is  very  amenable  to 
treatment,  but  later  on  none  are  more  obstinate,  the  patient  being  only  relieved,  and 
rarely  cured.      Happily,  however,  under  common  care  it  never  threatens  life. 

When  the  affection  is  first  discovered,  the  local  treatment  mu.st  be  directed  to  assist 
the  venous  circulation  by  the  raised  position  of  the  limb,  the  patient  being  recumbent ; 
friction,  too.  shoald  bo  steadily  applied  upward;  all  sitting,  standing,  or  walking  should 
be  strictly  prohibited  ;  and  when  possible,  this  treatment  should  be  persevered  in  for 
three  or  four  weeks.  When  exercise  is  allowed,  .steady  pressure  by  a  well-applied  band- 
age from  below  upward  should  be  maintained  or  an  elastic  stocking  worn,  and  in  the 
course  of  time,  the  extent  of  which  greatly  varies,  a  cure  may  be  effected  and  main- 
tained. 

During  this  time  the  general  treatment  must  not  be  neglected.  Where  the  powers 
are  feeble  tonics  mu.st  be  given,  and  of  these  iron  is  the  best,  twenty  drops  of  the  tinc- 
ture of  the  perchloride.  with  ten  of  the  tincture  of  nux  vomica  and  a  drachm  of  glycerine 
in  water,  being  an  excellent  compound. 

A  generous  diet  must  be  given  when  indicated,  and  the  rever.se  where  the  portal  sys- 
tem has  been  overgorged  by  excess.  Mild  aperients  are  always  of  value  under  these  cir- 
cumstances, salines  being  preferable  to  the  purgative  extracts.  The  natural  waters  are 
of  great  value. 

When  rest  cannot  be  given,  well-applied  pressure  must  be  relied  upon,  the  best  forms 
being  a  pad  of  cotton-wool  over  the  part,  with  a  bandage  of  Domett  elastic  tissue  or  pure 
rubber  applied  from  the  toes  upward.  The  patient  must  be  impressed,  however,  with  the 
necessity  of  assuming  the  horizontal  position  as  much  as  he  can.  aiding  the  circulation  by 
friction,  as  already  indicated,  and  by  general  treatment.  The  bandage  should  alwavs  be 
put  on  before  the  legs  are  moved  off"  the  bed  and  removed  only  after  the  recumbent  po.si- 
tion  is  again  resumed. 

In  bad  cases  of  local  varix  the  pressure  may  be  more  local  and  permanent,  a  pad  of 
cotton-wool  well  fixed  on  by  strapping  being  very  valuable.  When  the  veins  are  inflamed, 
they  must  be  treated  on  principles  already  laid  down  in  the  chapter  on  phlebitis. 

If  a  vein  burst,  bleeding  can  be  controlled  by  the  application  of  a  finger  to  the  .spot, 
and  any  further  flow  is  prevented  by  the  elevation  of  the  limb.     A  pad  carefully  adjusted 


406  INJURIES  AND  DISEASES   OF  THE    VEIXS. 

to  the  bleeding  point  and  fixed  by  strapping  applied  like  a  bandage  or  by  a  roller  makes 
the  patient  safe. 

Operations  for  Varicose  Disease  of  the  Veins. 

It  has  been  observed  that  nature  not  unfrequently  obliterates  a  varicose  vein  by  means 
of  a  coagulum  which  subsequently  contracts,  and  even  organizes,  the  clot  and  vein  together 
forming  an  impervious  cord.  Acting  on  this  knowledge,  surgeons  now  endeavor  to  make 
use  of  nature's  processes,  and  by  artificial  means  to  induce  coagulation  of  the  blood  in 
some  portion  of  the  varicose  vessel,  with  the  hope  that  it  may  contract  or  so  to  destroy 
some  part  of  the  vein  itself  as  to  compel  the  circulation  to  find  another  course.  This  is 
the  so-called  "  radical  cure,"  but  it  is  to  be  thought  of  only,  as  Mr.  Gay  so  truly  says, 
when  the  vein  is  hopelessly  deteriorated  or  so  inflamed  and  painful  as  to  threaten  to 
burst,  or  in  cases  in  which  all  palliative  and  other  treatment  is  inapplicable  or  has  failed. 

Caustics  were  employed  by  ^layo  for  this  purpose,  and  also  by  Brodie.  Key.  and 
others.  They  should  be  thus  applied  :  A  small  piece  of  A'ienna  paste  (compo.sed  of  four 
parts  of  potassa  fusa  and  four  of  quicklime,  made  into  a  paste  with  spirits  of  wine  prior 
to  its  application),  or  chloride  of  zinc  paste  of  the  size  of  a  small  pea,  should  be  applied 
upon  the  vein,  the  surrounding  skin  being  previously  protected  by  a  ring  of  plaster  care- 
fully adjusted ;  the  paste  should  be  fixed  on  and  left,  the  object  being  to  cause  a  .slough 
through  the  tissues  into  the  vein.  This  slough  should  not  be  large,  but  three,  four,  or 
more  applications  may  be  simultaneously  made  about  an  inch  apart,  in  order  to  guarantee 
success.  The  caustic  may  be  left  for  twelve  or  twenty-four  hours  and  then  removed, 
water  dressings  being  afterward  applied  to  the  part.  During  all  this  treatment  the  patient 
must  be  kept  in  bed  with  the  limb  raised.     I  cannot,  however,  recommend  this  treatment. 

Subcutaneous  division  of  the  vein  was  practised  by  Brodie,  but  after  some 
experience  he  came  to  the  conclusion  that  ••  it  really  appears  it  is  not  worth  patients' 
while  to  submit  to  it."' 

Excision  of  a  portion  of  the  diseased  vein  has  likewise  been  employed  with  success, 
and  where  an  operation  is  called  for  it  is  doubtless  the  best.  My  colleague.  Mr.  Davies- 
Colley,  in  1874  reintroduced  the  practice  (Guj/s  Boxp.  Rep.,  vol.  xx.  series  iii.),  which 
has  been  followed  by  myself  in  bad  cases  and  others.  The  operation,  which  is  a  good 
one,  consists  in  the  exposure  of  the  varix  by  a  free  incision  and  its  removal  after  the 
application  of  a  carbolized  catgut  ligature  to  the  trunk  of  the  diseased  vein  above  and 
below.  Mr.  Marshall  in  1875  adopted  a  like  practice  {  Lancf.  June  23.  1875).  taking 
away  some  inches  of  diseased  vein  with  forceps  and  sei.'ssors  after  having  isolated  the  por- 
tion to  be  removed  by  means  of  pins  passed  under  the  vein  above  and  below. 

Another  operation  much  favored  and  practised  is  that  of  aoupressiire.  It  is  performed 
by  passing  a  pin  beneath  the  vein,  but  not  through  it,  as  in  Davat's  plan,  and  obstructing 
the  circulation  through  the  vein  by  means  of  a  twisted  suture  either  of  .silk,  india-rubber, 
or  wire  applied  round  the  pin.  or  by  a  piece  of  thin  india-rubber  stretched  across  it  on  the 
pin,  as  suggested  by  Mr.  Lee.  Two,  or  even  six,  of  these  acupressure  needles  may  be 
inserted  about  an  inch  or  an  inch  and  a  half  apart,  according  to  the  extent  of  the  disease. 
Mr.  Lee  employs,  also,  the  subcutaneous  division  of  the  vein  between  the  pins  at  the 
same  time,  and  my  own  experience  confirms  the  wisdom  of  this  practice.  Mr.  A\  ood 
employs  an  elastic  steel  spring  to  keep  up  tension  on  tire  ligature  till  it  cuts  its  way 
through  the  vein. 

On  several  occasions,  having  obstructed  the  circulation  through  the  vein  as  already 
described,  I  have  injected  the  vein  between  the  pins  with  perchloride  of  iron,  one  drop 
being  generally  sufficient  to  cause  coagulation  of  the  blood  :  in  others  I  have  used  a  con- 
centrated solution  of  tannin  ;  and  in  all  a  good  result  ensued.  The  syringe  should  be 
that  used  for  hypodermic  injections. 

The  time  for  withdrawal  of  the  pins  varies  according  to  the  effect  intended  to  be  pro- 
duced. When  inserted  to  induce  coagulation  of  the  blood  only,  and  not  inflammation, 
they  may  be  withdrawn  on  the  third  or  fourth  day,  and  in  the  practice  suggested  of  acu- 
pres.sure  and  injection  this  plan  .should  be  followed.  Sir  W.  Fergusson  states:  '-They 
should  be  left  until' they  have  excited  considerable  swelling  and  slight  ulceration,  and  in 
some  instances,  where  the  former  is  not  very  conspicuous,  the}'  may  be  permitted  to 
separate,  by  ulceration  through  both  vein  and  skin.  I  recommend  that  the  process  of 
inflammation  should  be  more  implicitly  relied  upon  than  that  of  coagulation.  '  He  adds, 
moreover,  that  he  has  not  met  with  any  seriously  unpleasant  eff"ects  out  of  the  numerous 
instances  in  which  it  has  been  employed. 


VENKSECTIoy. 


407 


/ 


It  iinist  1)0  ropi'iitcd,  Iiowcvi-r,  that  tlics*?  Dpcrations  Hhoiild  hf  prar-tised  only  in 
extreme  cases,  and  not  wliere  palliativi'  treatment  is  apjilieahle.  Wlien  a  vein  threatens 
to  hirst  or  lias  hurst  ami  endaiiLrers  lite.  siir;_'i<-al  treatment  is  justitiahle. 

Mr.  (Jay  called  attention  (  jjoml.  MimI.  Soc,  Oetoher,  IHTI^  to  a  class  of  cases  in  which 
the  superficial  or  complementary  veins,  as  he  calls  tlium,  arc  ohiiteratcil,  and  as  a  result 
the  ri'tiirn  ot"  the  venous  hlood  is  carried  on  entirely  hy  the  deep  veins.  These  con.se- 
(pii'iitly  hecome  disca.sed,  tlu"  circulation  tliroui;h  them  <rrr)ws  f'eehle,  and  dc^rcneration 
t)t"  the  tissues  ensues,  as.sociateil  with  deep-seated  solid  a'dema  of  the  limh,  not  suhcuta- 
neous  Lcdema,  which  boloiiL's  to  ohstruction  only  in  the  suhcutaneous  veins.  For  this 
<lisorder  exercise,  warm  applications,  tonics,  etc.,  are  re(|uired,  but  bandages  and  rest  do 
harm. 

Venesection. 

At  the  present  time  this  operation  is  very  rari'  indeed,  and  at  'Juy'.s  Hospital  it  i.s  as 
rare  as.  if  not  more  so  than,  amputation.  Forty  years  ago  it  was  one  of  the  mo.st  com- 
mon, and  there  seems  some  reason 
to  believe  that  it  will  soon  be  prac- 
tised again  with  greater  fre(|uency, 
especially  when  we  find  Sir  dame.s 
Paget  asserting  '•  that  we  undoubt- 
edly overvalue  the  blood  and  esti- 
mate too  cautiously  the  hjss  of  it ;" 
that  '■  the  loss  of  blood  up  to  faint- 
ing, and  in  some  cases  I  remember 
with  those  e])ileptiform  convulsions 
that  come  with  the  loss  of  blood,  is 
absolutely  harmless" — that  is,  when 
performed  upon  a  large  series  of 
healthy  persons,  as  was  the  custom 
in  his  student  days  (Lancet,  August 
15,  1874). 

It  is  not  a  difficult  operation,  but 
requires  nicety  and  care.     It  is  usually  performed  at  the  bend  of  the  elbow.     The  first 
thing  the  surgeon  has  to  do  is  to  render  the  veins  prominent  by  arresting  the  circulation 
through  them  by  means  of  a  piece  of  broad  tape  or  narrow  bandage  carried  twice  round 
the  arm  a  few  inches  above  the  elbow  and  tied  in  a  bow, 
but  not  tight  enough  to  stop  pulsation  in  the  arteries 
(Fig.  1S4).     He  then  selects  the  vein,  the  largest  being 
the  best.     Where  the  outer  vein  or  median  cephalic  is  of 
good  size,  it  .should  be  cho.sen,  as  the  inner  or  median 
basilic  lies  immediately  over  the  brachial  arterj-  ;  either, 
however,  may  be  selected,  care  being  observed  not  to  go 
t/niiii;/fi  the  vein.     He  should  also  assure  himself  that  no 
malposition  of  the  artery  exists,  as  many  cases  are  on 
record  where  a  superficial  artery  has  been  opened  for  the 
vein. 

The  vessel,  then,  having  been  selected,  the  surgeon 
should  stand  in  front  of  the  extended  arm  and  hold  it 
with  his  left  hand,  the  thumb  being  fixed  on  the  vein  below 
the  s;)ot  which  is  to  be  opened.  With  his  right  hand  an 
obli(|ue  incision,  not  a  puncture,  should  be  made  through 
the  skin  into  the  vein,  describing  with  the  lancet  a  semi- 
circular movement.  The  bleeding-basin  having  been 
brought  close  to  the  arm.  the  surgeons  left  thumb  may 
be  removed  and  the  stream  of  blood  allowed  to  flow.  If 
this  be  feeble,  the  patient  may  be  asked  to  grasp  a  stick 
and  jiut  the  muscles  of  the  fore-arm  well  into  action. 

The  required  amount  of  blood  having  been  withdrawn, 
the  tape  can  be  removed,  the  left  thumb  of  the  operator 
being  applied  to  the  wound,  and  the  parts  clean.sed.      A 
pad  of  lint  is  then  to  be  placed  over  the  incision,  the  edges  of  which  are  to  be  kept  well 
in  contact,  whilst  the  thumb  is  slipped  downward  to  allow  of  the  adjustment  of  the  pad, 


Venesection.    (From  Heath. 


Fig.  185. 


After  Venesection. 


/ 
(From  He.ith.) 


408  VENESECTION. 

which  is  to  bo  fixed  by  a  figure-of-8  bandage  (Fig.  185).  The  arm  should  then  be 
slightly  bent,  care  being  taken  that  the  pad  does  not  slip  during  this  process. 

On  the  second  or  third  day  the  pad  may  be  removed,  the  wound  having  probably  by 
that  time  healed. 

Opening  of  the  external  jugular  vein  is  sometimes  called  for,  particr.l.rly 
when  venesection  is  required  in  a  child,  and  that  part  of  the  vein  where  it  passes  over  the 
sterno-mastoid  muscle  should  be  selected.  The  vein  can  be  steadied  and  rendered  prominent 
by  the  left  thumb  of  the  surgeon  applied  at  the  root  of  the  neck  above  the  clavicle,  or  this 
may  be  done  by  means  of  a  pad.  It  then  is  to  be  opened  with  the  lancet  by  an  incision  made 
in  the  course  of  the  sterno-mastoid  muscle,  and  consequently  across  the  platysma.  Blood 
will  then  flow  freely,  and  when  enough  has  been  taken,  the  wound  should  be  closed  by 
means  of  a  pad  carefully  adjusted.  The  thumb,  which  hitherto  has  been  acting  as  a 
compress,  may  then  be  removed.     The  pad  should  be  fixed  by  good  strapping. 

In  both  these  operations  of  venesection,  if  the  wound  in  the  skin  be  made  smaller 
than  that  in  the  vein  or  the  position  of  the  arm  be  changed,  a  blood  tumor  or  thrombus 
may  form,  from  the  escape  of  blood  beneath  the  integument;  and  if  this  interferes  with 
the  flow  of  blood,  instead  of  reintroducing  the  lancet,  the  best  practice  is  to  untie  the  arm 
and  apply  a  pad  to  the  wound,  opening  a  vein  in  the  other  arm. 

In  fat  subjects  there  is  occasionally  some  difficulty  in  finding  a  vein.  Friction  of  the 
surface  of  the  fore-arm  will  at  times  help  the  surgeon,  or  the  application  of  a  hot  flannel 
round  the  arm,  which  should  be  made  to  hang  down  by  the  side  of  the  body.  When  these 
means  fail  and  venesection  is  imperative,  a  vein  of  the  foot  may  be  opened. 

In  opening  the  jugular  vein  great  care  must  be  taken  not  to  admit  air  into  it  by  the 
removal  of  the  thumVj  during  the  operation  and  until  the  pad  has  been  adjusted ;  other- 
wise, life  may  be  endangered. 

Gross,  Dr.  S.  W.,  Amer.  Journ.  of  Med.  Science,  1867  and  1871. — Callender,  Holmes's  Syylem  of 
Surgery,  3d  ed.,  1883. — Travers,  Surcfical  Ensays,  1818. — Laxgexbeck  of  Berlin,  Archiv  fiir 
Klinmhe  Chir.,  1860. — Arnott,  Med.-Cidr.  Trans.,  vol.  xv.,  1829. — Lee,  Henry,  Disease  of  Veins, 
1866. — Greene,  James  S.,  Dorchester,  Mass.,  American  Journ.  of  Med.  Science,  1864. — Gay,  Vcricose 
Diseases  of  Ley,  1868. 


T\iK  siiiu;krv  0 


K  DKiESTlVE  OIUUNS. 


CHAPTKK    XII. 


AFFECTIONS   OF   THE   LIPS,    MOUTH,   TONGUE,    PALATE,   AND   TONSIL. 

Wounds  of  the  Lip. 

Under  all  circuinstances  these  womuls  slioiikl  be  well  cleansed  from  dirt,  foreifjn 
bodies,  and  blood,  and  then  carefully  brought  tof^fether  by  sutures,  which  should  be 
deeply  inserted  and  removed  on  the  second  or  third  day. 

Plaster,  as  a  rule,  is  not  required.     Superficial  wounds  in  Fig.  186. 

the  inside  from  the  teeth  may  be  left  to  granulate.  When 
much  bleeding  exists  the  surgeon  should  examine  the 
part  with  care,  as  Erichsen  adduces  a  case  in  which  from 
the  coronary  artery  so  much  blood  was  lost,  swallowed, 
and  brought  up  again  by  vomiting  as  to  lead  to  the  sus- 
picion of  .some  internal  injury. 


Congenital  Fissures  of  the  Lips. 

These  occur  more  frequently  as  harelip  than  in  any 
other  form.  Sir  W.  Fergu.sson  has,  however,  quoted 
three  cases  in   his  Practical  Surgert/  in  which  the  fissure 

extended    from  the    an^le    of  the    mouth in    one    case  to    Congenital  Fissure  of  Lower  Lip  and  .Taw, 

the  malar  bone,  in  the  second  toward  the  angle  of  the  dike-s'^casl.r  *"  ^'''"'"''  ^^''  '^''"'"°' 
jaw,  and  in  the  third  to  the  base  of  the  lower  jaw;  and 

from  a  case  reported  in  the  Med.  and  Surg.  Reports  of  the  City  Hospital  of  the  citv  of 
Boston,  LTnited  States,  1882,  it  seems  that  the  lower  jaw  and  soft  parts  over  it  may  be 
fissured  in  the  median  line  (Fig.  18G).  In  the  case  recorded,  when  the  patient,  fet!  20, 
opened  her  mouth,  the  two  halves  of  the  lower  jaw  protruded  laterally  like  horns  and  pre- 
sented a  large  cavity,  and  the  tip  of  the  tongue  was  bound  down  to  the  tissues  in  front 
of  the  hyoid  bone.  Dr.  Thorndike,  who  reports  the  case,  closed  the  fissure  by  first  dis- 
secting up  the  tongue  from  its  adhesions'  and  uniting  the  bones  and  soft  part  by  a  plastic 
operation. 

Harelip. 

congenital  deformity  is  due  to  a  want  of  union  between  the  natural  centres  of 
development  of  the  upper  lip.  Thus,  the  upper 
lip  is  made  up  of  a  central  and  two  lateral  portions, 
the  central  being  connected  with  the  intermaxillary 
bones  and  the  lateral  with  the  superior  maxil- 
lary (Fig.  187).  A  want  of  union  between  the 
central  and  lateral  piece  on  one  side  gives  rise  to 
simple  harelip  ;  a  want  of  union  between  the  cen- 
tral and  lateral  pieces  to  double  harelip. 

When  the  fissure  is  central — a  very  rare  condi- 
tion— the  intermaxillary  bones  are  either  absent  or 
divided.  A  specimen  of  the  former  exists  in  the 
Museum  of  the  Royal  College  of  Surgeons,  London, 
and  a  drawing  of  a  like  case  taken  from  a  patient 
of  my  colleague.   Mr.   Howse,  is  seen  in  Fig.   188.       These  fissures  may  be  partial  or 

409 


Fig 


Showing  the  Develop- 
ment" of  the  Inter- 
maxillary and  -Max- 
illary Bones.  (From 
Fergusson.) 


Central  I  issure  ot 
Lip  with  Deficien- 
cy of  Intermaxil- 
lary Rones.  (Mr 
Howse's  case.) 


410  HARELIP. 

complete,  and  may  involve  the  skin  alone,  as  also  the  bone,  and  the  latter  in  variable 
degrees. 

Congenital  cicatrices  are  occasionally  met  with  in  the  upper  lip  (vii/e  Fig.  52)  along 
the  line  of  union  of  the  central  with  one  or  other  lateral  portion.  Fig.  189  was  taken 
from  a  patient  with  this  imperfection,  and  in  her  case  there  was  a  slight  elevation  of  the 

Fig.  189.  Fig.  190.  Fig.  191. 


Fig.  190. 

A'f       , 

,iuMy 

^#-^^. 

Tarelip  as  Slight  Notch. 

Congenital  Cicatrix.  Harelip  as  Slight  Notch.  As  Deep  Fissure  on  Right  Side. 

mucous  margin  of  the  prolabium.  which  may  be  said  to  be  the  very  earliest  indication  of 
a  harelip;  the  child  of  this  woman  had  a  complete  fissure.  In  more  complicated  cases 
the  cleft  will  extend  through  the  alveolar  process  in  a  line  corresponding  with  the  labial 
fissure,  Fig.  191  ;  in  others  it  will  involve  the  hard  palate;  while  in  a  still  worse  class 
both  hard  and  soft  palate  will  be  fissured. 

In  a  small  percentage  of  the  cases — about  a  tenth — the  harelip  is  double.  In  these 
it  is  not  uncommon  to  find  a  double  fissure  extending  through  the  palate,  the  two  superior 

maxilU>3  with  the  skin  having  failed  to  unite  with 

Fig.  192.  Fm.  193.  the  intermaxillary   bones.      Under  these    circum- 

^^„  stances   the   intermaxillary  bones  will  often  pro- 

'~^  _,       ject,   covered  with   a   small   flap  of  skin,  and  at 

times  even  stand  out  from  the  tip  of  the  nose.    In 

a   rare  case  (illustrated  in  Fig.  193)  the  fissure 

involved   the  lip  and   intermaxillary  bones  alone, 

the  maxillae  being  complete. 

This   affection'  is    more   frequent  on    the   left, 
than  on  the  right  side  of  the  mouth,  and  is  more 

Uncomplicated  Complicated  with  Fissure      ,  •  i        .lT,         •       r         i  i  -i      •       ^i 

Double  Harelip.  of  Alveolus  and  Projec-     Common   in  males  than  in   feniales,  while  in  the 

tion  of  Intermaxillary     more    Complicated    examples    this    disproportion 

Bone,  the   Palate  being      ,  '-  .,  .  Vm  ■  i      •        n 

Perfect.  becomes  more  striking.      Ihus,  in  an  analysis  oi 

cases  to  be  found  in  my  Leffsomiaii  Lecftirfs  on 

the  Surgical  Disrasfn  of  Children,  18(33,  four-fifths  of  the  bad  cases  were  in  boys,  those 

of  double  harelip  almost  always  being  found  in  the  male  sex. 

Treatment. — When  ought  a  child  with  harelip  to  be  operated  upon?  Sir  W. 
Fergusson  says,  "  I  am  of  opinion  that  the  earlier  the  operation  is  performed,  the 
better — assuredly  before  teething;"  and  the  majority  of  surgeons  would  support  this 
opinion.  Judging  from  my  own  experience,  I  am  not  disposed  to  coincide  altogether 
with  this  view  ;  for  in  my  analysis  of  cases  at  Guy's  Hospital  a  larger  number  of  failures 
followed  the  operation  when  performed  during  the  first  few  weeks  of  life  than  after  the 
third  month.  In  healthy  inftmts  it  is  probable  that  success  may  attend  the  operation 
whenever  undertaken,  but  in  the  more  feeble  it  is  equally  probable  that  success  will  be 
more  certain  at  a  later  than  at  a  very  early  period.  Under  these  circumstances,  I  always 
advise  the  operation  to  be  postponed  until  after  the  third  month — that  is,  when  no  neces- 
sity exists  to  hurry  on  the  operation,  such  as  inability  to  take  food,  etc.  On  account  of 
this  last-named  condition,  I  have  operated  with  complete  success  on  the  fifth  day. 

The  position  of  the  patient  is  important.  If  an  infant,  the  whole  body  and 
arms  should  be  bound  round  with  a  good  towel  and  the  head  fixed  by  the  hands  of  an 
assistant,  placed  on  either  side.  The  child  should  be  firmly  held  in  a  nurse'  lap,  in  the 
sitting  posture  (Fig.  194).  In  other  cases  the  child's  head  may  be  laid  on  the  surgeon's 
knees,  the  body  on  the  nurse's. 

If  an  older  child,  the  semi-recumbent  position  should  be  chosen,  with  the  head  raised 
on  a  pillow  and  fixed  as  directed  above. 

The  operator  may  sit  or  stand  behind  the  patient  when  the  recumbent  position  is 
selected,  or  at  one  side  if  the  patient  be  sitting. 

Operation. — Anaesthetics  may  be  given  without  fear  in  such  cases,  although  in 
uncomplicated  examples  the  operation  is  so  expeditiously  performed  as  not  to  render  it 
essential.   ' 

The  surgeon  has  in  the  operation  two  main  objects  in  view — viz.,  to  pare  the  edges  of 


II  Ml  i:  I.I  r 


ni 


Operation  fi)r 
Single  Harelip. 


tlif  fissurf,  and  ti>  adapt  tliciii  so  a.s  to  midi-r  ilir  drl'oriiiit y  :is  slij^lit  as  possible.  But 
litd'orc  this  an  important  pndiininary  sti^p  demands  attontion,  and  on  it  the  success  of  the 
cast- materially  rests:  it  is  to  freely  separate  hoth  sides  of  the  lip  from  the  alveoli,  and 
when  the  nostril  is  widely  e.xpainled  to  freely  separate  al.so  the  alu  nasi  from  the  hone. 
'I'lie  olijeet  of  this  step  is  to  allow  the  soft  parts  to  movt;  freely  over  the  bones  and  to  be 
ji  iiuirht  the  more  readily  into  apposition.  Some  save  the  true  frjenum  and  divide  all 
(>;her  adlu-sions.  but  I  see  no  necessity  for  this  practice.  To  pare  the  edj^es  of  the 
cleft  the  knife  should  be  employed,  such  an  instrument  making  a  cleaner  .section  than 
scissors;  and  this  cleanness  of  the  incision  is  a  point  of  importance.  With  respect  to  the 
I'.irm  of  incision,  numbers  have  been  devi.sed,  but  most  surgeons  fall  back  upon  the  old- 
fashioned  straiirht  one  above  the  prolabium,  commenciu}.;  at  the  apex  of  the  cleft  and 
y      ^,)^  ending  at  its  free  l)order,  care  beinjr  taken  to  cut  off*  a  good  piece.     The 

plan  I  always  follow  when  the  knife  reaches  the  red  border  of  the  lip 
is  to  turn  its  edge  oblifjuely  toward  the  cleft,  thereby  .saving  a  portion 
of  the  mucous  covering  of  the  lip  and  lessening  materially 
the  notch  in  it  (Fig.  1  !>.')).     The  incision  having  been  made       Fig.  lOo. 
and  all  bleeding  vessels  twisted,  the  surgeon   should  pro-      y 
ceed  to  adjust  the  parts  ;  and  he  had  better  commence  at     v^^*- 
the  free  margin.     When   pins  are   used,  they   should  be 
fine,  with  flat  heads,  and  one  should   be  introduced  about 
.1  third  of  an  inch  from   the  margin   of  the  wound  and 
brought  out  just  under  the  mucous  lining  of  the  lip,  rein- 

/\\vi^^,-_^.j/j,  <  roduced  on  the  opposite  side,  and  passed  through  the  lip. 
l//"/  '  '  if  \  \  '  '"^  edges  can  then  be  brouglit  together  by  means  of  a  twisted  well- 
\/' /  \V  ■  \  "iled  suture,  care  being  taken  to  adapt  accurately  the  parts  at  the  red 
laargin  of  the  lip.  If  this  end  be  attained,  the  second  and  third  pins 
should  be  inserted  above,  one  close  to  the  nostril,  the  second  between  the 
two.  and  both  fastened  separately.  If  the  interrupted  silk,  gut,  or  horsehair  suture  be 
e.uployed  instead  of  pins — a  practice  I  greatly  prefer,  having  given  up  i)ins  in  simple 
cases — it  is  wi.se  to  introduce  a  needle  as  the  first  pin  to  adjust  the  parts,  and  then  insert 
the  second  and  third  stitches,  initting  in  afterward  the  marginal  suture  by  simply  draw- 
ing the  needle  that  had  been  introduced  as  a  pin  tlirough  the  flaps.  In  most  cases  it  i.s 
serviceable  to  insert  a  fourth  suture  into  the  red  border  of  the  lip  itself.  The  button 
suture  (Fig.  8)  may  be  used  instead  of  the  above,  if  preferred. 

After  the  operation  Hainsby's  tru.ss  should  be  employed  wdien 
possible  (Fig.  196).    It  keeps  the  parts  well  together  and  prevents  Fig.  196. 

any  traction  upon  the  wound.  It  is  a  valuable  instrument.  When 
it  cannot  be  obtained,  the  cheeks  .should  be  well  drawn  forward 
and  held  by  some  good  plaster,  applied  either  from  ear  to  ear  or 
from  the  temple  on  one  side  beneath  the  chin  to  the  temple  on  the 
other.  The  sutures  or  pins  may  generally  be  removed  about  the 
second  or  third  day  at  the  latest,  and  after  their  removal  the 
clieeks  must  be  held  forward  by  strapping. 

Mr.  Maurice  Collis  in  18()()  (  Diih.  Quarf.).  in  an  able  paper  on 
h:\relip,  among  other  points  laid  great  stress  upon  the  propriety 
of  utilizing  the  ])arings.  He  never  threw  away  a  particle  of  them, 
but  used  them  all.  I  have  followed  his  suggestions — in  many 
cases   with   admirable   succes.s — and   am   disposed    to   think   that  iiainsby's  Truss. 

where  the  lips  are  thin  his  method  is  of  service.     His  operation  is 

as  follows:  He  first  made  an  incision  from  A  to  B  (Fig.  197)  through  the  thickness  of 
the  lip  down  to  the  mucous  membrane,  but  not  through  it.  and  turned  the  flap  back.  On 
the  other  side  he  transfixed  the  lip  at  c  and  Separated  the  flap  as  far  as  D,  dividing 
the  flap  in  the  centre  at  E.  He  then  brought  the  two  sides  together  by  fixing  the  upper 
flap,  c  E,  by  a  suture  to  A.  and  the  lower  flap.  E  D,  to  B.  "  Two  intermediate  sutures 
])eing  applied  (Fig.  198),  I  thus  obtain,"  says  ('ollis.  "  a  lip  nearly  double  in  depth  what 
I  could  possibly  have  got  by  the  ordinary  incisions." 

Malgaignes  operation  is,  in  a  measure,  somewhat  similar  to  the  above,  utilizing  as  it 
does  the  flaps  of  skin  by  turning  them  down  and  stitching  them  together  TFig.  199).  In 
some  cases  one  of  the  pared  edges  may  be  left  attached  and  united  with  the  opposite  side 
that  has  been  sloped  to  receive  it.  This  suggestion  T  had  from  3Ir.  Dix  of  Hull  in  1859 
(MrJ.    Tim,!,  ,n„I  Gaz..  Julv  2)- 

Double  Harelip. — When  this  is  uiicom])licated  with   bone  displacement,  it  can  be 


412 


CHEIL  OPLA STIC  OPERA  TTOXS. 


dealt  with  as  simple  harelip.  In  a  general  way.  it  i-  well  to  operate  on  both  side?  at  once, 
more  particularly  if  the  lower  flaps  of  the  lateral  portions  are  utilized  by  being  turned 
down   and  united  beneath  the  central  piece   (Fig.  201).    If   there   be.  however,  much 


Fig.  197, 


Fig.  198. 


Fig.  199. 


Fig.  200. 


Fig.  201- 


Collis  b  Operation  for  Harelip. 


Malgaigne's   Opera- 
tion. I  From  Holmes.) 


Operation  for  DouMe  Harelip. 


Fig.  204. 


separation,  and.  consequently,  traction  upon  the  lateral  portions,  the  operations  upon  the 
two  .sides  should  be  performed  separately. 

When  the  intermaxillary  bones  project  to  any  extent  and  are  separated  from  the 
maxillary,  there  will  be  some  difficulty  in  the  treatment.  I  believe  the  better  plan  is  to 
remove  them  with  the  knife  or  scissors ;  for  when  broken  and  bent  back,  the  central 
incisor  teeth  too  often  grow  in  some  abnormal  position  and  are  in  the  way.  When 
removed,  the  maxillary  bones  subsequently  approximate,  and  the  lateral  incisor  teeth 
frequently  assume  the  position  of  the  central.     Sir  W.  Fergusson  latterly  removed   these 

bones,  or  the  milk  tooth  with  its  bonv  bed,  sub- 
cutaneously.  and.  I  think,  with  advantage.  When 
they  are  so  pu.shed  forward  as  to  form  a  kind  of 
appendage  to  the  tip  of  the  nose,  as  seen  in  Fig. 
2(12.  they  ought  to  be  removed.  The  portion  of 
skin  over  the  bones,  however,  must  always  be  util- 
ized, either  to  form  a  columna  nasi  where  none 
existed,  as  in  Figs.  203  and  204.  or  to  be  brought 
down  and  inserted  between  the  two  lateral  portions 

Lefore  Opera-  of  the  lip. 

tion.  When    primary    union    fails,  the   surgeon    can 

often  succeed  in  securing  union  by  the  third  inten- 
tion by  scraping  the  .surface  of  the  wound  and  reapplying  the  sutures  ;  and  he  mav  do 
this,  although  the  parts  have  sloughed  at  first,  as  soon  as  healthy  granulations  appear. 


Fig.  203. 


Front  View. 


Fig.  205. 


Cheiloplastic  Operations. 

These  are  demanded  for  deformit\-  of  the  mouth  from  destructive  ulceration  or  slo^.icrh- 
ing.  as  from  canerum  oris,  and  are  somewhat  similar  to  tho.se  for  harelip.  When  under- 
taken for  contraction  of  the  mouth,  the  surgeon  .should  always  try  and  turn  up  some 

portion  of  the  mucous  membrane  from  within  the 
mouth,  to  cover  over  the  new  angle  and  thus  pre- 
vent its  subsequent  contraction.  I  have  done  this 
in  several  cases  with  gratifying  success,  one  of 
which  is  figured  Fig.  205.  The  deformity  was  the 
result  of  .sloughing  after  fever.  At  times  new  tis- 
sue must  be  brought  up  from  the  chin  or  down 
from  the  cheek.  Indeed,  these  cases  tax  the  in- 
genuity of  the  surgeon  to  the  utmost,  since  no 
general  rules  can  be  laid  down  regarding  them,  each  requiring  to  be  dealt  with  on  its  own 
merits.  But  this  much  may  be  said — that  no  part  of  the  body  heals  .«o  rapidly  or  so  well 
as  the  face,  and  in  none  are  plastic  operations  more  satisfactory. 


Deformity  Hesiili 
of  Sloughing. 


After  Second. 


Cancer  of  the  Lips. 

This  term  is  generally  applied  to  epithelioma  or  cancroid  disease,  true  cancer  or  car- 
cinoma being  very  rare.  It  is  a  disea.se  of  middle  life,  four  out  of  five  cases  attacking 
patients  between  forty  and  .sixty  years  of  age.  The  3'oungest  .subject  I  have  seen  affected 
by  it  was  a  sweep  aet.  27.  and  the  oldest  also  a  sweep  aet.  86.  It  affects  the  lower  lip  more 
frequently  than  the  upper  in  the  proportion  of  25  to  1.  In  my  own  table  of  54  consecu- 
tive cases.  3  instances  were  found  in  women  to  51  in  men. 


CANCKii  or  Tifh'  urs. 


413 


Kxtrtiue  K.xaniple  of  Cancer  of 
l.ip. 


Siiinkiii^,  or  ratlicr  tin-  irrit;iti»ii  ni'  ;i  |ii|M'.  has  generally  been  ascribed  as  a  euiiimon 
cause  ;  and  it  is  probable  that  such  an  irritation  is  sufficicMit  to  set  up  the  disease  when  a 
pre<lisp(»sition  to  its  development  already  exists.  It  is  interest- 
inir  to  note,  however,  that  It  out  of  54  eonseeutive  eases  in  which 
I  made  the  in<|uiry  had  never  smoked  ;  and  this  proportion  is 
probalilv  about  that  (d'tlie  non-smokers  amtmiist  the  male  jiopu- 
lation  in  this  eountry. 

The  disease  irenr'rally  commences  as  a  dry  seal)  on  the  red 
niarLcin  of  the  lij),  and  it  may  be  that  this  scab  forms  over  a 
crack  or  excoriation,  but  as  often  as  not  it  apjiears  alone;  occa 
sionally,  too,  it  commences  as  a  wart.  In  its  early  stage  the 
progress  of  the  disease  is  generally  very  slow,  and  only  when 
some  ulcerative  action  ap])ears  does  it  develop  more  rapidly.  It 
is  under  these  circumstances  that  the  patient  first  applies  for 
advice  ;  the  disease  in  the  dry  state  is  passed  by  uidieeded. 

The  appearance  of  an  epithelial  cancer  is  tolerably  characteristic  (  Fig.  208)  ;  it  has 
generally  an  irregular  warty  aspect,  but  when  ulcerating  has  thickened  everted  edges. 
It  has  always  a  well-detined  indurated  base.  When  ulcerating,  it  discharges  a  sanious 
pus  containing  epithelial  scales  in  abundance  ;  and  when  dry,  it  is  covered  with  a  .scab 
of  the  same  material.  Microscopically,  it  contains  epithelial  elements  arranged  in  cap- 
sules.    (  ]7(/*'  Fig.  45.) 

In  its  early  stage  it  should  be  regarded  as  a  local  disease.  It  rarely  affects  more  than 
one  part  at  the  same  time,  but  I  have  seen  several  cases  in  wliich  two  separate  centres 
existed,  and  one  in  which  there  were  three.  In  the  latter,  two  growths  on  the  lower  lips 
were  excised,  and  nine  years  subsequently  a  similar  disease  attacked  the  tongue,  which  I 
removed  in  June,  1870. 

AVhen  the  ulceration  stage  has  set  in  and  the  disease  has  been  left  to  run  its  course, 
the  glands  beneath  the  jaw"  will  probably  become  affected,  and  the  affection  will  steadily, 
if  not  rapidly,  progress  until  all  the  tissues  with  which  it  comes  in  contact — integument, 
gums,  bone,  teeth,  and  glands — are  destroyed.  It  destroys  life  by  exhaustion  and  hemor- 
rhage, and  may  do  so  by  secondary  deposits  in  the  lungs  or  viscera,  but  far  less  fre- 
quently than  does  carcinoma.  In  a  case  under  the  care  of  Mr.  Howse,  in  1875,  the  dis- 
ease spread  from  the  lip  to  the  lower  jaw  and  along  the  course  of  the  fifth  nerve  to  the 
base  of  the  skull  and  brain,  destroying  life  by  meningitis. 

Tre.vtment. — There  is  but  one  treatment  that  can  be  recommended,  and  that  is  the 
speedy  removal  of  the  disea.se.  When  once  the  nature  of  the  case  is  clear,  the  sooner  the 
growth  is  taken  away  the  better;  and  in  doing  this  the  surgeon  must  deal  freely  with  the 
surrounding  parts.  He  had  better  err  by  removing  too  much  than  too  little  of  the  sur- 
rounding tissues.  To  tease  the  parts  with  mild  caustics  is  bad  practice,  as  it  merely  irri- 
tate >,  and  rarely  destroys,  the  whole  growth.  Caustics  cannot  as  a  rule,  be  recommended. 
Exci.-«ion  is  probably  the  best  method.  When  the  disease  is  superficial,  it  may  be  sliced 
off,  leaving  the  parts  to  granulate ;  when  it  involves  more  of  the  lip.  a  V-shaped  piece 
may  be  taken  out,  the  two  edges  being  brought  together  as  in  harelip.  When  much  of 
the  lip  is  affected,  the  whole  must  be  removed  and  a  new  lip  formed  by  bringing  up  the 
soft  parts  from  the  chin  as  indicated  in  Figs.  209,  210. 


•200. 


Fig.  210. 


Diagram  showing  the  Lines  of  Incision  for  New 
Lip  after  Removal  of  a  Cancer. 


Diagram  showing  Position  of  Flaps  when 
brought  Up. 


Recurrence  of  Disease. — After  the  removal  of  the  disease  a  cure  may  follow, 
but  in  the  majority  of  eases  a  return  takes  place,  and  generally  in  the  same  spot.  Similar 
treatment  must  again  be  resorted  to,  even  to  a  second  and  third  operation,  as  there  seems 


414 


HYPERTROPHY  OF   THE  MUCOUS  GLANDS  OF  THE  LIP. 


reason  to  believe  that  after  each  operation  a  longer  interval,  of  immunity  may  be  promised. 
Thus,  a  man  who  had  a  cancer  of  the  lip  removed  a  year  after  its  appearance  was  well  for 
two  years,  when  a  second  operation  was  required.  He  remained  well  for  three  years, 
when  a  third  was  performed  and  this  time  four  years  elapsed  before  a  return  took  place. 
It  was  then  excised  for  a  fourth  time. 

In  another  case  a  man  set.  G5  had  a  cancer  of  his  lip  removed  fifteen  years  before  he 
came  under  my  care.     He  remained  well  for  eight,  when,  the  disease  returning,  a  second , 
operation  was  demanded ;  and  seven  3'ears  after  this  he  was  well.     Epithelioma  of  the  lip 
is  of  slow  growth.     I  have  removed  one  from  a  man  Kt.  7-i  of  twenty  years',  and  another 
from  a  man  fet.  5h  of  eight  years',  growth. 

Horny  growths  may  spring  from  the  lip.  as  from  other  parts  of  the  cutaneous 
surface  (Prep.  1678^.  Guy's  Hosp.  Mus.). 

Ch.ancres,  syphilitic  or  otherwise,  are  at  times  met  with  on  the  lips,  and  the  sur- 
geon should  be  on  his  guard  not  to  mistake  them  for  cancer.  They  mostly  appear  as 
raised  smooth  sores  with  bases  of  cartilaginous  hardness,  and  are  usually  attended  with 
considerable  inflammatory  swelling  as  well  as  with  secondary  glandular  enlargement. 
They  have  neither  the  clinical  history  nor  aspect  of  such  an  affection  as  cancer,  but  make 
much  more  rapid  progress,  and  are,  moreover,  usually  met  with  in  younger  subjects. 
When  syphilitic,  the  constitutional  symptoms — commonly  called  •'  secondaries  " — will 
mark  their  true  nature. 


Hypertrophy  of  the  Mucous  Glands  of  the  Lip. 

The  mucous  covering  of  the  lip  is  often  found  to  be  thickened,  two  elevated  or  pen- 
dulous portions  of  tissue  appearing,  one  on  either  side  of  the  middle  line.  This  con- 
dition authors  have  described  as  /i>/pertrophi/,  though  the  name  does  not  appear  to  be 


Fig.  211. 


Fig.  212. 


CA...^ 


Hypertrophy  of  Mucous  Glands  of  Lip. 


Hypertrophy  of  Lip.    Olr.  Davies-Colley's  case.) 


always  correct,  for  on  removing  the  so-called  hypertrophied  mucous  membrane  in  many 
cases  a  number  of  small  granular  bodies  the  size  of  hemp-seeds,  and  made  up  of  gland 
cells,  are  to  be  found  underlying  a  healthy  mucous  membrane.  The  disea.se  appears, 
therefore,  to  be  often  due  to  an  increase  in  the  size  of  the  natural  glands,  and  not  of  the 
mucous  membrane  of  the  part  (Fig.  211).  It  should  be  treated  only  by  the  careful 
excision  of  the  diseased  submucous  tissue,  the  incision  being  made  in  the  line  of  the  lip 
and  the  edges  brought  together  by  fine  sutures.  I  have  seen  as  many  of  such  cases  in 
the  upper  as  in  the  lower  lip.  and  rarely  does  it  involve  both  lips.  I  have  never  known 
it  to  recur. 

A  genuine  hypertrophy  of  the  hp  it>elf  is  a  common  affection.  It  often 
begins  as  a  chronic  inflammation,  or  rather  oedema,  of  the  part,  the  inflammatory  deposit 
becoming  organized.  There  can  be  little  doubt  that  many  of  the  so-called  thick  strumous 
lips  have  this  origin.  Attention  to  the  general  health  and  its  improvement  is  the  means 
by  which  cure  may  be  expected.  In  some  instances  the  hypertrophy  is  very  marked. 
Thus,  in  a  case  recorded  by  Mr.  Davies-Colley,^  and  illustrated  in  Fig.  212,  nothing  less 
than  an  excision  of  a  V-piece  from  its  centre  was  of  any  use. 


Cystic  Tumors  of  the  Lip. 

Mucous  cysts  are  often  seen,  and  generally  in  the  lower  lip.     They  appear  as 
tense,  globular,  and  at  times  semi-translucent,  tumors  beneath  the  mucous  membrane, 

^  C^in.  Soc.  Trans.,  vol.  xvi. 


.1  rirriioi s  stoma  riris.  415 

and  lire  ri-adily  <'urc(l  hy  cxcisiiiii  ur  liy  ciitliiiL'  ofl  llicir  iipjicr  Wall  hy  means  of  scissors 
and  sliar|i-|i<iiiiti'(l  i'orccip^.  An  iiici>inii  into  tliiin  laniy  docs  ;z"od.  Tlicy  coiitaiii  a 
plairy    iiiin-nid   fluid. 

Glandular  Tumors. — <)"  st-vt-ral  «icc-asioiis  I  h-AW.  turm-d  out  of  the  lip,  fruiu 
liciicalli    till-   uiiiciius   imiuhratu'.   s(did   ciicysti'd   tuin<irs   witli   a   j:laiidular  structun-. 

Naevi  "»f  tho  lip  ari-  often  seen  ;  and  wlitii  tliey  involve  the  whole  thielcness  of  the 
part,  their  reniovul  hy  a  V-ineision  is  the  hest  treatment.  I  have  done  this  on  many 
occasions  with  a  henctieial  result.  When  they  are  <inly  su[)erficial  or  beneath  the  mucous 
lininir.  they  may  he  treateci  locally,  as  already  nn-ntioned  in  the  chapter  on  naevuH. 

Phlegmonous  or  carbuncular  intlainmation  of  the  lijt  is  an  alarming  affection  ; 
it  is  never  foun<l  except  in  the  feeble  and  eaehectic.  It  attacks  the  upper  as  well  as  the 
lower  lip,  and  shows  itscH"  as  a  <reneral  infiltration  of  the  part,  which  becomes  enormously 
swollen,  tense,  and  painful.  When  seen  in  an  early  stage,  a  free  incision  into  it  or  its 
mucous  surface  gives  relief  and  expedites  the  sloughing  of  the  cellular  tissue  that  is 
sure  to  follow.  Fomentations  and  warm-water  dressings  are  the  most  beneficial,  with 
good  living  and  tonics,  such  as  (juinine  and  iron  in  full  doses.  At  times  this  affection 
ends  in  sloughing,  and  then  puts  on  the  appearace  of  what  is  called  "  cancrum  oris."  It 
is  very  prone  to  be  followed  by  septicemia. 

Cancrum  oris,  or  gangrenous  stomatitis,  is  generally  met  with  in  the  ill- 
fed  and  feelile   child   after   one  of  the  exantlicuiata.      It  is  seen   also  where  mercury   has 
been  given  to  salivation.      It  commences  often  as  a  phleg- 
monous inflammation   of  the  cellular  tissue  of  the  cheek  or  ^^^-  2^^- 
lip,  going  on  rapidly  to  sloughing  and  phagedaenic  ulcera- 
tion, or  to  sudden  death  of  a  part  of  the  cheek,  the  tissue 
becoming  white  and  bloodless  and  then  sloughing.    At  times 
this  sloughing  process  will  involve  a  large  portion  of  the 
cheek,  and  even  of  the  gum  or  the  bone.      It  is  a  most  fatal     \ 
and    dangerous   disease.      Before    the    sloughing   has   taken 
place  the  part  involved  will  be  much  thickened  and  indura- 
ted.   It  will  feel  of  a  brawny  hardness  and  appear  of  a  dusky 
color  in  the  centre,  with  a  red  border.    When  the  skin  cover- 
ing in  the  dead   cellular  tissue  has  sloughed  away,  a   deejt. 
excavated,   irregular   surface   will   be    seen    discharcciiiir   an     ,,,  i  i  o^w?"^™'^*^"^\t 

a-        ■  •  a    ■^  i    -p     i         t  i       •    ^i  .(McKiel  26^,  Guv's  Hosp.  Museuiu.) 

offensive  sanious  fluid  :   and  it  the  disease  spreads,  it  does 

so  by  sloughing  and  ulceration  (Fig.   213).     It  generally  kills  by  exhaustion,  sometimes 

by  bleeding  from  the  sloughing  of  an  artery. 

Treat.ment. — The  general  treatment  consists  of  tonics  and  good  feeding,  milk,  eggs, 
and  wine,  beef  tea,  and  any  other  nutritious  food  being  of  primary  importance.  When 
food  cannot  be  taken  by  the  mouth,  it  must  be  given  by  the  bowel  as  enemata.  Tonics 
also  must  be  administered,  as  the  li<|uor  cinchonte,  quinine,  or  iron,  in  such  doses  as  the 
child  can  bear. 

LoaiUi/.  till  the  slough  has  separated,  little  more  than  fomentations  and  cleanliness 
can  be  employed ;  but  when  the  sloughing  and  ulceration  spread,  the  application  of 
strong  nitric  acid  or  tincture  of  iodine  is  of  great  value.  It  must,  however.  l>e  liberally 
brushed  over  and  into  the  parts,  so  as  to  destroy  all  their  surface  and  induce  a  fresh 
action. 

Absolute  cleanliness  should,be  observed,  the  wound  being  washed  and  irrigated  by 
means  of  a  steady  stream  of  water  to  which  carbolic  acid  one  part  to  twenty,  Condy's 
fluid,  chloride  of  zinc,  or  iodine  tincture  in  the  proportion  of  n^xx  to  the  ounce  of  water 
may  be  added.  When  recovery  takes  place,  it  is  frequently  with  the  loss  of  large  portions 
of  the  affected  parts,  for  which  some  plastic  operation  will  subsequently  be  required. 

Aphthous  stomatitis  i?'  another  affection  often  mistaken  for  cancrum  oris,  but  is 
not,  hiiwcver.  half  so  dangerous.  It  occurs,  likewise,  in  the  unhealthy  and  ill-fed  child, 
but  as  often  as  not  is  independent  of  the  exantliemata.  It  begins  as  an  aphthous  ulcera- 
tion of  the  tongue,  gums.  lips,  or  cheeks,  by  which  these  parts  become  covered  with  a 
white  or  ash-colored  secretion.  With  these  local  symptoms  there  will  be  a  foul  tongue 
and  fetid  breath,  as  well  as  some  evident  symptoms  of  derangement  of  the  bowels  and 
digestive  organs.  In  very  feeble  children  this  superficial  ulceration  may  pass  on  to 
sloughing  of  the  parts,  or  ulcemtire  sfomafitif!,  thus  simulating  caucrnm  oris,  but  with 
this  difference :  in  cancrvm  oris  the  disease  begins  in  the  cellular  tissue,  the  skin  slough- 
ing subsequently ;  in  ulcerative  stomatitis  or  noma  it  begins  as  a  skin  or  mucous  mem- 
brane ulceration,  sloughing  following  upon  it. 


416 


RANULA    OR  SUBLINGUAL   CYSTS. 


Treatment. — Of  all  drugs,  the  chlorate  of  potash  has  the  best  action,  and  should  be 
administered  in  five-,  or  even  ten-,  grain  doses  mixed  with  bark  or  with  milk,  a  lotion  of 
the  same  drug,  3J  to  a  pint  of  water,  being  used  as  an  application.  Milk  diet  is  the 
best  where  it  can  be  taken,  beef  tea  and  eggs  being  given  otherwise  or  in  addition. 
Wine  must  be  administered  with  great  caution,  and  only  when  the  powers  of  the  child 
are  very  feeble,  as  in  the  phagedj\inic  form.  A  rhubarb  purge  is  usually  required  at  the 
beginning  of  the  aifection.  to  clear  the  way,  as  foul  excreta  are  too  often  present,  and  in 
the  later  stage  the  more  powerful  tonics,  such  as  iron  or  quinine,  are  often  demanded. 
At  times  small  doses  of  laudanum,  say  one  or  two  drops  every  few  hours,  relieve  pain 
and  allow  the  child  to  feed  with  comfort,  and  consequently  with  benefit.  This  affection 
is  a  disease  generally  due  to  intestinal  irritation  from  bad  feeding,  and  requires,  there- 
fore, for  its  treatment  careful  attention  to  this  matter. 


Eanula  or  Sublingual  Cyst,  with"  Salivary 
Duct  lying  upon  it.  (Guy's  Hosp.  Mus.,  No. 
22931J.    Hilton's  case.) 


Ranula  or  Sublingual  Cysts. 

These  are  now  known  not  to  he  due  to  any  obstruction  of  the  salivary  ducts,  submax- 
illary or  sublingual,  but  to  ob.struction  of  one  of  the  mucous  glands  situated  beneath  the 
tongue,  such  as  the  glands  and  ducts  of  Rivini.  They  are  probably  analogous  to  the 
mucous  cysts  of  the  lip  already  alluded  to,  and  of  the  mucous  passages  generally.     They 

contain  a  clear,  glairy,  mucoid  fluid,  but  never  saliva. 
I  have  the  notes  of  several  that  were  congenital. 
They  sometimes  attain  a  large  size  ;  and  when  placed 
beneath  the  tongue  (their  usual  position),  the  sali- 
vary duct  can  readily  be  traced  lying  over  them  (Fig. 
214).  Sometimes  they  are  multiple,  and  on  several 
occasions,  on  opening  one  cyst,  1  have  seen  a  second 
within.  When  neglected  and  allowed  to  increase, 
Ton^iut  they  may  so  press  the  tongue  upward  as  to  prevent 
the  patient  speaking,  or  they  may  form  a  large  swell- 
ing beneath  the  jaw.  Within  the  mouth  they  appear 
as  semi-transparent  cysts  beneath  the  tongue,  and 
they  are,  as  a  rule,  painless  and  merely  give  trouble 
mechanically.  When  opened,  a  glairy  mucoid  fluid 
escapes.  This  operation,  however,  rarely  is  service- 
able, as  the  fluid  re-collects. 

Treatment. — The  best  treatment  is  to  raise  the 
upper  wall  of  the  cyst  by  means  of  a  pair  of  pointed  forceps  or  a  tenaculum,  and  with 
scissors  to  cut  it  off".  M.  Panas  of  Paris  has  lately  injected  these  cysts  with  three  to  ten 
drops  of  a  solution  of  chloride  of  zinc  (forty-five  grains  to  an  ounce  of  distilled  water) 
with  success.  In  large  tumors  the  cavity  may  be  plugged  with  lint  soaked  in  iodine 
after  it  has  been  freely  incised.  The  application  of  a  seton  is  at  times  beneficial,  though 
an  uncertain  remedy  ;  simple  plugging  of  the  cyst  was  a  mode  of  treatment  that  I  for- 
merly employed  till  I  discovered  that  the  plans  above  suggested  were  preferable.  It  is 
rarely  possible  to  excise  the  cysts,  as  they  have  no  definite  walls.  I  have,  however,  seen 
this  practice  carried  out  with  success. 

Encysted,  tumors  are,  however,  met  with  beneath  the  tongue.  I  have  had  two 
under  care,  and  both  I  mistook  for  ranula.  The  error  w'as  discovered  only  on  opening 
them,  and  in  both,  on  making  my  incision,  I  had  to  cut  through  the  mucous  lining  of  the 
mouth  over  the  cyst,  and  then  the  cyst  wall  itself.  From  both  a  cheesy  sebaceous  secre- 
tion escaped. 

These  tumors — which  have  nothing  to  do  with  ranula — have  distinct  capsules  beneath 
the  mucous  membrane  and  appear  to  be  sebaceous  ;  they  are  probably  congenital.  In  the 
cases  I  have  mentioned  the  patients  were  under  twenty  years  of  age.  In  both  I  pulled 
out  as  much  of  the  cyst  wall  as  I  could,  dissecting  it  from  its  bed,  and  in  one  with  com- 
plete success.  In  the  second  a  return  followed,  which  called  for  another  operation, 
which  was  crowned  by  a  good  result.  I  have  never  known  any  of  these  cysts  require 
removal  from  below  the  jaw.  In  one  of  my  cases  I  contemplated  this  plan,  and  Sir  W. 
Fergusson  and  Mr.  A.  Barker  give  cases  where  it  was  adojited.  It  is  probable,  however, 
that  incising  and  plugging  the  cyst,  to  set  up  suppuration,  after  evacuating  its  contents, 
■would  be  a  simpler  and  equally  eflScacious  practice. 


SAi.iwu:)-  iis'ni.A.  117 

Salivary  Calculus. 

Tlu'  salivary  tliicts  liciicatli  the  t(»ii<xiu!  may  be  obstructed   iti   exeepliorial   eases  from 
the   introtluetioii   ol'  fVtreiLTii    liodies.  but    more   e((iiimoMlv    Iritin   ctifni/ns.      Steiio's   or   the 
duet  <»t"  the  parotid   may  be  thus  aH'eeted,  but  the  W'hartoniau  or  the   sublin<.'ual  salivary 
duct    is   that    more  eouimoiily  involved,      ^\'hell    the   obstruction    is   eomjilele. 
|mtieiit.s  eomplaiii  duriuu"  de;:lutiti(tii  ofitain  and  swelling;  in  the  eorresjtondin;^     I'l''.  -lo. 
salivary  j;land  ;    such   syni|)toius,  which   arc   clearly  due   to   retained  salivary 
secretion,   soon    subside  on   the    completion    of    maHtication.      In   exceptional 
examples  suppuration  may  attack  the  ^dand. 

The  calculus  depicted  in  Fi<;.  21')  was  taken  f'r(»m  the  sublirif^ual  duet  of 
a  man  by  my  IVii-nd  Mr.  C.  Sells  of"  (.Juildf'ord,  and  weijrhed  forty-eight 
grains. 

This  affection  can  usually  be  easily  recr»gnized  on  the  a|)|pIicatioii  of  the 
finger  beneath  the  tongue,  the  calculus,  as  a  rule,  holding  a  superficial  posi- 
tion. On  feeling  the  stone  the  surgeon  may  often  with  his  nail  tear  it  out  of 
its  bed.  I  have  removed  .several  by  this  plan  when  not  larger  than  }iem[>- 
seeds.  When  larger,  the  best  plan  is  incision,  the  surgeon  being  careful  to 
cut  through  the  duet  where  it  seems  to  be  thinnest  and  scoop  the  calculus 
out  of  its  bed  by  means  of  a  director  or  bent  probe.  These  calculi  may  attain 
considerable  dimensions,  even  one  inch  long.  On  one  occasion  I  Vjroke  a  calculus  to 
pieces  in  attempting  to  remove  it  from  the  centre  of  a  suppurating  sublingual  gland  of  a 
man  aet.  42  who  had  had  evidence  of  its  presence  for  years.  He  came  to  me  with  the 
parts  hard  as  well  as  ulcerating,  having  been  told  he  had  a  cancer,  but  a  rapid  recovery 
followed  its  removal.  Occasionally  after  the  removal  of  a  calculus  from  a  salivary  duct 
a  stricture  results,  and  then  the  gland,  under  stimulus,  may  inflame  and  be  the  source  of 
trouble.  I  have  seen  several  ca.ses  demonstrating  this  fact.  A  free  division  of  the  duct 
is  then  the  right  treatment  to  adopt. 

Salivary  Fistula. 

When  Steno's  duct,  the  duct  of  the  parotid  gland,  has  been  obstructed  near  its  orifice 
in  the  mouth  or  has  been  opened  by  a  wound  or  ulceration,  a  salivary  fistula  may  take 
place — that  is.  the  saliva,  instead  of  being  poured  into  the  mouth,  will  escape  upon  the 
cheek.  When  this  affection  originates  in  some  obstruction  to  the  duct  itself,  it  will  com- 
mence as  a  soft  fluctuating  swelling  in  the  cheek,  caused  by  retained  salivary  secretion  ; 
and  after  a  time,  usually  when  the  duct  has  acquired  about  the  size  of  half  a  walnut,  the 
swelling  will  ulcerate  through  the  skin  and  clear  saliva  or  saliva  mixed  with  pus  will 
escape.  If  this  swelling  be  opened,  the  same  result  will  ensue;  and  after  this  the  cavity 
may  contract,  but  the  fistula  will  remain. 

Treat.ment. — Tlie  only  successful  treatment  of  this  affection  is  to  establish  a  free 
opening  into  the  mouth  from  the  oral  end  of  the  duct,  which  may  be  effected  bv  passing 
a  fine  probe  into  the  fistula  through  the  duct  into  the  mouth.  When  this  can  Ite  accom- 
plished through  the  natural  opening,  all  the  better;  but  it  is  not  a  matter  of  much  import- 
ance, as  an  artificial  opening  near  the  oral  orifice  of  the  duct  will  answer  everv  purpose. 
The  probe  should  be  armed  with  a  piece  of  thick  .silk  or  three  or  four  threads  of  fine  silk 
and  drawn  through  the  mouth,  the  ends  hanging  from  the  cheek  and  those  from  the  mouth 
being  tied  together,  the  whole  acting  as  a  seton  to  establish  an  artificial  fistulous  commu- 
nication with  the  mouth.  This  object  will  probably  be  secured  in  about  a  week  or  ten 
days,  when  the  seton  may  be  removed.  The  fistula  in  the  cheek  will  then  probably  con- 
tract and  close  of  itself;  but  if  this  does  not  take  place,  the  edges  of  the  fistula  mav  be 
cauterized  by  the  galvanic  or  benzoline  cautery,  and  thus  cicatrization  be  encouraged. 
The  operation  may  be  repeated  if  required.  A  plastic  operation  may  be  attempted  when 
these  means  fail. 

Cervical  Salivary  Fistula. — I  have  known  parotid  salivary  fistula  follow  upon 
the  suppuration  of  the  gland  after  fever  in  three  cases,  the  orifice  in  all  being  small  and 
placed  behind  the  angle  of  the  jaw.  In  none  of  these  was  there  any  obstruction  to 
Steno's  duct.  It  was  troublesome  only  from  the  trickling  of  saliva  during  mastication, 
though  to  one  of  the  patients,  who  was  a  lady,  this  caused  much  annoyance.  I  tried  the 
cautery  in  one  of  these  cases,  but  without  success. 
37 


418  AFFECTIONS  OF  THE  TONGUE. 

Parotiditis,  or  "  Mumps." 

This  is  a  simple  although  an  infectious  disease,  having  a  tendency  to  get  well  with 
simple  fomentations  of  the  parts,  a  saline  purgative,  and  a  mild  tonic.  It  generally 
attacks  the  young,  but  I  have  met  with  it  in  a  lady  -xi.  82.  Its  incubation  period  may 
extend  over  three  weeks.  It  is  frequently  meta.stutic  to  the  testicle.  When  it  follows 
upon  a  fever,  it  is  a  severe  aft'ection,  and  not  unfrequently  passes  on  to  suppuration. 
Such  abscesses  spread  easily,  the  deep  fascia  covering  them  in  forbidding  a  natural 
outlet  except  by  burrowing.  As  a  complication  of  pya?mia  it  is  very  serious.  Salivary 
fistula  in  the  neck  may  follow  in  such  cases.  Professor  Crocq  of  Brussels  believes  this 
disease  is  the  result  of  a  stomatitis  propagated  along  the  duct  of  the  parotid  gland  to  the 
gland  itself. 

Parotid  Submaxillary  Tumors. 

These  have  one  peculiarity — viz.,  that  they  are  almost  always  more  or  less  cartilag- 
inous, the  ordinary  form  of  tumor  in  this  region  being  the  fibro-cartilaginous ;  they  are, 

moreover,  mostly  encysted,  having  a  peculiar  hard,  elastic 
Fig.  216.  feel  and  botryoidal  outline.     The}'  are  generally  imbedded 

in  the  structure  of  the  gland  and  vary  much  in  their  depth, 
tumors  that  appear  movable  and  superficial  too  often  dip- 
ping deeply  down  into  the  tissues,  and  thus  increasing  the 
difficult}'  of  their  removal.  These  simple  tumoi's  may  grow 
to  a  large  size  and  stretch  the  skin  greatly  over  them  :  they 
should  always  be  removed — the  earlier,  the  better.  In  re- 
moving them  the  surgeon  should  be  careful  to  make  his 
incision  well,  down  to  the  capsule,  when  he  will  probably 
be  able  to  enucleate  the  growth.  It  is  far  better  practice 
to  do  this,  even  with  the  application  of  a  little  force,  than 
to  be  too  free  with  the  knife ;  for  the  facial  nerve  is  gen- 
erally in  close  contact  with  the  tumor  and  the  deep  vessels 
are  beneath.  He  should  also  always  cut  upon  the  tumor, 
'  dividing  only  such  tissues  as  hold  it  down,  taking  great 

Submaxillary  Tuiuor.  ^^^'e  too  that  the  large  vessels  are.  if  possible,  left  unin- 

jured. In  deeply-placed  tumors  this  removal  by  enuclea- 
tion is  still  more  necessary.  "When  the  tumor  is  large,  there  is  always  a  strong  probability 
that  the  facial  nerve  will  be  divided  or  injured;  hence  it  is  as  well  to  prepare  the  patient 
for  the  fact.  Fig.  21  6  illustrates  the  situation  and  external  appearance  of  one  of  these 
tumors. 

Cancerous  tumors  of  the  parotid  are  likewise  met  with,  but  assume  a  very 
diff"erent  appearance  from  the  last.  They  are  mostly  infiltrations  of  the  gland,  fixed,  dif- 
fused, and  deep-seated ;  they  are,  moreover,  generally  associated  with  paralysis  of  the 
facial  nerve,  diff"ering  in  this  way  from  innocent  growths.  In  such  cases  surgical  inter- 
ference is  rarely  beneficial. 

The  difficulty  of  deciding  as  to  the  removal  of  large  growths  in  this  position  is  very 
great,  and  the  best  guide  is  their  mobility.  Sir  W.  Fergusson,  who  had  more  experience 
in  these  cases  than  any  man  of  modern  times,  says,  "  If  it  were  evident  that  the  part  slid 
freely  over  the  subjacent  textures,  I  should  not  hesitate  about  using  the  knife,  whatever 
might  be  the  bulk  of  the  disease,"  etc. ;  "  but  if  the  tumor  seemed  fixed,  its  limits  were 
not  clearly  defined,  or  an  attempt  to  move  it  caused  pain,  I  should  not  readily  be  induced 
to  use  the  knife,  however  small  the  mass  might  be  ;"  and  I  endorse  these  views. 

AFFECTIONS  OF  THE  TONGUE. 

Tong'Qe-tie  is  occasionally  met  with,  but  not  a  tithe  of  the  cases  so  ascribed  are  of 
this  nature.  It  is  due  to  a  tying  down  of  the  tip  of  the  tongue  by  the  frajnum  lingua?, 
which  prevents  the  infant  from  projecting  the  organ  beyond  the  gums,  thereby  interfering 
with  suckling. 

Treatment. — It  is  easily  remedied  by  dividing  the  fra?num  perpendicularly  downward 
behind  the  gum  with  a  pair  of  blunt-pointed  scissors,  the  point  of  the  tongue  being  eleva- 
ted with  the  finger  or  a  pair  of  dressing  forceps  applied  beneath. 

Ankyloglossis. — Under  this  heading  cases  of  fixed  tongue  are  grouped.  In  some 
the  organ  is  whollv  adherent  to  the  floor  of  the  mouth ;  in  others,  by  bands.     Under  the 


CONG  KMT.  IL    A  Fl'i:<  TlOSS.  -1 1  !> 

latter  ciiciimstances  fret'ditiii  iiiav  l»c'  ^ivfii  hy  tin-  (livi>ii»ti  of  tin?  han«ls.  hut  urnl<T  the 
roniicr  litth'  hupf  can  he  expectrd  hy  trfatiin-iit,  althuiiirli  an  attempt  to  rai-i'  the  (»r;raii 
would  hi;  justitiahle. 

Wounds  of  the  Tongue. 

Tliese  arc  soinetiinos  troiihlesoiiu'  from  hcmorrliage,  l)ut  when  the  parts  arc  hrou<rht 
toj^fther  the  hleedin;:,  as  a  rule,  ceases;  all  hlce(lin<:  vessels,  however,  ou^'ht  to  he  tied 
or  twisted.  I  have  known  death  to  follow  a  small  wound  in  a  child  IVom  the  lrickliii<^ 
of  hlood  <lown  the  jdiarynx  as  well  as  the  larynx,  the  child  dyiii<r  in  the  latter  case 
asphyxiated  ;  and  all  surireons  recoj^nize  the  danger  of  slow  hleedin;^  after  a  t<»n<;ue  ope- 
ration. Sutures  should  always  he  employed  when  gaping  exists,  and  these  must  he  put 
in  deeply,  to  draw  the  whole  thickness  of  the  divided  jiarts  together.  (Jn  (»ne  occasion, 
owing  to  a  neglect  of  this  practice,  I  had  to  pare  the  surface  of  an  old  wound  that  had 
pas.sed  through  the  half  of  the  tongue  transversely,  and  then  hring  the  j)arts  together. 
The  child  was  unahle  to  talk  clearly,  on  account  of  the  injury;  yet  after  the  oj»eration 
all  was  well. 

Dentists'  W^ounds. — Since  the  introduction  of  nitrous-oxide  gas  for  dental  ope- 
rations, the  element  of  hurry  has  had  the  effect  of  causing  many  wounds  of  the  tongue 
of  the  contused  kind.  They  are  the  result  of  the  forceps  of  the  dentist  seizing  the  tongue, 
with  or  without  a  tooth,  in  a  hastj'  extraction.  On  .several  occasions  I  luive  found  it 
neces.sary  to  cut  off  the  contu.sed  and  lacerated  flap  of  tongue.  When  hleeding  is  ohsti- 
nate  and  the  parts  cannot  be  brought  together,  the  cautery  or  pcrchloride  of  iron  may  be 
usefully  employed.  In  exceptional  cases  the  ranine  artery  may  refjuire  a  ligature.  Ice 
in  the  mouth  arrests  slight  hemorrhage. 

Congenital  Affections. 

Hypertrophy,  or  macnj-glossia,  is,  without  d(uiht.  a  congenital  affection,  although 
in  certain  rep'yi-t(  d  cases  it  may  not  have  been  observed  till  the  first  or  second  year  of 
life.  It  is  usually  an  affection  of  slow  growth  and  trouldesome  on  account  of  the  mechan- 
ical obstruction  it  causes  to  deglutition  and  speech  ;  when  tlie  disease  has  existed  for  years, 
it  produces  deformity  of  the  teeth  and  jaws,  from  the  local  pressure  of  the  tongue  upon 
the  former  and  the  non-closure  of  the  mouth.  Syme  published  a  case  in  which  the  tongue 
projected  for  three  inches  out  of  the  mouth  of  a  girl  aged  14;  and  Humphry  another,  in 
a  child  aged  11,  in  which,  when  the  tongue  was  withdrawn  into  the  mouth  as  far  as  pos- 
sible, the  expo.sed  part  measured,  from  the  upper  lip  to  its  tip,  two  inches.  Many  other 
cases  are  also  on  record.  As  a  rule  this  affection  involves  both  sides  of  the  tongue,  but 
in  exceptional  cases  it  may  affect  but  one.  The  growth  is  generally  painl'?ss,  and  the  dis- 
ease not  rarely  affects  idiots  and  children  wnth.  ill-formed  crania.  A  ca.se  in  which  the 
disease  was  congenital  and  confined  to  the  right  half  of  the  organ  occurred  in  a  boy  who, 
when  six  years  of  age,  was  admitteil  intct  (Juys  Hospital,  under  the  care  of  the  late  Dr. 
Thomas  Addison,  with  his  tongue  protruding  far  out  of  his  mouth  and  obstructing  res- 
piration. His  mother  stated  that  the  tongue  had  been  affected  ever  since  his  birth,  and 
that  he  had  never  been  able  to  articulate  distinctly.  Whenever  he  took  cold,  the  tongue 
became  swollen  and  blisters  formed  upon  it,  which  burst  and  bled.  The  increase  of  the 
disease  had  been  gradual.  He  was  treated  with  mercurials,  and  he  derived  so  much 
benefit  from  them  that  he  left  the  hospital  with  the  tongue  fairly  retracted.  He  reap- 
peared, however,  three  years  later  (185(j)  with  the  same  disea.se,  the  growth  having 
rapidly  increased  for  one  month  before  his  admission;  he  then  came  into  the  hands  of  the 
late  Mr.  John  Hilton.  At  that  time  the  right  half  of  the  tongue,  with  the  submaxillary 
glands,  was  much  enlarged  ;  the  whole  organ  was  protruding  from  the  mouth  and  the 
papilla  on  the  affected  side  of  the  tongue  were  much  hypertrophied.  He  was  again 
treated  with  half-drachm  doses  of  the  solution  of  the  perchlnride  of  mercury,  and  left 
relieved.  In  anr)ther  three  years  the  tongue  had  grown  as  large  as  ever,  and  he  was 
readmitted  for  the  third  time,  when  the  tongue  presented  much  the  same  appearance  as 
it  had  on  his  previous  admission,  although  the  papill;\?  seemed  coarser.  He  was  treated 
in  the  same  way  as  on  the  two  previous  occasions,  and  he  left  relieved.  No  further  his- 
tory of  his  case  is  known. 

It  should  be  mentioned  that  in  this  case  there  were  no  .symptoms  of  the  presence  of 
njevoid  tissue.  The  tongue  appeared  coarse,  thickened,  and  enlarged,  as  if  from  simple 
muscular  hypertrophy,  and  yet,  from  the  fact  that  the  enlargement  diminished  under  the 
influence  of  mercury,  there  must  be  a  question  as  to  this  being  its  true  nature.     Indeed, 


420  ON  GROWING  AND  DEGENERATING  NJ^VI  OF  THE   TONGUE. 

the  case  appears  pathologically  to  be  like  one  shown  at  the  Pathological  Society  in  1872 
by  Mr.  H.  Arnott,  in  which,  after  its  removal,  there  was  visible  niicroscopically  very  little 
true  muscular  hypertrophy  of  the  organ,  but  the  epithelial  covering  of  the  tongue  was 
very  thick  and  the  papillae  were  enlarged  ;  the  blood  vessels  were  larger  than  usual,  and 
there  were  large  irregular  spaces  with  thin  walls,  which  were  filled  with  blood  or  clear 
•fluid  ;  a  few  vesicular  bodies,  which  may  have  been  enlarged  lymphatics,  were  also  present. 
Macro-glossia,  as  a  disease,  is,  according  to  Mr.  Arnott,  probably  due  to  a  variety  of  causes 
— that  is,  to  (1)  a  true  muscular  hypertrophy  of  the  organ;  (2)  a  nsevoid  affection  of  its 
blood  vessels  ;  (3)  a  thickening  and  induration  caused  by  a  long-continued  subinflam- 
matory  state  ;  or  (4)  a  general  enlargement  of  the  lymphatics  of  the  tongue. 

Treatment. — The  treatment  of  this  affection  has  hitherto  been  excision  either  of  a 
wedge  of  tongue,  as  successfully  performed  by  Humphry,  or  the  removal  of  the  project- 
ing portion  of  the  organ  by  the  knife  or  ecraseur.  Good,  also,  has  said  to  have  been 
derived  from  ignipuncture.  But  mercurial  treatment  should  certainly  be  employed  in 
some  cases  before  recourse  is  had  to  surgical  interference,  since  in  the  case  I  have 
recorded  the  benefit  of  the  drug  was  most  striking. 

In  some  cases  of  enlargement,  and  more  particularly  when  the  disease  is  not  con- 
genital, but  acquired,  and  consequently  probably  inflammatory,  the  eff"ect  of  the  iodides 
should  also  be  tried.  In  the  following  case  of  a  gentleman  Eet.  20  who  consulted  me 
some  years  ago  for  enlargement  of  the  tongue  of  twelve  years'  standing,  and  which  I 
from  its  history  regarded  as  inflammatory,  the  drug  proved  valuable.  The  enlargement 
was  associated  with  a  protrusion  of  the  organ  and  all  the  consequent  evils.  lodism, 
induced  by  ten-grain  doses  of  the  iodide  of  potassium  three  times  a  day,  was  followed  by 
the  speedy  disappearance  of  the  aff'ection,  though  at  the  time  death  appeared  imminent 
from  the  excessive  swelling  of  the  organ  caused  by  the  drug. 

I  should  like  to  mention  that  so  early  as  1807,  Sir  A.  Cooper  removed  a  portion  of  a 
tongue  weighing  on  removal  2  ounces  2^  drachms  (Troy)  and  measuring  3>]  inches  in 
length,  3  inches  in  breadth,  and  Ih  inches  in  thickness,  from  a  man  aet.  53  who  had  been 
troubled  with  the  enlargement  for  six  months.  The  disease  was  supposed  to  have  been 
brought  about  by  the  use  of  mercury  given  for  syphilis.     The  case  did  well. 

On  Growing  and  Degenerating  N^vi  of  the  Tongue. 

These  cases  are  not  very  common,  and  out  of  about  half  a  dozen  that  I  have  seen  the 
following  is  the  best.  I  first  saw  the  case  when  the  girl  was  an  infant,  and  the  tongue 
presented  the  appearance  and  feel  of  a  vascular  sponge.  The  whole  organ  at  that  time 
was  swollen,  and  large  distended  veins  coursed  over  and  under  its  surface,  more  particu- 
larly on  its  right  side  ;  it  had  likewise  a  very  full  arterial  supply.  On  the  application  of 
pressure  by  means  of  the  thumb  and  fingers  the  tongue  was  readily  emptied  of  its  blood, 
and  on  its  removal  it  at  once  refilled.  The  case  was  brought  to  me  for  treatment.  I 
advised  that  nothing  should  be  done,  and  I  did  so  on  the  recognition  of  the  fact  that  na3vi 
have  a  tendency  to  undergo  degenerative  changes,  and  in  the  hope  that  these  changes 
would  take  place  in  the  tongue.  In  this  hope  I  was  not  disappointed,  for  during  the 
twelve  years  that  passed  since  I  first  saw  the  case  many  changes  took  place  in  the  part, 
and  the  most  typical  was  the  cystic  degeneration  of  the  naevus.  These  changes  began 
when  the  child  was  about  six  years  of  age  and  have  steadily  continued.  At  present  the 
tongue  has  quite  lost  its  spongy  feel.  In  consistence  it  is  tolerably  firm,  but  it  feels 
harder  in  some  spots  than  in  others.  To  the  eye  its  surface  looks  to  be  made  up  of  vesic- 
ular warts,  these  vesicles  being  filled  either  with  clear  or  more  or  less  blood-stained  serum. 
In  fact,  the  tongue  appears  precisely  as  any  nasvus  appears  which  has  undergone  the 
peculiar  cystic  warty  degeneration  to  which  such  growths  are  prone.  It  has,  however, 
probably  less  of  the  papillary  hypertrophic  growths  on  its  dorsum  than  many  na3vi  on 
mucous  surfaces  show.  These  appearances  are  confined  to  the  upper  surface  of  the 
tongue,  for  its  lower  aspect  still  presents,  in  a  degree,  the  venous  engorgement  which, 
originally  characterized  the  whole  growth. 

The  appearances  I  have  described  are  absolutely  typical  of  a  degenerating  najvus, 
since  no  other  growths  ever  undergo  like  changes  or  present  any  like  features. 

I  must  mention  here  a  curious  co7vph'ciifion  which  presented  itself  in  this  case,  and 
which  is  difficult  to  explain,  though  I  am  disposed  to  think  it  had  something  to  do  with 
obstruction  of  the  lymphatics.  It  appeared  when  the  child  was  ten  years  of  age  and 
when  the  cystic  degeneration  of  the  naevus  had  far  advanced ;  it  showed  itself  as  a  pain- 
less swelling  of  the  neck,  which  began  in  the  right  submaxillary  region  and  descended 


iciiriiYosis  OF  Tin:  rosavE.  421 

hackwanl  tnwanl  tin-  aiiirlt'  i»f  tlic  jaw  ami  ilnwiiwanl  aluiiL'  tlic  in  rk.  NNln-ii  I  saw  it, 
tluTc  was  a  sul't,  tiaccitl,  l)ai:i:y  fiilarL^i-iiiciit  nf  the  part,  witlmiit  any  extiTiial  or  ;;eiieriil 
si^iis  of  iiiflaiiiiiiatiiiii.  I  looki'd  iipuii  it  as  cystic  and  adviscfl  its  removal.  On  uttcmpt- 
int;  to  carry  tint  tiiis  )iracticf  I  louinl  no  sii^ns  of  a  cyst  wall.  Itut  sini|»Iy  a  collection  ot"  a 
thin,  watery,  l»iit  liii,'lily  alliiiminous  fluid  in  tlic  deep  comu-ctive  tissue  of  the  neck. 
Indeed,  when  an  incision  had  i)ecn  made  into  the  swelliiiL:  and  the  fliiiil  was  evacuated, 
I  never  saw  nor  made  a  more  perfect  dissection  of  the  sulimaxillary  and  dijiastric  .sjtacc-, 
than  then  showed  itsidf.  The  Hiiid  had  clearly  heeii  poiin-d  out  into  the  connective  tissue 
of  these  deep  spaces  ami  there  was  no  cyst  wall.  I  waslie<l  the  cavity  out  with  iodine 
water  ami  introduced  a  drainaj;e-tul)C.  and  under  the  kind  care  of  Dr.  () '.Mcara  of  Sutton 
Bridire.  Lincolnshire,  the  case  subse(jueutly  did  perfectly  well,  and  no  return  of  trouble 
ha.s  taken  place. 

It  is  (|uite  possible  that  at  the  present  time  the  tonjrue  of  this  child,  beiiifr  lar<:e  and 
coarse  in  a])jn'arance.  mitrlit  be  mistaken  for  a  case  of  macro-<rlossia  or  one  of  the  forms 
of  hvpertro])liy.  Xo  one,  however,  who  recojrnizes  the  peculiar  cystic  appearance  of  its 
surface  shouhl  mistake  it  or  fail  to  recognize  its  lutvoid  oriLfin. 

Such  ca.ses  as  this  have  doubtless  been  described  by  authors  as  examples  of  vesicular 
disease  of  the  tonirue. 

Nicvi  of  the  toiiiruc  do  not,  however,  more  than  \yx\'\  of  other  parts,  always  underfro 
desrenerative  chanires.  although,  when  they  do,  they  for  the  most  i)art  assume  such  modi- 
tioations  as  of  necessity  result  from  the  surface  being  cutaneous  or  mucous.  Such  naevi 
will  prol)ably  reijuire  treatment. 

Congenital  Tumors  of  the  Tongue  other  than  N^vi. 

These  do  occur,  though  rarely,  and  they  may  appear  as  outgrowths,  warty  orotherwi.se. 

I  have  seen  a  warty  growth  covering  the  dorsum  to  the  extent  of  a  sixpence,  and  a 
growth  as  large  as  a  rice-seed  projecting  as  an  outgrowth. 

I  remember  al.so  cutting  oft'  from  the  dorsum  of  an  infants  tongue  a  pedunculated 
fibro-cellular  congenital  growth  the  size  of  a  pea.  and  a  good  recovery  followed. 

In  removing  these  pedunculated  growths  it  is  well  to  cut  well  into  their  bases,  since 
cases  have  been  recorded  in  which  a  return  after  removal  has  taken  pdace. 

Congenital  tumors  of  a  deeper  kind  may  likewise  occur,  though  none  have  come  under 
my  notice.  A  remarkable  instance  of  such  was  recorded  by  Mr.  Hickman  in  the  twen- 
tieth volume  of  the  Pathologivdl  Societj/s  D-ansarfions,  in  which,  sixteen  hours  after  birth, 
an  infant  was  suft'ocated  by  a  growth  on  the  base  of  the  tongue,  made  up  of  hypertrophied 
racemose  glandular  structures  normally  existing  in  the  part. 

Amongst  the  congenital  tumors  of  the  tongue  must  likewise  be  mentioned  the  exist- 
ence of  gummata  in  the  subjects  of  hereditary  syphilis. 

Ichthyosis  of  the  Tongue. 

This  peculiar  disease  of  the  tongue,  to  which  the  attention  of  surgeons  was  first 
drawn  by  Mr.  Ilulke  in  18(34  (Clin.  Soc,  18(58),  is  now  generally  recognized,  although 
it  is  often  known  as  "psoriasis."  It  is  met  with  in  several  forms.  In  the  /tfisf  common 
variety  the  papilhv  themselves  seem  to  be  hypertrophied  and  the  disease  appears  as  a 
coarse  tongue,  in  which  the  papillje  are  very  large  and  in  some  cases  covered  with  a  den- 
dritic, horny  epithelial  covering.  In  the  more  common  kinds  the  surface  of  the  tongue 
wholly  or  in  part  assumes,  on  the  one  hand,  a  smooth  and  bluish-white  appearance,  tessel- 
lated in  a  small  or  large  pattern  and  delicately  furrowed,  with  an  absence  of  papilhi?.  or. 
on  the  other  hand,  it  presents  a  more  or  less  extensive  whitish  or  yellow  raised  plaque 
made  up  of  finer  or  coarser  epitlielial  elements  with  a  uniform  surface,  the  parts  when 
wet  having  a  wet  white-kid  or  yellow  wash-leather  aspect  and  a  harsh  feel,  and  when  dry 
a  brown  appearance  and  a  horny  touch. 

These  three  forius  of  disea.sc  may  well  be  called,  as  suggested  by  Mr.  Henry  Morris, 
the  p'ipi/lomatoits  (Fig.  217),  smooth  trsseJlatecL  and  raised  jylaque  varieties. 

The  disease  is  generally  met  with  in  subjects  of  middle  age.  although  I  have  .seen  it 
in  a  woman  as  young  as  twenty-two  ;  and  it  is  more  common  in  men  than  in  women.  It 
is  in  the  majority  of  instances  confined  to  the  tongue,  but  in  about  one-third  of  the  cases 
the  buccal  membrane  is  implicated  as  well. 

It  is  very  frequently  associated  with  cancer,  as  in  four  out  of  the  last  ten  cases  I  have 
noted,  and  in  thirteen  out  of  twentv-seven  tabulated  bv  Mr.  Morris:  it  is  said  by  some 


422  ICHTHYOSIS  OF  THE  TONGUE. 

authors  always  to  lead  up  to  it.     It  may  or  may  not  be  found  complicated  with  syphilis, 
but  that  it  has  a  syphilitic  origin  can  with  some  confidence  be  denied. 

In  one  instance  I  found  it  associated  with  elephantiasis  arabum  of  the  legs  and  geni- 
tals.     It  was  in  a  gentleman  ;T3t.  42  who  had  had  the  elephan- 
^'if'   -^"  tiasis  for  ten  years  and  the  ichthyosis  of  the  horny  type  much 

longer.  It  is  met  with  in  the  temperate,  but  more  frecjuently 
1^  in  the  reverse ;  and  it  is  as  often  as  not  found  in  those  who  do 
not  smoke.  It  is  a  slow,  insidious  disease,  and  is  rarely  recog- 
nized, except  by  accident,  until  it  has  assumed  a  very  marked 
type  or  become  the  seat  of  changes  which  suggest  or  charac- 
terize epithelioma. 

The  microscopical  features  of  this  disease  are  somewhat  cha- 
racteri.stic  ;  they  have  been  well  described  in  the  following  reportj 
made  by  my  friend  Mr.  Symonds,  of  a  specimen  which  was  taken 

from  Mr.  B. ,  aet.  64,  1882,  in  whom  the  ichthyotic  disease 

had  existed  for  twenty  years  and  the  cancer  for  seven  months : 

Papiiio.natou.s  Ichthyosis  of  '"^^^^  microscopical  examination    shows  the  papilla3  to  be 

Tongue.  much   wasted,  their  arrangement  resembling  more  that  in  the 

skin  than  in  the  tongue. 
"  The  superficial  layer  of  epithelium  is  very  much  thickened.  The  deeper  layer  varies 
in  different  parts.  The  cells  are  seen  with  a  higher  power  to  become  altered  and  to  be 
mingled  with  those  of  the  mucosa.  As  the  epithelioma  is  approached  the  limit  is  more 
marked  for  some  distance,  and  the  processes  are  shorter  until  the  epithelial  ingrowths  are 
reached. 

"  The  mucosa  is  infiltrated  with  crowds  of  nuclei.  They  diminish  rapidly  toward  the 
epithelioma,  but  remain  fairly  abundant  in  the  opposite  direction.  This  diminution  of 
nuclei,  with  increased  definition  of  the  basement  membrane  toward  the  epithelioma,  is  a 
striking  feature  in  the  sections." 

Treatment. — It  has  been  already  stated  that  the  majority  of  the  cases  of  this  dis- 
ease do  not  come  under  the  notice  of  the  surgeon  until  the  affection  is  a  confirmed  one, 
and  under  these  circumstances  it  can  readily  be  understood  why  the  affection  has  been 
pronounced  incurable.  If  seen  earlier  and  treated,  there  is  some  reason  to  hope  that 
benefit  might  be  derived  from  treatment,  if  not  a  cure  brought  about. 

This  hope  is  supported  by  the  assertion  of  those  who  tell  us  that  they  have  seen  cases 
of  so-called  psoriasis  (not  syphilitic)  of  the  tongue  cured  ;  and  I  am  sure  that  in  several 
examples  of  ichthyosis  I  have  found  arsenic  as  an  internal  remedy,  boracic  acid  or  chlor- 
ate of  potash  as  a  local  one,  and  as  near  an  approach  to  milk  diet  as  possible,  with  a  total 
abstinence  from  wines,  spirits,  and  smoking,  highly  beneficial. 

In  cases  of  advanced  disease  it  is  difficult  to  find  patients  who  will  submit  for  a  suffi- 
cient period  to  this  treatment,  but  in  others,  where  it  is  met  with  in  its  early  stage,  the 
treatment  would  not  be  of  necessity  so  prolonged.  I  am,  however,  convinced  of  its  value 
and  would  urge  its  adoption. 

In  confirmed  disease  I  know  of  nothing  but  the  excision  of  the  organ,  wholly  or  in 
part,  that  can  offer  any  prospect  of  effecting  a  cure  ;  and  if  the  pathological  doctrine  be 
correct  that  this  disease  always  ends  in  cancer,  there  can  be  no  difficulty  about  the  course 
which  should  be  taken.  I  think,  however,  at  present  it  may  with  some  confidence  be 
asserted  that  this  positive  opinion  is  "  not  proven  ;"  and  under  these  circumstances,  Avhilst 
the  surgeon  is  justified  in  not  rushing  into  operative  interference  in  all  cases,  he  should  so 
watch  the  case  as  to  be  prepared  to  take  steps  for  the  complete  removal  of  the  aflected 
organ  as  soon  as  he  can  see  that  active  changes  are  occurring  in  it  or  anything  like  an 
ulcerative  or  degenerative  change  makes  it  appearance. 

If  the  surgeon  should  err,  let  him  do  so  on  the  side  of  early  interference  rather  than 
that  of  delay,  for  it  must  be  added  that  when  a  cancer  attacks  a  tongue  the  subject  of 
ichthyosis,  it  usually  develops  rapidly  ;  and  when  the  disease  returns  after  removal,  it 
does  so  more  commonly  in  the  submaxillary  or  cervical  glands  than  in  the  part.  The 
return  growtli,  moreover,  always  display  great  malignancy. 

In  connection  with  this  subject  of  ichthyosis  of  the  tongue  and  its  close  association 
with  cancer  I  should  like  to  record  the  following  fact : 

In  1879  I  saw  a  gentleman  aet.  57  who  was  the  subject  of  congenital  ichthyosis  of 
his  skin,  with  an  ulcer  on  his  foot  of  six  years'  standing,  which  became  cancerous  and 
had  to  be  removed. 

This  gentleman  was  one  of  nine,  the  eight  being  women,  and  four  of  these  eight  had 


inn. inn  osr  i.\  riii:  rosdui':.  \'i:\ 

llio  saiiH'  iciitliyntic  (liscasc.  Tlif  iimlliiT  nl"  tliot-  iiiiic  lia<l  the  sarin'  <liscasr,  and  Iht 
latlicr  Id-lnrc  Iht.  Tin-  ;.M'iitl»'inaii  liiinsrlf  was  inarruil  and  liad  .six  (.liiMnri,  three  huyn 
and  three  L'irls.      Two  td'  the  hiiy.s  were  siniihirly  aHeeted. 

Inflammation  and  Suppuration  of  the  Tongue. 

Inllannnation  <d'  the  tunLMU',  when  deep-seated  and  irein-ral,  is  a  <:rave  affection,  since 
the  swellinL'  wliitdi  aeeonipanies  it  i.s  often  so  Huthh-n  and  severe  as  to  tlireaten  life  l)y 
sufloeation.     Siudi  oases  are,  however,  rare  ;   I  have  seen  hut  one. 

I  say  this  e.\eludin<;  from  consideration  tho.se  cases  of  .sudden  enlar^'cment  of  thi- 
totijrue  tlie  result  of  salivation  from  mercury  or  iodism,as  in  a  case  already  reported.  In 
the.se  the  sym])toms,  though  severe,  as  a  rult!  subside  rapidly  under  local  treatment  and  on 
tlie  removal  of  their  cause. 

In  rare  cases,  however,  the  tont:ue  may  slouirU  <>tV  al'ter  jityaiism. 

Inflammation  of  the  tonjiue.  when  local,  may  he  acute  or  chronic.  It  may  follow  an 
injury  or  come  on  without  any  other  asifj;na])le  cause  than  cold  or  exposure.  It  may  begin 
as  a  sudden  swelliiiLr  "f  one-half  of  the  orj;an,  associated  with  con.stitutional  symptom.s 
of  fever,  etc.,  or  it  may  show  itself  simply  as  a  chronic  enlargement  of  the  part,  with 
few.  if  any,  general  symptoms,  and  no  more  local,  than  are  to  Vjc  explained  by  the 
mechanical   enlargement  id'  the  organ. 

The  disease,  however,  under  both  circumstances,  is  not  dangerous,  since  it  is  well 
amenable  to  treatment  and  has  a  tendency  toward  recovery.  I  have  seen  many  examples 
of  this  affection,  and  in  all  a  good  result  took  place. 

Tkeat.mknt. — When  acute  inflammation  attacks  the  tongue  as  a  whole  and  threatens 
life  by  suffocation,  free  puncturing  or  free  incisions  made  in  a  vertical  direction  into  the 
organ  may  be  recjuired,  these  openings  being  made  with  the  view  of  relieving  mechani- 
cally the  turgid  condition  of  the  vessels  and  of  giving  exit  to  the  inflamnuitory  fluids 
which  infiltrate  the  part.  Serious  hemorrhage  may,  however,  at  times  follow  these  incis- 
ions, and  in  a  case  I  witnessed  of  the  late  Mr.  Poland's  the  result  was  nearly  fatal. 

In  more  local  inflammations  the  benefit  of  puncturing  the  swollen  part  is  very  great 
— in  the  early  stage  to  let  out  the  serous  fluids,  and  in  the  later  to  let  out  pus. 

By  way  of  medicines,  salines  and  tonics  are  beneficial ;  but  the  di.sease  has  a  tend- 
ency to  get  well  by  natural  proces.ses. 

Hydatid  Cyst  in  the  Tongue  giving  Rise  to  Suppuration. 

The  possibility  of  a  chronic  cystic  enlargement  of  a  tongue,  as  of  other  parts,  being 
due  to  the  presence  of  an  hydatid  should  always  be  in  the  mind  of  the  surgeon,  and  more 
particularly  when  the  enlargement  is  paiidess  and  gives  rise  to  trouble  mainly  from 
mechanical  causes.  Also  when  a  chronic,  painless  globular  tumor  has  existed  in  a  part 
for  some  time,  say  months,  and  then  suddeidy  increases,  the  possibility  of  the  swelling 
being  due  to  the  presence  of  an  hydatid  which  has  died  and  given  rise  to  suppuration 
should  be  entertained,  for  hydatid  tumors  in  their  early  stages,  in  the  tongue  as  else- 
where, give  rise  to  symptoms  of  a  mechanical  kind,  and  at  a  later  period,  when  they  die, 
to  suppuration. 

I  have  seen  two  cases  of  this  affection  ;  one  occurred  in  the  person  of  a  middle-aged 
patient  who  had  a  chronic  cystic  enlargement  of  one  .side  of  tht;  tongue.  When  the  cyst 
was  punctured,  a  globular  hydatid  escaped,  and  a  good  recovery  ensued. 

The  second  case  occurred  in  18S1,  in  the  person  of  a  girl  rot.  17  who  came  to  me  with 
a  central  cystic  swelling  of  the  tongue  of  seven  or  eight  months'  existence.  The  enlarge- 
ment had  been  ouite  painless  and  felt  like  a  tight  globular  tumor  embedded  in  the  tongue. 

I  punctured  the  swelling  with  a  lancet  and  evacuated  a  collapsed  hydatid  cyst  floating 
in  pus,  and  a  good  recovery  took  place. 

In  the  first  case  related  the  hydatid  was  turned  out  entire  ;  in  the  second,  the  hydatid 
had  died  and  had  given  ri.se,  as  any  foreign  body  might,  to  suppuration.  A  cure  in  both 
cases  took  place  as  soon  as  the  foreign  body  was  removed. 

Chronic  Superficial  Glossitis  or  Smooth,  Glossy  Tongue. 

A  smooth  glazed  tongue  is  often  mot  with  in  practice,  and  tliere  can  be  little  doubt  as 
to  its  being  the  result  of  a  chronic  inflammation  of  the  mucous  membrane  of  the  organ. 
At  times  it  is  associated  with  ulceration.  This  inflammation  is  in  many  cases  due  to  the 
heat  or  irritating  influence  of  a  hot  pipe,  cigar,  or  spirits. 


424  THE  SIMPLE  OR   DYSPEPTIC   ULCER   OF  THE   TONGUE. 

It  is  well  described  by  Mr.  F.  Clarke  (Diseases  of  Tongue^  pp.  159-lGl).  It  shows 
itself  in  patches  more  or  less  oval  or  oblong,  of  a  deep  red  color  and  raw  a.spect,  the 
other  portions  of  the  tongue  presenting  their  natural  appearance.  The  surface  of  these 
patches  is  smooth  and  glossy,  though  at  times  ulcerated.  The  tongue  itself  is  occasion- 
ally swollen,  and  where  the  disease  has  existed  for  some  time  the  patches  feel  thickened 
and  as  if  elevated.  Should  the  disease  be  checked  in  its  progress,  a  complete  recovery 
may  ensue ;  but  more  commonly  the  patches  remain  smooth  and  shining  or  become  the 
seat  of  a  white  patch. 

In  Preparation  1672''',  Guy's  Museum,  there  is  an  interesting  example  of  the  affection, 
which  occurred  in  a  man  aet.  49  who  was  admitted  with  pemphigus  and  erysipelas  in 
March,  1878,  and  who  gave  a  clear  history  of  syphilis  five  years  previously. 

The  preparation,  as  described  by  Dr.  (xoodhart,  shows  that  the  tongue  was  changed  in 
appearance  completely.  Its  surface,  in  place  of  being  rough-looking,  had  lost  all  its 
papillae,  even  the  circumvallate,  the  whole  being  scarred  over  with  smooth  cicatricial 
tissue.  The  mucous  covering  of  the  tongue  was  thicker  than  normal,  smooth,  and  white. 
At  two  spots  were  ulcers,  one  the  size  of  a  threepenny  piece,  with  an  indolent,  unhealthy 
surface,  the  other  larger  and  more  superficial,  healing.     The  tongue  was  not  fissured. 

Microscopically,  these  patches  "  are  either  entirely  denuded  of  epithelium  or  it  is 
reduced  to  an  extremely  thin  layer,  and  the  papillse  are  obliterated  by  distension." 
Pathologically,  the  disease  "  appears  to  be  a  chronic  inflammation  of  the  mucous  mem- 
brane which  has  gradually  produced  complete  alteration  in  the  characters  of  the  epider- 
mis and  thickening  of  the  corium  and  submucous  tissue  "  (Butlin,  MeJ.-Ckir.  Trans. ^ 
vol.  61). 

The  disease  is  constantly  tlie  precursor  of  a  cancer. 

Ulceration  of  the  Tongue. 

In  a  clinical  point  of  view  it  is  expedient  to  divide  the  ulcers  of  the  tongue  into  the 
stiperjicial  and  deep,  since,  in  a  general  sense,  the  superficial  are  local,  simple,  and  readily 
curable,  whereas  the  deep — which  are  due  to  the  breaking  down  of  inflammatory,  tuber- 
cular, syphilitic,  or  cancerous  elements — are  complicated,  difficult  to  diagnose  and  treat, 
and,  moreover,  are  dangerous. 

The  superficial  sores  include  the  aphthous  and  dyspeptic  ulcers,  those  associated 
with  chronic  glossitis,  ulcers  excited  and  kept  up  by  decayed  or  ragged  teeth,  as  well  as 
some  due  to  syphilis,  congenital  or  acquired. 

The  deep  ulcers  are  always  either  syphilitic,  cancerous,  or  tuberculous. 

Superficial  Ulcers. 

The  ordinary  aphthous  inflammation  of  the  tongue  is  a  common  affection,  and  is 
met  with  in  children  and  adults  as  a  result  of  irritation  of  the  stomach  or  intestines  from 
dietetic  or  other  causes.  In  feeble  subjects  the  white  aphthous  spots  may  ulcerate  and 
thus  become  the  source  of  much  trouble,  and  the  ulceration  may  be  extensive,  though 
rarely  deep.      In  cachectic  patients  the  parts  may  slough. 

The  TREATiMENT  of  these  cases  must  be  mainly  determined  by  the  cause,  but  in  the 
majority  a  lotion  of  chlorate  of  potash,  or  boracic  acid  of  five  grains  to  the  ounce  of  water, 
and  the  internal  administration  of  the  same  drugs,  with  or  without  bark  or  the  mineral 
acids,  is  generally  sufficient  to  bring  about  a  cure,  though  in  feeble  subjects  this  may  be 
slow. 

In  the  more  limited  affection  the  local  application  of  the  nitrate  of  silver  often  acts 
very  beneficially,  and  in  the  more  chronic  quinine  is  of  great  value. 

The  Simple  or  Dyspeptic  Ulcer  of  the  Tongue. 

This  form  of  superficial  ulcer  of  the  tongue  may  be  the  sequel  of  the  aphthous,  but 
more  commonly  it  begins  as  an  ulcer,  a  result  of  chronic  glossitis,  which  steadily  spreads. 
It  rarely,  if  ever,  dips  into  the  muscular  tissue  of  the  organ,  but  is  confined  to  the  mucous 
membrane  covering  it.  The  ulcer  may  be  inflamed,  indolent,  sloughing,  or  irritable  ;  indeed, 
it  may  vary  as  may  any  ulcer  in  another  part  of  the  body  ;  and  if  chronic,  it  will  be  indu- 
rated. Its  surface,  however,  will  almost  always  be  smooth,  and  it  will  never  display  the 
irregular  or  deeply-excavated  appearance  of  the  deep  sores ;  it  will,  moreover,  almost 
always  be  seen  upon  the  dorsum  of  the  tongue,  although  in  exceptional  instances  it  may 
spread  downward. 


SYl'llll.iric   DISEASE   or   THE   ToSal'E.  425 

'I'kKATMKNT. — 'Pile  nlilv  mhiikI  |)riliri|i|c  nl'  t  rent  liic'lll  is  :i  mmiI  liili;.'  mi«\  ail<l  tllc  cllii'f 
pootl  is  to  1)0  ;;aimMl  hv  iiu'iiiis  of  ilii't.  'I'liis  is  to  he  rt';^uiatcil  in  flic  most  can-i'iil  maii- 
MiT,  and  all  food  sliotiM  Im-  tor))i(l(li>ii  that  can  possibly  irritate  Milk  food,  when  it  can 
he  taken,  is  tlit"  hest,  and  with  it  it  is  \v<'ll  to  'X\\^-  alkalies,  siwdi  as  lime  water,  hicarhonute 
of  potash,  or  chlorate  of  potash.  an<l  at  times  opium  in  small  dosc's.  Animal  hroths  are 
liencliiial  ;  hut  little  meat  should  he  allowed.  All  heer  and  sjiirits  should  he  interdicted; 
and  when  stimulants  are  ahsolutely  m-cessary.  they  should   he  ^Mven  as  wine  well  diluted. 

liocallv,  the  lotion  of  horacic  aeid  or  chlorate  of  |)otasli  is  henclicial.  and  caustics  are 
rarelv  re(|uired.  Uf  tonics  the  harks  are  the  hest  I'orm,  hut  at  times  the  mineral  aeid.s 
are  of  value. 

Ulcers  Originating  from  Local  Irritation. 

These  are  very  coninmii  in  the  toiitiue,  and  the  fact  is  due  to  the  restless  imdjility  of 
the  ori,^an  and  the  necessary  friction  which  it  must  receive  from  any  sharp  process,  of  a 
hroken  or  decayed  tooth,  or  any  ed<rc  of  rouirh  tartar,  or  even  from  the  jiresence  of  an 
exostosis  of  the  lower  jaw.  T  have  known  an  ulcer  due  to  the  last  cause  to  he  looked 
upon   as  cancerous. 

These  ca.ses  are  at  times  very  troublesome  and  obstinate  unless  their  cause  i.s  recog- 
nized, and  they  may,  and  do,  without  doubt,  often  become  cancers. 

They  in:»y  show  themselves  as  mere  bli.sters  or  superficial  ulcers,  the  other  part  of  the 
toiiLiue  being  healthy,  but  in  chronic  cases  the  local  sore  may  be  indurated  and  thus  simu- 
late a  cancer.     In  the  case  of  a  woman  aged  40  the  ulcer  had  existed  two  years. 

Some  subjects  are  more  susceptible  to  irritation  than  others,  and  I  have  known  a 
patient  have  repeated  blistering  and  ulceration  of  the  tongue  from  the  irritation  of  a 
rough  decayed  tooth  after  sleeping  on  the  aifected  side.  The  mere  weight  of  the  tongue 
against  the  tooth  and  the  unconscious  friction  between  the  two  parts  when  in  contact 
proved  enough  to  ]>roduce  a  blister  in  the  soft  parts. 

Treatmknt. — The  nun-e  knowledge  of  the  cause  of  this  affection  suggests  the  reujcdy 
— namely,  the  removal  of  the  cause,  the  removal  of  the  point  of  irritation  when  possible, 
and  the  extraction  of  the  tooth  when  nothing  less  is  sufficient.  Indeed,  as  a  general  rule 
of  practice,  the  surgeon  should  always  advise  the  removal  of  any  local  source  of  irritation 
I'rom  the  tongue,  as  frcun  any  other  part  of  the  body,  for  such  is,  without  doubt,  the  cause 
of  the  majority  of  local  cancers. 

Infiltrations  and  Deep- Seated  Ulcers  of  the  Tongue. 

I  have  of  necessity  grouped  these  cases  together,  for  the  majority  of  the  deep-seated 
ulcers  of  the  tongue  begin  as  local  infiltrations  and  are  due  to  the  subsequent  breaking 
down  of  the  infiltrated  and  infiltrating  material. 

The  group  con.se(|uently  includes  cases  of  syphilitic  di.sease,  of  epithelial  cancer,  and 
of  tubercular  disease  of  the  tongue,  each  of  which  claims  a  distinct  notice. 

Syphilitic  Disease  of  the  Tongue. 

This  shows  itself  in  many  ways  and  under  many  circumstances.  Thus,  it  may  occur 
as  a  comjenital  (tffectio)i  and  appear  either  as  a  mucous  patch  on  the  tongue  associated 
with  other  constitutional  symiitoms.  or  as  a  deep  fissure,  as  recorded  by  Dr.  Barlow  {Path. 
Sue.  Trans.,  \o\.  31)  or  as  a  superficial  ulceration.  Of  the  former  kind  I  have  .seen  several 
examples  ;  of  the  latter  but  one,  and  that  through  the  kindness  of  my  colleague.  Dr.  Good- 
hart,  in  whose  practice  it  occurred. 

A  full  report  of  tlie  case  may  be  read  in  the  Guys  Hospital  R< ports  for  1883. 

As  an  acquired  disease,  .syphilitic  disease  of  the  tongue  shows  itself  either  as  a  mucous 
patch  or  as  a  more  or  less  extensive  local  infiltration  of  the  tongue  with  gummous  deposit, 
the  breaking  down  of  which  leads  either  to  superficial  .sores,  to  fissures,  or  to  deeply  exca- 
vated irregular  ulcers,  and  later  on  to  the  iiulurated  and  irregular  cicatricial  tongue. 

In  some  instances  the  gummous  material  is  either  poured  out  soft  or  as  a  solid  which 
soon  breaks  down,  under  both  circumstances  appearing  as  a  cystic  enlargement  in  the 
body  of  the  tongue.  I  have  seen,  in  some  cases,  four  or  five  of  these  cystic  swellings  in 
a  tongue  thus  affected,  and  on  opening  the  sanu^  have  given  exit  to  a  thin  fluid. 
The  enlargements  appear  as  single  or  multiple  globular  tumors  in  the  body  of  the 
tongue. 


426  SYPHILITIC  DISEASE  OF  THE  TOyCiUE. 

When  the  disease  occurs  in  the  shape  of  mucous  patcJirs,  it  is  usually  associated  with 
other  symptoms  :  the  patches  are  commonly  multiple  and  are  for  the  most  part  situated 
on  the  upper  surface  and  edges  of  the  organ.  They  appear  either  as  moist  papules  with 
whitish  tops,  as  i-ed,  circular,  or  irregular  excoriations,  or  as  granulating  surfaces  project- 
ing as  white,  moist,  raised  growths.  The  mucous  patches  in  the  tongue  are  precisely  like 
those  seen  in  other  mucous  membranes,  and,  indeed,  are  identical  with  them. 

The}'  may  occur  with  the  first  onset  of  constitutional  symptoms  or  not  show  them- 
selves till  a  remoter  period  of  syphilitic  inoculation.  They  are  very  prone  to  reappear 
after  their  supposed  cure. 

When  syphilis  attacks  the  tongue  as  a  local  infiltration  of  gummous  deposit,  it  does 
so  usually  long  after  the  primary  inoculation,  even  after  twenty  or  more  years. 

It  may  do  so  as  a  single  or  more  commonly  as  a  multiple,  more  or  less  rounded  infil- 
tration of  the  submucous  or  muscular  tissue  of  the  tongue,  and  the  swellings  may  be 
pea-like  or  nut-like ;  at  first  these  swellings  will  be  hard,  but  as  time  progresses  changes 
will  occur  in  them.  If  allowed  to  run  their  course,  they  will  enlarge  and  break  down, 
open  and  discharge  ;  if  treated,  they  may  soften  and  be  reabsorbed  or  wither  and  dry  up, 
the  latter  change  being  very  rare. 

When  this  affection  is  allowed  to  run  its  natural  course,  the  swelling  will  enlarge  and 
subsequently  break  up  ;  the  hard  lump  will  increase  and  become  softer  ;  the  soft  parts 
covering  it  in  will  redden,  inflame,  and  open  either  by  an  ulcerating  or  sloughing  process  ; 
and  when  the  contents  of  the  lump  have  been  discharged,  either  a  ragged  cavity  will  be 
left  to  granulate  or  a  fissure  to  heal.  The  edges  of  the  cavity  or  fissure  are  under  all 
circumstances  perpendicular  and  sharply  cut. 

The  cavity,  when  the  parts  have  opened  by  a  sloughing  process,  will  be  more  or  less 
ragged,  according  to  the  amount  of  destruction  of  the  tissue  of  the  tongue,  and  it  will 
present  a  surface  which  will  vary  according  to  the  stage  of  the  disease.  When  looked  at 
during  the  period  of  sloughing,  the  dead  tissue  infiltrated  with  the  yelloio  infiltrating 
material,  of  a  wet,  wash-leather  appearance,  will  readily  be  recognized  ;  and  when  seen  at 
a  later  period,  the  irregularly  excavated  cavity  with  sharply-cut  perpendicular  uninfil- 
trated  edges  will  generally  enable  the  surgeon  to  diagnose  the  disease  from  the  one  for 
which  it  is  often  mistaken — a  sloughing  cancer.  The  common  want  of  enlargement  of 
the  lymphatic  glands  in  this  specific  affection  of  the  tongue  is  another  help  to  diagnosis. 
At  a  later  period,  when  repair  has  taken  or  is  taking  place,  an  irregular,  yellow-white 
cicatrix  (leucoma)  will  be  seen,  and  the  tongixe  eventually  will  show  marked  evidence  of 
the  destructive  processes  of  which  it  has  been  the  seat,  wasting  of  some  parts  of  the 
tongue,  scarring  of  others,  mixed  up  with  irregular  cicatricial  tissue,  being  the  chief 
characteristics  of  a  repaired  syphilitic  tongue. 

In  tongues  that  are  brought  rapidly  under  the  influence  of  appropriate  treatment,  the 
changes  that  have  now  been  described  may  be  considerably  modified.  Thus,  the  nodular 
infiltrated  mass  may  soften  and  the  deposited  material  may  be  reabsorbed.  The  tongue 
itself  will  become  supple  and  more  natural,  and  a  cure  may  take  place — a  cure,  however, 
which  in  some  cases  is  attended  with  a  wasting  of  the  portion  of  tongue  that  was  infil- 
trated, or  a  loss  of  the  natural  papillary  tissue  upon  the  surface  of  the  tongue  which  cor- 
responds to  the  seat  of  infiltration. 

AVhat,  however,  is  of  far  greater  importance  to  remember  is  that  a  tongue  which  has 
been  the  seat  of  syphilitic  disease  frequently  becomes  the  subject  of  a  cancer.  The 
altered  nutrition  brought  about  by  the  irritation  of  the  one  affection  encourages  the 
development  of  epithelial  disease.  A  relapse  of  this  aff'ection  after  an  apparent  cure  is 
also  very  common. 

Treatment. — When  the  diagnosis  of  this  many-faced  disease  has  been  made,  the  line 
of  treatment  to  be  adopted  is  not  difficult  to  lay  down,  for  there  can  be  but  little  doubt 
that  some  mercurial  medicine  is  the  most  certain  drug  to  employ  where  there  are  no  indi- 
cations against  its  use  ;  and,  on  this  being  rejected  or  found  wanting,  the  iodides  of 
potassium,  sodium,  or  ammonium,  in  gradually  increasing  doses,  are  to  be  used. 

The  disease  must  be  dealt  with  as  a  general,  and  not  as  a  local,  one  ;  and  the  local 
aff'ection  is  to  be  regarded  as  one  of  the  manifestations  of  a  constitutional  disorder  which 
may  appear  in  other  seats,  though  as  yet  it  may  not  have  done  .so. 

when  mercury  is  prescribed,  the  perchloride  in  doses  of  one-sixteenth  of  a  grain  in 
bark  may  be  given,  or,  what  I  like  as  well,  a  pill  of  half  a  grain  of  the  green  iodide  of 
mercury  twice  a  day.  In  both  cases  the  dose  should  be  gradually  raised  to  double  the 
strength  indicated. 

When  mercury  is  contraindicated  on  account  of  the  patient's  cachectic  or  feeble    con- 


CANCER   OF  Till:-  To.\(;rj:.  -127 

ditioii,  tlu'  icMlidc'S  may  '"i'  (••iiiimfiiffil  at  fivc-triaiii  dnscs  and  steadily  iinTcascd  wi-i-k  l»y 
wt'i'k  hy  a  grain  up  to  twtdvi--,  tirtccn-.  or  twenty-grain  doses  tlirco  times  a  dav.  The 
iodide  ol'  sodium  may  he  at  times  suhstituted  tor  the  iodide  of  jxttassium.  Tonies  are 
often  re<|uired  at  tlie  same  time,  with  good  simple  food,  fresh  air,  and  regular  hahits. 
Stimulants  should  he  givi-u  very  sparingly,  and  all  smoking  should  he  strietly  jindiiliitcd. 
A.s  ii  loeal  ajiplieatiou  tin-  lotion  of  horair  acid  or  (ddorate  of  potash  gr.  x  to  the  ^  of 
water  is  of  value,  and  the  n-eomniendation  of  Mr.  II.  Morris  to  ruh  a  piece  of  hlue-pill 
nia.ss  onee  or  twiee  daily  over  the  surface  of  the  .s(»re  is  worthy  of  adoption.  When  the 
di.seu.se  has  apparently  di.sappeared,  the  treatment  must  he  continued  for  some — possihly 
for  six — months,  this  practice  heing  necessary  to  guard  against  a  relapse.  The  routine 
practice  of  apjdying  the  nitrate  of  silver  to  these  .sores  cannot  be  too  strongly  con- 
demned. 

In  the  "  lumpy  tongue,"  in  the  stage  in  which  the  lumps  are  softening,  I  have  found 
the  .simple  operation  of  puncturing  the  tumors  to  he  of  great  use  hy  procuritig  the  esca]»e 
of  the  contents  of  the  lumps,  which  are  often  serous,  thereby  relieving  tension  and  cer- 
tainly expediting  the  cure. 

In  cases  of  long-standing  disease  the  fear  of  the  tongue  becoming  the  seat  of  cancer 
shmild  ever  be  b(»i'ore  the  surgeon,  and  the  fact  of  a  tongue  having  been  the  seat  of  an 
old  syphilitic  affection  should  tend  rather  to  support  tlian  to  weaken  the  view  of  a  doubt- 
ful excavated  ulcer  of  the  tongue  being  of  a  cancerous  nature.  At  any  rate,  where  the 
doubt  exi.st.s,  let  it  rather  encourage  surgical  interference  than  prolonged  n)edicinal  treat- 
ment ;  for  in  a  clinical  point  of  view  a  chronically  affected  syphilitic  tongue  had  better 
be  occasionally  removed  than  a  cancerous  one  left  to  run  its  course. 

Cancer  of  the  Tongue. 

This  distressing  disease  is  met  with  in  about  five  out  of  every  hundred  cases  of 
cancer,  and  is  an  affection  of  adult  life.  An  analysis  of  102  consecutive  patients 
admitted  into  Guy's  Hospital,  and  seen  by  me,  shows  that  80  out  of  every  100  aff"ected 
by  it  were  over  the  age  of  forty-five;  12  were  under  forty  years  of  age;  27  between 
forty-one  and  fifty  ;  31  between  fifty-one  and  sixty  ;  25  between  .sixty-one  and  seventy  ; 
and  7  over  seventy  years  of  age.  This  disease  may.  however,  occur  as  early  as  twenty- 
seven.     It  is  more  common  in  male  than  female  subjects,  in  proportion  of  80  to  22. 

The  disease  is  ahiays  of  the  epithelial  form,  and  is  essentially  an  isolated  infiltration 
of  the  papillary  or  mucous  surface.  It  usually  shows  itself  as  a  blister,  crack,  ulcer, 
wart,  or  superficial  tumor  upon  the  tip  or  side  of  the  tongue,  and  is  in  the  majority  of 
eases  single.  It  then  breaks  down  and  discharges,  leaving  a  more  or  less  ragged,  irregu- 
lar, excavated  sore  with  raised,  indurated,  infiltrated,  and  mostly  everted  edges. 

The  disease  is  at  first  always  local,  but  later  on,  when  allowed  to  take  its  course,  it 
will  spread  and  involve  the  floor  of  the  mouth,  fauces,  gums,  or  jaw-bone.  It  will,  more- 
over, always,  sooner  or  later  implicate  the  lymphatic  glands. 

At  times  the  diseased  parts  slough  more  or  less  extensively,  and  in  a  case  which  was 
under  my  care  in  18G6  the  whole  organ  sloughed  off"  before  the  man  died.  It  aff"ects  one 
side  of  the  tongue  as  much  as  the  other,  and  is  at  times  central.  But,  wherever  it  may 
commence,  it  will  soon  involve  neighboring  parts. 

It  originates  at  times  without  anj-  definite  cause,  but  in  the  majority  of  cases  it  is 
excited  by  some  local  irritation,  such  as  that  caused  by  a  broken  or  rough  tooth,  a  hot 
pipe,  an  antecedent  .syphilitic  affection,  or  the  disease  which  is  now  known  as  ichthyosis. 

It  may  originate  also  in  a  scar  on  the  tongue,  as  it  is  well  known  to  do  in  scars  of 
other  parts.  In  1880  I  saw  a  case  in  which  the  disease  had  attacked  the  tongue  of  a  man 
aet.  57  who  had  bitten  off"  its  tip  five  months  before  in  an  epileptic  fit,  and  a  second  in 
1875,  in  a  man  aet.  70  who  had  injured  his  tongue  by  a  fall  two  years  before. 

Diagnosis. — Any  localized  iujiltration  of  the'  papillary  or  mucous  covering  of  the 
tongue,  however  limited  it  may  be,  in  a  patient  over  forty,  .should  be  su.spected  to  have 
an  epithelial  origin  ;  and  should  this  be  found  in  a  part  of  the  tongue  in  which  no  local 
source  of  irritation  can  be  discovered,  the  suspicion  becomes  a  certainty. 

Should  the  infiltration  coexist  with  ulceration  and  a  local  source  of  irritation  be  made 
out — such  as  a  broken  or  rough  tooth — the  probabilities  of  its  being  due  to  this  local 
irritation  may  be  regarded  as  great ;  but  should  the  di-sease  fail  to  undergo  a  rapid  cure 
upon  the  removal  of  its  supposed  cause,  the  conclusion  should  be  drawn  that  the  disease 
is  cancerous. 

When  a  tongue  has  been  the  seat  of  a  chronic  syphilitic  aff"ection,  and  more  par- 


428  CANCER   OF  THE   TONGUE. 

ticularly  is  one  in  which  a  series  of  relapses  has  taken  place,  with  uncertain  intervals  of 
apparent  convalescence  ;  and  when, it  presents  an  indurated,  infiltrated  tissue,  with  a  more 
or  less  excavated,  ulcerating,  or  sloughing  cavity,  with  irregular,  everted,  and  raised, 
rather  than  sharply  cut  and  defined,  edges, — the  diagnosis  of  the  disease  being  cancerous 
is  highly  probable ;  and  when  with  these  symptoms  the  lymphatic  glands  beneath  the 
jaw  are  found  enlarged,  the  diagnosis  becomes  a  certainty. 

When,  again,  this  local  infiltration,  with  or  without  ulceration,  is  found  in  a  tongue 
which  has  been  the  seat  of  an  old  syphilitic  leucoma  or  the  subject  of  that  peculiar 
disease  of  the  papillary  mucous  membrane  known  as  ichthyosis,  there  should  be  no  fjues- 
tion  as  to  its  true  nature  ;  for  it  should  be  accepted  as  a  fact  that  chronic  syphilitic  as 
well  as  chronic  ichthyotic  disease  renders  the  tongue  peculiarly  liable  to  undergo  changes 
in  its  epithelial  elements  which  most  commonly  reveal  themselves  as  epithelial  cancer. 

Mr.  Morris  has  recorded,  in  an  able  paper  on  this  subject,'  the  fact  that  out  of  55 
cases  of  cancer  of  the  tongue,  in  13,  or  about  one-fourth,  the  organ  had  been  the  seat  of 
ichthyosis.     I  am  quite  prepared  to  support  him  in  this  average. 

Treatment. — There  is  but  one  form  of  treatment  of  cancer  of  the  tongue  that  can  be 
recommended  with  any  confidence,  and  that  is  the  removal  of  the  disease  by  some  sur- 
gical operation.  And  there  is  but  one  period  at  which  this  operation  is  likely  to  prove 
successful  as  a  cure,  and  that  is  in  the  early  stage  of  the  disease  when  the  cancer  is  local 
and  when  it  involves  no  other  tissues  than  those  in  which  it  was  primarily  placed. 

When  the  disease  has  extended  beyond  these  limits  and  through  the  lymphatic  chan- 
nels has  implicated  the  lymphatic  glands,  the  prospects  of  a  cure  are  not  favorable,  even 
if  they  can  be  said  to  exist,  since,  whilst  the  glands  that  lie  along  the  ramus  of  the  jaw 
may  be  readily  removed,  those  that  lie  buried  behind  the  angle  are  beyond  the  surgeon's 
reach,  and  to  remove  some,  and  not  all,  of  the  infected  glands,  is  a  futile  proceeding. 

When  a  local  cancerous  disease  is  removed,  it  should  be  a  rule  of  practice  that  all 
enlarged  lymphatic  glands  should  be  removed  likewise  ;  and  this  rule  is  as  applicable  to 
the  tongue  as  it  is  to  other  parts. 

As  to  the  best  means  for  the  removal  of  a  tongue,  wholly  or  in  part,  surgeons  are 
found  widely  to  diiFer — one  advocating  strongly  the  removal  by  the  knife  or  scissors, 
whilst  others  as  stroTigly  urge  the  use  of  the  ecraseur,  employed  either  as  a  crushing  or 
as  a  burning  force.  The  chain  or  wire  instrument  is  used  in  the  crushing,  and  the 
platinum  wire  heated  by  means  of  a  galvanic  battery  as  the  cautery  ecraseur.  For  many 
years  I  employed  the  galvanic  ecraseur  and  found  no  fault  with  it ;  of  late  I  have  again 
resorted  to  the  chain  or  wire  instrument,  but  have  had  no  reason  to  be  better  satisfied 
with-  my  results.  I  altei-ed  my  practice  in  deference  to  a  strong  opinion  that  has  been 
given  by  some  surgeons  as  to  the  dangers  of  the  galvanic  and  greater  safety  of  the  simple 
ecraseur,  but  this  opinion  does  not  find  support  from  my  facts. 

With  the  view  of  testing  this  point  I  have  extracted  from  our  Guy's  Hospital  records 
46  consecutive  cases  of  operation,  and  find  that  of  36  operated  on  by  the  galvanic  ecraseur 

4  died  from  the  operation,  or  11.1  per  cent.,  and  4  from  other  causes.  Of  7  cases  operated 
on  by  the  chain  or  wire  ecraseur,  1  died  from  the  operation  and  1  from  the  disease.  Of 
1  removed  by  excision  and  2  by  ligature,  none  died.    Of  the  whole  number  of  46  cases, 

5  died  from  the  operation,  or  10.8  per  cent.,  and  5  from  other  causes. 

Of  the  5  fatal  cases  from  the  operation,  2  sank  on  the  eighth  day — 1  from  pleurisy 
and  the  other  from  broncho-pneumonia  ;  1  on  the  twentieth  day  from  broncho-pneumonia, 
and  1  on  the  twentieth  from  exhaustion  and  repeated  small  bleedings.  The  single  fatal 
case  after  the  use  of  the  chain  ecraseur  was  on  the  twelfth  day  from  broncho-pneumonia. 

One  of  the  5  cases  that  died  after  the  operation,  though  not  from  it.  sank  on  the 
thirty-sixth  day,  from  recurrent  disease  and  gangrene  of  the  lung ;  3  on  the  fifty-third, 
forty-eighth,  and  thirty-second  days,  respectively,  from  recurrent  disease  and  exhaustion  ; 
and  1  on  the  thirty-eighth  day,  from  recurrent  disease  and  pya?mia. 

It  will  be  thus  seen  that  f/irce  out  of  the  8  cases  that  died  after  the  use  of  the  gal- 
vanic ecraseur,  and  o)ic  out  of  2  cases  that  had  been  operated  on  with  the  chain  or  wire 
instrument,  or  four  out  of  the  whole  number  of  46  cases  of  operation,  or  8.7  per  cent., 
died  from  lung  complication  ;  and  the  records  of  the  pathologist  tell  us  that  such  a  com- 
plication is  by  no  means  infrequent  when  no  operation  has  been  performed.  At  any  rate, 
evidence  is  wanting  to  show  that  this  lung  complication  is  more  common  after  operation 
than  it  is  without,  or  when  it  follows  operation  that  the  operation  has  anything  to  do  with 
the  lung  disease. 

It  is  true  that  the  inhalation  of  fetid  or  septic  elements,  when  the  tongue  is  slough- 

1  Trans,  of  Med.  Soc,  1882. 


c.ixch'n  OF  THE  ToMiri:.  429 

iiii;  citlicr  liy  ii;itiir;il  proi-i-sst's  (ir  ;is  a  (■(iiis('(|iu'ii('c  nl"  n|ifr;itii)ii,  iiiiisl  nl'  iicccssit v  be 
proiio  to  liiiiiij;  tmt  this  liiii^'^  inmldo;  l)iit  tliis  iact,  iiistt^ad  dl'  l)eiii<r  adducctl  as  an  ar;ru- 
luc'iit  against  opiTat ivc  iiilcircri'iKH',  may  fairly  hi'  used  as  oiic  in  its  f'avdr.  siiK-e  t<»  ^'ct 
rid  of  till'  sldiij^liinii'  and  I'ctid  or;^an  is  one  i\\'  tin-  suri^con's  aims  in  an  (i]i('ration,  an<l  to 
do  so  in  the  (|nicki'st,  salrst,  and  simplest  way  is  liis  olijccl. 

Wlicii  tilt'  liiilvaiiic  I'crasi'iir  is  used  and  tlii'  cauterized  tissue  is  renden-il  asepti(.'  )>v 
means  ol  a  pliij:;  of  iodoform  <iaiize  well  iiressed  upon  the  surface  after  operation,  or  when 
the  clianid  (ir  bruised  surface,  aficr  the  use  of  the  fi;alvanic  or  wire  ecraseur,  is  kept 
tweet  liy  the  repeated  aj»plieation  of  the  colloid  styptic — wliich,  Mr.  Morris  tells  us, 
•'  tans  the  surface  of  the  wound,  causes  little  or  no  slou<;h,  and  corrects  the  fetor  of  dis- 
char<;e '" — there  is  less  fear  of  any  evil  result  from  septic;  causes  than  there  was  before 
the  disease  was  removed. 

There  is,  coiise((ueiitly.  no  ari^unient  auaiii.'-t  the  use  of  the  ecraseur  that  has  any 
weight. 

Whilst,  therefore,  for  the  removal  of  a  tongue,  wholly  or  in  part.  I  have  a  jiicference 
for  the  ecraseur,  and  f(U'  the  •ralvanic  over  the  wire  or  chain  instrument.  I  am  ready  to 
admit  the  value  of  excision  by  means  of  scissors  or  the  knife,  or  of  any  of  the  ditt'erent 
inoditieatioiis  of  these  of)erations  which  the  ingenuity  of  different  surgeons  has  suggested, 
for  T  believe  that  in  individual  cases  one  form  of  operation  may  be  more  applicable  than 
another,  and  that  in  the  hands  of  any  surgeon  the  mode  of  operating  he  excels  in  is  the 
best  for  his  patient. 

I  may  say,  however,  tliat  I  have  not  yet  seen  a  case  in  wliich  the  division  of  the 
lower  jaw  as  taught  by  Syme  has  been  required. 

Most  tongues  can  be  removed  tlirough  the  mouth,  liowever  extensive  the  disease  inay 
be,  if  the  organ  be  well  drawn  forward  by  means  of  a  thick  ligature  introduced  througli 
the  body  of  the  tongue,  and  if  it  is  freed  from  its  attachment  to  the  lower  jaw  and  fauces 
by  the  division  of  its  mucous  membrane  attachments.  There  is  no  objection  to  the 
removal  of  a  whole  tongue  in  halves,  though  there  is  no  advantage  in  so  doing.  If  more 
room  should  be  recjuired.  this  is  best  obtained  by  means  of  an  incision  across  the  cheek 
from  the  angle  of  the  mouth,  the  ecraseur  being  then  worked  sideways. 

Bleeding  during  an  operation  need  cause  no  alarm  if  the  operation  be  performed 
leisurely,  since  it  can  be  speedily  controlled  by  the  torsion  of  the  divided  artery  if  the 
tongue  be  well  drawn  forward  ;  in  many  cases  the  simple  drawing  forward  of  the  tongue 
suffices  to  bring  about  this  result,  the  artery  receding  into  the  muscular  tissue. 

I  can  see  no  advantage  in  adopting  the  practice  of  Demarquay  of  ligating  before  the 
operation  the  lingual  arteries,  although  when  severe  bleeding  takes  place  after  the  opera- 
tion the  practice  may  be  good.  The  operation,  however,  may  be  performed,  in  ca.ses  in 
which  the  removal  of  the  disease  is  inexpedient  or  impracticable,  with  the  view  of  bring- 
ing about  wasting  of  the  diseased  organ.  The  division  of  the  lingual  gustatory  nerve  on 
the  inner  side  of  the  lower  wisdom  teeth,  as  practi.sed  by  Hilton  (1850)  and  Moore 
(18G1).  for  the  purpose  of  relieving  pain,  is  also  a  practice  to  be  strongly  recommended. 

It  mu.st  likewise  be  recorded  as  one  of  the  advantages  of  excision  of  the  tongue  that 
should  a  return  of  the  disease  take  place  it  is  more  likely^  to  do  so  in  the  lymphatic 
glands  of  the  neck  than  anywhere  else.  Under  these  circumstances,  the  patient  is  relieved 
of  his  distressing  local  affection  and  sinks  slowly  and  comparatively  painlessly.  I  have 
often  heard  with  pleasure,  even  under  these  miserable  conditions,  expressions  of  grati- 
tude from  patients  who  have  gone  through  the  operation — gratitude  for  the  sufferings 
they  have  been  released  from  and  spared. 

I  may  also  add  that  it  seems  probable  that  life  is  materially  increased  by  the  opera 
tion.  In  some  cases  I  have  to  record,  the  increase  was  great,  and  even  when  a  return 
takes  place  there  is  a  degree  of  increase.  Mr.  Morris  states  that  out  of  15  cases  opera- 
ted upon  the  average  duration  of  life  was  sixteen  months,  whereas  in  those  which  no 
operation  was  performed  it  was  but  ten  and  a  half,  only  two  ca.ses  having  been  known  to 
ha'.'e  lived  eighteen  months. 

In  the  cases  I  now  record  a  decided  increase  to  life  must  be  admitted,  and  particularly 
if  we  take  the  average  of  life  with  this  disease  when  left  alone  as  ten  and  a  half  months. 

In  18GG  I  removed  the  anterior  half  of  the  tongue  from  W.  P. ,  a3t.  GO.     The 

patient  remained  well,  so  far  as  the  tongue  was  concerned,  for  fi/feen  years,  when  disease 
reappeared  in  the  scar.  The  patient  at  this  time  was  suffering  from  hemiplegia  and 
senile  decay,  of  which  he  died. 

In  1872  I  removed  from  Mr.  S .  a?t.  45,  half  his  tongue  for  a  local  cancer.     He 

reported  himself  to  me  as  well  (ei)  i/earg  later,  1882. 


430  TUBERCULAR    ULCERATION  OF  THE  TONGUE. 

In  1871  I  removed  a.  local  cancer  from  the  tongue  of  Mr.  K.  W .      No  return  ever 

took  place,  though  the  patient  lived  y?i'e  years  and  died  from  anaemic  gangrene  of  the  foot. 

In   1870  I  operated   on   H.  S ,  a3t.  70,  and  removed  a  cancer,  with  the  anterior 

two-thirds  of  the  tongue.      Three  and  a  half  years  later  he  reported  himself  as  well. 

In   18G9  I  removed  a  portion  of  the  tongue  from  H.  J ,  fet.  42.     He  lived  two 

years  and  had  no  return,  and  died  from  lung  disease. 

I  can  trace  two  cases  now  alive  and  well  who  have  been  operated  on  for  two  years,  and 
two  who  are  well  one  year  after  operation,  and  have  records  of  three  who  survived  the 
operation  for  eighteen,  eighteen,  and  eleven  months  respectively. 

Altogether,  out  of  a  somewhat  limited  personal  experience,  the  above  record  of  facts 
must  be  regarded  as  encouraging,  clearly  showing  the  possible  benefit  of  the  operation, 
and  the  probability  of  a  cure  being  obtained  in  a  larger  number  of  cases  if  the  operation 
were  undertaken  as  soon  as  the  diagnosis  of  the  local  disease  has  been  made. 

Tubercular  Ulceration  of  the  Tongue. 

It  is  right  that  this  disease  should  have  a  special  notice,  since  it  is  neither  common 
nor  generally  recognized.  It  has.  however,  features  of  its  own  which  claim  attention.  I 
have  seen  several  examples  of  it,  but  have  records  of  only  two. 

Symptoms. — It  occurs  in  feeble  subjects,  and  begins  as  a  papule  which  soon  ulcerates 
and  in  spite  of  treatment  passes  into  a  sore  or  fissure.  A  second  and  a  third  sore  soon 
follow  the  first  and  run  the  same  course,  the  same  in  its  obstinacy  and  the  same  in  its 
tendency  to  form  a  fissure  or  excavation.  When  it  presents  the  latter  appearance,  the 
surface  of  the  sore  will  be  that  of  an  old  indolent  ulcer  on  other  parts ;  its  base  will  be 
more  or  less  infiltrated,  but  never  hard,  like  that  of  cancer ;  and  its  edges,  though  infil- 
trated, will  not  present  the  sharply  cut  aspect  of  the  syphilitic  fissure  or  the  elevated 
everted  irregular  border  of  the  cancerous  ;  the  secretion  from  the  sore  is  often  cheesy.  In 
fact,  the  sore  is  neither  like  the  syphilitic  nor  like  the  cancerous,  and  yet,  for  want  of  its 
recognition,  it  is  usually  taken  for  one  or  the  other. 

In  one  case  the  ulcer  appeared  as  a  fissure  with  an  indurated  base  and  infiltrated  edge. 
In  another  the  ulcers  were  irregular,  their  edges  but  little  thickened  or  hardened,  and 
their  floors  were  formed  by  a  soft-looking  cheesy  material.  Add  to  this  that  the  cuticular 
covering  of  the  tongue  was  unnaturally  glazed  and  red  or  livid,  with  numerous  small  super- 
ficial erosions,  of  similar  type  to  the  larger  ones,  aff'ecting  a  large  part  of  the  surface,  and  the 
disease  makes  a  picture  which,  once  seen,  is  neither  likely  to  be  forgotten  nor  mistaken. 

"  Sections  of  the  tongue  showed  that  the  cheesy  material  had  invaded  the  muscular 
structures  to  some  depth,  and  of  the  microscopical  examination  it  is  only  necessary  to  say 
that  it  revealed  a  thick  infiltration  of  the  tissue  by  lymphoid  cells,  which  were  in  many 
parts  granular  from  degenerative  changes."  ^ 

Altogether,  the  clinical  and  pathological  features  of  this  disease  make  up  a  picture 
which  possesses  characters  of  its  own  sufficiently  marked  to  render  its  diagnosis  tolerably 
clear. 

Could  the  ulcerating  surface  have  been  well  scraped  and  thus  destroyed,  it  is  probable 
that  a  cure  might  have  been  brought  about,  but  this  method  of  treatment  could  hardly 
have  been  carried  out  in  such  an  organ  as  the  tongue  ;  at  any  rate,  its  removal  answered 
well,  as  a  speedy  cure  followed. 

The  case  is  allied  to  chronic  inflammatory  sores  of  other  parts  in  which  the  inflamma- 
tory elements  organize  as  granulation  tissues  and  dip  down  deeply  into  the  parts  around. 
In  such  nothing  less  than  the  complete  excision  or  scraping  of  the  infiltrated  tissue  will 
Turing  about  a  cure. 

Other  tumors  of  the  tongue  are  met  with,  and  I  have  recorded  some  in  the  Guys 
Hospital  Reports  for  1882,  vol.  xxvi. — more  particularly  an  example  of  blood  cyst  at  the 
base  of  the  tongue,  and  another  of  adenoma.     Such  cases  are,  however,  rare. 

The  Operation  for  the  Removal  of  a  Tongue. 

This  operation  is  comparatively  a  successful  one,  about  one  case  in  ten  dying.  It 
moreover  interferes  but  little  with  articulation.  There  are  two  good  methods  of  perform- 
ing it — one  by  means  of  the  ecraseur,  galvanic  or  otherwise  ;  the  other  by  excision, 
efl"ected  by  either  a  knife  or  scissors.  As  a  rule,  when  the  tongue  is  diseased,  it  is  wise 
to  remove  the  whole  width  of  the  organ  ;  and  under  all  circumstances  care  should  be  taken 

1  Guy's  Hosp.  Reports,  1883,  p.  134. 


TiiK  ()i'i:n.\'ri()S  for  tiii'.  removal  or  a  roxauE. 


431 


to  keep  well  clear  of  the  disease.      A  |Mii-tioii  <>\'  tin-  t()Mi::iu,'  slioiiM   l>e  taken   away  only 
wIu'U  the  disease  is  very  local. 

'i'o  reuiov(!  a  tongue  wholly  or  in   part,  tiic  patient  shniijil  In-  anaesthetized,  and  when 
the   galvanic  eeraseur   is   used   clilorot'onn   eni])loyed.      The   mouth   shouhl   he  kept  open 


I'Ki.  -Jl.S. 


>A.-y-U. 


Ficj.  219. 


l)rawiMg  showing'  tin;  <)]ii'iati()ii  for  the  Iteiiioval  of  the  Anterior  two-thirds  of  the  Tongue. 

with  a  gag-,  and  the  t()nfi;ue  well  drawn  out  of  the  mouth  by  means  of  a  thick  ligature 
passed  through  its  substance  ;  and  this  necessary  proceeding  will  be  much  aided  by  the  free 
divi.sion  with  scissors  of  the  attachments  of  the  organ  to  the  fauces  and  to  the  lower  jaw. 

When  the  eeraseur  is  used,  one  or  more  curved  needles  on  handles  .should  then  be 
passed  well  behind  the  growth,  to  isolate  it  from  the  healthy  parts  and  to  prevent  the  wire 
or  chain  of  the  eeraseur  slipping  forward.  The  eeraseur  is  then  to  be  adjusted  behind 
the  needles,  and,  being  made  secure,  slowly  screwed  home.  Should  the  operator  prefer 
to  divide  the  tongue  down  the  centre  as  a  preliminary  measure,  each  half  of  the  organ 
niav  be  removed  separately.  AVhen  the  scissors  are  used,  the  part  to  be  removed  should 
be  snipped  away  slowly  and  all  divided  vessels  twisted.  Mr.  W.  Whitehead  of  ^lanches- 
ter  warmly  advocates  this  method. 

The  amount  that  can  be  removed  through  the  mouth  by  these  means  is  measured 
only  by  the  a])pliances  the  surgeon  has  at  his  command  to  fix  its  posterior  boundary. 
In  the  case  figured  above  more  than  the  anterior  two-thirds  of  the 
tongue  were  removed,  and  by  means  of  the  curved  needle  shown  in 
the  drawing  no  difficulty  was  experienced  in  passing  the  ligature  or 
in  removing  the  organ.  When  the  diseased  tongue  cannot  be  iso- 
lated and  surrounded  with  certainty  through  the  mouth,  various 
expedients  have  been  suggested.  Professor  Syme  divided  the  lower 
lip  and  jaw  in  the  median  line  to  give  room  for  the  operation 
(a  to  B,  Fig.  219).  Regnoli  of  Pavia  made  an  incision  from  the 
hyoid  bone  to  the  chin,  and  two  lateral  cuts  from  the  anterior 
extremity  of  this  along  the  lower  border  of  the  jaw  (b  to  E  and 
c  to  D,  Fig.  219).  dividing  through  to  the  motith  all  the  tissues  that 
connected  the  tongue  with  the  lower  jaw  at  the  symphysis,  thereby 
giving  abundant  room  to  draw  the  tongue  downward.  Nunneley  of 
Leeds  introduced  beneath  the  jaw,  between  its  ba.se  and  the  hyoid  bone, 
a  sharp-pointed  curved  knife  four  inches  long,  and  brought  it  out 

in  the  mouth  at  the  fr:>jnum  linguji?  (n,  Fig.  219).  With  a  probe  illustrating  the  Different 
guided  upon  this  knife  he  then  drew  through  the  wound  the  wire 
rope  of  the  eeraseur,  drawing  a  good  loop  throtigh  the  mouth  and 
withdrawing  the  probe,  the  two  ends  of  the  rope  hanging  beneath  the  chin.  He  then 
seized  the  tongue  with  forceps,  forcibly  pulling  it  out  of  the  mouth,  and  pushed  through 
the  base  of  the  tongue  three  long  and  strong  pins,  making  their  ends  appear  in  its  upper 
surface  near  the  base  and  behind  the  disease.  He  then  passed  the  loop  of  the  ecra.seur 
behind  the  pins  and  drew  it  tight,  thus  completely  encircling  the  whole  organ.  The  pro- 
cess of  removal  then  went  on.  Sir  J.  Paget  has  done  away  with  the  submental  puncture, 
and  gives  freedom  to  the  tongue  by  dividing  the  soft  parts  that  hold  it  down  at  the  flSoor 
of  the  mouth  close  to  the  bone,  thus  allowing  the  organ  to  be  pulled  well  forward.  At 
the  same  time,  he  rightly  insisted  that  care  should  be  taken  to  divide  the  tongue  perpen- 
dicularly through  its  thickness,  and  not  obliquely ;  this  practice,  however,  is  fairly 
guaranteed  by  the  introduction  of  pins,  as  already  mentioned.     Collis  of  Dublin  advised 


Operations    for  the   Re- 
moval of  a  Tongue. 


432 


FISSURES  OF  THE  PALATE. 


that  the  cheek  be  laid  open  from  below  its  angle  to  give  room  for  manipulation  when  the 
disease  is  far  back  (r,  Fig.  219).  By  one  or  other  of  these  means  room  can  be  obtained 
to  free  the  tongue  from  its  attachments,  to  isolate  the  growth  by  pins  and  remove  it  by 
the  ecraseur,  wire  rope  being  used  when  the  galvanic  cautery  ecraseur  cannot  be 
obtained.  To  isolate  the  disease,  I  have  found  the  curved  needle,  as  seen  in  Fig.  218, 
introduced  through  the  base  of  the  tongue,  behind  the  disease,  to  be  very  valuable. 


Fig.  220. 


Fissures  of  the  Palate. 

The  hard  and  the  soft  palates  are  liable  to  fissure,  partial  or  complete,  or  both  palates 
may  be  involved.  It  may  be  that  the  fissure  appears  as  a  mere  notch  in  the  alveolar 
process,  in  the  line  of  junction  of  the  superior  maxilla^  with  the  intermaxillary  bone,  as 
is  seen  so  commonly  in  harelip,  or  it  may  pass  backward  toward  the  velum.  On  the 
other  hand,  the  soft  palate  may  show  only  a  bifid  uvula  or  a  complete  fissure.  The 
fissures  in  the  hard  and  soft  palates  are  almost  always  in  the  middle  line,  although  where 
they  involve  the  alveoli  they  diverge  as  they  involve  one  or  both  sides  of  the  inter- 
maxillary bone  ;  in  fact,  they  usually  follow  the  line  of  suture,  as  seen  in  Fig.  187. 
Fissure  of  the  soft  palate  alone  is  more  common  than  that  of  the  hard.  Yet  it  is  very 
rare  for  the  intermaxillary  bone  to  be  so  displaced,  as  seen  in  Fig.  198,  without  fissure  of 
the  palate.  Mr.  Mayland  has  recorded  an  exceptional  example  of  this  deformity  (^Lan- 
cet, November  24,  1883),  and  in  a  case  I  recently  treated  the  girl  had  a  transverse  band 
half  an  inch  wide  joining  the  two  sides  of  an  otherwise  complete  fissure  at  the  level  of 
the  palate  bone.  These  malformations,  when  severe,  interfere  much  with  speech  and  give 
rise  to  much  difficulty  in  sucking  and  deglutition,  the  food  passing  through  the  nose. 
To  relieve  this,  Mr.  Oakley  Coles  has  ingeniously  adapted  a  flap  of  india-rubber  to  the 
upper  surface  of  the  nipple  of  an  ordinary  feeding-bottle,  which,  when  the  infant  sucks, 
rises  up  and  fills  in  the  gap.  Where  this  cannot  be  obtained,  the  child  should  be  fed 
from  a  bottle  with  a  piece  of  elastic  tubing  on  its  nozzle  to  fall  over  the  roof  of  the 
tongue.     Partial  fissures  are  of  little  importance. 

Treatment. — When  fissure  of  the  palate  coexists  with  harelip,  the  lip  may  be 
operated  upon   as  usual,  irrespective   of  the  fissure.     Operations  for  the  repair  of  the 

fissure  have  till  recently  been  put  off'  till  the 
child  was  of  an  age  to  give  assistance  to  the 
operator.  Billroth  was  the  first  to  operate 
in  infancy,  and  did  so  with  success  on  a  child 
twenty-eight  weeks  old  in  three  operations. 
In  18G8,  Mr.  Thomas  Smith  introduced  to 
the  profession  a  gag  (Fig.  220)  that  holds 
the  jaws  open  and  depresses  the  tongue, 
enabling  the  surgeon  (with  the  patient  under 
the  influence  of  chloroform)  to  undertake  the 
operation  at  a  very  early  period ;  indeed, 
Mr.  Smith  has  quoted  cases  where  he  ope- 
rated at  three  years  of  age  (Met/.-Chir. 
Trans.,  1868;  *SV.  Barth.  Hosp.  Rrp.,  1871). 
It  may  generally  be  undertaken  at  the  age  of  five  in  a  healthy  child,  and  I  have  per- 
formed it  successfully  at  four  years  of  age. 

Roux  was  the  first  who  practised  the  operation  with  advantage,  having  in  1819  suc- 
cessfully treated  a  medical  student  for  cleft  palate.  Dr.  Mason  Warren  of  Boston  did 
also  much  toward  encouraging  the  practice,  but  in  this  country  there  is  no  doubt  that 
to  Sir  W.  Fergusson  is  due  the  credit  of  having  demonstrated  the  value  of  the  operation  aud 

of  suggesting  improvements  therein.  In  his  chief  paper, 
published  in"l8-t5  {Mcd.-Cldr.  Trans.),  he  showed  "how 
the  levator  jnilati  on  each  side  had  such  free  and  uncon- 
trolled action  that  whenever  excited  it  drew  the  margin 
of  the  cleft  outward  and  upward,  and  so  tugged  upon 
the  stitches  put  in  by  the  surgeon  that  ulceration  in 
their  sites  was  a  most"  probable  result."  He  therefore 
suggested  the  division  of  this  muscle  in  all  cases,  and 
that  of  the  palato-pharyngeus  in  some.  He  did  this  by 
means  of  a  curved  knife  (Fig.  221)  passed  through  the 
fissure,  so  that  its   point  can  be  laid  on  the   tissues  immediately  above  the  soft  velum, 


T.  Smith's  Gag. 


Fig.  221. 


Fergusson's  Knives. 


FISSURES   OF  THE   I'ALATi:. 


433 


inidwav  Ix'twooii  its  attacliiiiciit  to  the  Ixtrics  atnl  tlic  iiostcrinr  margin  and  aV)out  half- 
way Ix'twi'i'ii  tlio  vt'lmii  and  tlie  lower  end  <d'  tlic  Kiistacliiaii  tube.  The  point  is  then 
tlirust  deep  and  curried  half  an  incli  or  more  backward  and  forward,  so  as  to  cut  the 
levator  jiahiti.  By  these  means  tlie  jtahite  is  paralyzed  for  a  tinu;,  and  so  repair  goes  on 
with  greater  certainty. 

For  fissures  of  the  hard  ])alate  much  lias  been  done  in  more  recent  times.  Dr.  Mason 
Warren  in  lS4;i  described  the  jirocess  oi"  separating  the  hard  from  the  soft  palate  with 
the  view  of  its  closure,  though  it  lias  been  left  to  iiangenbcck,  iiillroth,  I'ollock,  Avery, 
Lawson  Tait,  Aiinaiidale,  T.  8mitli,  and  others  to  perfect  the  process. 

Opekation. — (Miloroform  is  not  necessary  in  a  patient  old  enough  to  understand  the 
necessity  of  being  still  and  assisting  the  surgeon.  In  young  children,  with  Smith's  gag, 
it  is  an  advantage. 

The  recumbent  position,  with  the  head  sufficiently  thrown  back,  is  probably  the  best, 
although  some  surgeons  make  the  patient  sit.    The  operator  should  stand  on  the  patient's 


Fig, 


Figure  showing  the  Paring  of  the  Edges 
of  Fissure  after  the  Introduction  of 
the  .Sutures. 


Needles  employed  in  Fissured  Palate. 


right  .side  or  in  front.  The  steps  of  the  operation  have  been  hitherto  as  follows :  Pare 
the  edges  of  the  fissure,  pass  the  sutures,  paralyze  the  muscles,  and  fix  the  stitches.  To 
pare  the  edges  a  blunt-pointed  bistoury  is  generally  used  and  a  thin  border  of  mucous 
membrane  cut  off  from  below  upward,  the  bifid  uvula  being  held  by  a  tenaculum-pointed 
forceps  (Fig.  222).  The  incision  also  should  be  made  as  clean  as  possible.  When  it  is 
made  from  above  downward,  a  sharp-pointed  bistoury  is  needed.  To  pass  the  sutures,  a 
corkscrew  needle  may  be  employed,  or  a  curved  needle  flattened  laterally  (Fig.  223).  with 
a  slit  in  it  for  an  eye,  or  an  eye  in  the  end.  The  lowest  suture  should  be  inserted  first 
and  both  ends  held,  this  practice  facilitating  the  introduction  of  the  others.  The  best 
material  for  sutures  is  fine  gut ;  Mr.  Smith  uses  horsehair  for  the  lower  stitches.  I  have 
rarely  used  anything  but  gut  for  all  plastic  operations  since  the  year  1860,  taking  the 
precaution  to  select  and  to  soak  it  in  water  for  some  minutes  before  using  it. 

If  Sir  W.  Fergusson's  plan  of  paralyzing  the  muscles  be  employed,  it  should  be,  as 
he  advises,  as  a  preliminary  step  to  the  operation.  If  Sedillot's  or  Pollock's  plan  be  fol- 
lowed (Fig.  225,  b),  it  may  now  be  done  by  inserting  a  knife  through  the  velum  about  a 
third  of  an  inch  from  the  highest  suture  and  cutting  along  the  posterior  edge  of  the  hard 
palate  toward  the  free  margin,  but  not  through  it.  This  is  the  course  I  have  until  recently 
adopted.  The  two  pillars  of  the  fauces  may  then  be  snipped  with  .scissors.  The  sutures 
have  then  to  be  fastened,  and  the  best  plan  is  to  run  a  perforated  shot  over  the  gut  and 
clamp  them,  tying  the  ends  of  the  gut  in  a  knot,  to  prevent  the  possibility  of  their  slip- 
ping. I  usually  begin  at  the  highest.  Care  should  be  taken  not  to  draw  the  stitches  too 
tightly.  ••  Sutures,"  says  Pollock,  •'  should  hold,  not  draw,  parts  together,  if  union  is  to 
follow."  The  parts  should  be  sponged  as  little  as  possible  ;  and  the  less  manipulation 
there  is,  the  better,  any  irritation  causing  .so  free  a  secretion  of  mucus  as  to  interfere 
greatly  with  the  surgeon's  proceedings.  Rapidity  in  operating  is,  consequently,  an  advan- 
tage.    When  the  parts  require  to  be  cleansed  in  the  adult,  iced  water  may  be  used  as  a 

28 


434 


FISSURES  OF  THE  PALATE. 


gargle ;  and  with  a  child  under  chloroform  the  stitches  may  at  times  be  inserted  and  the 
edges  pared  before  any  cleansing  is  required.  In  deep  mouths,  where  difficulty  is  expe- 
rienced in  passing  the  sutures,  a  clever  manoeuvre  suggested  by  Avery  may  be  called  for, 
and  is  illustrated  in  Fig.  225,  b;  one  end  of  the  gut C  is  pulled  through  the  soft  palate 
and  the  end  passed  through  a  loop  of  silk  a  inserted  on  the  right  side  ;  on  pulling  the 

Fig.  224.  Fig.  225. 


Figure  illustrating  Line  of  Incision.  <^Employed 
to  relieve  tension  of  the  palate  after  the  edges 
have  been  adjusted.) 


A,  Avery's  plan  of  passing  sutures. 

B,  Fergusson's  plan  of  fastening  sutures. 


loop  the  end  c  will  be  drawn  through  the  right  side.  When  silk  is  used,  the  double  reef 
knot,  as  shown  at  the  lower  part  of  Fig.  225,  and  generally  adopted  by  Fergusson,  is  very 
serviceable. 

In  some  cases  I  have  been  able  to  simplify  the  operation  by  altering  its  steps ;  that 
is  to  say,  I  have  first  introduced  sutures  through  the  soft  palate,  taking  care  to  do  .so  a 
quarter  of  an  inch  from  the  free  border  of  the  fissure,  and  secondly  pared  the  edges, 
employing  for  this  purpose  a  pair  of  scissors  with  short  blades  placed  at  right  angles  to 
their  shanks,  or  a  knife.  By  this  practice  the  introduction  of  the  sutures  is  an  easy  pro- 
ceeding, and  consequently  very  rajiidly  effected,  and  the  bringing  together  of  the  pared 
edges  can  be  readily  accomplished. 

To  relieve  tension  of  the  parts.  I  now  divide  the  soft  palate  laterally,  as  shown  in 
Fig.  224.  the  side  cuts  (a  )  subsequently  gaping,  so  as  to  appear  as  arches  (b);  in  this 
way  the  muscles  of  the  palate  are  completely  paralyzed,  and  the  soft  palate  itself  appears 
as  one  large  uvula. 

I  have  performed  the  operation  already  described  on  many  occasions,  and  with  suc- 
cess. In  none  was  there  even  a  pinhole  left.  Its  simplicity  is  very  striking.  It  cannot, 
however,  be  applied  in  all  cases. 

The  stitches  may  be  left  in  for  five,  ten,  or  even  fourteen,  days,  the  amount  of  irri- 
tation being  the  guide  to  their  removal.  When  union  has  taken  place,  the  sutures  only 
act  as  irritants ;  and  in  this  as  in  all  pla.stic  operations  they  should  be  removed  as  early 
as  possible  with  safety.  During  the  process  of  repair  the  patient  may  freely  take  soft 
food,  swallowing  by  no  means  tending  to  sepjarate,  but,  on  the  contrary,  to  close,  the 
wound.  Stimulants  may  be  given  when  desiral>le.  The  operation  should  be  undertaken 
only  in  healthy  patients ;  in  the  feeble  it  is  almost  sure  to  fail.  After  the  operation  the 
patient's  friends  .should  not  be  led  to  expect  that  an  immediate  change  for  the  better  will 
be  traced  in  the  voice,  as  such  is  never  the  case  ;  indeed,  a  long  interval  of  time,  as  well 
as  a  process  of  education,  is  necessary  to  acquire  this  result,  although  in  many  instances 
the  improvement  is  very  great.  How  far  an  operation  in  infancy  tends  in  this  direction 
has  not  yet  been  proved,  sufiicient  experience  in  these  early  operations  not  having  as  yet 
been  acquired.  If  a  small  orifice  near  the  hard  palate  be  left  after  the  operation,  no 
necessity  exi.sts  to  interfere  again,  because  it  is  a  clinical  fact  that  they  have  a  .strong 
tendency  to  contract ;  and  the  younger  the  patient,  the  greater  the  probability  of  com- 
plete closure. 

Mr.  Tait  believes — and  I  think  rightly — that  if  the  muco-periosteum  of  the  hard 
palate  be  elevated  with  a  raspatory  from  the  semilune  of  the  palate  bone,  the  tendinous 
attachment  of  the  ten.sor  palati  will  be  raised  with  it  and  thus  paralyzed,  thereby  doing 
away  with  the  necessity  of  any  such  division  of  muscles  as  practi-sed  by  Pollock  or  -Fer- 
gusson and  diminishing  the  ri.sk  of  the  pinhole  orifice  at  the  junction  of  the  hard  and 
soft  palates.  He  advocates,  moreover,  two  or  more  operation.s — viz.,  the  hard  palate  to 
be  first  closed,  and  the  soft  after  some  months'  interval. 


VLVFJlATloys   OF   Tin:    IIM'J)    WD   SOFT   I'M.ATFS. 


1:55 


Fu 


>26. 


Fir;.  227. 


B— 


Fissures  of  the  Hard  Palate.  TImsc  urc  to  In-  ircatfd  on  .similar  itriiiciple.s  to 
tliu-c  ot"  tlir  .siit't,  till,'  ;rr<';it  jKiiiit  <il'  (liHiTfiicf  fon.sistiii^'  in  tlu;  .xf)iarati<iii  nl'  the  .^nft 
parts  with  the  pi-riiLsti-iuii  I'miu  the  hmic.  For  thi.s  |»ur|>o.s('  Ijaii^a-iihcck  s  iii.stniint'iit  is 
the  he.st — a  kiiul  of  .small  Imi' ;  with  this,  after  making'  an  iiieisiitii  ihtwti  to  the  hone  ahjiij^ 
the  eil<:e  of"  the  jrum.  he  serapes  all  the  .soil  parts  tiom  the  hone  down  to  the  free  honler 
of  the  tissnre,  the.eoverinj^  of  the  ])alate  then  han^injr  as  a  free  eurtain.  Care  is  reijuired 
in  this  pmeeedin^'  not  to  tear  or  injure!  the  soft  parts,  and  more  particularly  the  anterioi 
and  posterior  ]Mirtions  where  the  ves.stds  enter.  The  other  steps  of  the  operation  are  sueh 
as  have  heen  aln-ady  deserihed.  Sinee  Novemher  22,  l.S7!>,  howevtjr.  Sir  \V.  Ferfrusson 
has  adopted  with  <;reat  sueeess  a  metlu)d  of  dealinj;  with  fissures  of  the  hard  palate  whi(di 
was  ori<rinally  proposed  by  Diefteidjach  in  Ins  O/irrftfivf  Sitrt/rn/  (1845).  There  is  a  want 
ot'evidenee  that  the  operation  was  ever  previously  performed,  and  Sir  W.  Fergusson  wa.s 
not  aware  even  of  the  suggestion  when  he  published  his  paper  (Brit.  Med.  Juiirn.,  April, 
1S74).      The  operation  as  seen  in  Figs.  2li)!  and  227  is  as  follows: 

Holes  are  first  drilled  with  a  curved  l)rad-awl  through  the  margins  of  the  hard  palate 
(Fig.  22(!,  (•)  lor  the  jiassage  of  the  threads,  while  the  palate  itself  is  then  cut  through 
with  a  chisel  in  a  line  j>arallel  to 
and  about  half  an  inch  from  the 
edge  of  the  cleft  (  Fig.  22(1,  h),  such 
a  step  being  much  facilitated  by  act- 
ing upon  .Mr.  .Mason's  suggestion  of 
previously  drilling  the  bone  with  the 
curved  brad-awl  (Fig.  22G,  a).  This 
loosening  of  the  nnirgins  of  the  hard 
palate  allows  the  borders  of  the  cleft  c 
to  be  brought  together  along  its 
whole  length  after  the  margins  have 
been  pared  and  the  stitches  twisted 
(Fig.  227).  When  any  difficulty  is 
experienced  in  appro.ximating  the 
loosened  portions  of  the  hard  palate, 
the  bones  may  be  separated  and 
prised  down  by  means  of  the  chisel 
and  the  lateral  openings  plugged 
with  lint.  Indeed,  if  the  bones  are 
well  loosened  and  the  lateral  oi)enings  well  plugged,  no  sutures  are  required  through  the 
hard  palate,  the  parts  falling  well  together.  The  operation  is  very  valuable,  and  in  my 
hands  has  been  successful. 

When  operative  relief  cannot  be  given  in  these  cases  or  has  failed,  the  patient  must 
be  handed  over  to  an  experienced  dentist ;  for  with  a  good  obturator  of  gold  or  other 
material  great  comfort  can  be  given,  and  even  a  velum  may  be  supplied  of  india-rubber. 
On  these  points  an  article  in  JI>/lmes\s  Surgery^  by  my  friend  Mr.  James  Salter,  may  be 
consulted  with  advantage.  Operative  relief,  however,  is  always  superior  to  instrumental, 
as  in  the  latter  the  patient  is  entirely  dependent  upon  the  mechanist. 

W^OUnds  of  the  palate  are  met  with  in  practice  from  patients  falling  with  pointed 
instrunuiits  in  their  nmuths.  such  as  pipes,  sticks,  spoons,  etc.  Small  wounds  need  no 
attention  and  generally  do  well ;  lacerated  wounds  dividing  the  velum  should  be  brought 
together  by  sutures  :  Init  where  they  have  been  left  and  a  separation  ensues,  the  edges 
may  be  sulise(|iiriitly  juired  and  lirought  together  as  a  fissured  palate. 

Perforations  of  the  hard  palate  are  generally  due  to  the  exfoliation  of  bone, 
and  no  plastic  operation  is  of  use.  The  proper  treatment  of  such  cases  is  to  close  the 
aperture  by  an  accurately-fitting  plate  of  metal  or  vulcanite  attached  to  the  teeth  and 
arching  immediately  below  the  palate,  but  making  no  pressure  upon  the  edges  of  the  hole 
itself,  as  the  effect  of  a  plug  is  to  enlarge  the  aperture  by  absorption. 


A,  Preliminary  punctures  with  awl  to  give  line  for  chisel. 

B,  Incision  through  bone  completed  by  chisel. 

C,  Holes  bored  through  hard  and  soft  palate  for  sutures. 
I),  .Junction  of  hard  and  soft  palate. 

E,  Lateral  openings  subsequently  filled  up  by  granulation. 
(These  drawings  were  kindly  made  for  me  by  Mr.  W.  Rose.) 


Ulcerations  of  the  Hard  and  Soft  Palates. 

These  are  very  common  as  a  result  of  syphilis,  and  appear  as  superficial  idceratious 
about  the  pillars  of  the  fauces  and  margins  of  the  velum.  They  are  often  preceded  hy 
an  erythematous  redness  and  take  on  a  sloughing  action  in  cachectic  subjects.  They 
appear,  too,  also  as  tnurous  patches  at  anj'  stage  of  syphilis,  congenital  or  acquired,  involv- 
ing at   the   same  time  the  topsils,  tongue,  etc.     They  appear  as  slightly  elevated  spots 


436 


ULCERATIONS   OF  THE  HARD  AND  SOFT  PALATES. 


covered  with  ashy  or  yellowisli  membranes,  beneatli  which  .some  sliglit  ulceration  may  be 
found.  Fre(juently  they  are  associated  with  other  symptoms.  They  are  to  be  treated  as 
part  of  a  constitutional  disease,  such  local  treatment  being  applied  as  the  aspect  of  the 
surface  may  demand.  Local  astringents,  as  alum  and  borax,  are,  as  a  rule,  of  value,  and 
also  nitrate  of  silver  or  iodoform  when  local  stimulants  are  needed. 

Strumous  Ulceration  of  the  Palate. — 'I'his  is  a  distressing  affection,  the 
ulcerative  actidii  being  oi'ton  s(j  rapid  as  to  destnjy  within  a  few  days  the  whole  fauces. 
It  is  chiefly  met  with  in  the  young  and  feeble.  In  other  instances  it  is  slower  in  its 
action,  though  equally  destructive,  gradually  eating  away  all  the  soft  tissues,  even  to  the 
hard  palate  and  pharynx,  and  is  often  mistaken  for  syphilitic  disease,  or  vice  versa.  The 
history  of  the  ease  alone  can  determine  the  point.  Tonics  and  local  stimulants  are,  as  a 
rule,  the  only  re(juisite  treatment,  good  food  of  a  liquid  nutritious  kind  being  supplied  in 
abundance.  When  gargles  are  difficult  to  use,  carbolic  acid  lotion,  sulphurous  acid, 
Condy's  fluid,  or  iodine  lotion  (a  drachm  of  the  tincture  to  a  pint  of  water)  may  be 
scattered  over  the  parts  with  the  spray-producer.  In  certain  cases  a  powerful  local 
caustic,  such  as  nitric  acid,  applied  with  a  glass  brush,  tends  to  arrest  the  action.  As 
a  result  of  ulceration  of  the  soft  palate,  it  sometimes  happens  that  the  palate  becomes 
completely  adherent  to  the  posterior  part  of  the  pharynx.  In  one  case  under  my  obser- 
vation there  was  only  an  opening  the  size  of  a  crow-quill  between  th.e  pharynx  and  the 
nose,  which  I  subsequently  enlarged  and  kept  dilated  by  means  of  tents  with  great 
advantage.  In  another  a  central  fissure  existed,  leading  down  to  the  oesophagus  and 
upward  to  the  nose.  In  this  case  the  patient  experienced  great  difficulty  in  deglutition. 
He  had  to  eat  with  the  greatest  caution  ;  otherwise,  the  food  would  pass  into  the  larynx. 
Cases  are  on  record  in  which  it  has  been  found  necessary  to  enlarge  this  pharyngeal  open- 
ing, and  even  to  open  the  trachea  to  maintain  life.  Under  such  circumstances  it  is  prob- 
ably a  wise  maxim  always  to  open  the  windpipe  before  any  operative  interference  is  under- 
taken, in  order  to  enlarge  the  pharyngeal  opening. 

Tumors  of  the  palate,  cystic  or  solid,  are  occasionally  met  with.  I  have  treated 
several  cases  of  warty  growths,  simple  and  malignant,  and  in  Gin/s  Reporti^  (18(59)  I 
have  recorded  an  interesting  case  of  myxoma  which  covered  the  whole  of  the  hard  palate 
and  was  cured  by  removal. 

In  August,  1872,  I  also  removed  from  the  soft  palate  of  a  man  ret.  38  a  globular 
fibrous  tumor  of  six  years'  growth,  the  size  of  an  unshelled  walnut,  which  'had  been  for 
six  weeks  seriously  interfering  with  deglutition  and  respiration. 
I  enucleated  the  growth  after  making  a  free  incision  into  its 
capsule,  having  previously  been  obliged  to  perform  tracheotomy 
to  prevent  suftocation.  In  this  case  I  employed  Dr.  Trendelen- 
burg's tracheal  tampon  (Fig.  228),  and  found  it  of  great  value. 
It  effectually  prevented  the  entry  of  blood  into  the  air-passages, 
allowed  the  jtatient  to  be  kept  under  the  influence  of  chloro- 
form, and  enabled  me  to  complete  the  operation  with  facility  and 
safety.  (See  Med.  Timr.s  mid  Guz.,  May,  1872.)  Where  tliis 
instrument  is  not  at  hand,  the  fauces  may  be  well  plugged  with 
sponge  after  simple  tracheotomy. 

The  majority  of  cases  of  tumors   that  involve   the  palate 
spread  from  the  gums  or  upper  jaw. 

Elongation  of  the  uvula  from  inflammatory  oedema 
is  sometimes  a  very  acute  affection.  It  comes  on  rapidly  at  times 
and  gives  rise  to  suffocative  symptoms.  I  have  seen  a  case  in 
which  the  uvula  became  as  thick  as  a  finger  and  rested  on  the 
Section  of  Trachea,"^  Dr.  tongue  with  its  tip  forward,  and  of  this  there  is  a  drawing  at 
Trendeieaburg's  Tracheal  Quy's.  An  incision  into  it,  or  several  punctures,  may  give  relief ; 
'^^'"^'"''  but,  as  a  rule,  it  is  better  to   cut  off  the   lower  half  of  the 

organ.  Elongation  from  congenital  or  other  causes  is  far  more  common  and  is  generally 
to  be  recognized  by  the  peculiar  hacking  cough  and  husky  voice  to  which  it  gives  rise, 
the  end  of  the  uvula  acting  as  a  constant  irritant  to  the  epiglottis,  or  even  to  the  glottis. 
There  is  reason,  indeed,  to  believe  that  not  a  few  of  the  cases  of  suppos-ed  laryngeal  irri- 
tation are  due  to  this  cause.  The  removal  of  the  lower  half  of  the  organ  by  means  of  a 
long  pair  of  forceps  or  scissors  rapidly  gets  rid  of  all  the  symptoms. 

A  polypus  composed  of  simple  mucous  membrane  may  grow  from  the  uvula.  I 
have  removed  one  from  the  tip,  and  another  from  the  base.  They  give  rise  to  symptoms 
identical   witli   those  of  elongation.      I   had  also  a  case  under  observation  in  which   the 


Fig.  228. 


ciUKiMc  i:si.M'j.i:mi:s r  or  /•///■;  rnssn.s. 


437 


nolypiis  hail  so  ImiLr  a  iicdiinclc  as  to  fall  al  liiiHv-  into  tlic  milirc  nl'  tlic  laiviix  and  excite 
a  violent   spa-iinMlie  eiiiit:;|i,  l»ut  tin-  Iiiaii  ri'liiseil  In  liaV4'  it   reliniVeil. 

Tonsillitis. — As  an  aeiiti-  art'eclidii  this  is  known  as  i/ninxj/.  and  is  ehaiaelerized  hy 
tlu-  rapid  swelling  ol'  tin-  part,  aeute  pain.  I'onl  ton!j;ne,  and  I'ever.  Within  three  <hiy.s,  or 
loiiirer,  snppnration  may  occur;  and  when  snthii-ativ*-  symptoms  make  their  appearance, 
thf  siirjrooii  s  interrerence  may  Ix' (h'lnandetl.  At  tinn-s  life  may  he  sacrificed  hy  tin-  want 
of"  suri^ical  attention.  Some  years  a;:o  a  case  came  hef'ore  my  notice  where  a  diild  two 
years  of"  aire  was  sutlocated   from  the  InirstiuLr  of  a  tonsillitie  ahsccss. 

<ireat  redness  and  rapitl  swellin;;  of  tlie  ort;aiis  are  tlie  chief  hical   symptoms. 

'I'kk.vtmknt. — Fomentations  externally,  the  inhalatii f  iiot  steam.  an<l  the  admin- 
istration of  saline  purL'atives  are  essential  points  (d'  jiractice.  As  t(»  dru^s.  none  seem  to 
have  so  ]iowerfiil  an  intlueiici'  over  the  disease  as  i^uaiaeuni  an  ounce  of  the  tni.\tiire  with 
some  comp(Uind  spirits  of  ammonia  heini;-  the  best  form;  and  when  this  is  employed  early, 
suppuration  rarely  appears.  When  an  aliscess  has  formed,  the  sooner  it  is  o]iened  the 
better.  The  bi-st  mode  of  doinu'  this  i,s  to  cover  a  straight  bistoury  to  within  half  an  inch 
of  its  ]ioint  with  lint,  and,  havini;'  depressed  the  tonj^iie  with  the  fitifrer.  to  introduce  it 
into  the  swollen  tissue,  makin;j;  a  free  incision,  care  beiii<:  taken  not  to  direct  the  point 
of  the  knife  outward,  Imt  directly  backward.  Should  ]ius  a))pear  behind  the  pharynx,  it 
must  be  let  out.  Tonics,  such  as  ((uinine  or  iron.  >1i(mi!(1  tlitii  be  i^iven,  with  good  footl  ; 
a  speedv  convalescence,  as  a  rule,  ensues. 

Tonsillitis  Maligna. — This  is  a  fonn  of  inflammation  of  the  tonsihs  met  with  in 
feeble  subjects  which  results  in  ulceration  and  is  often  most  intractable.  It  begins  a.s 
other  forms  of  inflammation  and  runs  its  course  rapidly,  the  ulcerating  process  being  gene- 
rally associated  with  sloughing.  The  parts  about  the  tonsils,  even  the  root  of  the 
tongue,  often  become  involved.     The  disease  is  at  times  associated  with  .scarlet  fever  or 

Treatment. — This  affection,  l)eing  always  found  in  feeble  or  cachectic  subjects, 
requires  tonic  treatment  with  both  food  and  medicine.  Good  broths  and  milk,  with 
stimulants,  are  always  reijuired  ;  nutrient  enemata  should  be  used  when  enough  nonri.sh- 
ment  cannot  be  swallowed.  Quinine  and  iron  as  medicine  are  also  called  for.  with  small 
doses  of  laudanum  to  soothe  ]>ain.  Locally,  suljdnirous  acid.  em])loyed  every  hour  or 
less  as  a  spray,  is  very  beneficial,  or  tlie  local  application  of  the  mixture  of  iron  and  gly- 
cerine. 

Chronic  Enlargement  of  the  Tonsils. — This  is  frequently  met  with  in  feeble 
children  as  well  as  in  adults  living  in  marshy  and  damp  localities.  It  is  often  a  sequel 
of  the  acute  inflammation,  but  more  often  it  appears  without  any  such  cause.  There  is 
reason,  too,  to  believe  that  some  of  the  cases  of  so-called  chronic  enlargement  of  the  ton- 
sils are  due  to  new  adenoid  tonsillitie  growths.  On  two  occasions  when  removing  these 
enlarged  organs  I  have  turned  out  distinct  tumors  the  size  of  nuts  embedded  in  and  sur- 
rounded by  tonsillitie  tissue.  The  tumors  were  distinctly  glandular,  and  under  the  micro- 
scope could  not  be  distinguislied  from  tonsil  tissue.  In  both  cases  the  enlargement  was 
unilateral.  Bilateral  increase  is  probably  always  due  to  hypertrophy  or  chronic  inflam- 
matory enlargement. 

Enlarged  tonsils  give  rise  to  a  peculiar  nasal  twang  in  speaking  and  to  a  most  distress- 
ing snoring,  the  patient,  as  a  rule,  having  a  half-opened  mouth  night  and  day.     They  are 

Fig.  229. 


Cniillotiuo  prepared  for  Use. 


commonly  associated  with  irritable  mucous  membranes  generally.  I  have  seen  them  so 
troublesome  in  a  child  three  and  a  half  years  old  as  to  prevent  the  deglutition  of  solid 
food,  the  patient  having  lived  for  six  months  on  liquid  nourishment.  Tonic  treatment  is 
essentia]  in  all  these  cases;  so  is  a  simple  nutritious  diet.  A  mixture  of  bark  and  soda 
at  first  is  the  best  to  soothe  and  give  tone  to  the  digestive  api)aratus.  cud-liver  oil.  quinine, 


438 


CANCER    OF  THE  TONSIL. 


and  iron  being  subsequently  prescribed.  "When  the  organs  are  congested  from  inflamma- 
tion, a  mixture  of  glycerine  and  tincture  of  the  perchloride  of  iron  in  equal  parts  should 
be  used.  It  is  wise,  also,  to  give  the  patient  some  solid  iodine  in  a  perforated  box,  to 
stand  on  a  shelf  in  the  day  as  well  as  in  the  sleeping-room  ;  the  gradual  evaporation  of 
the  iodine  purifies  and  iodizes  the  air  in  a  beneficial  manner. 

When  the  glands  are  white  and  hard,  all  hopes  of  curing  them  by  medical  treatment 
are  at  an  end ;  excision  is  the  only  thing  to  do.     For  this  purpose   the  guillotine  (Fig. 


Fig.  2.30. 


Fig.  231. 


Operation  on  Tonsil  with  (niillotine. 


Removal  of  Tonsil  with  Knife. 


229)  is  the  best  instrument  to  employ  when  it  is  at  hand ;  otherwise,  a  pair  of  vulsellum 
forceps  and  a  bistoury  must  be  used,  guarding  the  base  of  the  latter  with  lint  or  strap- 
ping to  protect  the  lips  (Fig.  231). 


Calculus  in  the  Tonsil. 

In  1860  such  a  case  came  under  my  care.  A  man  aet.  38,  after  having  suffered  from 
enlargement  of  the  right  tonsil  for  a  year  and  a  half,  expectorated  a  calculus  the  size  of  a 
nut,  the  expulsion  of  it  having  been  preceded  for  three  days  by  severe  local  pain  and 
immediately  beforehand  the  sensation  of  something  having  given  way  in  the  parts. 
"When  I  saw  him,  there  was  a  distinct  cavity  in  the  tonsil.  The  stone  was  hard  and 
ragged,  and  appeared  to  be  made  up  of  phosphatic  salts ;  but  the  patient  claimed  the 
stone,  and  therefore  it  was  not  examined.  Small  calculi  the  size  of  mustard-seeds  are 
more  common,  and  are  supposed  to  be  calcified  tuberculous  deposits.  In  Guy's  Hosp. 
Mus.  (Prep.  1677^")  there  is  a  specimen,  analyzed  by  Dr.  Babington,  which  consisted  of 
phosphate  of  lime. 

Cancer  of  the  Tonsil. 

This  rapidly  fatal  affection  happily  is  rare  and  has  not  received  much  attention.  It 
may  appear  as  a  primary  or  secondary  affection  and  in  the  encephaloid  or  fibrous  form. 
The /bn?ifr,  being  the  more  frequent  and  rapid  in  its  course,  destroys  life  mechanically 
by  secondary  glandular  enlargement,  as  well  as  by  pharyngeal  and  laryngeal  obstruction. 
The  latter  is  seen  mostly  as  an  ulceration  and  proves  fatal  by  exhaustion.  I  have  in  one 
case  seen  this  disease  cause  death  by  sudden  and  violent  hemorrhage  owing  to  extension 
to  and  perforation  of  the  internal  carotid  artery. 

This  affection  begins  as  an  ordinary  enlargement  of  the  gland,  but  is  more  rapid  in 
its  growth,  and  is  mostly  attended  by  early  enlargement  of  the  lymphatic  glands  at  the 
angle  of  the  jaw,  and  subsequently  of  those  of  the  neck.  When  it  ulcerates,  the  ulcer 
assumes  the  indurated  jagged  appearance  of  a  cancerous  sore,  not  unlike  the  deep  syphi- 
litic sore  after  the  breaking  down  of  a  gummy  tumor.  It  has,  however,  a  more  indurated 
base  and  border  than  the  syphilitic.  It  attacks  men  mostly  of  middle  age.  bat  I  have 
had  under  m}-  care  a  sweep  only  seventeen  years  of  age  with  the  hard  form. 

Treatment. — Palliative  treatment  is  probably  the  best  to  adopt,  although  Dr. 
Cheever  of  Boston  has  proved  that  the  tonsil  may  be  successfully  extirpated  by  external 
incision  (Boftton  Med.  Surg.  Jnurn.,  1871).  Its  removal  from  within  seems  almost  hope- 
less, whether  by  caustics — Maisonneuve's  plan — the  ecraseur,  or  enucleation.  I  attempted 
the  latter  in  one  case  only  with  partial  success,  and  the  operation  prolonged  life. 

Dr.  Cheever  performed  his  operation  through  an  incision  made  below  the  angle  of  the 
jaw  of  three  and  a  half  inches,  along  the  anterior  border  of  the  sterno-mastoid  muscle, 
with  a  second  incision   extending  along  the   lower  border  of  the  jaw.     The  flaps  were 


DTSEASFS  ()F  Till':  CfMS,  ./.Ill's'.    ETC  439 

n'flcctcd  aiiJ  a  lar<re  <;laiKl  wa.s  fiiuclfated.  The  (lijrastric,  .stylu-hyoiJ.  and  .styl'>-;rlo.x.su8 
luu.sclos  wore  cut,  the  tihre.s  of  the  .superior  con.strictor  heiii;;  divided  u])on  a  director. 
The  pharynx  wa.s  opened.  The  finjjjer  of  the  ()])erator  wa.s  then  swept  round  the  di.sea.sed 
tonsillitic  mass,  which  was  enucleated.  The  heniorrlia<;e  was  free,  tlioujrh  not  excessive, 
and  twelve  liiratures  were  apj)lied.  A  steady  convalescence  followed.  "'The  lacility."  adds 
Dr.  Cheever,  "  with  which  the  tonsil  can  he  enucleated  with  the  finger  is  surprisiufr." 
This  operation  has  been  frci|Ui'ntly  repeated,  and  with  enou;ih  success  to  justify  its  per- 
formance ill  cases  in  which  the  ulamls  are  not  too  far  involved.  For  further  information 
on  this  sultjcct  refereiict'  may  he  made  to  the  article  ''Aniyj^dales,  No.  2,"  I)i' liimiiuirn  de 
JUti/ecine,  180").  and  to  Poland's  artiflc.  /hit.  (iml  Fonlijn  Rrririr.  April.  1S7-. 


CHAPTER    XIII. 

DISEASES  OF  THE  GUMS,  JAWS,  TEETH,  PHARYNX,  AND  (ESOPHAGUS. 

Hypertrophy  of  the  Gums. 

Cases  of  this  nature  have  been  recorded  by  Salter,  Gros.s,  Heath,  and  others,  and 
they  are  said  to  be  congenital.  The  disease  may  be  jreneral  or  local,  and  for  its  cure 
nothintr  less  than  its  exci-sion,  with  the  aft'ected  alveolus,  is  of  any  use,  the  gum  dipping 
down  into  the  sockets  of  the  teeth  in  the  same  way  as  other  periosteal  growths  are  seen 
to  do. 

Polypus  of  the  gum,  or  outgrowths  of  gum  structure,  are  due  to  the  irritation 
of  carious  teeth  or  to  uncleanly  habits.  They  can  be  cured  by  the  removal  of  the  growth 
and  its  cause. 

Vascular  tumors  are  met  with  on  the  gums,  and  generally  between  the  front 
teeth.  They  are  sometimes,  but  not  always,  associated  with  carious  teeth.  The  out- 
growth is  usually  small  and  more  or  less  pedunculated,  bleeding  on  the  slightest  manip- 
ulation. The  vascular  tumor  occasionally  presents  more  the  features  of  a  naevus.  I 
have  destroyed  many  of  these  growths  by  means  of  the  galvanic  cautery  with  .succe.ss, 
but  they  can  be  removed  by  the  knife  or  any  caustic.  When  a  carious  tooth  appears  to 
be  the  cause  of  the  disease,  it  should  be  at  once  removed. 

A  cancerous  disease  <>f  the  gums  puts  on  precisely  similar  appearances  to  tho.se 
seen  in  similar  diseases  of  the  fauces,  face,  or  tongue — an  irregular,  excavated,  ulcerating 
surface  discharging  fetid  pus,  associated  with  pain  and  glandular  enlargement.  Most  of 
the  cases  of  cancerous  epulis  are  epithelial.  The  benign  form  of  epulis  is  generally  an 
affection  of  young  life,  and  the  cancerous  of  the  old  and  middle-aged. 

Inflammation  and  ulceration  of  the  gums  is  met  with  in  children,  the 

result  of  stomatitis,  and  in  adults  from  other  cau.ses.     It   always  occurs  in  cachectic  sub- 
jects and  must  be  treated  generally. 

Abscesses  about  the  gums  are  very  common  and  are  frequently  the  result  of 
disease  of  the  teeth.  Dentists  tell  us,  however,  that  these  "  gum-boils "'  rarely  induce 
any  disease  of  the  bone,  though  they  sometimes  arise  from  it.  When  connected  with  a 
carious  tooth  and  of  long  standing,  nothing  but  the  removal  of  the  tooth  will  effect  a 
cure.  A  free  incision,  however,  into  the  inflamed  gum  generally  gives  relief,  cuts  short 
the  disease,  and  may  save  a  tooth  :  it  may,  moreover,  prevent  burrowing  and  much 
further  trouble.  When  associated  with  disease,  such  as  *■  necrosis,"  or  death  of  the  bone, 
the  removal  of  the  dead  portion  is  an  absolute  neces.sity. 

Necrosis  of  the  Jaws. 

Necrosis  may  take  place  as  a  result  of  ostitis  or  periostitis  or  it  may  follow  a  fracture. 
It  is  well  known  to  follow  an  exanthem  and  to  be  brought  about  by  the  fumes  of  phos- 
phorus or  of  mercury.  It  is  found  in  both  upper  and  lower  jaws.  An  analysis  of  50 
consecutive  cases  shows  that  10  were  in  the  upper.  29  in  the  lower,  and  2  in  both,  thus 
controverting  the  assertion  of  Stanley,  which  has  been  repeated  by  others,  that  necrosis 
of  the  upper  jaw  is  rare.  It  may  show  itself  at  any  period  of  life.  I  have  seen  it  in  an 
infant  a  furtnioht  old.  althouiih  it  is  more  common  in  the  vouiiir  and  middle-aired  than  in 


440  NECROSIS  OF  THE  JAWS. 

the  aged.  It  may  attack  any  portion  of  the  bones,  and  even  the  condyloid  processes  of 
the  lower  jaw  may  die  and  be  removed,  leaving  a  movable  jaw  by  the  spontaneous  for- 
mation of  a  new  joint.  The  child,  ast.  8,  from  whom  I  removed  the  bone  illustrated 
below  (Fig.  232),  could  move  the  jaw  as  well  as  if  the  condyle  had  never  been  destroyed, 

and   in    Guy's  Iloi^p.  Rep.  for  1869  I  recorded  another 
F'iG.  232.  similar  case.     After  necrosis   of  the  upper  jaw  there 

is  little  or  no  osseous  repair  to  be  expected  ;  in  the 
lower  jaw  it  may  be  very  complete. 

Necrosis  of  a  bone  is  always  preceded  by  symp- 
toms of  inflammation,  such  as  swelling  and  pain,  fol- 
lowed ra])idly  by  suppuration  and  the  formation  of 
sinuses  leading  down  to  the  bono,  which  may  be  felt 
l)y  a  probe.  A  single  sinus  beluw  the  jaw  or  in  the 
neighborhood  may  be   due   to  the  presence  of  a  dis- 

Portion  of  Lower  Jaw  reiiKivtii  IVir  Necrosis    *^'^^t;d  tOOth. 

irom  a  Child  at.  8,  the  .Movements  of  the         Necrosis  is  likewise  a  common  aifcction  as  the  con- 

,Jaw     subsequently     being     perfectly    Ke-  o  n  ^i  i    xi  •     £■     i.    • 

gained.      ^        ■'  "    '  •'  sequence  oi  some  lever  or  exanthem,  and  this  lact  is 

now  fairly  recognized.  It  is  more  common  in  chil- 
dren than  in  adults.  As  a  rule,  it  appears  on  the  decline  of  the  fever,  with  pain  and 
swelling  about  some  portion  of  the  gums,  and  rapidly  passes  on  to  suppuration  and  death 
of  the  bone.  The  necrosis,  however,  is  generally  confined  to  the  alveolus  ;  in  exceptional 
instances  only  it  involves  the  body  of  the  bone.  Both  jaws  are  equally  liable  to  the 
affection.  In  the  Guy's  IIosp.  Reports  for  18<J0  I  recorded  a  series  of  cases  to  illustrate 
these  points.  In  one  case,  narrated  in  detail — that  of  a  woman  a?t.  25  who  in  infancy 
had  lost  a  large  portion  of  her  upper  jaw  after  measles — the  lower  jaw  had  grown  up  to 
fill  in  the  deficiency  in  the  upper.  It  was  nearly  one  inch  higher  in  its  vertical  measure- 
ment on  the  right  side  than  theleft;  it  seemed,  indeed,  as  if  the  lower  jaw  had  grown 
upward  for  want  of  the  regulating  influence  of  the  natural  pressure  which  the  teeth  of 
the  upper  jaw  must  exert  upon  those  of  the  lower  when  in  contact  with  them.  I  have 
recently  seen  a  similar  case  where  the  increase  of  growth  had  taken  place  in  the  upper 
jaw,  in  consequence  of  a  deficiency  in  the  lower. 

Necrosis  of  the  jaws  as  a  result  of  the  phosphorus  poison  is  now  rarely  seen,  in  conse- 
quence of  the  common  phosphorus  being  less  frequently  employed  than  formerly  in  the 
making  of  lucifer  matches.  Dr.  Bristowe  in  his  report  to  the  Privy  Council  in  18G3 
clearly  showed  that  it  is  to  its  influence  the  disease  is  to  be  attributed,  flie  amorplious 
2>hosp/ioriis  being  harmless.  The  first  notice  of  the  affection  in  this  country  was  by  my 
colleague.  Dr.  Wilks,  in  the  Guy's  Hasp.  Rep..  1847,  page  1(J3.  The  disease  is  acute  in 
every  sense.  It  may  involve  a  part  only  or  the  whole  of  the  upper  or  lower  jaw.  both 
seeming  to  be  equally  liable  to  the  affection  ;  but  in  the  majority  of  cases  the  teeth  of  the 
aff"ected  bone  are  more  or  less  diseased  or  deficient.  It  is  a  rare  thing  to  find  the  disease 
in  subjects  who  have  sound  teeth  or  in  those  who  have  a  complete  set.  Some  openings 
down  to  the  bone,  either  through  carious  or  deficient  teeth,  appear  to  be  necessary  to 
enable  the  phosphorus  fumes  to  act  upon  the  bone.  Dr.  J.  Wood  of  New  York  records 
a  case  in  which  the  whole  bone  died  and  was  restored.  The  disease  begins  for  the  most 
part  by  a  general  aching  of  the  teeth,  followed  by  rapid  suppuration  and  necrosis  of  the 
aff"ected  bone.     The  constitutional  are  usually  as  severe  as  the  local  symptoms. 

Treatment. — When  dead  bone  can  be  detected  in  either  the  upper  or  the  lower  jaw, 
its  removal  is  the  only  one  form  of  practice  which  ought  to  be  entertained ;  and  this 
should  be  eff"ected  by  the  mouth  with  as  little  disturbance  as  possible  to  the  soft  parts  or 
to  the  new  bone-forming  tissues,  such  as  the  periosteum.  When  external  incisions  are 
neces.sary,  they  should  be  made  where  afterward  they  will  be  little  seen. 

In  necrosis  of  the  upper  jaw  the  bone  can  nearly  always  be  reiuoved  by  means  of 
incisions  made  heneeith  the  cheek.  An  incision  through  the  check  never  seems  necessary. 
In  necrosis  of  the  fow;^?- jaw,  when  incisions  through  the  integument  are  demanded,  they 
should  be  made  below  the  lower  border  of  the  bone.  When  the  dead  bone  is  fixed,  or 
rather  before  it  has  been  thrown  off"  from  its  attachments  and  before  a  new  easing  of  bone 
has  been  formed,  all  operative  interference  must  be  condemned,  particularly  in  the  lower 
jaw,  as  there  seems  little  room  to  doubt  that  the  muscles,  acting  upon  the  new  bone  before 
it  has  become  consolidated,  may  alter  its  shape  and  produce  deformity.  Under  these  cir- 
cumstances, the  surgeon  should  content  himself  with  seeing  that  all  pent-up  pus  has  free 
exit  by  means  of  incisions  through  the  gum,  also  that  the  patient's  mouth  is  kept  as  clean 
as  possible  by  frequent  washing,  and  that  his  general  condition  is  maintained  by  means 


KPrrjs. 


441 


of  toiiif  nu'tlicine  and  nutritious  diet.  Wlu-n  thr  necrosis  is  confincil  to  the  alveolus  in 
which  the  teiujiorary  teeth  are  situated,  j:reat  care  should  he  taken  that  the  parts  heneath 
are  not  disturhed  and  that  the  ]iernianent  teeth  are  not  interfered  with.  Even  when 
exposed,  these  penuanent  teeth  need  not  of  necessity  he  removed.  In  youiiL'  |iatients 
where  nuich  loss  of  hone  has  taken  place  it  seems  desirahle  to  have  some  artificial  suhsti- 
tute,  in  order  to  prevent  the  occurrence  of  such  an  overirrowth  of  the  opposin;.'  jaw  as 
took  place  in  the  cases  already  referred  to.  Where  the  antrum  is  exposed  l»y  exl'oliation, 
much  mav  he  done  hy  the  dentist  to  till  in  the  jrap.  At  times,  also,  the  fistulous  f»peninj; 
takes  jdace  externally;  thus,  in  1S(I4,  I  was  called  on  to  treat  a  woman  :et.  v>4  who  nine 
years  previously  had  had  extensive  necrosis  of  the  upper  jaw.  and.  as  a  conse<|uence,  a 
fistulous  openini:  the  size  of  a  sixpence  was  left  l»el<tw  the  riL'ht  eye.  communicating 
directly  with  the  antrum.  The  soft  jiarts  were  firndy  connecte<l  with  its  marL'^ins  and  the 
lower  lid  was  drawn  down.  I  raised  the  intei;iimcnt  from  the  hone  hy  making  free  suh- 
cutaneous  incisions,  pared  the  edges  of  the  flajis,  and  hntught  them  together  over  the 
ojiening  in  the  hone.      Good  union  followed,  and  the  deformity  was  removed. 


Epulis. 

Under  this  term  ■epulis'"  arc  included,  rightly  or  wrongly,  most  of  the  tumors  of  the 
gums,  polypoid  or  difiused,  simple  outgrowths  from  the  gums  due  to  the  irritation  of  a 
carious  tooth  or  stumji,  papillar}',  fihrous,  fibroplastic,  myeloid,  ejuthelial.  and  cancerou.s 
tumors. 

The  true  or  fibrous,  fibroplastic,  and  myeloid  epulis  (for  the-^e  elements  enter  in  differ- 
ent proportions  into  all  the  benign  forms  of  epulis)  are  diseases  chiefly  of  the  periosteum 

Fig.  234. 


Filirous  Epulis  Irmii  <  luin. 
(Drawing,  (iuy's  Hosp.  Mus.,  171'".    Mr.  Birkett's  case.) 


Epulis  springing  from  P?one. 
(Mr.  Key's  case,  i 


(Fig.  233)  and  are  rarely  cured  without  removal,  together  with  the  portion  of  bone  upon 
which  they  are  placed,  since  the  growth  dips  down  into  the  sockets  of  the  teeth  about 
which  it  springs.  At  times,  however,  they  invade  the  bone  itself  (Fig.  234),  the  endo.steal 
membrane  which  lines  the  bone  being  continuous  with  the  periosteal  covering  it.  They 
appear  as  simple  fleshy  outgrowths  of  the  gum  about  a  tooth  and  develop  into  a  large 
mass  of  a  firm  or  semi-elastic  tissue.  At  a  later  stage  this  mass  may  ulcerate  and  break 
down. 

In  exceptional  cases  a  tumor  that  appears  to  be  an  epulis  results  from  the  abnormal 
development  of  a  tooth;  this  was  the  case  in  a  boy  xt.  11,  from  which  Fig.  235  was 


Fig.  235. 


Fig.  236. 


Front  view  of  Tumor  of  Alveolus.  fDue 
to  hypertrophy  and  dilatation  of 
tooth  fang.) 


Odontone  after  Removal. 


Section  of  Odontone,  showing 
expanded  thickened  Foot  of 
Incisor  Tooth. 


taken,  the  expansion  of  the  alveolus  having  been  brought  about  by  the  development  of 
an  odontone  of  the  root  fang  of  an  upper  incisor  tooth  which  had  been  growing  for  three 
or  four  years. 


442  TUMORS  OF  THE  JAWS. 

Fig.  235  illustrates  the  swelling  of  the  gum  before  the  removal  of  the  disease,  Fig. 
236  the  tumor  on  its  removal,  and  Fig.  237  the  same  in  .section.  My  friends  Messrs.  Sal- 
ter and  Moon  informed  me  that  this  is  a  unique  case.  In  the  diagnosis  of  such  a  case 
the  protrusion  of  the  crown  of  the  tooth  becomes  a  valuable  guide. 

Treatment. — The  removal  of  the  disease  of  the  teeth  or  stumps  that  are  involved 
in  it,  as  well  as  of  the  bones  with  which  it  is  connected,  is  the  only  sound  practice  to 
adopt.  A  good  pair  of  cutting  pliers  which  will  nip  off'  as  much  of  the  alveolar  process 
as  seems  involved  is  the  best  instrument  to  use,  a  small  hand-saw  having  marked  out  ver- 
tically the  limit  of  the  incision.  AVhen  the  bone  is  not  removed,  a  return  of  the  disease 
is  almost  certain. 

Tumors  of  the  Jaws. 

Some  of  the  most  remarkable  tumors  of  these  bones  are  due  to  hypertrophy  or  hyper- 
ostosis, the  lower  jaw,  with  other  bones  of  the  face  and  head,  being  generally  involved. 
Mr.  Howship's  well-known  case  of  disease  of  the  upper  jaw.  which  is  noticed  everywhere, 
is  a  case  in  point:  so  is  that  of  3Ir.  Bickersteth,  which  was  exhibited  at  the  Pathological 
Society  in  1866,  and  which  he  described  with  all  minuteness  in  the  Transactions  of  the 
year.  The  disease  is  usually  symmetrical,  showing  it.self  as  a  uniform  enlargement  of 
the  bones  involved,  the  upper  jaws  projecting  as  two  large  globular  masses.  When  the 
ascending  ramus  of  the  lower  jaw  becomes  hypertrophied  and  elongated,  a  curious  one- 
sided deformity  of  the  face  exists. 

Cystic  Disease  of  the  Antrum. — This  is  a  special  affection  and  often  connected 
with  irregular  dentition,  though  how  often  has  not  yet  been  determined. 

Suppuration  of  the  cavity  is  often  due.  doubtless,  to  an  extension  of  inflammation 
from  the  teeth,  and  may  arise  from  a  blow  or  other  cause.  It  is  known  by  severe  local 
pain  extending  over  the  face  and  forehead,  local  swelling,  and  extreme  tenderness,  the 
constitutional  symptoms  being  often  very  severe.  AYhen  pus  has  formed,  there  may  be 
rigors ;  and  the  abscess  may  burst  either  into  the  nose  or  into  the  mouth  beneath  the 
cheek,  the  antrum,  under  these  circumstances,  becoming  much  distended.  In  rare  cases 
it  may  make  its  wa}'  through  the  cheek,  and  in  one  where  this  occurred  an  opening  into 
the  antrum  the  size  of  a  fourpenny  piece  was  found  on  making  an  incision  down  in  the 
bone  beneath  the  cheek.  In  neglected  instances  the  floor  of  the  orbit  may  be  displaced 
and  vision  interfered  with,  or  even  destroyed.     (  T7c7e  Salter.  Meil.-Chir.  Trans.,  1863.) 

Treatment. — When  suppuration  has  been  made  out,  the  antrum  should  be  opened ; 
and  if  its  anterior  wall  be  expanded,  an  opening  may  also  be  made  into  it  without  fear  at 
the  most  projecting  point  with  a  trocar  or  other  sharp  instrument.  The  relief  given  by 
these  means  is  very  .signal.  In  one  case  of  a  lady  that  came  under  my  care  some  years 
ago  it  was  instantaneous  and  permanent.  When  diseased  teeth  are  present  in  the  bone, 
they  should  all  be  tested  by  a  sharp  blow  and  the  most  tender  removed.  A  jet  of  ether 
spray  on  each  tooth  will  prove  an  admirable  test,  the  cold  searching  out  the  slightest  dis- 
ease. It  is  never  advisable  to  remove  sound  teeth  unless  some  evidence  exists  of  their 
alveoli  being  diseased.  In  all  these  cases  the  cavity  must  be  kept  clean  by  syringing. 
A  chronic  abscess  in  the  antrum  may  be  so  insidious  in  its  formation  as  to  induce  the 
surgeon  to  believe  that  a  tumor  exists.  Liston  gives  an  instance  in  his  Practical  Sure/cry 
of  such  an  error,  in  which  removal  of  the  jaw  was  attempted.  In  all  tumors  of  the  upper 
jaw  the  probability  of  the  pi*e.sence  of  a  large  cyst  should  never  be  forgotten. 

Hydrops  Antri. — Under  this  term  is  grouped  a  number  of  "cases  which  include 
examples  of  cysts  of  the  antrum,  cysts  of  its  wall,  and  cysts  placed  outside  the  bone, 
and  all  are  characterized  by  a  gradual,  painless  expansion  of  the  part  which  rarely  pro- 
duces other  symptoms  than  tho.se  due  to  mechanical  pressure.  The  swelling  may  encroach 
on  the  nose,  and  cause  obstruction  ;  on  the  orbit,  and  press  on  the  globe  :  on  the  mouth, 
and  produce  bulging  of  the  palate  ;  and  on  the  cheek,  so  as  to  cause  deformity ;  indeed, 
it  is  often  because  of  this  that  the  patient  is  induced  to  seek  advice.  When  the  expan- 
sion is  great,  the  shell  of  bone  may  become  so  thin  as  to  crackle  like  parchment  under 
pressure  or  to  appear  as  if  only  membranes.  M.  Giraldes  in  1853  ( Montyon  prize)  was 
the  first  to  describe  these  cy.sts  with  clearness,  although  Mr.  W.  Adams  had  previously 
recognized  them.  (See  St.  Thomas's  Hospital  Museum  Catalogue.')  The  old  surgeons 
looked  upon  this  affection  as  the  result  of  obstruction  to  the  aperture  between  the  nostril 
and  antrum,  the  dilatation  of  the  bone  being  due  to  retained  mucus  :  but  this  is  now 
known  to  be  an  error.  Giraldes  regards  these  cysts  as  dilatations  of  the  glandular  follicles 
of  the  mucous  membrane.  The  fluid  contents  of  these  cysts  are  always  viscid,  occasion- 
ally  clear,   but   mostly  blood-stained,   sometimes   purulent,   containing  cholesterine,  but 


Ti'M>>i:s  OF  Tin:  ./.I  ii'.s'. 


443 


iii'vcr   pure   imii-ii- 


II  l^TS  I  Ii:i(l  a  casf  in  :i  1m. y  .ft.  !'•.  witli  tlie  lato  Mr.  K.  I*lullii».s 
of   Lfiii>t('r  S<|iian',  \vli('r<'  tlu"  fluid  was  .scnuis  ami  lil<i(Hl->laiiir.l  in  a  lii;ili  ilc;.M-L'e. 

Tlu"  Ininrjiiw  may  likewise  he  the  seat  ul'  a  simple  cystic  tuiimr  (ir  expansion.  In 
IST")  1  hail  a  ease  in  a  wnnian  ;i'l.  I-  in  wlmm  tin;  eyst  hail  expamleil  the  aseemlin}^  as 
well  as  part  of  the  hori/oiital  ramus,  ami  it  loiitaiiieil  no  irrowth.  The  preparation  is  in 
the  tJiiy's  .Mii>riiiii  (  lOlM'). 

DentigerOUS  cysts  ;'i<'  iliuiially  elo.-ely  allinl  to  thoM-  jii>t  ile>rril>eil  ;  patholoj.M- 
eally  they  may  ilifler  ;  hut  there  ean  he  no  iloul)t  that  the  cysts  are  coniiecte<l  with  the 
teeth,  wliieh  are  in  some  cases  fully  ilevelopeil  ami  in  others  imperfectly  so.  'i'hey  are 
fouml  in  hoth  upper  ami  lower  jaws.  Heath,  in  his  e.vcellent  Knsnij  on  llii  Jnux  (oil  eilit., 
ISSl),  informs  us  that  cysts  of  small  size  in  connection  with  the  fari^rs  of  jiermaiieiit  teeth 
are  frei|ueiitly  found  on  extracting  the  latter,  Itut  -ive  rise  to  no  symptoms  ilemamliii<,' 
surpcal  interference.  Occasionally  j^rowing  to  a  large  size,  they  i.rodiicc  ah.sorittion  of 
the  containinu;  alveolus  and  give  rise  to  a  prominent  swelling.  The  disea.se  is  generally 
slow  in  its  i)rogress  and  tolerahly  painless;  hy  its  pressure  the  cyst  may  cause  ahsorption 
of  the  hone  with  which  it  is  in  contact  and  lead  to  a  deep  excavation.  Paget  relates  in 
his  Suiyic'if  I',ithi>ln,ji/  such  a  case  as  a  cyst  near  the  gums,  and  1  have  had  under  oh.ser- 
vation  a  woman  whi)  had  a  tumor  in  her  left  cheek  for  years,  which  when  opened  dis- 
charged some  watery  fluid.  She  applied  to  me  for  a  hony  jjrojcction  of  the  cheek  that 
was  clearly  the  edge  of  the  alveolar  jiroce.ss  of  the  ui)per  jaw,  the  bone  above  having 
become  absorbed  by  the  pri'ssure  of  the  cyst,  thus  causing  a  cup-like  dejiression.  She 
had  had  all  her  teeth  removed  at  ditterent  times  by  dentists,  under  the  impression  that  the 
disease  was  due  to  them. 

The  (Iriifii/t'i-ods  ci/sf^  arc  found  in  both  jaws,  and  are  almost  always  connected  with  the 
permanent  teeth,  rare  cases  being  recorded  in  which  the  temporary  were  implicated.     In 

Fig.  238.  '  l'"-  -•;'•'• 


Tooth  as  seen  tlinnigh  opening  in 
L"pper  Jaw. 


Natural  Size  of  Tooth  when 
Removed. 


Canine  Tooth  as  seen  in  Case  of  Mis3 

R .    in    eximiuled   Lower  .law, 

with  Tooth  (6)  of  its  Natural  Size. 
a,  bone  removed  by  the  trephine. 


this  affection  the  teeth  fail  in  development  and  remain  within 

the  jaw;  the  tooth  acts  as  a  foreign  body,  sets  up  irritation, 

and  causes  the  cy.stic  affection  I  am  now  considering,  or  some 

solid  growth.    Thus,  in  a  boy  'Xt.  G  who  came  under  my  care 

some  years  ago  a  cystic  enlargement  of  the  jaw  of  three 

years'   development   existed.      It   encroached   on   the   orbit, 

mouth,  and  cheek.      1  made  a  free  opening  into  the  anterior 

wall  of  the  cyst,  in  the  bone,  and  through  this  an  incisor 

tooth   was  seen   with  its  crown   upward   (Fig.   23S).     The 

tooth  was  removed,  and  a  good  recovery  ensued.     In  January,  1872.  T  treated  a  similar 

case  in  a  girl  xt.  17.  .sent  to  me  by  ]Mr.  Salter,  who  had  her  under  observation  for  two 

years.     The  disease  was  in  the  right  upper  jaw,  and  the  right  canine  tooth  was  deficient. 

I  exposed  the  cavity  and  removed  the  tooth  (which  was  growing  in  an  abnormal  direction 

upward  and  inward),  a  good  recovery  taking  place.     On  July  24,  1875.  I  trephined  a 

tumor  of  the  lower  jaw,  of  three  or  four  years'  growth,  of  Miss  R ,  xt.  30,  a  patient 

of  Mr.  K.  Moon  of  Norwood  and  also  of  Mr.  Salter,  and  removed  from  it  a  canine  tooth 
which  was  resting  obliquely  in  the  cavity  (Fig.  239).  Mr.  Salter  has  collected  many 
similar  cases.  It  is  well  to  remember  that  these  dentigerous  cysts,  like  other  cysts  of  the 
jaws,  may  simulate  solid  tumors.  When  they  occur  in  the  lower  jaw  and  expand  the 
bone,  this  error  is  very  likely  to  take  place.  Thus,  in  1881  a  gentleman  a^t.  58  came  to 
me  with  an  enlargement  of  the  left  horizontal  ramus  of  his  lower  jaw  which  had  been 
coming  on  for  years,  and  with  this  there  has  a  little  discharge  from  his  gums.  I  explored 
this  and  struck  a  tooth,  which  Mr.  Moore  skilfully  removed.  It  was  a  molar  tooth,  which 
was  lying  horizontally  in  the  bone  with  its  crown  forward  and  its  fiings  grasping  those  of 
the  last  molar.     In  all  tumors  of  the  jaws  that  have  a  smooth  or  cystic  outline  it  is  well 


444 


TUMORS  OF  THE    UPPER  JAW. 


Fig 


to  make  an  exploratory  puncture  for  the  purpose  of  diagnosis.     Wlien  the  walls  crackle 
\om  the  thinness  of  the  expanded  cavity,  the  diagnosis  is  simple. 

Treatment. — The  free  opening  of  the  cyst,  with  the  extraction  of  any  tooth  that 
may  be  present  in  it,  is  the  one  essential  point  of  practice  to  observe  in  all  these  cystic 
diseases  of  the  jaws,  upper  or  lower.  This  can  be  done  with  a  knife  or  a  sharp  pair  of 
forceps  after  a  perforating  wound  has  been  made  by  a  trephine,  drill,  gouge,  or  pointed 
instrument.  To  induce  suppuration  of  the  cyst,  it  is  a  good  practice  to  plug  the  cavity 
with  lint.  When  the  cavity  is  large,  it  is  wise  to  take  away  a  considerable  portion  of  its 
wall.  Removal  of  a  segment  of  bone  for  cystic  disease  is  rarely  needed.  Before,  how- 
ever, the  pathology  was  understood,  this  nuilpractice  was  often  perpetrated,  as  our  differ- 
ent museums  too  truly  testify. 

DentigerOUS  tumors  may  likewise  occur.  In  Fig.  240  is  illustrated  a  case  in 
•which  I  removed  the  iiitper  jaw  of  a  child  set.  8  for  a  nearly  solid  myeloid  tumor  of  the 
jaw  clearly  originating  in  a  malplaced  tooth  which  was  growing  from 
the  posterior  part  of  the  orbital  plate  of  the  bone ;  one  or  two  cysts 
existed  in  the  growth  enough  to  allow  of  its  being  called  cystic.  There 
was  no  possibility  of  making  a  diagnosis  in  this  instance  ;  such  exam- 
ples are  very  rare. 

Tumors  of  the  Jaws. — These  are  of  different  kinds,  simple 
and  malignant,  connected  and  unconnected  with  teeth.  When  in  the 
antrum,  their  dental  origin  should  be  suspected  ;  but  in  both  upper 
and  lower  jaws  solid  tunuirs  of  all  kinds  have  been  found  with  teeth 
as  their  centres. 

Polypi  of  the  antrum — as  are  those  of  the  nose — are  occa- 
sionally met  with,  and  they  show  themselves  mostly  as  ])rojections 
into  and  through  the  nostril,  the  tumor  making  its  way  through  the 
nasal  wall  of  the  antrum,  and  at  the  same  time  generally  expanding 
its  facial  wall.  I  have  seen  four  well-marked  cases  of  this  sort,  and  in  two  the  whole 
mass  was  removed  through  the  nostril,  which  was  laid  open  and  turned  back.  In  the 
third  the  cheek  was  reflected  outward  at  the  same  time  and  a  large  opening  made  into 
the  antrum,  allowing  the  surgeon  to  scoop  out  the  growth.  Two  of  tliese  eases  occurred 
in  the  practice  of  Mr.  Cock,  and  two  in  my  own.  The  constant  flow  from  the  nostril  of 
the  aff"ected  side  of  a  quantity  of  clear  fluid  is  a  valuable  symptom  of  these  growths,  as 
shown  by  Paget's  case  (*"////.  <SV>r.   Tnins.,  1879). 

Tumors  of  the  Upper  Jaw. — Weber,  quoted  by  Heath,  informs  us  that  in  an 
analysis  of  307  cases  of  tumors  of  the  upper  jaw,  more  than  one-third  of  the  whole 
number  may  be  set  down  as  sarcomatous  simple  tumors,  one-third  as  osseous,  and  less 
than  one-third  cancerous,  the  myeloid  being  included  in  the  first  of  these  groups.  They 
may  grow  also  from  any  part  of  the  bone  or  periosteum.     When  they  originate  in  the 


Dentigerous  i  iiinor 
J:nv 


Fig.  241. 


Fig.  242. 


Knchondroma  of  Upper  ,Taw. 
Before  operalion.     (Model,  Guy's  IIosp.  Mus.,  SS'".)  .\fter  death.     (Model,  Guy's  IIosp.  Mus.,  .^S'S.) 

antrum,  they  expand  its  cavity,  as  is  the  case  in  the  cystic  disease,  and  cause  a  bulging 
of  one  or  more  of  its  walls.  When  they  spring  from  a  surface  or  plate,  the  tumor  will 
project  from  it,  leaving  the  other  surfaces  unaffected.  The  fibrous,  in  all  its  forms,  and 
the  osseous  are  usually  of  slow  growth.     They  are  often  painless,  and  trouble  only  from 


r)rsi:.\sKs  or  rin-:  jaws. 


445 


their  size.  The  sarcomatous,  myeloid,  ami  cancerous  are  of  more  rapifl  ^Towth.  The 
fibrous  «)r  sarcoMjatous  are  usually  periosteal  jrrovvtlis;  tlu?  osseous  aii«l  myeloid,  eiulos- 
teal.  The  cancerous  may  li«'lon^  to  liotli.  The  cartila;:iiious  are  very  variable  in  their 
])r(»j;ress — now  very  slow,  ami  then  rapid.  Tliey  are  cliieHy  of  the  mixed  kind,  fibre  tis- 
sue larjrelv  ])redominatinji  in  tumors  of  slow  formation.  They  frecjuently  invtdve  many 
bones.  Sir  J.  i'aj^et  (Snniicdl  l'<itli.)  states  that  in  tht;  (»nly  case  on  rt!Cord  (jf  enchon- 
droma  of  the  upper  jaw  aloiie  tlic  disea.si;  was  removiMl  by  .Mr.  .Morjran.  late  of  (Juy's, 
from  a  man  ;et.  '1\\  the  tumor  was  of  the  ri<;ht  ma.xilla  and  was  of  nine  years'  growth. 
The  patient  survive<l  the  operation  .seven  years.  Figs.  241  and  'lA'l  illustrate  the  case, 
the  first  being  taken  before  .Mr.  .Morgan  s  operation  and  the  second  after  the  patient's 
death.  Dr.  llevfelder  of  .Munich  says,  however,  that  he  found  S  su(d>  cases  out  of  4r)() 
of  disease  of  the  upper  jaw. 

Tkk.vT.MK.N'T. — .Ml  solid  tumors  of  the  upper  jaw  must  be  e.xtirpated.  but  imt  inon,- 
(if  I  lie  biiiie  should  l)e  reuiovi'tl  than  is  necessary.  Sir  W.  Fergusson  established  this 
rule  in  practice,  and  it  is  one  that  all  surgeons  should  strive  to  follow.  Thus,  when  the 
disease  .springs  and  projects  I'rom  the  facial  surface  of  tlie  bone,  the  tumor,  with  tlie  facial 
plate  alone,  requires  excision.  When  the  alveolar  process  is  alone  implicated,  the  other 
portions  of  the  bone  must  not  be  touched.  Where  ]»ossible,  the  palate  plate  should  be 
preserved  ;  and  it  is  bad  surgery  to  interfcMc  with  the  orbital  plate  without  an  aVj.solute 
necessity.  When  the  whole  bone  is  involved  in  the  disease,  it  must  be  removed  ;  but 
such  cases  are  exceptional.  In  many  cases  when;  the  disease  originates  in  the  antrum  a 
partial  renu)val  of  the  bone  will  suthce,  if  the  surgeon  can  at  first  only  lay  open  the  cavity 
and  find  out  the  base  of  the  growth.  For  ])erforating  the  antrum  with  a  view  to  explora- 
tion Sir  W.  Fergusson  recommends  an  ordinary  carpenter's  gimlet. 

Operation  for  the  Removal  of  Part  or  the  Whole  of  the  Upper  Jaw. 

— The  incision  now  almost  universally  adopted  for  the  removal  of  tumor,-,  from  the  u]iper 
jaw  is  the  one  of  Sir  W.  Fergusson  (Fig.  -4:5),  as  by  it  all  the  necessary  room  is  given  to 
remove  even  the  largest  growth.  The  facial  nerve  and  artery  are  divided  where  by  their 
size  they  are  of  small  conseciuence  and  the  scars  are  so  placed  as  to  become  almost  imper- 
ceptible. In  tumors  of  modc.rufe  size  the  incision  should  be  carried  through  the  median 
line  of  the  lip  into  the  nostril,  when,  by  raising  the  nostril  and  retracting  the  cheek  out- 
ward, abundant  roirm  is  o])taincd.     When  more  room  is  required,  the  operator  may  extend 

his  incision  round  the  ala  and  up  the  side  of  the  nose 
toward  the  inner  canthus ;  and  if  this  is  still  insuffi- 
cient, a  third  incision  may  be  made,  from  the  termina- 
tion of  the  second  along  the  lower  border  of  the  orbit. 
These  incisions  are  indicated  in  Fig.  243.  which 
was  taken  from  a  man  xi.  35  from  whom  I  removed 
an  osteo-chondroma.  of  twelve  years'  duration,  involv- 
ing the  facial  and  palate  plates  of  the  superior  max- 
illa. The  dark  line  indicates  the  incision  made  ;  the 
dotted  extra  line,  that  which  may  be  required  in  excep- 
tional instances.  Fig.  244  illustrates  Gensouls  and 
Liston's  method. 

In  some  cases  the  ala  of  the  no.se  alone  may  be 
turned  up.  T  removed  a  fibrous  tumor  growing  from  the  nasal  process  of  the  superior 
maxilla  by  this  incision,  and  found  ample  nxnn.  The  incision  having  been  made  and  the 
integument  reflected  sufficiently  to  ex])ose  the  tumor,  all  bleeding  should  be  stopped  by 
ligature  or  torsion.  Assuming  that  the  whole  bone  has  to  be  removed,  the  incisor  tooth 
of  the  affected  side  must  be  extracted  and  the  palate  plate  of  the  U})per  jaw  witli  the 
alveolus  divided  with  a  fine  .saw  (Fig.  245)  introduced  into  the  nostril.      The  malar  process 


Fig.  244. 


Ker^u.sson's  Incis-  'I'he  dotted  line,  n,  (ien- 
ion  for  Iteinov-  .soul's  Incision  ;  }>,  Li- 
al  of  Upper  .law.         zar's  and  Liston's. 


Kk;.  ^lAr^. 


Fig.  24(i. 


Lion  Forceps. 


of  the  maxillary  bone  is  then  to  be  partially  sawn  through,  as  well  as  the  nasal  process 
of  the  superior  maxilla,  their  complete  section  being  made  with  bone  forceps.  The  tumor 
should  then  be  seized  with  the  Lion  forceps  (Fig.  246)  and  the  whole  wrenched  off,  bone 


446 


DISEASES  OF  THE  JAWS. 


forceps  and  scissors  being  employed  to  complete  any  section  that  may  be  required.  The 
infraorbital  nerve  should  be  divided  with  scissors  and  the  soft  palate  left  as  little  injured 
as  possible.  If  any  portions  of  the  disease  remain,  they  can  now  be  removed.  All  bleed- 
ing vessels  are  to  be  treated  by  ligature,  torsion,  actual  cautery,  or  styptics,  and  the  parts 
carefully  brought  together  with  interrupted  sutures. 

When  the  disease,  says  Heath,  is  of  less  amount  and  the  orbital  plate  not  involved^ 
this  should  be  preserved  by  carrying  a  saw  horizontally  below  it ;  and  if  the  palate  be 
not  involved,  this  may  be  advantageously  kept  intact  by  making  a  similar  cut  immediately 
above  it.  Sir.  W.  Fergusson  advises  that  the  disease  should  be  cleared  out  from  the  centre 
toward  the  circumference,  so  as  not  to  remove  healthy  structures  unnecessarily ;  and  this 
may  be  readily  accomplished  by  means  of  the  many  forms  of  curved  bone  forceps  with 
which  surgeons  are  now  familiar,  aided  by  the  gouge. 

In  a  case  of  myeloid  disease  of  the  upper  jaw  involving  the  whole  of  the  hard  palate 
I  peeled  off  all  the  soft  parts  from  the  bone,  beginning  at  the  alveolus,  and,  having 
removed  the  diseased  bone,  brought  them  up  again  in  position  and  fixed  them  to  the  mu- 
cous membrane  of  the  cheek  where  it  had  been  separated  from  the  bone.  By  this  means 
I  preserved  the  roof  of  the  mouth  from  the  first,  and,  what  is  more,  eventually  obtained 
an  excellent  new  palate.  The  practice,  particularly  in  young  subjects,  is  probably  worth 
following. 

Fig.  247. 


Periosteal   Sarcoma  of   Lower   .hiw. 
View  of  sectiuii.  Kxternal  aspect  of  Tumor. 

Tumors  of  the  lower  jaw  grow  to  enormous  dimensions,  and  pathologically  are 
very  similar  to  those  of  the  upper.  The  fibrous  in  one  of  its  forms  is  probably  the  most 
common,  the  periosteal  tumor  being  more  frequent  than  the  endosteal.  The  latter  may 
occupy  the  dental  canal,  as  illustrated  by  a  case  of  Mr.  Cock's  (Guy's  Hosp.  Mus., 
1091")  in  which  the  dental  nerve  passed  through  the  tumor.  The  periosteal  growth  is 
often  an  epulis,  and  a  good  example  of  this  form  is  represented  in  Fig.  232.  But  a  more 
typical  example  of  a  true  periosteal  sarcoma,  which  I  removed  in  1872  from  a  girl  aet.  20, 

Fig.  250. 


Fig.  248. 


Fig.  249. 


Fibro-Cystic  Disease  of  Lower  ,Taw. 
Guv's  Hosp.  Mus.,  Drawing  45'.  Guy's  Hosp.  Mus.,  10905o.( Key's 

"(Key's  case.    During  life.)  case.  Tumor  after  removal.) 

is  illustrated  in  Fig.  247.  The  tumor  was  of  three  months' 
growth.  It  returned  three  months  after  removal  and  destroyed 
life  by  suffocation,  having  grown  to  the  size  of  the  patient's 
head.      Microscopically,  the  tumor  was  a  spindle-celled  periosteal 

Eow«Sf^"'^^r^H^ath'.s  caS  sarcoma.  One  of  the  largest  fibro-cellular  tumors  of  the  bone 
on  record  occurred  in  Mr.  Heath's  practice,  and  is  illustrated, 

with  his  permission,  in  Fig.  248.      It  was  removed  from  a  man  aet.  32,  and  the  disease  was 

of  eleven  years'  growth ;  it  weighed  4  pounds  6  ounces.     The  man  died  from  exhaustion 

on  the  sixth  day. 


I) rsi:. I .s7;.v  of  rir/-:  ./ .  1 1 1 's.  1 1 7 

FibrO-Cystic  tumors  "f  tin-  lowt-r  jaw  an-  vi  ry  coiiiiiKiii  ami  liav*;  the  saiiu; 
clinical  history  and  aspfrt  as  the  cystic  tiiiiiois  to  whidi  attention  lias  liccii  already 
directed.  The  most  lieaiitiful  e.\aiii|ile  on  record  is  that  \vhi(di  was  removed  liy  the  late 
I>r.  Iluttoii  of  the  l{ichmond  llosjiital,  iMihlin,  and  is  illustrated  in  Heath's  huolc  ;  it  was 
made  up  of  cysts  <>{'  nine  years'  };n»\vth  and  in  a  younir  woman  oidy  LJO.  A  yet  mom 
remarkalile  case  was  operated  upon  hy  Mr.  Key  in  ISH  in  a  hoy  let.  \'.i  f  Fijrs.  24It, 'i'lO). 
The  tumor  was  of  two  years' j^rowth  and  painless,  .^lr.  Key  removed  the  whole  hy  saw- 
ing; throuiih  the  lowi-r  jaw  just  helow  the  anule  on  eaidi  side,  and  a  ^'ood  recovery  ensued. 
Mr.  Kve  in  his  exci-llenf  leeturi'sat  the  Colleire  r»f'  Surj;eons  in  iSSlJ  strove  to  show  that 
thex- t'v>tie  luniniv  111"  the  lower  jaw  are  in  their  orijrin  e.vamples  ot"  epithelioma. 

Cartilaginous  growths   :iie    uncommon   and   occur   in  early  life,  and.  as  alreaily 

stated,  are  periosteal  and  endosteal.      A  iii xaniple  of  the   latter  can    he  seen    in    Prep. 

lO'Jl''.  and  lOltl"',  (luys  llosp.  Mus.,  wiiich  Mr.  Key  removed  in  1S4(!  from  a  woman  iet. 
29  in  whom  the  di.sease  had  heen  comint;  on  for  nine  years.  In  the  preparation  the  fibro- 
cartilajiinous  substance  is  seen  to  be  placed  between  the  plate.s  of  bone  of  the  jaw,  the 
teeth  beinu:  in  the  middle  of  the  new  growth.    The  perio.steal  tumor  grow.s  to  a  large  size. 

Osseous  tumors  arc  simictimes  the  result  of  ossified  enchondroma.  There  is  in 
St.  Thomas  s  Museum  a  specimen  of  this  kind  which  was  removed  by  .Mr.  ('line.  Bone 
luav.  however,  (tccur  as  an  independent  growth  in  the  form  of  cancellated  or  ivory  exos- 
tosis, which  may  sometimes  grow  to  a  large  size.  Other  troubles  may  .spring  from  such 
a  growth  ;  for  example,  iu  .March,  1877,  I  had  to  remove  a  portion  of  the  lower  jaw  from 
a  lady  ;vt.  50  who  had  had  an  exostosis  growing  for  twenty  years  from  its  inner  surface 
at  a  point  corresp»mdiug  to  the  right  bicuspid  and  canine  teeth.  The  growth  had  not 
given  rise  to  any  trouble  till  the  soft  parts  ccn'ering  its  apex  had  begun  to  ulcerate,  when, 
from  its  roughened  surface,  the  bone  .so  irritated  the  floor  of  the  mouth  as  to  set  up 
ulceration  which  was  thought  to  be  cancerous.  I  removed  the  excstosis  with  the  bone, 
and  then  reached  the  suppo.sed  cancer,  which  I  isolated  by  needles  passed  through  the 
base  of  the  growth  and  removed  by  means  of  the  galvanic  ecraseur.  A  good  result  fol- 
lowed, and  the  lady  is  now  well. 

Sarcomatous  tum.OrS  are  met  with  in  great  variety,  the  softer  kinds  being  recur- 
rent and  clinically  malignant.      Some  of  the  very  vascular  pulsate. 

Cancerous  tumors  are  mostly  periosteal  and  invade  the  bone  by  extension.  They 
are  of  the  epithelial  I'onu  when  attacking  the  gums  and  mucous  membrane,  and  of  the 
tuliular  variety  in  the  nose  and  antrum  when  originating  where  the  epithelium  is  columnar. 

Thkat.mknt. — Tumors  of  the  lower  jaw,  as  of  the  upjier,  are  to  be  treated  by  excision, 
and  the  operation,  though  large,  is  most  successful.  I  have  on  more  than  thirty  occasions 
removed  large  portions  of  the  jaws  with  but  one  death,  and  that  was  from  inflammati(Mi 
of  the  lungs.  Heath  .says  that  Mr.  Cusack  removed  large  portions  in  seven  cases  with 
only  one  fatal  result,  and  Dupuytren  operated  in  twenty  with  only  one  death.  The  suc- 
ce.ss  of  Sir  W.  Fergus.son,  Syme,  and  Li.ston  is  well  known. 

Small  tumors  of  the  jaw,  and  particularly  of  the  alveolus,  may  with  good  cutting  for- 
ceps be  removed  from  the  mouth.  If  more  room  be  required,  an  incision  may  be  made 
outward  or  downward  at  the  angle  of  the  mouth.  On  many  occasions  I  have  obtained 
all  the  room  I  required  by  making  a  horizontal  inci.sion  below  the  level  of  the  jaw  and  a 
dissection  of  the  soft  parts  oft'  the  bone. 

3Ir.  Maunder  has  shown  that  large  portions  of  the  lower  jaw  the  seat  of  tumor  may 
be  taken  away  without  external  incision  after  detaching  periosteum  by  means  of  the 
raspatory. 

When  a  large  tumor  has  to  be  removed,  it  may  readily  be  exposed  by  a  curved  incisirm 
carried  along  the  posterior  surface  of  the  tumor  froni  above  the  angle  of  the  jaw  to  the 
median  line,  turning  the  soft  parts  up.  In  doing  this  the  facial  artery  will  be  divided, 
when  the  two  ends  should  be  at  once  secured  by  torsion.  The  knife,  says  Fergu.sson, 
should  be  so  lightly  carried  over  the  artery  that  the  vessels  need  not  be  divided  till  the 
flap  is  being  raised.  In  this  way  blood  is  saved.  The  labial  margin  of  the  lip  rarely 
need  be  divided.  The  tumor  having  been  exposed,  its  surface  must  be  well  examined, 
with  the  view  to  the  removal  of  the  growth  by  cutting  away  the  external  plate  of  bone 
which  covers  it  in,  by  means  of  the  gouge  and  bone  forceps.  This  step  is  wise  in  doubt- 
ful cases,  as  a  large  number  of  tumors  of  the  jaw.  particularly  the  cystic,  may  be  scooped 
out,  and  recovery  will  ensue.  If  the  tumor  and  jaw  reipiire  excision,  a  tooth  must  be 
extracted  in  front  where  the  bone  is  to  be  divided  and  a  small  saw  applied,  after  which 
the  bone  should  be  grasped  with  the  Lion  forceps  and  drawn  outward,  the  surgeon  subse- 
quently carefully  dividing  all  the  soft  parts  that  hold  it  in   position   on   its  inner  surface 


448  DISEASES  OF  THE  JAWS. 

and  keeping  the  knife  dose  to  the  hone.  When  the  disease  stops  at  the  angle,  the  saw 
and  forceps  are  again  to  be  applied  and  the  tumor  removed.  Where  disarticulation  is 
required  on  account  of  the  extension  of  the  disease,  the  jaw  must  be  forcibly  depressed, 
so  as  to  bring  the  coronoid  process  within  reach  and  allow  of  the  division  of  the  insertion 
of  the  temporal  muscle.  The  condyle  may  then  be  twisted  out,  the  knife  dividing  cau- 
tiously the  insertion  of  the  external  pterygoid  and  such  ligamentous  fibres  as  are  put  on 
the  stretch.  Fergusson  says  that  in  doing  this  he  found  that  the  condyle  actually  sepa- 
rated from  the  periosteum  on  its  inner  side,  thus  facilitating  its  removal ;  and  in  two  cases 
of  my  own  I  found  this  to  occur — in  one  after  the  division  of  the  periosteum  Avith  the 
knife.  When  the  tumor  is  so  large  as  to  be  wedged  in  and  to  prevent  this  mode  of  dis- 
location, the  best  plan  is  to  reapply  the  saw  and  cut  off  the  tumor  as  high  as  may  be, 
and  subsequently  to  remove  the  remaining  portion  of  jaw. 

When  the  central  portion  of  the  lower  jaw  is  removed,  there  is  danger  of  the  tongue 
falling  back  and  causing  suifocation  ;  to  prevent  this  a  ligature  may  be  passed  through 
the  tip  of  the  tongue  and  held  during  the  operation,  and  on  the  completion  of  the  ope- 
ration fastened  to  the  wound.     The  ligature  should  be  removed  on  the  second  or  third  day. 

After  the  operation  all  arterial  bleeding  should  be  stopped  and  any  oozing  arrested 
by  the  application  of  a  sponge  wrung  out  of  hot  iodine  water ;  the  edges  of  the  wound 
.should  be  brought  together  by  interrupted  sutures.  Convalescence  is  generally  rapid 
and  recovei'y  complete.  The  deformity  that  follows  the  operation  is  in  most  ca-ses  so 
slight  as  not  to  be  observed ;  the  interval  left  by  removal  of  bone  is  filled  with  dense 
fibre  tissue.  Bone  is  never  reproduced,  but  the  tissues  soon  become  firm  enough  to  bear 
the  support  of  artificial  teeth. 

The  half-sitting  position  is  probably  the  best  in  all  these  operations  on  the  jaws,  and 
chloroform  may  be  given  without  fear. 

For  more  details  connected  with  this  subject  the  student  may  refer  to  Heath's  admir- 
able Monograph  on  the  Jaivs ;  Fergusson's  Surgery;  Liston's  paper,  J/«7.-CV///-.  Trans., 
vol.  XX..  and  his  Pract.  Surgery. 

Disease  of  the  tempore -maxillary  articulation  is  rarely  met  with — more 

rarely,  indeed,  than  disease  of  any  joint  in  the  body.  Uf  the  few  examples  of  it  I  have 
seen,  one  was  in  a  woman  aet.  34  who  had  had  it  for  nine  years,  suppuration  having 
existed  for  six  ;  several  sinuses  led  down  to  the  joint  and  the  jaw  was  nearly  fixed  :  dead 
bone  appeared  to  be  present,  but  the  patient  refused  to  have  any  surgical  interference. 
Another  case  was  a  girl  aet.  18  in  whom  both  sides  of  the  lower  jaw  were  completely 
anchylosed.  In  Guy's  Hosp.  Museum  there  is  also  a  splendid  specimen  (No.  1070)  of 
complete  synostosis  of  the  articulation. 

The  cases  already  quoted  of  necrosis  of  the  condyloid  process  of  the  lower  jaw  and 
recovery  with  a  sound  joint  may  here  be  referred  to. 

Closure  of  the  jaws  niay  be  caused  by  some  spasmodic  condition  of  the  muscles 
of  the  jaw  secondary  to  disease  of  the  teeth  or  to  the  cutting  of  the  wisdom  teeth.  In 
the  latter  case  the  mouth  must  be  forced  open,  under  chloroform,  by  means  of  the  screw 
gag  or  wedges,  and  the  tooth  removed,  or.  what  is  better,  room  made  for  it  to  come  for- 
ward by  the  extraction  of  a  neighboring  molar.  It  may  Hkewi.^e  be  caused  by  anchylosis 
or  by  the  contraction  of  cicatrices,  either  within  or  without  the  mouth.  In  February, 
1878,  I  operated  upon  a  woman  tet.  43  who  for  thirty-seven  years  had  had  her  jaws 
locked  from  adhesions  between  the  cheeks  and  gums  which  had  compelled  her  to  live  on 
liquid  food  for  the  whole  of  this  period.  I  divided  the  cicatrices  and  opened  the  jaws 
with  a  promise  of  a  good  recovery.  Two  years  later  she  could  take  and  masticate  food. 
The  condition  had  followed  scarlet  fever.  Dr.  S.  Gross,  in  his  System  of  Surgery,  informs 
us  that  ulcerative  causes  are  the  most  common,  and  he  attributes  the  majority  to  the  evil 
practice  of  giving  calomel  to  salivation.  In  rarer  cases  the  immobility  is  occasioned  by 
an  osseous  bridge  extending  from  the  lower  jaw  to  the  temporal  bone,  this  condition 
being  generally  associated  with  chronic  articular  arthritis.  "  HoAvever  induced."  writes 
Gross,  "  the  effect  is  not  only  inconvenient,  seriously  intei'fering  with  mastication  and 
articulation,  but  it  is  often  followed,  especially  if  it  occur  early  in  life,  by  a  stunted 
development  of  the  jaw,  exhibiting  itself  in  marked  shortening  of  the  chin  and  in  an 
oblique  direction  of  the  front  teeth.'' 

Treatment. — Where  the  cause  is  in  the  joint,  and  cannot,  as  can  dead  bone,  be 
removed,  the  surgeon  may  attempt  to  break  uj)  the  adhesions  by  forcibly  opening  the 
mouth  under  chloroform,  or  he  may  divide  the  bone  below  the  joint.  When  due  to  cica- 
trices and  nodular  plastic  matter,  little  good  has  ever  been  derive<l  from  their  division, 
although  in  the  case  previously  alluded  to  the  result  was  satisfactory.     Esmareh  of  Kiel, 


DfsijicATio.x  or  riiF.  ./.III'. 


119 


in  ;i  papt'i"  (hi  f/ir  Tmitniftif  nj'  ('/usiirr  "/'  tin  .Imrs  j'roiii  dioi/ririK^  1S()0,  has,  however, 
dt'.Sfrilie<l  an  operation  which  the-  .Messrs.  Henry.  ('.  Heath,  .MacCoriiiac,  Mason,  liawson, 
and  Annanihile  in   this  eountry  have  practised  with   success  enoutrh  to  indicate  its  value. 

()l'Kll.\Tl<»N. — This  eon.sist.s  of  the  removal  of  a  piece  (»!"  tlu'  h)wer  jaw  for  the  forma- 
tion of  a  new  joint,  and  is  to  he  curried  <Mit  hy  makin;r  an  incision  ahtn<r  the  h»wer  l»ordcr 
of  the  jaw  in  front  ot"tlie  masseter.  raisinj;  the  intejrunn-nt,  and  reinoviii^r  with  a  liand- or 
cli;iin-saw  a  weduc  oi'  hmio  measurinii;  ahout  an  inch  ahove  and  a  half  incli  l)elow.  Where 
oidv  "»ne  side  of  the  jaw  is  affected,  it  is.  without  doubt,  the  l)est  operation  that  can  be 
performed,  the  |)atients  recovering;  their  masticatory  power  in  two  or  three  W(!ek.s.  It  mii.st 
be  mentioned  that  about  the  year  IS()(),  Kizzoli  of  Holofrna  performed  a  .somewluit  similar 
operation  to  Ksinarch's,  dividintr  the  jaw,  but  not  removing  any  portion  of  it. 

Deformities  of  the  jaws  :ire  sometimes  .seen  a.s  a  con.se({uencc  of  .some  disease 
of  the  toniiue,  such  as  hypertropliy,  the  mechanical  pressure  of  tumors  during  growth, 
the  evil  influence  of  cicatrices,  more  ]iarticularly  about  the  neck  and  mouth,  and  of 
various  other  causes.  For  these  surgery  may  often  do  much  ;  but  when  this  fails,  the 
dentist  can  often  give  relief.  I  have  seen  the  upper  jaw  in  at  least  si.x  cases  of  torticollis 
nearly  one  inch  less  in  its  vertical  diameter  than  the  opposite  l)one,  and  I  have  already 
alludetl  to  a  ca.se  where  the  lower  jaw  was  nearly  an  inch  higher  than  natural,  to  make 
up  for  a  deticiency  in  the  teeth  of  the  upjier  jiw  which  had  e.xi.sted  from  childhood. 


Fi( 


DLslocatioii  of  the  Lower 
Jaw.  (Couper's  case, 
J.iinilim  Hosp.  Rep., 
1S64.) 


Dislocation  of  the  Jaw. 

This  may  involve  one  or  both  condyles,  two  out  of  every  three  cases  being  bilateral. 
It  may  be  caused  by  direct  violence  on  the  jaw,  but  more  frequently  by  yawning.  Sir 
A.  Cooper  tells  of  a  case  in  a  child  where  it  was  produced  by  the 
forcible  introduction  of  an  apple  into  the  mouth,  and  dentists  know 
of  its  being  produced  even  by  the  extraction  of  a  tooth. 

Tn  the  double  dislocation  the  mouth  is  widely  open,  the  jaw  is 
fixed  and  projecting,  the  lips  are  separated,  and,  as  a  consequence, 
speech  is  very  difficult.  Deglutition  is  much  interfered  with,  and 
the  saliva  flows  from  the  open  mouth.  Tn  front  of  the  ear  a  marked 
hollow  will  be  perceptible,  and  aborr.  the  zygoma,  in  the  temporal 
fossa,  an  undue  prominence  (Fig.  251).  Adams  of  Dublin  (^Dub. 
Quart.  Journ.  Med.  Science.,  vol.  i.)  first  noticed  these  symptoms,  and 
Dr.  R.  W.  Smith  (^Frachires,  1854)  believes  them  to  be  caused  by 
the  "  displacement  and  stretching  of  the  fibres  of  the  temporal 
mu.scle  on  the  upper  surface  of  the  condyle." 

In  the  single  dislocation  the  chin  is  oblique,  but  usually  directed 
toward  the  sDimd  in.stead  of  toward  the  injared  si(Je,  as  in  fracture  of 
the  neck  of  the  bone.     In  exceptional  cases,  however,  this  is  not  to 
be  observed.     The  other  symptoms  are  similar  to  those  of  double  dislocation,  the  hollow 
in  front  of  the  ear  being  the  most  characteristic. 

Congenital  dislocations  have  been  described  by  Smith,  Guerin,  Langenbeck, 
and  Caiitnii.  Sir  A.  Cooper  has  also  drawn  attention  to  si(b/i(xa(t'ou,  in  which  he 
assumed  that  the  condyle  of  the  jaw  slip))ed  in  front  of  the 
interarticular  fibro-cartilage.  It  is  caused  and  characterized 
by  the  same  conditions  as  those  of  dislocation,  and  it  is  prob- 
ably a  partial  di.slocation  forward. 

Tre.\t.ment. — Partial  dislocations  or  those  described  as 
subluxations  are  usually  reduced  by  the  patients  themselves 
by  some  lateral  movement  of  the  jaw^  or  by  gentle  pressure 
upon  the  chin.  Cases  of  complete  dislocation  have  likewise 
been  similarly  reduced,  but  more  frequently  the  surgeon's  aid 
is  demanded.  To  reduce  the  dislocation,  the  surgeon  should 
stand  in  front  of  his  patient,  who  should  be  seated  in  a  chair 
with  his  head  su]q)orted.  The  surgeon  should  then  introduce 
his  thumbs,  well  protected  with  a  towel  or  lint,  into  the 
patient's  mouth  upon  the  last  lower  molar  teeth  and  grasp 
the  jaw  with  his  outer  fingers  ;  he  should  next  make  pressure 
upon  the  teeth  downward  and  backward,  so  as  to  depress  the 
condyles  from  their  false  position,  and  at  the  next  moment 
elevate  the  chin  with  the  outer  fingers  (Fig.  252).  Some 
29 


Via.  2o: 


IJeduction  of  Dislocatiou  of  Lower 
Jaw. 


450  FRACTURES  OF   THE  JAWS. 

surgeons  prefer  using  a  piece  of  wood  or  the  handle  of  a  fork  introduced  between  the 
molar  teeth  to  depress  the  jaws.  When  strong  leverage  is  required,  as  in  old  cases, 
Stromeyer's  forceps  may  be  employed.  Nelaton's  advice  to  press  directh^  upon  the 
coronoid  processes,  and  Pollocks  practice  of  applying  pressure  upon  the  chin  by  means 
of  Petit's  tourniquet  fixed  upon  the  head,  are  worthy  of  attention.  It  is  well  to  reduce 
both  sides  together,  and  old  standing  dislocations  may  be  thus  reduced.  Mr.  Morley 
reduced  one  after  thirty-five  days,  Spilt  after  fifty-eight,  Demarquay  after  eighty-three, 
Donovan  one  after  ninety-eight,  Pollock  after  four  months,  and  Golding-Bird  after  eigh- 
teen weeks. 

Fractures  of  the  Jaws. 

Fractures  of  the  upper  jaw  are  not  nearly  so  frequent  as  those  of  the  lower  ; 
and  when  they  occur,  it  is  generally  from  direct  violence :  when  the  "  key  "  was  employed 
for  the  extraction  of  teeth,  a  fracture  of  the  alveolus  was  frequently  the  result.  In 
severe  injuries  much  displacement  and  copious  hemorrhage  may  take  place.  Cases  are 
on  record  where  the  internal  maxillary  artery  was  ruptured  and  fatal  results  ensued. 
The  infraorbital  nerve  or  its  branches  are  occa.sionally  injured,  when  some  loss  of  sensa- 
tion in  the  cheek  will  be  produced.  I  have  known  emphysema  of  the  cheek  or  orbit  to 
follow  such  an  injury,  and  have  seen  subconjunctival  hemorrhage  from  it.  One  of  the 
worst  examples  of  fracture  of  the  upper  jaw  I  have  seen  occurred  in  a  man  aet.  .30  from 
a  fall  from  a  height.  Both  upper  jaws  were  completely  detached  from  the  skull  and 
could  be  moved  about  in  any  direction,  yet  a  good  recovery  ensued.  I  saw  a  second  in 
an  asylum,  and  it  was  caused  by  the  blow  of  a  lunatic's  fist.  In  this  case  the  whole  of  the 
alveolar  process  of  the  right  upper  jaw  was  broken  off"  and  the  lower  jaw  fractured  in 
two  places. 

Tre.\tment. — Where  no  displacement  has  taken  place,  little  treatment  is  required  ; 
the  parts  should  be  left  alone  for  natural  processes  to  effect  a  cure.  When  tJiqjla cement 
exists  and  can  be  remedied  by  manipulation,  such  means  .should  be  applied,  some  slight 
retentive  bandage,  with  or  without  a  pad.  being  employed  to  keep  the  parts  in  position. 
When  the  palate  plate  is  much  interfered  with  and  displaced,  the  dentist's  aid  may  be 
called  into  requisition,  a  gold  plate  well  adapted  to  the  parts  tending  to  keep  the  frag- 
ments together.  (See  Salter.  Lemcet.  1860.)  Hemorrhage,  as  a  rule,  can  be  arrested  by 
the  application  of  ice  or  styptics.  When  the  soft  parts  are  injured  and  bleeding  takes 
place  from  them,  the  vessel  should  be  secured.  When  the  bone  is  comminuted,  there  is 
no  need  for  the  removal  of  fragments ;  !Malgaigne  laid  this  down  as  a  law.  and  Hamilton 
asserts  that,  owing  to  the  extreme  vascularity  of  the  bones  composing  the  upper  jaw,  the 
fragments  have  been  found  to  unite  after  the  most  severe  gun.<hot  injuries.  In  rare  cases 
of  separation  of  the  maxillte  a  spring  passing  behind  the  head  and  causing  pressure  upon 
the  maxillae,  after  the  manner  of  Hainsby's  harelip  apparatus.  Heath  says,  might  be 
advantageously  employed. 

Fractures  of  the  lower  jaw,  like  those  of  the  upper,  are.  as  a  rule,  the  result  of 
direct  violence,  and  when  produced  by  gunshot  injuries  are  at  times  most  severe.  They 
are  almost  always  compound  toward  the  mouth,  as  the  gum  tissues  readily  give  way. 
The  body  of  the  bone  is  more  frequently  broken  than  any  other  part,  although  the  ramus 
and  the  neck  of  the  jaw  may  be  fractured.  The  line  of  fracture  is  generally  oblique 
and  very  commonly  near  the  canine  tooth.  Double  fractures  are  very  common,  eleven 
out  of  twenty-four  cases  recorded  by  Hamilton  being  of  this  nature.  Comminuted  frac- 
tures are  more  rare.  A  case  came  under  the  care  of  Mr.  Poland  at  Guy's  in  which  the 
jaw,  by  the  kick  of  a  horse,  was  broken  in  five  places. 

Symptoms. — The  symptoms  of  fracture  are  generally  very  clear,  crepitus  being  often 
felt  by  the  patient  in  attempting  to  move  the  jaw,  and  it  is  readily  made  out  by  the  sur- 
geon. The  irregularit}-  of  the  teeth  is  also  a  very  characteristic  symptom,  and  the  care 
of  the  patient  to  hold  the  parts  in  position,  conjoined  with  his  inability  to  speak,  is  a 
typical  sign.  When  any  doubt  exists  as  to  the  presence  of  a  fracture,  the  mobility  of 
the  broken  bones  will  disperse  it.  Considerable  displacement  sometimes  complicates  the 
case ;  the  position  and  the  line  of  fracture  determine  the  degree :  an  oblique  fracture 
near  the  insertion  of  a  large  muscle,  as  the  masseter.  necessarily  shows  a  tendency  to 
override.  In  double  fracture  of  the  body  of  the  bone  this  displacement  is  usually  very 
marked,  the  muscles  that  connect  the  lower  jaw  with  the  hyoid  bone  draAving  the  lower 
portion  down.     In  some  cases  this  displacement  cannot  be  completely  remedied. 

In  rare  cases  the  teeth  may  be  depressed  into  the  alveoli,  and  the  bone  at  the   same 


I'll M Trill's  or  Tiir  jaws. 


151 


tiiiu'  iiiav  I'f  lniiktii.  Such  a  casi-  i-aiiu-  uinltr  my  fare  in  May,  l!SSt2,  in  tlir  person  of  a 
porter  ;i't.  17  who  in  a  fall  ofV  a  slcanicr  stru<'k  his  chin  ajrainst  the  ed'rt;  of  the  (juav. 
As  a  result  he  was  renderetl  inseiisilile  I'or  a  hrief  perioil,  and  was  hrou;_dit  to  (Juy  s  with 
a  wound  lienealh  the  (diin  ;  there  was  also  loosenin;.'  of  the  left  eaiiimr  tooth,  with  a  frac- 
ture of  its  alveolus  ;  there  was,  hesides,  most  eomjdcte  depression  of  the  two  rifrht  lower 
bicuspid  and  two  mcdar  teeth,  their  cusps  hein*.'  (Ui  a  level  with  tlie  necks  of  the  other 
tooth,  and  vertical  spliltin;,'  of  one  (d"  the  hicuspids  and  two  of  tiie  molars  of  tlie  left 
iipjier  jaw  also  existetl.  There  was  likewise  lileedin;r  fntin  the  left  ear,  which  lasted 
twenty-four  hours,  and  later  on  jtaralysis  oi"  the  facial  nerve,  suf;<rc.stive  of  a  fracture  of 
tlio  base  id'  the  skull.  The  teeth  were  rai.scd  hy  -Mr.  .Ninon,  but  they  never  became  firm. 
Othi-rwi.so,  the  man  (piite  recovered. 

Fractures  of  the  neck  Of  the  jaw  ;tre  always  the  result  of  direct  violence,  and 
are  not  very  readily  made  out.  Pain  ai^'L^avated  by  any  attempt  to  move  the  jaw  is  a 
constant  symptiun,  and  so  ahso  is  crepitus,  perceivable  by  the  patient.  '"The  condyle," 
says  Heath.  "  is  drawn  inward  and  forward  by  the  ptery<.'oideus  e.xternus,  as  can  be 
ascertaine(l  by  passiuL'  the  tinjrer  into  the  mouth,  and  the  jawbone  is  ajtt  to  become 
slightly  displaced,  so  that  the  chin  is  turned  toward  the  afll'ected  side,  and  not  from  it,  as 
in  dislocation."  I  liave  had  under  my  care  a  man  mi.  .'>')  with  a  fracture  of  both  sides 
of  the  jaw  just  below  the  condyles,  and  with  fracture  of  the  symjdiysis.  jtrrjduced  by  a 
severe  blow  upon  the  jaw  behtw  the  chin;  from  the  displacement  that  followed  the  house 
surgeon  thought  il  was  a  case  of  double  dislocation,  but  on  attempting;  to  reduce  it  it 
'•  wont  in  "  without  the  characteristic  snap  of  dislocation.  O.stitis  and  necro.sis  of  the 
whole  bone  below  the  condyles  followed  the  accident,  and  a  new  jaw  formed,  the  man 
recoveriiiir  with  good  movement  of  tlie  bone. 

Fracture  of  the  COronoicl  procesS  i''  very  rare,  and  Sansom  says  that  such  a  frac- 
ture never  unites. 

Tkk.vt.me.nt. — When  the  bones  can  be  brought  into  apposition,  the  treatment  may  be 
described  as  simple  ;  and  where  difficulties  are  met  with  in  reducing  the  fracture,  the 
treatment  is  most  difficult  and  uncertain.  In  an  ordinary  ca.se  of  fracture  of  the  jaw, 
where  no  or  very  little  displacement  exists,  the  common  four-tailed  bandage,  a  yard  long, 
with  a  slit  in  the  chin-piece  of  about  four  inches,  made  and  applied  as  illustrated  in 
Fig.  2."))],  is  useful  for  temporary  purposes,  but  for  pcrmancut  treatment,  in  the  few  cases 
in  which  no  displacement  exists,  it  is  well  to  mould  on  a  splint  of  gutta-percha  made 


Fig.  253. 


Fig.  254. 


Fi(4.  255. 


-K^y 


Bandage  and  Splint  for  Fracture  of  Lower  Jaw. 


Thomas's  mode  of  adjusting  Fractiires  of  the 
Lower  Jaw  with  Wire  and  Key. 

according  to  the  shape  given  above  (b)  and  applied  as  seen  in  Fig.  254,  A,  or,  what  is  far 
better,  adjust  a  four-tailed  bandage  made  of  five  or  six  layers  of  muslin  dipped  in  fresh 
plaster  of  Paris  and  moulded  to  the  chin,  the  bandage  being  held  in  position  whilst  the 
plaster  sets.  When  healthy  teeth  are  present  at  the  line  of  fracture,  they  may  be  fa.st- 
ened  together  with  wire,  after  the  method  of  Hammond's  splint  (Fig.  258)' 

When  difficulties  are  felt  in  the  adjustment,  as  in  double  fracture,  where  the  chin  is 
much  drawn  down,  a  good  pad  may  be  firmly  tied  under  the  chin  or  a  block  of  wood 
adjusted.  But  in  these  cases  the  surgeon's  ingenuity  is  often  taxed  to  the  utmost  to 
meet  the  wants  of  the  individual  case. 

Some  surgeons  have  suggested  that  the  bones  should  be  fastened  together  by  sutures 
when  all  other  means  fail,  and  Mr.  Hugh  Owen  Thomas  of  Liverpool  has  published  cases 
to  illustrate  the  practice.     He  applies  the  wire   litrature  after  the  fashion  illustrated  in 


452 


FRACTURES   OF  THE  JAWS. 


Fig.  255,  using  a  one-twenty-fourth-incli  silver  wire  and  fixing  it  with  a  key  (Fig.  255) 
{JLanctt.,  1867,  and  pamphlet,  1875).  In  the  case  of  comminuted  fracture  already  alluded 
to,  two  or  three  wire  sutures  were  applied  with  the  best  results.  Others  advise  the  use 
of  wedges  of  cork  so  adjusted  between  the  teeth  as  to  maintain  the  jaw  in  its  right  line. 
Hamilton  speaks  highl}"  of  gutta-percha  moulded  to  the  teeth  and  gums  within  the 
mouth,  and  Tomes  has  invented  a  silver  cap  to  fit  the  teeth  for  some  distance  on  each 
side  of  the  fracture.  Barrett  carries  out  the  same  idea  in  vulcanite.  Berkeley  Hill's 
modification  of  Lonsdale's  apparatus  is  serviceable,  and  Moons  splint,  as  made  for  him 
by  Millikin,  is  excellent.  It  has  the  advantage  of  all  the  other  interdental  splints  already 
enumerated,  is  readily  adapted  to  a  jaw  of  any  size,  and,  being  introduced  separately,  is 
easily  applied,  and  can  be  as  readily  I'emoved,  when  desired,  without  shifting  the  cap, 
which  fits  the  teeth  on  either  side  of  the  fracture.  Moon's  splint,  therefore,  seems  to  be 
the  best  interdental  one  we  possess,  and  it  should  be  used  when  simpler  forms  are  inap- 
plicable (Fig.  256).  Mr.  Moon  tells  me  that  Gunning's  interdental  splint  is  one  of  the 
most  valuable  for  some  fractures  of  the  upper  jaw,  and  also  for  fracture  of  the  lower  jaw 
where  the  teeth  will  not  admit  the  use  of  Hammond's. 


Fig.  256. 


Fig.  257. 


Moon's  Interdental  splint.  (Made  in  two  halves, 
BB,  with  horizontal  rods  to  keep  cap,  Fig.  257,  in 
position.) 


Metal  Cap  fitted  over  Fractured  Jaw.  fRepresentsd 
as  wired  on  for  a  time,  after  the  witlidrawal  of 
external  splint.) 


Among  these  simpler  forms  I  must  class  Hammond's,  which  I  had  brought  under  my 
notice  in  1874  by  Mr.  Moon.  It  is  a  very  simple  and  valuable  splint  for  the  general 
treatment  of  fractures  of  the  jaw,  and  has  answered  admirably  in  the  many  cases  to 
which  I  have  had  it  applied. 


Fig.  258. 


Fig.  259. 


Hammond's  Wire  Splint  for  Fracture  of  the  Jaw. 


Hammond's  Wire  Splint  applied  to  Fractured  Jaw. 


The  following  description  of  the  apparatus  and  its  application  is  given  in  Mr.  Ham- 
mond's own  words  : 

"  I  first  place  the  patient  in  as  convenient  a  position  as  circumstances  will  permit,  then 
direct  him  to  rinse  the  mouth  with  alcohol  and  water  largely  diluted,  which  not  only 
cleanses  the  mouth,  but  removes  the  fetor  of  the  breath.  I  next  bring  (temporarily)  the 
broken  ends  into  approximation  by  passing  a  silk  thread  between  and  round  the  two  teeth 
on  each  side  of  the  fracture,  and  then  secure  by  tying  in  front.  Then  with  a  suitable 
tray  and  very  soft  wax  I  take  an  impression  of  the  teeth,  to  which,  after  its  having  been 
cast  in  plaster  of  Paris,  I  adjust  a  frame  of  iron  wire  (Fig.  258),  which  can  be  done  with 
a  pair  of  small  curved  pliers.  When  all  is  ready,  I  slip  the  frame  over  the  teeth  in  the 
mouth  (Fig.  259),  and  while  it  is  held  in  position  by  an  assistant  proceed  to  tie  by  pass- 
ing small  lengths  of  thin  iron  binding  wire  after  the  manner  shown  in  Fig.  259,  twisting 
them  in  front  until  each  ligature  is  nearly  tight,  turning  the  ends  on  one  side  until  they 
are  secured.  Next,  with  the  aid  of  an  assistant,  I  twist  the  wires  quite  tight,  working 
alternately  each  side  of  the  mouth,  so  as  to  exert  an  equal  pressure,  and  thus  bring  the 


Itl'.STM.    Sl'IiCKRY.  453 

bone  iiitii  a  natural  position,  also  takiiitr  rare  imt  t(j  ovcrtwist  or  break  thcin.  T  th.-ri  cut 
oft'  the  iiids  aixl  turn  tlicni  in  lietwi-cn  tin-  ti'i-lli.  Now  tlu;  jaw  will  be  t'ound  cunijiara- 
tivt'ly  Hnii — so  solid,  indi'cd,  tliat  tlu'  |»atit'nt  can  bite  steadily  <tri  it  without  pain.  All 
that  now  remains  to  be  done  is  to  secure  the  jaw  perfect  rest  by  the  four-tailed  bandaj^e" 
(^Mnittlili/  lirrlnr  iif  Deiitnl   Siirffrn/,  May,  iHTiJ). 

It  is  not  absolutely  necessary  in  all  cases  to  take  a  cast  of  the  broken  jaw,  although  it 
is  so  in  some,  for  the  surgeon  may  mould  a  frame  of  iron  wire  of  the  thickness  that  will 
pass  between  the  necks  of  the  teeth  as  far  as  possible  on  each  side  of  the  fracture,  and 
fix  the  ends  by  passing  them  through  a  small  tube  a  <(uarter  of  an  inch  long  an<l  l)eiiding 
them  baekward  on  the  tube.  This  method  is  far  preferable  to  any  twisting  of  the  ends. 
It  has  been  taught  at  (iuy's  for  some  time  Ity  Mr.  Moon. 

This  frame  should   In-  worn  for  six  weeks. 


DENTAL   SURGERY. 

Hy  Mr.   henry   .MOOX. 

General  Remarks  on  Dental  Surgery. 

Dental  surgery,  in  its  manipulative  details,  must  necessarily,  for  the  most  part,  be  left 
to  those  wlio  make  its  practice  a  specialty  ;  but  some  acquaintance  with  affections  of  the 
teeth  and  with  the  principles  on  which  they  are  treated  is  required  by  every  one  who  i.s 
engaged  in  the  practice  of  medicine  or  surgery,  for  without  such  knowledge  he  will  be 
unable  to  advise  his  patients  on  the  preservation  of  their  teeth  (a  subject  of  importance 
as  regards  their  general  health)  or  save  them  from  the  sometimes  serious  local  complica- 
tions which  may  attend  tooth  disease.  Nor  will  he  be  able  to  diagno.se  the  true  nature 
of  certain  tumors  and  cysts  of  the  jaws,  or  to  attach  the  proper  importance  to  the  teeth 
as  the  possible  cause  of  neuralgia  of  the  head  and  face  and  of  more  remote  nervous  affiec- 
tions. 

In  the  following  pages  only  a  sketch  of  this  branch  of  surgery  is  aimed  at,  and  the 
reader  is  referred  for  details  to  the  excellent  Dental  Surgery  by  the  Messrs.  Tomes,  and 
to  the  interesting  pages  of  Mr.  Salter's  work.  Dental  Pdfhology  and  Surgeri/. 

The  various  parts  of  our  subject  ma}'  with  advantage  be  discussed  in  two  main  divis- 
ions. In  the  first  section  will  be  considered  the  defects  in  structure  and  abnormalities 
in  form  which  maj-  arise  during  a  tooth's  development,  together  with  irregularities  in  its 
placement.  In  the  second  section  will  be  considered  the  diseased  conditions  to  which  a 
fully  formed  tooth  is  liable  after  it  has  assumed  its  destined  position  in  the  mouth. 

The  eff"ect  which  disease  or  malposition  of  a  tooth  may  have  on  the  structures  imme- 
diately around  it  and  on  the  general  health  will  also  be  noted. 

That  a  clear  idea  of  the.se  subjects  may  be  obtained,  some  points  in  a  tooth's  develop- 
ment, structure,  and  connection  with  surrounding  parts  must  be  borne  in  mind. 

Description  of  a  Tooth  :   its  Development  and  Connections. 

A  perfected  human  tooth  (see  accompanying  illustration.  Fig.  260)  may  be  described 
as  consisting  of  an  unyielding  case  of  dentine  or  ivory  enclosing  a  highly  sensitive  vas- 
cular pulp;  the  portion  of  this  case  that  forms  the  crown  of  the  tooth  is  protected  by  a 
covering  of  an  extremely  hard  substance.  "  enamel."  which,  becoming  lessened  in  thick- 
ness as  it  extends  down  the  sides  of  the  crown,  finally  terminates  at  the  neck  of  the  tooth; 
the  portion  of  the  case  that  forms  the  root  or  roots  is  covered  by  "  crusta  petrosa,"  or 
tooth  bone,  and  is  implanted  in  the  alveolar  portion  of  the  jaw;  the  crusta  petrosa  is 
covered  externally  by  a  sensitive  and  vascular  membrane,  "  the  alveolo-dental  membrane," 
or  '•  periodontum ;"'  this  membrane  invests  the  root  of  the  tooth  and  lines  the  bony 
socket,  and  is,  besides,  intimately  connected  with  the  dentinal  pulp  at  the  apex  of  the 
root,  and  with  the  gum  also  where  the  latter  structure  encircles  the  neck  of  the  tooth. 

Through  the  foramen  at  the  end  of  the  root  blood  ves.sels  and  nerves  pass  for  the 
supply  of  the  dentinal  pulp,  while  other  nerves,  derived  from  the  same  source  (viz.,  the 
second  division  of  the  fifth  in  the  case  of  the  upper  and  the  third  division  in  the  case  of 
the  lower  teeth),  are  distributed  to  the  alveolo-dental  membrane.     The  teeth  are  implanted 


454 


DEVELOPMENT  OF  TEETH. 


Fig.  260. 


in  the  alveolar  process  of  the  jaw,  which  is. developed  with  them  and  is  reahsorhed  when 

they  are  lost. 

Development. — The  twenty  developing  temporary  teeth,  enclosed  in  their  respect- 
ive sacs,  are  contained  in  the  jaw  at  the  time  of  birth,  as 
are  also  germs  of  the  permanent  molars  and  those  of  the 
anterior  permanent  teeth ;  these  latter,  receding  from  their 
position  near  the  surface  of  the  gums  and  becoming  encap- 
suled,  gradually  pass  down  in  the  rear  of  the  temporar}-  teeth 
and  remain  embedded  in  the  jaw,  developing  at  leisure  within 
their  bonj'  crypts  until  wanted  to  replace  their  more  fragile 
predecessors.     (See  Fig.  2G6.) 

The  following  is  the  normal  process  attending  the  eruption 
of  one  of  the  anterior  permanent  teeth  :  The  roots  of  the  ante- 
cedent temporar}'  tooth  having  been  absorbed,  its  crown  is 
shed,  and  the  tooth,  released  by  the  absorption  of  superja- 
cent bone,  gradually  uprises  from  the  gum,  the  jjrotrusion 
of  its  crown  taking  place  simultaneously  with  the  continued 
elongation  and  development  of  its  root. 

The  development  of  a  permanent  tooth  thus  occupies 
many  years.  Take,  for  examples,  the  fii'st  permanent  molar 
and  central  inci.sor,  the  teeth  which  are  the  first  developed 
of  the  permanent  set.  Their  pulps  commence  to  take  form 
during  foetal  life ;  their  calcification  commences  by  birth  or 
in  the  first  months  of  infancy.      Their  eruption  takes  place 

from  the  sixth  to  the  eighth  year,  and  their  root  canals,  with  their  terminal  foramina,  are 

not  reduced  to  their  ultimate  dimensions  for  two  or  more  j'eai's  later. 

The  three  hard  structures  which  enter  into  the  composition  of  a  tooth  have  distinct 

sources  of  origin.     (  Vide  diagram.  Fig.  261.) 

Fig.  261. 


/> 


A  Vertical  Section  through  a  Lower 
Wolar  Tooth,  showing  its  differ- 
ent Component  Structures  and  its 
Connection  with  Parts  around. 


Diagram  of  developing  Lower  Molar  Tooth. 

A,  Dentinal  pulp  becoming  centripetally  encased  by  dentine. 

B,  Space  occupied  Ity  enamel  organ  between  centrit'ugally  forming  enamel  and  tooth  sac 

in  the  formation  of  a  dentigerous  cyst. 

C,  C,  The  base  of  dentinal  pulp,  which  remains  attached  and  developing  until  the  tooth  is  comjileted 

outgrowth  at  this  point  a  radicular  odontome  would  be  formed. 


In  this  space  fluid  collects 
By  abnormal 


The  enamel,  developed  from  the  "enamel  organ"  of  epithelial  origin  (which  occu- 
pies the  space  B  in  the  accompanying  diagram),  is  formed  centrifugaUi/  on  the  coronal 
dentine,  and  through  the  obliteration  of  its  formative  organ  becomes,  on  the  eruption  of 
the  tooth,  incapable  of  further  growth  or  nutritional  change. 

The  dentine  is  developed  from  the  "  dentinal  pulp  "  of  vascular  connective  tissue 
(vide  diagram.  Fig.  261,  a)  by  the  immediate  agency  of  a  .superficial  layer  of  cells  called 
odontoblasts. 

The  dentinal  pulp  or  bulb,  arising  from  the  bottom  of  the  tooth  sac  and  projecting 
into  its  interior,  grows  up  beneath  the  enamel  organ  and  progressively  takes  the  destined 
form  and  dimensions  of  the  dentine  ju.st  prior  to  the  formation  of  that  structure ;  thus, 
the  free  end  of  the  bulb  having  taken  the  form  of  the  cutting  edge  or  masticatory  sui-- 
face  of  the  future  tooth,  becomes  capped  by  dentine,  which  forms  on  it  from  without 
iuAvard,  and,  this  crown  cap  being  formed,  the  remainder  of  the  tooth  is  developed  by  the 
gradual  growth  of  the  pulp  at  its  attached  surface  or  base  (see  diagram.  Fig.  261,  c,  c) 
and  its  subsequent  encasement  by  dentine.  In  the  fully-developed  tooth  the  pulp  comes 
to  occupy  a  comparatively  constricted  central  chamber  corresponding  in  form  pretty  accu- 
rately to  the  external  contour  of  the  tooth,  and  this  chamber  may  be  yet  further  dimin- 
ished in  size  by  a  renewal  of  the  centripetal  growth  of  dentine. 

Dentine,  remaining  as  it  does  in  connection  with  its  formative  organ  through  the 
medium  of  the  tubuli  of  which  it  is  mainly  built  up,  is  capable  of  a  certain  amount  of 


U  DOS  TOMES.  -155 

ineroascd  sdlidiiicatioii.  I'ven  at  its  ]M'rijilicrv,  ami  iinilcr  certain  conditions  is  eiidnwed 
witii  must  aciitt-  sciisitivi'iii'ss. 

The  Crusta  petrosa  i><  forinfil  on  tlic  mailuallv  cionjratin^'  root  tliri>u'.'li  the 
ai:iiicv  i>r  till'  dental  >ae  iir  ra]>siile  wliieli  sunoiinds  the  rmmini.'  tooth  cruwn.  and 
ultimately  eonies  to  invest  the  mut  in  the  Iniin  ol'  the  lihin-vaseniar  ■•  alveuln-fh-ntal 
niemlirane."  ' 

The  alvotdar  jiortion  of  the  jaw  grows  up  with  and  is  moulded  around  the  developing 
tet'th.and  upon  the  eruption  of  their  crowns  affords  the  teeth  firm  implantation  by  closely 
surrounding:  their  roots. 

llavinir  thus  far  traced  a  tooth's  development,  we  now  pass  to  the  consideration  of  the 
etVects  which  fidlow  departures  from  this  nt)rnial  process. 

Odontomes. 

Tumors  wliieli  result  IVom  tin-  ahnornial  and  e.\C(!ssive  development  of  tlie  dental 
structures  at  any  time  ilurini;'  the  tooth's  formation  have  heen  grouped  together  hv  M. 
Broca  under  the  name  "odontomes."'-  and  elassitied  by  him  as  follows: 

I.  Odontomes  EmbryoplastiqueS. — Those  which  arise  l)efore  the  dental  i)ulp 
has  develn|HMl  odontolihists.  and  liefore  the  enamel  organ  has  acfjuired  special  enamel- 
forming  cells. 

II.  Odontomes  OdontoplastiqueS. — Those  which  arises  after  the  si)ecial  den- 
tine- and  enamel-forming  cells  have  been  developed,  but  prior  to  the  formati(jn  of  the  cor- 
onal cap  of  dentine. 

Ill-  Odontomes  Coronaires. — Those  which  arise  while  the  crown  is  forming. 

IV.  Odontomes  RadiCUlaireS. — Those  which  arise  during  the  formation  of  the 
root. 

These  four  designations,  pointing  respectively  to  the  periods  in  the  tooth'.s  develop- 
ment at  which  the  hypergenesis  of  the  pulp  has  arisen,  also  indicate  to  a  certain  degree 
the  structural  formation  of  a  tumor  formed  at  either  jieriod ;  but  in  adopting  these  terms 
it  must  be  understood  that  in  one  sense  the  embryoplastic  and  odontoplastic  conditions 
are  present  con.secutively  during  the  whole  period  of  dentitication,  and  also  that  if  the 
odontoblast  layer  of  cells  is  destroyed  at  any  point  true  dentine  will  not  there  be  formed, 
although  tlie  imlp  may  uiidiTgn  ealeitieation,  resulting  in  a  kind  of  osseous  structure. 

Embryoplastic  Odontomes. — Under  this  name  M.  Broca  ranges  encysted 
fibrous  and  tibro-plastic  tumors  of  the  jaw.  As  the  dental  germ  at  the  time  of  their 
origin  contains  no  special  dentine-  and  enamel-forming  cells,  di.stinctive  dental  .structures 
would  of  necessity  be  absent  from  these  growths ;  and  such  absence  must  of  course  leave 
their  dental  origin  in  doubt. 

In  one  instance  (mentioned  by  Tomes)  M.  Robin  met  with  a  tumor  in  the  lower  jaw 
of  a  child  ait.  2  years  and  t!  months;  this  tumor,  apparently  fibrous,  was  studded  with 
papilla?,  on  which  distinct  dentine  and  enamel  were  found.  Now.  whatever  doubt  may 
arise  as  to  the  origin  of  the  before-mentioned  tumors,  tliere  can  be  no  doubt  as  to  the 
dental  origin  of  this  one,  and  it  is  probable  that  in  it  a  longer  existence  would  have  been 
accompanied  by  further  dentification.  In  another  odontone,  which  occupied  half  of  the 
lower  jaw  of  a  girl  a;t.  2  years  and  9  months,  M.  Broca  found  the  formation  of  dentine 
proceeding  at  numerous  points  ;  and  the  fusion  of  these  secondary  bulbs,  coated  as  the}' 
were  with  enamel  organ,  would  result  in  bringing  about  the  structural  conditions  found 
in  an  odontoplastic  odontome. 

Odontoplastic  odontomes,  in  outward  form,  may  bear  not  the  slightest  resem- 
blance to  a  tooth. 

Structurally,  they  consist  of  a  more  or  less  confused  ma.ss  of  dentine,  enamel,  and 
osseous  structure,  the  dentine  occurring  in  tracts,  between  which  the  enamel  has  dipped 
down,     f^namel  is  also  found  capping  nodular  projections  which  occur  on  the  surface. 

The  bulbs  of  one  or  more  teeth,  normal  and  supernumerary,  may  enter  into  their  for- 
mation. 

The  case  met  with  by  Dr.  Forget,  and  reported  by  him,  may  be  cited  as  an  example. 

'  From  the  dental  sac  is  also  probably  derived  the  membrane  known  as  the  "  cuticula  dentis."  or 
"Xasmyth's  menibrane,"  which  in  an  unworn  tooth  is  found  continued  over  the  crown,  and  is 
regarded  by  C.  Tomes  as  an  undeveloped  cemental  layer. 

-  Exostosis  of  the  root  and  "deinine  excrescence"  in  the  pulp  chamber  are  called  by  Mr.  Salter 
"secondary  odontomes"  and  naturally  come  Tuider  tliat  desi.<niation,  as  niisrbt  also  the  outgrowth  of 
the  pulp  which  sometimes  follows  the  exposure  of  that  structure;  but,  as  these  are  affections  of  the 
fully-developed  tooth,  they  will  be  considered  in  the  second  division  of  our  subject. 


456 


ODONTOMES. 


Fig  26i>. 


A  man  ast.  20,  presented  himself  with  disease  of  the  lower  jaw  from  which  he  had  suffered 
since  Jie  was  five  years  old.  On  looking  into  the  mouth  a  hard,  smooth  tumor  was  seen 
occupying  nearly  the  whole  of  the  left  side  of  the  lower  jaw.     None  of  the  teeth  beyond 

the  first  bicuspid  were  present.  On  removal  (by 
.section  of  the  containing  bone),  this  tumor  proved 
to  be  a  hard,  oval,  tuberculated  mass  the  size  of  an 
egg,  chiefly  composed  of  dentine,  with  enamel  invest- 
ing the  nodules  and  dipping  into  crevices.  Be- 
tween the  tumor  and  the  osseous  crypt  which  it 
occupied  there  was  a  thick  fibro-cellular  membrane. 
The  forming  second  bicuspid  tooth  and  the  crown 
of  a  molar  were  found  impacted  in  the  jaw  through 
the  superposition  of  this  mass. 

In  one  case  reported  and  figured  by  Tomes  a 
large  tumor  presenting  the  appearance  of  a  malig- 
nant growth    occupied    the   incisive   region   of  the 
upper  jaw  of  a  man  xt.  25,  his  four  upper  incisors 
Represents,  on  a  much  reduced  scale,  the  half  of  not  having  appeared.     A  probe  introduced  into  the 
the  jaw  removed  in  this  case    (The  dots  across  t^mor  impinged  on   something  hard,  which  proved 

the  ascending  ramus  mark  the  line  of  its  sec-  i  ^  T  i  i 

tion.)  to    be   sundry  masses  of  tooth  structure,    best    de- 

scribed as  odontoplastic  odontomes,  together  with 
some  ill-formed  teeth.  These  specimens,  numbering,  in  all,  fifteen,  are  in  the  mu.seum  of 
the  Odontological  Society  of  London. 

In  a  case  reported  by  the  late  Mr.  Harrison  an  odontoplastic  odontome  occupying  the 
space  between  the  incisors  and  molar  teeth  came  away  spontaneously.  This  case  and  the 
nature  of  other  reported  cases  show  that  the  extirpation  of  an  odontome  should  never 
involve  the  removal  of  the  containing  portion  of  the  jaw. 

In  one  or  two  reported  cases  the  tooth  bulb,  having  produced  an  eccentric  formation 
such  as  described  instead  of  an  ordinary  crown,  has  afterward  assumed  normal  limits  and 
formed  fairly-shaped  roots. 

Coronary  Odontomes. — In  these  the  main  outline  of  the  tooth  is  preserved,  but 
an  irregular  outgrowth  nmre  or  less  circumscribed  projects  from  the  crown.  This  out- 
growth, having  arisen  while  the  crown  was  in  process  of  formation,  consists  of  the  coro- 
nal tooth  structures — viz.,  enamel,  dentine,  and  possibly  enclosed  pulp.  If  small  and 
involving  the  neck  of  the  tooth,  an  outgrowth  of  this  nature  may  be  at  first  mistaken  for 
tartar. 

Somewhat  allied  to  these  cases  are  those  in  which  a  tooth  presents  one  or  two  super- 
numerary cusps  or  supernumerary  teeth  merged  with  it. 

A  small  globular  projection  of  enamel  is  also  occasionally  met  with  on  the  root  of  a 
tooth,  and  has  been  ranged  among  odontomes  by  Salter,  who,  finding  that  it  caps  a  cone 
of  dentine,  calls  it  "  a  submerged  tooth  cusp."  The  crown  of  a  simple  supernumerary 
tooth  has  been  found  attached  in  the  same  po.sition.  and  probably  these  cases  have 
a  like  origin. 

Radicular  Odontomes. — This  form  of  tumor,  which  in  several  recorded  cases 
has  attained  the  size  of  a  chestnut,  is  found  attached  to  the  neck  and  root  of  a  fully- 
formed  tooth  by  a  moi'e  or  less  constricted  base,  and  results  from  an  irregular  outgrowth 
from  the  dentinal  pulp. 

Structurally,  radicular  odontomes  generally  consist  of  osteo-dentine  more  or  less  cov- 
ered in  by  a  layer  of  dentine,  with  a  coating  of  cementum  externally. 

An  odontome  of  this  kind,  embedded  in  front  of  the  anterior  margin  of  the  ascending 
ramus  of  the  lower  jaw  and  passing  vtp  behind  the  tuberosity  of  the  superior  maxilla,  was 
removed  by  me  at  Guy's.  This  tumor  (see  Fig.  2Go)  was  attached  to  the  lower  wisdom 
tooth  of  a  woman  aet.  38.  The  patient  had  experienced  no  inconvenience  from  her  mouth 
rip  fo  the  age  of  fhirfi/,  when  great  swelling  over  the  ascending  ramus  occurred,  accompa- 
nied by  closure  of  the  jaws  and  excruciatir^g  pain.  These  symptoms — icf/h  intervals  of 
complete  cei^sation  for  two  or  three  months  at  a  time — recurred  until  the  odontome,  which  was 
gradually  being  extruded,  was  removed  (very  easily)  by  extracting  the  tooth  to  which  it 
was  attached. 

In  the  case  which  is  figured  and  reported  at  page  441  of  this  volume.  Fig.  236,  a  sym- 
metrical enlargement  of  the  whole  root  occurred,  producing  a  dilated  hypcrtrophied  tooth 
fang. 

Odontoplastic  and  radicular  odontomes  are  very  rare,  only  a  few  cases  of  each  in  the 


ohos  roMi'.s. 


■')4 


iitlicrs    wliifli    have 


;    lull    I  lie    rcco; 
denial    (iri'Mti    ii 


riiitiiiii  i>r  til 


true   nature  o 
of  the 


I'  tlicsf  titiii(jr.s 
V\(i.  ii*i:i 


I^Klic'iiliir  •  iili  III  tome. 


hiiniaii 
antl    III" 

liiulicsi  iiii|Hirtaiici'.  as  it  will  avert  an  unnecessarily  severe  (ijiera- 
titui  tor  their  reinnval.  In  the  ease  ul"  tumors  anil  cysts  nf  the  jaws 
the  undue  alisenee  uj'  any  tooth  will  jioint  to  the  ](r(d)aliility  of 
their  dental  (U'iLrin.  hut  the  possihility  of  such  ori^'in  would  not  lie 
exeluiled  if  the  mwinal  uuniher  id'  teeth  were  |)reseut.  as  a  sujier- 
liunu'rarv  looili    may  oriuinale  either  an  odontonie  nr  a  dentii:erou> 

A  irlanee  at  the  close  packiiit:'  ol  teeth  ill  a  cliild  >  .ii'\\'-  ii"^ 
sliown  ill  i-'ii:'.  2()S,  will  show  the  stroni:  ]iroltal)ility  of  a  dental 
origin  for  tiiiniu-s  and  cysts  of  the  jaws  in  youii<:  suhjects.  especially 
when  it  is  reuienihered  that  eaidi  of  the  forty-eight  teeth  to  he  seen 
in  such  jaws  at  one  time  is,  or  has  heen.  the  centre  of  develo|i- 
luental  activity  ;  the  likelihood,  also,  that  tumors  may  cause  in- 
volvement  or  displacenieiit    (d'  iieiuhhiUMULr   teeth    will    he   readily    realized. 

Gemination,  or  the  union  of  eontiu'iious  ti'eth.  due  to  the  fusion  id"  their  pulp.s,  i.s 
met  with  nceasiuiially  in  hoth  the  temporary  and  the  permanent  set.  Normal  teeth  may 
he  thus  joined,  lU"  normal  and  supernumerary. 

Dilaceration,  or  the  ahrupt  chan<:;e  in  the  direction  of  the  tirst-  and  last-formed  por- 
tions (d"  a  tooth,  sometimes  occurs,  and  i.s  due  to  a  shifting  of  the  forming  tooth  on  its  base. 

DentigerOUS  Cysts  are  cysts  formed  by  the  accumulation  id"  fluid  within  the 
dental  capsule  at  some  period  of  the  tooth's  development,  or  around  a  fully-developerl 
tooth  which  has  not  erupted.  They  may,  therefore,  advantageously  be  classified,  like 
odontomes,  according  to  the  point  to  which  the  tooth's  development  has  proceeded  wlien 
the  change  occurs  which  eventuates  in  tlieir  formation. 

When  fully  developed,  a  dentigerous  cyst  usually  con.sists  of  a  thick  membranous  sac 
covered  in  by  a  thin  osseous  shell,  formed  by  the  expansion  of  tlie  bone  oi'  the  jaw.  In 
a  case  met  with  by  Mr.  Fearn  one-half  of  the  lower  jaw  was  expanded  by  a  cyst  which 
separated  its  external  and  internal  plates  and  contained  a  canine  tooth.  In  a  unii|ue 
specimen  of  Mr.  Cartwright's  a  cyst  with  calcified  walls  containing  a  supernumerary 
tooth  expanded  so  as  to  fill  the  antrum,  while  having  attachment  only  to  the  floor  of 
that  cavity.  The  cyst  at  first  usually  contains  a  serous  fluid,  which  may  become  puru 
lent  through  the  occurrence  of  inflammation. 

The  uncut  tooth  (temporary,  permanent,  or  supernumerary)  about  which  the  cyst  hag 
expanded  may  be  represented  by  a  small  shapeless  calcified  mass  if  its  formation  was 
disturbed  in  the  earliest  odontoplastic  period.  This  fact  was 
well  exemplified  by  the  case  of  a  girl  aged  13  who  was  at 
Guy's  under  the  care  of  Mr.  Cooper  Forster.  (8ee  Fig.  2(i4.) 
Here  two  small  irregular  masses  of  dentine  and  enamel,  the 
representatives  of  an  absent  canine  and  lateral  incisor,  were 
contained  in  two  distinct  cysts,  which  caused  great  protrusion 
of  the  anterior  wall  of  the  superior  maxilla.  The  enclosed 
tooth  may  be  attaclied  firmly  to  the  cyst  wall  or  may  be 
found  free   within  the  cyst. 

A  dentigerous  cyst,  forming  in  the  uj)])er  jaw.  may  ex- 
pand into  atul  cause  di.stension  of  the  antrum.  Professor 
Baum  met  with  a  case  of  immense  dilatation  of  both  antra, 
one  containing  a  molar,  the  other  a  canine. 

In  .some  cai^es  the  tooth  crown  only  or  the  crown  and  part 
of  the  root  have  been  formed  prior  to  the  expansion  of  the 
capsule  by  serum,  and  these  may  be  said  to  behtng  to  the 
coronary  and  radicular  periods.  In  other  cases,  again,  the 
cyst  develops  around  fully-formed  impacted  teeth,  which  may 

be  found  inverted.  In  one  in.stance.  mentioned  by  Tiunes,  no  less  than  twentv-eight 
separate  and  adherent  denticles  (or  small  sujiernumerary  teeth)  were  found  in  a  cyst  of 
the  upper  jaw.  and  are  probably  to  be  looked  upon  as  the  ununited  constituent  parts  of 
teeth  that  were  missing. 

Although  both  odontomes  and  dentigerous  cysts  have  their  origin  in  early  life,  years 
may  elapse  before  the  irritation  caused  by  the  presence  of  the  odontome  or  the  increasing 
disfigurement  and  pain  resulting  from  the  enlargement  of  the  dentigerous  cyst  may  lead 
a  patient  to  seek  surgical  aid. 


Fig.  2(54. 


Case  of  Dentigerous  Cyst  not 
involving  .Antrum. 


458  SYPHILITIC  TEETH. 

Cysts  developed  on  the  root  of  erupted  and  fully-formed  teeth  are  not  classed  here  as 
(hntigerous,  as  they  form  only  an  appendage  to  the  tooth.  They  will  be  referred  to 
among  the  diseases  of  the  teeth,  but  it  may  be  here  remarked  that  they  sometimes  attain 
to  a  large  size,  and  may,  like  dentigerous  cysts,  expand  i?'to  the  antrum,  and  also  that 
their  contents  under  inflammation  may  become  purulent. 

Supplemental  teeth — /.  e.,  extra  teeth  exactly  corresponding  to  a  neighboring 
normal  tooth — are  occasioiuilly  developed  in  both  temporary  and  permanent  sets,  usually 
in  the  front  of  the  mouth.     If  they  cause  crowding  or  are  placed  before 
Fig.  265.         qj.  behind  their  doubles,  they  should  be  extracted. 

Supernumerary  teeth — i.  '..  teeth  differing  in  form  from  any 
of  the  normal  .series — -are  not  infrequently  found  in  the  upper  incisive 
region,  and  occasionally  in  other  parts  of  the  mouth.  A  pair  of  teeth 
somewhat  resembling  incisors,  but  of  greater  anterio-posterior  depth,  are 
occasionally  developed  behind  the  permanent  upper  front  teeth,  and 
others  more  resembling  small  molars  or  bictispids  are  also  occasionally  met 
Denticle  or  most  witli ;  but  by  far  the  commonest  form  that  the  crowns  of  supernumerary 
elementary  Tooth  teeth  present  is  that  of  a  siniide  cone  or  of  a  cone  truncated  and  fitted  on 

Formation.  .  ^.,  ,,,  ^         ,,'  ,  ..  -i,,  -ii- 

its  summit,  and  tliese  teeth  have  a  characteristic  straiglit  terminal  line  to 
the  enamel  at  their  necks.  They  are,  in  fact,  the  most  elementary  form  of  tooth  forma- 
tion.    (See  Fig.  265.) 

Treatment. — As  a  general  rule,  supernumerary  teeth  are  to  be  extracted,  and 
will  alwav's  be  found  to  have  a  single  root,  which  may.  however,  be  contorted  and 
expanded. 

Malformed  Teeth. — Abnormalitie.s^in  the  form  of  teeth  may  result  from  the  dwarfing 
or  excessive  development  of  the  different  parts  or  lobes  of  which  they  are  architecturally 
built  up,  and  also  from  a  defective  formation  of  their  enamel.  These  abnormalities  may 
be  of  great  value  in  the  diagnosis  of  constitutional  peculiarities  and  in  throwing  light  on 
the  condition  of  health  present  during  a  patient's  early  years. 

Syphilitic  Teeth. — Mr.  Jonathan  Hutchinson  in  1860  first  pointed  out  the  asso- 
ciation between  congenital  syphilis  and  a  given  niisshapement  of  the  permanent  incisor 
teeth,  and  this  fact  may  be  considered  fully  proven.  In  1875.  Mr.  Hutchinson  drew 
attention  at  the  Pathological  Society  to  his  belief  that  defects  in  enamel  were  in  many 
cases  due  to  the  administration  of  mercury  in  infancy.  The  investigation  of  a  large  num- 
ber of  cases  has  convinced  the  present  writer  of  the  truth  of  this  belief,  and,  in  fact, 
when  he  first  gave  his  attention  to  the  subject,  in  1868,  it  was  apparent  to  him  that  tlie 
illustrations  of  syphilitic  teeth  given  in  several  works  were  misleading,  and  that  the  mal- 
formation they  portrayed  was  not  that  one  distinctive  of  syphilis,  but,  if  at  all  due  to 
that  cause,  was  one  that  had  been  obscured  by  some  complication. 

Certain  popular  teething  powders,  containing  calomel  together  with  an  opiate,  appear 
to  be  the  commonest  form  in  which  mercury  acting  injuriously  on  the  enamel  has  been 
administered. 

The  distinctive  change  of  shape  in  the  syphilitic  tooth  is  essentially  due  to  a  deformed 
development  of  the  dental  pulp  prior  to  its  calcification  ;  while  rocky  or  honeycombed 
enamel  is  a  result  and  permanent  record  of  depressed  or  interrupted  nutrition  of  the 
forming  enamel  at  a  particular  period,  brought  about  by  the  action  of  mercury,  and 
probably  also  by  illnesses  which  lower  the  system  generally  or  disturb  the  circulation 
locally. 

The  key  to  the  right  understanding  of  these  and  other  maldevelopments  is  to  be 
found  in  an  accurate  knowledge  of  the  normal  forms  of  the  teeth,  and  in  the  recognition 
of  the  fact  that  they  are  archlfecfnralli/,  though  not  structurally,  built  up  of  simpler  forms 
which  are  liable  to  an  individual  alteration  under  certain  pathological  conditions.  The 
distinctive  features  given  to  teeth  by  syphilis  and  by  mercury  are  apt  to  be  obscured  by 
the  action  of  both  in  the  same  case.  As  through  this  and  other  causes  vague  notions  on 
this  subject  are  still  prevalent,  typical  forms  of  normal,  syphilitic,  mercurial,  and  what 
may  be  regarded  as  syphilitic-mercurial  teeth  are  on  page  459  presented  at  one  view, 
together  with  a  verbal  description  of  their  differences. 

Fig.  266,  A,  B,  C,  D,  represents  four  typical  sets  of  teeth.  The  bicuspids,  which  in 
neither  case  suffer  alteration,  are  withdrawn  on  the  right  side  to  bring  the  finst  molars 
better  into  view. 

A.  Normal  teeth. — The  labial  surfaces  of  the  incisors  are  seen  built  up  of  three  equal 
columns  and  present  a  greater  width  at  their  cutting  edges  than  at  their  necks.  The  upper 
central  incisors  are  longer  than  the  laterals.     The  first  lower  molars  are  large  and  angular 


SYl'lIIJJTTC  TEETH. 


459 


teeth  and  have  live  well-inarkeil  eiisps.  shar|i-|M(iiiteil  throuj^'h  the  greater  pnimineiice  cjf 
a  eeiitral  tuljereh-.  The  ii|i|ti'r  first  iiinlars  are  also  larg*'  teeth  with  \vell-»iiarkc(l  cusp.s. 
The  euttinijedires  i>t'  the  iiieisurs  t|iiickly 
hiso  tlu'ir  tlir«>e  pnniiiiiciices  hy  wt-ar. 

H.  Si/j>li!litir  hith. — -In  the  ii|>|i(r 
central  ineisors  the  eentral  enlunin  is 
<finii/ii/  anil  the  side  enliinms  incline 
toward  eaeh  other,  eaiisini;  the  enttinLC 
cd<re  of  the  tooth  to  he  less  in  hreadth 
than  its  neck.  'I'liey  are  often  niiieh 
less  prouiinent  than  the  teeth  on  eaeh 
side  of  them.  thronLrh  their  diminished 
size,  and  also  from  a  want  of  vertical 
depth  in  the  portion  of  alveolar  process 
in  which  they  are  imi)lanted.  C'ora- 
monly  tliese  teeth  have  a  (piarter  turn 
which  hrintrs  their  distal  side.s  to  face 
sliiihtly  to  the  fn)nt.  The  h)wer  inci- 
sors have  their  cutting  edges  rounded 
oft',  and  therefore  not  touching  their 
neighhors.  The  first  molars  are  re- 
duced in  size  and  r/owj^-shaped.  through 
the  dwarfing  of  the  central  tubercle  of 
eaeh  cusp.  Syphilitic  teeth  may  have 
a  perfect  covering  of  enamel,  and  will 
not  then  he  di.scolored. 

C.  Tcrfli  icitli  dcfcctlvi'  enamcL — 
Alia.ses.  "  stomatitic,"  "  honeycombed," 
^'  rocky,"  "  mercurial."  Are  malformed, 
not  through  a  changed  shape  of  dental 
pulp,  but  from  failure  of  enamel  to 
form  an  even  centrifugal  encasement 
over  tliem.  If  the  deficiency  of  enamel 
is  superficial,  the  color  of  the  tooth  may 
be  uiu\ltered  ;  but  if  the  pittings  are 
deeper,  they  usually  appear  as  black 
points,  or  the  more  or  less  discolored 
dentine  is  revealed  and  imparts  to  the 
tooth  a  dirty  "'size-colored"  appearance. 
The  bicuspids,  second  molars,  and  wis- 
dom teeth  usually  escape  through  their 
later  development.  The  age  at  which 
the  depressed  nutrition  occurred  and  its 
duration  are  accurately  recorded  on  the 
teeth. 

D.  Si/philf'(ic-mercurial  fnt]). — As  re- 
gards syphilis,  the  contour  of  these  teeth 
would  be  the  point  of  chief  diagnostic 

value.  In  the  left  central  upper  inci.sor  a  small  central  tubercle  of  dentine  is  seen 
denuded  of  enamel,  which  looks  as  if  it  had  l)een  gouged  out  from  above  downward  ;  in 
the  right  central  the  exposed  dentine  has  broken  away,  leaving  a  crescentic  notch.  In  the 
first  molar  a  dcjiressed  area  is  seen  on  the  masticating  surface,  circumscribed  by  a  ridge 
of  enamel,  the  denuded  and  ill-formed  points  of  dentine  representing  the  cusps  having 
been  lost. 

Syphilitic  malformation  of  teeth  ranges  from  an  excessive  dwarfing,  in  the  worst  cases 
leaving  only  a  shapeless  peg  to  represent  the  incisor,  to  the  merest  indication  of  the  typ- 
ical form.  It  is  not  present  at  all  in  some  cases  of  congenital  .syphilis,  and  one  child  in 
a  family  even  may  escape  it.  while  the  older  and  younger  children  have  it. 

In  honeycombed  teeth  an  irregular  aiul  insufficient  develojunent  of  enamel  produces 
horizontal  groovings  or  pittings  of  its  surface  and  most  often  afi'ects  the  first-formed 
points  of  the  cusps,  sometimes  leaving  them  entirely  denuded,  as  shown  in  the  figure 
given  ;  but  when  the  agency  which  arrests  the  enamel  formation  is  brought  to  bear  later, 


460  CUTTING   OF  THE  TEETH. 

the  cutting  edges  of  the  incisors  and  the  tips  of  the  cusps  of  the  molars  will  have  a  per- 
fect covering  of  enamel  and  the  defective  lines  will  be  below  them.  Sometimes,  presum- 
ably when  the  cause  has  been  gently  exerted  for  a  long  time,  slight  horizontally-arranged 
pittings  cover  the  whole  crown. 

The  irregularly-formed  enamel  may  be  structurally  defective,  as  shown  by  its  dis- 
coloration ;  and  this  may  conduce  to  decay,  as  does  also  the  pitting  of  the  enamel  if  it 
extends  through  to  the  dentine.  In  other  cases  the  diminished  size  of  these  teeth — which 
prevents  their  being  crowded  and  exposes  their  sides  to  healthful  friction — renders  them 
less  obnoxious  to  decay  than  might  have  been  expected. 

Some  children  of  different  families  seen  by  me 
Fig.  267.  present,  together  with  great  peculiarities  of  their 

eyes  and  a  general  weakness  in  the  development 
of  their  dermal  structures,  the  following  peculiar- 
ities in  their  teeth  :  The  middle  lobes  are  sharp, 
recurved,  and  excessively  long,  while  the  lateral 
lobes  are  dwarfed.  In  these  cases,  however,  the 
resulting  pointed  form  can  be  readily  distinguished 

Pointed  Teeth  well  covered  with  Enamel  (not       ,>  ^i        ,  ,     i  -,    •  i-i         p  ^■^• 

syphilitic).  irom   the  truncated  screw-driver-hke  lorm   indica- 

tive of  congenital  syphilis.     (See  Fig.  267.) 

Imperfections  in  Structural  Development. 

At  the  present  day  the  early  decay  and  loss  of  teeth  are  very  common,  and  are  prob- 
ably in  part  due  to  an  insufficient  supply  of  food  containing  the  elements  which  go  to 
build  up  the  osseous  structures,  malnutrition  in  early  life,  from  whatever  cause,  leaving 
inevitably  its  mark  on  the  exteriors  of  the  teeth,  which,  once  ill  formed,  have  no  power 
of  recuperation. 

In  infancy  and  childhood  plenty  of  good  milk  and  the  use  of  "  rclwlc  flour  meal  "  are 
to  be  recommended ;  it  is  to  be  borne  in  mind  that  until  a  child  begins  to  take  animal 
food  the  above  are  the  sources  of  supply  of  lime  salts.  The  diet  of  the  pregnant  mother 
may  also  with  advantage  receive  attention. 

Structural  Defects  in  Enamel  Development. — Perfect  enamel  contains 

upward  of  95  per  cent,  of  earthy  matter,  and  consists  of  rods  united  together  without 
intervening  matrix  and  placed  at  right  angles  to  the  surface  of  the  dentine.  Enamel, 
when  well  formed,  is  semi-transparent,  but  when  defective  from  a  want  of  homogeneous- 
ness  in  its  structure  presents  an  opaque,  white,  chalky  appearance,  and  is  then  easily 
disintegrated.  At  the  bottom  of  the  natural  sulci  of  otherwise  well-formed  teeth 
enamel  is  sometimes  deficient  in  thickness  and  in  soundness,  and  this  favors  the  ingress 
of  decay. 

Structural  Defects  in  Dentine  Formation. — AVell-formed  dentine  is  uni- 
formly dense  and  ivory-like.  It  is  built  up  of  tubuli  and  intertubular  substance,  the 
tubuli  serving  to  convey  nutrition  from  the  pulp  to  the  periphery.  Dentine  is  endowed 
with  sensitiveness  through  the  soft  tissue,  which  passes  from  the  pulp  to  the  surface  and 
renders  the  dentine  immediately  beneath  the  enamel  especially  sensitive. 

Through  imperfect  development  a  (so-called)  granular  layer  which  is  found  on  the 
surface  of  dentine  in  the  root  may  be  present  on  the  surface  of  coronal  dentine.  The 
(so-called)  globular  condition  of  dentine  is  another  developmental  defect.  When  the 
enamel  covering  is  lost,  imperfect  dentine  softens  rapidly  under  decay  without  becoming 
darkened,  and  is  also  apt  to  be  exceedingly  sensitive. 

Cutting  of  the  Teeth. 

During  the  eruption  of  the  temporary  teeth,  if  there  is  disturbance  of  the  general 
health  traceable  to  dental  irritation,  and  especially  if  there  be  the  least  sign  of  cerebral 
(disturbance,  there  should  be  no  hesitation  in  freely  lancing  the  gum — tumid  or  tense — 
which  covers  the  tooth  that  is  presenting.  In  the  case  of  a  front  tooth  a  straight  incision 
should  be  made  on  to  i\\e  front  of  its  cutting  edge  ;  in  the  case  of  the  molars  a  crucial 
incision  should  be  made  from  corner  to  corner. 

As  a  rule,  the  permanent  teeth  erupt  very  easily,  but  an  incision  with  a  lancet  may 
sometimes  with  advantage  be  had  recourse  to  in  cases  where  cerebral  disturbance  is  easily 
excited ;  and  it  is  often  well  to  remove  bodily  the  gum  from  above  an  erupting  wisdona 
tooth  when  an  antagonist  tooth  bites  upon  and  irritates  it. 


iiiiiim  I 'LA  iiiTY  OF  Ti'.irni. 


M'A 


Irregularity  of  Position. 

liriiiiiliiilti/  iA'  ;irr;iiii:<'iin"iit  li;iriliv  fViT  orciirs  amorij.^  tlic  ti'iii|)()r:iry  Ici'tli,  luit  ;iii 
uiuluc  primiiiu'iifi!  nf  (lie  ii|i|)fr  incisfirs,  wliit-li  soiin'tiiiics  is  aci|iiirc<l  tlinMi^h  tlmrulj' 
suc'kiiii:  ami  a  tt'iidi'iicv  to  iiiiilfrliaii^iiiijr,  iVuiii  tlic  ftvcr-iltnrlopiiieiit  nl"  tliu  lower  jaw  as 
coiuitait'd  witli  tin-  u|i|M'r,  slimild  ivccivc  attcntinii,  in  order  that  thi-st'  comlifioiis  may  not 
he  perpetuated  in  the  sreond  set.  The  ahsenee  of  tlie  spaeiii;;  of  the  temporary  tettth, 
whicli  shoiihl  |MH'ee<h'  their  sht-ddiiiL'.  will  point  to  a  likelihood  <d'  crowding  anioni.'  the 
fomintr  permanent  teeth  and  deniaml  watchfulness. 

limiuJiirUy  of  the  permanent  teeth  <iften  resiilt.s  from  the  want  of  timely  e.xtractioii, 
and  even  oftener  from  the  untimely  extraction  of  temporary  teeth.  It  therefore  behooves 
the  surgeon  who  may  he  ealled  ujton  t<j  e.xtract  teeth  from  young  subjects  to  aeijuaint 
himself  with  the  time  of  eruption  (d'  the  different  permanent  teeth  and  with  the  points 
ol"  diflerenee  between  temporary  and  |iermanent  teeth. 

\Vell-develo|ieil  adult  jaws  should  eonseijuently  In;  thoroughly  studied  as  a  type  and 
compared  with  the  jaws  in  ehildhood.  It  will  be  then  seen  that  develoi)ment  has  <jccurred 
longitudinallv  backward  for  the  ai-comiuodatiou  of  tin;  permanent  molars,  while  the  part 
of  the  jaws  that  was  occupied  by  the  ten  temporary  teeth,  having  undergf^ne  additional 
development  on  its  anterior  face,  is  in  the  adult  occupied  by  the  incisors,  canines,  and 
bicuspids.  In  order  tluit  these  latter  may  have  room  for  even  arrangement,  it  is  import- 
ant that  the  anterior  ]>ermanent  molars  (the  si.x-year-old  teethj  shouhl  not  be  allowed  to 
take  11)1  a  too  forward  position,  which  they  will  do  if  the  temporary  molars  are  prema- 
turely lost  from  neglected  decay.  Un  this  account,  therefore,  the  timely  stopping  of  the 
back  temporary  molars  is  a  practice  to  be  recommended. 

The  accompanying  figure  will  show  how  easily 
irregularities  may  be  brought  about,  as  the  retention  Fig.  268. 

of  the  root  of  a  temporary  tooth  is  enough  to  pre- 
vent the  permanent  tooth  from  taking  up  its  proper 
position. 

In  judging  of  the  amount  of  space  that  there 
will  be  for  the  accommodation  of  the  coming  teeth, 
it  is  to  be  renieml)ered  that  the  alveolar  portion  of 
the  jaws  grows  up  with  and  is  moulded  around  the 
teeth  it  supports,  and  that  there  is  a  strong  tendency 
for  teeth  to  assume  their  proper  position  (the  action 
of  the  tongue  and  lips  conducing  thereto),  while  the 
replacement  of  the  temporary  molars  by  bicuspids 
increases  the  space  for  the  front  teeth. 

A  ver}'  common  form  of  irregularity  results  in 
otherwi.se  well-developed  jaws  from  the  permanent 
upper  incisors  being  erupted  to  the  rear  of  their 
unshed  predecessors.  In  such  a  case  the  prompt 
removal  of  the  temporary  teeth  is  demanded ;  for  if, 
on  the  further  elongation  of  the  upper  permanent 
incisor,  the  edge  once  passes  behind  the  incisor  of  the  lower  jaw,  at  each  closure  of  the 
mouth  the  evil  is  increased,  and  can  then  be  corrected  ordy  by  the  use  of  a  regulating 
plate.  On  the  same  score,  lower  incisors  may  sometimes  be  kept  in  the  rear  of  the  tem- 
porary teeth  in  order  that  they  may  be  ready  to  wedge  forward  the  upper  incLsors  and 
thus  secure  the  ovf-rJapping  of  the.  iijjpi  r  front  teeth,  which  allows  of  their  true  incisive 
action,  while  it  spares  them  undue  wearing  away. 

In  spite  of  the  above  precautionary  measures  at  the  time  of  the  second  dentition, 
cases  of  irregularity  will  occur  from  malformation  and  insufficient  development  of  the 
jaws.  Some  of  the  .slighter  of  these  irregularities  are  amenable  to  surgical  treatment — 
that  is,  a  timely  extraction  will  allow  nature  to  .set  all  straight ;  but  if  a  tooth  is  taken 
out  on  one  .side  of  the  mouth  to  relieve  overcrowding,  the  preservation  of  symmetry  will 
often  demand  the  extraction  of  another  on  the  opposite  side.  The  patient's  profile  and 
the  relative  prominence  of  the  upper  and  lower  dental  arches  have  to  be  considered  in 
deciding  whether  permanent  teeth  should  be  extracted  for  regulating  purposes,  while  the 
soundness  of  teeth,  the  direction  taken  by  their  roots,  the  firmness  of  their  implantation, 
and  their  comparative  durabilitv  are  all  points  to  be  considered  in  deciding  which  tooth 
should  be  sacrificed  for  the  benefit  of  the  remainder. 

Sometimes  the  first  permanent  molar  may  with  advantage  be  taken  out  when  the  tend- 


M  A'' 

A,  Permanent    incisor  teeth. 

B,  Peruiaiieiit  canine. 

Drawing  of  .laws  of  <"hild  set.  6.  (.\  and  B  point 
to  permanent  incisors  and  canines.  The  Id- 
cuspids  are  seen  embraced  by  the  roots  of  the 
temporary  molars.  The  permanent  molars, 
with  the  e.Kception  of  the  wisdom,  are  pres- 
ent.i 


462  IRREGULAEITY  OF  TEETH. 

ency  to  overcrowding  is  decided.  If  this  tooth,  which  is  particularly  liahle  ta  decay,  is 
pa*t  hope  of  permanent  preservation  by  stopping,  its  extraction  in  time  allows  the  second 
molar  to  come  forward  and  partly  occupy  its  .site  and  the  wisdom  tooth  to  come  well  into 
place,  while  it  also  enables  the  front  teeth  to  .spread  and  thus  escape  undue  lateral  pres- 
sure and  consequent  decay. 

On  the  other  hand,  there  is  the  strongest  reason  for  preserving  this  tooth  when  the 
upper  incisors  are  so  prominent  as  to  require  drawing  back,  as  it  often  affords  the  only 
satisfactory  point  from  which  traction  can  be  exercised;  and  a  bicuspid  in  such  cage 
should  by  preference  be  sacrificed.  Another  valid  objection  to  the  extraction  of  the  first 
permanent  molar  occurs  when  the  withdrawal  of  the  prop  which  this  tooth  affords  at  the 
back  of  the  mouth  would  cause  the  lower  incisors  to  bite  up  unduly  on  to  the  necks  of 
the  uppers  and  drive  them  forward. 

.Here  it  may  be  remarked  that  in  all  attempts  to  improve  the  regularity  of  the  teeth 
the  relative  positions  of  the  antagonist  teeth  in  the  other  jaw  must  be  taken  into  account. 

So  far.  only  those  cases  have  been  considered  that  are  capable  of  being  benefhed  by 
timely  extraction,  but  many  cases  require  for  their  treatment  the  use  of  mechanical  appli- 
ances. Among  these  appliances  a  lever  for  expanding  the  arch  of  the  upper  teeth  (while 
it  presses  back  the  lower)  and  elastic  bands  are  of  great  use.  while  in  more  advanced 
cases  a  regulating  plate  must  be  worn,  the  principle  of  its  action  being  that  it  affords  a 
fixed  j)oint  from  which  continuous  pressure  or  traction  is  kept  up  on  the  teeth  to  be  moved. 

The  movement  of  teeth  by  mechanical  means  should  be  gradual,  or  absorption  of 
bone  will  result  without  a  compensatory  development  and  the  teeth  will  be  loosened. 
Twisted  teeth  can  be  turned  on  their  axes.  In-standing  upper  front  teeth  can  be  trained 
out,  and  will  be  retained  in  their  new  position  as  soon  as  they  are  brought  to  overlap^  the 
lower  teeth  ;  prominent  and  projecting  upper  teeth  can  be  gradually  trained  in,  but  will 
be  required  to  be  kept  in  place  for  some  time  by  mechanical  means,  to  prevent  their 
reverting  to  their  original  position.  The  lower  lip  pa.«sing  behind  prominent  upper  inci- 
sors inci'eases  the  deformity  which  is  usually  associated  with  a  contracted  arch. 

In  regulating  teeth  much  greater  difficulty  has  to  be  overcome  where  contraction  or 
malformation  of  the  jaw  causes  the  irregularity  than  in  those  cases  where  there  is  simple 
misdirection  of  the  teeth  them.selves. 

In  some  cases  complete  underhanging  of  the  jaw  is  present — i.  e.,  the  xipper  teeth, 
back  as  well  as  front,  are  set  within  the  arch  of  the  lower  teeth ;  this  condition  does  not 
admit  of  much  remedy  when  once  firmly  established,  but  may  be  prevented  to  a  certain 
extent  by  timely  extraction  of  lower  teeth  together  with  a  training  out  of  the  upper. 
The  earlier  that  irregularities  receive  attention  the  better,  in  order  that  the  misplacement 
may  not  be  increased,  and  also  because  the  moving  of  teeth  can  be  safely  effected  only  in 
the  young. 

Canine  and  wisdom  teeth,  owing  to  the  lateness  of  their  eruption  and  the  position  they 
occupy  during  development,  are  peculiarly  liable  to  be  shut  out  from  the  dental  arch. 
The  canine,  being  a  durable  tooth,  should  in  many  cases  have  room  made  for  it  by  the 
extraction  of  one  of  the  teeth  that  have  closed  in  upon  its  .site.  The  cutting  of  wisdom 
teeth  is  frequently  attended  with  much  trouble,  and  it  may  be  remembered,  in  the  case 
of  young  subjects  with  small  maxillfe  whose  first  or  second  molars  are  much  decayed, 
that  the  timely  extraction  of  either  of  these  teeth  may  allow  the  wisdom  tooth  (if  devel- 
oped) to  erupt  easily  and  occupy  a  useful  position.  In  the  upper  jaw,  if  the  wisdom  is 
forced  to  take  an  outward  direction,  and  so  cause  irritation  of  the  cheek,  it  .should  be 
extracted.  In  the  lower  jaw.  where  there  is  insufficient  room  for  it  between  the  second 
molar  and  the  ascending  ramus,  its  efforts  to  erupt  often  produce  nerve  irritation,  chronic 
spasm  of  the  masseter.  the  formation  of  pus  between  the  crown  of  the  tooth  and  the  super- 
jacent gum  ;  it  may  also  cause  absorption  of  the  root  of  the  second  molar  and  lay  bare 
its  pulp. 

In  all  cases  where  the  impaction  of  a  lower  wisdom  tooth  is  a  source  of  irritation  the 
impaction  .should  be  at  once  got  rid  of  by  the  extraction  of  either  the  wisdom  tooth  or 
the  tooth  in  front.  The  operation  required,  as  well  as  the  serious  results  which  may 
attend  purulent  inflammation  about  an  impacted  wi.sdom  tooth,  will  receive  notice  later. 

Teeth  are  sometimes  erupted  in  strange  positions  ;  thus,  Salter  records  a  case  of  inver- 
sion and  eruption  of  lateral  incisors  in  the  nares.  and  Tomes  figures  the  case  of  a  molar 
erupted  in  the  median  line  of  the  palate,  and  another  case  in  which  the  crown  of  a  molar 
pierced  the  cheek  at  the  angle  of  the  jaw.  In  another  case,  figured  by  Tomes,  the  crown 
of  a  molar  presented  at  the  sigmoid  notch,  but  remained  impacted. 

Impaction,  or  retention  of  a  tooth  within  the  maxillary  bone,  often  occurs  witliout  any 


ininMrLMirrv  or  tf.eth.  103 

ill  iTsuIrs,  hut  occjisidiiallv  it  is  iirdtliictivc  ul'  st-vcrc  iiiisfliift".  Tliiis,  in  ;i  ciiM-  wliidi 
occiinfj  ill  ilif  |ii:ictici'  ut'  Mr.  {'artwrii.'^lit.  Sr.  (ami  which  is  repdrtcd  at  h-ii^th  hy  Mr. 
Salter ),  it  wj^  iiiddiictive  of  si'Vcrc  iicural^Ma.  In  this  casti  the  in-t'sciice  of  an  inipaott-d 
upper  (-aninc,  which  caused  a  pri>niinenc(!  itu  tho  palate,  ^ave  ris/^  for  ci^'ht  years  to  con- 
stautlv-recurrin^^  most  .seven;  neuralj.'ie  pain,  conHued  to  a  cir(;uinscrihcil  spot  u\\  the  left 
side  of  tlie  vertt'.v  oi'  the  heail.  In  other  cases  it  may  jrivc  rise  to  cystic  eidar<:eincnt  or 
altsccss,  the  latter  perhaps  late  in  life,  fntui  the  Imried  tooth  hecomin;;  more  superficial 
t-hrouirh  ahsorptinn  ut'  the  containing  hone.  The  palate  may  he  involved  if  a  tooth  is 
impacted  within  the  pahitine  process  of  the  superior  maxilla,  or  an  ah.sce.ss  may  be 
formed   helow   the  tongue  from   impacted   lower  teeth. 

The  foUowiut;  case  was  reported  hy  Mr.  McCoy  in  the  Lnnat,  1871  :  A  boy  ;et.  14 
had  a  tumor  of  the  antrum  the  size  of  an  apricot,  due  to  an  impacted  canine,  the  crown 
of  wlrieli  projected  into  the  antrum,  while  the  root  was  impacted  in  a  socket  in  the  na.sal 
proccjis:;  the  antral  cavity  contained  a  litth;  j^lairy  fluid,  hut  was  chiefly  filled  by  a  gelatin- 
ous sflirstauce — apparently  thickened  mucous  membrane. 

Absence  of  Teeth. — A  few  cases  are  recorded  of  edentulous  jaws.  Wisilom  ami 
upper  lateral  incisors — the  teeth  most  liable  to  variations  in  size  and  shape — are  also  the 
most  liable  to  su])pression.  Occasionally  other  permanent  teeth — notably,  lower  second 
bicuspids — fail  to  make  their  a]ij)earance,  in  which  case  it  may  be  right  to  leave  their  pre- 
decessors undisturbed  if  they  show  no  signs  of  loosening;  temporary  molars  may  in  such 
cases  serve  for  many  year.s. 

The  tendency  of  particular  teeth  to  take  irregular  positions  and  the  liability  of  others 
not  to  be  developed  are  facts  that  have  to  be  borne  in  mind  in  connection  with  the  prob- 
able dental  origin  of  tumors  and  cysts  of  the  jaws. 

Before  passing  to  the  second  division  of  our  subject  it  may  be  useful  to  enumerate 
the  miu-bid  conditions  which  may  be  simulated  by  the  tumors,  cy.sts,  etc.  which  origin- 
ate from  an  unerupted  tooth  in  the  ways  described  in  previous  pages. 

Odontomes  niay  give  ri.se  to  appearances  such  as  may  be  presented  by  benign  or 
malignant  tumors,  whether  arising  spontaneously  or  due  to  the  impaction  of  a  foreign 
bodv.  such  as  root  of  tof)th,  splinter  of  bone,  or  a  bullet. 

iDentigerOUS  cysts,  when  slowly  forming  and  before  they  have  thinned  the  enclos- 
ing bone  to  an  extent  which  would  allow  of  the  characteristic  sign  of  crfojnrmrtit  on  pres- 
sure, may  be  diffieult  to  diagnose  from  solid  tumors. 

A  dentigerous  cyst  may  also  produce  the  .same  symptoms  as  a  cyst  formed  on  the  root 
of  an  erupted  and  diseased  tooth;  and  when,  through  inflammation,  its  fluid  contents 
become  purulent,  it  may  in  like  manner  resemble  an  alveolar  abscess — /.  e.,  an  abscess 
formed  around  the  root  of  a  diseased  tooth — and,  like  it,  will  be  apt  to  give  rise  to  a  fistu- 
lous opening. 

Empyema. — Suppuration  in  the  antrum,  or  empyema,  arises  probably  in  two  dis- 
tinct ways.  Ill  the  one  case  it  is  due  to  inflammation  of  the  lining  membrane  of  the 
cavity,  which,  being  continuous  with  the  mucous  membrane  of  the  nose,  allows  of  the 
escape  of  the  contained  purulent  fluid  into  the  middle  meatus  by  the  natural  orifice.  In 
the  other  case  the  pus  is  contained  in  a  sac  which  has  expanded  into  the  antral  cavity, 
carrying  the  lining  memlirane  before  it,  and  then  the  pus  does  not  find  exit  by  the  na.sal 
opening;  this  latter  condition  (as  pointed  out  by  Otto  Weber)  is  generally  present  when 
the  root  of  a  tooth  originates  the  mischief  by  penetrating  the  cavity,  and  when  an  alve- 
olar abscess  extends  into  it,  while  cysts  formed  on  a  root  and  dentigerous  cysts  expand 
into  tliQ  cavity  in  this  manner  and  may  afterward  suppurate. 

Dl.\GN'OSl.s. — The  history  of  these  cases  may  throw  light  upon  their  nature,  while  a 
careful  examination  of  the  mouth  should  be  made  to  decide  whether  the  due  number  of 
permanent  teeth  have  been  erupted  as  to  the  existence  of  disease  in  any  tooth  in  the 
neighborhood  of  the  tumor.  An  exploratory  puncture  or  opening  should  be  made  in  any 
case  that  may  have  a  dental  origin  before  any  serious  operation  is  undertaken  for  the 
extirpation  of  the  disease. 

Tiu:.\TME.\T. — For  treatment,  it  will  here  sufiice  to  say  that  the  complete  removal  of 
any  tooth  or  dental  formation  involved  is  demanded,  and  that  for  the  renniining  treatment 
the  ordinary  rules  of  surgery  apply. 

Diseases  of  the  Teeth. 

The  largeness  of  the  nerve  supply  to  the  dental  pulp  and  periodontal  membrane,  and 
the  liability  to  irritation  and  inflammation  to  which  these  confined  vascular  structures  are 


464  DISEASES  OF  THE   TEETH. 

subject,  give  an  importance  to  diseases  of  the  teeth  which  they  would  not  otherwise  pos- 
sess;  the  pain,  direct  or  reflex,  which  nearly  always  attends  the  involvement  by  disease 
of  these  dental  vascular  structures  and  the  serious  local  lesions  which  may  follow  their 
suppurative  inflammation  often  cause  the  mere  destruction  of  the  tooth  as  an  organ  of 
mastication  to  be  a  matter  of  secondary  importance,  although  in  itself  sufiiciently  regret- 
able.  Bearing  in  mind  the  description  of  a  tooth  given  at  page  453.  it  will  be  understood 
how  the  maintenance  of  a  tooth  in  its  usefulness  depends  on  the  integrity  of  its  compo- 
nent structures,  and  how  it  happens  that  the  pulp  and  alveolo-dental  membrane,  which  in 
a  condition  of  health  are  tissues  simply  subsidiary  to  the  nutrition  of  the  hard  structures 
around  them,  become,  when  the  tooth  is  attacked  by  disease,  the  parts  which  have  espe- 
cially to  be  protected  from  invasion. 

The  morbid  conditions  which  may  produce  irritation  of  the  dental  nerves  may  with 
advantage  be  grouped  in  two  divisions. 

T/ie  first  division,  including  those  which  cause  irritation  of  the  nerves  supplied  to  the 
pulp  with  their  continuation  into  the  dentine,  consists  of — 

(o)  Exposure  to  irritation  of  sensitive  dentine  through  loss  of  enamel  resulting  from 
caries,  erosion,  or  fracture. 

(b)  Irritation  and  chronic  or  localized  inflammation  of  the  pulp  when  deprived  of  its 
protective  covering  of  dentine  through  the  more  extended  action  of  the  destructive 
agencies  named  under  (a). 

(c)  General  inflammation  of  the  pulp,  following  sooner  or  later  on  the  previous  con- 
ditions and  resulting  in  its  sphacelus. 

(d)  Irritation  of  the  pulp  through  the  presence  of  irregular  formations  of  secondary 
dentine  in  the  pulp  chamber. 

Tht^  second  division,  including  the  morbid  conditions  that  cause  irritation  of  the  nerves 
supplied  to  the  alveolo-dental  membrane  and  to  the  dental  nerves  external  to  the  tooth, 
consists  of — 

(a)  Dental  periostitis — i.  e.,  inflammation  (plastic  or  suppurative)  of  the  periodontal 
membrane.  This  results  by  far  the  most  commonly  from  inflammation  and  sphacelus  of 
the  dental  pulp ;  it  may  be  caused  by  rheumatism  and  by  syphilis  or  may  be  a  symptom 
of  salivation.  It  may  be  produced  by  irritation  of  the  periodontum  at  the  neck  of  the 
tooth  where  it  meets  the  gum,  and  occasionally  results  from  the  undue  pressure  of  an 
opposing  or  contiguous  tooth. 

(/j)  Exostosis—/.  (?.,  hypertrophy  of  the  crusta  petrosa — sometimes  resulting  from, 
sometimes  the  cause  of,  irritation  and  inflammation  of  the  periodontum. 

(c)  A  needle-like  pointing  of  the  end  of  the  root  and  a  roughening  of  its  end  by 
absorption. 

((/)  Impaction  of  permanent  teeth  in  the  maxillary  bones  and  futile  attempts  to  erupt 
made  by  such  teeth,  especially  in  the  case  of  lower  wisdoms. 

(e)  Overcrowding  of  the  teeth. 

Irritation  of  the  dental  nerves  may  excite  pain  at  the  point  of  irritation,  pro- 
ducing toothache,  the  pain  being  either  confined  to  the  faulty  tooth  or  centred  in  it  and 
radiating  to  the  adjoining  teeth  and  to  the  nerves  of  the  same  side  of  the  face  and  head ; 
but  not  "infrequently  it  gives  rise  to  reflex  pain,  in  which  case  the  tooth  at  fault  often 
escapes  suspicion  on  account  of  its  freedom  from  pain.  More  remote  sympathetic  nerve 
afi"ections  are  also  sometimes  caused  by  dental  irritation. 

A  most  unequal  amount  of  pain  or  nerve  disturbance  occurs  in  difl"erent  subjects  from 
dental  lesions  of  an  apparently  similar  nature.  Such  diS"erences  must  be  referred  to  struc- 
tural peculiarities  of  the  teeth,  to  the  conditions  of  health,  and  to  the  diathesis  of  the 
patient. 

A  faulty  tooth  is  the  real  origin  of  many  cases  of  neuralgia  about  the  head  and  face, 
although  cold  or  depressed  vital  power  will  determine  the  time  of  onset. 

That  remote  sympathetic  pain  may  be  due  to  dental  irritation  will  be  easily  realized 
by  any  one  who  has  felt  the  distribution  of  his  spinal  nerves  demonstrated  on  the  scraping 
of  sensitive  dentine  in  his  tooth. 

Toothache  (or  localized  dental  pain)  varies  in  character  according  to  the  part  of 
the  tooth  involved;  these  diff'erences  will  be  apparent  as  the  effects  of  disease  in  the  sev- 
eral dental  structures  are  considered,  but  it  may  be  here  remarked  that  a  darting  pain 
(which  may  fade  away  with  an  ache)  betokens  irritation  and  probable  exposure  of  the 
pulp  ;  that  intense  pain  of  a  violent,  throbbing  character  points  to  general  inflammation 
of  the  pulp  and  may  be  expected  to  cease  entirely  with  the  destruction  of  that  structure's 
vitality  ;  and  that  the  pain  which  attends  irritation  and  inflammation  of  the  periodontal 


IIKMOTI:  Sl.llVnrs  AFFKCTIOSS.  lOo 

imiiiKraiu'  is  id'  ;i  dull  or  L'liawiiiLT  diaiaftrr,  Iml  may  assuiiu;  ;i  tlircthhiii^r  character  if  ati 
lilvciilar  alisci'ss  is  t"c'iiiu'(l. 

HyperaBSthesia  of  the  pulp  may  Im  expected  to  coexist  with  the  coiiditi<.tirt 
whicli  act  oil  its  iierves,  ami  is  eviiU-iiced  hy  sensitiveness  of  the  to(»tli  to  heat  and  cold. 
A  hot  instrument  ajijdit'd  in  succession  to  tlu'  crowns  of"  susj»ected  teeth  may  afford  valu- 
able eviih'uce  on  this  point,  and  tapping;  the  teeth  may  also  reveal  the  oversensitiveness 
of  any  one  tooth.      Slight  periosteal  irritation  may  accompany  this  condition. 

Dental  periostitis  at  its  onset  is  often  attended  Ity  a  sensaticju  of  fulness  in  the 
tooth  w  liirli  iMclincs  tlic  patii'iit  to  )>ress  it  firmly  into  its  socket  ;  this  .sensation  is  suc- 
ceede«l  hy  painful  tendi'rness  on  pressure  of  the  tooth,  whicdi  is  often  slightly  raised  and 
looseiu'd,  while  the  |^uni.  which  at  first  presents  a  narrow  red  line  arouiul  the  neck  of  the 
tooth,  tends  to  become  diffusely  red  and  tender  over  the  root. 

In  ob.scure  cases  of  pain  the  presence  or  absence  of  cireunj.scribed  periodontitis  and 
of  irritation  due  to  exostosis  may  be  diagno.sed  by  pressing  the  crown  of  the  tooth  in 
different  directions,  so  as  to  tilt  the  end  of  the  root  against  the  socket  ;  the  biting  of 
something  hard  witli  one  tooth  after  another  may  also  be  adopted  as  a  means  of  finding 
out  if  irriiiitiiui  of  this  obscure  nature  is  present  in  a  root. 

Reflex  Nerve  Affections  due  to  Dental  Irritation. 

The  nerves  of  the  second  and  third  divisions  of  the  fifth  are  more  liable  than  any 
others  t(j  reflex  affections  due  to  dental  irritation.  Next  to  the  several  branches  of  the 
trigeminus,  the  nerves  of  the  cervical  and  brachial  plexuses  are  most  often  involved. 

Neuralgia. — The  following  are  the  most  common  sites  for  the  manifestation  of 
reflex   pain  ; 

(a)  Another  tooth  than  the  one  in  fault,  frequently  the  one  that  antagonizes  it  in  the 
opposite  jaw,  and  occasionally  a  tooth  in  front  of  the  one  irritated  (thus,  an  innocent 
bicuspid  may  ache  when  the  wisdom  tooth  is  at  fault). 

(/O  The  side  of  the  head,  with  the  focus  of  pain  near  the  parietal  eminence,  due  to 
irritation  of  a  tooth  (generally  an  upper  back  one)  of  the  same  side ;  this  is  the  source 
of  many  cases  of  unilateral  headache.  ♦ 

((')  The  eyebrow,  with  the  focus  of  pain  at  the  supraorbital  notch,  and  the  cheek,  with 
the  focus  of  pain  at  the  infraorbital  notch,  the  irritation  in  these  cases  being  located  in 
the  upper  teeth. 

(^/)  From  irritation  of  the  back  lower  teeth  there  may  result  earache  and  pain  extend- 
ing over  the  temple,  and  also  pain  passing  down  the  neck. 

Pain  over  the  upper  cervical  vertebi'a  appears  generally  to  come  on  secondarily  to  the 
above-mentioned  neuralgias. 

More  Remote  Nervous  Affections. 

Pain,  to  quote  the  words  of  ^Ir.  Salter,  is  only  one  of  the  phenomena  of  reflex  dental 
nerve  irritation.  There  may  be  produced  muscular  spasm  and  muscular  paralysis,  paraly- 
sis of  some  of  the  nerves  of  special  sense,  perverted  nutrition.  In  these  pages  only  an 
enumeration  of  some  of  these  affections  can  be  made,  and  the  reader  is  referred  for  details 
of  cases  to  the  work  on  Dental  Fatliologu  (tud  Surycri/,  by  the  above-named  author,  and 
to  the  second  edition  of  Tomes's  Dental  Sunjery. 

The  following  secondary  and  remote  nervous  affections  may  arise  from  irritation  iu 
the  teeth  and  be  curable  by  the  removal  of  the  exciting  cause: 

Convulsions,  etc.,  resulting  fi'om  irritation  in  teething. 

Epileptiform  seizures.  In  these  cases,  when  an  uneasy  sensation  is  felt  in  the  mouth 
previous  to  the  attack,  the  best  results  may  be  hoped  for  from  stopping  or  extraction,  as 
the  case  may  demand. 

Delirium  from  retarded  eruption  of  wisdom  teeth. 

Firm  closure  of  the  mouth  through  chronic  spasm  of  the  masseter  muscle  is  a  fre- 
quent complication  of  irritation  in  or  about  the  lower  back  teeth. 

Wry  neck.     Pain  in  the  course  of  the  cutaneous  branches  of  the  cervical  plexus. 

Partial  paralysis  of  the  arm  and  hand,  with  an  inability  to  grasp  with  the  fingers, 
accompanied  by  aching  pain.  (Several  such  cases  have  recently  been  under  my  obser- 
vation— a  f\\ct  which  shows  their  comparative  frequency.) 

Amaurosis.     Strabismu.*.     (Ptosis  and  deafness  are  also  recorded  complications.) 

Ulceration  in  the  course  of  a  branch  of  the  fifth  nerve. 
;io 


466  REMOTE  NERVOUS  AFFECTIONS. 

A  case  of  obstinate  leucorrhoea  and  acute  uterine  pain  cured  by  the  extraction  of  a 
tooth  was  recorded  by  the  kite  Mr.  Sercome. 

One  case  of  fatal  tetanus  is  quoted  by  Mr.  Tomes  as  having  followed  the  operation  of 
pivoting. 

Such  are  some  of  the  reflex  pains  and  remote  complications  which  may  arise  from 
dental  irritation  in  a  patient  of  neuralgic  diathesis,  but  apparently  similar  exciting  causes 
are  constantly  present  without  producing  any  such  results. 

Dental  Diseases. — In  an  apparently  sound  tooth  an  irregular  formation  of  dentine 
in  the  pulp  chamber  is  sometimes  the  cause  of  neuralgic  pain,  and  may  be  suspected  if 
hypersesthesia  of  the  pulp  exists  in  a  tooth  exhibiting  no  other  cause  for  oversensitive- 
ness. 

Exostosis,  and  occasionally  needle-pointing  of  the  fang,  may  also  be  the  cause  of  neur- 
algic pain  at  the  root  of  a  sound  tooth,  and  may  have  their  probable  presence  revealed 
by  the  tooth  exhibiting  tenderness  on  pressure  into  the  socket,  and  perhaps  later  on  by 
other  evidences  of  periosteal  irritation.  Being  otherwise  irremediable,  extraction  is 
demanded  in  these  not-to-be-foreseen  conditions. 

With  the  exception  of  the  above  comparatively  rare  cases  it  will  be  noticed,  by 
referring  to  the  list  of  morbid  dental  conditions  given  at  page  4G4,  that  all  the  aff'ections 
there  enumerated  may  result  from  the  spread  of  disease  from  one  dental  structure  to 
another,  and  therefore  demand  treatment  for  their  prevention  and  limitation.  Thus,  when 
the  exterior  of  a  tooth  is  the  first  part  attacked — as  it  always  is  in  caries  and  erosion — 
the  aim  should  be  to  preserve  the  pulp  from  irritation  and  exposure ;  and  when  the  pulp 
is  already  exposed  through  the  above  diseases  or  by  fracture,  the  aim  should  be  to  prevent 
its  inflammation,  while,  if  the  vitality  of  the  pulp  is  past  saving,  means  should  be  taken 
to  prevent  the  involvement  of  the  periodontum  ;  and  finally,  if  that  tissue  is  involved, 
extraction  of  the  tooth  may  be  demanded  to  relieve  pain  and  to  prevent  the  formation  of 
alveolar  abscess  with  its  possible  complication  of  fistulous  openings  on  the  face,  or  the 
still  graver  consequences  which  inflammation  external  to  the  tooth  may  bring  about. 

Three  facts  in  the  nature  of  a  tooth  aid  dental  surgery  in  its  conservative  efl'orts. 

The  first  is  that  the  dense  and  evascular  character  of  the  enamel  and  dentine  allows  a 
diseased  portion  of  them  to  be  removed  and  the  remainder  to  be  preserved  by  friction  or 
by  a  filling  inserted  in  the  place  of  the  removed  portion. 

The  second  favoring  fact  is  the  continued  presence  on  the  surface  of  the  pulp  of  the 
odontoblast  layer  of  cells,  ready  to  form  secondary  dentine  over  the  pulp,  and  thus  shield 
it,  if  they  are  stimulated  to  renewed  action  by  irritation  of  the  primary  dentine. 

And  thirdly,  the  small  calibre  of  the  root  canal  in  a  perfected  tooth,  and  the  minute- 
ness of  the  aperture  that  remains  at  the  end  of  the  root  for  the  passage  of  the  vessels 
and  nerves,  cause  the  pulp  to  be  so  comparatively  isolated  that  when  diseased  it  can 
with  safety  be  destroyed  by  escharotics  and  be  extirpated  before  its  sphacelus  has 
involved  the  structures  external  to  the  root. 

The  practical  remark  may  here  be  made  that  up  to  middle  age  probably  90  per 
cent,  of  the  teeth  that  are. lost  owe  their  destruction  to  caries,  while  later  in  life  recedence 
of  the  gums  and  absorption  of  the  alveolus — often  prematurely  induced  by  the  presence 
of  tartar — lead  to  the  loss  of  many  teeth  by  depriving  them  of  implantation. 

Before  reviewing  the  agencies  destructive  to  the  teeth  it  will  be  well  to  consider  the 
nature  of  secondary  dentine  and  cemental  exostosis,  which  occupy  a  debatable  position 
between  healthy  and  pathological  tooth  formations. 

Secondary  Dentine. — Three  diff"erent  developments  come  under  this  name.  The 
firat^  called  by  Salter  "  dentine  of  repair,"  has  been  already  alluded  to.  The  loss  of 
dentine  externally  through  abrasion,  caries,  erosion,  or  fracture  will  oftentimes  produce 
compensatory  development  internally  at  the  point  where  the  affected  dentinal  tubuli  abut 
on  the  surface  of  the  pulp  ;  this  reparative  growth  prevents  pulp  exposure  when  from 
attrition  the  enamel  and  a  considerable  portion  of  dentine  have  been  worn  away  from  the 
surface  of  a  tooth,  and  sometimes  it  will  obliterate  the  pulp  chamber.  In  cases  of  decay 
"dentine  of  repair"  does  not  often,  unaided,  prevent  exposure  of  the  pulp,  but  it  hinders 
it  and  becomes  a  valuable  auxiliary  in  its  protective  treatment.  (See  bicuspid,  in  D, 
Fig.  270,  p.  470.) 

Second  Form. — Cases  have  been  described  by  Salter  and  others  in  which  a  nodular 
outgrowth  of  dentine  or  osteo-dentine  has  projected  into  the  pulp  chamber  of  a  sound 
tooth  and  given  rise  to  severe  neuralgia.  This  development  must  be  regarded  as  morbid, 
and  has  been  named  by  the  above  author  "  dentine  excrescence." 

The  third  form  ^  or  secondary  dentine,  is  essentially  an  affection  of  the  pulp.    "  Intrin> 


DENTAL   CARIES,   OR  DECAY.  }(;? 

sic  {•iilcilication"  is  tlic  iiaiiii'  proposctl  i'ur  it  l>y  Mr.  Salti-r.  wlut  has  described  its  foriiiu- 
tiiiii  as  tluis  (ifcurriiit;  :  Isolated  masses  ul"  osteo-deiitiiie  f'onii,  at  first  usually  in  the  axis 
of  the  )»ul|) ;  these  masses  eiilar<re  and  mor^e  into  one  another,  spread  t(»\vard  the  periph- 
ery, and  may  at  length  occupy  tlie  whoh;  of  the  l»ulp  ehamher.  _  This  formation  may 
he  reuarded  as  .sometimes  resultinLT  from  and  as  sometimes  the  cause  of  pulp  irrita- 
tion. 

Exostosis  if*  !i  term  applied  U)  enlur<.'ement  or  out<rro\vth  of  the  crusta  jtetrosa  (see 
molar,  in  J],  I'iu.  270),  ranj^iiif^  in  amount  from  a  .sli<rht  ^'eneral  thickeninj^  (when  it  can 
hardly  he  reiiarded  as  ))atholoj;ical)  to  an  outjrrowth  which  may  double  the  size  of  the 
root  and  sometimes  has  i'used  toi:;ether  the  roots  of  contiguous  teetli.  The  dejiosition  cd' 
cementmn  may  alternate  with  its  absorption,  and  not  inlVefjuently  it  will  be  found  thiek- 
eiu'd  on  the  upper  part  (d"  a  root  where  chronically  inllained  j»eriosteum  exists,  while  the 
end  of  the  root  will  be  bare  of  it  and  bathed  in  the  juis  of  an  alveolar  abscess.  It  often 
causes  a  ulobular  enlariremi-nt  of  the  end  of  the  root.  Sometimes  snuill  excrescences  of 
it  will  form  on  tooth  alter  tootii,  and  by  i^ivini:-  rise  to  most  severe  neuralgia  will  nece.s- 
sitate  their  extraction. 

Exostosis  may  arise  secondarily  to  inflammation  of  the  periodontum,  and  will  then  be 
accompanied  by  extra  va.scularity  and  tenderness  of  adjacent  ^^um.  etc.  The  means  for 
detecting  its  presence  in  its  early  stages,  when  arising  primarily  and  causing  neuralgia, 
have  been  already  mentioned ;  symptoms  that  will  be  likely  to  attend  its  prolonged  pres- 
ence as  a  source  of  irritation  are  those  of  periodontal  inflammation. 

The  nature  of  the  agencies  tliat  destroy  the  dense  structures  of  the  tooth  will  now  be 
considered,  and,  ina.smuch  as  the  sequence  of  disease,  when  once  the  pulp  is  exposed,  is 
much  the  same  whether  the  exposure  has  occurred  through  caries,  erosion,  or  fracture, 
the  treatment  of  progressive  dental  disease  and  the  various  affections  of  the  pulp  will  be 
considered  and  illustrateil  once  for  all ;  and,  finally,  dental  disease  external  to  the  root, 
with  its  complications,  will  receive  notice. 

The  great  ))revalence  of  caries  at  the  present  day  makes  it  desirable  that  its  nature 
and  the  means  for  its  prevention  should  be  understood.  These  subjects  will  therefore  be 
discussed  somewhat  at  length. 

Dental  Caries,  or  Decay, 

may  be  described  as  the  disintegration  of  the  hard  structures  of  the  tooth  by  decalcifica- 
tion. It  always  commences  on  the  exterior  of  a  tooth  and  saps  inward ;  when  the  crown 
is  attacked  by  it,  a  fault  in  the  enamel  is  the  first  step  in  its  course  and  may  be  due  to 
original  faulty  development  or  to  mechanical  or  chemical  injury. 

Fracture  may  produce  the  enamel  lesion. 

A  fre(|uent  cause  of  disintegration  of  the  enamel  is  the  attrition  exercised  by  the  sides 
of  crowded  teeth  on  each  other,  and,  as  this  sets  up  interstitial  decay,  a  nidus  is  thereby 
formed,  which  serves  as  a  laboratory  for  the  production  of  chemical  destructive  asrents 
which  act  on  the  adjoining  tooth. 

Chemical  solvents  are  formed  by  acids  derived  from  the  buccal  mucus  and  food  mixed 
with  saliva,  which,  lodging  between  the  teeth  and  in  natural  depressions,  undergo  decom- 
position. 

It  is  now  also  pretty  clearly  established  that  micro-organisms,  which  are  constantly- 
found  present  in  carious  cavities,  play  an  important  part  in  the  disintegrating  process. 

Overcrowding  of  the  teeth,  viscid  buccal  mucus  giving  an  acid  reaction,  a  vitiated 
condition  of  the  fluids  of  the  mouth  due  to  derangement  of  the  digestive  organs,  the  eat- 
ing of  sweetmeats  (as  carried  by  some  young  people  to  a  most  injurious  extent),  conduce 
to  decay,  and  should  therefore  be  avoided  or  prevented.  The  condition  of  the  mouth 
attendant  on  fevers  accelerates  decay. 

The  great  preventive  of  decay  is  friction — that  is.  the  keeping  of  the  surfaces  of 
the  teeth  swept  clean  of  the  food,  mucus,  etc.,  that  tend  to  lodge  between  or  about  them. 
With  this  object  their  lingual  as  well  as  labial  and  buccal  surfaces  should  be  brushed 
night  and  morning;  the  direction  of  the  brushing  .should  be  always  from  the  gum — i.e., 
downward  for  the  upper  and  upward  for  the  lower  teeth — as  this  removes  "food  from 
between  them  by  the  natural  lines  of  clearance ;  the  masticating  surface  of  the  back 
teeth  should  also  be  brushed.  Where  the  mucus  is  ropy  and  clings  to  the  teeth,  a  sapo- 
naceous tooth  powder  should  be  used. 

Rinsing  out  the  mouth  after  meals  is  a  practice  to  be  generally  encouraged,  and  the 
use  of  a  weak  alkaline  mouth-wash  may  with  advantage  be  had  recourse  to  in  order  to 


468 


TEEATMEXT  OF  DECAY. 


correct  undue  acidity  of  the  oral  fluids,  and  also  to  neutralize  the  local  effects  of  strong 
acid  medicine. 

Among  preventive  measures  must  be  classed  what  may  be  termed  ••  preventive  stop- 
ping. For  example,  a  small  spot  of  decay  is  often  found  near  the  distal  edjre  (of  the 
masticating  surface)  of  the  second  temporary  molar  ;  if  this  be  not 
stopped,  the  decayed  posterior  surface  of  the  tooth  will  come  in 
contact  with  the  mesial  surface  of  the  first  permanent  molar  on  its 
eruption  and  deca}'  be  started  in  it ;  then,  on  the  shedding  of  the 
temporary  molar,  its  successor,  the  second  bicuspid,  will  have  its 
distal  surface  exposed  to  decay  from  contact  with  that  already 
existing  in  the  first  molar,  and  thus,  from  lack  of  a  small  stopping 
in  a  temporary  tooth,  two  permanent  teeth  are  frequently  lost  or 
saved  only  by  elaborate  fillings. 

The  progress  of  decay  is  usually  very  insidious,  a  minute  and 
unnoticed  fault  or  fissure  of  the  enamel  often  leading  to  extensive 
decay  of  the  dentine.  (See  decay  depicted  on  masticating  surface 
of  molar  in  D.  Fig.  270. )  A  warning  by  pain  is  by  no  means 
always  given,  but  sometimes  a  twinge  or  slight  ache  is  experienced 
when  the  periphery  of  the  dentine  is  reached  and  becomes  irritated 
by  saccharine  or  sapid  substances  or  by  thermal  changes  ;  if  this 
warning  is  neglected,  often  nothing  more  is  felt  till  an  acute  twinge 
shows  that  the  pulp  is  exposed  or  the  caving  in  of  the  enamel 
reveals  a  large  cavity.  It  thus  happens  that  the  detection  of 
decay  in  its  earlier  stages  can  be  ensured  only  by  frequent  inspec- 
tion of  the  teeth.  Such  inspections  should  begin  with  the  first 
teeth  and  be  carried  out  systematically  several  times  a  year  if  the 
teeth  are  to  be  preserved  and  much  stopping  avoided. 

For  the  purpose  of  examination,  a  mouth  mirror  and  a  pointed 

instrument  are  required ;  the  double-pointed  searcher  here  figured 

(Fig.  269)  is  particularly  useful,  its  curved  ends  being  adapted  to  pass  between 

the    necks  of  the  teeth  :   it  .should  be  employed  very  lightly  in  finding  out 

whether  a  pulp  is  exposed. 

The  natural  fissures  and   all  depressions  of  the   tooth's  surface,  together 
with  the  sides  of  such  teeth  as  are  in  contact,  should  be  carefully  examined. 
A  darkening  of  fissures  often  points  to  decay  in  their  depths,  and  its  presence 
„  in  them  may  be  considered  certain   if  the  fine  point  of  the  searcher  passes 

J  '  through  to  the  dentine.     Enamel  on  the  plane  surface  of  a  tooth,  when  affected 

y^  by  decay,  is  usually  first  opaque  and  of  a  chalky  whiteness,  but  may  become 

bi'own  or  blackened. 
In  interstitial  decav  the  defect  in  the  enamel,  being  out  of  sight,  usually  escapes 
detection,  and  the  first  evidence  of  its  presence  is  given  by  a  darkening  of  the  underlying 
dentine,  which  darkening  shows  through  the  enamel,  and  in  the  case  of  a  front  tooth  is 
first  observable  on  the  lingual  or  labial  surface,  and  in  the  case  of  the  back  teeth  usually 
on  the  masticatory  surface.  (See  Fig.  270,  A.)  The  amount  of  discoloration  varies, 
sometimes  a  distinct  black  spot  being  visible  and  showing  through  the  enamel,  in  other 
cases  a  smoked  appearance  or  a  slate  color  being  imparted  to  the  affected  quarter  of  the 
tooth,  the  variable  depth  of  shade  being  dependent  on  the  distance  from  the  enamel  sur- 
face at  which  the  decayed  dentine  lies,  and  also  upon  the  character  of  the  decay. 

In  young  teeth,  with  their  deficient  den.sity.  decay  runs  a  rapid  course,  and  the  pulp, 
being  larger,  is  quickly  exposed.  The  teeth  of  women  during  the  term  of  pregnancy  are 
apt  to  decay  rapidly  and  to  be  peculiarly  sensitive — a  reason  for  having  them  put  in  good 
order  in  anticipation  of  that  event. 


Treatment  op  Decay. 

To  stay  the  progress  of  decay  in  the  hard  structures  of  the  crown  two  methods  are 
practised — viz..  '•  cutting  out"  and  "  stopping."  In  either  case  the  affected  dental  struc- 
tures must  be  thoroughly  removed  and  the  cavity  obliterated. 

'•  Cutting  out  ■'  decay  is  accomplished  by  removing  adjacent  sound  enamel  and  den- 
tine, together  with  the  disea.sed  portion,  in  such  a  manner  that  there  is  left  an  even  sur- 
face of  hard  and  healthy  tooth,  which  should  be  well  polished.  The  full  depth  to  which 
disease  has  affected  the  dentine  should  be  ascertained  before  the  adoption  of  this  method, 


riu:.\TMi:sr  of  my  ay.  469 

wliitli  sliimld  1)0  liad  nwourso  li»  only  in  Inaliliy  iiioutlix  .iiiil  only  in  casos  wlicn-  tin;  (-ut 
snrtai'i'  will  lie  ('X|Hist'il  to  IViction. 

Sto|i|»inu:  consists  in  tlio  mnoval  of  (liscascil  structure,  in  tlic  ^'iviufr  to  the  resulting 
cavity  a  retaininjr  sliain',  and  in  the  insertion  into  it  of  a  sto])|»in^'  wliicli  is  luude  flush 
with  and  accurately  adapted  to  the  edfjcs  oi"  sound  surrouuilin;;  tooth  structure. 

The  accurate  preparation  of  the;  cavity  and  its  edges  is  of  the  higliest  inijiortance  in 
stopping. 

In  practice,  cutting  away  and  stopping  are  often  conihimrd.  Dentine  lel't  e.vposed 
should  always  he  well  polished;  an<l  il'  s(!nsitive,  spirits  ol'  wine  may  with  advantage  be 
applied  to  it  daily,  or  it  may  l)e  touidied  with  chloride;  of  /inc.  or  in  the  hack  of  the  mouth 
nitrate  ol'  silver  or  a  spirit  solution  of  tannin  may  he  a])]»lied  to  it. 

Narious  materials  are  usimI  for  stoppings. 

(lold,  skilfully  inserted,  gives  the  best  results  wlien  the  tooth  is  in  a  condition  to 
bear  its  introduction. 

Amalgauis  (among  wliiidi  the  so-called  gohl  amalgam  is  ver)'  good)  can  Ite  introduced 
into  a  cavity  in  a  plastic  state,  and  therefore  can  be  packed  round  corners  and  adapted  to 
thin  walls  that  might  not  bear  the  pressure  necessary  to  con.solidate  gold. 

I*rei)ared  gutta-percha,  from  its  non-conduction  of  heat  and  cold,  is  valuable  a.s  a  tem- 
porary tilling,  and  is  particularly  well  adapted  for  cavities  which  pas.s  below  the  gum  ;  in 
positions  where  it  is  not  exposed  to  the  wear  of  mastication  it  sometimes  la.sts  for 
years. 

••  ().steo "  stoppings,  consisting  of  oxychloride  or  oxyjdiosphate  of  zinc,  have  the 
advantage  of  clinging  to  the  walls  of  the  cavity,  which  consequently  i-equires  less  shap- 
ing ;  they  are  also  non-compressible,  which,  with  their  property  of  non-conduction,  ren- 
ders them  valuable  as  tcTnporary  fillings  where  the  pulp  is  almost  or  quite  exposed. 
They  will  not  last  long  if  in  contact  with  the  gum,  and  are  not  to  be  trusted  in  interstitial 
fillings,  but  for  .stopping  large  cavities  on  the  masticating  surfaces  of  teeth  in  which  the 
pulp  is  almost  exposed  '•  o.steo  "  is  a  most  valuable  substance ;  and  if  it  wears  away  on 
the  surface,  some  of  it  may  witli  advantage  be  left  in  the  lower  part  of  the  cavity,  while 
the  upper  part  is  packed  with  gold.  A  saturated  solution  of  mastic  in  spirits  of  wine  (or 
some  such  preparation),  mixed  with  cotton-wool,  is  serviceable  as  a  temporary  filling 
when  a  carbolic-acid  dressing  has  to  be  retained  in  the  tooth  for  any  time  not  exceeding 
a  fortnight. 

Whatever  stopping  is  used,  the  cavity  should  be  kept  absolutely  dry  Avhile  it  is  being 
filled. 

The  front  upper  teeth,  whicli  are  very  liable  to  interstitial  decay,  can  (especially  in 
the  young)  be  temporarily  separated  by  wedging  them  apart,  thus  allowing  of  their  being 
filled  from  the  side  or  lingual  surface  without  interfering  witli  their  contour  or  leaving 
the  stopping  visible  ;  B  and  C  in  Fig.  270  show  how  hidden  cavities  in  other  situations 
can  be  reached  and  stopped  if  they  cann(jt  be  got  at  by  a  gradual  process  of  wedging. 

In  shaping  cavities  for  filling  the  proximity  of  the  pulp  with  its  outstanding  cornua 
has  to  be  borne  in  mind  and  its  exposure  avoided.      (8ee  molar,  in  D,  Fig.  270.) 

If  a  liealthy  ])ulp  is  exposed  in  preparing  a  tooth  for  stopping,  a  cap  of  .some  non- 
conducting material  which  has  been  moistened  with  carbolic  acid  should  be  at  once  placed 
over  it,  and  then  a  stopj)ing  introduced.     (See  bicuspid,  in  D.  Fig.  270.) 

If  an  exposed  pulp  has  become  inflamed  at  the  point  of  its  exposure  and  has  taken 
on  a  secreting  action,  repeated  dressings  with  carbolic  acid  or  eucalyptus  oil  and  iodoform 
to  get  rid  of  this  ulcerating  condition  maybe  liad  recourse  to,  and  if  successful  a  stopping 
may  be  introduced  over  the  capped  pulp  ;  but,  as  a  rule,  if  the  pulp  has  shrunk  away 
from  the  aperture  of  exposure  or  been  the  seat  of  continued  pain,  it  cannot  be  preserved 
with  comfort,  and  the  best  treatment  in  such  a  ca.se  consi.sts  in  rapidly  bringing  al)out  its 
death  by  the  application  of  arscnious  acid,  and  then,  when  it  is  devitalized,  by  withdraw- 
ing it  and  thoroughly  filling  the  pulp  cliamber  and  its  root  extensions.  (See  bicuspid,  in 
E,  Fig.  270.) 

The  accompanying  series  of  drawings  (A,  B,  C,  D,  E,  Fig.  270)  illustrate  progressive 
disease  in  a  tooth,  and  its  treatment. 


470 


TREATMENT  OF  DECAY. 


Q 


-'^-  A  represents  the  masticatory  surfaces  of  second  upper  bicuspid  and 

first  molar.  The  darkening  of  the  decay  beneath  shows  through  the 
enamel  on  the  bicuspid.  A  searcher  is  introduced  to  explore  the  mesial 
surface  of  the  molar  for  decay. 

B.  the  same  teeth.  The  front  surface  of  the  molar,  having  presented 
superficial  decay,  has  been  chiselled  down,  which  gives  space  for  stop- 
ping-instruments to  be  brought  to  bear  upon  the  deeper  cavity  in  the 
bicuspid. 

C,  the  same  teeth  with  decay  more  advanced.  The  cavity  in  the  front 
of  molar,  proving  too  deep  for  "cutting  out.''  is  reached  by  stopping- 
instruments  introduced  via  the  cavity  in  the  bicuspid.  The  latter  tooth, 
having  had  the  enamel  on  its  masticatory  surface  too  much  undermined 
for  preservation,  will  have  its  contour  restored  by  a  stopping  introduced 
into  the  dovetail-shaped  cavity,  here  seen  from  above. 

D  represents  continuation  of  disease  as  seen  in  vertical  section  of  lower 
bicuspid  and  first  molar.  In  the  bicuspid  the  pulp  has  been  just 
exposed,  but.  being  healthy,  has  had  a  carbolized  cap  and  a  non- 
conducting stopping  placed  over  it.  and  has  developed  a  protective 
shield  of  secondary  dentine.  A  gold  stopping  is  seen  in  the  molar,  of 
a  shape  that  would  ensure  its  retention  if  solid.  Commencing  decay 
is  also  shown  at  the  masticating  surface  of  this  tooth. 

E.  same  teeth.  The  pulp  of  the  bicuspid  is  supposed  to  have  been 
destroyed  with  arsenious  acid  and  withdrawn  from  the  pulp  chamber,, 
which,  with  its  extension  to  the  end  of  the  root,  is  represented  as  filled, 
the  lost  portion  of  the  crown  being  also  restored.  The  eflfects  of 
unchecked  disease  are  seen  in  the  molar,  the  anterior  root  being  occu- 
pied by  purulent  fluid  and  its  apex  bathed  with  pus  of  an  alveolar 
abscess.  The  posterior  root,  in  which  some  living  pulp  still  remains, 
is  represented  as  exostosed.  but  might  with  equal  truth  have  been 
depicted  as  covered  with  thickened  and  inflamed  periodontum. 

When  a  pulp  has  been  extirpated  immediately  after  its  loss  of  vital- 
ity, the  root  canals  should  be  stopped  to  their  apices  forthwith  ;  but 
when  a  dead  pulp  has  remained  in  a  tooth  for  any  time,  a  thorough 
purification  by  the  use  of  antiseptics  must  precede  the  stopping. 

In  some  cases  after  the  pulp  has  been  extirpated,  instead  of  filling 
the  roots,  an  alternative  plan  must  be  adopted  if  the  tooth  is  to  be 
saved. 

This  consists  in  drilling  a  fine  canal  beneath  the  free  edge  of  the 
gum  into  the  emptied  and  cleansed  pulp  chamber,  which  is  then  covered 
over  with  a  cap  and  superjacent  stopping. 
Fig.  271  represents  a  tooth  so  treated.     The  gum  in  this  case  acts  as  a  valve  opposed 
to  the  ingress  of  food.  etc.     The  vent  fwhich  may  be  made  through  a  stopping),  by  pre- 
venting the  accumulation  of  fluid  or  gas  in  the  pulp  chamber,  stays 
J^~        Fi^^--'--  the  development  or  allows  the  subsidence  of  inflammatory  mischief 
about  the  root. 

Pivoting'. — When  no  other  teeth  want  replacing  and  the  crown 
of  one  of  either  of  the  six  upper  front  teeth  is  lost  through  fracture 
or  decay,  the  operation  of  pivoting  a  new  one  on  to  the  root  is  much 
to  be  preferred  to  other  modes  of  attachment. 

In  the  case  of  a  healthy  root  the  crown  can  with  advantage  be 
pivoted  on  it  once  for  all  after  the  end  of  the  canal  has  been  filled 
with  gold  or  other  durable  stopping,  but  in  other  cases  the  following 
mode  of  operating  is  to  be  preferred :  The  canal  at  the  end  of  the  root  is  left  open  and 
the  new  crown  is  affixed  to  the  root  by  a  split  gold  pin.  which  is  sheathed  in  a  platinum 
tube  fixed  with  stopping  into  the  rifled  barrel  of  the  root.  Here  the  tooth  crown  can  be 
removed  and  replaced  at  pleasure,  while  the  root  is  preserved  from  further  decay  by 
being  lined  with  metal :  and  by  this  method  a  root  not  fully  formed  or  one  that  is  the 
subject  of  alveolar  abscess  mav  safelv  be  used  for  supportins:  a  pivoted  crown.  (See 
Fig.  272.)  '  '  IF         -       F 

Decay  at  its  commencement  is.  as  a  rule,  capable  of  sati.sfactory  and  quite  or  com- 
paratively painless  treatment.  The  difficulties  of  its  successful  treatment  increase  with 
its  onward  progress,  while  the  nerve  complications  that  have  been  noticed  and  the  severe 


AFFKCTIOSS  OF   TIIK   FT  LP.  }71 

inflainuiatory    lesions    wliidi    will    lie    cmiiiHrattMl    iartlitr   on    are    most    f'rtMjiieiitly    the 
8e((uel;e  ot"  neglected  decay. 

Fracture  of  Teeth. 

Teeth,  espeeiallv  |irnjfctini;  npjK-r  incisors,  are  liable  to  he  fractured.  It'  only  :» 
small  portion  of"  the  crosvn  is  chijiiicd  ofl',  the  fractured  edge  may  he  .•imoothed  with  a 
tile  or  stone  and  touched  with  >|)irit  to  keep  it  hard  and  insensitive  (tiling  to  amend  shape 
shouhl  not  lie  had  recourse  to  while  the  jiaticnt  is  very  young).  If  the  portion  broken 
otf  is  so  large  that  the  tooth  will  lu'  jiermanently  disfigured,  and  yet  the  [lulp  has  escaped 
destructive  irritation,  the  remainder  of  the  crown  may  he  removerl  and  a  new  crown 
pivoted  on  to  the  root  ;  in  a  young  suhject  the  destruction  of  the  pulp  preparatory  to 
pivoting  should  lie  postponeil  until  it  is  reduceil  to  its  ultimate  tenuity  liy  the  perfecting 
of  the  root. 

If  it  is  evident  that  the  pul|i  has  become  inflamed  through  the  fracture,  it  will  be 
desirable  to  at  once  destroy  and  extirpate  it,  in  order  that  the  periodontum  may  be  pre- 
served in  a  healthy  condition,  and  therefore  the  rout  be  in  a  positi<tn  to  carry  a  pivoted 
crown  with  comfort.  In  young  subjects,  when  the  teeth  are  much  crowded  and  rela- 
tively prominent  as  compared  with  those  in  tlie  lower  jaw,  it  may  be  desirable  to  extract 
the  fractured  tooth  and  to  train  in  the  neighboring  teeth  to  occupy  its  site. 

Arrested  or  Carbonized  Decay. — Sometimes,  in  young  .subjects,  when  the 
enamel  is  lost  almost  simultaneously  over  the  whole  masticating  surface  of  a  molar  tooth, 
decay  becomes  arrested,  the  exposed  dentine  assuming  a  dark  mahogany  or  black  color 
and  presenting  a  tlensity  which  (jualifics  it  for  mastication.  8uch  a  result  may  be  aided 
by  the  muniling  off  of  projecting  enamel  edges. 

Erosion. — Occasionally  the  enamel  and  the  subjacent  dentine  are  gradually  lost  by 
a  process  which  was  called  by  Hunter '•  decay  by  denudation,"  and  by  recent  writers 
"  erosion."  The  surface  of  the  cavity  so  formed  remains  hard  and  polished  and  often  free 
from  discoloration.  It  is  probable  that  this  gradual  wa.sting  awa}'  of  the  tooth  substance 
without  any  of  the  ordinary  appearances  of  caries  is  due  to  the  combined  action  of  chem- 
ical solution  and  friction ;  the  enamel,  in  the  first  in.stance,  being  affected  over  a  compar- 
atively large  area,  the  dentine,  when  reached,  is  exposed  to  friction,  which  prevent.s  it.s 
softening. 

This  erosion  may  affect  other  parts  of  a  tooth,  but  usually  attacks  the  labial  surface 
at  the  neck  ;  frequently  many  teeth  in  the  same  mouth  are  affected  by  it.  a  groove  being 
gradually  .scooped  in  the  teeth  just  above  the  gum  until  the  pulp  is  exposed. 

Tre.vtmknt. — An  alkaline  mouth-wash  should  be  prescribed  and  horizohtal  bru.shing 
interdicted  :  and  if  the  exposed  dentine  is  sensitive,  either  of  the  solutions  mentioned  at 
page  4tJ9  may  be  applied  to  it.  In  cases  admitting  of  it  stopping  should  be  had  recourse 
to,  that  the  pulp  may  be  preserved  from  expo.sure. 

Affections  of  the  Pulp. 

An  exposed  dentinal  pulp  is  subject  to  mechanical,  thermal,  and  other  irritation.  The 
pain  produced  by  such  irritation  is  of  a  sharp  lancinating  character,  sometimes  passing 
away  with  an  ache. 

Chronic  Inflammation. — Circumscribed  superficial  inflammation  with  increase 
of  sensitiveness  may  be  developed  in  the  pulp  at  the  point  of  exposure  and  may  continue 
for  a  long  time  in  an  unsuspected  cavity,  giving  rise  to  reflex  pain  or  (so-called)  neur- 
algia. 

Ulcerative  Condition. — The  exposed  surface  of  the  pulp  may  take  on  a  secre- 
tive action  and  the  tooth  be  free  from  pain  as  long  as  the  exuded  sero-purulent  fluid  finds 
an  exit  and  the  pulp  escapes  fresh  irritation. 

Acute  or  general  inflammation  of  the  pulp  is  attended  by  terrible  pain 
of  a  violent  throbbing  character,  which  after  lasting  several  hours  or  days  may  cease  as 
suddenly  as  it  began,  its  ees.sation  betokening  the  death  of  the  pulp.  In  this  case  every 
factor  for  the  production  of  agonizing  pain  is  present ;  the  distensible  pulp,  largely  sup- 
plied with  nerves,  undergoes  vascular  engorgement  within  an  unyielding  case  closed  in  at 
all  parts  except  at  the  aperture  of  exposure,  through  which  it  may  bulge  and  -uffer  fur- 
ther constriction.  The  pain  is  not  usually  confined  to  the  faulty  tooth,  but  spread^  from 
it  to  the  neighboring  teeth  and  to  the  side  of  the  face  :  during  the  paroxysms  the  tooth 
often  becomes  tender  to  pressure,  owing  to  a  sympathetic  irritation  of  the  periodontal 
membrane.     Prompt  measures  should  be  taken  to  prevent  the  products  of  decomposition 


472  ALVEOLAR  PERIOSTITIS. 

■which  resuh  from  the  sphacelus  of  the  pulp  from  passing  beyond  the  interior  of  the  tooth, 
and  so  causing  the  inflannnatory  involvement  of  the  periosteum  and  the  formation  of 
alveolar  abscess. 

The  l>ulp  occasionally  loses  its  vitality  without  producing  noticeable  j)ain. 

Tardy  Destruction  of  the  Pulp. — Instead  of  losing  its  vitality  at  once,  the 
pulp  niay  die  piecemeal,  the  chronic  irritation  that  attends  tliis  process  often  being  pro- 
ductive of  morbid  changes  on  the  exterior  of  the  root.  A  pulp  chamber  that  contains 
the  remains  of  a  decomposed  pulp  emits  a  strong  and  peculiar  phosphatic  smell. 

Calcification  of  pulp  has  been  described  already  under  the  head  of  ''  Secondary 
Dentine." 

An  insensitive  polypoid  growth  of  the  pulp,  consisting  of  granulations  which  throw 
off  a  secretion  and  readily  bleed,  sometimes  projects  from  the  pulp  chamber  into  a  cavity 
in  the  crown  of  a  tooth  ;  it  usually  necessitates  the  extraction  of  a  tooth  on  account  of 
the  successful  resistance  it  offers  to  extirpation. 

A  sensitive  sprouting  of  the  pulp  may  follow  fracture  of  a  tooth.  Extraction  would 
be  the  treatment  for  this  condition,  which,  by  extirpation  of  the  pulp,  should  be  prevented 
from  developing  if  the  retention  of  the  root  is  desirable. 

Necrosis  of  the  pnlp  may  occur  within  the  unopened  pulp  chamber  of  a  sound 
tooth.  It  is  most  often  consequent  on  a  blow  (sometimes  a  very  slight  one)  rupturing 
its  vessels  as  they  enter  the  apex  of  the  root.  It  may  supervene  on  fever.  A  darkening 
of  the  whole  tooth  results,  and  is  due  to  the  permeation  of  the  dentine  by  the  decomposed 
coloring  matter  of  the  blood. 

Salter  has  pointed  out  that  the  pulp  thus  devitalized  may  be  disposed  of  by  fatty 
degeneration.  In  the  absence  of  treatment — /.  e.,  extirpation  of  the  pulp,  etc. — it  often 
leads  to  alveolar  abscess. 

A  tooth  knocked  out  and  immediately  replaced  may  become  quite  firm  and  obtain 
vital  connection  with  the  alveolo-dental  membrane,  and  will  then  be  in  the  same  condition 
as  the  above.  In  this  case  or  in  cases  of  transplantation  the  replacement  of  the  dead  pulp 
by  an  indestructible  filling  is  required  to  prevent  after-inflammation.  Death  of  the  pulp 
will  be  evidenced  by  the  absence  of  sensation  in  a  tooth  when  touched  with  an  instru- 
ment hot  enough  to  evoke  sensation  in  its  neighbors. 

Affections  of  the  Alveolo-Dental  Membrane. 

Dental  periostitis  i»'iy  be  local  or  general,  chronic  or  acute. 

General  inflammation  of  the  periosteal  investment  of  the  teeth  and  their  sockets 
results  from  rheumatism  or  attends  on  a  debilitated  or  unhealthy  condition  of  the  system, 
and  demands  constitutional  treatment. 

Treatment. — When  slight  in  amount  and  causing  only  a  loosening  of  the  teeth  and 
a  sense  of  fulness  and  uneasiness  about  them,  no  local  treatment  may  be  required  beyond 
the  use  of  an  astringent  mouth-wash.  When  the  gums  also  are  congested,  they  should 
be  scarified  and  a  stronger  astringent  (tannin  dissolved  in  spirits  of  wine  is  eificient) 
applied  to  them.  Tincture  of  iodine  is  a  favorite  application  with  some.  Any  root  or 
tooth  that  may  be  an  excitant  of  inflammation  is  best  removed,  and  tartar  should  be 
thoroughly  got  rid  of  from  beneath  the  free  edges  of  the  gum. 

The  continuance  or  oft-repeated  recurrence  of  a  congested  condition  of  gum  leads  to 
the  absorption  of  the  alveolar  edge  and  consequent  loss  of  implantation  for  the  teeth  ; 
the  gradual  deposition  of  tartar  upon  the  root,  besides  being  one  of  the  commonest  causes 
of  this  condition,  is  apt  to  attend  upon  and  increase  it  when  arising  from  other  causes. 
When  the  periosteal  inflammation  is  more  acute  and  pus  is  formed  about  the  necks  of  the 
teeth,  a  solution  of  chloride  of  zinc  eight  grains  to  the  ounce  will  be  found  a  beneficial 
mouth-wash  and  will  correct  foetor. 

The  general  symptoms  of  dental  periostitis  have  been  given  at  page  406  ;  it  may  be 
added  that  when  due  to  rheumatism  toothache  is  apt  to  be  present  and  swelling  and  sup- 
puration absent;  that  it  will  often  subside  of  itself,  while  in  a  scrofulous  subject  or  when 
due  to  syphilis  the  pain  is  often  slight  and  the  tendency  to  suppurative  inflammation 
marked  ;  that  in  these  cases  the  loss  of  the  teeth  is  imminent ;  and  that  their  extraction 
at  once  may  be  desirable.  Periostitis  of  the  alveolar  process  of  the  jaw,  leading  to  necro- 
sis, may  be  caused  by  a  primary  syphilitic  chancre  (apt  to  be  mistaken  for  a  gum-boil), 
also  syphilis  in  its  tertiary  stage,  by  sloughing  of  the  gums,  by  acute  alveolar  abscess,  or 
may  have  a  traumatic  origin. 

Rigg's  Disease. — In  dyspeptic  patients  the  above  conditions  occur  in  their  greatest 


A  I  A' EO  LAI  I    .1  HSCKSS.  173 

si'Vi  rit\ .  Tlif  tuiniil  liuins,  coiifji'sttMl  witli  venous  1)1(i(kJ,  are  detacluMJ  from  tlie  necks  of 
tlif  teeth,  IVnni  altout  the  roots  of  which  a  thiek  letiJ  disohar<ie  can  be  pressed  uj».  The 
runts  (if  the  teeth  are  ^^radiially  denmled  of  their  periosteum  and  c(»vered  ]>y  hard  dark- 
uri'en  iKiduIi's  of  tartar.  whiK'  the  reeedintr  edires  of  the  alveoli  disappear  hy  caries. 

TitKAT.MKNT. — The  local  treatiueiit  of  this  condition  consists  in  free  scarification  of 
the  irunis,  a  thornuirli  renmval  with  tine  special  instnimcnts  of  tin.'  encrustinjr  tartar,  ami 
the  application  of  stroni;'  carbolic  acid  introduced  on  thin  slips  of  wood  hctween  the  root 
and  the  socket  which  is  desertini:  if. 

IJitr.ir,  who  called  marked  attentinn  to  this  eonditidn.  n'C(iinnieiiile<l  the  reninval  Uvilh 
strong  scrapinir  instruments)  of  the  afi'ected  marjrins  of  the  alveoli;  hut  the  thorou^rh 
antiseptic  treatment  above  described  seems  as  satisfactory  as  can  be  expected. 

The  fumes  of  phosphorus,  productive  of  '•  phosphorus  necrosis,"  jtrobably  find  a  readier 
inirress  when  tlu'  pulp  of  a  tooth  is  exposed,  and  other  irritants  productive  of  periosteal 
inflammation  may  act  through  the  .same  channel. 

Necrosis  of  the  alveolar  portion  of  the  jaw  in  cliildren  may  follow  either  of  the  exan- 
themata, and  will  not  always  lead  to  the  loss  of  tlie  permanent  teeth  if  due  time  i.s  given 
for  the  separation  of  the  necrosed  portion. 

Inflammation  of  a  sultacute  type  n)ay  attack  the  pcriodontum  of  one  tooth  after 
another  and  lead  to  their  successive  loss  in  cases  where  the  roots  of  the  teeth  are  e.xposed 
throuLrh  the  rcccdence  of  the  uums  and  alveolar  margin  from  senile  absorption  or  other 
causes. 

Local  Dental  Periostitis. — Witli  the  exception  of  the  condition  just  named, 
inflammation  attacking  the  alveolo-dental  meml)rane  of  a  single  tooth  results  from  pre- 
existing disease  in  the  tooth  or  is  due  to  some  local  cause  of  irritation,  such  as  a  ligature 
applied  carelessly  for  regulating  iiurpo.ses  or  for  fracture  of  the  jaw,  the  accumulation  of 
tartar,  or  the  undue  and  obli(|ue  jiressure  of  an  antagonist  tooth.  Chronic  inflammation 
and  thickening  of  the  periodontum  are  often  complicated  either  as  cause  or  effect  with 
exostosis  or  with  a  very  small  chronic  alveolar  abscess  about  tbe  apex  of  a  stump,  and 
are  in  these  cases  associated  sometimes  with  severe  neuralgia. 

Dental  Cysts. — The  dental  cysts  which  sometimes  form  on  the  roots  of  teeth  are 
probably  generally  the  outcome  of  conditions  which  in  their  more  sthenic  form  lead  to 
the  formation  of  alveolar  abscess.  An  alveolar  abscess  may  pass  into  a  cystic  condition, 
and  it  is  certain  that  the.se  cysts  (which  may  contain  cholesterine)  may  suppurate,  and 
then,  to  all  intents  and  jiurposes.  they  become  converted  into  alveolar  abscesses. 

Periodontal    inflammation    of    an  acute    form,   producing   alveolar 

abscess,  is  the  natural  se([uel  of  death  of  the  pulp,  the  products  of  the  decompositicjn 
of  this  structure  passing  through  the  foramen  at  the  end  of  the  root  giving  rise  to  it. 
Pus  formed  between  the  root  and  its  investing  membrane  may  separate  the  latter  from 
the  former  and  escape  around  the  neck  of  the  tooth  ;  in  which  case,  if  the  dentinal  pulp 
also  is  dead,  the  tooth  becomes  absolutely  necrosed  and  is  to  be  regarded  as  a  foreign 
body.  Pus  may  become  diffused  beneath  the  gum,  and  this  is  especially  likely  to  occur 
in  the  case  of  lower  iiupacted  wi.sdom  teeth.  Far  more  commonly,  pus  derived  from  the 
pulp  chamber  or  due  to  the  breaking  down  of  inflammatory  lymph  which  has  been  thrown 
out  about  the  apex  of  the  fang  is  contained  in  a  circumscribed  abscess  which  embraces 
the  end  of  the  root  (.see  Fig.  27U,  E)  and  occu))ies  an  excavation  in  the  maxilla.  Pre- 
ventive treatment  consists  in  the  complete  clearing  out  of  the  root  canals  and  their  thor- 
ough purification  by  antiseptics ;  this,  with  the  administration  of  a  saline  purgative  and 
the  local  abstraction  of  blood  from  the  gum  over  the  root,  affords  the  best  chance  of  cut- 
ting short  periodontal  inflammation  that  tends  to  the  formation  of  abscess.  The  forma- 
tion of  an  alveolar  abscess  is  usually  jireceded  by  great  local  tenderness  to  pressure  on  or 
over  the  root  of  the  tooth  and  attended  by  pain  of  a  throbbing  character,  sometimes  by 
rigors  and  considerable  constitutional  disturbance.  The  possible  occurrence  of  pyaMnia 
fr(un  this  cause  is  not  to  be  overlooked.  Great  serous  effusion  into  the  cancellated  bone 
and  the  soft  surrounding  tissues  not  infrequently  takes  place,  mistaken  sometimes  for 
erysipelas  and  oecasiorially  resulting  in  suppuration  ;  the  closure  of  the  eye  of  the 
affected  side  or  a  swelling  from  the  lower  jaw  reaching  half  down  the  neck  may  thus  be 
produced.  An  abscess  connected  with  an  upper  molar  sometimes  causes  a  fulness  over 
the  lower  jaw.  "When  an  abscess  is  formed,  the  contained  pus  tends  to  find  an  exit  either 
through  a  gum-boil  (so  called)  or  by  a  fistulous  opening  on  the  face.  etc..  an  opening  on 
the  gum  being  naturally  formed  when  the  mucous  membrane  is  reflected  from  gum  to 
cheek  at  a  distance  from  the  alveolar  border,  and  a  canal  through  the  body  of  the  bone 
if  the  root  of  the  tooth  extends  below  such  reflection  of  the  mucous  membrane. 


474  IXFLAMMATORY  ACTION. 

An  alveolar  abscess  attached  to  the  upper  teeth  may  perforate  the  antrum,  when 
attached  to  an  incisor  may  open  into  the  nare.s,  or  when  connected  with  a  lateral  incisor 
may  pass  backward  between  the  compact  layers  of  the  palatine  pi'ocess  of  the  superior 
maxilla  or  between  the  periosteum  and  the  hard  palate  and  open  through  or  behind  the 
soft  palate.  It  may  also  form  fistulous  openings  on  the  face  .near  the  inner  canthus  or 
under  the  edge  of  the  malar  bone.  An  alveolar  abscess  connected  with  lower  incisors 
may  open  under  or  in  front  of  the  chin  and  above  or  under  the  margin  of  the  jaw  when 
connected  with  the  other  lower  teeth;  from  a  wisdom  tooth  the  pus  may  pass  forward  to 
the  canine,  backward  to  the  fauces,  or  escape  at  the  angle  of  the  jaw.  Pus  from  an 
alveolar  abscess  may  pass  down  the  neck,  and  in  one  case  it  found  final  exit  below  the 
clavicle,  and  in  another  and  fatal  case  it  reached  the  armpit. 

The  pus  of  an  alveolar  abscess  that  distends  the  mucous  membrane  of  the  gum  or 
cheek  should,  of  course,  be  evacuated  by  an  incision  if  the  extraction  of  the  tooth  does 
not  suffice  for  the  purpose.  A  chronic  gum-boil  ma}-  be  regarded  as  a  safety-vent,  but 
abscesses  with  such  a  fistulous  opening  on  the  gum  may  sometimes  be  cured  by  pumping 
carbolic  acid  through  the  root  of  the  tooth  until  it  escapes  on  the  gum,  followed  up  by 
stopping  of  the  root. 

When  alveolar  abscess  has  formed  and  does  not  tend  to  open  on  the  gum.  but  causes 
a  distension  of  the  bone  over  it,  together  with  local  inflammation,  the  tooth,  as  a  rule, 
should  be  extracted  without  delay  to  prevent  further  mischief,  although  in  some  cases  a 
clearing  out  of  the  pulp  chamber  and  the  performance  of  rhizodontropy,  coupled  or  not 
with  a  direct  opening  into  the  abscess  to  evacuate  the  pus,  may  be  the  right  practice. 

In  alveolar  abscess  of  the  lower  jaw  a  prominence  passing  out  from  any  diseased  tooth 
and  obliterating  the  natural  sulcus  between  gum  and  cheek  will  point  to  the  tooth  which 
should  be  extracted,  and  a  vertical  incision  across  the  abscess  track  within  the  mouth  may 
be  advisable  to  prevent  the  next  step  in  the  formation  of  an  external  fistulous  opening — 
namely,  the  distension  and  thinning  of  the  skin  preparatory  to  its  perforation.  In  these 
cases  warm  water  should  be  held  in  the  mouth,  and  poultices  should  not  be  applied  to  the 
outside  of  the  face. 

A  fistulous  opening  on  the  face  which  has  given  exit  to  a  continual  discharge  for 
years  will  at  once  close  up  on  the  extraction  of  the  tooth  or  buried  root  which  has  caused 
it,  but  a  permanent  depressed  cicatrix  will  be  left ;  in  these  cases  a  probe  introduced  from 
the  outside  wall  very  likely  impinge  on  something  which  feels  rough  and  hai'd  like  dead 
bone,  but  is  really  an  exostosed  and  roughened  tooth  fang.  Absence  of  fetor  in  the  dis- 
charge and  singleness  of  the  opening  point  to  the  presence  of  a  diseased  tooth  and  not 
bone  disease. 

Serious  Local  Complications  of  Inflammatory  Action  set  up  by 

Tooth  Disease. 

The  disfigurement  of  a  fistulous  opening  on  the  face  due  to  neglected  alveolar  abscess 
is  comparatively  common,  but  far  more  severe  complications  are  sometimes,  but  very 
rarely,  produced  by  the  inflammatory  involvement  of  surrounding  structures.  The 
seventh  nerve  has  thus  been  involved,  producing  facial  pstralysis.  Necrosis  of  the  involved 
bone  has  led  to  a  fatal  result.  Sevei'al  cases  are  detailed  by  Salter  in  which  permanent 
loss  of  sight  in  one  eye  followed  antral  abscess  or  inflammation  about  the  upper  teeth. 
In  one  case  amaurosis  of  thirteen  months'  duration  was  got  rid  of  by  the  extraction  of  a 
carious  tooth  from  the  end  of  which  a  splinter  of  wood  projected.  In  the  case  of  a  patient 
who  recently  came  with  symptoms  of  tumor  in  the  orbit  into  Guy's  and  there  died.  Dr. 
Goodhart  traced  the  origin  of  mischief  to  caries  of  the  first  left  lower  molar,  which  gave 
rise  to  abscess,  suppuration  in  the  inferior  dental  canal,  acute  ostitis  of  left  side  of  lower 
jaw,  extension  of  disease  by  pterygo-maxillary  fossa  to  orbit,  suppuration  in  both  orbits, 
ostitis  of  vault  of  skull,  and  pyaemia. 

The  spasm  of  the  mas.seter  which  frequently  attends  disease  about  the  lower  back  teeth  is 
sometimes  probably  due  to  inflammatory  involvement  of  the  nerve, -and  not  simply  to  reflex 
irritation.  Extraction  of  the  tooth  is  its  cure,  and  the  mouth  may  be  opened  sufficiently 
to  allow  of  this  being  accomplished  by  the  persevering  use  of  a  wedge  between  the  teeth. 

Tartar,  or  salivary-  calculus,  consists  of  lime  salts  precipitated  from  the  oral  fluids, 
together  with  "  leptothrix  buccalis,"  epithelial  scales,  etc.  ;  it  especially  tends  to  form  on 
the  lingual  surface  of  the  lower  front  teeth  and  on  the  buccal  surface  of  upper  molars  ; 
a  small  rim  may  be  often  found  on  all  the  teeth  under  the  free  edges  of  the  gum,  which 


Ill 


EXTii ACTIOS  or  TKirrii.  475 

„.uv  tlu'M  prt'Si'iit  a  narrow  hliic  liiu-  or  \tc  y^vnvr.iWy  eonjfested.  I{ru>Iiiii;;  in  the  inaiiiier 
rcfoiiiinemlrd  I'or  the  prevention  of  ih-eay  eheeks  its  (h-positioii.  Its  presence  in  lar^'e 
muss  may  eaiise  uK-eration  <»t"  the  tonfrue,  etc.,  ami  in  much  smaUer  (piantity  causes  hiose- 
niiijr.  !iii<l  if  allowed  to  accumulate  the  loss,  of  the  teeth,  it  should  he  carefully  and 
thorouuhly  remove«l  with  small  scalinu'  instruments,  used  so  as  not  to  make  the  ;.'um  Meed. 

All  t«'etli  that  are  retained  in  the  mouth  should  he  rendered  as  sound  and  firm  as 
possilile  hv  stoppinj^  and  scaling:.  A  patient  with  tartar-loaded  and  decayinj;  teeth  may 
travel  I'or  fresh  air.  hut  will  hardly  find  it. 

All  sharp  and  ja;:Lred  I'dires  of  teeth  should  he  rcinovcil  l.y  a  tih"  ;  this  is  of  special 
importance  in  after-lil'e.  as  localization  of  epitheliuma  of  the  t<jnjrue  is  fre(|uently  trace- 
ahle   to  irritation    so   produced. 

Tumors  and  other  Affections  of  the  Gums. 

8undrv  L'uni  ath-ctions  are  intimately  connected  with  the  teeth. 

Simple  hypertrophy  of  the  trums.  chiefly  on  their  labial  .surface,  is  sometimes  met 
with  when  the  teeth  are  overcrowded,  the  fruni  beinjj  .shut  out,  a.s  it  were,  from  between 
the  necks  of  the  teeth.  The  preventive  treatment  for  this  condititm  is  self-evident,  but 
when  it  is  established  and  extraction  is  inadmissible,  it  may  be  reduced  by  free  scarifica- 
tion and  the  application  of  tannin,  etc. 

Occasionally,  in  unhealthy  sulijects.  hypertrophy-  assumes  lar<:er  yiropcjrtions,  the 
crowns  of  the  teeth  beinji  buried  in  lobulated  masses  of  gum.  The  treatment  consists 
of  scalintr.  free  scarification  (and  sometimes  excision),  together  with  the  local  use  of 
astringents  and  fetor-correcting  applications.  Absorption  of  the  underlying  alveolus, 
and  consequent  loss  of  implantation  for  the  teeth,  is  apt  to  attend  upon  this  hypertrophy, 
as  it  does  u])on  continued  extra-vascularity  of  the  gums. 

A  polypus  of  the  gum  is  fre(|uently  found  to  project  into  dental  carious  cavities 
which  extend  beluw  the  gum  ;  it  is  vascular  and  insensitive,  ami  should  be  cut  away  and 
packed  out  of  the  tooth  cavity  preparatory  to  the  filling  of  this  latter.  This  gum  poly- 
pus is  .sometimes  liable  to  be  mistaken  for  polypus  of  the  dentinal  pulp. 

Epulis. — The  tumors  classed  under  this  name  present  in  varying  proportions  a 
fibrous  or  myeloid  character,  and  not  infrecjuently  have  small  o.s.seous  development  at 
their  basis.  As  regards  the  maxillse.  these  growths  es.sentially  belong  to  the  alveolar  or 
tooth-bearing  portion,  and  conse<|uently  can,  as  a  rule,  be  completely  removed  without 
interference  with  the  basal  portion  of  the  bone.  The  fibrous  tissue  of  the  gum.  the 
endosteum,  and  the  alveolo-dental  membrane,  having  continuity,  may  each  share  in  the 
development  of  an  epulis  ;  it  therefore  follows  that  for  the  complete  eradication  of  the 
disease  the  extraction  of  an  adjoining  tooth  or  root  may  be  demanded,  together  with  the 
excision  of  the  growth  and  involved  bone. 

Vascular  Tumors. — Mr.  Salter  has  recorded  a  case  of  a  vascular  tumor  the 
size  and  color  of  a  Morello  cherry  which  he  found  attached  by  a  narrow  neck  to  the  peri- 
osteum of  a  tooth.  In  my  own  practice  a  lobulated  tumor  of  polypous  character  and 
having  much  the  appearance  of  an  epulis  overlapped  the  hard  palate,  and  was  found  to 
be  attached  by  an  exceedingly  narrow^  pedicle  to  the  edge  of  the  periosteum  of  a  decayed 
molar  tooth.  In  both  these  cases  hemorrhage  of  a  really  alarming  extent  had  occurred, 
and  in  both  the  tumor  was  removed  by  extracting  the  tooth. 

The  painful  ulcerative  stomatitis  so  fre(|uently  met  with  in  hospital  practice 
among  young  children  olttu  demands  the  extraction  of  loosened  and  irritating  teeth, 
coupled  with  the  internal  administration  of  its  specific  remedy,  chlorate  of  potash. 

The  Extraction  of  Teeth. 

Speaking  generally,  extraction  may  be  required  for  regulation  of  teeth,  which  includes 
the  prevention  of  overcrowding ;  to  prevent  or  get  rid  of  impaction  of  a  wisdom  or  other 
tooth  ;  for  neuralgia  and  nerve  irritation  when  its  origin  in  a  tooth  is  not  confined  to 
.some  condition  of  the  pulp  which  can  otherwise  be  got  rid  of;  as  a  rule,  in  eases  where 
periodontitis  (not  rheumatic)  is  established  and  resists  curative  treatment;  when  an  alve- 
olar abscess  tends  toward  opening  externally  ;  in  cases  of  vertical  fracture  of  the  tooth  ; 
in  the  case  of  loose  and  di.seased  teeth  or  roots  which  keep  up  an  unhealthy  condition  of 
the  mouth  :  w^hen  an  epulis  has  probable  connection  with  alveolo-dental  membrane  ;  and. 
finally,  in  some  cases,  to  allow  of  more  satisfactory  artificial  restoration. 

Forceps  and  elevators  are  the  instruments  now  used  for  the  extraction  of  teeth.     The 


476  EXTRACTION  OF  TEETH. 

forceps  adapted  for  the  removal  of  the  different  teeth  will  be  found  described  in  Tomes's 
Dental  Sure/cry,  and  only  a  few  special  points  will  be  here  noticed  with  regard  to  them 
and  their  use.  Forceps  should  be  finely  made  and  well  tempered,  with  blades  which 
should  grasp  the  tooth's  neck  without  pressing  on  the  crown,  as  extraction  is  seldom 
required  for  sound  teeth,  but  for  those  that  are  broken  down  or  hollowed  out  by  decay. 

In  extracting  a  tooth  the  forceps  should  be  applied  lightly  and  closely  to  its  neck  and 
then  sent  firmly  up  (or  down,  as  the  case  may  be)  until  they  grasp  a  part  of  the  tooth 
that  will  resist  some  pressure  ;  the  edges  of  the  blades  will  thus,  as  a  rule,  be  made  to 
pass  just  within  the  edges  of  the  socket,  while  in  the  case  of  the  molars  the  points  of  the 
blades  will  take  grip  at  the  bifurcation  of  the  roots  ;  the  right  hold  being  obtained  by  this 
first  movement,  the  instrument  is  thenceforth  kept  at  one  with  the  tooth,  which  is  first 
separated  by  a  particular  movement  from  its  socket  attachments  and  then  withdrawn. 

The  accompanying  drawing  (Fig.  273)  shows  the  manner  of  holding  forceps.  The 
little  finger  may  be  used  as  a  kind  of  opening  spring,  and  the  thumb  should  act  as  a  stop 
between  the  handles  and  prevent  any  crushing  pressure. 

The  particular  movement  required  for  the  dislodgment  of  a  tooth  depends  on  the 
shape  of  its  root.  Thus,  the  upper  incisors  and  canines,  together  with  the  lower  bicus- 
pids, are  more  or  less  conical,  and  are  therefore  to  be 
Fin.  273.  rotated  ;  while  the  lower  incisors  and  canines,  together 

with  the  upper  bicuspids,  are  more  or  less  flattened 
from  side  to  side,  and  therefore  are  to  be  moved  out- 
ward and  inward.  The  molar  teeth  are  also  to  be 
moved  outward  and  inward  befoi'e  being  extracted. 
The  direction  in  which  teeth  are  withdrawn  from 
]\ranner  of  holding  Forceps.  their  sockets  depends  on   the  position  held  by  their 

roots.  Upper  molars  are  extracted  downward  and 
outward;  lower  molars  upward  and  often  somewhat  backward;  while,  in  order  to  follow  the 
curves  of  their  respective  roots,  upper  wisdoms  should  be  extracted  downward,  backward  and 
outwai'd,  while  the  crowns  of  lower  wisdom  teeth  should  be  carried  backward  and  upward. 

An  elevator  should  not  be  used  in  extracting  the  upper  wisdom  tooth,  on  account  of 
the  fragile  nature  of  the  tuberosity  of  the  maxilla  in  which  it  is  lodged,  but  may  some- 
times be  used  with  advantage  for  a  lower  wisdom  when  the  second  molar  is  sound  and 
firmly  implanted. 

Before  attempting  to  extract  a  buried  and  impacted  lower  wisdom  tooth  a  careful 
examination  should  be  made  with  a  probe  to  see  how  it  is  situated  ;  sometimes  it  will  be 
found  to  hold  a  horizontal  position,  its  crown  impinging  upon  and  causing  absorption  of 
the  root  of  the  second  molar.  In  cases  where  it  is  possible  to  extract  the  impacted  tooth, 
lower  hawksbill  stump  forceps  with  a  double  curve  and  an  elevator,  such  as  is  shown  in 
Fig.  275,  B,  will  be  found  very  useful.  In  cases  where  the  ascending  ramus  would  be 
necessarily  injured  in  attempts  to  remove  the  wisdom,  the  second  molar  should  be 
extracted,  and  then  the  buried  tooth  may  erupt  without  further  trouble  or  can  be  easily 
removed  if  still  a  source  of  irritation.  Stump  forceps,  as  here  figured  (Fig.  274),  are  far 
better  adapted  for  the  extraction  of  bicuspids  than  the  so-called  bicuspid  forceps. 

In  the  case  of  a  much-broken-down  or  hollowed-out  lower  molar,  instead  of  using  molar 
forceps,  it  is  better  to  grasp  with  stump  forceps  the  one  of  the  two  roots  which  offers  the 
best  hold  ;  and  if  the  union  between  the  roots  is  not  strong  enough  to  allow  of  their  with- 
drawal together,  the  remaining  separate  root  will  be  easily  removed. 

The  three  undivided  roots  of  a  crownless  upper  molar  may  be  extracted  with  "  Cole- 
man's forceps,"  or  with  long  flat-bladed,  loose-jointed  stump  forceps  as  made  by  Collins. 

Occasionally  dividing  forceps  may  be  used  with  advantage  in  extracting  united  roots 
of  either  upper  or  lower  molars. 

When  a  root  is  partially  covered  over  with  gum,  the  position  of  its  edges  should  be 
defined  with  a  probe  before  any  attempt  is  made  to  grasp  it. 

With  well-made  forceps  lancing  the  gums  before  extraction  is  usually  unnecessary, 
but  sometimes,  in  isolated  teeth,  especially  wisdom  teeth,  the  gum  is  strongly  adherent 
to  the  tooth,  and  is  apt  to  be  torn  away  with  it  if  not  first  separated. 

Fistulous  openings  on  the  fiice  are  seldom  seen  in  connection  with  children's  tempo- 
rary teeth,  but  the  external  alveolar  plate  is  often  perforated  and  the  end  of  a  root  pro- 
jects through  and  causes  ulceration,  which  may  lead  to  adhesion  between  gum  and  cheek; 
the  teeth  causing  this  irritation  are  easily  pushed  out  with  an  elevator. 

Persistent  hemorrhage  following  the  extraction  of  a  tooth  and  resisting  cold  may  be 
stayed  by  tightly  packing  the  socket  with  rolls  of  softened  matico  leaf  (Tomes)  or  with 


AFFECTioys  or  'nil-:  /'irAinwx  .ixn  (i:sni'/r.iGUs. 


a  strip  of  lint  cut  to  a  |H.iiit  ami  dipped  in  a  spirit  solution  ol"  tannin,  a  (<ini|)ress  being 
placed  over  and  kept  in  place  liy  the  (tpposite  teeth.  At  the  sann;  tinit;  astringents  or 
iron  should  he  given  internally  if  the  henjorrhagic  diathesis  exists,  or  appropriate  measures 
he  taken  if  the  hleeding  in  the  case  of  a  woman  appears  to  he  vicarious. 

\\  hen  natural  teeth  are  lost,  artificial  ones  un(|uestionahly  conduce  to  comfort  and 
health, 

(iiild  is  generally  lln-  hest  hase  for  artificial  ileiitures  when  a  few  teeth  only  want 
restoring;    hut    when    the   gums  have   heeri   ahsorhed   and   many  teeth  lost,  vulcanite  or 

Fk;.  -j:  J. 


in. — A,  I'pper  stump  forceps.  Fig.  27.i. — Wcdnc-Shaped  Scoop  Klevators,  wliidi  are  very  useful 

H,  Lower  stump  forceps,  in  extractiiit;  Ijuried  or  much  liollowed-out  roots,  such  a-s  ('. 

A,  Elevator  for  upper  roois.  B,  One  of  a  pair  of  elevators  de- 
vised by  Mr,  (',  Rogers  for  lower  stumps.  Such  a  root  as  »'  may 
sometiiiies  be  best  removed  from  the  upper  jaw  with  an  instru- 
ment having  a  spiral  cut  on  it,  used  like  a  corkscrew, 

some  such  substance  is  preferable.  Various  modes  of  fixing  teeth  are  adopted.  Atmo- 
spheric pressure  alone,  bands  applied  to  the  natural  teeth  in  the  least  liarmful  way,  and 
occasionally  springs  (those  devi-sed  by  Mr.  Henry  Rogers  being  by  far  the  best)  are  each 
to  be  used  in  fitting  cases. 

In  elderly  people  teeth  that  project  in  an  unsightly  manner  can  often  be  shortened 
with  much  advantage  and  without  pain.  The  roots  of  upper  front  teeth  and  of  lower 
teeth,  if  healthy,  may  often  be  retained  in  the  mouth  with  gain.  The  wholesale  and 
indiscriminate  extraction  of  teeth  is  to  be  strongly  reprobated,  leading,  as  it  does,  to 
premature  ab.sorption  of  the  alveolar  processes,  and  thus  often  reducing  in  middle  age 
the  lower  jaw  to  a  level  with  the  root  of  the  tongue,  and  therefore  ill  fitted  to  support 
artiOcial  teeth.  Several  painful  cases  resulting  from  extreme  absorption  due  to  this  prac- 
tice have  lately  been  seen  by  me. 

In  the  cases  of  cleft  or  perforate  palate  which  are  not  amenable  to  surgical  treatment 
artificial  restoration  should  be  had  recourse  to. 

An  obturator  should  span  the  orifice  only  in  recent  cases  of  perforation,  in  order  that 
occlusion  by  the  approximation  of  the  edges  of  the  opening  may  not  be  interfered  with  ; 
and  in  no  case  should  a  method  of  fixing  in  the  plate  be  used  that  will  tend  to  enlarge 
the  aperture. 

AFFECTIONS  OF  THE  PHARYNX  AND  (ESOPHAGUS. 

Inflammation  and  Suppuration  of  the  Pharynx 

are  met  with  in  the  feeble  and  cachectic  subject,  and  come  on  with  general  and  local 
symptoms  not  unlike  those  of  quinsy  ;  indeed,  the  two  affections  are  often  associated. 
The  chief  local  symptoms  are  pain  and  swelling,  with  difliculty  in  swallowing,  and  the 
chief  general  symptom  fever  with  constitutional  disturbance. 

Abscess  which  ma}-  be  the  result  of  an  acute  or  chronic  inflammation  of  the  part 
shows  itself  by  some  bulging  or  projection  of  the  mucous  covering  of  the  pharynx,  and 
it  may  be  so  large  as  to  interfere  with,  if  not  to  prevent,  deglutition,  or  even  to  impede 
respiration.     I  have  seen  this  occur  at  least  twice  in  cases  of  spinal  disease.    When  these 


478  DYSPHAGIA. 

conditions  exist,  the  abscess  must  be  opened  ;  and  the  best  instrument  to  use  for  the 
purpose  is  a  straight  bistoury  protected  up  to  the  point  by  a  piece  of  lint  or  strapping. 
Tonics,  such  as  quinine,  iron,  or  the  mineral  acids,  are  almost  always  required  in  these 
cases.  Steaming  the  throat  gives  great  comfort,  as  well  as  external  warm  applications. 
Nutritious  food  should  always  be  allowed.  The  surgeon  should  remember  that  a  post- 
pharyngeal abscess  may  be  due  to  disease  of  the  vertebrje  or  base  of  the  skull,  but  such 
(rases  are  generally  chronic.  He  should  also  be  alive  to  the  fact  that  such  an  abscess 
may  be  associated  with  a  fracture  of  the  spine.      (  Vide  "  Fracture  of  Spine."  p.  238.) 

Tumors  of  the  pharynx  may  also  give  rise  to  the  external  appearances  of  a 
chronic  abscess  by  pressing  the  mucous  membrane  forward ;  cancerous  tumors  are  very 
liable  to  do  this.  One  of  the  most  marked  cases  of  the  kind  I  ever  saw,  which  turned 
out  to  be  a  syphilitic  gumma,  was  so  large  as  to  make  me  suspect  its  cancerous  nature ; 
it  was  cured  by  ten-grain  doses  of  the  iodide  of  potassium  in  bark  three  times  a  day. 

The  cancerous  tumors  generally  commence  in  the  upper  part  of  the  pharynx  and  cause 
obstruction  of  the  posterior  nares  ;  as  they  grow  downward  they  simulate  a  pharyngeal 
polypus.  Two  such  cases  in  young  people  have  been  under  my  care,  and  terminated 
fatally.  It  was  a  question  in  looth  whether  the  disease  was  not  originally  in  the  tonsil, 
but  it  appeared  to  have  originated  above  the  gland. 

Granular  pharyngitis,  or  hypertrophy  of  the  adenoid  tissue  of  the  pharyngeal 
mucous  meuibrane,  shows  itself  as  a  chronic  catarrhal  affection,  associated  with  the  secre- 
tion and  hawking  up  of  a  thick  viscid  mucus,  which  is  often  tinged  vrith  blood. 

There  is  also  at  times  a  constant  burning  sensation  in  the  throat,  and  frequently  a 
nasal  twang  in  the  voice.  There  is  likewise  commonly  deafness.  To  the  eye  the  pharynx 
presents  a  granular  appearance,  the  granules  at  times  being  as  large  as  peas.  I  have  at 
times  seen  them  larger — once  as  large  as  half  a  nut. 

Treatment. — There  is  but  one  form  of  treatment  of  use,  and  that  is  the  removal  of 
the  glandular  bodies  by  scraping  or  the  galvanic  cautery.  When  the  disease  is  limited, 
the  latter  practice  is  preferable  ;  but  when  extensive,  scraping  should  be  employed,  the 
operation  not  only  removing  the  new  tissue,  but  starting  up  a  new  action  in  the  membrane 
which  is  beneficial.  Tonics  and  the  local  application,  later  on,  of  glycerine  and  iron  expe- 
dite cure. 

Soft  polypi  grow  occasionally  from  the  pharynx.  In  1883  such  a  case  came  under 
my  care  in  the  person  of  a  man  a?t.  80.  It  had  been  growing  two  years  and  was  about 
the  size  and  color  of  a  large  mulberry.     It  sloughed  off  after  much  manipulation. 

Dysphagia 

is  a  symptom  due  to  a  variety  of  conditions,  and  it  may  arise  either  from  some  want  of 
power  in  the  pharyngeal  muscles  or  from  oesophageal  nlcemtioii  or  obstruction.  In  the. 
former  case  the  condition  may  be  due  to  a  paralysis  of  the  muscles  of  the  part  from  cere- 
bral disease,  hysteria,  or  a  previous  diphtheria,  a  more  or  less  complete  loss  of  power  in 
the  act  of  swallowing  existing  under  all  these  circumstances,  food  or  fluid  passing  into  the 
nose  or  larynx,  producing  suffocation.  This  condition  is.  moreover,  often  present  after 
the  operation  of  tracheotomy  for  croup,  the  want  of  adaptive  power  in  the  muscles  of 
deglutition  allowing  liquid  food  to  travel  down  the  larynx  and  appear  at  the  external 
tracheal  wound. 

Dysphagia  from  oesophageal  obstruction  may  be  brought  about  by  either  spasmodic 
or  organic  stricture  of  the  tube  itself  secondary  to  cancerous,  syphilitic,  or  simple  ulcera- 
tion. It  may  be  produced  likewise  by  pressure  from  a  thoracic,  cervical,  or  aneurismal 
tumor,  or  by  the  presence  of  a  foreign  body  in  the  tube.  Laryngeal  and  pharyngeal 
tumors  and  tumors  about  the  base  of  the  tongue  can  also  produce  the  same  symptom. 

Stricture  of  the  oesophagus,  as  a  rule,  takes  place  at  its  junction  with  the 
pharynx  behind  the  cricoid  cartilage,  though  it  may  occur  at  other  parts.  It  may  be 
^ptmnodic  or  hysterical,  but  more  frequently  it  is  associated  with  .some  simple,  syphilitic, 
or  cancerous  iilcerative  action  ;  occasionally  it  is  cicatricial.,  the  result  of  a  former  injury, 
such  as  the  swallowing  of  a  corrosive  fluid.  In  the  majority  of  cases,  however,  the 
disease  is  due  to  cancer.  It  is  a  great  question  whether  a  simple  fibrous  stricture  of  the 
oesophagus,  such  as  is  found  in  the  urethra,  ever  takes  place.  Thoracic  aneurism  is 
capable  of  prodvicing  every  symptom  of  this  affection. 

Spasmodic  or  hysterical  stricture  is  usually  met  with  in  the  young,  but  it 
may  be  found  at  all  ages.  Paget  has  described  it  as  a  kind  of  stammering  of  the  mus- 
■cles.     It  is  probably  always  associated  with  some  local  irritation,  follicular  inflammation. 


(EsoriiAdF.M.  oiis'iiircrms.  179 

or  iiIciTatinii,  wliidi  \\:\<  cillirr  urii^inali'd  liv  itscH'itr  Inllnwcil  an  injury  siidi  as  a  scratch 
from  tin'  j»;iss!il:;i'  oI'  ;i  lijinl  or  sharp  hoily.  It  is,  Mmrrovcr,  usually  associatcil  with 
dysphaiiia.  'I'lu-  tlys|ihai.'i:i  is  likewise  interMiitteiit  and  iiM<-ertaiii,  and  a  patient,  when 
•riven  food  or  Huid  to  test  her  power,  will  often  say  that  it  is  inipo.ssihle  for  her  to  do 
what  is  re(|uired  ;  and  should  she  attempt  to  swallow,  she  will  to  a  certainty  lialf  choke. 
Yet  at  other  times,  when  otherwise  en^aired,  food  ean  he  taken.  If  a  prolianir  he  used  to 
examine  tlie  part,  its  introduction  will  he  violently  opposed  hy  the  pharyngeal  muscles, 
thouuli  with  a  little  steady  prosiire  all  olistniction  will  l>c  overcome. 

(Esophageal  Obstruction. 

When  a  patient  complains  of  difficulty  in  swallowinji'.  or  rather  of  difficnity  in  passiiif; 
food  (inward  down  the  a\sopha<;us  alter  tho  act  of  swallowin<;  ha.s  bccti  performed,  and 
of  Its  suhse(|ueMt  return  into  tho  moutli,  the  surgeon,  in  hjoking  for  it.s  cause,  should  first 
think  of  thoracic  aneurism,  then  of  cancer  of  some  portion  of  the  tuhe.  and  lastly  of  sim- 
ple or  .syjihilitic  ulci-ration.  lie  should  also  always  in(iuirc  into  the  history  of  the  ca.se 
and  satisfy  himself  that  in  no  previous  ]teriod  has  the  patient  sustained  any  local  injury 
from  tlie  swallowinir  of  a  foreiiiii  body,  of  hoilinu-  water,  or  of  corrosive  fluid.  If  the  last 
cause  he  eliminated  and  a  careful  examination  of  the  chest  with  other  modes  of  investi- 
iration  dispose  of  the  (|uestion  of  aneurism,  then  that  of  cancer  becomes  the  most  import- 
ant, since  there  is  little  doubt  that  such,  in  the  majority  of  ca.ses  of  organic  stricture  of 
the  oesophagus,  is  the  true  cause.  The  minority  include  examples  of  simple  and  of  syjdi- 
ilitic  ulceration  or  contraction.  Tn  the  early  stages  of  the  affection  the  diagnosis  is  diffi- 
cult ;  indeed,  at  this  period  the  surgeon  is  seldom  consulted,  for  so  long  as  solid  food 
passes  the  patient  is  hardly  aware  of  any  obstruction  existing,  the  habit  of  swallowing 
smaller  boluses  of  food  gvowmy:  pari  passu  with  tlie  obstruction.  An  attack  of  spasm  is 
perhaps  the  first  symi)tom  that  attracts  notice — a  spasm  which  completely  closes  the  canal 
and  causes  rcgnrgitatiou  of  the  food. 

At  this  early  period  of  the  disease  the  surgeon  will  probably  be  able  to  pass  a  pro- 
bang,  thougli  it  may  be  oidy  a  small  one.  As  the  disease  ])rogresses  some  signs  of  ulcer- 
ative action  may  appear,  such  as  the  discharge  ofpus  or  blood,  which  usually  comes  up  with 
the  regurgitated  food  ;  and  when  this  occurs,  there  is  no  better  indication  of  the  presence 
of  ulcerative  action.  If  the  patient  be  middle-aged,  the  probabilities  of  the  disease  being 
of  a  cancerous  nature  are  very  strong  ;  and  should  there  be  any  local  thickening  behind  the 
larynx  or  glandular  enlargement,  these  probabilities  are  enhanced.  When,  however,  the 
patient  is  a  young  adult  and  a  history  of  syphilis  exists,  its  syphilitic  nature  is  rendered 
probable.  .Sim])le  or  syphilitic  ulceration  of  the  u?so])hagus  is  sufficient  of  itself  to  cau.se 
complete  oesophageal  obstruction  and  to  simulate  stricture,  the  spasmodic  contraction  of 
the  muscles  of  the  tube  having  much  to  do  in  bringing  about  this  result.  The  following 
case,  which  occurred  in  a  patient  of  Dr.  Habershon's,  illustrates  these  points  very  forci- 
bly :  The  patient,  ast.  48,  was  dying  from  starvation  caused  by  inability  to  swallow  on 
account  of  oesophageal  disease,  and  for  it  I  performed  the  operation  of  gastrostomy.  The 
man  lived  six  days  afterward,  and  died  of  pneumonia.  After  death  nearly  a  complete 
ring  of  ulceration  was  found  at  the  upper  part  of  the  a^sophagus,  which  had  caused  all 
his  symptoms.  Its  syphilitic  nature  could  not  be  decided,  although  the  man  gave  a  his- 
tory of  having  had  the  di.sease  twent}-  years  previou.sly.  The  repair  at  the  seat  of  opera- 
tion was  most  complete,  the  stomach  and  integuments  having  tirndy  united.  No  peri- 
tonitis existed. 

I  once  saw.  in  consultation  with  Mr.  Pink  of  (xreenwich  and  Dr.  Wilks.  a  case  of 
complete  a^sophageal  obstruction  which  we  all  believed  to  be  cancerous,  but  which  so  far 
improved  under  the  expectant  treatment  as  to  allow  of  the  passage  of  well-minced  food 
with  comparative  comfort.  Several  months  later,  however,  complete  dysphagia  returned 
and  the  man  died,  a  direct  communication  having  taken  place  between  the  oesophagus  and 
the  respiratory  tract  from  extension  of  the  cancerous  ulceration.  Had  a  bougie  been 
passed  in  this  case,  a  fatal  result  would  probabh'  as  a  consequence  have  taken  place. 

As  the  disease  progresses  other  symptoms  will  appear,  for  the  ulcer  may  eat  its  way 
into  the  larynx  or  trachea,  when  it  .soon  proves  fatal.  It  is  from  this  fi^ct  that  the  sur- 
geon should  always  be  very  chary  of  pas.sing  a  bougie  down  the  a'sophagus,  and  more 
particularly  when  there  is  any  evidence  of  the  presence  of  ulceration,  since  he  will  be 
very  liable  to  do  harm,  and  may  cause  perforation  of  the  ulcer  into  the  air-passages  or 
pleura. 

Treatment. — Assuming  the  pathology  of  stricture  of  the  oesophagus  which  has  been 


480  FOREIGN  BODIES. 

given  to  be  correct,  the  treatment  by  dilatation  must  be  looked  upon  as  a  dangerous  meas- 
ure except  when  the  stricture  is  of  the  cicatricial  form.^  the  passage  of  an  instrument  in 
cancerous  or  any  ulcerative  disease  being  likely  to  hasten  the  fatal  termination  of  the 
disease.  In  the  cicatricial  form,  however,  or  that  which  follows  some  local  injury,  such 
as  can  be  produced  by  an  irritant  or  caustic  fluid,  dilatation  is  of  gi-eat  value ;  and  such 
treatment,  if  it  does  not  cure  the  disease,  will  at  least  prolong  life.  A  bougie  as  large  as 
can  be  passed  should  be  introduced  daily  and  retained.  The  patient  should,  when  pos- 
sible, take  solid  food  finely  minced  ;  and  when  otherwise,  fluid  nourishment.  Milk  can 
often  be  drunk  when  other  food  is  refused.  Beef  tea  is  always  useful,  and  Hassall's 
flour  of  meat  mixed  with  it  is  an  excellent  addition.  Brand's  li([uid  essence  of  meat  is 
also  invaluable. 

When  swallowing  becomes  impossible,  the  cautious  passage  of  a  fine  flexible  tube 
through  the  stricture  for  the  introduction  of  liquid  food  may  be  undertaken  ;  and  my 
colleague,  Mr.  Durham,  has  advocated  its  retention,  the  tube  in  some  cases  irritating  less 
by  its  retention  than  by  its  frequent  passage.  The  practice  seems  a  good  one  when  it  can 
be  tolerated.  Nutritious  enemata  are  always  of  great  use,  beef  tea  thickened  with  flour 
or  arrowroot,  with  milk  and  egg  or  part  of  a  mixture  of  a  pound  of  minced  beef  and  one- 
third  of  a  pound  of  fresh  pancreas,  as  a  suppository,  administered  every  four  hours  alter- 
nately, tending  more  than  anything  else  to  keep  up  the  powers  of  the  patient.  When,  all 
these  means  fail — or.  rather,  before,  for  it  is  known  that  life  cannot  be  very  long  main- 
tained under  such  circumstances — the  question  of  opening  the  stomach  by  an  operation 
mu.st  be  entertained. 

Billroth  recently  has  cut  down  upon  the  oesophagus  and  excised  the  cancerous  growth, 
but  without  success ;  the  operation  is  commended  to  our  considei-ation  only  by  the  emi- 
nence of  the  surgeon  who  performed  it. 

W^OUnds  of  the  pharynx  as  a  result  of  accident  are  occasionally  met  with, 
falling  with  a  sharp  body  in  the  mouth  being  the  most  frequent ;  and  Avhen  they  do  not 
involve  any  large  vessel,  they  generally  do  well.  Durham  relates  a  case  of  a  boy  aet.  7 
in  Holmes  s  System  of  Surr/ery  (third  edition,  vol.  i.  p.  745),  in  which  Mr.  Johnson  of  St. 
George's  had  to  ligature  the  carotid  artery  for  repeated  bleedings  following  a  punctured 
wound  of  this  part,  produced  by  the  end  of  a  parasol,  in  which  an  excellent  recovery 
ensued. 

Foreign  Bodies 

are  occasionally  arrested  in  the  pharynx,  and  when  pointed  may  become  fixed  in  the  soft 
parts  about  the  base  of  the  tongue  or  between  the  pillars  of  the  fauces  ;  but  when  bulky 
and  solid,  they  are  generally  arrested  at  the  narrowest  portion  of  the  tube,  its  lowest  por- 
tion, behind  the  cricoid  cartilage,  or  at  the  cardia.  The  discomfort  caused  by  this  acci- 
dent is  at  times  very  great,  and  difficulty  in  swallowing,  pain,  and  the  disposition  to  vomit 
are  common  symptoms.     A  pricking  sensation  in  the  part  is  generally  present  when  the 

substance  is  pointed,  although  it  must  be  remem- 
FiG.  276.  ^  bered  that  this  symptom  often  remains  after  the 

substance  has  been  dislodged.  Where  the  epi- 
glottis or  upper  orifice  of  the  larynx  is  irritated, 
cough  and  other  laryngeal  symptoms  will  be  pro- 
duced, and  the  same  may  be  said  when  a  solid 
body  becomes  impacted  behind  the  larynx,  the 
larynx  under  the.se  circumstances  being  either 
so  compressed  as  to  cause  suff'ocation  or  so  irri- 
tated as  to  give  rise  to  spasm,  either  of  these 
causes  being  sufficient  to  produce  death. 

When  small  bodies  lodge  in  the  part,  they 

may  give  rise  to  inflammation   and  abscesses  in 

the  pharynx  and  neck;  indeed,  instances  are  on 

record  in  which  disease  of  the  cervical  vertebrae 

Revolving  Pharyngeal  Forceps  for  the  Removal  of       has  been  the  result.      Coins  may  be  impacted  in 

Foreign  Bodies,  etc.  ^j^^  pharynx  for  many  months,  and  Dr.  0.  Ward 

relates  a  case  {Path.  Trans.,  1848-49)  in  which  a  halfpenny  was  so  placed  for  eight  months, 

the  child  at  last  in  a  fit  of  coughing  bringing  it  up. 

Treatment. — Whenever  a  foreign  body,  large  or  small,  is  suspected  to  have  become 
lodged  in  the  pharynx,  a  surgical  exploration  of  the  mouth,  base  of  the  tongue,  and 
fauces  should  be  made;  and  by  carefully  sweeping  these  parts  with  the  index  finger  any 


FORKKis  nnnihs  i.\  Tif/-:  (lyorn.iaus. 


181 


fon'iirii  Ixiily  will   111'  (IciiMtcd.      liy  tliis  |ni)c litiir  tin-   f'urcitrii   IhmIv  iiiuv  )»'  ilisiu(l;.'t'd. 

Wlit'U  any  Ixuly  is  tixtMl  in  a  part,  it  may  In*  rfinovcd  hy  rnrrcps.  the  onlinarv  <lrfssiiifi^ 
lorcep.s.  as  a  rule,  snrtifinir;  wlicii  tlic  Ixiily  is  lower  down,  the  revolvinj,'  a'sii))lia;;i,'al 
loreejis  as  made  tnr  me  liy  Mr.  Kroline  (  Kiir.  -7<»)  may  \ni  used.  When  a  coin  has  lieen 
swallowed  l»y  a  eliild  and  Ix'come  impacted  in  the  pharynx,  tlie  (diild  should  l»e  laid  acroHH 
a  i)illow  upon  his  Kelly  on  a  tahle,  with  the  head  han<;in;;  over  tht;  end,  and  supported. 
The  surgeon  should  then  Introduce  his  iiuLier  into  the  mouth  and  depress  the  child's 
tonirue,   the   coin    l»y   tliis   inameuvre   sliilinir  out   ol'  its   place. 

When  a  solid  mass  has  beconu!  impacted  in  the  lower  part  of  the  pharvn.v  Ixdiind  the 
cricoid  cartilage  and  the  fini^er  cannot  dislodL,^'  it,  no  f'orcihle  attempt  should  be  made  to 
])ush  it  down  into  the  stomach,  althouuh  laryn;i(jtomy  may  he  called  for  to  preserve  life. 
If  rt  second  attempt  to  move  the  impacted  body  fail,  it  is  well  to  desi.st,  as  by  the  lapse 
of  time  the  spasm  which  existed  when  tlie  first  attempt  failed  may  disappear,  and  a 
renewed  effort  may  lie  crowned  with  success.  Soft  })odies  likewise  become  softer,  and 
oonse(|ucntly  can  be  the  better  removed  or  puslied  downward.  A  iroml  deal  mav.  how- 
ever, l)e  done  by  digital  manipulation,  both  inside  and  outside  the  imtuth,  either  to  dis- 
Iod<j;c  the  foreiiin  body  or  to  so  alter  its  sliape  by  s(jueezin<;  as  to  enable  it  to  pass  down- 
ward. The  larynLiosoo])ie  mirror  is  (d'ten  of  <ireat  service  in  detecting  tl)e  presence  of  a 
small  impacted  l)ody  and  in  liuidiiiu  the  surireon  to  its  positi<Mi.  False  teeth  not  infre- 
(|uently  ))ecome  dislodtreil  ami  impacted  in  the  ))haryiix.  Pat^et  has  related  such  a  ca.se,' 
where  a  man  in  a  tit  had  one  of  his  sets  in  the  pharynx,  where  they  remained  four 
months.  They  were  afterward  dislodi;ed  from  Itetween  the  base  of  tonirue  and  the  epi- 
glottis. 

Before  giving  dilorot'orm  to  old  people  the  teeth  always  should  be  examined  and 
false  sets  removed.  When  such  bodies  become  impacted,  much  care  is  needed  in  their 
extraction,  ami  tho  utmost  gentleness  used. 

Foreign  bodies  in  the  oesophagus  are  mostly  arrested  at  the  two  narrowest 
portions  of  the  tube — its  origin  behind  the  cricoid  cartilage,  or  at  its  lower  end  just  above 
the  diaphragm — and  anything  that  can  be  swallowed  may  be  so  impacted.  The  symp- 
toms to  which  this  accident  gives  ri.se  are  extremely  uncertain.  When  the  upper  part 
of  the  tube  is  obstructed,  the  laryngeal  symptoms  are  generally  alarming  (Fig.  277)  ; 
and  when  the  obstruction  is  not  complete,  they  may  be  very  .slight. 
Vomiting,  however,  under  both  circumstances,  will  probably  take 
place  to  expel  the  obstructing  body  ;  and  when  this  is  severe,  rup- 
ture  of  the  aaophiKpoi  ma}'  ensue.  This  accident  is  to  l)e  suspected 
when,  after  severe  and  repeated  straining,  the  foreign  body  is 
ejected  with  violence,  its  ejection  being  attended  with  hemorrhage 
and  followed  by  emphysema  of  the  neck.  An  interesting  paper  on 
this  subject  may  be  referred  to,  by  Dr.  Fitz  {American  Journal  of 
Med.  Science.,  January,  1877).  As  a  rule,  however,  besides  the 
mechanical  symptoms  which  the  luere  presence  of  a  foreign  body  in 
the  tube  produces,  secondary  inflammatory  symptoms  may  be  set 
up  which  Tuay  give  rise  to  a  ftital  result.  Thus,  a  case  is  on  rec- 
ord in  which  a  fish  bone  perforated  the  heart  and  caused  a  fatal 
hemorrhage  (Andrews,  Lancrt,  1860)  ;  in  another,  where  a  sharp 
spiculum  of  bone  cau.sed  ulceration  on  the  third  day  into  the  aorta 
(Hume-Spry,  Patli.  Thiva..  vol.  xix.  ]).  219)  :  and  in  a  third,  where 
disease  of  the  spinal  cord  ensued  as  a  consequence  of  ulceration  of 
the  intervertebral  substance  following  the  arrest  of  a  piece  of  bone 
in  the  (esophagus  (Ogle,  J.  W.,  Fofh.  Tranx..  vol.  iv.  1858). 
Krichsen    also   records   a  case   in   which    a    piece  of   sjutta-percha 

f.irmed  for  itself  a  bed  in  the  wall  of  the  esophagus  for  upward  of  ^^Mec^'of  Pud.nnKimpact 
six  months,  and  destroyed  life  by  causing  ulceration  into  a  ve.ssel 
and  hemorrhage  :  and  a  .second,  in  which  a  man  died  suddenly  from 
hi\?matemesis,  the  cause  being  discovered  after  death  to  be  a  half 
crown  impacted  in  the  oe.sophagus,  ulcerating  into  the  aorta. 
Gairdner  likewise  gives  a  case  where  a  fish  bone  passed  through  the  posterior  wall  of  the 
oesophagus  ami  was  found  embedded  in  pus  in  front  of  the  vertebral  column  <  Mnl.-Chir. 
Soc,  Edinburgh.  1850).  and  my  friend  Dr.  Sutton  also  has  told  me  of  an  instance  where 
a  lunatic  so  plugged  his  jdiarynx  with  tow  as  to  cause  death  by  suffocation. 

DiAONosi.s. — It  is  impossible  for  a   surgeon  under  all  circumstances  to  say  with  cer- 

'  Med.  Times,  1862. 
31 


Fig.  27 ■ 


ed  in  <Eso|>bagus  of  a 
Child  a;t.  2  years,  which 
caused  Death  by  Laryn- 
geal .Spasm,  ((iuy's  Hosp. 
Mus.,  1793<".r 


482 


FOREIGN  BODIES  IN  THE   (ESOPHAGUS. 


tainty  as  to  the  presence  or  absence  of  any  foreign  body  in  the  oesophagus.  When  it 
can  be  felt  by  the  finger  or  bougie,  no  doubt  can  be  entertained  ;  yet,  on  the  other  hand, 
when  no  such  evidence  is  obtainable,  a  foreign  body  may  often  be   present,  and,  being  of 


Fig.  278. 


(Esophageal  Bougie  with  Metal  olivary  End. 

small  size,  may  become  so  fixed  in  one  side  of  the  tube  as  to  escape  detection  in  the  pas- 
sage of  an  instrument.  The  best  bougie  for  diagnostic  purposes  in  one  made  of  whale- 
bone with  a  smooth  polished  iron  knob  at  its  end  (Fig.  278),  the  one  with  a  sponge  at 
the  end  being  useless. 

Treatment. — When  a  foreign  body  is  detected,  the  sooner  it  can  be  taken  away  the 
better.  If  the  material  be  so/f  and  (ligestihle,  it  may  be  pushed  downward  by  means  of 
an  ordinary  sponge  or  ivory  probang  or  the  tube  of  a  stomach  pump,  care  being  taken 
not  to  use  force,  for  such  material  will  .soften  by  the'  natural  secretion  of  the  part  after 
the  lapse  of  a  few  hours,  and  thus  will  be  more  readily  pressed  on.  Should,  however, 
the  oifending  body  be  pointed,  hard,  or  large,  all  idea  of  pushing  it  on  must  be  dismissed, 
such  a  practice  being  most  dangerous,  although  it  has  been  done  with  impunity,  a  jagged 
plate  with  teeth  having  been  pushed  into  the  stomach  and  passed  per  anum.  Sm<dl 
pointed  bodies  may  be  caught  by  the  "horsehair"  probang  (Fig.  279),  pas.sed  carefully 


Fig.  279. 


Fig.  280. 


-r^^^rt — 


Horsehair  Probang,  Expanded  and  Unexpanded. 


Money  Probang,  with  .'Sponge  at  one  End. 


beyond  the  position  in  which  the  foreign  body  is  supposed  to  be  placed,  and  then  gently 
expanded,  rotated,  and  withdrawn,  the  compression  and  rotation  of  the  instrument  caus- 
ing the  hair  to  spread  out  and  to  expand  the  oesophagus.  The  addition  of  a  skein  of  silk 
to  the  extremity  of  the  probang  adds  at  times  to  its  value.  Sharp-pointud  bodies  or 
impacted  hard  irregular  boi/ie!<  should,  when  possible,  be  removed  by  forceps.  Those  fig- 
ured in  No.  276  are  the  best,  as  they  can  be  made  to  open  when  in  the  pharynx  in  all 
directions. 

Vomiting  will  often  cause  the  dislodgment  of  a  foreign  body,  though  at  times  it  may 
render  it  more  fixed.  When  vomiting  cannot  be  produced  by  the  administration  of  medi- 
cine, a  solution  of  tartarized  antimony,  or  of  apomorphia  gr.  Jq,  injected  beneath  the  skin 
is  said  to  act  as  well. 

Coins  and  other  flat  but  not  pointed  bodies  can  often  be  removed  by  means  of  the 
money  probang  (Fig.  280)  or  Graafe's  coin  catcher,  the  circular  hook  catching  the  coin 
and  drawing  it   upward. 

Swallowing  a  large  bolus  of  bread  may  carry  downward  any  fine  hone  or  bristle,  a 
draught  of  any  liquid  assisting  the  process. 

CEsophagotomy  for  the  removal  of  foreign  bodies  has  an  established  position  in 
practical  surgery,  and  the  principles  laid  down  many  years  ago  by  Arnott'  are  now  gene- 
rally accepted — viz.,  "  Where  a  solid  substance,  though  only  of  moderate  size  and  irreg- 
ular shape,  has  become  fixed  at  the  commencement  of  the  oesophagus  or  low  down  in  the 

'  Mecl.-Chir.  Trans.,  vol.  xvlii. 


ly.fi'Kih's  or  Tin-:  .\r. domes.  48:3 

y)h:ir}n.\,  mid  lias  resisted  a  lair  trial  iur  its  extraetioii  or  (lis|ilaeemerit,  its  renioval  slimild 
(//  oncf  he  etteeted  l)V  iiieisiuii.  alth(iiij:li  iid  ur;;eiit  syiii|it(iiiis  may  be  present."  Mr.  ('nek 
endorsed  this  opinitiii  wlieii  he  wrote  in  l.S(!7:'  "The  hmp-r  a  foreijrn  l»«>dy  is  aUowed  to 
remain,  unh'ss  we  wait — a  t'nrhtrn  hope — for  su)»piiration  to  hiosen  it.  the  m<ire  finnly  it 
will  heeome  impacted.  It  would  appear  that  suecess  attends  a  speedv  operation  ;  whereas, 
where  the  useid'tlie  knite  has  lieeii  delayed  until  local  iuflainmati(jn,  suppuration,  or  (.'Veii 
sloiiirliini:.  has  heen  estaltlished,  the  result  oi"  the  operation  has  heen  fatal.  Dr.  I).  Cheever 
of  Boston,  r.  S..  likewise  iiri.H's  it.  I'p  to  the  end  of  ISSIJ,  45  cases  of  this  operation  for 
the  removal  of  fnrei<rn  hodies  were  recorded,  and  of  these  i-J')  were  successful,  and  in  the 
fatal  cases  the  result  was  m(»re  from  the  (hday  than  the  operation. 

This  operation  has  heen  recently  advocated  in  case.s  of  .stricture,  cancerou.s  or  otlier- 
wise,  with  the  view  of  introduciiif;  food  permanently  into  the  stomach;  but  the  re.sult8 
of  the  operation  are  not  sufficiently  satisfactory  to  enable  me  to  advise  its  adoption.  It 
is  only  possible  when  the  seat  of  stricture  is  lii<rh  up.  and  advisable  when  the  stricture  is 
of  the  cicatricial   form  ;   under  other  circumstances,  gastrostomy  should   be  preferred. 

Ol'KHATloN. — The  patient  should  be  jdaced  in  the  recumbent  position,  with  his 
slioulders  sliirhtly  elevated,  the  head  being  turned  to  the  right  or  left  side,  according 
to  the  {loint  of  projection  of  the  foreign  body.  Where  this  guide  is  lost,  the  left  side 
should  be  selected,  the  (csojthagus  inclining  rather  to  that  .side.  An  incision  should  then 
be  made  along  the  anterior  border  of  the  sterno-mastoid  muscle,  about  four  or  five  inches 
long,  its  centre  corresponding  to  the  position  of  the  foreign  body,  and  all  the  .soft  part.s 
carefully  divided.  The  omo-hyoid  will  then  ct)me  into  view,  and  underneath  this  the 
carotid  sheath,  with  its  vessels,  will  be  .seen.  The  deep  cervical  fascia  is  then  to  be  laid 
open  ;  and  if  more  room  be  required,  the  sterno-hyoid  and  sterno-thyroid  muscles  may 
also  be  partially  divided.  The  vessels,  with  the  .sterno-mastoid  muscle,  should  then  be 
drawn  well  (uitw^ard  by  means  of  hooked  retractors.  The  larynx,  with  the  u?sophagus 
behind,  can  then  be  examined  and  the  position  of  the  foreign  body  accurately  made  out, 
pressure  with  the  finger  on  the  opposite  side  tending  materially  to  make  this  point  clear. 
Should  the  foreign  body  project,  the  larynx  may  be  drawn  well  forward  or  toward  the 
opposite  side  and  a  cut  made  down  upon  the  projecting  part,  the  wound  being  carefully 
enlarged  to  allow  of  an  extraction  without  force.  When  the  foreign  body  does  not  pro- 
ject, a  guide  should  be  used,  such  as  a  silver  catheter,  flexible  lead  or  tin  sound,  or  a  long 
pair  of  forceps  introduced  througli  the  mouth  downward  into  the  pharynx,  the  point  of 
the  instrument  pressing  forward  the  oesophageal  wall.  All  vessels  that  bleed  during  the 
operation  should  at  once  be  twisted  or  ligatured.  On  opening  the  oesophagus  the  recur- 
rent laryngeal  nerve  should  be  carefully  avoided.  The  wound  should  be  left  open.  The 
patient  must  be  fed  for  a  few  days  by  means  of  a  small  oesophageal  tube,  introduced 
through  the  mouth  into  the  cesophagus  below  the  wound,  care  being  taken  during  its 
introduction  to  keep  the  point  again.st  the  opposite  wall.  Convalescence,  as  a  rule,  goes 
on  steadily.  I  have  been  fortunate  enough  to  see  the  operation  successfully  performed 
twice  by  my  colleague,  Mr.  Cock,  and  the  facility  with  which  it  was  done  has  given  me  a 
very  favorable  opinion  of  its  value. 


CHAPTER    XIV. 

INJURIES   OF   THE   ABDOMEN. 

Contusions  and  Rupture  of  the  Viscera. 

Injuries  of  the  abdomen,  like  tho.se  of  the  cranium,  derive  their  principal  importance 
from  the  nature  of  the  cavity's  contents.  The  integuments  and  muscles  that  form  the 
abdominal  parietes  may  be  severely  injured  and  results  follow  which  are  simply  of  local 
importance  :  but  when  the  peritoneal  lining  of  the  cavity  is  involved  or  any  of  the  vi.scera 
are  injured,  the  case  assumes  a  grave  aspect.  The  gravest  internal  abdominal  injuries 
may,  however,  coexi.st  with  the  slightest  or  with  no  external  evidence  of  mischief,  and 
even  without  shock.  When  a  wound  is  present,  an  extra  element  of  danger  is  added 
which  is  to  be  measured  by  the  extent  and  character  of  the  visceral  complication. 

^  Guy's  Reports,  1858,  lS'o7. 


484  INJURIES   OF  THE  ABDOMEN. 

Under  certain  conditions  a  trifling  blow  on  the  abdomen  may  give  rise  to  symptoms 
of  an  alarming  nature,  when  a  severe  one  may  be  recovered  from  without  exciting  more 
than  a  fear.  "  The  absence  of  shock  immediately  succeeding  a  severe  lesion  may  lull 
suspicion,  as  its  presence  may  by  simple  contusion  excite  alarm."  Every  abdominal 
injury,  however  trivial  it  may  appear,  must  consequently  be  regarded  with  apprehension 
and  the  utmost  care  observed  in  its  treatment.  This  can  be  easily  accounted  for.  says 
Poland,'  "  when  we  consider  the  numerous  and  vital  structures  contained  in  the  abdomen 
— a  serous  membrane  highly  prone  to  inflammation  ;  the  '  peritoneum,"  occupying  an 
extensive  amount  of  surface  ;  a  lengthy  coil  of  organized  tubing,  '  the  stomach  and  intes- 
tines ;'  solid  substances,  made  up  chiefly  of  blood  vessels,  etc.,  the  liver,  spleen,  and 
kidneys,  readily  lacerable  and  liable  to  rupture,  causing  nearly  always  fatal  hemorrhage  ; 
receptacles  for  fluid,  'the  gall  and  urine  bladders,'  which  under  distension  and  undue  force 
may  burst ;  large  vessels  coursing  along  the  posterior  wall.  '  the  aorta,  vena  cava,'  etc. ; 
and  lastly,  above  all,  the  sympathetic  nerves,  consisting  of  the  solar  plexus  and  its 
numerous  satellite  plexues  and  branches  of  such  high  organic  importance  that  injury  or 
shock  thereto  may  be  attended  with  irreparable  results.  All  these  structures  are.  moreover, 
enclosed  with  soft  elastic  parietes  capable  of  great  distension,  which,  although  readily 
able  to  resist  shock  and  external  violence  without  injury  to  themselves,  yet  may  allow 
the  force  to  be  transmitted  and  expended  on  the  contents  with  dire  effect,  and  yet  with- 
out leaving  a  trace  or  mark  on  the  exterior." 

In  forming  a  diagnosis  in  this  class  of  cases  exclusion  is  the  only  sound  method  ; 
every  possible  complication  should  be  entertained  and  dismissed  only  when  the  weight  of 
evidence  is  against  it,  the  ultimate  conclusion  being  founded  as  much  on  negative  as  on 
positive  evidence. 

"  I  am  unacquainted,"  writes  Le  Gros  Clark  (^Surgical  Diar/nosiii,  1869),  "  with  any 
diagnostic  sign  by  which  we  may  predicate  whether  shock  following  an  abdominal  injury 
exists  primarily,  apart  from,  or  as  expressive  of,  actual  breach  of  texture.  Time  alone 
can  develop  the  true  nature  of  the  case,  either  by  renewal  of  vigor  or  by  the  develop- 
ment of  fresh  symptoms." 

An  injury  to  the  abdomen  from  a  blow,  fall,  or  the  passage  of  a  wheel  over  the  part 
may  cause  either  a  more  or  less  severe  contusion  of  the  abdominal  wall  with  no  visceral 
complication  whatsoever,  or  a  laceration  or  rupture  of  a  viscus  or  vessel  which  will  end 
in  death,  without  any  (or  very  slight)  external  sign  of  mischief. 

Shock  or  collapse  as  a  direct  consequence  of  a  blow,  when  of  a  passing  nature,  is 
of  small  value  as  a  diagnostic  sign,  although  when  j^ersisfoit  or  relapsing  it  indicates  great 
mischief,  as  more  or  less  complete  collapse  is  a  common  effect  of  all  abdominal  injuries. 
A  collapse,  however,  coming  on  at  a  distinct  interval  of  time  after  an  injur}-,  as  a  rule, 
indicates  internal  hemorrhage. 

Pain  as  an  immediate  effect  of  injury  is  no  indication  of  internal  mischief,  for  in 
simple  abdominal  contusions  it  is  at  times  very  severe.  When,  however,  it  lasts  or 
becomes  Jixeil,  it  is  a  symptom  of  importance  :  and  when  it  radiafes  from  a  point,  it  is 
most  characteristic. 

Persistent  vomiting  is  always  a  suspicious  symptom  of  visceral  injury. 

How  far  sudden  death  is  attributable  to  a  shock  or  collapse  from  a  blow  on  the  epi- 
gastrium or  stomach  without  organic  lesion  is  not  yet  a  settled  question.  Dr.  A,  Taylor 
in  his  Mediral  Jurisprvdpncp  adduces  a  case,  that  of  Mr.  Wood,  in  which  a  man,  when 
fighting  and  intoxicated,  suddenly  died  after  the  receipt  of  a  left-handed  blow  on  the  pit 
of  the  stomach  ;  but  the  evidence  in  the  case,  as  well  as  the  facts  revealed  at  the  po.st- 
mortem,  was  by  no  means  conclusive  as  to  the  cause  of  death.  The  opinion  has  probably 
been  accepted  on  the  authority  of  Sir.  A.  Cooper,  who  was  in  the  habit  of  relating  that 
as  two  men  were  working,  one  of  whom  was  wheeling  along  a  heavy  load,  his  comrade 
thus  addressed  him  :  "  That  is  too  much  for  you  ;  stand  a.side,  and  let  me.  a  better  man, 
take  it."  He  accompanied  these  remarks  with  a  slight  blow  on  the  scrobiculus  cordis, 
and  the  man  immediately  let  the  barrow  fall  and  died  on  the  spot.  After  death  no  lesion 
was  discovered.  The  case,  however,  had  only  been  related  to  Sir  A.  Cooper.  Surgeon 
A.  Harding,  of  the  Army  Medical  Department,  in  his  Report,  1881,  vol.  xxi.,  Appendix  No. 
VII.,  gives  a  case  "  the  history  and  post-mortem  appearances  of  which  apparently  point 
to  sudden  death  the  result  of  shock  to  the  sympathetic  system  of  nerves,  paralyzing  the 
cardiac  plexus,  and  thus  causing  cessation  of  the  heart's  action.  The  man,  as  far  as  can 
be  ascertained  by  inquiring  of  his  intimate  comrades  and  examination  of  his  medical 
history  sheet,  had  been  previously  perfectly  healthy,  thus  excluding  heart  disease,  and 

1  Guys  Rep.,  1858. 


I.X.I rinhs  OF  Tin:  .\v,i><>mi:s.  48o 

no  tract's  (if  injiny  liciiii:  tniiml  \v\h\>  lairlv  tn  ilio  almvc  (•(difliisioii."  Tlie  case  wa*  that 
Iff  J.  Coyli',  an  (itficcr'.s  servant,  who  in  drivin;:  away  a  jiony  from  his  master's  tent  received 
a  kick  from  the  animal  over  i\\v  reirioiiof  the  liver,  lie  at  once  said  to  a  comrade  stand- 
ing near  liim.  "  I'm  done  for,"  and  fell  down  dead.  I>r.  Hanlin;.::  saw  him  so  live  minutes 
after  the  accident.  At  the  aiito])sy,  made  twenty-two  hours  after  death,  all  the  viscera 
wiMc  found  heahliy  ;  luiit^s  collapseil  ;  heart  full  of  Huid  hhiod  ;  liver  normal  in  size,  hut 
full  of  l.lnod  .  s)ileen  and  kidneys  also  full  (d"  lilood.  I  concur,  however,  with  Mr. 
I'ollock.  that  ••sudden  death  att rihutalile  to  a  lilow  on  the  stomach  or  epijxastriuni  must 
he  a  rare  occurrence,  and  that  nu'dical  men  should  he  extremely  guarded  in  offering  an 
opiniim  as  to  the  cause  of  death  in  such  supposed  injuries  without  satisfyinj;  themselves 
by  mo.st  careful  and  minute  post-mortem  investigation  that  no  violence  lias  been  done  to 
the  viscera,  either  ahdominal  or  thoracic"     (  IlolinesH  S//sfrm,  :^d  edit.,  vol.  i.  ji.  S(»7j. 

What,  tlii'n.  it  may  he  asked,  are  the  usual  conseiiuences  of  an  alidominal  injury  or 
contusion,  and  what  are  its  risks  and  complications?  The  following  facts  will  answer 
these  i|ueries. 

At  (Juys  IIos])ital,  during  eight  consecutive  years,  seventy-one  cases  of  ahdominal 
injuries  were  admitted.  In  xcvcnteeu  cases,  or  about  one-fourth  of  the  whole  number, 
rupture  of  the  viscera  took  place.  \n  foiti/-fonr,  beyond  a  passing  collapse  and  tender- 
ness over  the  injured  part  from  the  contusion,  no  evidence  of  any  internal  mischief 
showed  it.self.  In  these  ca.ses  rest  in  bed  for  a  few  days,  with  the  local  ajiplicatiftn  of  a 
•warm  fomentation,  was  the  chief  treatment,  and  in  all  convalescence  was  rapidly  estab- 
lished. In  ti-n  r((ses  syniptoms  of  peritunitis  followed,  as  evidenced  by  excessive  tender- 
ness over  the  injured  part,  increased  by  movement,  thoracic  respiration — resulting  from 
the  indisposition  of  the  abdominal  mu.scles  to  act,  and  the  pain  caused  during  that  action 
by  pressure  on  the  inflamed  peritoneum — nansea,  and  in  some  cases  vomiting.  Fever  and 
constitutional  disturbance  varied  according  to  the  severity  of  the  inflammation.  In  seven 
of  these  ten  cases  tihsolufe  rest  in  the  horizontal  posture,  warm  local  applicatiims,  either 
by  means  of  fomentation  or  cataplasms,  in  some  instances  leeching,  and  in  (ill  opium  given 
in  moderately  full  and  repeated  doses,  was  the  treatment  adopted;  and  in  every  case  the 
inflammation  was  subdued  before  it  had  attained  a  dangerous  degree  of  severity.  In  the 
remaining  tlirie  rases,  however,  acute  peritonitis  set  in,  which  in  one  terminated  fatally. 
As  a  type  of  an  ordinary  case  of  peritonitis  after  injury,  I  adduce  the  following  case : 

A  man  set.  22  received  from  a  woman,  while  figliting,  a  blow  on  his  right  side,  which 
was  follow'ed  by  syncope,  but  from  which  he  soon  recovered ;  no  pain  or  inconvenience 
followed  the  injury  for  a  week,  and  the  man  resumed  his  usual  occupation.  At  this  date 
severe  abdominal  pain  appeared  at  the  seat  of  injury,  which  rapidly  increased  and  spread 
over  the  whole  abdomen  ;  vomiting  also  began,  accompanied  with  considerable  constitu- 
tional disturbance ;  and  in  this  condition  he  was  admitted  into  Guy's.  He  was  put  to 
bed,  twenty  leeches  were  at  once  applied  to  the  seat  of  injury,  and  a  grain  of  opium 
given,  which  was  ordered  to  be  repeated  three  or  four  times  daily  ;  perfect  rest  was  also 
enjoined.  In  a  few  days  these  .symptoms  subsided  and  he  was  enabled  to  take  food  with- 
out vomiting,  pain  ceased,  and  convalescence  became  gradually  esta})lished. 

Re.marks. — Such  a  case  is  interesting  from  the  fact  that  some  days  elapsed  between 
the  receipt  of  the  injury  and  the  appearance  of  the  peritoneal  symptoms,  as  well  as  from 
the  important  practical  point  to  be  learnt  from  the  rapid  success  that  followed  upon  the 
treatment  which  was  pursued.  Rest  to  its  fullest  extent  was,  doubtless,  the  chief  ele- 
ment of  success — rest  by  position  in  the  horizontal' posture,  and  rest  of  the  injured  parts 
maintained  by  the  administration  of  opium.  It  is  not  unfair  to  maintain  that  if  this 
treatment  had  been  adopted  earlier,  the  symptoms  exhibited  would  never  have  made  their 
appearance;  but,  the  man  following  his  occupation,  the  repair  which  was  ref|uired  after 
the  injury  could  not  be  efficiently  carried  out,  and,  as  a  consequence,  inflammation  ensued. 
Of  all  cases,  abdominal  injuries  require  absolute  rest,  and  in  no  example,  however,  appar- 
ently trivial,  should  it  be  neglected.  If  the  mischief  is  but  little,  that  little  will  more 
rapidly  be  repaired  ;  if  great,  its  evils  and  its  consequences  w^ill  be  materially  modified. 
The  case  already  quoted  indicates  both  points — viz.,  its  primary  necessity  and  its  .second- 
ary good  results. 

It  is  thus  seen  that  a  blow  upon  the  abdomen  may  be  followed  by  a  simple  contusion 
of  the  abdominal  wall,  and  in  exceptional  eases  by  peritonitis,  which  may  terminate 
fatally,  although  in  the  majority  where  such  a  result  ensues  it  is  from  rupture  or  lesion 
of  some  internal  part.  A  local  peritonitis  after  an  injury  is  not,  however,  to  be  looked 
upon  with  di.spleasure,  for.  as  pointed  out  by  Mr.  Hilton,  the  coagulable  lymph  whitdi  is 
poured  out  under  these  circumstances  forms  a  temporary  splint   until   the  injured  struc- 


18()  RUPTURE  OF    VISCERA. 

tures  repair  themselves.  The  inflaimnatory  effusion  produces  a  certain  degree  of  rest  to 
the  injured  structures,  and  thus  contributes  to  the  work  of  reparation. 

^Yhat,  then,  are  the  symptoms  of  an  internal  abdominal  lesion  ?  How  can  the  pres- 
ence of  such  be  made  out?     And  what  guides  are  there  to  the  viscus  that  is  wounded? 

To  answer  these  questions  satisfactorily  much  space  is  needed — more,  indeed,  than  can 
Well  be  spared  in  this  work  ;  yet  helps  to  diagnosis  may  be  given,  and  among  these  the 
nature  and  position  of  the  injury  are  the  best.  Where  the  loins  are  the  part  involved, 
the  kidneys  are  most  likely  to  suffer :  where  the  right  hypochondriac  region,  and  the  ribs 
on  that  side  are  fractured,  the  liver  is  probably  the  organ  that  may  be  injured.  When 
the  injury  is  on  the  left  side  the  stomach  or  more  probabh'  the  spleen,  when  in  the 
umbilical  region  the  intestines,  when  in  the  pelvic  region  the  bladder,  are  the  organs 
involved. 

Rupture  of  the  liver  usually  destroys  life  by  hemorrhage,  and  in  the  majority 
of  cases  within  a  few  hours  of  the  injury — in  some  within  a  few  days.  Thus,  out  of 
nine  consecutive  cases  of  ruptured  liver,  five  died  rapidly  :  three  survived  three,  seven, 
and  nine  days  respectively. 

There  is  little  doubt,  however,  that  recovery  may  take  place  when  the  fissure  is  limited 
and  the  case  uncomplicated.  Preps.  19-48-1 95P  in  Guy"s  Hosp.  Museum,  with  drawings, 
illustrate  this  truth.  Such  cases,  when  they  occur,  are  classed  with  those  of  traumatic 
peritonitis  ;  and  when  they  prove  successful  their  true  nature  is  not  revealed. 

When  the  laceration  is  extenshr,  death  is  always  speedily  produced  by  the  shock  and 
hemorrhage ;  coldness  and  general  pallor  of  the  whole  body,  with  a  feeble  pulse,  sighing 
respiration,  and  restlessness,  preceding  the  fatal  issue.  When  the  laceration  is  kss  severe 
life  may  be  prolonged  ;  and  I  have  recorded  in  another  work  the  case  of  a  man  aet.  45 
who  when  drunk  fell  from  a  cart  and  the  wheel  was  said  to  have  passed  over  his  head. 
Intoxicated  to  an  extreme  degree,  he  was  admitted,  under  Mr.  Birkett's  care,  into  Guy's 
Hospital,  presenting  no  collapse  or  s3'mptom  of  abdominal,  or  even  cranial,  mischief, 
beyojid  slight  hemorrhage  beneath  the  right  conjunctiva.  He  was  put  to  bed,  soon  fell 
asleep,  and  on  the  following  morning,  with  the  exception  of  the  hemorrhage  into  the 
orbit,  )io  sigim  of  mischief  could  be  detected.  Rest,  however,  in  the  horizontal  position 
was  strictly  enjoined,  but  to  this  he  would  not  submit ;  and  thirty-six  hours  after  the 
accident  he  got  up,  walked  about,  and  with  a  sudden  pain  in  his  side  fell  back  and  died. 
After  death  a  fissured  fracture  of  the  skull  was  found  passing  across  the  right  orbit, 
without  brain  complication,  and  about  a  pint  of  blood  in  the  peritoneal  cavitv,  which  had 
evidently  escaped  from  a  severe  laceration  of  the  liver,  a  mass,  situated  in  the  right  lobe, 
the  size  of  a  man's  fist  having  been  nearly  separated.  The  right  kidney  was  al.so  fissured 
on  its  surface  and  covered  with  coagulated  blood.  In  this  case  the  man  clearly  died  from 
secondary  hemorrhage  the  result  of  the  ruptured  liver.  In  October.  1883,  a  boy  aet.  16 
icalked  into  Guy's  Hospital,  although  in  pain,  after  the  wheel  of  a  cart  had  passed  over 
his  abdomen.  There  were  no  external  signs  of  injury,  and  the  only  prominent  symptom 
was  vomiting.  He  appeared  to  be  doing  well,  when  on  the  fifth  day.  after  an  action  of 
the  bowels,  he  suddenly  died.  After  death  a  fissure  three  inches  in  depth  was  found  in 
the  right  lobe  of  his  liver,  filled  with  clots  and  covered  with  lymj)h. 

In  rare  instances  the  liver  may  be  crushed  partially  and.  strange  to  say,  its  peritoneal 
covering  be  uninjured  ;  yet  in  such  cases  life  can  be  prolonged,  and  when  the  mischief  is 
not  extensive  may  be  saved. 

Fissures  of  the  liver  are  usually  met  with  on  its  upper  surface,  and  a  diseased  organ 
is  more  liable  to  rupture  than  a  healthy  one. 

The  spleen  is  frequently  injured,  and  such  cases  are  by  no  means  always  fatal. 
Prep.  2018.  Guys  Museum,  illustrates  its  repair  after  injury.  This  organ,  too.  is  some- 
times lacerated  by  a  fractured  rib  or  torn  by  a  dragging  of  its  surface.  When  fatal,  the 
result  occurs  from  hemorrhage  or  peritonitis.  A  child  xt.  5  was  run  over  and  admitted 
with  fracture  of  the  left  ribs  and  lower  jaw.  He  had  no  abdominal  symptoms.  On  the 
tenth  day  he  sat  up,  when  symptoms  of  acute  peritonitis  set  in,  followed  by  death  on  the 
twelfth  day.  After  death  pleurisy  and  fractured  ribs  were  found,  with  blood  in  the  left 
loin  and  four  ounces  of  blood  and  pus  between  the  surfaces  of  a  ruptured  spleen. 

Subdiaphragmatic  abscess  way  occur  as  a  consequence  of  abdominal  injury, 
and  the  surgeon  should  suspect  its  presence  in  all  cases  where  recovery  is  slow  and 
attended  with  abdominal  pain. 

Rupture  of  the  stomach  generally  proves  fatal  from  shock  or  irrecoverable  col- 
lapse, the  amount  of  distension  of  the  organ,  its  contents,  and  the  extent  of  laceration 
influencing  the  result.      When  the  rupture  is  large  and  effusion  of  its  contents  into  the 


iiri'Tiiu-:  OF  VISCERA.  487 

altdniiiiiiiil  ciivity  fiikes  place,  acute  peritonitis,  witli  or  without  hemorrliafre,  will  prove 
fatal,  ii'  the  siiock  does  not.  When  the  rupture  is  small  and  tin;  stomach  empty,  there  is 
some  ehanee  of  recovery,  local  pc^ritonitis  sul>s(M|ueMtly  Lcluin^j  the  itijurtMl  part  to  the 
surroundint;  tissues. 

When  death  is  imt  iiiiiiicdiate,  the  jiatii'iit  will  (•(unpjaiii  ut"  an  acute  and  constant  pain 
radiatiiiL'  tVmn  the  seat  oi'  inj\irv — so  peculiar,  ini]ei;d,  that  "  tlu;  intensity  of  it  ahsorhs 
the  whole  mind  of  the  patient,  who  within  an  hour  from  the  enjoyment  of  perfe(;t  health 
expres.ses  his  serious  and  decideil  conviction  that  if  the  pai:i  he  not  s|ieedily  alhiviated  he 
must  die  '  (Poland).  \'omitinir  is  a  ctuistant  .symptom.  Hrst  ot"  the  contents  of  the  stom- 
ach, and  often  afterward  of  hlood  ;  collapse,  ri<^or,  ami  syncope  are  often  met  with. 

Incomjilete  rupture  of  the  coats  of  the  stomach  is  found  .sometimes  after  death,  and 
in  (Juv's  Mu.seum  (Prep.  lS17"'j  there  is  the  stomacli  of  a  child  ;et.  7  in  which,  from  a 
sudden  Mow  upon  the  distended  viscus,  the  mucous  memhrane  was  detached  and  lacerated 
in  a  reniarkalile  manner. 

Rupture  of  the"  intestines,  l»oth  lar<re  and  small,  is  a  .somewhat  common  form 
of  alxloininal  iiijurv.  and  may  tie  produced  by  a  fall,  a  blow,  the  passage  of  a  whetd  over 
the  abdomen,  or  even  violent  muscular  exertion.  Hennen  (Millfdri/  Siir<j' ri/)  <;ives  a 
case  where  a  soldier  received  a  contusion  of  the  abdomen,  and  sloujrhinfj:  of  the  integu- 
ment followed  with  artificial  anus,  yet  in  six  months  the  feces  resumed  their  natural 
course  and  a  recovery  took  place.  In  (jruy's  Museum  there  is  a  specimen  (Prep.  ISol'^^j 
of  jierforation  of  the  small  intestines  of  a  man  who  had  received  a  kick  from  a  horse  and 
died  thirteen  days  after  the  accident  with  extensive  peritonitis  from  fecal  effusion.  Prep. 
IS;")!'*''  consists  of  a  portion  of  jejunum  taken  from  a  man  who  had  been  kicked  in  the 
abdomen,  the  injury  being  quickly  followed  by  .symptoms  of  extravasation  and  death  in 
forty-eight  hours;  Prep.  1850'*-  was  taken  from  a  case  of  perforation  of  small  intestine 
from  the  kick  of  a  horse,  terminating  in  death  in  twenty-four  hours  ;  No.  185P*  is  a  por- 
tion of  jejunum  in  which  are  two  openings  through  which  the  mucous  membrane  is 
inverted  and  resulting  from  a  kick  in  the  abdomen  ;  No.  1851"'  is  an  example  of  lacera- 
tion of  the  jejunum  in  which  the  bowel  is  completely  divided.  It  was  taken  from  a  man 
jet.  ;57  who  had  been  run  over  by  a  cart  and  lived  twenty-four  hours.  Lastly,  the  speci- 
men marked  1S51-'  is  from  a  case  that  occurred  in  the  practice  of  my  father,  the  late  Mr. 
T.  E.  Bryant  of  Kennington,  and  is  a  portion  of  ileum  in  the  coats  of  which  there  is  a 
small  perforation,  the  injury  being  produced  by  running  against  a  post,  and  followed  by 
collapse,  from  which  the  patient  did  not  rally,  but  died  on  the  third  day. 

Cases  are  also  on  record  in  which,  after  injury,  a  portion  of  intestine  has  sloughed 
and  subsequently  pas.sed  per  rectum,  a  recovery  taking  place.  In  the  anatomical  museum 
of  the  University  of  Edinburgh  several  such  preparations  exist. 

The  duodenum,  is  rarely  ruptured,  its  position  protecting  it ;  nevertheless,  such 
an  accident  does  occur.  Taylor,  in  his  Medical  Jurisprudence,  gives  a  case  where  a  boy 
jet.  13,  after  a  blow  on  the  abdomen,  walked  a  mile  with  but  little  assistance;  and  when 
he  died  (thirteen  hours  after  the  accident),  the  duodenum  was  found  to  be  completely 
torn  across.  In  a  case  of  my  own  a  man  jet.  25  walked  into  Gruy's  after  an  abdominal 
injury.      He  lived  thirty-six  hours,  and  after  death  his  duodenum  was  found  ruptured. 

The  jejunum  is  doubtless  more  frequently  ruptured  than  any  other  part  of  the 
intestines,  its  fixed  position  rendering  it  liable  to  be  torn  away  from  the  duodenum  by 
such  an  injury  as  the  passage  of  a  wheel  over  the  abdomen.  Poland  gives  fourteen 
examples  of  this  kind,  and  in  half  of  these  the  laceration  was  at  its  upper  part.  In  one 
case,  after  death,  three  or  four  pints  of  thin  pink-colored  fluid  were  found  in  the  abdomen 
— probably  the  iced  water  of  which  he  had  freely  partaken  after  the  accident — and  in  all 
death  took  place  from  collapse  and  peritonitis.  A  man  aet.  40  received  a  kick  on  the 
abdomen  from  a  horse.  He  walked  to  the  hospital,  but  did  not  appear  to  be  very  ill.  He 
was  admitted  for  precautionary  reasons.  He  died  suddenly  in  thirty-.six  hours,  and  after 
death  fecal  extravasation  was  found,  and  a  perforation  in  the  jejunum  three  feet  from  the 
duodenum. 

The  ileum  is  also  frequently  ruptured,  and  most  commonly  from  a  direct  blow  or 
fall  on  a  hard  body.  In  the  majority  of  such  cases  there  is  no  external  mark  of  injury, 
and  fecal  effusion  with  peritonitis  is  the  usual  cause  of  death.  AVhen  the  rupture  is  large, 
little  hope  exists  of  a  recovery  ;  when  small,  such  a  hope,  however,  may  be  entertained. 
In  these  ca.ses  death  is  usually  rapid  :  in  the  following  case,  however,  of  a  man  an.  21 
who  was  run  over  and  vomited,  death  did  not  take  place  for  eighteen  days.  It  followed 
an  action  of  the  bowels,  and  after  death  a  coil  of  intestine  three  feet  from  the  caecum 
was  found  lacerated  and  adherent. 


488  RUPTURE  OF  VISCERA. 

When  a  patient  is  the  subject  of  hernia  and  receives  a  blow  upon  the  tumor,  a 
ruptured  intestine  may  doubtless  take  place.  Aston  Key  made  this  the  subject  of  a 
memoir  in  the  Guys  Reps,  for  18-42.  and  Poland  has  collected  many  such  cases  in  the 
same  periodical  for  1858.  Rupture  of  the  gut  is  the  usual  result  of  .such  an  accident; 
and  when  it  occurs,  a  fatal  termination  is  to  be  expected.  When  the  bowel  is  only 
bruised,  however,  it  may  recover  or  slough  and  be  followed  by  an  artificial  anus. 

In  none  of  these  cases,  when  symptoms  of  inflammation  or  of  injury  are  severe, 
should  any  attempt  at  reduction  be  made.  The  surgeon  should,  however,  explore  the 
sac.     In  all  recorded  eases  where  the  bowel  has  been  returned  a  fatal  result  took  place. 

The  large  intestine  is  rarely  ruptured  from  violence.  When  over-distended  from 
fecal  accumulation  tlic  result  of  stricture  or  otherwise,  such  a  result  may  ensue,  but 
under  ordinary  circumstances  it  is  too  well  protected.  I  have,  however,  known  florid 
blood  to  flow  from  the  bowel  after  an  abdominal  contusion,  and  have  from  that  fact  sus- 
pected laceration  of  the  colon. 

Treatment. — The  chief  point  to  insist  on  is  the  absolute  necessity  of  treating  everi/ 
case  of  injury  to  the  abdomen  with  excessive  caution,  as  very  severe  mischief  may  be 
caused  by  violence  and  yet  the  immediate  symptoms  not  be  marked.  Collapse  after  the 
injury,  as  has  been  shown,  is  by  no  means  a  necessary  consequence ;  for  rupture  of  the 
intestine  itself  may  take  place  without  exciting  such  a  condition,  and  a  patient  may  walk 
after  having  ruptured  liver  or  intestine.  The  surgeon,  therefore,  should  be  guarded  in 
his  prognosis  as  well  as  careful,  watchful,  and  expectant  in  treatment. 

Collapse,  when  present,  unless  it  threatens  to  be  fatal,  should  be  disregarded,  since 
it  ma}'  have  a  most  beneficial  influence  in  checking  or  preventing  bleeding. 

Ill  every  case  absolute  rest  in  the  horizontal  position  should  be  secured  and  maiutained. 
If  the  injury  be  slight,  convalescence  will  soon  be  established  by  such  treatment ;  if 
severe,  secondary  bad  results  may  be  prevented,  and.  at  any  rate,  be  relieved.  The 
application  of  cold  to  the  injured  part  gives  comfort,  and  by  checking  the  circulation 
does  good.  A  Leiters  metallic  coil  {Fig.  9)  is  the  nicest  mode  of  applying  it.  or  an  ice 
poultice  or  bag  when  the  coil  cannot  be  obtained.  In  some  cases  fomentations  or 
cataplasms  give  greater  comfort.  In  exceptional  ca.ses.  when  local  pain  from  peritonitis 
is  great,  the  application  of  twenty  or  thirty  leeches  gives  relief.  Opium  should  always 
be  given  in  small  and  repeated  doses,  such  as  one  grain  every  four  or  six  hours-  for  an 
adult.  It  allays  pain,  assists,  by  checking  peristalsis,  in  maintaining  rest  to  the  injured 
peritoneum  and  viscera,  and  tends  materially  to  arrest  inflammatory  action. 

The  patient  should  be  kept  free  from  all  excitement  and  as  little  nourishment  admin- 
istered by  the  mouth  as  will  suffice  to  su.stain  life  ;  if  the  intestines  are  believed  to  have 
been  ruptured,  starvation  treatment  must  be  carried  out.  Whatever  is  given  should  be 
liquid  and  cold.  Milk  and  ice  in  limited  quantities  make  the  best  and  simplest  combina- 
tion, and  upon  this  life  can  be  sustained  without  difficulty.  If  great  thirst  exists,  ice 
may  be  given  ;  but  this  must  be  given  with  caution,  as  the  case  already  quoted  well 
illustrates.  When  the  intestine  is  believed  to  be  injured,  the  allowance  of  food  must  be 
very  scanty,  the  patient  s  powers  being  kept  alive  by  enemata  of  beef  tea  administered  in 
small  quantities,  say  three  or  four  ounces  repeated  every  four  or  .six  hours. 

Ort  no  account  ought  a  purgative  to  be  adriiinlster< d.  This  rule  is  golden  in  these 
cases  and  should  never  be  deviated  from,  as  by  infringing  it  in  a  careless  moment  the 
whole  of  nature's  processes  in  repairing  the  injury  may  be  undone  and  irreparable  mis- 
chief follow.  Constipation  is  the  .sign  of  a  passive  condition  of  bowel  to  the  preservation 
of  which  all  our  treatment  is  directed ;  a  purgative  is  merely  an  irritant  and  in  its  eff'ects 
in  these  cases  absolutely  destructive. 

In  all  cases  the  prognosis  and  treatment  should  be  most  guarded,  cautious,  and 
expectant,  and  in  all  the  state  of  the  bladder  should  be  well  attended  to.  for  retention  of 
urine  from  disturbed  nerve  influence  is  a  common  accompaniment  and  mu.st  not  be  over- 
looked. No  case  of  abdominal  injury,  however  trivial,  can  be  pronounced  well  within  a 
fortnight. 

Rupture  of  the  kidney  is  an  accident  from  which  recovery  is  more  common 
than  from  any  otlier  viscus,  and  its  po.sition  in  the  loins  outside  the  peritoneal  cavity  is 
doubtless  a  sufficient  explanation  of  this  fact.  When  the  injury  is  not  very  severe  and 
uncomplicated  with  other  injuries,  such  cases  usually  do  well.  It  is  generally  known  by 
an  attack  of  htematuria  and  local  pain  following  the  blow  on  the  lumbar  region.  The 
haematuria  may  be  but  slight  and  passing  or  not  .show  itself  till  the  second  day.  It  may 
cease  al.so  after  the  lapse  of  two  or  three  days,  when  it  is  probable  that  only  a  contusion 
of  the  kidneys  had  taken  place,  for  in  more  severe  injuries  the  bleeding  may  last  fifteen 


nri'Ti'iu-:  of  visceha.  489 

or  even  more  days.  At  times  elnts  will  lif  pussed,  }issumiii<:  the  shape  of  the  ureter,  and 
I  have  before  nie  the  notes  of  sonic  liall'  dozen  eases  in  whieh  these  symptoms  were 
present  and  from  which  recovery  took  phiee.  These  elots,  liowever,  at  times  frivo  rise  to 
retention  of  urine  liy  hlockini;  up  the  nretlira.  lictraction  of  the  testiele  is  an  occasional 
symptom,  and  so  is  pain  in  tlic  coiirst;  of  tin;  ureter  and  ah)!ijr  tlie  course  of  one  of  the; 
lumliar   nerves. 

TllK.VTMKNT. — Tlie  ireatMient  to  lie  piirsueil  in  these  eases  is  rest  in  lierl  und  milk  iliet. 
In  cases  where  tlie  hleedin^r  is  profuse  the  tincture  of  erpit  in  full  doses  is  a  valuable 
dru^,  or  a  trrain  of  the  acetate  of  lead  may  be  triven  with  half  a  L'rain  of  opium  three 
times  a  day.  or  jrallie  acid  in  teii-jrrain  doses.  Opium  should  always  be  ;.'iveii  with 
caution. 

When  the  orfran  is  crushed,  the  injury  is  likely  to  be  complicated  with  other  mi.sehief, 
and  under  such  circumstances  peritonitis  and  hemorrha<re.  siii<rly  or  combined,  frenerally 
prove  fatal.  When  the  organ  is  single  and  becomes  injured,  a  fatal  result  is  also  likely  to 
occur.  In  page  125  of  my  Ctinicdl  Hnrijrrij  I  have  recorded  such  a  ca.se.  When  peri- 
tonitis exi.sts,  opium  is  of  great  value ;  where  urinary  ab.scess  in  the  loin  follows,  as  it 
occasionally  does,  particularly  in  gunshot  wounds,  the  surgeon  must  make  a  free  incision 
into  it  on  the  outer  border  of  the  quadratus  lumborum  muscle. 

Rupture  of  the  ureter  was  first  ntiticed  by  Stanley  in  the  Mcd.-iliir.  7/v///.s-., 
vol.  .x.wii..  and  in  the  two  cases  he  related  a  fluctuating  tumor  formed  by  the  effusion  of 
urine  e.visted  in  both.  Poland,  in  the  (iliti/a  Rfj).  for  1808,  has  recorded  a  third  case; 
but  beyond  these  no  others  are  on  record.  Four  cases  of  wounded  ureter  are.  however, 
published  bv  lleuiieii  (Mil.  Siny.).  In  all  these  cases,  it  seems,  the  ureter  was  ruptured 
iiv  stretcdung.  its  ri'ual  end  having  suffered  ;  and  I  have  seen  two  of  these  which  occurred 
in  the  practice  of  my  colleague,  ^Ir.  Ilowse. 

The  symptoms  are  very  obscure,  particularly  where  no  exteriuil  wound  exists  ;  indeed, 
there  are  none  to  indicate  the  nature  of  the  accident  in  its  early  stage.  At  a  later  period 
a  lumbar  tumor  may  appear,  of  a  cystic  nature,  caused  by  the  retention  of  the  secreted 
urine,  and  there  may  be  more  or  less  peritonitis.  When  a  lumbar  .swelling  exists,  tap- 
ping the  cavity  should  be  performed,  the  operation  being  repeated  from  time  to  time  as 
the  fluid  re-collects,  the  kidney  in  time  probably  ceasing  to  secrete.  When  this  treatment 
fails,  there  is  little  doubt  that  a  free  opening  into  it  in  the  loin  is  the  correct  treatment. 
Nephrectomy  may  be  required.  Under  other  circumstances  the  case  must  be  treated  as 
all  others  of  abdominal  injury,  by  rest  and  opium. 

Mr.  Holmes  records  in  the  Mcd.-C/iir.  Trans,  for  1877,  vol.  xlii.,  an  interesting  case 
of  wound  of  the  ureter  which  occurred  in  a  boy  aet.  13  where  a  clasp-knife  had  entered 
his  body  from  l)ehind,  upward  and  outward,  just  on  the  right  of  the  middle  line  and  about 
on  the  level  of  the  posterior  superior  spine  of  the  ilium.  The  wound  discharged  urine  for 
two  weeks  and  then  closed,  the  boy  recovering. 

Rupture  of  the  gall-bladder  has  been  recorded  as  the  result  of  accident ;  and 
when  it  occurs  death  is  usually  rapid.  The  accident  is  marked  by  extreme  collapse  and 
pain  in  the  seat  of  injury.  Poland  in  his  Fothergillian  prize  essay,  has  given  us  .such  a 
case,  and  Dr.  Fergus,  in  the  Med.-C/n'r.  Tnais..  vol.  xxxi.,  has  recorded  another.  In  one 
the  death  occurred  from  eolla])se,  and  in  the  other  from  peritonitis. 

Rupture  of  the  hepatic  duct  may  also  occur.  In  Poland's  Fothergillian  essay 
such  an  instance  is  recorded,  and  occurred  in  a  boy  as  the  result  of  a  blow  on  the  abdo- 
men, the  accident  being  (juickly  fatal.  My  friend  Dr.  Sutton  has  kindly  given  me  the 
details  of  a  second  ca.se,  which  took  place  in  the  Loudon  Hospital  in  18(i7.  It  was  in 
that  of  a  man  iiet.  21(  who  was  knocked  down,  and  the  wheel  of  a  spring-dray  passed  over 
his  .stomach.  He  felt  pain  in  the  right  hypochondriac  region  directly  and  '  liad  hard 
work  to  get  his  breath."  Abdominal  pain  increased  and  jaundice  ajtjieared.  and  for  a 
month  he  kejit  his  bed.  On  the  thirtieth  day  after  the  accident,  as  he  did  not  improve, 
he  was  admitted  into  the  London  Hospital  under  Drs.  Herbert  Davies  and  Sutton.  Then 
he  had  abdominal  pain,  tenderness,  and  di.sten.sion.  There  were  distinct  a.scitic  fluctuation 
over  the  abdomen  and  deep  jaundice.  He  sank  eight  days  after  his  admission  and  thirty- 
eight  days  after  the  accident.  The  autopsy  revealed  the  fact  that  the  hepatic  duct  was 
torn  across  a  ((uarter  of  an  inch  above  the  spot  where  the  cystic  joins  the  common  duct ; 
no  other  part  of  the  liver  was  injured.  The  abdominal  cavit}'  contained  (juarts  of  olive- 
green  bile-.stained  fluid,  and  the  peritoneum  was  covered  with  yellow  matter  of  the  color 
and  consisteuce  of  jiaiiit.  wliicli  was  found  to  V»e  inspissated  bile. 

Rupture  of  the  urinary  bladder  may  occur  with  or  without  fracture  or  dislo- 
cation of  the  pelvis.     It  is  usually,  but  not  always,  due  to  external  violence  applied  to  a 


490  RUPTURE  OF  VISCERA. 

distended  organ.  As  a  rule,  the  rupture  takes  place  at  its  posterior  wall,  the  urine  escap- 
ing into  the  peritoneal  cavity  and  rapidly  causing  death.  In  exceptional  cases  it  affects 
the  anterior  wall,  when  the  urine  infiltrates  the  cellular  tissue  of  the  pelvis.  In  the 
former  cases  the  term  "  ?'«^ra-peritoneal  "  is  applicable  :   in  the  latter,  "  f-rAro-peritoneal." 

In  estimating  any  suspected  case  the  surgeon  .should  remember  that  a  distended  blad- 
der can  scarcely  e.scape  from  an  abdominal  contusion,  when  an  empty  one  mav  elude  the 
greatest  violence,  and  that  a  bladder  partially  distended  is  more  likely  to  be  bruised  than 
ruptured  by  direct  external  violence  or  torn  when  dragged  backward. 

This  accident  is  more  commen  in  men  than  women  in  the  proportion  of  five  to  one, 
and  it  occurs  chiefly  in  young  adults.  The  »?.x-Y/v/-peritoneal  is  far  less  dangerous  than 
the  /»^r«-peritoneal  rupture,  but  "  the  accompaniments  of  fracture  and  dislocation  of  the 
pelvis  cannot  be  said,"  according  to  Rivington.  "  of  themselves  to  exercise  much  influence 
in  the  length  of  the  survival.'" 

The  bladder  generally  gives  way  in  its  weakest  point.  The  main  predisposing  condi- 
tion of  rupture  is  distension  of  the  organ,  but  this  need  not  be  very  great.  In  exceptional 
cases,  as  in  one  recorded  by  Rivington.  the  bladder  was  empty,  the  undistended  viscus 
being  dragged  backward  with  the  peritoneum  when  a  cart-wheel  pas.^ied  over  the  patient's 
abdomen.     The  rupture  in  this  case  was  in  front,  above  the  prostate  gland. 

A  second  predispo.sing  condition  is  some  obstacle  to  the  exit  of  urine,  urethral  or 
prostatic  :  and  where  with  this  obstacle  there  is  .sacculation  of  the  bladder,  a  very  little 
external  violence,  or  vesical  contraction  only,  brings  about  a  rupture. 

In  283  fatal  cases  collected  by  Rivington.  224  were  brought  about  by  traumatic  and 
59  by  idiopathic  causes — that  is,  in  the  latter  the  bladder  was  ruptured  by  muscular 
action  combined  with  overdistension  from  some  obstructive  cause  such  as'  .stricture.  I 
have  seen  one  ease  of  this  kind  the  result  of  stricture  in  which  the  bladder  gave  way  on 
its  anterior  or  upper  wall  outside  the  peritoneum,  which  got  well  after  free  abdominal 
incision.  A  rupture  from  overdistension  may  be  either  intra-  or  extra-peritoneal,  accord- 
ing to  the  conditirfn  of  the  individual  bladder.  Gross  reports  that  in  his  cases  the  peri- 
toneum remained  intact  in  all.  The  aperture  in  the  bladder  when  ruptured  is  not  a  clean- 
cut  one,  but  partakes  of  the  characters  of  a  lacerated  wound.  The  edges  are  more  or  less 
jagged  and  contused,  one  coat  being  often  torn  more  than  another. 

The  bladder,  as  a  rule,  contracts  after  rupture,  and  it  is  only  in  exceptional  oases  that 
it  holds  more  than  a  few  ounces.  There  may  be  much  bleeding  from  the  wound,  post- 
mortem records  revealing  the  fact  that  a  large  quantity  of  blood  may  be  found  in  the 
peritoneal  cavity  after  death.  Mr.  Bransby  Cooper  stated  that  in  his  case  three  or  four 
pints  of  blood  had  been  poured  out. 

Symptoms  and  Diagnosis. — '•  The  typical  primary  symptoms  of  rupture,  whether 
traumatic  or  idiopathic,  are  a  feeling  of  .something  giving  way.  pain,  shock,  inability  to 
stand  or  walk,  desire,  but  want  of  power,  to  micturate,  and  removal  from  the  bladder 
with  the  catheter  of  blood  only  or  a  small  quantity  of  bloody  urine.  The  deficiency  of 
urine  and  the  loss  of  power  to  micturate  often  continue  throughout."  The.se  words  are 
those  of  W.  Rivington.  taken  from  a  recent  monograph  on  the  subject  (1884)  which 
merits  praise,  as  it  claims  close  study.  In  any  given  case  there  may  be  no  external  signs 
of  injurv.  though  the  abdomen  may  be  swollen,  prominent,  and  tender. 

Should  an  attempt  be  made  to  pass  a  catheter,  a  variable  quantity  of  blood  or  of  blood 
and  urine  may  be  drawn  off:  and  should  the  catheter  by  chance  pass  through  the  rent  in 
the  bladder,  the  quantity  of  fluid  evacuated  may  be  great.  Mr.  Durham  in  one  case 
removed  three  quarts.  The  catheter,  when  in  the  abdominal  cavity,  will  probably  be 
passed  its  whole  length  and  be  very  movable.  Indeed,  in  some  cases  it  has  been  felt 
through  the  abdominal  wall.  The  stream  of  fluid,  when  it  comes  from  the  peritoneal 
cavity,  is  slow  and  languid  ;  it  may  be  intermittent.  As  the  case  progresses  .symptoms 
of  more  or  less  acute  peritonitis  develop. 

Should  the  patient  survive  the  accident  five  or  six  days,  there  may  be  hope  of  recovery; 
for  repair  locallv  will  have  gone  on.  and  with  it  both  local  and  general  symptoms  will  have 
ameliorated.  The  bladder  will  then  probably  begin  to  act  naturally,  pain  will  have  dimin- 
ished, and  the  patient  will  be  able  to  take  food.  Dr.  S.  Smith  reports  (1851)  three  cases 
in  which  the  inability  to  urinate  continued,  and  twelve  in  which  it  returned  on  the  second 
or  a  later  day.  In  extra-peritoneal  cases  all  the  primary  sA'mptoms  will  be  more  subdued 
than  in  the  intra-peritoneal,  and  the  secondary  symptoms  will  approach  those  of  extrava- 
sation of  urine  elsewhere,  such  as  diffused  cellulitis  locally  and  those  of  blood  poisoning 
constitutionally. 

Treatment. — Up  to  the  present  time  no  definite  line  of  treatment  has  been  laid  down. 


nrrrrin:  or  vis<'i:n.\.  l!H 

suid  as  a  cuiisiMiiu'iirc  the  results  ul"  trfatinciit  liavt-  hceri  most  ilisustroiis.  Out  of  more 
than  two  liuiidrcii  cases  tahulated  \\y  liiviuirton,  but  eij^ht  have  Ikm-ii  n-corilud  as  exaui- 
|)l('s  of  rccoviTV.  and  it  must  he  a(hh'd  that  in  them  the  tividiMiee  of  their  hehjnjiin;;  to 
the  //(//'/-peritoneal  <;rou|i  is  not  unim|ieaehal)le.  Still,  a  careful  examination  of  tiic  evi- 
dence artorde(|  l»v  these  and  other  exam)iles  is  encouraging,  and  iMiou^h  t<i  support  a  line 
of  treatment  wliicli  is  liased  upon  a  principle  and  upon  lines  which  may  hrinir  aljout  a 
<;;ootl   result. 

The  treatment,  tn  Itc  siicces>ful.  must  he  local  ;  <^('neral  treiitment  hy  itself  has  been 
proved  to  be  absolutely  useless. 

The  indications  for  local  treatment  are — -Jii-Atlij,  to  withdraw  the  extravasated  urine 
from  the  peritoneal  cavity  ;  and  srcoiu/lj/,  to  secure  a  free  exit  for  fresh  urine  as  secreted. 

To  carry  out  the  first  when  the  diaj^nosis  is  clear,  laparotomy  should  be  performed 
by  an  incision  two  or  three  inches  in  len<;th  made  above  the  pubes.  throu<rh  which  the 
peritoneal  cavity  should  be  well  (deared  of  all  })lood  and  urine  and  sponj^ed  dry  with  anti- 
septic sponges.  The  rent  in  the  bladder  should  be  closely  stitched  by  a  silk  suture  like 
that  of  Lembert's  for  the  intestine  (  FIlt.  -H2,  pa<;e  4i>4),  and  to  facilitate  this  step  I  would 
sugjrest  the  nse  of  the  rectal  inflator  as  described  and  illustrated  (Fig.  'Mf'-i),  since  by  its 
use  the  base  of  the  bladder  and  prostate  will  be  raised  out  of  the  pelvis  and  well  into 
view,  thus  facilitatini;  manipulation. 

After  this  operation  and  the  abdominal  wound  has  been  carefully  stitched  up,  cyst- 
otomy should  be  performed  for  drainage  |>iirposes. 

Should,  however,  much  difficulty  be  experienced  in  suturing  the  vesical  wound,  the 
surgeon  may  find  comfort  in  the  result  of  Dr.  Walter's  case  (Jirnikinf/s  Abstract,  1862), 
in  which  laparotomy  was  performed,  the  abdominal  cavity  was  cleaned,  and  a  rent  two 
inches  long  seen  in  the  fundus  of  the  bladder  left  alone,  the  bladder  being,  sub.sequent  to 
the  operation,  relieved  by  catheterism,  and  recovery  took  place. 

When  the  diagnosis  is  not  sure,  the  treatment  above  advised  rejected,  or  the  ca.se  is 
late  for  treatment,  a  drain  for  the  urine  should  be  made  by  lateral  cystotomy,  after  which 
the  urine  will  flow  away  as  secreted.  Median  cystotomy  with  the  introduction  of  a  tube 
within  the  neck  of  the  bladder  is  likewise  good  practice,  but  it  does  not  .satisfy  the  require- 
ments of  the  case  .so  well  as  the  lateral. 

When  a  catheter  has  been  passed  per  Hrcthrmn  into  the  bladder,  and  probably  through 
the  rent  into  the  peritoneal  cavity,  a  free  irrigation  of  the  cavit}'  should  be  employed. 
Mr.  Thorp's  case  ( Dublin  Quart.  Journal,  vol.  xvi.),  so  far  as  it  goes,  tends  to  support 
this  practice,  and  Mr.  C.  Heath  strongly  advises  it. 

In  extra-peritoneal  rupture  and  urinary  extravasation,  supra-pubic,  and  possibly  peri- 
neal, incisions  may  be  called  for  and  a  free  vent  for  secreted  urine  provided  by  lateral  or 
median  cystotomy. 

The  probabilities  of  obtaining  a  successful  result  in  any  of  these  cases  turns,  how- 
ever, more  upon  the  time  that  has  elapsed  when  they  are  put  into  execution  than  any- 
thing else,  fresh  urine  not  being  nearly  so  irritating  to  a  healthy  surface  as  urine  under- 
going septic  changes ;  and  these,  when  once  begun,  go  on  rapidly.  In  Walter's  successful 
cases  the  operation  of  laparotomy  was  performed  ten  hours  after  the  extrava.sation  ;  in 
Willet's  and  Heath's,  unsuccessful,  thirty  and  forty-two  hours  respectively. 

•'  The  records,"  writes  Rivington,  "  appear  strongly  to  indicate  the  necessity  of  bold 
action.  The  chances  of  recovery  entirely  hinge  upon  the  promptitude  of  the  surgeon 
adopting  efficient  measiires.  In  doubtful  cases  an  exploration  with  the  finger  through  a 
perineal  incision  would  be  perfectly  justifiable  and  could  .scarcely  introduce  any  fresh 
element  of  danger.  If  the  diagnosis  of  intra-peritoneal  rent  be  clear  at  the  outset,  the 
urine  cannot  too  soon  be  evacuated  by  a  supra-pubic  incision  and  the  peritoneal  cavity 
carefully  clean.sed.  At  the  same  time,  a  perineal  opening  may  be  made  with  advantage. 
I  am  disposed  to  think  sewing  up  the  rent  in  the  bladder  unnecessary,  provided  a  free 
perineal  exit  V;e  secured  for  all  urine  secreted  after  laparotomy." 

The  only  general  treatment  should  be  the  admini.stration  of  opium,  a  grain  of  the 
solid  or  its  equivalent  of  liquid  being  given  every  four  or  six  hours,  to  allay  pain  and 
relieve  peristalsis. 

Food  of  a  simple  character  should  be  given  all  through. 

Injury  to  the  uterus,  when  large  from  pregnancy,  deserves  a  passing  notice,  for 
such  cases  are  serious.  A  contused  organ  may  inflame  and  be  followed  by  abortion  or 
miscarriage,  or,  should  pregnancy  continue,  its  .structure  may  be  so  altered  as  to  be  liable 
to  rupture.  In  obstetric  works  cases  ase  recorded  in  which  this  accident  happened.  I  have 
known  also  an  intra-uterine  fracture  of  a  child's  thigh  to  take  place  as  a.consequence  of  a  fall. 


492  WOUNDS  OF  ABDOMEN. 

Rupture  of  an  ovarian  cyst  from  a  blow  is  also  recorded,  and  under  certain 
circumstances  a  good  result  may  take  place ;  all  obstetricians  have  met  with  such  cases. 
The  removal  of  the  ruptured  cyst  is  probably  the  best  practice  to  be  followed,  since,  if 
left,  a  fatal  peritonitis  irenerally  follows. 

Rupture  of  the  diaphragm  occurs  in  practice,  but  it  is  an  accident  difficult  to 
diagnose.  It  is  generally  the  consequence  of  some  violent  injury,  such  as  a  crush  or  the 
passage  of  a  heavy  wheel  over  the  waist.  In  such  cases  the  injury  is  complicated,  and 
usually  with  hernia  of  the  abdominal  contents  into  the  thorax.  This  injury  can  occur 
only  on  the  left  side.  Dr.  Wilks,  in  the  Lancf^t  for  1858,  reported  three  instances  of  this 
diaphragmatic  hernia,  and  pointed  out  that  fxcesdve  thirst  was  the  most  prominent  symp- 
tom in  each.  I  had  the  opportunity  of  seeing  these  three  cases,  and  others  since  have 
come  under  my  notice  in  which  this  symptom  of  insatiable  thirst  was  most  characteristic. 

Wounds  of  the  Abdomen  involving  Parietes  and  Viscera. 

The  parietes  of  the  abdomen  are  often  wounded  by  sharp  substances,  whether  by 
accident  or  design ;  and  so  long  as  the  wounds  are  confined  to  the  parietes,  the  danger  is 
small.  When  the  peritoneum  is  punctured  or  perforated,  the  viscera  are  also  probably 
involved  :  and  under  such  circumstances  th(5  case  becomes  serious.  In  rarer  instances  the 
intestines  protrude,  when  an  additional  element  of  danger  is  added. 

Wounds  of  the  parietes  alone  rerj^nre  the  same  treatment  as  wounds  of  any 
other  part.  The  surface  should  be  well  cleansed  and  ;J1  foreign  bodies  removed.  Hem- 
orrhage should  be  arrested  by  torsion  or  ligature  and  the  edges  of  the  wound  brought 
together  with  sutures.  In  deep  or  lacerated  wounds,  where  the  muscles  are  involved  and 
the  risk  of  suppuration  great,  absolute  rest  in  the  horizontal  position  should  be  enjoined. 
When  suppuration  appears,  the  surgeon  must  be  careful  to  let  out  all  fluid,  either  by 
reopening  the  wound  or  by  a  fresh  opening.  All  punctured  icounds  should  be  left  open; 
when  bleeding  persists,  the  wound  should  be  enlarged  and  the  vessel  secured. 

Penetrating  Wounds  of  the  Parietes. — There  is  always  a  difficulty  in  diag- 
nosing these  cases — that  is.  in  making  out  the  true  nature  of  the  accident,  more  particu- 
larly in  punctured  wounds.  When  the  depth  of  the  wound  is  known  by  the  extent  of 
insertion  of  the  offending  body  and  the  relative  position  of  the  viscera  at  the  wounded 
spot  also,  some  notion  as  to  its  nature  may  be  formed ;  but  when  no  such  guides  can  be 
found,  the  surgeon  has  to  rest  upon  surmise  and  probabilities.  As  a  rule,  where  want  of 
evidence  is  felt,  it  is  well  to  treat  the  case  as  serious.  All  penetrating  wounds  are  serious, 
whether  incised,  lacerated,  punctured,  or  gunshot :  but  punctured  wounds  are  bv  far  the 
most  common. 

When  there  is  a  total  absence  of  all  symptoms  be3'ond  those  of  the  parietal  wound, 
the  viscera  are  probably  uninjured,  these  neyntire  si/mptoms  wffording  the  Lest  positire  evi- 
dence of  the  simple  nature  of  the  accident.  When  the  viscera  are  injured,  there  will  gen- 
erally be  more  or  less  lasting  s^'ncope  or  collapse ;  there  will  probably  be  severe  local 
pain,  soon  becoming  radiating;  there  will  also  frequently  be  vomiting,  possibly  of  blood, 
or  the  passing  of  blood  from  the  bowel  or  bladder.  If  life  is  prolonged,  there  will  be 
peritonitis.  When  the  bowel  or  omentum  protrudes,  when  the  feces,  bile,  urine,  or  blood 
appear  at  the  wound,  the  evidence  is  clear.  The  surgeon,  however,  will  find  much  help 
from  collateral  evidence  in  forming  an  opinion — as,  for  instance,  in  the  size  of  the  wound 
compared  with  the  instrument  that  inflicted  it,  the  position  of  the  blood-stain  on  the  instru- 
ment, the  force  with  whieli  the  blow  was  struck,  the  direction  of  the  force  in  relation  to 
the  position  of  the  patient,  and  the  thickness  of  the  abdominal  parietes.  By  these  several 
means  an  approximate  opinion  may  be  formed,  but  in  no  case  can  a  positive  diagnosis  be 
made  with  certainty. 

Under  all  circumstances,  however,  the  tre.a.t.me.\t  must  be  the  same.  Absolute  rest 
in  the  horizontal  posture,  with  the  legs  flexed  to  relax  the  abdominal  muscles,  is  essen- 
tial ;  no  movement  should  be  allowed,  not  even  for  passing  the  evacuations.  With  respect 
to  LOC.^L  TRE.\TMEXT.  the  greatest  simplicity  should  be  employed.  The  wound  should  be 
cleansed  and  all  bleeding  vessels  secured,  but  anything  like  an  exploration  of  the  wound 
is  to  be  condemned.  All  probing,  fingering,  or  manipuJating  the  wound  should  be  avoided 
as  dangerous  and  only  pertaining  to  surgical  curiosity.  The  edges  of  the  wound,  when 
it  is  large,  .should  be  brought  together  by  sutures  and  some  simple  antiseptic  dressings 
applied,  with  cold  by  the  metallic  coil.  Punctured  wounds,  when  perforating,  like  others, 
should  be  left  open.  Even  after  the  lapse  of  .some  days,  when  no  symptoms  of  wounded 
viscera  appear,  the  same  caution   should  be  observed,  two  or  three  weeks  being  ahvnys 


i\.n'i:ii:s  m  riii:  Aiu>nMh\\. 


493 


allowed  before   frcfiloin  i>  u'ivfii.      I'lKltT  ;ill  circunistaiiccs   the  cori<liti<jfi  of  the  />/<i</<l^r 
slioiilil   lie   iiHUiireil   into. 

Onliiiii  ill  iiioderate  or  full  doses,  accordiiijr  to  cireuinstances,  is  demanded,  to  keep  the 
bowels  i|uiet  and  check  peristalsis,  it  beiiiir  well  to  keep  a  patient  under  its  influence  for 
several  days  by  irivin<.'  oik;  f^rain  every  four  or  six  hours.  Lov  diet — that  is.  milk  iliet — 
•should  be  allowed,  all  food  bein-,'  <j:iven  cold  and  in  small  nuantities  ;  iee  to  suck  is  refre.sh- 
inir.      J'lin/iifirrs  shoiihl  on  no  account  be  ixiveii  till  the  nature  of  the  ca.se  i.s  declared. 


Penetrating  Wounds  with  Protruding  Viscera. 

It  is  hardly  neces.sary  to  remark  that  the  special  risk  of  any  of  these  cases  is  deter- 
mined jrreatly  by  the  viscus  that  is  involved  and  the  amount  of  injury  it  has  .sustained. 
Thus,  a  penetratinir  abdominal  wound  with  protrudin-r  omentum  is  far  less  dangerous  than 
when  hernia  of  the  intestines  ex- 


ists, and  a  protrmliii":  wounded 
bowel  is  of  irraver  importance 
than  an  uninjured  one.  It  is 
consef[uently  necessary  for  the 
surgeon  in  all  these  cases  men- 
tally to  run  over  the  position  of 
the  viscera,  in  order  that  he  may 
form  an  opinion  as  to  the  prob- 
abilities of  the  case.  Fig.  281 
will  refresh  his  memory  on  the.se 
points. 

'•Of  the  hollow  viscera  any 
portion  of  the  intestinal  canal 
may  be  protruded,  from  the 
stomach  to  the  sigmoid  flexure, 
according  to  the  situation  and 
degree  of  distension  of  the  vis- 
cera, the  small  intestines  most 
frequently,  next  tJie  large,  then  n.^itineu 
the     stomach,    and,    lastly,    the     ^,  ,.,. 

_.  „  '    ,  1-1     -  •  Lmbuicus 

caecum.  Of  the  solid  viscera 
the  omentum  is  by  far  the  rao.st 
common,  and  is  often  associated 
with  that  of  the  viscera"  (Po- 
land's prize  essay). 

In  Amall  wounds  a  limited 
hernia  of  the  abdominal  con- 
tents can  alone  take  place ;  but 
when  it  occurs,  the  protruded 
viscus  is  very  liable  to  be  stran- 
gulated. In  hirrjp  wounds  the 
hernia  will  probably  be  of  great- 
er extent,  but  their  constriction 
is  rare. 


Fig. 281. 


Diagram  showing  the  Positions  of  the  Abdominal  Viscera. 


When  the  omentum  protrudes  through  a  recent  wound,  and  uninjured,  it  .should 
be  washed  by  means  of  a  stream  of  antiseptic  water  and  returned  with  all  gentleness,  the 
patient  being  placed  in  such  a  position  as  to  relax  the  injured  muscles.  The  wound  should 
never  be  enlarged  to  allow  of  the  return  of  the  omentum.  When  the  omentum  has  been 
extruding  for  some  time  and  is  congested  from  incarceration  or  strangulation,  when  it  has 
become  inflamed,  or  perhaps  sloughing,  it  is  well  not  to  make  any  attempt  at  its  reduction. 
As  time  goes  on  and  the  projecting  mass  swells  and  granulates  it  may  be  ligatured  in 
halves.  This  should  not  be  "done,  however,  for  at  least  two  weeks  after  its  protru.sion. 
During  this  time  the  greatest  (juiet  -should  be  enforced  and  moderate  doses  of  opium  given 
with  li(|uid  food.  After  a  few  days  all  fear  of  peritonitis  will  have  passed.  Some  prefer 
not  to  interfere  with  the  ])rotrusio'n.  in  the  belief  that  it  will  wither  up  sooner  or  later,  but 
such  a  process  is  tedious;  the  application  of  a  ligature  to  it  in  halves  is,  moreover,  rarely 
attended  with  any  risk.  If  the  omentum  is  much  bruLsed  or  torn  at  the  time  of  injury, 
such  injured  portions  may  be  cut  off  and  all  divided  vessels  secured. 


494 


INJURIES  TO   THE  ABDOMEN. 


When  the  bowel  protrudes  throujih  the  Wdnml  and  is  itiiiiijurid.  it  sliDuld  be 
cleansed  and  returned  under  all  circnmstdncfs.  the  wound  being  carefully  enlarged  for  the 
purpose  in  the  course  of  the  muscular  fibres  should  its  reduction  be  otherwise  impossible. 
To  facilitate  this  the  muscle  should  be  relaxed  and  the  parts  last  descended  returned  first. 
In  returning  the  intestine  the  pressure  should  be  directly  backward  :  if  made  obliquely, 
the  bowel  might  be  pushed  up  beneath  the  fascia  or  muscles,  and  thus  outside  the  peri- 
toneum.     The  wound  should  be  closed  by  sutures  and  treated  as  already  described. 

When  the  protruded  bowel  is  gangrenovs.  it  must  be  left  in  situ  to  slough  and  that  an 
artificial  anus  may  form,  the  wound  in  the  abdominal  parietes  being  enlarged,  but  where 
there  is  any  prospect  of  its  recovery  the  abdominal  cavity  is  its  best  place. 

When  the  intestine  is  "wounded  and  the  opening  a  mere  prick  tlirough  which 
no  intestinal  contents  exude,  the  bowel  may  be  returned,  a  few  hours  being  enough  for 
the  wounded  part  to   become  sealed  by  plastic  exudation  and  repair  to  be  completed. 


Fig.  282. 


Fig.  283. 

Sut'uns  l,'ir(iut/]i  srrou!  ront 


ires  Cliroutih 
Jnueous  coat 


Fig.  282. — Lembert's  Suture,  including  Peritoneal  Coat  alone. 

Fig.  283. — Double  Suture.     1.  Of  mucous  and  muscular  coats.     2.  Of  serous,  as  in  Lerabert's.     (In  distal  side  of  bowel 
the  serous  suture  should  precede  the  niiicuus;  in  proximal,  the  mucous  suture  should  be  applied  first.) 

When  the  mucous  lining  protrudes,  the  opening  should  be  tied  by  a  single  fine  ligature. 
W^hen  the  wound  is  suflBciently  large  to  permit  of  the  escape  of  the  visceral  conitnts^  it 
must  be  stitched  up  with  the  form  of  suture  seen  in  Fig.  282  or  283,  cleaned,  and 
returned,  the  ends  of  the  sutures  being  cut  ofl'  close. 

When  the  wound  involves  nearft/  the  whole  calibre  (f  the  Imu-d  and  the  bowel  is  much 
bruised  or  injured,  it  is  wiser  to  stitch  the  edges  of  the  bowel  to  those  of  the  wound, 
thereby  making  an  artificial  anus,  than  to  stitch  the  two  divided  ends  of  the  intestine 
together,  and  to  return  the  whole  into  the  abdominal  cavity,  although,  says  Pollock,  if 
the  division  be  caused  by  a  clean  sharp  instrument,  the  extremities  may  be  brought 
together  by  sutures  and  returned  ;  but  if  the  separation  be  the  result  of  an  irregular  lace- 
rated wound,  as  from  gunshot,  etc.,  we  should  not  hesitate  to  fix  the  edges  to  the  exter- 
nal wound  and  risk  the  chance  of  an  artificial  anus.  When  the  bowel  is  stitched  to  the 
edges  of  the  external  wound,  care  should  be  taken  to  maintain  the  line  of  the  canal  as 
much  as  possible,  and  not  to  draw  the  intestine  more  out  of  its  position  than  is  absolutely 
necessary. 

The  general  and  local  treatment  of  all  these  cases  is  similar  to  that  already  laid  down 
for  the  treatment  of  other  abdominal  and  visceral  injuries. 

Penetrating  abdominal  wounds  complicated  with  wounds  of  the 

viscera,  but  without  protrusion,  are,  doubtless,  far  more  serious  than  any  that 
have  been  hitherto  considered  ;  and  tlieir  eflfects  depend  greatly  on  the  condition  of  the 
viscus  when  wounded.  Thus,  the  puncture  of  a  distended  stomach,  intestine,  or  bladder 
will  to  a  certainty  be  followed  by  extravasation  into  the  abdominal  cavity,  and,  as  a 
result,  by  great  shock  and  diff'use  peritonitis  :  whereas  these  organs,  when  empty,  and 
therefore  contracted,  may  receive  a  limited  injury  without  any  such  consequences  taking 
place,  local  inflammation  rapidly  arising  under  these  circumstances  and  sealing  the 
wound. 

The  chief  risks  of  wounds  of  the  viscera  when  the  solid  organs  become  implicated 
are  hemorrhage  ;  and  when  the  hollow,  extravasation.  When  the  contents  of  the  wounded 
organ  escape  externally  through  the  wound,  the  danger  of  the  case  is  undoubtedly  less- 
ened. When  the  stomach  is  supposed  to  be  wounded  by  a  puncture,  the  utmost  care  is  called 
for  to  prevent  the  administration  of  any  food;  indeed,  nothing  should  enter  the  stomach 
for  several  days,  and  life  should  be  maintained  by  nutrient  enemata,  because  to  excite 
any  action  of  the  organ  would  undo  what  nature  may  have  done  for  the  repair  of  the 
injury,  and  thus  jeopardize  life  by  increasing  the  risk  of  extravasation.  When  the  intes- 
tine is  wounded  or  suspected  to  have  been  wounded,  the  .same  care  is  necessary.  When 
the  bladder  is  wounded,  it  should  be  drained  by  lateral  cystotomy. 


ABSOiiMAi.  .wrs,  I'ly.iL  Fisrri.A.  4H5 

(J/n'iini  slidiihl  l»('  jiivcii,  aii<l  is  lu-st  :Mliiiiiii.>-t«T»<l  l»v  Mi|«|n)>it(irics.  tlu-  iiiorphia  sup- 
positories of  tin*  IMi:iriiia(n|iu'ia  ht-iiiL"^  tin-  licst  |irfparati<iii  to  ciiiiiloy  in  all  casi-s  of  altdom- 
inal  surirtTy.  Tin-  priiiciplfs  of  tri-aliunit.  liowi'Vcr,  art-  tlu-  saiiii;  as  liavi-  Id-t-ii  laid 
down  ill  former  pa<.'t's.  In  marked  peiietratin<r  woumls  of  tlie  alxlonieii  in  wliieli  evidence 
of  a  wounded  liollow  viseus  exists,  the  /not/  irouml,  as  ^ein-raily  advisi-d.  slmnlil  !,<■  It  ft 
njHiis  or  covered  only  with  a  loose  eovi-riiiL' ;  for  to  elose  the  wound  so  as  to  prevent  tlie 
eseape  of  the  eoiiteiits  of  the  wounded  viseus  externally  wouhl  he  to  elose  the  only  ;rate 
throuLrh  which  return  to  health  i>  possilile.  1  am.  however,  disposed  to  think  that  the 
wisest  course  would  he  to  enlar;:e  the  wound  or  reopen  the  ahdoininal  cavity,  search  for 
the  wounded  vi.scus.  and  sew  uji  the  opeiiiiifr  in  it.  suhse«juently  cleansinj:  tlie  alxhtniina! 
cavity  and  dealin<r  with  the  case  as  described  in  a  former  jtajre,  the  chances  of  a  jrood 
result  heiiiL'  I'ar  u'reater  by  this  practice  under  the  circumstances  than  they  can  by  any  other. 

Heniarkable  eas«-s  of  recovery  after  iDi]ialemeiit  are  on  record,  and  not  the  least  is  that 
of  a  boy  ;et.  11  who  fell  upon  a  rick  stake,  the  stake  penetrating'  his  body  for  seventeen 
and  a  hall"  inches.  Tt  entered  the  abdominal  cavity  in  the  n't//i/  ^^roin.  beneath  I'ou]>art's 
ligament,  passed  thr<iui:h  it  to  the  left  side  into  the  thorax,  through  the  diaphragm — dis- 
placing tlie  heart  and  pushing  it  to  tlie  right  side  of  the  sternum — into  the  left  lung.  an<l 
passed  out  of  the  chest,  between  the  seventh  and  eighth  ribs,  into  tli.e  axillary  space. 
Tlie  stake  was  removed  four  hours  after  its  introduction,  and  not  a  teaspoonful  r)f  blood 
was  lost.  Some  intestine  which  jirotruded  from  the  wound  in  the  groin  was  replaced  and 
the  inguinal  wound  stitched  up.  Opium,  with  calomel,  was  freely  given  subse(|uently. 
and  in  six  weeks  the  boy  was  able  to  sit  up.  {day,  and  eat  his  ordinary  food.  F'ive  months 
after  the  accident  he  was  free  from  pain  and  able  to  walk  freely.  The  case  occurred  in 
the  practice  of  Mr.  Reynolds  of  Thame.  Oxon,  and  is  recorded  in  the  M'd.  Times  and 
Gaz.,  September  23,  1871. 

Abnormal  Anus,  Fecal  Fistula. 

Confining  the  term  urtijicioJ  mm^  to  the  surgical  operation  of  forming  an  anus  other- 
wise than  natural  for  the  relief  of  intestinal  obstruction,  whether  by  colotomy  or  enter- 
otomy.  and  nbii'>nnal  anus,  or  intestinal  fistula — -fical  fistnhi — or  an  unnatural  communi- 
cation between  the  intestinal  canal  and  the  outside  of  the  body,  is  generally  the  result  of 
sloughing  or  iilcerating  bowel  in  strangulated  hernia,  although  it  may  occur  either  from  a 
wound  to  the  intestine  from  some  external  cause,  or  from  a  perforation  of  the  intestine 
from  an  ulcerating  process  originating  from  within. 

When  it  follows  a  hernia,  the  opening  is  usually  at  the  neck  of  the  hernial  sac ;  when 
it  follows  a  wound,  at  the  seat  of  injury  ;  when  it  is  the  result  of  some  ulcerative  process 
originating  from  within,  the  fecal  abscess  may  burrow  into  the  pelvis  (opening  into  the 
vagina,  bladder,  or  even  bowel  again),  or  between  the  abdominal  muscles,  and  make  its 
appearance  in  the  groin,  iliac  fossa,  or  loin.  When  the  opening  is  large  and  direct  into 
the  bowel,  it  has  been  called  "artificial  anus;'  when  small,  indirect,  or  fistulous,  "fecal 
or  intestinal  fistula." 

The  most  important  point,  however,  connected  with  this  subject  has  reference  to  the 
amount  of  intestine  involved.  When  only  a  small  ]iortion  of  its  calibre  has  been  lost, 
the  fistula  generally  will  be  small  :  when  a  large  portion  of  its  calibre  or  a  whole  knuckle 
has  been  involved,  the  fecal  orifice  will  be  large.  Tender  the.se  circumstances,  the  two 
orifices  communicating  with  the  upper  and  lower  ends  of  the  bowel  respectively  can  gen- 
eralh'  be  made  out,  a  fold  of  membrane  ffirmed  by  the  junction  of  the  h>ent  tube  stand- 
ing as  a  partition  between  the  two  portions  of  the  gut.  At  times  this  partition  will  pro- 
ject so  far  forward  as  to  close  completely  the  orifice  of  the  lower  part  of  the  bowel,  and 
this  is  the  usual  state  of  affairs  when  a  complete  knuckle  of  bowel  has  been  involved  in 
the  disease  and  under  these  circum.stances  a  cure  by  natural  processes  is  almost  impossiVjle. 
At  other  times  the  partition  will  be  but  limited  and  a  portion  only  of  the  contents  of  the 
bowel  will  pass  externally,  the  other  jiortion  taking  its  normal  course  downward  toward 
the  anus,  when  it  is  more  than  probable  that  nature  alone  or  but  slightly  assisted  by  art 
will  effect  a  cure.  When  the  orifice  is  large,  there  is  almost  always  some  prolap.se  of  the 
bowel.  Under  all  these  conditions  the  intestines  within  the  abdomen  are  closely  connected 
by  means  of  adhesions  to  the  external  orifice,  the  serous  surface  of  the  intestine  becom- 
ing firmly  fixed  to  that  of  the  opening  in  the  abdominal  parietes.  Beyond  these  adhesions 
it  is  rare  to  find  other  coils  of  intestine  adherent  about  the  part :  on  the  contrary,  the 
parts  are  otherwise  usually  so  free  that  coils  of  bowel  will  be  found  separating  the  two 
portions  of  intestine  that  are  adherent  at  the  wound,  and  may  so  dip  down  between  them 


496  ABNORMAL  ANUS,   FECAL   FISTULA. 

as  to  push  forward  a  serous  sac  into  the  artificial  opening,  and  even  to  form  a  hernia.  The 
nature  of  the  discharging  fluid  will  fairly  indicate  the  portion  of  the  bowel  involved  : 
when  well-formed  feces  pass,  the  large  or  lower  part  of  the  small  intestine  is  probably  the 
seat ;  when  the  fluid  is  thin  and  inoflPensive,  the  jejunum  is  indicated. 

Prognosis. — The  yellow  semi-feculent  contents  of  the  ileum  can  generally  be  recog- 
nized. The  nearer  the  opening  is  to  the  stomach,  the  worse  is  the  prognosis,  as  nutrition 
under  such  circumstances  must  be  seriously  interfered  with.  The  nearer  it  is  to  the  lower 
end  of  the  canal,  the  better  are  the  prospects  of  life. 

Treatment. — When  the  orifice  is  fistulous  and  the  canal  below  the  fistula  is  fairly 
open  for  the  passage  of  feces  a  cure  may  with  some  certainty  be  looked  for  by  natural 
processes ;  and  such  a  result  is  by  no  means  unusual  in  the  artificial  anus,  which  is  met 
with  after  the  return  of  a  small  hernia  into  the  abdomen,  and  particularly  of  a  femoral 
hernia.  In  these  cases  the  surgeon  has  little  more  to  do  than  to  keep  up  the  strength, 
give  simple  nutritious  diet,  maintain  perfect  cleanliness  of  the  wound,  and  ap])ly  gentle 
pressure  to  the  part.  When  the  fistulous  communication  is  larger,  the  san)e  treatment 
must  be  employed,  though  with  less  hope  of  success.  Lawrence  recommended  the  con- 
stant use  of  a  truss  in  these  cases  to  prevent  jirolapsus,  and  Pollock  strongly  advocates 
the  importance  of  the  recommendation,  adding  that  "a  compress  of  linen  placed  on  the 
opening,  with  a  larger  pad  over  it,  and  a  truss  applied  over  the  whole,  will  in  a  great 
measure  restrain  the  contents  as  well  as  prevent  the  protrusion  of  the  bowel."  To  assist 
the  contraction  of  small  fistulas  the  edges  may  be  cauterized,  or  even  ])ared,  a  plastic  ope- 
ration being  justifiable  under  certain  circumstances. 

With  respect  to  surgical  interference  in  these  cases,  the  recommendations  I  have  to 
offer  are  not  very  satisfactory.  Dupuytren '  suggested  an  operation  to  get  rid  of  the  pro- 
jecting fold  or  septum  that  has  been  described.  He  did  this  by  an  instrument  called  an 
enterotome.  a  pair  of  forceps  with  one  blade  grooved,  into  which  the  other  closed,  the 
approximation  of  the  blades  being  regulated  by  a  screw.  The  septum  was  crushed 
between  the  blades,  and  so  held  till  its  destruction  was  effected.  The  instrument,  as  a 
rule,  came  away  about  the  seventh  day,  and,  Dupuytren  says,  "  by  the  division  and  loss 
of  substance  the  ridge  and  the  double  septum  which  separate  the  two  ends  of  the  bowel 
are  destroyed,  so  as  to  re-establish  the  interrupted  communication  between  them  and 
restore  the  natural  course  of  the  aliment  and  feces."  Jobert  advises  the  pressure  of  the 
instrument  to  be  gradual,  fatal  cases  having  occurred  when  Dupuytren's  rapid  process 
has  been  employed.  The  theory  of  this  operation  is  good,  and  is  based  on  nature's  own 
processes ;  for  I  have  seen  the  septum  of  an  artificial  anus  ulcerated  through  by  natural 
processes,  leaving  an  opening  through  which  feces  passed  from  the  upper  to  the  lower 
bowel,  a  narrow  band  above  alone  existing  to  prevent  a  freer  feculent  flow.  The  success 
of  the  operation  has  also  been  good,  inasmuch  as  out  of  forty-one  operations  recorded  by 
Dupuytren  twenty-nine  recovered,  nine  were  relieved,  and  three  died.  In  this  country 
the  operation  has  been  little  practised.  Dr.  Buchanan  of  Glasgow,  however,  has  recorded 
a  successful  case  (Edin.  Med.  Jonm.,  18G9). 

When  a  fee(d  ahsce.^tti  has  formed  in  the  abdominal  walls,  the  .sooner  it  is  opened,  the 
better;  and  when  opened,  the  incision  should  be  free.  In  abscesses  connected  with  the 
csecum  or  its  appendage  this  rule  is  important ;  and  if  acted  upon,  good  results  may  be 
anticipated.  For  intestinal  fistula  opening  directly  into  the  vagina  little  can  be  done 
surgically  beyond  attending  to  the  general  condition  of  the  patient,  giving  nutritious 
food,  though  not  such  as  is  likely  to  distend  the  bowel,  and  observing  perfect  cleanliness 
of  the  passage.  The  external  opening  should  be  enlarged,  however,  if  anything  like 
retained  pus  exist.  Under  these  circumstances  a  natural  recovery  may  take  place.  In 
recto-vaginal  fistula  plastic  operations  are  most  successful. 

When  the  horvel  has  ulcerated  into  the  bladder,  natural  processes  appear  to  be  rarely 
capable  of  effecting  a  cure  ;  and  under  such  circumstances,  to  save  the  patient  from  the 
miseries  caused  by  the  passage  of  solid  feces  into  the  bladder,  the  operation  of  colotomy 
may  be  entertained.  I  have  performed  this  operation  on  many  occasions  under  these 
circumstances  with  success,  the  operation  in  all  giving  great  relief.  One  of  my  patients 
is  now  (1884)  alive,  free  from  all  pain,  the  operation  having  been  performed  on  July  5, 
1870  (Clin.  Soc.,  1872).  In  another  case,  operated  upon  on  August  16,  1869,  the  gentle- 
man lived  to  March,  1875,  and  died  from  heart  disease  at  the  age  of  seventy.  The  third 
died  from  some  kidney  affection  some  months  after  the  operation  (Med.-CJiir.  Rev.,  1869). 
The  others  died  some  weeks  after,  from  the  cancerous  affection  for  which  the  operation 
was  demanded,  but  free  from  all  pain. 

•     1  Mem.  de  I' Acad,  de  Med.,  1828. 


FORKicy  nonncs  /.v  thk  stomach  ash  istestises. 


497 


Foreign  Bodies  in  the  Stomach  and  Intestines. 

Forei{j;n  bodies  are  ofti'ii  tukcii  intutlic  stoiiiach  fnjin  accid(;iit  and  design,  and  the 
roeords  of  casi's  ])rove  that  tVoin  the  ahst'iite  or  niihiness  of  syn)|)toins  no  surgeon  should 
pronounce  against  the  |)ossil)ility  of  their  introduction.  They  are  ]»assed  as  often  as  not 
P'l- miitiii  witliout  giving  rise  to  very  distressing  symptoms,  although  when  retained  they 
cause  nothing  hut  evil.  Snntut/i  /innf  f/oi/iis,  such  as  e<»ins  and  stones,  as  a  rule,  pa.s.s 
readily  without  giving  rise  to  any,  or  other  than  slight  colicky,  symptoms  ;  hut  shurj)  and 
piiiiiftt/  IdhHos,  such  as  hones,  jiins.  knives,  metallic  plates  with  teeth.  (;tc.,  give  rise  to 
such  as  vary  according  to  the  position  of  the  intestines  at  which   they  hecome  impacted. 

A  foreign  hody  taken  into  the  stomach  may  be  ejected  by  vomiting,  discharged  exter- 
nally through  the  abdominal  parietes.  retained  in  the  stomach,  or  passed  onward.  In 
Fig.  284  is  illustrated  a  piece  of  inm  wire  that  was  swallowed  by  a  female  lunatic  a3t.  50 

Fig.  284. 


Fig.  285. 


Piece  of  Iron  Wire  l)iscliai>,'ed  I'i-diii  .\l)scess  in  Alidoniinul  Wiills  after  having  been  Swallowed.    (Natural  size.) 

on  March  10,  IST^^.  The  .symptoms  that  followed  were  .so  slight  that  some  dou})ts  as  to 
the  occurrence  existed,  and  it  was  not  till  May  lo.  two  months  later,  when  a  swelling  wa.s 
detected  in  the  right  of  the  umbilicus,  that  the  history  was  credited.  The  swelling  rap- 
idly increased,  and  opened  on  ^Nlay  20,  and  the  point  of  the  iron  wire  projected.  This 
was  withdrawn  by  Dr.  T.  B.  Dyer,  the  surgeon  of  ("olney  Hatch,  and  a  rajiid  recovery 
followed,  no  single  bad  .symptom  making  its  appearance.  My  friend  Mr.  Lund  of  Man- 
chester has  likewise  recorded  a  similar  case  in  the  Liiy>ipool  and  MoncliPister  Mpd.-Snrg. 
Reports  for  1873.  When  retained,  a  foreign  body  may  re.st  without  giving  rise  to  very 
serious  symptoms — a  rare  result — or  set  up  ulceration,  which  may  in  its  turn  give  rise  to 
a  fatal  peritonitis.  In  the  more  fortunate  it  will  be  passed  on  through  the  canal  and 
discharged. 

To  prove  these  points  I  may  record  the  case  of  a  man  aet.  22  who  came  under  1113-  care 
in   1882,  two  days  after  having  swallowed,  in  the  night,  an   artificial   metal  plate,  two 

inches  long  by  one  wide,  with  three  incisor  teeth, 
and  metal  hooks  to  catch  the  right  two  and  left 
first  bicuspid  teeth  (Fig.  285).  He  passed  the 
plate  per  (tnnrn  without  pain,  on  the  eighth  day, 
and  restored  it  to  its  original  position,  and  was  no 
way  injured  by  its  passage.  The  reader  may  also 
refer  to  Mr.  Pollock's  article  in  Holmes's  Si/sfem, 
vol.  i..  where  he  gives  a  ca.se  in  which  a  lady  vom- 
ited a  gold  plate  three-quarters  of  an  inch  long, 
with  two  false  teeth,  after  it  had  been  lodged  in 
the  oesophagus  for  nineteen  and  in  the  stomach  for 
ninety-.seven  days.  A  case  is  likewise  on  record 
in  which  a  lady  passed/)^;-  amim  a  plate  two  and 
fi  quarter  inches  in  diameter,  with  four  teeth,  six  months  after  she  had  swallowed  it. 

A  remarkable  case  of  this  kind  has  been  recently  recorded  in  the  Tln'rtieth  Reiv.rt  of 
(lie  Commissioners  in  Liinoq/,  1876.  A  woman  <\?t.  43  (having  made  previou.slv  many 
suicidal  attempts)  on  July  31,  1875,  swallowed  thirteen  screws,  each  .screw  consisting  of 
a  body  two  and  a  half  inches  long  and  half  an  inch  thick,  a  raised  collar  nearly  two- 
thirds  of  an  inch  in  diameter,  and  a  s(|uare  head,  the  whole  thirteen  screws  weighing 
twenty-four  ounces.  She  was  fed  on  pudding  and  gruel,  morphia  was  injected  subcuta- 
neously  to  relieve  pain,  and  after  a  few  days  ounce  doses  of  castor  oil  were  given  daily. 
On  the  forty-first  day  the  first  of  the  screws  passed  by  the  bowel,  and  by  the  end  of  the 
sixth  month  the  last  came  away.  The  screws  in  their  pas.sage  had  lost  four  ounces  and 
three-quarters  in  weight.  This  case  occurred  in  the  Bristol  Asylum  under  the-  care  of 
.Or.  Thompson.  Poland  has  also  recorded  in  his  prize  essay  the  case  of  a  lunatic  who 
died  from  ulceration  of  the  duodenum  owing  to  the  pressure  of  a  spoon-handle  that  had 
been  swallowed  about  three  months  before,  with  fhirti/  others,  besides  nails,  pebbles,  and 
pieces  of  iron.  These  foreign  bodies  were  extracted  from  the  stomach  after  death,  and 
weighed  in  all  forty  ounces.     The  most  complete  list  of  cases  of  foreign  boilies  in   the 


Plate  with  Ted 


on  Eiuhth 


498  GASTROTOMY  AXD   GASTROSTOMY. 

digestive  canal  will  be  fouml  in  tlie  L'nion  Mi'dlcah  for  November.  1874,  b}-  Dr. 
Mignon. 

In  Guy"?-  Museum  (Prep.  1800)  there  is  an  enlarged  and  thickened  stomach  of  a  sailor 
who  had  swallowed  clasp-knives.  He  was  net.  23,  and  in  June,  1799,  he  swallowed  four 
clasp-knives,  which  were  discharged  from  the  bowels.  In  March,  1805.  he  swallowed 
from  fifteen  to  twenty  more,  after  which  his  health  became  impaired.  He  vomited  the 
handle  of  one  and  passed  portions  of  the  blades  of  others,  and  in  ^larch,  1809,  died  in  a, 
state  of  exhaustion.  After  death  one  blade  was  found  perforating  the  colon  opposite  the 
kidneys,  but  without  extravasation  of  feces,  and  another  was  fixed  across  the  rectum.  In 
the  stomach,  too.  were  numerous  blades  partially  dissolved,  or  between  thirty  and  fnrty 
fragments  in  all. 

At  times  intestinal  calculi  form  from  the  agglomeration  of  hair,  husk — particularly 
oat-husks — or  other  foreign  substances,  and  prove  fatal.  Dr.  Down  has  recorded  such  a 
case'  in  a  boy  aet.  13  who  died  of  exhaustion  after  fifteen  days'  illness.  Not  many  years 
ago  I  saw  an  artist  a?t.  36  who  died  from  intestinal  obstruction,  through  whose  abdominal 
walls  a  globular  indurated  mass  was  readily  felt  on  the  right  of  the  umbilicus.  I  sus- 
pected it  to  be  made  up  of  hair,  for  he  was  in  the  habit  of  sucking  to  an  excess  the  paint- 
brushes of  his  pupils  ;  but  the  diagnosis  could  not  be  verified  after  death. 

Treatment. — Rest  in  the  horizontal  position  and  expectant  treatment  are  in  these 
cases  the  two  essential  points  to  be  observed.  Purgatives  should  on  no  account  be  given. 
The  "  smasher,"  according  to  Pollock,  who  con.stantly  swallows  false  coin  when  caught  in 
the  act  of  passing  it.  avoids  pvrgatiLes,  but  takes  a  constipating  diet,  such  as  hard-boiled 
eggs  and  cheese,  together  with  his  usual  food,  thinking  that  the  money  is  more  likely  to 
be  caught,  and  consequently  passed,  in  a  bulky  stool  than  in  a  liquid  one.  The  surgeon 
should  act  on  this  principle.  When  the  foreign  body  becomes  impacted  in  the  stomach 
or  intestine  or  sets  up  inflammator}'  action  and  peritonitis,  the  abdomen  should  be  opened 
and  the  foreign  body  removed  by  gdRtrdtomy.  ten  cases  out  of  eleven  in  which  this  opera- 
tion has  been  performed  having  recovered.  (  Vide  paper  by  Dr.  Pooley  of  Xew  York,  R'n li- 
mond  Med.  Jouni.,  April,  1875. J 

Gastrotomy  and  Gastrostomy. 

When  the  stomach  has  to  be  opened  for  the  removal  of  a  foreign  body,  the  operation 
is  rightly  described  as  that  of  '•  gastrotomy."  When  the  same  operation  is  performed 
•with  a  view  to  establish  a  permanent  fistula  for  the  introduction  of  food,  as  first  per- 
formed by  Sedillot  in  1849,  and  described  by  him  as  gastro-stomie.  the  term  "  gas- 
trostomy." as  suggested  by  Dr.  Poole}-,  seems  to  be  the  more  applicable  term. 

That  the  operation  of  gastrotomy  is  not  necessarily  fatal  is  proved  by  the  fact  that  it 
has  been  performed  at  least  eleven  times,  and  in  ten  with  success  ;  and  though  in  the  fifty 
or  sixty  cases  in  which  gastrostomij  has  been  undertaken  for  cancer  life  has  never  been 
prolonged  for  more  than  six  months  (my  own  case.  Lancet.  May  6.  1882).  the  relief  it 
has  afforded  to  those  who  have  been  subjected  to  it  is  sufiicient  to  prove  that  it  is  based 
upon  a  sound  principle  and  a  humane  practice,  the  operation  having  been  undertaken 
more  with  a  view  of  mitigating  the  horrors  of  a  death  from  hunger  and  thirst  and  of 
prolonging  what  remained  of  life  than  from  any  curative  object.  I  have  had  an  oppor- 
tunity of  watching  the  progress  of  some  of  the  early  cases  under  the  care  of  my  colleagues, 
Messrs.  Cooper  Forster  and  Durham,  of  many  under  my  own  care,  and  of  some  under  the 
care  of  other  colleagues,  and  I  am  free  to  acknowledire  that  the  advantages  given  by  the 
operation  are  worth  the  risk,  and  that  if  life  was  not  prolonged  it  was  certainly  rendered 
more  endurable. 

When  the  operation  is  performed  for  a  cicatricial  stricture,  better  results  may  be 
recorded;  for  out  of  eleven  cases  reported  eight  recovered.  The  interesting  cases  operated 
upon  at  Rostock  by  Dr.  Trendelenburg,  March  8,  1876  (Med.  Record.^  March,  1878),  in 
Paris  by  M.  Verneuil  {Gaz.  de.<  Hop..  October  28,  1876;  Lancet,  January  13,  1877),  and 
my  own  case  i  Lancet.  April  8.  1881)  support  this  view. 

Trendelenburg's  case  was  in  a  lad  who  had  swallowed  some  sulphuric  acid  six  months 
previously,  and  the  stricture  was  in  the  lower  end  of  the  gullet.  At  the  end  of  the  fifth 
month  after  the  operation  the  weight  of  the  boy's  body  had  increased  by  one-fourth.  The 
boy  took  food,  as  usual,  by  the  mouth,  masticated  it.  and  then  blew  the  contents  of  his 
mouth  through  a  long  elastic  tube  directly  from  the  mouth  into  the  cavity  of  the 
stomach. 

1  Path.  Trans.,  1867. 


tiASTRnroMY  AM)   CASTROSTOMV.  400 

\'i'riu'uil  .s  jiatitiit  was  a  iiiasdii  a-t.  17.  and  tlie  stricture  a  cicatricial  one  due  to  the 
accidental  swallowiii';  of  some  caustic  putasii  i»n  l''e))ruary  4,  iSTtl.  (Kso]dia^<itoinv  was 
out  of  the  (|U»'stiou,  as  the  stricture  was  situati'd  h»w  (hiwri  in  the  tiihc,  and  relief  was 
called  for  Itecause  Hwallowini::  was  inipossiMc.  <  )n  .lune  litJ  <;astrostoiny,  conse((uently, 
was  performed,  and  a  rapid  recovery  foilnwed.  The  man  was  up  and  about  on  Aujrust 
20.  A  caoutchtnie  .sound  was  kej)t  in  the  w<iund  for  feeding  purpo.ses.  In  the  report  of 
the  ca.se  it  is  stated  that  when  food  is  poured  into  the  stomach  the  oidy  sensati«»n  experi- 
enced is  that  of  heat  or  cold.  iSaliva,  however,  is  at  the  time  freely  .secreted,  and  the 
man  executt's  masticatory  movements.      l)i<;estion  goes  <jn  well  without  the  aid  of  saliva. 

.^ly  own  ease  was  a  girl  ivt.  'I'l  who  seven  months  before  her  admissirjn  into  (Juy's,  in 
July,  ISSO.  had  swallowed  a  wineglassful  of  sulphuric  acid.  The  ce.sophagus  was  almost 
co\npletely  closed,  and  no  Ixtugie  could  he  passed.  A  rapid  recovery  fulluwed  the  opera- 
tion, and  the  itpeniug  int(»  stomach  was  very  small.  The  jiatieiit  is  now  well,  but  unable 
to  swallow  anythiuir.  The  opening  into  the  stomach  is  hardly  visible  and  the  ]»arts 
around  it  are  (juite  dry.  She  can  feed  herself  when  standing  and  no  regurgitation  of 
food  or  fluid  takes  place. 

These  cases  are  most  satisfactory,  and  are  sufficient  to  encourage  the  belief  that  better 
success  wouhl  follow  this  operation,  even  when  undertaken  for  cancer,  if  it  were  per- 
forme<l  at  an  earlier  period  of  the  di.sease  than  has  hitherto  been  the  practice. 

We  perform  colotomy  on  a  patient  with  cancerous  stricture  of  the  intestine  or  other 
mechanical  obstruction  without  hesitation,  and  surgeons  are  now  willing  to  admit  the 
great  advantages  afforded  by  this  means.  Surely,  the  advantages  offered  by  '•  gastros- 
tomy '  for  stricture  of  the  oesophagus,  cancerous  or  otherwise,  are  not  less  potent;  and 
slioitll  it  /»'  iiiuhrfaken  he/ore  tlie  puti'mt^  poircrs  Ittivr,  breu  hronglit  to  too  low  un  ebh^  there 
is  no  reason  why  it  should  not  be  e((ually  effective.  In  one  of  my  own  ca.ses  performed 
for  cancer  the  man  lived  five  days,  and  the  operation  had  nothing  to  do  with  the  death, 
there  being  no  peritonitis,  and  the  local  repair  was  most  complete.  In  the  second  case 
the  patient  lived  two  days;  in  the  third,  tifty-one  days;  in  the  fourth,  six  months.  So 
also  was  colotomy  unsuccessful  till  it  was  undertaken  at  an  earlier  stage  of  the  disease. 
Gastrostomy,  as  a  rule,  has  been  put  off  until  too  late;  it  has,  however,  now  become  an 
established  operation  in  surgery. 

Operation. — An  anaesthetic  should  be  given,  although  the  risks  of  vomiting  as  a 
consequence  are  not  slight.  The  patient  .should  be  placed  upon  his  back  and  an  incision 
made  parallel  with  and  half  an  inch  below  the  margin  of  the  left  ribs.  The  cut  should 
be  from  three  to  four  inches  in  length,  and  its  centre  should  correspond  with  the  line  of 
the  linea  semilunaris ;  the  tissues  should  be  divided  seriatim  down  to  the  peritoneum. 
Every  vessel  should  be  twisted  or  tied  as  it  bleeds,  and  all  capillary  oozing  arre.sted  by 
a  large  sponge.  The  peritoneum  may  then  be  divided  and  the  stomach  sought.  In  the 
ca.ses  I  have  operated  upon  it  was  seized  readily.  If  the  liver  presents,  it  should  be 
raised  ;  and  if  the  omentum  comes  into  view,  it  should  be  drawn  downward.  The  colon 
should  not  be  mistaken  for  the  stomach.  When  the  stomach  is  found,  it  .should  be  held 
well  forward  against  the  abdominal  parietes  with  a  pair  of  tenaculum  pointed  forceps  and 
two  loops  of  fine  silk  introduced,  one-third  of  an  inch  apai't,  by  means  of  a  delicate  curved 
needle,  through  the  peritoneal  and  muscular  coats  of  the  viscus.  The  ends  of  these 
loops  should  be  left  long,  for  a  purpose  to  be  described  later  on.  The  stomach  may  then 
be  carefully  secured  to  the  margin  of  the  wound  by  means  of  a  sufficient  number  of  silk 
sutures ;  the  sutures  should  be  made  to  include  the  peritoneal  and  muscular  coats  of  the 
stomach  and  the  parietal  layer  of  peritoneum  and  muscles.  Some  surgeons  introduce  a 
double  row  of  sutures,  but  I  do  not  believe  this  step  is  neces.sary. 

The  first  half  of  the  operation  is  now  completed. 

The  second  half  is  really  the  completion  of  the  operation,  for  it  includes  the  opening  of 
the  stomach  :  and  this  should  be  carried  out  on  the  fifth  or  sixth  day  after  the  first  step, 
and  is  effected  with  ease  and  without  pain  by  simply  holding  the  stomach  forward  by 
means  of  the  two  loops  of  ligatures  which  were  introduced  into  its  walls  when  first  caught, 
and  puncturing  the  exposed  area  with  a  tenotomy  knife.  The  opening  into  the  stomach 
need  not  be  larger  than  one-eighth  of  an  inch.  The  silk  loops  niav  now  be  removed.  By 
this  small  puncture  the  surgeon  gains  all  he  can  desire,  for  the  walls  of  the  stomach 
being  elastic,  the  small  opening  readily  yields  to  the  slightest  pressure,  so  that  a  tube  the 
.size  of  a  No.  10  catheter  can  readily  be  introduced  into  the  stomach  for  feeding  purposes, 
and  by  virtue  of  this  same  elasticity,  when  the  tube  is  withdrawn,  the  artificial  orifice 
closes,  and  as  a  result  there  is  little  or  no  escape  of  the  contents  of  the  stomach  to  satur- 
ate the  patient's  linen  or  to  irritate  the  soft  parts  around  the  artificial  orifice  and  thus  add 


500  INTESTINAL    OBSTRUCTION. 

to  the  patients  discomfort.  In  the  case  recorded  above  the  wound  is  now,  as  it  has  been 
since  ISSU.  quite  dry. 

For  feeding  purposes  after  the  first  few  days  have  passed,  and  during  which  warm 
milk  with  eggs  is  the  best  diet,  the  food  should  be  thick,  and  for  its  easy  introduction 
Messrs.  Krohne  of  8  Duke  street,  Manchester  Square,  have  made  for  me  an  apparatus 
which  con.sists  of  a  small  Higginson's  springe  with  a  small  tube  at  one  end  to  be  intro- 
duced into  the  stomach,  and  a  larger  one  in  the  other  connected  with  a  glass  funnel  as  a 
receptacle  for  food.  With  this  thick  food,  such  as  peptonized  meat,  can  easily  be  thrown 
into  the  stomach. 

It  must  be  added  that  Sedillot  was  the  first  person  to  perform  the  operation  in  1849, 
and  Mr.  Cooper  Forster,  on  the  suggestion  of  Dr.  Habershon.  was  the  first  to  do  it  in 
this  country  in  1857.     Since  then  it  has  been  repeated  about  fifty  or  sixty  times. 

By  way  of  conclusion,  gastrostomy  .should  be  undertaken  for  cancerous  or  cicatricial 
stricture  of  the  oesophagus  as  soon  as  there  is  a  practical  difficulty  in  the  introduction  of 
solid  food  into  the  stomach,  life  being  prolonged  and  much  misery  saved  by  such  a  prac- 
tice when  the  di.sease  is  cancerous,  and  life  being  saved  indefinitelv  when  the  cause  is 
traumatic. 

When  the  ulceration  is  not  cancerous,  but  simple  or  syphilitic,  a  cure  may  be  looked 
for.  my  colleague,  Mr.  Davies-Colley.  having  now  a  patient  alive  for  whom  he  performed 
gastrostomy  some  years  ago  to  save  her  life  from  starvation,  and  nine  months  later  closed 
the  fistula,  the  ulceration  having  healed  and  the  power  of  swallowing  having  been  restored. 

The  operation  should,  when  practicable,  be  divided  into  two  steps,  as  suggested  hy 
Mr.  Howse,  and,  his  improvement  being  so  great,  it  should  be  described  as  "  Howse's 
operation." 

The  opening  into  the  stomach  should  not  be  larger  than  that  made  by  an  ordinary 
tenotomy  knife,  or  about  one-eighth  of  an  inch. 

Intestinal  Obstruction. 

In  cases  of  acute  or  chronic  intestinal  obstruction,  when  the  physicians  art  has  failed 
to  give  relief,  the  surgeon's  aid  is  required ;  and  it  would  be  well  for  the  medical  mind  to 
recognize  the  fact  that  in  a  large  proportion  of  iu.stances  this  aid  is  sought  at  too  late  a 
period — that  is.  when  the  patient's  powers  have  become  so  exhausted  as  to  exclude  all 
hope  of  a  successful  issue  being  obtained  by  any  treatment,  or  when  the  involved  tissues 
have  undergone  such  changes  from  peritoneal  complications  as  to  forbid  any  reasonable 
expectation  of  the  competency  of  nature's  reparative  powers  to  efl'ect  a  cure  even  where 
the  cause  of  the  obstruction  has  been  removed. 

It  should  ever  be  remembered  that  cases  of  acute  intestinal  obstruction,  like  those  of 
strangulated  hernia,  require  prompt  and  active  treatment  if  they  are  to  be  successful, 
and  that  those  of  chronk  obstruction  require  a  no  less  decided  line  of  action.  It  must 
be  admitted,  also,  that  there  is  no  class  of  cases  which  claim  for  diagnostic  purposes  more 
thought  and  judgment,  that  the  difficulties  of  diagnosis  as  to  the  cause  of  the  obstruction 
are  sometimes  great,  and  that  the  question  of  operative  relief  has  to  be  decided,  conse- 
quently, upon  uncertain  grounds.  But  such  arguments,  to  my  mind,  are  in  favor  of 
operative  measures  for  diagnostic  as  much  as  for  curative  purposes,  and  in  no  way  tell 
again.st  them  when   the  diagnosis  is  clear. 

When  the  diagnosis  is  clear  and  the  nature  of  the  case  decided,  delay  is  dangerous 
and  a  want  of  courage  in  the  surgeon  to  act  upon  the  diagnosis  is  criminal.  The  ques- 
tion of  diagnosis  is,  consequently,  all-important  and  will  first  claim  attention. 

Diagnosis. — In  a  clinical  point  of  view,  cases  of  intestinal  obstruction  may  be  divided 
into  acute  and  chronic.  The  acute  include  strangulation  of  a  portion  of  bowel  from  exter- 
nal or  internal  hernia,  omental,  mesenteric,  peritoneal,  or  foetal  bands,  or  twists  of  the 
intestine  ^volvulus).  The  chronic  embrace  inflammatory,  syphilitic,  or  cancerous  stric- 
tures of  the  large  or  small  intestine,  the  occlusion  of  the  bowel  from  the  mechanical  pres- 
sure of  tumors,  adhesions  of  the  intestines  from  inflammatory  peritoneal  changes,  and  last, 
but  not  least,  the  impaction  of  feces. 

Perityphlitis,  the  passage  of  a  gall-stone,  and  acute  peritonitis  due  to  perforation  may 
simulate  acute  ob.struction.  Intussusception  belongs  to  both  divisions,  since,  when  the 
invaginated  portion  of  bowel  is  acutely  strangulated,  acute  symptoms  will  show  them- 
selves ;  and  when  the  same  portion  is  incarcerated,  the  symptoms  will  be  chronic,  although 
in  their  onset  they  may  be  sudden.  The  relative  frequency  of  these  conditions  will  be 
seen  in  the  followin<r  table; 


Acrri-:  istkhsm.  strangulatios  or  riii:  r.oWEL. 


'^)\ 


Causes  of  Intestinal  Obstruction,  excluding  Hernia, 

bfiiik'  ill!  aiiiily.siK  of  VH  consecutive  ciwch  extracted  from  the  |io>*t-ni(>rteiii  rceordn  of  (iiiy's  Mo><(>ital  tiy  I)r.  Hilton 
iiiKKu  from  1H.VI  to  \m^  (<t<tij>  AV/..,  IMlM,  und  Mr.  Kusseil  I'roiu  !»«»  to  l«7«  i  uiipuljliblied^. 


(iiiy's 

Cases. 

33 


.Vtl'TK 
OUSTKUCTION. 


CUKONIC 
OBSTRUCTION 


15 


Intussusckp- 

TIONS 


124 


1  littiTiml  huriiiii. 

7  twistw  (volvulus 

1  i  1 


pit. 
')  (liviMticiila. 


2")  liaiids 


AnalyNix  of  K',  ca.se»  of  stricture  of 
•)  ..iiiii'tiiliv  <"i.<-i  intestines  as  civen  in  a  paper  by 

-  .l|>|HIl  11\  (..(1.  Coupland  ainf  Morris  ' /ir<7.  .»/«/. 

I       2  til  iK'ck  (it    IliTUial  .xac.  ./oui«.,  .lanuary  2f.,  1W7H). 

I  t'roiri  |)C'(lulcM)f  ovarian  tiiiiKpr.  Middlesex      I'atlioloKical 

<  a.ses. 

1  iinpa.lion.  :.^^.'!'^ 


.'5  iiu'ciiaiiical  pfcssiirc  of  tumors. 


f 


r  2  small 

intfstine. 
(  4")  large. 


23  mattinjr  together  of  in- 
testinal   coils    from 
peritoneal  and  can- 
cerous disease. 
(Contractions.) 
2  rectal. 
7  ileo-ctecal. 
6  small  intestine. 


>'•>  rectimi  and  sig- 
ntoid  flexure  . 

7  tran.sveise  colon 
with  hejtatic 
and  splenit- 
flexures  .... 

5  ciccum  or  ileo- 
cjecal 


Miiall. 

24 

3 
1 


.Society. 

.'.\  iarije 

intestines, 

1  small. 


(ienenJ 
Total. 


21 

9 
1 


=      78 


In  all 


s  (if  intestinal  obstruction  the  diagnosis  should  be  made  upon  the  principle 
of  exclusion,  the  [iractitioner  coming  to  a  conclusion  by  first  running  over  every  possible 
cause  and  eliminating  each  sen'dtiin,  and  subsequently  weighing  the  points  in  favor  of  the 
proliable  cause. 

The  possibility  of  the  symptoms  being  due  to  a  strangulated  or  incarcerated  external 
hernia  should  always  be  carefully  investigated. 


Acute  Internal  Strangulation  of  the  Bowel, 

whether  from  an  internal  hernia,  twist  (volvulus),  or  a  foetal  or  peritoneal  lymph  band, 
may  take  place  at  any  period  of  life,  and  the  symptoms  to  which  it  gives  ri.se  are  those 
of  an  acute  strangulated  external  hernia — viz.,  sudden  and  definite  onset  of  the  illness  in 
a  healthy  subject,  .severe  paroxysmal  central  abdominal  pain,  attended  by  sickness  and 
more  or  less  collapse ;  constipation,  inability  to  pass  wind  downward,  and  hiccough  ;  occa- 
sionally, also,  scanty  urine,  or  even  its  suppression  ;  coils  of  distended  bowel  are  some- 
times visible  through  the  parietes. 

There  will,  however,  be  no  distinct  abdominal  tumor,  no  tenesmus,  and  no  hemorrhage 
from  the  bowel,  such  as  is  often  present  in  an  acute  intussusception.  There  mav,  how- 
ever, be  some  evidence  of  one  coil  of  intestine  being  more  tense  or  distended  than 
another. 

When,  therefore,  a  case  presents  itself  with  these  symptoms,  there  can  be  no  difficulty 
in  coming  to  a  conclusion  as  to  its  nature,  although  it  may  be  difficult,  if  not  impossible, 
to  diagnose  the  precise  cause  of  the  .strangulation.  If,  however,  we  refer  to  the  table 
above,  some  guide  will  be  found  ;  for  it  will  there  be  seen  that  out  of  33  cases  25  were 
due  to  bands,  7  to  volvulus,  and  1  to  internal  hernia. 

When  there  has  been  a  history  of  old  hernia,  the  probabilities  of  the  existence  of  a 
band  are  much  enhanced,  since  it  is  true  that  with  hernia  such  bands  are  not  uncommon. 
Duchaussoy  in  his  paper  *•  On  Internal  Strangulation"'  (Mi'm.  <fr  FArad.  <Ip  Mi'tf.^  1860) 
gives  such  cases.  Fagge  quotes  one,  and  in  my  own  practice  four  have  occurred.  One 
died  unrelieved;  in  the  second  I  opened  the  empty  hernial  sac,  and  so  enlarged  my  inci.s- 
ion  upward  for  about  two  inches  as  to  detect  a  band  high  up  in  the  abdomen,  which  I 
divided  with  a  pair  of  scissors,  and  a  perfect  recovery  took  place.  This  case  occurred  in 
the  practice  tif  |)r.  Wilkinson  of  Sydenham,  and  is  fully  recorded  in  the  Med.-Chir.  Trans. 
for  18(>7.  The  patient  is  still  alive.  Tho  third  and  fourth  died  after  the  operation,  but 
the  band  was  divided  and  a  large  coil  of  intestine  released.  The  operations  had  been 
delayed  too  long. 


602 


ACUTE  INTERNAL  STRANGULATION  OF  THE  BOWEL. 


Mr.  Gay's  analysis  of  148  cases  tells  us  that  102  were  in  the  male  and  4G  in  the 
female,  and  that  the  largest  number  of  cases  took  place  in  patients  between  15  and  35. 

The  surgeon  under  the  circumstances  related,  however,  has  a  clear  case  and  an 
important  decision  before  him  ;  for  if  the  diagnosis  be  correct  and  a  portion  of  bowel  is 
stfaiiyalatid  within  the  abdomen,  obstructed  by  some  solitary  band,  or  twisted,  he  knows 

that  very  little  can  be  htoked  for  by  mcd- 


Ifim 

\ 


Fig.  286. 

'    iillaeluJ  li 

imi,  II  ri 


^^ 


I  junuTV, 


ical  treatment — that  by  leaving  things 
alone  and  the  case  is  unrelieved  death  is 
inevitable ;  and  he  is  aware,  moreover, 
that  the  hope  of  a  cure  by  natural  pro- 
cesses is  very  meagre ;  and  if  I  estimate 
that  hope  as  being  nearly  on  a  par  with 
that  entertained  in  a  case  of  ordinary 
strangulated  hernia  when  left  to  itself,  I 
shall  probably  be  about  the  mark,  since 
cases  of  strangulated  hernia  do  occasion- 
alhj  go  up  of  tjiemselves  when  all  surgical 
efforts  short  of  herniotomy  to  reduce  them 
have  failed,  and  cases  of  internal  strangu- 
lation, from  whatever  cause,  do  occasionally 
free  themselves.  Nevertheless,  no  pru- 
dent mind,  on  the  strength  of  these  ex- 
Case  of  StraiiKulation  of  the  Howel  by  Lvmph  Rand  constrict-  .•  1  II  •ii-  1 
ing  Ileum  alx.ut   three  inches  from  Csecuin  and  a  Coil  of    CCptlOnai      Occurrences,     WOuld      Willingly 

Jejunum.    (Taken  trom  a  man  set,  2G,  who  died  after  bowel  leave    a    case    of    external    strangulated 

ob.struction  01  hiteen  days  duration.     This  case  occurred  in    ,  .  .        ,„  iti-ii 

my  father's  practice  in   18:i8,  and  is  recorded  in  Trans.  Med.    hernia  tO  itsell  ;    and  i  think  that  no  pru- 

'  rativtfXSnce:)  '^^e  suggestion  was  then  made  of  ope-  ^ent  surgeon  ought  to  leave  unrelieved 

any  case  of  internal  hernia  or  strangula- 
tion to  the  same  almost  forlorn  hope,  because,  granting  that  the  diagnosis  of  the  case  can 
be  made,  by  no  medicine, 'no  manipulation,  no  expectant  treatment  can  the  mechanical 
obstruction  be  overcome,  and  under  these  circumstances  a  fatal  termination  must  be 
anticipated. 

Opium  may  relieve  pain,  mask  symptoms,  and  give  rise  to  a  pleasing  delusion  that  all 
is  doing  well  in  cases  of  internal  strangulation,  as  it  is  well  known  it  does  in  others  of 
external  hernia,  but  in  the  one  as  in  the  other  it  does  no  more.  It  does  not  accomplish 
the  only  true  remedy — viz.,  relieve  the  mechanical  strangulation  to  which  the  bowel  is 
subjected. 

In  external  acute  strangulated  hernia  the  only  recognized  correct  treatment  when  the 
hernia  cannot  be  reduced  is  herniotomy  ;  and  when  the  hernial  tumor  does  not  seem  to  be 
the  seat  of  strangulation  and  symptoms  of  strangulation  exist,  the  surgeon  regards  an 
exploratory  operation  at  the  seat  of  hernia  for  purposes  of  diagnosis  not  only  a  justifiable, 
but  a  called-for,  measure. 

In  /?(^'rjta/ hernia,  or  in  any  case  of  acute  strangulation  from  whatever  cause,  I  main- 
tain that  a  like  principle  of  practice  should  be  acted  upon;  for  when  the  diagnosis  is 
sure,  it  is  by  '•  laparotomy  "  alone  that  a  cure  can  be  brought  about ;  and  when  it  is 
uncertain,  it  is  by  "  laparotomy  "  alone  that  the  diagnosis  can  be  made  out  and  a  correct 
line  of  treatment  adopted. 

The  operation  of  ovariotomy  has  proved  to  us  that  the  exposure  and  the  manipulation 
of  healthy  intestine  are  not  of  themselves  fatal  measures,  and  there  is  every  reason  to 
believe  that  in  the  cases  now  under  consideration  a  good  result  might  often  be  secured  if 
the  operations  were  performed  before  a  fatal  peritonitis  had  set  in  or  the  strangulated 
bowel  been  injured  past  recovery.  At  any  rate,  as  matters  now  stand,  a  recovery  by 
medical  treatment  from  an  internal  strangulation  is  a  matter  of  wonder,  and  it  would  be 
well,  as  all  collateral  experience  indicates,  that  a  bolder  practice  should  be  employed. 

If  we  appeal  to  pathology — and  it  is  only  there,  unfortunately,  that  we  can  ajjpeal — 
we  receive  ample  facts,  since  the  late  Dr.  Fagge.  in  his  able  article  already  referred  to, 
tells  us  that  '■  there  might  in  many  cases  have  been  no  little  difficulty  in  finding  a  band 
among  the  distended  coils  ;  but  I  regard  the  facts  derivable  from  our  post-mortem  records 
as  indicating  no  insurmountable  obstacles  to  the  success  of  an  exploratory  operation  in 
the  great  majority  of  the  cases  of  true  internal  strangulation  which  are  to  be  found  in 
these  records."  Dr.  Brinton,  in  his  analysis  of  six  hundred  cases,  points  also  to  the  same 
conclusions.  Under  these  circumstances  I  feel  bound  to  express  my  conviction  that  on 
the  diagnosis  being  made  of  an  internal  strangulation,  from  whatever  cause,  the  operation 


( 'iirjiSK '  i.\TJ:sTf\. I  /.  oiisTii I ■( Tiny. 


5(^3 


of  ••  l;i|iar((t(iiii_v  slimild  he  |pcrli>nin  il.  ;ui<l  lliat  i>\\  llir  iliatriiosis  of"  tlit-  cause  heiiig 
uiH-fitaiii  laparotiiiii y  is  likcwix-  ralKil  iur  to  clt-ar  iij)  iliml)t.s  aiiil  to  deal  witli  conditioas 
wliitdi  ail'  otIuTwiso  inciiudialdf.  l{ut  this  ojifiati<iii  is  not  to  bu  jtciloniii'd  as  a  ih mli-r 
ri'ssurt  uioro  than  that  ior  f.vtcrnal  hernia,  hut  sliould  he  carried  out  as  early  in  tlie  prog- 
ress of  the  case  as  the  diairnosls  will  justily — when,  in  sjtite  of  the  f^ravity  of  the  meas- 
ure, irood  results  may  he  Icmkcd  I'm'. 

A  Help  to  Diagnosis  in  Cases  of  Abdominal  Obstruction. 


"  l.,et  uo  one  set  too 

nucli  value  on  any  one  sign  or  symi)tom." — l''A<i<< 

K. 

Aei'TK— 

ClOtONlC  OlLSTISeCTION. 

AccTK  OK  Chronic— 

Obstruction  orSlran- 

Iniiii  l>i.seasi' of  Large    I'roin  Ki.'tease  of  .Small          .    .                 ..              1 

Previous    cDiulition 

gulaliou. 

Intestine. 

Intestine.                     luui.Hsuscepuou. 

In  good  health. 

Ailing  for  some  time 

Ailing  with    previous    In  good  health. 

of  subject. 

with  abdominal  sy  m)>- 

attacks  of  incomplete 

toms.  . 

obstruction. 

'  Modeuf  uttui'k  

Very    sudden    and 

Symptoms     gradually 

I'aroxysms  of  colicky     Sudden  on.set,  and  in- 

1 

acute. 

increasing  in  severity, 

pain,  upon  old  symp-       creasing  when  acute,  ' 

or  acute  grafted  upon 

toms.                                    suli.siding            whea  ' 

chronic. 

chronic.                          ' 

1  arly  symptoms: 

k  aiu 

Abduntinn!          jiitin, 

Pnin,  dilTused  and  in- 

Pahi, iiaroxysmal.with 

Pnin,  fixed  and  often 

fixed,  central,  and 

creasing  with  disten- 

intervals of  ease  in 

relieved  by  pressure. 

paroxysmal. 

sion.                                      Iiypiigastric  sit  nation. 

1 

Noiuiting 

1  iimitiiiii,  rapidly  be- 

Intermittent and  fecal     (iccasicnal   during  at- 

Rapidly  becoming  fecal  ' 

! 

coming  I'ecal. 

towaid  the  last.                 tack  of  pain. 

in    acute    cases,    ab-  | 
sent   or   intermitteot 
in  chronic. 

1        (.'oUapse 

Cotlnpse,  very  mark- 
ed. 

Absent  till  tlie  end. 

Absent  till  late. 

Very  marked  in  acute 
cases,     not      so      iu 
chronic. 

CoDstipation 

Absolute     constipa- 

Gradually    increasing 

Attacks    of    constipa- 

Occasionally   present, 

tion  and  inability 

in  severity. 

tion,  alternating  with 

but,  as  a  rule,  "dys- 

to pass  flatus. 

natural  relief. 

enteric"     symptoms, 
straining,    tenesmus,  ' 
muco-sanguineoua 
stools,  or  hemorrhage. 

Abdominal     disten- 

Rapid   and    severe. 

(iradually    increasing. 

Never  great,  increased 

Rarely  .severe. 

sion. 

central  and  hypo- 
gastric. 

lumbar    and     epigas- 
t  ric. 

during  attack. 

Manipular      indica- 

Tympanitic, distend- 

A   tixed    swelling    at 

A    doughy    condition 

Distinct  tumor  often  to 

tions. 

ed  coils  at  times  to 

times   to    be    felt    in       of    bowel,    becoming 

be  felt,  its  shape  vary- 

be felt. 

either  iliac  fossa.              knotty  during  attack. 

ing  during  attack. 

Visible  indications... 

Abdomen    tense  in 

Abdomen  broadly  dis-    Coils  of  intestine  very 

Nothing  marked  to  be 

umbilical  and  hy- 

tended, coils  of  iutes-       visible. 

seen. 

pogastric    regioTis, 

tine  visible. 

with     visibly     dis- 

tended coils. 

Peristalsis 

Rarely  visible. 

Marked. 

Very  marked. 

Not  visible. 

trine 

Scanty  or  suppressed. 

Natural  in  ((uanlily.        Natural. 

Natural 

Rectal  examination.. 

Lower  bowel  prob- 

Stricture of  bowel  may     Nothing  abnormal. 

Rectum    may  contain 

ably  quite  empty. 

be   felt  in   rectum  or 

mucus,  blood  clot,  or 

in  sigmoid  Hexure  by 

invaginated  bowel. 

1 

manual  examination.  | 

Chronic  Intestinal  Obstruction 

now  claims  attention,  and  it  is  to  be  observed  ///  1 1  mine  that  the  clinical  history  of  these 
cases  is  very  distinct  from  that  of  the  acute  ;  for  whereas  in  the  *■  acute"  the  .symptoms 
appear,  as  a  rule,  suddenly  in  patients  who  have  been  apparently  in  good  liealth.  in  the 
"chronic"  it  will  almost  always  be  found  that  there  has  been  for  a  more  or  less  leniftliened 
period  some  abdominal  ]>ain  or  .symptom,  some  difficulty  in  ol)taiiiin<r  a  movement^ of  the 
bowels  or  in  the  act  of  defecation,  some  discharue.  })robably,  of  ylairy  mucus,  of  pus,  or  of 
blood,  separately  or  combined,  at  uncertain  intervals,  and  last,  but  not  least,  .some  cliaiiire  in 
the  form  and  character  of  the  stools,  the  motions  at  one  time  being  liquid  and  loose,  at 
another  hard  and  marble-lik;:.  while  at  intervals  they  are  pipe-  or  tape-like.  Under  all 
circumstances  there  will  be  .symptoms  of  long  standing;  and  if  acute  symptoms  exist 
when  the  case  comes  under  notice,  they  will  be  found  to  have  been  grafted  upon  the  old. 
If,  therefore,  we  are  called  to  see  a  patient  suffering  from  marked  symptoms  of  obstruc- 
tion of  some  days"  duration  and  obtain  such  a  history  of  the  case  as  has  just  been 
sketched,  and  find  him  with  abdominal  tympanitic  di.stension.  and  probably  pain,  possibly 
visible  ])eristalsis.  nausea,  vomiting,  hiccough,  and  borborygmi.  we  may  safely  come  to 
the  conclusion  that  the  case  is  one  of  chronic  obstruction,  and  that  it  has  for  its  cause 
one  of  those  named  in  the  table  (page  501).  It  will  prove  to  be  .stricture  of  either  th« 
colon  or  the  rectum,  the  mechatiical  pressure  of  a  pelvic  or  abdominal  tumor,  the  mat- 
ting together  of  the  intestinal  coils  from  old  or  chronic  inflammation  of  the  peritoneum 
or  mesentery  or  from  cancerous  abscess,  and  last,  but  not  least,  to  fecal  accumulations; 


504  CHRONIC  INTESTINAL   OBSTRUCTION. 

and  ill  every  case  of  obstruction  the  last  possibility  being  the  cause  should  be  borne  in 
mind.  Rare  instances  are  also  on  record  in  which  other  causes  have  existed,  and  I  have 
given,  in  the  chapter  on  hernia,  some  in  which  the  obstruction  had  been  clearly  traced  to 
the  influence  of  an  adhesion  between  the  bowel  and  a  hernial  sac  or  some  part  of  the 
abdominal  parietes,  or  to  an  obstructed  obturator  or  other  hernia. 

The  effects  of  obstruction,  from  whatever  cause,  ai-e  very  uniform,  and  every  case  will 
terminate  fatally  from  either  exhaustion  or  peritonitis  if  the  obstruction  is  not  overcome. 
When  chronic  peritonitis  occurs,  it  is  due  to  the  obstruction  ;  and  when  the  peritonitis  is 
acute,  it  is  due  either  to  a  perforating  ulcer  of  the  sigmoid  flexure  secondary  to  the  stric- 
ture, to  some  ulceration  of  the  caecum  or  colon  the  result  of  overdistension,  or  to  the 
mechanical  rupture  of  the  ctecum  the  direct  result  of  the  pressure  of  the  fecal  accumula- 
tion acting  backward  upon  the  ca3cal  cul-de-sac.  My  notes  describe  two  cases  in  which 
the  caecum  burst — one  in  which  it  was  purple  in  color  and  measured  fifteen  inches  round, 
and  another  in  which  it  had  sloughed.  I  have  also  notes  of  a  case  of  a  male  child  born 
with  an  imperforate  rectum  who  died  on  the  sixth  day  from  ruptured  ca2cum.  And  out 
of  eleven  consecutive  fatal  cases  of  untreated  stricture  of  the  rectum  at  Guy's  Hospital, 
collected  by  my  dresser,  Mr.  Russell,  death  was  caused  by  ruptured  caecum  in  three,  by 
perforation  of  the  sigmoid  flexure  in  two,  by  peritonitis  after  puncture  to  relieve  flatus  in 
one,  and  by  exhaustion  in  three.  Hence  the  importance  of  early  relief  before  tliese 
changes  have  been  started.  These  points  have  been  ably  brought  out  in  Coupland  and 
Morris's  paper. 

Diagnosis. — To  diagnose  the  true  cause  of  the  obstruction  is  therefore  the  surgeon's 
next  aim,  and  it  would  be  well  if  I  were  able  to  add  that  the  task  is  an  easy  one,  but 
such  is  not  the  case.  It  is  true  that  when  the  obstruction  is  in  the  rectum  a  digital 
examination  of  the  part  may  find  it  out,  that  when  in  the  sigmoid  flexure  the  cautious 
introduction  of  the  whole  hand  into  the  rectum  (after  the  method  of  Simon  of  Heidelberg) 
may  detect  it,  and  that  when  a  tumor  is  to  be  felt  by  palpation  to  the  left  of  the  umbili- 
cus, through  the  abdominal  walls,  the  probability  is  suggested  of  the  disease  being  in  the 
colon ;  but  without  these  guides  little  definite  knowledge  is  to  be  obtained  by  either  pal- 
pation or  percussion,  by  the  passage  of  the  long  tube,  or  by  the  amount  of  fluid  that  may 
be  injected  into  the  colon. 

Under  these  circumstances,  therefore,  the  surgeon  is  thrown  back  upon  the  probabili- 
ties of  the  case  as  read  by  the  light  of  pathological  knowledge ;  and  it  is  gratifying  to  be 
able  to  show  that  these  facts  speak  with  no  uncertain  sound.  Indeed,  they  speak  so 
strongly  and  decidedly  that  the  surgeon  may  rely  upon  them  with  confidence  and  base 
his  practice  upon  their  indications. 

The  facts  are  revealed  in  the  table  to  which  I  have  already  drawn  attention.  There 
it  will  be  seen  that  out  of  the  7(1  fatal  cases  of  chronic  obstruction,  3  were  due  to  fecal 
impaction,  3  to  the  mechanical  pressure  of  tumors,  23  to  what  Dr.  Fagge  described  as 
"  contraction,"  caused  by  the  matting  together  of  the  intestinal  coils  from  peritoneal  or 
cancerous  disease,  and  47  to  strictures  of  the  bowel. 

Now,  cases  of  fecal  accumulation  do  not  require  any  lengthened  treatment  in  these 
pages.  When  they  come  under  the  surgeon's  care  as  examples  of  obstruction,  they  are 
to  be  treated  by  the  mechanical  removal  of  the  feces  from  the  rectum  by  such  means  as 
the  finger,  the  lithotomy  scoop,  or  the  handle  of  an  iron  spoon,  these  measures  being  aided 
materially  by  the  free  use  of  grease,  oily  enemata,  and  medicines. 

The  fact  that  fecal  accumulation  may  give  rise  to  the  worst  symptoms  of  mechanical 
obstruction,  and  even  to  death,  should  always  be  before  the  surgeon  and  induce  him  to 
examine  the  rectum  with  care  in  all  cases  of  obstruction. 

Obstructions  due  to  the  presence  of  some  abdominal  tumor,  hydatid,  cancerous,  ovarian, 
or  otherwise,  are  to  be  diagnosed  and  dealt  with  on  their  own  merits,  although,  when  it 
is  the  lower  part  of  the  bowel  that  is  obstructed,  right  or  left  lumbar  colotomy  should 
not  be  neglected  when  other  means  of  relief  are  not  available.  I  have  performed  this 
operation  on  most  occasions  for  such  a  cause  with  gratifying  success. 

We  come  now  to  the  two  larger  divisions  of  cases — viz.,  those  of  sfricfui'e  and  contrac- 
lion  ;  and  a  very  little  consideration  will  show  that  these  cases  have  as  distinct  a  clinical 
history  as  they  have  a  pathology,  and  that  they  moreover  require  a  distinct  line  of  treat- 
ment. 

With  respect  to  their  pathology,  it  may  at  once  be  stated  that  "  contraction  "  is  the 
cause  of  chronic  obstruction  of  the  .small  intestines,  and  "  stricture  "  of  obstruction  of  the 
large  bowel ;  that  the  cases  of  "  contraction  "  are  due  to  the  matting  together  of  the 
intestinal  coils  from  more  or  less  diffused  inflammatory  or  cancerous  peritoneal  disease, 


VllltoSIC  IXTh'STIXAL   oiismn  TIOS.  505 

while  cases  (if  strict  lire  ;irc  dm-   to  a  local    iiarrowiiiL''  ol'  tlir   liowcl    from   disease  of  its 
coats. 

In  the  cases  of  ••contraction  "  tlif  iiction  ol'  ilir  intestines  (small  or  larL'cj  is  interfered 
with  from  adhesions  or  from  a  bendinir  or  douliliiiL'  of  the  liowcl  iipoii  itseli",  and  conse- 
quently there  is  an  interl"crcnce  with  the  iicristaltic  movements;  in  those  of '' stricture," 
the  action  of  the  Imwels  is  jircvcnted  from  the  direct  mechanical  ohst ructifin  occasioned 
by  the  strict uri-. 

The  clinical  history  and  symptoms  of  tliese  tw(»  classes  of  cases  consef(uently  differ. 

In  the  case  of  "  contraction  ""  the  symptoms  are  (dearly  referable  to  a  difficulty  in  the 
passajre  downward  of  the  intestinal  contents;  in  that  of  "stricture,"  t(i  a  difficulty  iti 
defecation. 

In  the  f'nrnicr  case  the  symptoms  are  attacks  of  ;j:ripin<r.  colicky  abdominal  pain, 
irrcirular  and  incomplete  intestinal  evacuations,  and  the  painless  dischar<re  of  healtliy 
motions  ;  in  the  /u/tcr  there  is  mostly  an  absence  of  abdominal  pain  lieyond  that  due  to 
distension,  more  or  less  complete  constipation,  alternatinjr  with  looseness  of  bowels,  the 
occasional  or  frequent  mixture  of  mucus  or  blood  with  the  motions,  and  painful  defecation. 

In  "contraction,"'  when  sickness  exists,  it  will  be  passinti  and  lasting  only  during  tlie 
attack  of  colicky  pain;  in  "stricture"  it  will  occur  toward  the  close  of  the  disease  when 
the  obstruction  is  more  complete. 

In  "  contractions  "  the  abdomen  probably  will  not  be  much  distended,  and,  if  it  be  so, 
only  during  the  attack ;  the  distension,  moreover,  will  be  central  and  hypogastric.  "  The 
intestines  will  then,"  writes  Fagge,  "  be  seen  writhing  and  coiling,  and  a  gurgling  of  fluid 
is  heard;  there  will  also  lie  visible  distinct  peristaltic  movements  of  the  intestines."  In 
"  stricture  "  the  abdomen  will  to  a  certainty  be  distended,  and  the  distension  will  be  lum- 
bar and  epigastric ;  large  coils  of  distended  bowel  w'ill  also  be  visible  with  peristaltic 
movements,  the  visible  peristalsis  in  both  cases  being  due  to  the  chronicity  of  the  affec- 
tion, and  consequently  to  the  hypertrophy  of  the  bowel  from  overwork. 

Such.  then,  are  the  broad  points  of  distinction  between  the  two  large  elas.ses  of  cases  of 
chronic  intestinal  obstruction,  and  they  are  enough  to  guide  the  surgeon  in  his  practice. 
At  times,  however,  the  distinctions  f^iil.  Indeed,  when  a  history  of  a  ca.se  of  either  con- 
traction or  stricture  is  deficient,  the  diagno.sis  is  most  difficult;  and  if  seen  when  the 
symptoms  are  at  their  height,  one  or  other  may  be  mistaken  for  a  case  of  acute  obstruc- 
tion, the  chronic  symptoms  of  which  nothing  can  be  known  having  lighted  up  into  the 
visibly  acute,  in  the  same  way  as  a  case  of  incarcerated  or  obstructed  hernia  may  sud- 
denly develop  into  one  of  acute  strangulation. 

Having,  then,  thus  mapped  out  the  chief  points  of  distinction  between  the  two  classes 
of  cases  of  chronic  intestinal  obstruction,  and  bearing  in  mind  that  in  the  "  contractions" 
the  small  intestines  are  the  parts  that  are  involved  and  in  the  "  strictures"  the  large,  it 
remains  for  the  surgeon  in  the  latter  class  of  cases  to  determine  the  seat  of  the  disease,  for 
a  correct  knowledge  upon  this  point  is  clearly  requisite  before  any  precise  operative  treat- 
ment can  be  entertained.  On  reference  to  the  table  this  point  comes  out  very  strongly ; 
for,  out  of  104  cases  which  have  been  tabulated,  in  78  the  disea.se  was  in  the  sigmoid 
flexure  or  rectum,  in  19  it  was  in  the  colon  or  one  of  its  flexures,  and  in  7  it  was  about 
the  caecum.  In  three-fourths  of  the  cases  the  disease  was  consequently  below  that  part 
of  the  bowel  that  would  be  opened  by  left  lumbar  colotomy,  and  in  about  four-fifths 
below  the  seat  of  right  lumbar  colotomy ;  in  but  a  very  insignificant  number  was  it 
higher  up. 

With  these  hard  facts  before  us,  the  conclusion  seems  tolerably  clear  that  in  all  cases 
of  obstinate  constipation  due  to  mechanical  ob.struction  in  the  large  intestine,  when 
medicinal  treatment  has  failed  and  the  removal  of  the  disease  by  operative  measures  is 
out  of  the  question,  in.stead  of  w^asting  valuable  time  by  the  persistent  administration  of 
aperients  which  must  do  harm,  of  eneniata  which  can  do  no  good,  of  opium  and  allied 
remedies  which  only  mask  symptoms  arid  mislead  the  practitioner,  colotomy  should  be 
performed.  The  operation  should  be  in  the  f't'f  loin  when  the  diagnosis  has  been  made 
of  disease  of  the  rectum  or  sigmoid  flexure,  and  in  the  n'///if  when  the  exact  position  of  the 
stricture  cannot  be  determined,  for  from  our  table  it  would  ajipear  that  in  not  one  case  in 
fifteen  is  it  likely  to  be  above  this  point;  right  lumbar  colotomy  also,  so  far  as  the  relief 
it  gives  is  concerned,  is  as  sati.sfactory  an  operation  as  left.  It  must  be  .stated,  moreover, 
that  this  relief  should  not  be  postponed  too  long,  becau.se.  from  the  f\icts  alleged,  the 
operation  will  be  of  little  avail  when  from  the  mechanical  effects  of  the  fecal  distension 
a  peritoneal  inflammation  has  set  in.  or  changes  have  tf^ken  place  in  the  caecum  or  large 
intestine  of  an  ulcerative  or  inflammatorv  character. 


50(3 


INTUSS  USCEPTIONS. 


With  respect  to  the  treatment  of  "contractions,"  much  may  be  done  by  judicious 
medical  measures,  more  particularly  by  helping  the  passage  onward  of  the  contents  of  the 
intestinal  canal^  by  means  of  laxatives,  those  of  an  oily  kind  being  the  best,  such  as  the 
oily  mixture  of  the  Guy's  Fharmacopojia. 

A  time  will,  however,  come  when  these  means  will  fail  and  others  must  be  looked  for, 
unless  the  patient  be  left  to  his  ftite  ;  and  of  these  "  enterotomy"  is  most  applicable.  The 
operation  consists  in  opening  the  small  intestine  in  the  right  or  left  iliac  fossa,  and  so 
■establishing  an  artificial  anus. 

The  operation  will  be  considered  farther  on. 


Intussusceptions, 
or  the  invagination  of  some  portion  of  the  bowel  into  a  lower  segment  (Fig.  287),  may 
occur  at  any  period,  though  most  common   in  infancy  and  child-life.     Tliey  may  take 
place  also  in  any  part  of  the  intestine,  my  table  recording  that  out"  of  the  15  cases  tabu- 

Fig.  2S7. 


Tttv,Tnm() 


tccl  Ilcivnt'^ 


Intussusception,  with  Diagram  showing  the  Entering,  Returning,  and  Receiving  Layers  of  Ileum  into  Colon. 

lated  2  were  rectal,  7  ileo-caecal,  and  6  small  intestine.  The  statistics  are  supported  by 
Gay's  analysis  of  74  cases,  in  which  8  involved  the  large  intestine  alone  and  were  colic, 
33  ileo-caecal,  and  33  small  intestine.  The  rectal  variety  is,  however,  more  frequently 
found  in  the  adult,  the  iliac  in  young  adults,  and  the  ileo-cjecal  in  infancy  and  childhood. 
When  the  invaginated  portion  of  intestine  becomes  sfnnif/iilafed,  the  symptoms  are  acute  ; 
when  simply  incarcerated^  they  may  be  chronic.  Sudden  invasion  of  symptoms,  however, 
is  the  rule  in  both  forms,  with  tenesmus  and  muco-sanguineous  discharges,  more  particu- 
larly when  the  ileum  is  involved  ;  discharge  of  blood  jier  rectum  occurs  in  the  acutest 
cases. 

Symptoms. — The  symptoms  may  be  very  acute  and  destroy  life  in  three  days,  or  so 
mild  as  to  be  only  those  of  intestinal  irritation.  The  development  of  symptoms,  as  well 
pointed  out  by  Mr.  Howard  Marsh  (*SV.  B(trfh.  Rep.,  vol.  xii.,  1876,  p.  98),  depends  upon 
the  occurrence  of  constriction — an  intussusception  in  this  respect  being  like  a  hernia, 
which  maybe  "down"  without  being  strangulated  or  even  obstructed — the  various  symp- 
toms in  each  case  depending,  not  on  the  mere  displacement  of  the  intestine,  but  on  the 
constriction  produced  by  the  displacement. 

When  acate^i  a  case  of  intussusception  at' its  onset  may  be  mistaken  for  one  of  strangu- 
lation by  a  "  band  ;"  and  yet  marked  points  of  difference  exist  between  the  two.  In  both 
the  attack  is  sudden  and  fcdlowed  by  collapse,  butjn  the  case  of  a  hainJ  pain  is  localized 
from  the  first,  is  paroxysmal  and  remains  severe  to  the  last,  and  is  also  unassociated  with 
tenesmus.  In  the  infitssuscej/fi't/ii  pain  varies  much  in  both  seat  and  intensity,  is  often 
relieved  by  pressure,  and  toward  the  last  ceases.  The  pain  is  likewise  commonly  associ- 
ated with  tenesmus.  In  strangulation  by  a  "  band  "  vomiting  soon  becomes  fecal  and  is 
constant;  in  "intussusception"  it  may  also  be  the  same,  but  it  as  often  ceases.  In 
"  band  "  constipation  is  the  rule,  with  inability  to  pass  flatus  ;  in  "  intussusception"  diar- 
rhoea, tenesmus,  and  bloody  mucoid  stools  are  characteristic  ;  constipation  is,  however,  at 
times  present  in  chronic  cases.  In  "  band  "  central  and  hypogastric  abdominal  distension 
is  an  early  symptom;  in  "  intussusception"  it  may  never  exist.  In  "  band  "  the  most 
that  may  be  felt  is  a  single  coil  of  distended  bowel  ;  in  "intussusception"  a  distinct  tumor 
may  be  felt. 

Dr.  Leichtenstein  of  Tubingen,  in  a  valuable  analysis  of  593  cases  of  this  affection 
(Fraqer  Vierteljahrschriff,  Bd.  11*9,  121,  1874),  informs  us  that  when  a  tumor  is  recog- 
nized in  the  epigastric  region  the  ileum  is  probably  the  part  invaginated  ;   when  in  the 


INTUSSUSCEPTIOXS.  507 

riu'lit  iliac  f'ctssa,  the  ilouin  into  the  ea'c-iim  ;  and  wlien  it  can  be  felt  in  the  rectum,  it  is 
pro})alilv  ik'iun.  Mr.  Morris  (  I'nih.  Tnnis.,  p.  i:{:j,  1S77)  has,  however,  jjointeij  out  the 
piissiliilit V  ol"  niistakinir  Itlood  fjut  in  tlir  rectum  tor  the  lower  end  of  intussuscepted 
itowel  ;  so  that  the  use  of  the  speculum  should  he  hrouj^ht  to  the  aid  of  the  tin;j:er  in  any 
case  of  doubt.  Lcichtenstcin  says  also  that  when  the  intussuscepted  j)ortion  of  bowtd 
.sloughs  ort"  it  occurs  between  the  eleventh  and  twenty-tirst  days  from  the  be<rinning  of 
the  disease,  and  that  it  is  trenerally  part  of  the  ileum.  This  result,  however,  is  very 
rarely   nu't    with   in   infancy. 

Tki:.\tmi:nt. — In  the  trcatnimt  i>\'  iut  u>>u>ifption  opt'rati\f  interference  is  not  to  be 
undertaken  in  a  hurry,  as  it  is  not  to  be  ijuestiom-d  that  cases  of  this  affection  cfjiistantly 
occur  which  riulit  themselves  either  by.  or  even  without,  the  aid  of  medical  or  surgical 
treatment,  the  bowel  either  freeing  itself  by  an  unexplained  jducess  or  in  some  acute 
cases  sloughing  away,  and  a  so-called  cure  resulting.  Fagge,  however,  well  ob.serves 
upon  this  point  that  "  when  this  cure  by  expulsion  occurs  it  frequently  only  po.stpones 
the  fatal  termination  instead  of  entirely  preventing  it.  The  patient  dies  .some  months 
afterward  from  contraction  of  the  cicatrix  which  had  formed  at  the  seat  of  the  di.sease, 
this  fact  affording  a  weighty  additional  argument  in  favor  of  an  attempt  to  explore  and 
pull  out  an  ilco-c:vcal  intussusception  when  the  case  is  correctly  diagnosed  at  an  early 
stage."  Mr.  Morris  says,  "  It  would  ap])ear  that  when  small  intestine  is  intussu.scepted 
into  xDt'if/  intestine  the  iiira^iimfiu;/  portion,  owing  to  its  small  relative  size,  is  too  much 
damaged  by  com])ression  from  within  to  allow  of  recovery  by  expulsion  of  the  reflected 
and  entering  portions." 

No  operation  should,  however,  l»e  tliouglit  of  in  intussusception  until  well-considered 
minor  measures  have  been  eniployed  and  failed,  care  being  taken  that  too  much  time  is 
not  expended  upon  them.  In  aciife  intussusception,  however,  where  the  bowel  is  clearly 
strangulated,  but  a  few  hours  should  be  given,  because,  unless  relief  is  speedily  found, 
death  ensues  ;  and  the  younger  the  patient,  the  more  rapid  the  result. 

In  chronic  intussusception,  where  the  bowel  is  probably  only  incarcerated,  the  surgeon 
should  not  withold  his  hand  for  more  than  a  week,  because,  if  relief  is  to  be  obtained  by 
treatment,  it  should  be  obtained  within  the  seven  days  it  is  justifiable  to  expend  in  the 
attempt  ;  and  if  failure  follows,  the  operation  of  laparotomy  should  be  undertaken.  In 
acute  strangulation,  if  relief  is  not  speedily  found,  sloughing  of  the  invaginated  bowel 
may  take  place  ;  and  in  the  chronic,  adhesion  of  the  invaginated  bowel.  Under  either 
circum,stance  operative  interference  mu.st  fail. 

Operative  interference  in  intussu-sception.  however,  has  not  hitherto  been  very  suc- 
cessful, and  its  failure.  I  believe,  is  owing  to  its  having  alway.s  been  postponed  to  too  late 
a  period.  Yet  recent  experience  has  been  more  encouraging,  even  under  not  very  favor- 
able circumstances,  for  Hutchinson  has  recorded  a  case  (Af/d.-C/n'r.  Trans.,  vol.  Ivii., 
187-1)  in  which  he  opened  the  abdomen  of  a  child  aet.  2  on  the  thirteenth  day  of  the 
symptoms  and  drew  out  the  invaginated  bowel  with  a  successful  issue.  Mr.  Howard 
Marsh  had  a  second  ca.se.  in  which  a  like  good  result  was  obtained  in  a  male  infant  seven 
months  old  after  symptoms  of  fourteen  days'  duration  ;  while  my  colleague.  Mr.  Howse, 
had  a  third,  in  a  woman  xt.  28.  a  patient  of  Dr.  Fagge  {ibhf..  vol.  lix..  1876),  in  which 
recovery  took  place.  I  have  likewise  performed  the  same  operation  in  a  dog,  pulling  out 
on  the  fifteenth  day  six  feet  of  invaginated  bowel  with  a  good  result. 

Dr.  H.  B.  Sands  of  New  York  has  also  published  another  successful  case,  in  a  child 
six  months  old  (Xctc  York  Mul.  Jmirn..  June.  1877).  the  operation  having  been  per- 
formed eighteen  hours  after  the  appearance  of  the  .symptoms.  In  intussusception,  how- 
ever, some  success  has  followed,  at  times,  the  practice  of  inflation — a  plan  of  treatment 
that  was  originally  recommended  by  Gorham  years  ago.  When  inflation  cannot  be  used, 
injections  may  be  substituted.  This  operation  has.  however,  its  dangers,  as  bowels  have 
been  ruptured  by  its  u.se.     I  cannot,  therefore,  recommend  it. 

Invpvsion  of  the  body  has  likewise  been  advised,  with  th«  chance  that  the  weight  of 
the  contents  of  the  bowel  above  the  involuted  or  ob.structed  .segment  may  suflSce  to  dis- 
engage it.  Mechanical  kneading  of  the  abdomen  and  the  administration  of  an  anjx'sthetic 
have  also  been  employed  with  a  similar  object. 

Opium  should  always  be  given  in  all  ca.ses  of  mechanical  obstruction,  the  drug  not 
only  relieving  i)ain.  but  checking  the  jKM-istaltic  action  of  the  bowel  which  is  so  injurious. 

These  remedies,  however,  are  doubtful  at  the  best  ;  they  should,  however,  be  tried  in 
early  cases,  as  well  as  when  the  diagnosis  is  uncertain  :  they  must  not  be  used  when  the 
diagnosis  is  certain  or  more  active  treatment  is  called  for  unless  such  treatment  is  abso- 
lutely rejected. 


508 


EyTEROlOMY. 


Laparotomy 

rfrom  kar.aoa.  "the  soft  parts  of  the  bod}-  below  the  ribs."  and  rtir^oj,  "I  cut")  is  a 
name  which  has  been  given  by  Dr.  John  Ashhurst.  Jr.  (^American  Jonrn.  of  Mrrl.  Sciena\, 
1874  j.  to  an  exploratory  operation  upon  the  abdomen  for  the  relief  of  an  internal  strangu- 
lation or  intussusception,  and  is  so  good  that  I  adopt  it.  The  term  '•  gastrotomy  "  is 
applied  to  operations  upon  the  stomach  for  the  removal  of  foreign  bodies  ;  ••  gastrostomy," 
to  an  operation  upon  the  .stomach  with  a  view  of  establishing  a  permanent  fistula  ;  "  colot- 
omy."  to  tho.se  upon  the  large  intestine ;  and  ■•  enterotomy.  "  to  those  upon  the  small. 

In  laparotomy  the  abdomen  should  be  ojtened  in  the  median  line  below  the  umbilicus^ 
though,  if  an  old  hernia  exist,  the  sac  should  be  explored  and  the  abdominal  incision 
made  upward  from  its  neck.  The  abdomen  should  at  first  be  explored  by  the  finger, 
and  more  particularly  toward  the  umbilicus,  since  it  seems  that  bands  are  more  often 
found  opposite  the  promontory  of  the  sacrum  than  anywhere  else.  The  finger  should 
then  be  passed  toward  the  right  iliac  fossa,  to  examine  the  caecum  and  to  feel  for  the 
contracted  empty  small  intestine  which  so  frequently  dips  into  the  pelvis  at  this  spot, 
and  if  found  forms  the  best  guide  to  and  proof  of  intestinal  obstruction.  If  the  finger 
fail  to  find  out  the  seat  of  oVjstruction.  the  opening  must  be  enlarged  and  the  part.s 
inspected.  When  the  operation  is  performed  for  intussusception  and  the  bowel  is  exposed, 
difficulty  has  been  experienced  in  freeing  the  involved  bowel,  and  under  such  circum- 
.stances  the  expedient  used  by  Mr.  Hutchinson  should  be  employed  and  the  invaginated 
portion  pushed  out  backward  from  its  sheath.  After  the  operation  the  peritoneal  cavity 
should  be  well  cleansed  with  antiseptic  sponges  and  the  wound  carefully  adjusted  by 
stitches.  The  p»atient  should  be  kept  under  the  influence  of  opium  or  morphia,  the 
morphia  suppository  every  five  hours  being  the  best  form  to  use.  Milk  diet  should  be 
given  in  small  quantities ;  and  if  recovery  is  to  follow,  it  will  probably  be  speedy,  a.s 
repair  takes  place  rapidly  in  all  abdominal  sections  when  a  ease  goes  on  well,  and  death 
ensues  early  when  the  rever.se  occurs.  Ashhurst  has  collected  123  eases  of  laparotomy, 
of  which  37  recovered  and  86  died. 

Enterotomy, 

or  the  opening  of  some  portion  of  the  small  bowel,  generally  in  the  right  groin,  is  an 
operation  of  great  value,  and  it  is  to  be  regretted  that  it  has  not  received  sufficient  notice. 
It  was  fir.st  p»erformed  Vjy  Xelaton.  at  least  twenty-five  years  ago,  upon  a  patient  of  Trous- 
seau for  chronic  intestinal  obstruction,  and  is  applicable  to  ca.«es  of  abdominal  obstruction 
in  which  the  clinical  evidence  points  to  the  conclusion  that  the  obstruction  is  high  up  in 
the  large  intestine  or  low  down  in  the  small :  to  cases  in  which  •  laparotomy  "'  is  inap- 
plicable and  ••  lumbar  colotomy  "  is  out  of  court :  to  cases  of  obstruction  in  which  relief 
is  required  and  a  more  exact  method  of  giving  it  is  not  clear,  either  from  some  difficulty 
in  diagnosis  or  other  cause.     It  is  described  by  Trousseau  as  follows  {Clin.  Med.,  Lec- 

FiG.  2^ 


Inguinal  Wound  made  in  X-'laton's  Operation  of  Enterotomy. 

ture  77)  :  '•  I  begin  the  operation,  as  Nelaton  advises,  by  making  in  the  right  side  an 
incision  an  inch  in  length,  a  little  above  the  crest  of  the  ilium,  parallel  with  Poupart's 
ligament  (Fig.  288)  ;  the  length  of  this  incision  is  subsequently  increased  to  three  or 


ESTEROTOMY. 


509 


Fig.  289. 


Miide  of  securing  Howel  before 
opening  it. 


four  inclu'S.  In  diviilinjr,  layer  l)y  layer,  tlu;  skin,  tlie  cellular  tissue,  the  iiiu.scles,  and 
a|ii)neur(»ses,  tying  as  may  ln'  re<|nin'il  the  larjre  vessels  involved  in  the  incision,  we  at 
hist  come  to  the  most  det'i»ly-seated  ajioneuntsis.  I'njceedinj^  always  very  slowly  and 
l>ein<r  very  particular  in  spuniiinu'  the  wound  carefully,  this  deej>  aponeurosis  is  cut 
throuirh.  when  forthwith  the  peritoneum  is  reache<l.  It  is  taken  hold  of  hy  a  small  for- 
ceps and  incised  ;  afterward,  usini;  the  <:reatest  j>ossihle  precautions,  a  silver  thntad  is 
carried  hv  means  (d'  a  curved  needle,  tirst  throu;j.h  the  intestine  and  then  throu<j:h  tlie 
ahdominal  walls;  four  sutures  are  then  made,  two  on  each  side  of  the  incision;  two  others 
are  made,  om-  at  the  superitu'  and  the  otiier  at  the  inferior  an<rle  oi'  the  wound;  hut  this 
tinu'  tlic  ahdominal  parietes  are  first  jierforateil,  then  the  intestine,  and  afterward  the 
ahdominal  parietes  on  the  opposite  side  oi"  the  wound.  (  Vide  V\\i.  2lS!>.j  In  this  way 
the  intestine  is  ti.xed  everywhere,  laterally  and  from  al)ove 
downward  to  the  walls  of  the  ahdonien  ;  by  this  proceeding;  n<j 
exudation  can  take  place  into  the  peritoneum.  It  is  then  onli/ 
necessdfj/  to  muke  aii  excrcdlugly  sjiiaU  Incision  in  the  intestine 
by  means  of  a  sharp-pointed  bistoury.  The  openitig  which 
N61aton  makes  is  less  than  a  third  of  an  inch." 

If  the  case  is  not  so  ursrent  as  to  demand  immediate  relief. 
it  would  be  well  to  postpone  opening  the  small  intestine  for 
one  or  two  days,  in  order  to  give  time  for  firm  adhesion  to  take 
place  between  the  bowel  and  the  abdominal  parietes.  Indeed, 
it  may  be  a  (|uestion  whether  it  is  necessary  to  fix  the  intestine 
to  the  abdominal  parietes  by  sutures,  and  whether  it  will  not  adhere  to  the  part  as  a  result 
of  its  simple  exposure  in  the  wound. 

This  operation  is  very  warmly  advocated  by  Trousseau  in  all  cases  of  intestinal  occlu- 
sion, from  whatever  cause,  '•  when  the  symptoms  of  occlusion  have  existed  for  six  or  eight 
days,  when  there  is  great  tympanitis,  when  the  matters  vomited  are  of  a  stercoraceous 
character,  and,  finally,  when  the  persistence  and  severity  of  the  symptoms  presage  immi- 
nent death."  He  had  recommended  its  adoption  in  five  ca.ses,  and  in  two  with  complete 
success,  the  patients  recovering,  who  without  it  would  have  been  hopelessly  lost. 

In  recent,  times  this  operation  has  been  successfully  performed  by  Mr.  McCarthy  on 
the  suggestion  of  Mr.  Maunder  in  1872  (M'd.-Chir.  Trans. ^  vol.  Iv.),  by  Mr.  Wagstaffe 
(St.  Thomas's  Ho.^p.  Rf'p.,  1873),  by  Mr.  Maunder  himself  in  ^fovember.  1875  (Trans. 
Clin.  Soc..  vol.  ix.,  187(J),  and  by  others. 

I  have  performed  it  three  times — once  in  187G  on  an  infant  twelve  davs  old.  who  was 
born  with  an  imperforate  rectum,  and  survived  the  operation  eight  days,  having  been 
gre.itly  relieved  by  it,  but  operation  had  been  postponed  until  too  hite.  The  second  was 
in  May,  1877,  on  a  man  jet.  57  who  had  been  a  patient  of  Dr.  Wilks  for  chronic  obstruc- 
tion of  small  intestine  of  many  months'  standing,  the  chronic  condition  being  aggravated 
every  week  or  ten  days  by  .symptoms  of  a  severe  character  which  threatened  life.  The 
seat  of  the  obstruction  was  too  uncertain  to  allow  of  the  operation  of  colotomy  being  per- 
formed ;  indeed,  the  symptoms  pointed  to  the  small  bowel  as  being  the  seat  of  the  disease, 
and  on  that  account  enterotomy  was  undertaken.  The  operation  gave  rapid  and  perma- 
nent relief,  and  the  man  was  convalescent  in  a  mouth.  His  temperature,  as  shown  by 
the  chart,  was  never  higher  than   1U(I°.     He  is  alive  and  well  at  the  present  day.  but  the 

Fk;.  290. 


DAY  or 

DISEASE.     ^      ^ 


1011  12  13  14  j: 


immmmf^immmSSkmmmmmmmA 


•Ise  \64\66\73\7^\76\7o\76id6W8^M\9O^^90\78\72\3'^\84'84\9c  76 


Therinograpli  of  i  ase  i)f  Knterotomr  in  a  Man  jet.  "  for  fhronio  *>hstructi'>n. 
(Temperature  never  readied  luo^,  and  patient  \va-  cmivalescent  in  a  niontli.    Fluctuation  of  temperature  very  slight.) 

inconvenience  connected  with  the  artificial  anus  is  so  troublesome  as  to  neutralize  greatly 
the  advantages  of  the  operation.  The  third  was  on  the  person  of  a  man  xi.  50  whom  I 
saw  in  consultation  with  Dr.  Cortis  of  Kennington  in  July,  1877,  for  complete  intestinal 
obstruction.  He  had  been  ill  two  months  with  abdominal  pain  and  constipation,  but 
sought  advice  only  when  the  pain  had  become  very  severe  and  vomiting  appeared.  When 
I  saw  him,  the  constipation  was  insuperable,  vomiting  incessant,  and  the  abdomen  much 


510  COLECTOMY. 

distended.  No  obstruction  could  be  felt  in  the  rectum  ;  both  loins  were  ver}'  resonant, 
and  it  was  believed  that  the  obstruction  was  about  the  cjujcuui.  I  consequently  per- 
formed Nelaton's  operation  of  enterotomy,  as  described,  on  July  7.  The  operation  gave 
immediate  relief  and  everything  went  on  well  subsequently,  the  temperature  never  rising 
beyond  99°.  He  left  the  hospital  six  weeks  afterward,  the  whole  of  his  motions  passing 
through  the  artificial  anus  and  not  a  trace  of  wind  or  motion  passing  jjer  a  num. 

On  his  return  home,  for  want  of  good  nursing,  a  bed-sore  appeared,  and  he  died  in 
November,  1877.  After  death  it  was  found  that  the  lower  part  of  the  ileum  had  been 
opened  three  inches  from  the  cascum,  and  that  the  seat  of  stricture  was  in  the  ascending 
colon,  just  above  the  caecum.  It  was  cicatricial  and  evidently  due  to  the  contraction  of 
some  old  ulcer ;  the  viscera  were  healthy.  I  subsequently  learnt  from  Dr.  Cortis  that 
this  patient  had  hurt  himself  in  the  right  side  of  his  abdomen  three  years  before  his  ill- 
ness in  a  fall  over  a  case  of  goods,  and  that  the  accident  was  followed  by  sickness  and 
pain,  with  nausea  and  occasional  vomiting.  It  is  quite  possible  that  the  stricture  was 
the  result  of  this  injury. 

This  patient,  as  well  as  the  other,  complained  sadly  of  the  annoyance  caused  by  the 
constant  flow  of  feces  from  the  inguinal  anus,  no  mechanical  appliance  having  the  power 
of  controlling  it.  .  , 

Colectomy. 

This  term  is  applicable  to  cases  in  which  a  portion  of  the  colon  has  been  removed 
either  by  abdominal  section  or  through  a  lumbar  wound.  Under  the  former  circumstances 
the  operation  might  be  called  "  abdominal."  and  under  the  latter  "  lumbar,"  colectomy. 

I  was  the  first  to  suggest  and  to  perform  the  latter  operation  in  this  country,  and  I 
did  so  on  September  10,  1881,  for  a  lady  tet.  50  who  had  sufl'ered  from  eight  weeks' 
obstruction,  with  such  success  that  she  lived  between  thirteen  and  fourteen  months,  and 
died  October  29,  1882,  of  cancer  of  her  liver  and  spleen.  (See  Met/.-Chir.  Trans. ^  vol. 
Ixv.,  1882). 

OPERAxroN. — I  commenced  the  operation  with  my  usual  oblique  lumbar  incision,  as 
for  "  colotomy,"  and,  having  reached  the  bowel  and  found  that  the  strictured  portion 
could  be  drawn  out  of  the  wound,  I  determined  to  excise  it.  This  I  did  by  first  stretching 
the  presenting  wall  of  the  intestine  above  the  strictured  portion  to  the  margins  of  the 
wound,  evacuating  the  contents  of  the  bowel  through  a  limited  orifice,  and  subsequently 
securing  the  under  lip  of  the  upper  portion  of  bowel  to  the  lower  margin  of  the  wound, 
having  with  scissors  .carefully  detached  the  strictured  segment  of  the  colon  from  its  upper 
attachments  and  stretched  the  bowel  to  the  orifice  of  the  wound  step  by  step. 

The  strictured  segment  of  gut  was  then  separated  from  its  attachments  below,  and 
the  upper  orifice  of  the  lower  portion  of  the  bowel  carefully  secured  to  the  wound  in 
close  contact  with  the  upper  portion.  Great  care  was  observed  all  this  time  to  keep  the 
parts  clean  and  prevent  anything  gravitating  into  the  abdominal  cavity. 

The  operation  was  not  a  difficult  one. 

The  idea  of  removing  an  organic  structure  of  the  large  bowel  through  the  wound 
made  for  a  left  lumbar  colotomy  suggested  itself  to  me  several  years  ago,  after  having 
seen,  in  operations  of  colotomy  as  well  as  in  the  post-mortem  room,  many  examples  of 
annular  or  localized  stricture  of  the  bowel  which  were  freely  movable  in  the  peritoneal 
cavity,  free  from  all  attachments,  and  within  easy  reach  of  the  surgeon's  fingers  through 
the  lumbar  wound.  For  it  is  in  these  cases,  and  in  these  alone,  that  the  operation  is 
possible. 

The  thought  was  likewise  encouraged  by  the  analyses  of  cases  tabulated  on  page  501, 
from  which  it  was  shown  that  in  three  out  of  four  cases  of  chronic  intestinal  obstruction 
the  stricture  is  located  in  the  descending  colon,  and  that  in  about  one-third  of  these  cases 
the  disease  is  of  an  annular  or  local  character,  such  strictures  being  the  least  malignant 
of  epithelial  growths. 

Should  this  operation  meet  with  the  support  it  deserves,  some  change  in  practice  may 
be  required  ;  for  it  would  be  wise  to  entertain  the  operation  of  colectomy  at  an  earlier 
period  of  the  stricture's  progress  than  it  has  hitherto  been  the  custom  for  physicians  or 
the  majority  of  surgeons  to  entertain  that  of  colotomy,  since  the  operation  of  colectomy 
would  be  more  readily  performed  when  the  bowel  above  the  stricture  is  undistended  and 
comparatively  healthy  than  when  it  is  full  of  retained  feces  and  probably  ulcerated  from 
overdistension.  The  operation,  moreover,  when  performed  under  those  more  favorable  cir- 
cumstances, would  be  safer,  since  in  the  healthy  bowel  above  and  below  the  strictured  seg- 
ment the  surgeon  may  with  more  confidence  draw  the  inward  portion  upward  from  the- 


COLOTOMY.  511 

pt'lvis  or  ili>wii\var<l  and  liackwanl  riipiii  ilii'  splriiic  rcirinn,  and  (•(nisci|M«iitlv  n-inov*^  it 
with  irri-atcr  safi-ty  and  facility. 

The  consideration  of  cnlcctoiny  in  any  ;.'ivon  case  will  consofjucntly  ;rive  a  lu;lp  to 
colotoiny  where  it  is  most  netMled.  for  it  will  enci>ura^(!  medical  men  to  entertain  the  (jue»- 
tion  of  operative  relief  for  ohstruetion  as  soon  as  the  dia<;noMis  of  organic  stricture  has 
been  made,  and  not  to  ]iostpone  it  till,  as  I  have  heard  it  advised,  oltstrnetion  has  existed 
for  six  weeks,  when  the  chances  of  success  hy  any  operation  are  indeed  small. 

I  helieve  tin;  operation  of  colectomy  for  the  treatment  of  localize(l  strictures  of  the 
sigmoid  Hexure  will  he  foun<l  to  he  a  valual)le  adilitional  means  of  <rivinfr  relief,  and  po.s- 
f<il>ly  of  curintr  a  certain  proportion  (d"  cases.  It  should  he  considered  in  all  ca.se  of  stric- 
ture <d'  the  deseendintr  liowtd  not  rectal,  and  entertained  as  snon  as  the  iliajrnosis  (jf  the 
case  has  heen  made  ami  lielure  symptoms  ot'  oKstniction  are  a  source  of  anxiety  or  of  a 
threatenini,'  character. 

Since  the  one  recorded  1  have  seen  two  cases  in  which  the  ojieration  seenaed  desirable. 
Iti  one  the  a<lvice  was  rejected,  in  the  other  it  was  acted  upon;  and  the  sur<;con  who  pcr- 
formeil  it  found  the  diairnosis  correct  and  removed  the  stricture,  but  without  success.  My 
friend  .Mr.  .Icdiii  Marshall  has  recorded  a  later  case  in  the  Laiiat  for  May  <»,  188-,  and 
has  given  an  interesting  lecture  ujion  the  subject  which  may  be  read  with  benefit. 

COLOTOMY. 

For  irremediable  stricture  or  mechanical  obstruction  of  the  rectum  from  any  cause, 
wluMi  colectomy  is  iiiaj))dioable,  Cd/fisfn'.s  operation  of  opening  the  colon  in  the  fe/f  loin 
should  be  lollmved  ;  but  when  the  seat  of  obstruction  is  higher  than  the  rectum,  and  if 
there  be  a  doubt  wliether  it  is  in  the  signioid  flexure  or  transver.se  colon,  Ai)iiisstif's  ope- 
ration in  the  right  loin  should  be  performed.  Callisen  first  suggested  colotoiny  in  l~iU] 
and  applied  it  to  the  descending  colon,  but  Amussat  revived  the  operation  and  extended 
it  to  the  ascending  coIoh  in  18iJI>. 

The  colon  in  this  ])osition  lies  behind  the  peritoneum,  immediately  beneath  the  tran.s- 
versalis  fiiscia.  The  kidney  is  in  close  contact  with  it  above,  and  in  one  case  on  which  I 
operated  the  organ  was  placed  so  low  down  as  to  fill  in  the  space  between  the  rib  and 
pelvis,  and  had  to  be  pu.shed  upward  to  allow  the  colon  to  be  seen  and  opened.  The  ope- 
ration on  the  left  loin  can  be  performed  as  follows: 

The  patient  is  to  be  placed  on  his  right  side,  with  a  pillow  beneath  the  loin,  in  order 
to  arch  somewhat  the  left  flank,  and  he  should  be  turned  two-thirds  over  on  his  face  ;  the 
outer  border  of  the  erector  spinne  and  of  the  quadratus  lumborum  muscle  can  then  be 
made  out.  this  latter  muscle,  which  is  on  a  deeper  plane,  being  the  surgeon's  main  guide. 
Its  outer  border,  with  the  descending  colon,  is  to  be  found  half  an  inch  to  an  inch  po.ste- 
rior  to  the  centre  of  the  crest  of  the  ilium,  the  centre  being  the  point  midway  between 
the  anterior  and  posterior  superior  sjiinous  processes.  Allingham  says  that  in  more  than 
fifty  dissections  he  has  always  found  the  descending  colon  to  be  situated  at  the  former 
point.  When  difiiculties  are  felt  in  the  operation,  he  believes  they  arise  from  the  colon 
being  looked  for  too  fixr  from  the  spine  (.SV.  Thomas's  Uo^pi/nl  Rrporfs,  1870),  and  in  that 
opinion  I  cordially  agree.  An  incision  is  then  to  be  made,  four  or  five  inches  long,  begin- 
ning an  inch  and  a  half  to  the  left  of  the  spine,  below  the  last  rib,  and  passing  downward 
and  forward  parallel  with  the  crest  of  the  ilium  ;  the  line  of  the  incision  should  pas? 
obliquely  across  the  external  border  of  the  quadratus  lumborum  muscle  about  its  centre, 
•so  as  to  take  the  same  direction  as  the  nerves  which  traverse  this  part.  By  this  incision 
the  integuments  ami  muscles  and  fascia  are  divided  and  the  outer  border  of  the  quadratus 
muscle  exposed.  The  abdojninal  muscles  can  be  divided,  to  give  room.  All  vessels  are 
now  to  be  secured.  The  transversalis  fascia  will  next  come  into  view,  and  beneath  this 
will  be  the  colon,  a  layer  of  fat  intervening.  The  fascia  is  to  be  opened  with  caution,  for 
in  the  loo.se  fat  and  cellular  tissue  the  colon  is  to  be  found.  When  distended,  the  bowel, 
on  dividing  the  fascia,  comes  at  once  under  the  eye;  but  when  empty,  some  little  trouble 
may  be  experienced  in  hooking  it  up  with  the  finger.  The  inflation  of  the  colon  with  air 
by  means  of  an  enema  syringe  or  Lund's  apparatus  is  at  this  stage  of  the  operation  often 
of  great  a.ssistance,  the  inflated  bowel  rolling  up  into  the  wound  in  a  very  satisfactory 
manner.  The  bowel  can  always  be  found  in  front  of  the  lower  border  of  the  kidney. 
This  organ  should,  consequently,  be  sought,  as  it  is  the  only  certain  guide  to  the  bowel. 
I  have  found,  however,  on  several  occasions,  at  this  stage  of  the  proceeding,  great  help  by 
rolling  the  patient  over  on  his  back-,  the  bowel  fiiUing  by  this  manoeuvre  on  the  finger  and 
beiii'.''  then  readily  caught. 


512 


COLO  TOM  Y. 


When  the  bowel  has  been  caught,  it  should  be  partially  rolled  forward,  in  order  to 
expose  its  posterior  surface  ;  for  if  this  be  not  done, there  is  a  risk  of  the  surgeon  wound- 
in  ti-  the  peritoneum  where  it  is  reflected  from  its  anterior  surface  on  to  the  abdominal  wall. 
The  bowel,  having  been  drawn  up  to  the  wound,  is  then  to  be  secured  to  the  integument, 
and  not  to  the  muscles,  by  the  passage  of  a  ligature  introduced  through  one  margin  of 
the  wound,  then  through  the  bowel,  and  lastly  through  the  other  margin.  The  bowel  can 
then  be  opened  by  an  incision  about  half  an  inch  long  between  the  ligatures  that  have, 
traversed  its  canal;  the  centres  of  the  ligatures  are  then  to  be  drawn  out  through  the 
wound  and  divided,  the  two  halves  of  the  ligatures  fixing  the  two  sides  of  the  divided  intes- 
tine firmly  to  the  margins  of  the  wound  ;  two  or  more  stitches  may  then  be  introduced,  to 
make  the  artificial  anus  secure.  AVhen  the  necessity  of  giving  relief  to  obstruction  is  not 
great,  the  bowel  may  be  carefully  stitched  to  the  margins  of  the  wound  and  opened,  as  in 
enterotomy  and  gastrostomy,  on  the  third  or  fourth  day,  the  risks  of  peritonitis  being 
diminished  by  this  means.  The  surgeon  may.  however,  do  what  my  colleague  Mr.  Howse 
has  done — simply  draw  the  bowel  out  of  the  wound  and  hold  it  out  for  two  or  three  days 
by  means  of  forceps,  when  the  protruded  bowel  will  have  become  firmly  united  to  the  mar- 
gins of  the  wound  and  may  be  opened  with  safety  or  removed  as  in  a  colectomy.  The 
margins  of  the  wound  may  be  oiled,  to  guard  against  the  irritation  of  feces,  and  the 
patient  placed  in  bed.  At  times  the  feces  escape  in  large  quantities  directly  the  bowel  is 
opened ;  at  others  some  slight  feculent  discharge  will  take  place  at  the  time,  the  larger 
flow  taking  place  later.  This  is  not,  however,  a  matter  of  any  importance,  and  the  sur- 
geon should  take  no  measures  to  cause  the  bowels  to  act ;  indeed,  it  is  better,  so  far  as 
the  operation  is  concerned,  that  the  flow  be  postponed,  for  within  an  hour  or  so  the  parts 
about  the  wound  become  sealed  with  lymph,  and  thus  the  risks  of  extravasation  are 
diminished. 

Callisen  originally  suggested  the  vertical  incision  in  the  left  loin,  and  Amussat  the 
trdiisce/f;''  in  the  right,  the  latter  crossing  at  right  angles  the  outer  border  of  the  quadratus 
luniborum  muscle,  the  former  run- 
ning parallel  with  it.  The  oUujue  Fig.  291. 
appears  to  me  to  be  preferable  to 
either,  as  it  gives  more  room  for 
manipulation  when  the  colon  is 
empty ;  it  takes  the  line  of  the 
nerves  and  vessels  that  traverse 
this  part  and  lessens  the  ri.<^k  of 
their  division  ;  it  follows  the  or- 
dinary integumental  fold  of  a 
patient  when  assuming  the  re- 
cumbent posture,  and  thus  favors 
repair,  and  seems  to  tend  much 
toward  the  prevention  of  the  pro- 
lapse of  the  bowel  that  is  always 
liable  to  follow  such  an  opera- 
tion. Fig.  291  illustrates  the  line 
of    incision    and    the    appearance 

of  the  artificial  anus.  It  was  taken  from  a  patient  set.  64  whom  I  operated  upon  in 
1860  for  vesico-intestinal  fistula,  and  who  died  five  and  a  half  years  subsequently 
(1875)  from  a  ruptured  heart.  The  gentleman  followed  his  avocation  without  any 
discomfoi't. 

After-Treatmext. — After  the  operation  a  sedative  should  be  given,  such  as  opium, 
morphia,  or  chloral,  and  the  recumbent  position  maintained,  a  piece  of  oil  lint  covered  with 
oakum  and  kept  in  place  with  a  soft  towel  being  the  best  application. 

The  sutures  may  be  removed  on  the  fourth  or  fifth  day.  according  to  circumstances, 
while  perfect  cleanliness  must  be  observed. 

Nutritive  food  and  stimulants  maybe  given  within  a  day  or  so  of  the  operation,  repair, 
as  a  rule,  going  on  favorably. 

When  the  wound  has  cicatrized,  the  patient  may  get  up  and  a  pad  be  applied,  covered 
by  a  folded  napkin  and  fastened  on  with  a  lumbar  binder  or  a  pure  rubber  plug  and  shield 
as  made  for  me  by  Messrs.  Krohne  of  8  Duke  street.  Manchester  !<quare. 

With  the  oblique  incision  the  prolapse  of  the  bowel  does  not  appear  to  be  the  cause 
of  much  annoyance,  since  it  seems  to  take  place  to  a  very  slight  extent. 

When  contraction  of  the  orifice  takes  place  to  too  great  an  extent,  a  .sponge  tent  or 


Artificial  Auus  after  Colotomy  with  the  Oblique  Incision. 


courroMY.  51. '3 

short  hdii^'if  may  <lai!y  Ik'  intnMliiccd.  I  have,  hnwi-v*  r.  met  with  Ijiit  one  case  requiring 
this  treatiui-nt. 

AfU'r  I'ouvak'scont'o  it  is  well  occasionally  to  wash  out  the  lower  j»ortion  of  the  howcl 
with  warm  wat«'r,  as  some  feces  are  apt  to  pass  the  artificial  ojtening  and  rest  in  the  rectum, 
causin<r  irritation.  When  the  anal  end  is  open,  it  is  best  to  do  this  through  the  natural 
openinu;  and  when   closed,  throu^^h  the  artificial. 

i'uuci.vosis. — I  have  now  perfurnicd  this  oporation  about  eighty  times,  and  in  no 
single  case  have  I  ever  regretted  doing  so,  although  in  a  large  number  I  have  wished 
earnestly  that  I  had  had  an  ojiportunity  of  performing  it  earlier,  since  in  no  instance  did 
it  fail  to  give  relief  One  of  the  cases  of  vesieo-intestinal  fistula  lived  nearly  six  years 
after  the  operation,  and  died  let.  TO  from  rupture  of  tin-  heart.  Another  is  now  alive, 
thirteen  years  after  the  operation,  ami  enjoying  life,  suffering,  indecil.  very  little  incon- 
venience from  the  artificial  anus  {Clin.  Sor.,\H~'l).  The  patient  with  fibrous  growths 
in  tile  rectum  was  operated  upon  November  14.  ISTT.  and  is  now  living  in  comfort. 

Of  the  patients  with  stricture,  cancerous  and  otherwise,  one  lived  five  years,  two  four, 
three  lived  three  years  after  the  operation,  several  two.  and  very  many  one.  Many  were 
alive  when  last  heard  of,  two  having  been  operated  ujion  three  years  previou.sly,  two  two 
years,  and  two  within  the  year.  In  every  ca.se  marked  relief  wa.s  afforded  to  .symptoms, 
and  in  many  the  patients'  expressions  of  gratitude  for  such  were  very  strong,  .several 
having  deeply  regretted  that  the  operation  had  not  been  performed  at  an  earlier  period. 
In  many  of  these  cases  the  operation  was  undertaken  as  a  last   resource. 

In  one  of  the  patients  colotomized  for  vesico-intestinal  fistula,  who  is  now  alive,  thir- 
teen years  after  the  nporation.  urine  finds  its  way.  when  he  is  recumbent,  out  of  the  lum- 
bar artificial  anus:  and  in  another,  who  survived  the  operation  nearly  six  years,  the  same 
complication  presented  itself.  In  neither  instance,  however,  was  the  flow  a  source  of 
trouble.  This  flow,  however,  might  have  been  enough  to  keep  patent  that  portion  of  the 
intestine  that  existed  between  the  artificial  anus  and  the  bladder  and  to  preserve  it  from 
atrophy,  such  a  result  of  colotomy  being  clearly  possible.  The  late  Dr.  Michael  Harris 
of  Liverpool  recorded  in  the  Llorpool  Hospital  Rrports  for  1S74  the  particulars  of  a  post- 
mortem examination  where  3Ir.  Hakes  had  performed  colotomy  five  years  previously  for 
vesieo-intestinal  fistula,  in  which  the  descending  colon  from  the  artificial  anus,  together 
with  the  sigmoid  flexure  and  rectum  as  far  as  the  bladder,  had  become  rompletelij  ohUf- 
erated  and  was  found  to  be  replaced  by  a  cylindrical  mass  of  fat.  The  length  of  this 
fatty  column  was  about  six  or  seven  inches,  and  in  the  centre  of  it  was  found  a  fibrous 
cord  of  about  a  line  in  thickness,  but  no  trace  of  a  canal  of  any  kind  could  be  therein 
detected. 

The  operation  of  colotomy  is  beneficial  in  all  cases  of  vesieo-intestinal  fistula  when 
solid  feces  flow  with  the  urine ;  in  all  cases  of  stricture  of  the  rectum  that  cannot  be 
removed  by  colectomy  so  soon  as  the  obstruction  becomes  serious  and  local  distress  great; 
in  all  other  cases  of  mechanical  obstruction  to  the  rectum  from  pelvic  causes  when  no  less 
severe  measures  for  relief  can  be  suggested;  and,  last,  but  not  least,  in  extensive  ulcera- 
tion of  the  rectum,  cancerous,  .syphilitic,  or  simple,  when  local  treatment  fails  to  give  relief 
and  local  distress  is  great,  when  the  general  powers  are  evidently  giving  way  from  the 
local  disea.se  quite  irrespective  of  mechanical  obstruction. 

In  no  case,  however,  should  the  operation  be  postponed  till  the  patient's  powers  are 
failing,  when  the  pro.spects  of  recovery  would  be  greatly  lessened  and  convale-scence  is 
often  rendered  improbable. 

Si'MMARY. — By  way  of  summary,  therefore,  it  may  be  stated  that — 

Laparotomy  is  an  operation  which  should  be  performed  in  all  cases  of  acute 
intestinal  uli-tructinn  due  to  bands,  internal  hernia,  and  intussusception  that  do  not 
speeilily   yield  to  otiier  treatment. 

Lumbar  Colectomy  should  be  performed  when  the  stricture  in  the  large  intes- 
tine is  aiimilar.  localized,  and  movable. 

Colotomy  is  applicable  to  cases  of  obstruction  to  the  large  intestine  from  stricture 
or  the  mechanical  pres-ure  of  tumors  that  cannot  be  relieved  by  other  means. 

Enterotom.y  aflbrds  a  means  of  relief  for  all  other  cases  of  intestinal  obstruction 
to  which  the  two  former  operations  are  inapplicable,  and  more  particularly  when  the  small 
intestines  are  involved. 

33 


514 


LUMBAR  COLOTOMY. 


REMARKS. 

I  have  been  induced  to  tabulate  and  analyze  my  own  cases  of  lumbar  colotomy,  and 
to  embody  the  results  of  the  analysis  in  a  paper  which  I  read  at  the  Copenhagen  Medical 
Congress,  1884.     (See  Transact ioits.') 

The  Tables  and  the  conclusions  drawn  from  the  analysis  and  consideration  of  them 
tell  much  in  favor  of  lumbar  colotomy,  and  on  that  account  I  have  deemed  it  expedient 
to  introduce  them  in  this  volume. 

The  conclusions  to  which  I  was  led  in  my  paper  were  embodied  in  the  following  prop- 
ositions, which  I  believe  my  material  proved ; 


Table  I. — Cases  of  Lumbar  Colotoray  for  Cancer 


No. 

Hospital  or  Private 
Patient. 

Name  of  Patient. 

Age. 

Date  of 
Operation. 

Colotomy 
Right  or  Left. 

1 

Hospital.— 

Dr.  T.  Addison. 

Mary  P . 

48 

Oct.      6,  1859. 

Left. 

2 

Private. 

Mr.  T . 

61 

Nov.    2,  1868. 

Left. 

3 

Hospital. 

William  B 

52 

xMay  12,  1871. 

Left. 

4 

Hospital. 

Thomas  M 

68 

Aug.  20,  1872. 

Left. 

5 

Hospital. 

Edmund  B . 

67 

May     7,  1872. 

Left. 

6 

Hospital. 

William  H 

64 

July  17,  1873. 

Left. 

7 

Private. 

Mr.  H 

69 

July  10,  1873. 

Left. 

8 

Hospital. 

Frederick  D . 

38 

Aug.  26,  1873. 

Left. 

9 

Hospital. 

Emma  W . 

44 

Jan.  12,  IS74. 

Left. 

10 

Private. — 

Mr.  R.  Phillips. 

Mr.  G 

37 

June,        1874. 

Left. 

11 

Private. — 
Dr.  Baber. 

Mrs.  B . 

56 

March,     1875. 

Left. 

12 

Private. 

Mr.  P . 

45 

July  30,  1875. 

Left. 

13 

Hospital. 

William  M 

44 

Sept.    3,  1875. 

Left. 

14 

Private. — 

Drs.  Huddard  and  Habershon. 

Mr.  B 

52 

March,     1876. 

Right. 

15 

Private. — 
Dr.  Owens. 

Mr.  S 

37 

Aug.  14,  1877. 

Left. 

16 

Hospital. 

Eliza  C . 

56 

Jan.     9,  1877. 

Left. 

17 

Hospital. 

William  T 

54 

Aug.  15,  1877. 

1 
Left. 

18 

Hospital. 

Michael  S . 

55 

Anril  4,  1879. 

Left. 

19 

Private. — 

Dr.  Gorham,  Tunbridge. 

Miss  H 

52 

Nov.  30,  1880. 

Left. 

20 

Hospital. 

Arthur  le  G . 

62 

Nov.  22,  1881. 

Left. 

21 

Private. — 

Dr.  Deeping,  Southend. 

Mr.  S 

64 

Feb.  10,  1882. 

Left. 

22 

Private. — 

Mr.  E.  Wright. 

Mr.  H 

64 

April  26, 1882. 

Left. 

23 

Private. — 

Mr.  W.  Burton. 

Mr.  H 

47 

June  25,  1882. 

Left. 

24 

Private. — 

Dr.  May  of  Maldon. 

Mrs. . 

51 

Oct.    18,  1882. 

Left. 

25 

Hospital. 

Eliza  H . 

55 

Dec.     5,  1882. 

Left.                   j 

26 

Private. — 

Dr.  Neumann. 

Mr.  A . 

52 

Aug.  22,  1883. 

Right.                ! 

Analysis  of  the  Twenty-six  Cases. — 19  in  males,  7  in  females.     Average  age,  53§  j-ears.     Average 
age  of  men,   54J ;    of  women,   51^.     Twenty-four   of  the   cases   were   on    the    left    side    and   2   on   the 


i.rM/iAi:  coi.nToMY. 


515 


Propositions. 

1.  Tliat  ill  all  i-asi's  of  caiiccrmis  stricture  (if'tiic  rcctiiiii  nr  colon,  iiicliidiii^  tlic  annu- 
lar— wliicli  arc  not  aincnal)Ic  to  liiniKar  rt,l,rti,nij/  or  anal  excision — ri;:lit  or  lel"t  lunihar 
colotoniy  is  stronjriy  to  l»e  atlvocatcd.  wiili  the  \vell-^'roiiinIc»l  hope  of  relievinj;  Kuft'erinf;, 
rctanliim  the  |iroj::ress  ol"  tho  di.seasc,  and  of  prolontrinir  |ilc  even  lor  five  or  six  yi'ars. 

'1.  'i'hat  liiiiiliar  colotoniy  is  valiiahle 'as  a  rnrtitirc  operation  in  syphilitic  and  simple 
ulcerations  (d"  the  howel  which  resist  other  treatnieiit,  includin^r  cases  ol"  recto-ve.sical 
listiila,  and  that  it  is  n'iiie(lial  in  examples  of  volvulus  of  the  sigmoid  flexure,  as  well  as 
of  olistniclions  caused  l»y  tuiimrs. 

:!.  That  to  secure  these  advantages,  it  is  necessary  i'or  the  operation  to  he  performed 
Ik  rmc  the  |ieriiicious  elli-cts  of  ohstruction  occur. 

1  trust  this  material  will  help  to  place  the  operation  ai'  luml»ar  colotoniy  in  the  posi- 
tion to  wliirli  it  is  cut itlcil. 


that  Di^d  within  the  Month  ("Too  Late  Cases' 


Disease  for  which  Operation  was  performed. 


Result. 


Annular  stricture  of  rectum.     Obstruction  complete 

for  f)  weeks. 
Cancerous  stricture  of  rectum.     Symptoms  2  years. 
Epithelioma  of  anus  and  rectum  of  fi  years'  growth. 

Cancerous  stricture  of  rectum.     Syiiipti>nis  2  years. 

Cancerous  stricture  of  rectum.  Severe  symptoms  S 
months. 

Cancerous  stricture  of  rectum.  Symptoms  2  years, 
blood  for  months. 

Cancerous  stricture  of  rectum.  Obstruction  complete 
for  weeks. 

Increasing  obstruction  for  6  years.  Reeto-vesical 
fistula  for  months. 

Cancerous  stricture,  with  symptoms  for  5  years.  Ob- 
struction for  5  months. 

Cancerous  stricture  of  rectum  of  many  months' 
staniling. 

Chronic  obstruction  complete. 

Cancerous  stricture  of  rectum. 

Cancerous   disease   of  rectum,  with    fecal   fistula   9 

months. 
Annular  stricture  of  transverse  colon.     Symptoms  1 

j'ear,  obstruction  4  weeks. 
Cancerous  stricture  of  rectum  of  slow  contraction. 

Cancerous  stricture   of  rectum.      Symptoms   3  or  -4 

years.     Blood. 
Cancerous    stricture    of  rectum.      Pain,    blood,    and 

mucus,  with  feces,  for  S  years. 
Cancerous  stricture  of  rectum.     Nine  months. 

Cancerous  stricture  of  rectum  many  months.  Ob- 
struction ?>  weeks. 

Cancerous  stricture  of  rectum.  Bleeding  for  18 
months. 

Cancerous  stricture  of  rectum. 

Cancerous  stricture  of  rectum. 

Cancerous  stricture  of  rectum. 

Cancerous  stricture  of  rectum. 

(^ancerous  stricture  of  rectum  and  vagina  15  months. 
Stricture  of  rectum. 


Sank.     Died  on  12th  day,  greatly  relieved. 

Sank  on  2d  day. 

Died    on    24th    day.     Sank ;    operation   wound 

healed.     1'.  M. — Cancer  of  viscera. 
Sank  on  ."'d  day.     P.  M. — Large  cancerous  mass 

in  jtelvis. 
Sank  on  6th  day.     P.  M.— Disease  quite  local. 

Sank  on  .^.d  day.     Peritonitis;  bowel  had  rup- 
tured above  the  stricture. 
Sank  on  20th  day. 

Sank  on  10th  day.  Cancerous  ulcer  into  blad- 
der, with  secondary  growths. 

Sank  on  ;jd  day.  Peritonitis;  cancerous  ulcer 
between  the  rectum  and  jejunum. 

Sauk  on  4th  day. 

Sank  on  7th  day. 

Sank  on  3d  day. 

Sank  on  3d  dav.     Peritonitis.     P.  M. — Bowel 

above  stricture  ruptured. 
Sank  on  1 0th  day.    P.  M. — Confirmed  diagnosis. 

Sank  on  5th  day. 

Sank  on  lid  day.     P.  M. — Cancer  in  viscera  and 

peritoneum. 
Died  on  ISth  day  suddenly,  from  sudden  pain, 

collapse,  and  ruptured  spleen.  No  peritonitis. 
Sank   on  23d  day.     P.   AI. — Peritoneal  cancer 

and  volvulus  of  sigmoid  flexure. 
Sank  on  3d  day. 

Sank  on  4th  day.     P.  M. — Peritonitis  and  much 

cancer. 
Sank  on  5th  day. 

Sank  on  5th  day. 

Sank  on  5th  day. 

Sank  on  5th  day. 

Sank  OP  27th  day. 
Sank  on  4th  dav. 


No. 


9 

10 

11 

12 
13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 
26 


right  side.      Eighteen  of  them    died    in   the   first  week,  3  in  the  second  week,  2  in   the  third 
and  3  in  the  fourth  week. 


week, 


516 


LUMBAB  COLOTOMY. 


Table  II. — Cases  of  Lumbar  Colotomy 


No. 

Hospital  or  Private 
Patient. 

Name  of  Patient. 

Age. 

Date  of 
Operation. 

1 
Colotomy 
Right  or  Left. 

1 

Hospital. 

James  W . 

39 

July  31,  1868. 

Left. 

2 

Hospital. 

Martha  P . 

57 

May  31,  1870. 

Left. 

3 

Private. 

Miss  B 

18 

Sept.    6,  1871. 

Right. 

4 

Hospital. 

Eliza  B . 

38 

Oct.    10,  1S71. 

Left. 

5 

Hospital. 

Richard  C . 

46 

Jan.     9,  1872. 

Left. 

6 

Private. 

Mrs.  B . 

24 

Feb.  10,  1872. 

Left. 

7 

Hospital. 

George  S — — . 

56 

April  14, 1873. 

Left. 

8 

Private. — 

Dr.  Stillwell  and  Sir  W.  Gull. 

Mrs.  B . 

72 

Dec.     6,  1874. 

Right. 

9 

Private. — 

Dr.  Brown,  Ealing. 

Mr.  R 

64 

June    2,  1876. 

Left. 

10 

Private. — 

Mr.  T.  Harries,  Aberystwzth. 

Mr.  T.  D -. 

57 

Feb.  12,  1877. 

Left. 

11 

Private. — 

Drs.  Chambers  and  Menzies. 

Mr.  A 

57 

Dec.  30,  1876. 

Left. 

12 

Private. — 

Mr.  Hodgson,  Brighton. 

Mr.  B 

54 

April  16,1878. 

Left. 

13 

Private. — 
Dr.  Drewry. 

Mrs.  B . 

56 

Mar.    4,  1878. 

Left. 

14 

Private. — 
Dr.  Wallace. 

Mr.  S 

42 

June  13,  1878. 

Left. 

15 

Hospital. 

John  B . 

39 

June  27,  1S7S. 

Left. 

16 

Hospital. 

George  W . 

51 

Nov.  12,  1878. 

Left. 

17 

Private. — 
Dr.  Bowes,  Heme  Bay. 

Mr.  S 

64 

April  5,  1879. 

Left. 

18 

Private. — 

Dr.  Kiddle,  Leamington. 

Mr.  H 

66 

Xov.    8,  1879. 

Left. 

19 

Hospital. 

Marv  T . 

59 

Dec.     9,  1879. 

Left. 

20 

Hospital. 

Alice  P . 

25 

Aug.    6,  ISSO. 

Left. 

21 

Hospital. 

Eliza  C . 

29 

Feb.     3,  1880. 

Left. 

22 

Private. — 
Dr.  Andrews. 

Mr.  W 

42 

Nov.  15,  1880. 

Left. 

23 

Hospital. 

Emma  R . 

38 

Nov.  61,  1880. 

Left. 

24 

Private. — 

Mr.  J.  Burton  and  Dr.  Higgens. 

Mrs.  S . 

42 

April,      1881. 

Left. 

25 

Hospital. 

Charles  H 

64 

June  18, 1S81. 

Left. 

26 

Hospital. 

Samuel  Robinson. 

15 

Dec.  30,  1881. 

Left. 

27 

Hospital. 

John  James. 

60 

Feb.  15,  1881. 

Left. 

28 

Hospital. 

Eliza  W 

46 

Feb.     4,  1881. 

Right. 

29 

Hospital. 

Sarah  A . 

33 

Nov.    2,  1881. 

Left, 

30 

Hospital. 

Richard  H . 

62 

Feb.  10,  1882. 

Left. 

31 

Hospital. 

Daniel  S . 

39 

May  12,  1882. 

Left. 

32 

Private. — 
Dr.  Bailey. 

Mr.  S 

35 

July  28,  1882. 

Left. 

33 

Private. — 
Dr.  Calthrop. 

Mr.  T 

62 

Mar.  16,  18S2. 

Left. 

34 

Hospital. 

John  C 

52 

April  8,  1884. 

Left. 

-J 

Analysis  of  the  Thirty-four  Cases,   or  56  per  cent. — 9  died  within  6  months,   7  lived  from  P 
to  12  months,  9  lived  from  1  to  5  years,  1  was  alive  5  years  after,  8  left  the  ho.spital  convalescent: 


LCMIlAl:    ciiLoroMY. 
for  Cancer  that  Recovered  from  the  Operation. 


517 


lUsi'ii.si'  for  «liiili  Oiniiiliiui  wiis  pi-rfiiriiifd. 

Result. 

Survived 
(>|H.'ratiun. 

No. 

Cuiiccrous   .st  lift  mo  nl'   rci'tiiin.     Sviiiptuiiit* 

Convalesced. 

I)ied  of  iibilominal  can- 

IS  nihs. 

I 

."!  voars. 

cer. 

("ain'crcdi.-'  stricture  of  rectimi. 

Convalesced 

in  7  weeks. 

Left  hospital. 

2 

Anmilur  stiiotiiii'  of  ri-ctiim. 

Convalesced. 

cer. 
Convalesced. 

Died  of   internal   can- 

\)  iiiontliH. 

3 

Supposcil  fiiiii'iT  III'  ifcliim.      Sviii]iti)iiis  IS 

Alive  5  years  «ub- 

4 

iiKinths.      Itloiiil  ami  iiiiu'us. 

quently. 

ram-or  i>l'  recto-vcsiral  si'|>luin. 

Convalesced. 

Lett  hospital. 

5 

lv\loii.''ivi>  rei'lal  iilforatiim,  .sii|iiiipscil  to   he 

('onval(!sced. 

Sank. 

.■{3  months. 

6 

canctT  anil  slrirtiirt-. 

Cancfion.s    stricturo    of    rci'tum    ami    iiniis. 

CiiniilcsiM-d. 

Sank.     ."Much  liK-al  can- 

Hi  months. 

7 

witli  ti'cal  tistula. 

cer,  no  visceral. 

Colloiil    oant'i-r    of     reftmii     ami     sigmoid 

Convalesced. 

Sank  later  from  disease. 

21  months. 

8  i 

Hoxiirc. 

1 

Cani-eroiis  stiit-turo  of  rcelmii,   with    recto- 

Convalesced. 

Sank. 

3i  months. 

9  1 

vesical  tistula,  .">  months. 

1 

rancorous  stricture  of  rectum.     Symptoms 

Convalesced. 

Sank. 

in  months. 

10 

1   year,      nieciling  U  months. 

Cancerous  stricture  of  rectum  2J  years.    No 

Convalesced. 

Sank. 

4  months. 

11 

solid  feces  for  \\  years. 

Cancerous  stricture  of  rectum  1  year. 

Convalesced. 

Sank. 

7  months. 

12 

Cancerous  .stricture  of  rectum,  with  profuse 

Convalesced. 

Sank. 

12J  months. 

13  1 

hemorrhage,  1  year. 

Cancerous   stricturo   of    rectum,    with    fecal 

Convalesced. 

Sank. 

12  months. 

14 

listula  many  months. 

Cancerous  stricture  of  rectum.     Symptoms 

Convalesced. 

Died    of    stricture    of 

10  months. 

15 

Ifi  months. 

urethra  (?) 

cancerous  stricture  of  rectum.     Symptoms 

Convalesced. 

Sank. 

y^  months. 

16 

2  years.     tJreat  obstruction. 

Cancerous  stricture  of  rectum.     Symptoms 

Convalesced. 

Died  of  apoplexy. 

41  months. 

17 

1  year. 

Cancerous  stricture  of  rectum.     Symptoms 

Convalesced. 

Sank.    Internal  cancer. 

2t)  months. 

18  1 

about  1  year. 

1 

Cancerous  stricture  of  rectum  9  months. 

Convalesced. 

Left  hospital. 

19 

Colloid  cancer  of  rectum. 

Convalesced, 
of  growth 

Died    from    perforation 
into  ]ieritoneal  cavity. 

0  weeks. 

20 

Cancer  of  rectum.     Symptoms  6  months. 

Convalesced 

n  5  weeks. 

Left  hospital. 

21   : 

Canceri>us  stricture  of  rectum.     Symptoms 

Convalesced. 

Sank. 

3  months. 

22  , 

fi  months.     Obstruction  2  weeks. 

Epithelioma  of  rectum  and  anus  2  years. 

Convalesced. 

Sank. 

13i  months. 

23 

Cancerous  stricture  of  rectum.     Obstruction 

Convalesced. 

Sank.    Visceral  cancer. 

15  months. 

24 

3  months,  complete  2  weeks. 

- 

Cancerous  stricture  of  rectum.     Symptoms 

Convalesced. 

Left  hospital. 

25 

6  months. 

Cancerous  stricture  of  rectum.     Symptoms 

Convalesced. 

Sank. 

3i  months. 

26 

h  months. 

' 

Cancerous  stricture  of  rectum.     S\'mptoms 

Convalesced. 

Left  hospital. 

27 

2.i  years.     Blood,  mucus,  and  increasing 

1 

difficulty  of  defecation. 

Cancerous  disease  of  rectum.     Sj'mptoms  9 

Convalesced. 

Died  from  extension  of 

6  weeks. 

28  1 

months. 

local  disea 

se. 

Cancerous  disease  of  rectum.     Symj)toms  2 

Convalesced. 

Died  suddenly.     Much 

30  days. 

29 

years.     Blood  and  ]iain. 

local  disease. 

Cancerous  stricture  of  rectum. 

Convalesced 

m  six  weeks. 

Left  hospital. 

30 

Cancerous  stricture  of  rectum.     Symptoms 

Convalesced. 

Sank. 

lOJ  months. 

31 

6  months. 

Cancerous  stricture  of  rectum. 

Convalesced. 

Sank. 

6  months. 

32 

Cancerous  stricture  of  rectum. 

Convalesced. 

Sank. 

6  months. 

33 

Cancerous  stricture  of  rectum. 

Convalesced 

in  1  month. 

Left  hospital. 

34 

21  occurred  in  males:   13  in  females;   'i\  were  on  the  left  and  3  on  the  right  side.     .Average  age,  44; 
of  men,  46 ;  of  women,  41. 


518 


No. 


Hospital  or  Private 
Patient. 


Hospital. 

Hospital. 
Hospital. 
Hospital. 

■  Hospital. 
Hospital. 
Hospital. 


LUMBAR   COLOTOMY. 

Table  III.— Cases  of  Colotomy  for  Simple  or 


Name  of  Patient. 


Eliza   0 ,   married,   2 

children,  4  stillborn,  1 
miscarriage. 

Louisa  C . 


Mary  S ,  married,  no 

children. 

Hans  K ,  been  abroad, 

but  not  had  dysentery. 


Age. 


29 


.33 


46 


65 


Date  of 
Operation. 


Colotomy 
Eight  or  Left. 


Mar.  19,  1872.     ,  Left. 


Dec.     5,  ISO". 
Mar.    .3,  1876. 


Left. 
Left. 


Dec.  .30,  1881.     '  Left. 


Eliza   B ,  married,    1  |     42     |     Feb.     6,  18S;i.     j  Left. 

I  Bowel  torn 
'       across. 
.37     I    Nov.  28,  1877.     i  Left. 


child,  1  miscarriage. 
Harriet  K- 


James  R- 


49 


Nov.  14,  1882.    I  Left. 


Cases  of  Lumbar  Colotomy  for  Non-cancerous 


8 

Hospital. 

William  D . 

40 

April  5,  1867. 

Left. 

9 
10 

Private. — 

Dr.  Habershon. 
Hospital. 

Robert  R . 

Mary  L . 

46 

38 

July     5,  1870. 
Aug.  12,  1873. 

Left. 
Left. 

11 

Hospital. 

Mary  P ,  married,  no 

children,     no     miscar- 
riage. 

37 

Nov.    9,  1881. 

Left. 

12 
13 

Hospital. 
Hospital. 

William  H ,  no  syph- 
ilis. 
Philip  K . 

27 
35 

Nov.    7,  1881. 
Dec.     2,  1882. 

Left. 
Left. 

14 

Hospital.* 

Caroline  H,  married,  had 

28 

May  10,  1878. 

Left. 

15 

Hospital. 

miscarriages. 
William    B ,   syphilis 

25 

July  12,  1878. 

Left. 

16 

Hospital. 

3  years. 

Susan  S ,  married,  had 

miscarrlagesi 

40 

May     3,  1881. 

Left. 

17 

Hospital. 

Louisa  P ,  married,  1 

child,     1     miscarriage, 
had  syphilis. 

24 

Sept.    2,  1874. 

Left. 

18 

Private. — 
Sir  W.  Gull. 

Mr.  T . 

64 

Mar.  16,  1869. 

Left. 

19 

Private. — 

Mr.  R.  Phillips, 

Mr.  S 

46 

Nov.  14,  1877. 

Left. 

20 

Hospital. 

John  S . 

38 

July  16,  1880. 

Left. 

21 
22 

Hospital. 
Private. — 

Mr.  R.  Phillips. 

Fred.  R . 

Mrs.  M . 

18 
46 

Mar.    2,  1874. 
April  5,  1870. 

Left. 
Left. 

Analysis  of  T"wenty-t"wo  Cases  not  Cancerous. — 19  for  stricture  and  ulceration  of  the  rectum  not 
cancerous,  1  for  obf^truetion  from  volvulus  of  the  sigmoid  flexum,  2  ditto  from  pelvic  tumors;  10  of 
the    19   cases   of  stricture  occurred  in   females,    9   in   males.      Average   age   of  19  cases,  40    years;    of 


Syphilitic  Stricture  of  Rectum  that  Died  wiihin  the  Month. 


519 


Diseuse  fur  which  (iperutluii  was  |iurfuriiicU. 


Svphilitii'  Hiricturt'  of  ri-i'liiiii.  ATlor  lust 
rliilil,  two  vi'iiTM  11^11,  hail  liowvl  lriiul>lc', 
whifh  stMin  j;iivc  ^i^o  to  fct-iil,  \  ii^iiiiil,  uml 
(lUlilllMll  tistiilif. 

C'hroiiii-  iilci-nitioii  of  roftiim,  with  iiicicii.*- 
iiij;  oli.slrnctioii  for  iiioiitlis. 

Very  narrow  stricture  from  I  inch  above 
anus:  bloud,  mucus,  ami  jiain  for  months, 
witli  incrcasinj;  olistruction. 

Ailiiiittcil  witli  rccto-vcsical  fecal  fistula  of  6 
weeks' standin;.; :  12  years  before  this  |ia- 
ticnt  iiad  for  weeks  ))asse(l  wind  witii  his 
water,  from  which  he  hail  recovered. 

Cicatricial  stricture,  witli  ulceration  of  5 
years'  standing,  commencing  A  inch  from 
anus. 

Very  narrow  stricture  and  ulceration  after 
t>  months'  symptoms. 


Ueiiult. 


.Survived 
Ufie  ration. 


No, 


Stricture  and   ulccr;iliipn. 
blood  for  ()  months. 


-Mucli   jiain   and 


."»ank.     1'.  .M. — (iood    repair   in    loin  :     On  Kith  day. 
rectum  almost  obliterated  from  cica- 
tricial bands. 

.'^ank.      I'.    M.^.'-^ijfinoid    flexure,   rec-     On   llh  day. 

tiim  and  uterus  all  matted  together; 

bowel  very  narrow  and  thickened. 
Sank.     P.  M. — E.xtremc  ulceration  of     On  ;!d  day. 

rectum   from    2    inches  above  anus, 

with  sinus. 
Sank.     1'.   M.— .Marked    signs  of  old     On  17th  day. 

ulceration   and   contraction    of   rec-  | 

tum  ;  sign  of  old  cicatrix  into  blad- 
der, with  recent  fistula. 
Sank.     P.   iM. — Howcl   very   ulcerated     On  -Ith  day. 

and  friable  up  to  colon  :  it  had  been  i 

torn  through  at  operation. 
Convalesced.    Died  of  ))hthisis.   Bowel  I  28  days. 

repaired  ;  one  stricture  ;!  inches,  and 

a  second  fi  inches,  from  anus. 
Sank.     P.  M. — Colon  much  ulcerated  ;  {  oO  days. 

bowel  contracted.  i 


Stricture  or  Disease  that  Convalesced  after  Operation. 


Recto-vesical   fecal    fistula,  with    rectal   ob-- 

struction  and  ulceration. 
Recto-vesical  fecal  fistula,  with  obstruction. 

Stricture  of   rectum   after   ulceration    for   0 

years.     Much  bleeding. 
Rectal  symptoms  for  1,')  years.    Pain,  blood, 

mucus  with  feces.     Admitted  with  narrow 

stricture,  probably  syphilitic. 


Stricture  and  ulceration  of  rectum  17  months. 
Blood  and  mucus  with  feces. 

Stricture  and  ulceration  of  rectum.  Symp- 
toms two  years. 

Syphilitic  stricture  and  ulceration  30  months. 
No  solid  feces  passed  for  6  months. 

Very  narrow  stricture,  lA  inches  above  anus. 
Symptoms  for  2  years. 

Admitted  with  narrow  stricture  and  vaginal 
and  perineal  fecal  fistula.  No  history  of 
syphilis. 

Admitted  with  recto-vaginal  fecal  fistula 
and  fistula  in  buttock.  Operation  per- 
formed for  relief. 


For  vesico-rectal  fecal  fistula. 


Multiple-rectal  fibrous  )iolypoid  growths  of 
3  years'  standing.  Had  had  polyjd  re- 
moved twice  before.  Great  tenesmus  and 
discharge  of  blood  and  serum.  At  once 
relieved  by  the  operation. 

Complete  obstruction  for  C  weeks.  Opera- 
tion to  save  life.  Case,  one  of  voh-nhis  in 
all  probability. 

Cancerous  j)elvic  tumor  occluding  rectum. 

Pelvic  tumor  obstructing  rectum  (cancer- 
ous). 


Convalesced.     Died  of  kidney  disease. 

Rectum  repaired  and  contracted. 
Con\alesced. 

Convalesced.  Died  of  kidney  disease. 
Rectum  healed  and  contracted. 

Convalesced.  Sank  from  kidney  dis- 
ease and  large  spleen :  lower  3 
inches  of  rectum,  lost  its  mucous 
membrane  with  cicatricial  tissue 
outside. 

Sank. 

Convalesced.      Bowel   healed    and  al- 
most closed. 
Convalesced.     Died  from  bronchitis. 


5  months. 

14    years,    alive 

and  well. 
34i  months. 

40  days. 


18  weeks. 

18  months,  well     l.S 

and  comfortable. 

1  year.  14 


Convalesced.     Bowel  had  healed  and     2i     years     later  '   15 

almost  closed  2  years  later.  alive  and  well.    ! 

Sank.     P.  M. — Rectum  greatly  indu-  ,  9  weeks.  16 

rated,    contracted,    and    ulcerated;  j 

ulcers  vertical.  • 

Died  of  hi])  disease.     All  the.  fistulic     4J  months 

had    closed    soon     after    operation. 

P.   M. — Lower  4  inches  of  rectum 

covered    with    bands   of    cicatricial  i 

tissue  much  contracted. 
Rapidly  convalesced.     No  feces  pass-     5J  years. 

ed  after  operation  through  rectum. 

Died    of   ruptured    heart.      P.   M. — 

Rectum  healed  ;  old  fistula  into  blad- 
der small. 
Convalesced,    and    died    from    pneu-     41  months. 

monia. 


Convalesced. 


Sank  from  the  disease  relieved. 
Relieveil  by  operation.    Died  from  rup- 
tured cancerous  mesenteric  tumor. 


4  years,  alive  and 
"well. 

7  weeks. 
4  days. 


females,  35:  of  males,  45.  All  operations  on  left  loin.  Nine  died  within  the  month;  5  within  G 
months;  4  lived  respectively  1  year,  3,  3i,  and  oj  years,  Four  are  now  alive  and  well,  IJ,  2J,  4  years, 
and  14  years  after  the  operation. 


520  "  TAPriSG    THE  JSTL'STIXE. 

Analysis  of  the  Whole  Number  of  Eighty-Two  Cases  of  Colotomy. 

60  were  iierformed  for  cancerous  stricture. 

19     "  "  "   stricture  and  ulceration  of  the  rectum  not  cancerous. 

1  was  performed  for  volvulus  of  the  sigmoid  flexure  of  the  colon. 

2  for  obstruction  due  to  pelvic  tumors. 

Side  operated  upon  : 

Left  lumbar  colotomy  was  performed  in  77  and  right  lumbar  colotomy  in  5  of  these  cases,  all 
of  the  5  being  cancerous.  Right  lumbar  colotomy  was  called  for  in  1  outof  12  cases  of  cancerous 
stricture. 

Duration  of  life  nj'ler  the  operation  : 

26,  or  43  per  cent.,  of  the  cancerous,  and  6,  or  31.5  per  cent.,  of  the  non-cancerous,  cases,  with 
1  of  the  ca.ses  operated  upon  for  obstruction,  or  40  per  cent,  of  the  whole  number  of  82  cases 
operated  upon,  died  within  the  month. 

.34.  or  56  per  cent.,  of  the  cancerous,  and  13,  or  68.5  per  cent.,  of  the  non-cancerous,  cases, 
with  the  case  of  volvulus  and  1  of  the  cases  of  obstruction,  or  60  per  cent,  of  the  whole  number 
of  cases  operated  upon,  received  more  or  less  fully  the  benefit  of  the  operation. 

Of  the  forty-nine  sucees-'ful  cases — 

16  cases,  9  cancerous  and  7  non-cancerous,  died  within  6  months. 
8      ■'      7  "  1  '•  lived  from  6  to  12  months. 

12      'I      9  "  3  "  lived  from  1  to  ol  years. 

o     "      \  "  4  "  were  alive  from  li  to  14  years  after  operation. 

_8     "    _8         "  _  had  left  the  hospital  convalescent. 

49  34  15 

Sex: 

Of  the  60  cancerous  ca.ses,  40  were  in  males,  20  in  females. 

"        19  non-cancerous,  10  "  9  " 

"  1  case  of  volvulus,  1  was  in  male. 

"  2  cases  of  obstruction,  J^  "  _  1  in  female. 

Of  the  82  cases,  52  were  in  males,  30  in  females. 

Cancerous  stricture  is  more  frequent  in  males.  Xon-cancerous  stricture  is  found  equally  in 
both  sexes. 

Age: 

The  average  age  of  the  cancerous  cases, 
AVhen  fatal,  was  53;  in  male  subjects  54,  in  female  51. 

"     successful,  was  44 ;  "  46,  "       41. 

The  average  age  of  the  successful  was  about  ten  years  less  than  that  of  the  fatal  cases. 
1^0  abnormality  as  to  the  position  of  the  colon  was  met  with  in  any  of  the  82  cases. 


Excision  of  the  Pylorus. 


This  operation  was  first  performed  for  cancer  by  Pean  of  Paris  in  1879,  and  Billroth, 
Wblfler.  Nicolay.sen.  Czerny,  Southam,  and  others  have  repeated  it  with  enough  success 
to  justify  its  repetition  in  ca.ses  in  which  the  diagno.sis  is  tolerably  certain  and  the  di.s- 
ease  movable.  Full  details  of  this  difficult  and  dangerous  proceeding  are  to  be  found  in 
Billroths  Cluneal  iiurgerij.  publi.^hed  by  the  New  Sydenham  Society  (1882). 

On  Tapping  the  Intestine. 

The  practice  of  tapping  the  intestine  with  a  fine  trocar  and  canula  in  cases  of  intes- 
tinal obstruction  is  one  which  deserves  serious  consideration,  since  there  is  good  reason 
to  believe  that  a  small  puncture  mav  often  be  made  into  a  distended  intestine  and  wind 
drawn  oif  without  any  extravasation  of  the  contents  of  the  bowel  taking  place,  and  that 
if  the  di.stension  of  the  strangulated,  twisted,  or  otherwise  obstructed  bowel  can  be 
relieved  by  the  operation  there  is  some  ground  for  hope  that  natural  efforts  may  then 
release  the  bowel  from  beneath  its  band  or  from  some  internal  peritoneal  ring,  and  that 
even  a  twisted  bowel  may  untwist.  The  operation,  however,  is  not  without  its  risk,  as  I 
have  on  several  occasions  known  fecal  extravasation  to  follow  the  practice,  and  Coupland 
and  Morris  quote  other  cases.  I  have  been  also  led  to  believe  that  even  in  a  large  hernia 
its  strangulation  might  be  relieved  by  a  like  operation  and  a  natural  reduction  take  place, 
for  a  strangulated  bowel,  outside  as  well  as  inside  the  abdominal  cavity,  is  damaged  by 
the  distension  of  the  intestine  itself  more  than  from  any  extra-intestinal  influence  :  and 


TM'I'ISC    rUi:  Alllxi.MKS.  621 

if  tilis  <list(Misi«iii  can  lie  rdicvcil  )iy  siuiply  ilrawiiiL:  "fV  tin-  contents  of  I  lie  liowcl  Uv 
means  of  a  very  fmt'  troear  ami  <-anula,  the  walls  of  tlie  intestine  would  c<)||a]»se,  stran- 
jiiilation  cease,  ami.  unless  ailliesions  eunliiu'il  the  howel  in  its  jtosition.  its  return  ini;^ht 
be  looked  for  hy  natural  efforts.  Tliest;  remarks  are  Inised  upon  the  fact  that  intestine 
may  he  so  treated  without  any  extravasation  I'ollowin^;  and  sueh  a  result  aetually  came 
before  me  in  a  ease  (»f  ileo-colie  scrotal  hernia  in  a  L'entleman  a't.  7<i,  when,  to  enable  luc 
to  reduce  the  bowel.  I  was  driven  to  puncture  the  protruilinj;  intestine  in  four  or  live 
places,  and,  althouLrh  mueli  mani])ulation  f(dlowt'(l  this  |»ractice,  no  extrava.sation  occurred 
at  the  time  or  after,  and  a  rapid  recovery  ensued  without  a  dro)»  of  sMp|turation.  The 
case  occurred  in  the  ]>ractice  <d"  Mr.  Kidson  Wriidit  of  Keiinin^'ton.  'I'hese  remarks  are 
only  to  be  read  as  su,i.'tr<'sti'»ii'<.  and  more  particularly  as  applied  to  larfre  umbilical  and 
scrotal  herni.-e.  Since  the  introductifin  of  the  pneumatic  aspirator  l)V  Dr.  Dieulal'ov  this 
practice  has  rcceivetl  much  I'McouraL'cmeiit.  For  more  detailed  evidenc(!  on  the  subject 
of  intestinal  obstruction  and  its  treatment,  the  followinj^  [tapers  may  be  referred  to: 

HiUNTON,  Crnoniiin  Lfcliiren,  1X59. — Fagge,  (?«_»/'•'♦  R''j>ori>i,  1808. — G.VY,  7Vani>.  Lond.  Med.  Soc, 
1861,  1S()"J. — (ioKii.vM,  Guy's  Reports,  vol.  iii.,  series  1. — HlXTO.v,  Amiciation  Med.  JoidtujI,  1853. — 
Smith,  Amiricnii  Joiiniul  of  Med.  Srienre,  18()2. — Bhyaxt,  Meil.  Timea,  1872. — A  TreiUUe  on  the  Pneu- 
vvttic  .Anpiratinn  of  Morbid  FInidx,  by  Du.  Gkorgk  DikuI-AFoV,  1873. — TroU-S-SKAU's  Clinical  Metl- 
irine. — IIlTcuiXsox,  Med.  Chir.  Tranif.,  vol.  Ivii.,  1874.— Coipland  and  MoRRI.S,  Bril.  Med.  Journ., 
Jamiary  2ti,  1878.— Bryant,  Lunret,  May,  IS7H.— CI inirfd  Sorietij,  IHIS.—Mcd.-Cltir.  Tram.,  1882. 

On  Tapping  the  Abdomen. 

Whenever  fluiil  collects  in  the  abdominal  cavity  so  a.s  to  interfere  with  life's  func- 
tions, the  ojieration  of  tapjting  may  be  called  for.  It  may  be  for  osrifeSj  a  C(dlection  of 
fluid  in  the  peritoneal  cavity  ;  for  orariait  ffrups//.  a  collection  of  fluid  in  a  .single  or  in  a 
polycystic  tumor;  or  for  fu/i/utid,  whether  hejtatic,  pelvic,  or  peritoneal.  It  iDay  also  be 
called  for  in  reudi  or  i^plmiic  cyst.s. 

It  would  be  out  of  my  province  to  enter  minutely  into  the  diagnosis  of  all  these  con- 
ditittns.  as  the  majority  of  such  ca.se.s  come  under  the  care  of  the  physician,  the  surgeon 
being  called  in  simply  to  operate.  Nevertheless,  it  may  be  as  well  to  give  some  of  the 
leading  points  of  diagnosis,  for  I  need  scarcely  say  that  the  operating  surgeon  is  not 
relieved  of  all  responsibility  of  diagno.sis  by  the  fact  that  a  medical  man  has  charge  of 
the  case.  The  operator,  as  such,  assumes  part,  at  least,  of  the  responsibility  of  the  case 
as  well  as  of  the  operation. 

Diagnosis. — In  a  general  way  it  may  be  asserted,  therefore,  that  ascites  is  the  result 
of  a  chronic  action  that  has  been  going  on  for  some  time,  arising  from  liver,  peritoneal, 
heart,  or  renal  disease,  the  abdominal  dropsy  being  one  of  the  results  only.  The  history 
of  the  case,  consequently,  will  be  a  great  help  in  arriving  at  a  conclusion.  The  fluid, 
moreover,  will  be  found  to  fill  the  abdominal  cavity  equally,  fluctuation  being  perceptible 
across  the  abdomen  and  from  befoi-e  backward  well  into  the  loins,  even  when  the  abdomen 
is  resonant.  As  a  rule,  the  intestines  will  be  found  floating  upward,  thus  giving  reso- 
nance on  percussion,  the  position  of  the  bowels  being  influenced  by  that  of  the  patient. 
With  the  body  horizontal,  they  will  give  resonance  at  the  umbilicus ;  with  the  pelvis 
depressed,  above  this  point ;  with  the  pelvis  well  rai.sed,  resonance  may  even  be  detected 
near  the  pubes.  In  almost  all  these  ca.ses  the  sound  over  the  loins  will  be  dull.  On 
looking  at  the  abdomen  the  surfiice  will  be  found  smooth  and  the  enlargement  equal. 
The  subject  of  diagnosis  of  ovarian  and  uterine  disease  will  receive  attention  in  Chapter 
XXVII. 

Operation. — The  instruments  required  for  the  operation  are  a  moderate-sized  trocar 
and  canula.  an  india-rubber  tube  about  six  feet  long  adapted  to  a  silver  tubular  plug  that 
fits  the  canula  when  the  trocar  is  removed,  a  lancet  or  small  scalpel,  a  pad  of  lint,  and  a 
roll  of  good  .stra])ping. 

Some  surgeons  prefer  one  of  the  modern  instruments  by  which  the  india-rubber  tube 
is  attached  to  the  canula  at  right  angles,  and  they  are  very  good  ;  but  those  I  have  named 
are  efticient. 

The  patient  should  be  brought  to  the  edge  of  the  bed  and  placed  in  the  recumbent 
position,  with  the  shoulders  raised,  a  folded  sheet  or  piece  of  mackintosh  cloth  having 
been  previously  so  arranged  as  to  protect  the  sheets.  A  catheter  .should  first  be  pas.sed ; 
then,  with  the  trocar  and  canula  warmed  and  oiled  and  a  pail  at  hand,  into  which  the  end 
of  the  india-rubber  tube  is  allowed  to  hang,  the  surgeon  may  with  a  lancet  make  a  small 
incision  through  the  skin  and  soft  parts,  about  three  inches  below  the  umbilicus  or  at  any 
other  spot  at  wiiich  the  operation  is  to  be  performed.     He  should  next  introduce  the 


522  II  YD  A  TIB   TUMORS. 

trocar  and  canula  with  a  direct  force  and  semi-rotatory  movement  of  the  wrist,  and.  with 
his  forefinger  fixed  about  one  inch  from  the  end  of  the  canula.  guard  against  inserting 
the  trocar  too  far.  The  abdomen  having  been  punctured,  the  trocar  may  be  removed 
with  the  right  hand,  the  canula  being  pushed  farther  in  at  the  same  moment  with  the 
thumb,  and  its  orifice  plugged  at  once  with  the  left  thumb,  to  prevent  the  escape  of  fluid. 
The  silver  plug  of  the  india-rubber  tube  may  then  be  introduced  and  the  fluid  allowed  to 
escape,  the  distal  end  of  the  tube  being  kept  submerged  in  the  fluid  in  the  receptacle,  the 
tube  acting  as  a  syphon. 

To  facilitate  the  flow  and  to  evacuate  the  whole  contents  of  the  cavity,  .some  surgeons 
roll  the  patient  over  on  the  side  or  place  him  so  at  the  first,  but  such  a  proceeding  is 
unnecessary. 

When  the  fluid  has  ceased  to  flow,  the  canula  is  to  be  gently  removed,  the  tliumli  and 
finger  of  the  left  hand  nipping  up  the  soft  parts  as  its  end  appears,  so  as  to  prevent  the 
admission  of  air  into  the  abdominal  cavity  and  the  trickling  of  any  fluid  down  the 
patient.  The  edges  of  the  wound  may  then  be  adapted  by  a  piece  of  good  strapping, 
and  a  pad  of  lint  applied  when  oozing  appears,  but  not  otherwise  ;  two  or  three  bands  of 
strapping  three  inches  wide  should  then  be  adjusted  to  the  front  of  the  abdomen  from 
side  to  side.  Where  great  hollowness  is  left,  a  pad  of  cotton-wool  often  gives  comfort. 
The  old-fashioned  flannel  bandage  may  be  abolished,  as  it  is  only  an  inconvenience. 

All  pressure  on  the  abdomen  during  the  flow  of  the  fluid  should  be  avoided  as  unneces- 
sary, and  also  all  pressure  after  the  operation,  support  only  being  required. 

The  usual  place  to  perform  the  operation  is  in  the  linea  alba,  about  two  or  three 
inches  below  the  umbilicus ;  but  in  ovarian  disease  any  point  in  the  linea  semilunaris  may 
be  opened,  and  in  rare  cases  any  other. 

When  a  hydatid,  renal,  or  splenic  cyst  requires  to  be  tapped,  a  small  trocar  and 
canula.  such  as  is  employed  for  tapping  a  hydrocele,  should  be  used,  though  in  these 
cases  the  pneumatic  aspirator  is  of  great  service,  for  by  its  use  the  fluid  can  be  removed 
without  the  possibility  of  air  being  introduced. 

Hydatid  Tumors 

of  the  liver,  spleen,  or  other  parts  of  the  abdomen  are  occasionally  met  with.  and.  how- 
ever large  a  size  they  attain,  they  rarely  produce  other  .symptoms  than  those  mechanically 
caused  by  their  size  ;  and  on  that  account  they  may  require  treatment.  Their  origin  is 
indicated  by  their  position,  although,  when  situated  in  the  pelvis,  there  may  be  an  impos- 
sibility in  diagnosing  them  from  ovarian  cysts.  They  are  almost  always  very  globular 
and  tense,  and  rarely  give  rise  to  distinct  fluctuation.  The  external  feel  of  a  hydatid  is 
somewhat  peculiar  and  characteristic.  In  1868,  I  removed,  with  permanent  success,  an 
enormous  hydatid  tumor  from  the  abdomen,  although  apparently  not  from  its  cavity,  of  a 
lady-patient  of  Dr.  Oldham,  aet.  35,  who  was  believed  to  have  had  ovarian  disease  (Gui/'s 
Hasp.  Rip..  1868),  while  Sir  Spencer  Wells  records  a  case  in  which  the  hydatids  were 
turned  out  of  the  abdominal  cavity.  Sometimes  the  hydatid  dies  without  surgical  inter- 
ference, and,  as  a  consequence,  severe  suppuration  is  set  up,  with  violent  constitutional 
disturbance,  which  requires  surgical  aid. 

Not  long  since  I  opened  with  marked  success  a  large  abscess  OA'er  the  liver  of  a  boy 
aet.  17,  and  evacuated  a  quantity  of  pus  bearing  the  peculiar  odor  of  hydatid  pus.  The 
abscess  clearly  came  from  the  liver  and  was  a  suppurating  hydatid.  The  boy  previously 
had  suflfered  from  tapeworms.  In  1869,  I  had  to  open  freely  a  suppurating  hydatid 
tumor  which  half  filled  the  abdomen  of  a  gentleman  a?t.  40  who  had  had  it  tapped  some 
months  before  in  Australia,  and  a  complete  recovery  ensued.  A  quantity  of  dead  hj'da- 
tid  cy.sts  escaped  through  a  large  canula  that  was  introduced.  The  cy.st  was  washed  out 
daily  with  great  benefit.  This  gentleman  is  now  quite  well.  I  have  had  at  least  ten 
other  cases  in  which  a  like  treatment  was  employed  with  success,  nor  have  I  lost  one, 
although  several  have  had  a  very  narrow  escape.  The  secret  of  the  treatment  of  suppu- 
rating hydatid  cysts  consists  in  a  free  outlet  for  all  purulent  and  dead  hydatid  deposits 
and  the  frequent  washing  out  of  the  suppurating  cavit}'  with  water  containing  iodine, 
Condy's  fluid,  carbolic  acid,  or  creosote,  with  or  without  the  introduction  of  a  drainage- 
tube  or  elastic  catheter.  For  the  operation  a  large  trocar  and  canula  should  be  employed, 
the  canula  being  left  in  for  some  days  until  a-  good  opening  is  established  ;  it  may  then  be 
exchanged  for  an  elastic  catheter  or  large  drainage-tube. 

Before  suppuration  takes  place,  however,  other  treatment  is  applicable,  such  as  drain- 
ing off"  partially  or  wholly  the  fluid  contents  of  the  hydatid  by  means  of  a  very  fine  trocar 


Tr.MoIlS   OF   Tin:    I'MJI/IJCCS.  o23 

iiiul  raiiiila.  I  liuvf  iifrfuriiu'd  this  tijH'iatiuii  mi  iiiaiiy  o<'casi()iis  witli  succos,  liul  jrcn- 
erally  prefer  to  draw  oft"  only  a  few  ounces  of  tin;  fluid,  clinical  exiierience  indicating.'  that 
by  this  measure  ahme  the  hydatid  may  lie  kiMed,  sul»se(juently  witlieriiifr  up  and  ccasin;^ 
to  liurt.  |)r.  J.  MiUer  of  Tasmania,  where  this  disease;  is  fre(j_uent,  speaks  liif:lilv  of  tlie 
use  of  twenty-irrain  doses  of  the  liromide  of  potassium  three  times  a  (hiy  after  the  tap- 
pin;.',  and  I)r.  IJird  of  .MeMxturne  eoinhine.s  with  it  drachm  (hises  of  the  tincture  of 
kanii'Iii.  At  times,  also,  cases  which  have  hcen  looked  upon  as  cured  are  n<tt  so,  and 
after  till'  lapse  of  years  the  disease  reappears.  Wlien  suppuration  follows  tappinj;,  how- 
ever, a  cure  ensues. 

The  (»])eration  of  simply  tapping'  a  liytlatid  with  even  the  finest  instruments  is  not. 
however,  free  from  danircr,  for  in  .January,  1877,  I  tapjted  a  man  ;et.  4lJ  who.  with  the 
exception  of  the  hydatid  tuuKtr  of  the  liver,  was  in  perfect  health,  and  drew  off"  half  a 
pint  of  hydatid  fluid,  havin<,'  to  perforate  the  structure  of  the  liver  to  the  depth  of  an 
inch  to  reach  the  eyst.  The  operation  was  not  attended  by  the  slijjhte.st  distress,  but  on 
the  removal  of  the  needle  an  agonizing  pain  attacked  the  man's  face  and  jaws,  accom- 
panied with  flushing  of  the  head  and  neck.  This  was  followed  by  vomiting,  extreme 
pallor,  and  stertorous  breatliing  for  a  minute,  followed  by  death  in  two  njinutes.  At  the 
necropsy  nothing  was  found  to  account  for  this  sudden  end — that  is,  there  was  no  embol- 
ism or  heart  troul)le,  no  brain  disea.se,  nothing  but  a  large  hydatid  cyst  behind  the  liver. 
The  needle  had,  however,  passed  through  a  misplaced  portal  vein  on  its  way  to  the  livda- 
tid.  and  the  (|uestion  arose  as  to  the  possibility  of  death  being  due  to  the  mixing  of  the 
hydatid  fluid  with  the  venous  blood.  No  blood  was  extravasated  (Cllii.  tSock'iij.  1878). 
3Iy  colleagues,  Dr.  Fagge  and  Mr.  Durham,  have  given  us  some  evidence  that  a  cure  can 
be  obtained  by  electrolytic  treatment  on  Dr.  Althaus's  plan  of  introducing  into  the  tumor 
two  electrolytic  needles,  one  or  two  inches  apart,  connected  by  means  of  wire  to  the  nega- 
tive pole  of  a  galvanic  battery  of  ten  cells,  and  completing  the  current  through  the  tumor 
by  means  of  a  moistened  sponge  attached  to  the  positive  pole  of  the  battery,  applied  for 
ten  or  more  minutes  at  a  time  to  diff'erent  points  over  the  swelling  (^Med.-Chir.  Trans., 
vol.  liv.).     This  operation  may  be  repeated  according  to  circumstances. 

Such  treatment  may  be  employed  when  simple  tapping  fails  to  cure.  Some  of  the 
patients  reported  as  cured  by  these  means  have  returned,  however,  with  the  disease;  and 
it  is  still  a  question  whether  more  is  gained  by  this  method  than  by  simple  puncture  and 
the  withdrawal  of  some  of  the  hyadit  fluid. 

Further  information  may  be  gained  from  Murchison's  work  on  the  liver  (1SG8)  ; 
Harley's  paper,  Med.-Chlr.  Trans.,  vol.  xlix.  ;  and  the  book  by  Dr.  Bird  of  Melbourne. 

Tumors  of  the  Umbilicus. 

Pedunculated  outgrowths  from  the  umbilicus  are  not  uncommon,  and  are  alway."?  found 
in  children,  being  composed  of  simple  granulation  tissue;  indeed,  it  seems  probable  that 
they  are  really  due  to  excess  of  granulation  growth  from  the  point  at  which  the  umbilical 
cord  separated.  They  .sometimes  attain  a  large  size  and  have  occasionally  a  .slight  central 
canal  or  orifice,  though  the  former  never  travels  far.  I  have  .seen  one  the  size  of  the  last 
joint  of  my  little  finger.  They  are  easily  cured  by  the  application  of  a  ligature  to  their 
bases. 

These  tumors,  however,  mu.st  not  be  confounded  with  a  condition  that  is  occasionally 
met  with — viz.,  the  presence  of  a  fleshy  outgrowth  not  unlike  a  glans  penis,  through 
which  a  real  canal  extends  into  the  bladder,  the  canal  being  clearly  an  open  urachns.  I 
have  seen  two  such  cases;  one  I  recorded  in  my  Lettsomian  lectures  on  the  surgical  dis- 
eases of  children  (18G3).  I  wished  to  cauterize  the  surface  of  the  canal  and  thus  cause 
its  contraction  and  closure,  but  was  not  allowed. 

I  have  also  seen  a  large  hernial  protrusion  appear  at  the  umbilicus,  with  the  whole 
surface  ulcerated,  in  which  there  were  some  solid  contents,  which  I  took  to  be  the  liver. 
It  sub.sequently  completely  cicatrized,  and  a  good  recovery  ensued.  The  drawing  of  this 
case  is  in  Guy's  Hospital  Museum.     {Vide  Fig.  319.) 

Sebaceous  tumors,  as  well  as  accumulations  of  sebaceous  matter,  are  also  met  with  at 
the  umbilicus  in  dirty  people.  I  have  turned  out  large  masses  of  such  indurated  secre- 
tion from  the  cuplike  depression. 

Cancerous  tumors,  etc.,  as  well  as  simple  warty  growths  and  syphilitic  condylomata, 
may  also  exist  in  the  same  position. 


524 


HERNIA. 


CHAPTER    XV. 


hp:rnia. 

Diagrams  illustrating  the  Different  Forms  of  Hernia,  with  some 

OF  its  Complications. 

In  all  these  diagrams  the  thick  black  line  represents  the  parietes  covering  in  the 
hernial  sac ;  the  thin  line,  the  peritoneum  and  hernial  sac ;  the  small  body  at  the  bottom 
of  the  sac,  the  testicle. 


Fig.  292. 


Fig.  293. 


Fig.  292.  This  diagram  illustrates  the  tubular  vaginal  process  of  peri- 
toneum open  down  to  the  testicle,  into  which  a  hernia  may  descend.  When 
the  descent  occurs  at  birth,  the  hernia  is  called  "  congenital  ;"  when  at  a 
later  period  of  life,  the  "congenital  form,"  Birkett's  "hernia  into  the  vagi- 
nal process  of  peritoneum,"  or  Malgaigne's  "hernia  of  infancy." 


Fig.  293.  The  same  process  of  peritoneum  open  halfway  down  the 
cord,  into  which  a  hernia  may  descend  at  birth  or  at  a  later  period. 
Birkett's  "  hernia  into  the  funicular  portion  of  the  vaginal  process  of 
the  peritoneum." 


Fig.  294. 


Fig.  294.  The  same  process  undergoing  natural  contraction  above  the 
testicle,  explaining  the  hour-glass  contraction  met  with  in  the  congenital 
form  of  scrotal  hernia,  as  well  as  in  hydrocele. 


Fig.  295. 


Fig.  295.  Diagram  .showing  the  formation  of  the  "  acquired  congenital 
form  of  hernia" — the  "  encysted  of  Sir  A.  Cooper,"  "  the  infantile  of  Hey" 
— the  acquired  hernial  sac  being  pushed  into  the  open  tunica  vaginalis, 
which  encloses  it. 


Fig.  296. 


Fig.  296.  Diagram  illustrating  the  formation  of  the  "  acquired  "  hernial 
sac,  distinct  from  the  testicle  or  vaginal  process  of  peritoneum  which  has 
closed. 


AIIDOMISAL    UlinSlA. 


525 


Via.  297 


Fl<i.  lillT  illustrates  tlif  neck  nf  the  licniial  sac  |iiis1i(m1 
back  boncatli  the  atiiliniiiiial  parit-ti's  with  tlic  straii^ailalcd 
buwd.    (  IV./r  Fig.  :{1L'.)    Mcll's  form. 


Second 
variety  of 
displaced 
hernia. 


Fifi.  '298. 


Fi(i.  lilts  shows  tlie  space  in  the  subperitoneal  connective 
tissue  into  which  intestine  may  be  jtushed  throu<;h  a  rup- 
ture in  the  neck  of  the  hernial  sac,  tlie  intestine  being  still 
strangulated  by  the  neck.    (^Vidr.  Fig.  314.) 


Third 
variety  of 
displaced 
hernia. 


Fig.  2!M).  Diagram  showing  how  the  neck  of  the  vaginal 
process  may  be  stretched  into  a  sac  placed  between  the  tis- 
sues of  the  abdominal  walls  either  upward  or  downward 
between  the  skin  and  muscles,  muscles  themselves,  or  be- 
tween the  mu.scles  and  the  internal  abdominal  fascia,  form- 
ing the  intra-parietal,  inter-muscular,  or  interstitial  sac. 
Hernia  en  hinMic  of  the  French  ;  '•  additional  sac  "  of  Birkett. 
(  Vide  Fig.  315.) 


Fig.  300.  Diagram  illustrating  the  reduction  of  the  sac 
of  a  hernia  en  masse  with  the  strangulated  intestine. 


Fig. 


Fourth 
variety  of 
displaced 
hernia. 


Fig.  30U. 


First 
^   variety  of 
displace  i 
hernia. 


ABDOMINAL  HERNIA. 

Abdominal  hernia  or  rupture  signities  the  ])rotrusion  of  any  viscus  through 
an  opening  in  the  parietes  of  the  abdominal  cavity.  This  protrusion  for  the  most  part 
occurs  at  the  iii(/i(iiifd  and  femoral  canals  or  umbilicus,  though  occasionally  at  other  parts 
when  the  abdominal  walls  have  been  weakened  by  some  inflammatory,  lesion,  rupture,  or 
division  of  muscle  from  injury  or  operation,  and  more  rarely  at  such  weak  points  of  the 
abdominal  walls  as  the  obturator  foramen,  the  perineum,  the  ischiatic  notch,  the  dia- 
phragm, or  the  vagina. 

It  is  met  with  in  subjects  of  every  social  condition,  but  most  frequently  among.st  the 
so-called  working  classes,  because  "  hernia  occurs  oftenest  in  the  most  numerous  classes, 
and  not  in  the  most  laborious." 

Agnew  tells  us  that  in  the  American  w^ar  50  out  of  1000  recruits  were  rejected  on 
account  of  rupture  ;  that  in  Germany  the  proportion  was  82  ;  in  FVaiice,  G5  ;  in  England, 
39;  in  Ireland.  30  ;   in  Italy,  70. 

Hereditary  Tendency. — Hereditary  predisposition  to  hernia  is  also  doubtless  a 
reality,  since  a  third  of  all  cases  acknowledge  a  history  of  having  a  parent  with  rupture; 
and  such  predisposition  probably  exi.sts  as  a  general  laxity  of  the  mesenteric  _folds  and 
parietal  layer  of  peritoneum.  I  have  been  called  upon  to  operate  on  an  old  gentleman 
the  male  branches  of  whose  family  for  four  generations — twelve  in  all — have  been  rup- 
tured. Inguinal  hernia  is  often  due  to  a  failure  in  the  natural  closure  of  the  .sheath  of 
peritoneum  that  travels  down  with  the  descending  testicle  ;  w^hich  failure  is  more  common 
on  the  right  -side. 

Subjects  w;ho  are  congenitally  feeble  and  others  who  become  weak  from  illness  or  old 
age  are  more  liable  to  hernia  than  the  robust,  the  weakness  of  the  abdominal   parietes 


526  ABDOMINAL  HERNIA. 

yielding  to  tlie  natural  pressure  of  the  abdominal  contents  under  the  influence  of  some 
sudden  or  prolonged  muscular  exertion.  A  large  number  of  the  cases  of  hernia  are  slow 
in  their  development,  many  are  sudden,  and  in  all  muscular  exertion  plays  an  import- 
ant part. 

Proportion  as  to  its  Seat. — Out  of  every  100  cases  of  hernia.  84  are  inguinal, 
10  /emor(d,  and  5  innhilicnl.  It  is  more  common  in  males  than  in  females  in  the  propor- 
tion of  4  to  1,  18,402  females  only  having  been  applicants  for  trusses  at  the  Truss 
Society,  out  of  the  total  of  90.886  (i?e/;>o;V,l871). 

Hernia  in  Females,- — Femahs  are  as  liable  to  inguinal  as  they  are  to  femoral 
hernia — to  the  inguinal  in  earl}^  life,  from  the  canal  of  Nuck  being  open  ;  to  the  femoral 
in  middle  and  old  age.  In  females  under  twenty  years  of  age  there  are  87  cases  of 
inguinal  to  13  of  femoral  hernia,  and  after  forty  years  there  are  32  cases  of  inguinal  to 
68  of  femoral.  The  largest  number  of  cases  of  femoral  hernia  are  developed  during  the 
child-bearing  period  of  a  woman's  life — that  is,  between  twenty  and  forty  years  of  age. 
Prior  to  menstruation  it  is  so  rare  as  to  be  almost  unknown.  Kingdon  gives  only  four 
such  cases. 

Hernia  in  Males. — In  males  inguinal  hernia  is  the  usual  form,  Kingdon's  table 
showing  that  the  largest  number  of  cases  occur  during  the  first  ten  years  of  life,  from  a 
want  of  closure  of  the  vaginal  process  of  peritoneum  that  covers  the  spermatic  cord.  It 
is  about  half  as  frequent  between  the  ages  of  ten  and  twenty  years,  while  between  twenty 
and  forty  it  is  as  common  as  it  is  at  the  early  period  of  life,  but  its  frequency  rapidly 
diminishes  after  that  pei-iod. 

Femoral  hernia  occurs  in  the  male  in  about  4  in  every  100,  though  it  becomes,  as  in  the 
female,  relatively  more  common  than  inguinal  as  age  advances.  During  the  first  ten  years 
of  life  it  is  not  met  with  more  frequently  than  1  in  300,  whilst  between  the  ages  of  ten 
and  twenty,  2  per  cent,  are  femoral ;  between  twenty-one  and  forty,  4J  per  cent. ;  between 
forty-one  and  60,  6  per  cent.  ;  and  above  sixty,  nearly  8  per  cent. 

Average  Age  when  Strangulated. — The  average  age  of  persons  suffering 
from  ittranguhtteil  Inguinal  hernia  is  forty-three,  but  from  femoral  fift^'-five.  A  hernia 
that  becomes  strangulated  in  its  first  descent  is  far  more  acute  and  fatal  than  that  which 
has  been  of  long  standing,  and  a  femoral  hernia  is  more  liable  to  become  so  strangulated 
than  an  inginual  in  the  proportion  of  3  to  1.  These  ''recent  cases"  of  femoral  hernia 
mostly  occur  in  old  women  about  sixty  years  of  age,  and  of  inguinal  in  young  men,  the 
hernia  being  in  the  latter  of  the  "  congenital  kind." 

Anatomy  of  a  Hernia. 

A  hernial  tumor,  with  few  exceptions,  is  composed  of  a  sac  with  its  contents  and 
the  soft  parts  covering  it. 

The  sac,  which  is  made  up  of  peritoneum,  is  formed  in  two  ways — -firstly,  by  the  grad- 
ual stretching  and  pouching  of  this  membrane  through  an  opening  in  the  abdominal 
parietes  by  the  protruding  viscera,  and,  being  artificial,  has  been  well  named  by  Birkett 
the  acquired  hernial  sac,  this  variety  being  common  to  all  forms  of  hernia  ;  and  secondly, 
of  the  open  vaginal  tubular  process  of  peritoneum  formed  by  the  descent  of  the  testicle, 
the  opening  that  normally  exists  in  f«tal  life  not  having  closed  owing  to  some  deficiency 
in  the  obliterating  process  that  naturally  commences  at  the  internal  ring  and  proceeds 
downward  toward  the  testis  in  the  scrotum,  this  variety — etjually  well  named  the  congeni- 
tal hernial  sac — being  found  only  in  inguinal  hernia. 

The  formation  of  the  hernia  in  the  former  case  is  a  gradual,  but  in  the  latter  a  rapid, 
process,  the  '•  acquired  "  hernia  being  an  aff"ection  of  middle  and  old  age,  the  '"  congenital 
form  "  usually  one  of  infiincy  or  young  adult  life. 

The  sac  is  also  composed  of  a  bod}'  and  a  neck,  which  communicates  by  a  mouth  with 
the  abdominal  cavity.  When  the  hernia  is  small,  the  neck  and  body  appear  as  a  small 
pouch,  into  and  out  of  which  the  hernial  contents  pass  with  facility,  the  sac  having  no 
narrow  neck  by  which  the  return  of  the  intestine  can  be  retarded ;  but  when  the  hernial 
sac  is  large  and  has  escaped  into  looser  tissues,  its  body  or  fundus  so  expands  as  to  render, 
by  comparison,  the  neck  of  the  sac  a  narro"w  canal  or  orifice,  when  the  return  of  the 
hernial  contents  often  becomes  one  of  difficulty ;  indeed,  it  is  under  these  circumstances 
that  it  frequently  becomes  strangulated. 

The  neck  of  the  sac  also  undergoes  changes  which  it  is  essential  to  understand,  par- 
ticularly in  cases  of  scrotal  hernia,  where  the  peritoneum  is  so  forced  outward  through  the 
inguinal  ring  as  to  fall  into  puckered  folds. 


MUxiMISM.    IIIIIMA. 


b-ll 


Tlit'se  fnlils  will  tliMipiM'iir,  liowcvfr,  il'llif  litTiiiii  ami  >a('  lie  i-imIuccmI  into  tin-  iilxlidiii- 
iial  cavitv  or  tlu'  cniistrictiii^^  riiiL'  «»t'  tissue  cxtcrtial  t<i  it  In-  iliviilcil,  tlu'  <lc<rr<'c  nf  uiii'uld- 
iiiLr  of  till'  iii'fk  nf  the  sack  hriiij;  ri'jriilatcd  l>y  tin-  aiin»uiit  of  i-xpaiisioii  of  wliicli  it  is 
capaliM'.  IJiit  sliduld  the  sac  he  iieitlicr  rctiinicil  nur  its  constricting  riiijr  of  outside  tissue 
diviilcil,  the  |iuckcrcd  folds  of  jteritoiieuin  will  adhere,  and  jirohahly  the  suhperitoiiciil  con- 
nective tissue  will  unite  with  it.  The  neck  of  the  sac.  under  these  circunistunces.  liecomes 
indurated  ami  thickened,  and  as  time  proj^resses  contracts;  as  a  conse<|Uence.  a  narrow- 
in*;  and  ritridity  of  the  lu'ck  <d'  the  sac  ensue,  which  necessitates  in  old  iiifruinal  hernia, 
when  an  operation  lor  strauLrulation  is  reipiired.  (he  openini:  nf  the  sac  and  :i  Wi'v  division 
of  its  neck. 

When  a  hernia  forms  at  the  seat  of  a  wouml  in  the  at)d((niii)al  wall,  there  is  no  .sac; 
and  the  .same  occurs  when  the  c;ecum  uy  colon  ]tn»trudes  throui:h  the  iniruinal  canal. 

The  contents  of  a  hernia  are  usually  small  intestine  and  funentum.  a  portion  of  the 
last  two  feet  ot'  ileum  heiuLT,  as  a  rule,  involved  ;  the  c;ecum  ami  colon  also  arc  riecasion- 
ally  so,  and  cases  are  on  record  in  which  the  lihidder.  stoma(di,  tivary.  or  gall-hladtler  has 
hoen  found  in  the  sac. 

At  times  the  omentum  is  .so  pushed  before  the  intestine  as  to  cover  it  completely,  thus 
forming  an  inner  sac  ;  tlie  bowel,  as  a  rule,  however,  lies  behind  the  omentum. 

When  intestine  protrudes,  the  hernia  is  called  an  e/(/e/oce/«  ;  when  omentum, ''y>»y>A^- 
ci'h' ;  when  both  intestine  and  omentum  occupy  the  sac,  cntero-fpiplocele  ;  when  bladder, 
ct/stoci'lf  ;   when  stomach,  i/nsfrocelf,  etc. 

The  tissues  that  cover  in  a  hernial  sac  will  necessarily  depend  upon  the 
seat  of  the  hernia.  Thus,  in  the  iiinhlliriil  it  may  be  only  the  menil)rane  of  the  conl.  skin, 
and  al)dominal  fascia;  in  the  .>>c/v;/cr/ it  will  be  the  scrotal  tissues;  in  the  /'f»io/vir/.  the  ^kin 
with  the  superficial  and  deej)  fasciae;  but  in  all,  and  more  particularly  in  the  femoral,  the 
sur<;eon  should  boar  in  mind  the  anatomical  fact  that  a  layer  of  fiiscia,  which  lines  the 
abdomiiuil  muscles  and  separates  them  from  the  peritoneum,  covers  in  the  true  peritoneal 
sac,  and  is  known  as  the  "  fascia  propria  "  of  Sir  A.  Cooper,  and  between  this  fascia  and 
sac  some  subperitoneal  fat  often  exists. 

When  a  hernia  comes  down  into  a  sac  and  i^oes  up  again,  either  by  itself  or  aided  by 
position  or  by  the  surgeon,  it  is  called  rtdncible ;  when  it  cannot  be  returned,  it  is  called 
irnduciUe ;  when  it  is  constricted  sufficiently  to  interfere  with  the  return  of  the  contents 
of  the  protruding  viscera,  it  is  known  as  incarcrafed,  but  would  be  better  called  ohatrncted  ; 
and  when,  in  addition,  the  circulation  of  the  part  is  interfered  with,  it  is  said  to  be  strangu- 
lated. 

When  the  i)rotrusion  takes  place  ahore  Poupart's  ligament,  through  the  internal  ring, 
but  does  not  traverse  the  canal  sufficiently  far  to  appear  through  the  external  ring,  the 


Fig.  301. 


Fig.  302. 


Oblique  In$;iiinal  Hernia. 

Bubonocele  on  ri^'lit  .-ide.  hut  passing  through 

external  ring  on  left. 


Direct  Inguinal  Hernia. 


hernia  is  called  a  Imhonocelr  (vide  right  side  of  Fig.  301)  ;  when  it  protrudes  through  the 
external  ring  into  the  scrotum,  a  scrotal  hernia  (vide  left  side  of  Fig.  301).  both  forms 
being  included  in  the<erm  oblique  imjninaJ  hernia. 

When  a  hernia  makes  its  way  directly  through  the  external  ring  without  having 
passed  down  the  inguinal  canal,  it  is  called  a  direct  iiKpiinal  (Fig.  302). 

A  crural  or  femoral  hernia  is  lehnc  Pouparts  ligament,  the  protrusion  having 


528  ABDOMINAL  HERNIA. 

come  down  through  the  crural  ring  on  the  inner  ^^ide  of  the  sheath  of  tlie  femoral  vessels 
(Fig.  'i(\y,). 

An  umbilical  hernia  or  exomphalos  is  a  protrusion  at  the  navel.  A  ventral  is 
a  protrusion  at  any  other  part  of  the  abdomen.  The  names  of  every  other  form  are 
according  to  the  locality. 

Symptoms. — A  hernia  in  its  early  stage  may  show  itself  as  a  mere  fulness  about  the 
internal  inguinal  ring,  the  crural  ring,  or  other  opening,  this  fulness  becoming  very  mani- 
fest on  the  patient  standing  and  coughing.  The  patient's 
attention  has  probably  been  drawn  to  the  part  by  a  feeling 
of  iceakiiess  o\\  n^aking  exertion  or  in  performing  any  natu- 
ral act  demanding  the  strong  action  of  the  abdominal  mus- 
cles. AVith  this  weakness  there  is  often  associated  some 
grijiing  abdominal  pain  or  feeling  of  uneasiness — wrongly 
attributed  to  constipation — and  in  old  people  these  symp- 
toms should  always  attract  the  notice  of  the  surgeon. 

As  the  hernial  pouch  increases  the  tumor  in  the  in- 
guinal canal,  at  the  femoral  ring  or  umbilicus,  will  show 
itself  as  a  distinct  swelling,  this  being  manifest  when  the 
patient  stands  or  coughs,  but  disappearing  on  his  lying 
down.  It  will,  moreover,  be  prevented  from  returning  on 
Femoral  Hernia.  the  patient  assuming  the  erect  posture  if  the  finger  of  the 

surgeon  is  placed  over  the  ring.  The  swelling  always  comes 
from  above  and  travels  downward.  As  the  tumor  still  further  increases  a  distinct  impulse 
will  be  felt  by  the  hand  when  placed  over  it  if  the  patient  coughs,  and  a  peculiar  gursling 
sound  will  be  heard  on  the  application  of  pressure  to  the  part  to  cause  its  reduction.  The 
return  of  the  bowel  also  into  the  abdominal  cavity  will  be  marked  by  the  disappearance 
with  a  jerk  of  the  contents  of  the  sac  and  a  distinct  appreciation  by  the  finger  of  the  aper- 
ture through  which  it  has  passed. 

"  If  the  surface  of  the  tumor  be  uniform  ;  if  it  be  ela.stic  to  the  touch  ;  if  it  become 
tense  and  enlarged  when  the  patient  is  troubled  with  wind,  holds  his  Itreath.  or  coughs  ; 
if  in  the  latter  case  it  feels  as  if  it  were  inflated  ;  if  the  part  return  with  a  peculiar  noise 
and  pass  through  the  opening  at  once. — the  contents  of  the  swelling  are  intestine.  If  the 
tumor  be  compressible ;  if  it  feel  flabby  and  uneven  on  the  surface ;  if  it  be  free  from 
tension  under  the  circumstances  just  enumerated;  if  it  return  without  a  noise  and  pass 
up  gradualh', — the  case  may  be  considered  as  epiphxeJe.  If  a  portion  of  the  contents  slip 
up  quickly  and  with  noise,  leaving  behind  something  which  is  less  easily  reduced,  the  case 
is  probably  an  enteio-epyi jdocele^   (Lawrence). 

In  infants,  where  ilalgaigne's  "  hernia  of  infants"  exists  (Fig.  292),  or  Haller's 
"  hernia  congenita.'"  both  being  caused  by  the  descent  of  intestine  into  the  open  vaginal 
process  of  the  peritoneum,  the  tumor  is  very  often  large  when  first  discovered,  and  often 
scrotal.  In  young  adults,  where  the  same  kind  of  hernia  exists,  the  swelling  comes  sud- 
denly and  at  once  by  one  ru.sh  downward  into  the  scrotum,  this  ru.sh  being  accompanied 
with  pain. 

Tre.-vtmen'T. — In  all  these  forms  of  hernia,  when  reducible,  either  xXxe  pallia  I  ivi  plan 
of  treatment   may  be  employed,  or  what  is  known  by  the  radical  cure. 

The  palliative  treatment  consists  in  the  application  of  a  truss — an  instrument 
composed  of  a  pad  or  cushion  connected  with  a  metallic  spring  or  with  straps,  and  so 
arranged  that  the  pressure  of  the  pad  keeps  the  hernia  from  descending ;  the  spring 
maintains  the  pad  in  position  and  at  the  same  time  allows  perfect  freedom  of  movement 
of  the  body.  Any  truss  that  accomplishes  this  is  beneficial,  but  any  that  fails  in  this  is 
worse  than  useless,  as  it  is  injurious  and  gives  false  confidence. 

The  operation  for  the  radical  CUre  of  hernia  will  be  considered  under  the  heading 
"  Inguinal  Hernia." 

Hydrocele  of  the  Hernial  Sac 

is  a  very  rare  affection,  and  not  more  than  six  cases  are  on  record.  I  have  seen  but  one 
true  example  of  it — that  is.  if  the  term  be  confined  to  such  cases  of  accumulation  of  fluid 
in  the  hernial  sac  in  which  the  neck  of  the  sac  is  occluded  by  some«adherent  omentum  or 
intestine  or  by  the  radical  cure.  The  case  occurred  in  a  man  aet.  40  who  had  been  treated 
for  hydrocele  of  the  right  testicle  £or  twenty  years,  and  had  frequently  been  tapped.  He 
came  under  my  care  with  a  right  scrotal  swelling  which  extended  up  to  the  internal  ring. 


iitRF.i) I V •iiii.r.  iii:i:.\/A. 


529 


anil  uhscuri'  sviiiptoiiis  ni'  intfstinal  obstruction.  lit-  was  tappcil  ami  serous  fluid  was 
drawn  ofl",  hut  the  syniptoins  continued.  After  tlie  lapse  (A'  two  or  three  days,  as  the 
ahdoininal  symptoms  increased  in  severity  in  my  absence,  an  exploratory  operation  was 
performed,  and  a  mass  of  what  was  suj)posed  to  he  omentum  or  an  omental  sac  contain- 
in<i  intestine  was  found  hlocking  up  the  internal  ring.  This  was  opened  and  the  inucouK 
inenihraru'  of  the  bowel  ex]>osed.  The  <»peiiiiij;  into  the  bowel  was  stitched  up.  but  the 
symptoms  persisted  ;  and  tlu!  man  died  two  days  later,  of  ])eritonitis.  An  examination 
after  death  showed  that  what  had  been  rej^'arded  as  an  hydrocele  was  a  dropsy  of  a  con- 
•^euital  hernial  sac,  ami  what  had  btM'n  opened  as  a  mass  of  ometitum  or  omental  sac  was 
a  kniiekli'  of  ileum  matteil  totfether  and  to  the  niick  of  the  sac  by  lymph,  this  adhesion 
j^ivin^-  rise  to  the  fatal  obstruction.  \o  hydrocele  existed.  Such  cases  as  these  should 
not  be  mistaken  for  dropsy  or  suppuration  of  tlu;  liernial  sac  after  herniotomy,  which  are 
bv  no  means   unfre(|uent    eoiiditioiis,  and  siiould   be  treated    by  tajiping  or  a  free  incision. 


Irreducible  Hernia. 

When  the  contents  of  a  hernial  tumor  cannot  be  returned  into  the  abdominal  cavity, 
an  irreducible  hernia  is  said  to  exist ;  and  this  condition  may  be  temporary,  brought  about 
by  anything  that  alters  the  relations  between  the  bulk  of  the  tumor  and  the  neck  of  the 
sac  or  the  opening  through  which  they  would  have  to  return,  such  as  .some  excess  of 
feces  or  flatus  in  the  part  or  some  fresh  descent  of  omentum  or  bowel.  A  hernia  may 
be  made  j)ermanently  irreducible  by  adhesions  between  the  .sac  itself  and  its  contents,  by 
bands  traversing  the  sac,  or  by  adhesions  between  the  intestine  and  .some  fold  of  omen- 
tum. In  long-standing  herni;e  the  .same  result  will  ensue,  from  the  development  of  fat 
in  the  omentum. 

The  tonic  or  spasmodic  contraction  of  the  structures  outside  the  neck  of  the  sac 
under  the  influence  of  irritation,  as  well  as  the  induration  of  the  neck  of  the  sac  itself 
or  of  the  surrounding  parts,  has  also  an  important  influence  in  preventing  the  reduction 
of  the  tumor. 

AVhen  the  caecum  or  large  intestine  forms  the  contents  of  the  hernia,  the  rupture  may 
be  irreducible,  from  the  fact  that  the  peritoneum,  which  is  naturall}'  adherent  to  these 
parts  and  is  dragged  down  with  them,  becomes  fixed  to  the  tissues  into  which  it  is  protruded. 
A  cjecal  hernia  is,  however,  always  difficult  of  reduction.  In  one  case  I  had  to  puncture 
the  bowel  with  a  trocar  and  canula  and  draw  off  the  air  it  contained  before  I  succeeded. 
Xo  harm  followed  this  step,  and  the  patient  did  well ;  but  the  measure  is  not  without  its 
dangers. 

Prognosis. — An  irreducible  hernia  is  always  a  source  of  anxiety  and  danger,  because 
when  composed  of  omentum  a  piece  of  intestine  may  at  any  time  slip  down  behind  it  and 
become  caught  in  one  of  its  folds  ;  and  when  composed 
of  omentum  and  intestine,  any  accumulation  of  the  con- 
tents of  the  bowel  within  the  hernial  sac  may  give  rise 
to  obstruction,  and  then  strangulation  of  the  hernia  is 
not  distant.  An  irreducible  hernia,  moreover,  is  always 
liable  to  injury. 

An  irreducible  scrotal,  or  even  femoral,  hernia  will 
sometimes  attain  a  large  size.  I  have  seen  examples 
of  both  reaching  halfway  down  the  thigh,  but  umbilical 
hernia  will  sometin)es  attain  a  still  greater  size. 

These  forms  of  hernia  often  give  rise  to  dyspeptic 
.symptoms,  to  irregularity  of  bowels  and  colicky  pains ; 
but  the  chief  danger  lies  in  their  tendency  to  become 
strangulated. 

Trkat.ment. — A  large  irreducible  entn-o-epiplnceJf 
mu.st  be  treated  by  a  bag  truss — that  is,  with  an  instru- 
ment so  adapted  as  to  support  the  hernia  and  prevent, 
as  far  as  possible,  its  increase.  A  .small  irreducible  um- 
bilical, inguinal,  or  femoral  hernia  ought  to  be  treated  by 
a  hollow  truss,  the  only  reliable  pad  being  one  moulded 
upon  a  plaster  cast  of  the  hernia,  taken  when  the  tumor 
is  at  its  smallest,  after  a  day's  rest.  The  pad  should 
be  made  of  metal  moulded  to  the  cast  and  lined  with  wa.sh-leather  (Fig.  304 :  vide  paper 
by  author,   British  Medical    Journal^  February  IG,  1884).      A  omental,   hernia  should  be 


Fig.  304. 


Drawing  showina  on  the  Eiohi  Siile  aTrus,s 
fitted  loan  Irreducible  Hernia,  in  which 
the  Pad  has  been  mouldetl  upon  a  Cast  of 
the  Patient's  Groin  ;  and  on  the  L'fl  .Side 
an  Irreducible  Hernia  with  the  Hollow 
of  the  Pad  exposed  to  View,  prepared  for 
Application. 


530  ABDOMINAL   HERNIA. 

treated  by  a  truss  made,  in  the  way  described,  upon  a  cast.  Every  patient  with  an  irre- 
ducible hernia  should  be  warned  against  takinir  violent  exercise  or  overdistending  the 
abdominal  viscera.  The  bowels  should  never  be  allowed  to  become  constipated,  and, 
above  all,  the  slightest  symptom  of  pain  or  increase  of  size  in  the  tumor  should  be  brought 
at  once  under  medical  advice,  since  these  irreducible  herniae  are  treacherous  things  and 
become  obstructed  and  strangulated  very  in.sidiously. 

In  many  cases  of  irreducible  hernia,  and  particularly  in  recent  cases,  reduction  may 
be  effected  by  rest  in  the  horizontal  posture,  a  brisk  purge  or  enema,  and  the  administra- 
tion of  small  doses  of  saline  purgatives,  such  as  the  sulphate  of  magnesia,  so  as  to  keep 
up  a  gentle  action  of  the  bowels,  with  the  local  application  of  ice.  the  diet  being  at  the 
same  time  nutritious,  though  not  of  a  bulky  nature.  In  this  way  I  have  procured  the 
reduction  of  cases  of  hernia  that  had  been  down  for  three  months  ;  in  .several  cases  I  have 
succeeded  after  three  week's  treatment.  Old  irreducible  hernia?  are.  however,  rarely  made 
reducible  by  treatment,  but  the  not  very  old  examples  and  the  recent  can  generally  be 
made  reducible  by  the  means  already  indicated. 

Obstructed  or  Incarcerated  Hernia. 

The  .SYMPTOMS  of  an  obstructed  hernia,  as  of  ob.structed  intestine,  are  not  very  defi- 
nite, but  the  chief  are  ob.scure  abdominal  pains  with  a  di-agging  sensation  about  the 
umbilicus  after  food,  nau.sea,  and  at  times  vomiting.  Con.stipation,  when  present,  aggra- 
vates the  symptoms  and  renders  the  local  nitjns  of  obstructed  hernia  more  marked,  the 
tumor  becoming  distended,  tympanitic,  and  painful.  On  manipulation,  the  intestine  in 
the  hernia  may  be  partially  or  wholly  emptied  of  its  gaseous  if  not  of  its  solid  contents, 
and  the  compression  of  the  tumor  be  accompanied  b}-  the  peculiar  gurgling  sound  of  gas 
and  fluid  as  these  traver.se  the  canal  toward  the  abdominal  cavity.  When  such  symp- 
toms are  chronic,  they  are  generalh-  known  as  indicating  an  incarceratefl  hernia;  but 
such  a  term  is  not  sati.sfactory,  it  being  applied  to  the  obstructed  as  well  as  to  the  redu- 
cible hernia,  and  should  be  discontinued. 

Treatment. — These  cases  require  great  care  in  their  treatment,  because,  if  neglected, 
they  pass  on  rapidly  to  inflammation  or  strangulation.  Rft^t  in  the  horizontal  position  is 
of  primary  importance,  and  the  tumor,  if  scrotal,  should  be  slightly  elevated.  \Wirmili 
to  the  hernia  also  often  gives  comfort,  relaxing  the  parts,  and  thus  favoring  reduction. 

When  constipation,  vnaccompanied  by  voraitinff,  exists,  a  brisk  purge  may  be  given  ; 
but  with  this  .symptom  a  purgative  enema  is  to  be  preferred,  the  natural  action  of  the 
bowels  being  stimulated  by  these  means  and  the  contents  of  the  hernial  sac  moved  on. 
The  tumor  itself  .should  not  be  manipulated  at  this  stage  of  the  case,  such  a  step  doing 
harm  by  bruising  or  setting  up  inflammatory  action.  When  success  does  not  attend  these 
efforts  and  the  symptoms  persist,  the  source  of  obstruction  will  have  to  be  sought  by  the 
surgeon,  as  it  will  probably  be  mechanical,  and  the  case  have  to  be  dealt  with  as  one  of 
strangulated  hernia. 

Inflammation  of  a  Hernia. 

An  inflamed  is  not  a  strangulated  hernia.  Inflammation  of  a  hernia  is  generally  the 
result  of  .some  injury  to  an  irreducible  hernia,  from  either  accident,  a  badly-fitting  truss, 
or  ill-advised  manipulation.  An  irreducible  hernia  after  an  attack  of  obstruction  may 
inflame.  A  reducible  hernia,  becoming  temporarily  irreducible  and  inflaming,  may  become 
permanently  irreducible  by  adhesions  forming  between  the  sac  and  its  contents. 

The  local  siyns  of  an  inflamed  hernia  are  pain,  swelling,  and  induration.  When  the 
tumor  contains  omentum,  it  becomes  nodulated  and  irregularly  hard ;  and  when  intestine, 
much  fluid  will  be  poured  into  the  sac.  When  the  action  is  enough  to  interfere  with  the 
natural  function  of  the  tube,  symptoms  of  general  peritonitis  or  obstruction  will  appear, 
which  must  be  dealt  with  on  ordinary  principles. 

Treatment. — Re>it  and  the  local  application  of  ice  in  a  bag  are  the  mo.st  important 
remedies,  also  purgatives  when  obstruction  in  the  hernia  does  not  exist,  and  opium  when 
it  does.  By  such  means  the  sv-mptoms  are  generally  arrested ;  and  when  this  result  does 
not  take  place,  the  case  passes  on  to  one  of  obstruction,  if  not  of  general  peritonitis. 

Rupture  of  a  Hernia, 

or  rather  of  the  sac  and  integuments  over  it.  has  been  recorded  by  B.  Pitts  of  St. 
Thomas's  Hospital  (^Lancet.  April  7,  1883).  and  the  accident,  as  proved  by  the  case,  is 


lyrKSTiXAL  ni!STi:r<rnK\,  inv.  5;51 

nut  iK'oi'ssarily  tatul.  It  ncciiiiiMl  in  a  wnniaii  a-t.  1*1  who  lia<l  ln-cii  i)|iciat(Ml  u|inii  t'ur  u 
straiijjTulatril  /I ///"/<«/ lu-riiia  two  Vfars  and  tlin-c  inoiiths  previously.  She  had  not  worn 
a  trusts  for  a  yi-ar  bctorr  tlir  accident,  and  tlie  hernia  hml  hecunie  as  hir^re  as  a  ehihJ'a 
liead.  It  liurst  durinjr  a  tit  of  couj^hinjr,  and  the  line  of  rupture  was  in  the  sound  skin 
near  the  cicatrix  ;  intestine  at  once  jirotruded  tlirough  the  wound.  After  the  hipse  of 
three  hours  Mr.  I'itts  .saw  her,  and  found  a  stout  woman  much  eolhip.sed.  with  a  f(M»t  an<l 
a  half  of  small  intestine.  Iiruised.  congested,  dirty,  and  very  cold,  protrudinir  through  an 
external  wound  altout  one  inch  long.  lie  cleansed  the  part  with  warm  carlxdic  lotion, 
and  after  enlarging  the  skin  opening  returned  the  protruding  liowel,  and  with  it  the  cjccum 
and  ahmit  live  feet  of  small  intestine  that  had  Keen  in  the  sac.  lie  cut  f>ft"  redundant 
skin  ami  sac  and  stitched  uji  the  part,  making  good  provision  for  drainage.  A  good 
recovery  ensued.  A  .second  case  like  the  above  is  also  recorded  by  Mr.  Jones  (Luncff^ 
Aj.ril,  1SS(»). 

Intestinal  Obstruction  and  Peritonitis  as  a  Result  of  the  Adhesion 
6f  a  Piece  of  Intestine  to  the  Hernial  Sac. 

I  published  such  a  case  in  1801  in  Part  III.  of  my  Clinical  Snryi  ri/,  and  Mr.  Birkett, 
in  his  excellent  article  in  Holmes  s  Snrgert/  f  third  edition,  vol.  ii.,  1883j,  has  given  a  sec- 
ond case  with  a  drawing,  which  I  also  had  the  advantage  of  seeing;  and  he  alludes  to  the 
fact  that  M.  Littre  called  the  attention  of  the  profession  to  the  cases  illustrated  by  the 
above  in  a  paper,  "  Sur  une  nouvelle  espece  de  Hernie,'  Mem.  de  CAcud.  Roijolf;  dcg 
SciiiiceK.  1700,  p.  300.     The  notes  of  my  case  are  as  follows: 

Lmbilicid  Ilentla ;  Ohgtruciion  to  tlu:  BoiveU  from  a  Socmhited  Adherent  Colon; 
Death. — A  woman  a?t.  56.  having  had  a  hernia  for  many  years,  was  suddenly  seized  some 
twenty-four  hours  before  her  admission  into  Guys,  under  the  care  of  Mr.  Cock,  with 
symptoms  of  strangulation.  The  taxis,  under  the  influence  of  chloroform,  proved  success- 
ful, but  collapse  and  death  followed  in  twelve  hours.  After  death  general  peritonitis  was 
found  to  have  been  present,  the  intestinal  coils  being  all  adherent.  An  umbilical  omental 
hernia  the  size  of  a  fist  existed,  the  omentum  forming  a  distinct  sac.  To  the  centre  of 
this  the  anterior  wall  of  the  transverse  colon  was  firmly  adherent,  forming  a  kind  of 
pouch.  The  colon  was,  however,  tolerably  free.  The  intestines  above  this  point  were 
distended,  and  below  it  contracted  and  empty.  The  ca?cum  was  of  an  enormous  size, 
almost  filling  the  lower  part  of  the  abdomen.  It  was  here  that  the  tension  had  been 
experienced  ;  it  was  black  and  in  places  the  peritoneal  coat  was  fissured,  leading  to  the 
belief  that  but  little  extra  distension  could  have  been  borne  without  a  rupture  taking 
place.  The  mucous  membrane  was  also  lacerated  transversely,  while  the  walls  were  so 
thin  that  they  were  nearly  ruptured  in  handling,  these  conditions  being  such  as  we  com- 
monly meet  with  in  cases  of  chronic  intestinal  obstruction. 

In  this  interesting  case  death  had  doubtless  been  caused  by  peritonitis,  although  not 
from  the  strangulation  of  the  umbilical  hernia,  but  from  a  partially-ruptured  and  over- 
distended  cjvcum — a  condition  of  bowel  which  had  clearly  been  produced  by  the  traction 
exerted  upon  the  transverse  colon,  the  result  of  the  adhesion  of  its  walls  to  the  omental  sac. 

As  elucidating  a  secondary  result  of  hernia  this  case  must  be  regarded  as  most  valu- 
able, illustrating,  as  it  does,  a  point  not  perhaps  sufficiently  recognized — namely,  the  influ- 
ence of  the  adhesion  of  the  bowel  to  a  hernial  sac  or  to  the  abdominal  walls  upon  the 
functions  of  the  intestines,  since,  doubtless,  such  adhesions  are  sufficient  to  account  for 
many  of  the  griping  and  painful  symptoms  which  exist  in  an  old  and  irreducible  hernia, 
as  in  other  cases  of  abdominal  trouble.  The  case  referred  to  must  also  be  regarded  as  a 
good  illustration  of  the  result  of  a  long-continued  interference  with  the  bowels  action, 
for  the  overdi,stension  of  the  caecum,  with  its  attendant  consequences,  was  apparently  due 
entirely  to  the  interference  with  its  functions  resulting  from  the  union  of  the  walls  of  the 
transverse  colon  with  the  omental  sac.  The  calibre  of  the  colon  itself  was  not  materially 
diminished,  but  its  power  of  acting  had  become  paralyzed ;  the  greater  the  distension  of 
the  intestine  above,  the  greater  must  have  been  the  traction  caused  by  the  adhesion,  and 
as  a  sequel  the  greater  was  the  effect  of  this  interference.  At  last  complete  paralysis  of 
the  part  had  taken  place,  and  complete  obstruction,  giving  rise  to  all  the  symptoms  and 
conditions  which  had  terminated  in  death. 

These  cases  tend  to  prove  that  the  smallest  traction  of  a  portion  of  the  calibre  of  the 
intestine  in  hernia  or  elsewhere,  although  accompanied  with  an  open  passage  of  the 
bowel,  is  quite  sufficient  to  interfere  with  the  bowel's  action,  and  even  to  cau.se  complete 
obstruction.     In  a  former  page  I  have  pointed  out  how  strangulation  of  the  bowel  within 


532 


ABDOMINAL  HERNIA. 


the   abdomen  may   result  from    the    formation   of    bands    associated   with    an    external 
hernia. 

Strangulated  Hernia. 

A  rupture  is  said  to  be  strangulated  when,  in  addition  to  its  solid  contents  being 
irreducible,  the  venous  circulation  of  the  parts  involved  is  more  or  less  completely 
arrested. 

This  result  may  be  brought  about  whenever  a  knuckle  of  intestine  slips  through  an 
opening  in  the  abdominal  walls  (external  hernia)  or  is  constricted  from  any  cause  within 
the  abdominal  cavity  (internal  hernia)  by  air  or  motion  entering  the  upper  extremity  of 
the  knuckle,  and  distending  it  so  as  to  compress  its  lower  end  against  the  neck  of  the 
constricting  orifice  through  which  it  may  have  passed  (Fig.  306).     The  greater  the  pres- 


FiG.  305. 


Fig.  306. 


Distemlccl  & 
con rie sled      te»^^   ^  / 


necTt  ojf  sa  c 


An  I'nstransrulatefl  Hernia. 


A  Straiisulate.l  Hernia. 


sure  from  above,  under  these  circumstances,  the  more  the  lower  end  of  the  bowel  will  be 
compressed ;  consequently,  the  more  complete  will  be  the  obstruction,  and  the  sooner 
the  compressed  or  strangulated  bowel  will  lose  its  life,  the  part  dying  from  static  gan- 
grene. 

Strangulation  may  happen  in  the  first  descent  of  the  rupture — recent  hernia ;  but 
more  commonly  it  takes  place  after  a  hernia  has  existed  for  man}-  years — old  hernia.  An 
analysis  of  cases  that  I  made  in  1856  {Guj/'s  Rejiort.^)  indicated  that  the  average  dura- 
tion of  an  inguinal  hernia  previous  to  its  becoming  strangulated  was  twenty,  and  of  a 
femoral  eleven,  years.  The  same  analysis  likewise  showed  the  most  important  practical 
fact  that  when  an  inguinal  hernia  becomes  strangulated  in  its  first  descent  it  is  generally 
of  the  "  congenital,"  and  not  the  "  acquired,"  kind;  also  that  femoral  hernia  was  far  more 
liable  than  inguinal  to  strangulation,  and  to  strangulation  on  its  first  descent,  and  that 
umbilical  hernia  is  less  liable  to  strangulation  than  either  of  the  two  other  forms,  that  it 
is  little  liable  to  stxangulation  in  its  first  descent,  and  that  when  strangulated  it  is  almost 
always  of  very  long  standing. 

A  hernia  strangulated  on  its  first  descent,  whether  of  the  inguinal  or  femoral  form, 
requires  operation  more  frequently  than  the  "  old  "  hernia  and  is  far  more  fatal,  a  stran- 
gulated inguinal  hernia  of  the  "  congenital ''  kind  being  by  far  the  most. 

The  SYMPTOMS  of  strangulated  hernia  are  those  of  strangulated  intestine  from  what- 
ever causes,  and  they  are  due  rather  to  the  obstruction  of  the  venous  circulation  of  the 
strangulated  part  than  to  the  obstruction  of  the  intestinal  contents.  In  old  inguinal 
hernia  of  many  years'  standing  they  may  be  chronic;  in  recent  hernia,  and  more  particu- 
larly of  the  femoral  or  congenital  inguinal  form,  they  are  acute. 

It  thus  often  happens  that  in  an  acute  or  "  recent "  inguinal  or  femoral  hernia  its 
descent  is  accompanied  by  severe  abdominal  pain  in  the  region  of  the  umbilicus,  vomiting 
first  of  the  contents  of  the  stomach,  then  of  those  of  the  duodenum  (biliary  vomiting), 
and  at  a  later  stage  of  the  yellow  contents  of  the  small  intestine,  and  even  of  feces,  and 
later  on  by  more  or  less  collapse.  Constipation  is  also  usually  present,  although  on  the 
first  onset  of  the  symptoms  it  is  not  uncommon  for  the  large  intestines  to  empty  them- 
selves. AVith  these  general  symptoms  of  obstruction  the  local  signs  of  hernia  will  be 
present  at  one  or  other  of  the  sites  at  which  a  hernia  may  occur;  the  hernial  tumor  will 
be  tense  and  painful  and  without  impulse  on  the  patient  coughing. 

The  general  symptoms  thvis  described  are  common  to  every  form  of  acute  intestinal 
obstruction,  whether  outside  the  abdominal  cavity  from  a  hernia,  or  inside  from  internal 
strangulation,  ileus,  or  other  cause.     In   every  case  in  which  they  occur  the  practitioner 


I'ATIlOLiH.KAL   r//.i.\v;AX  533 

sliould  (Mnf'ully  cxainiiif  the  site  of  every  jiossiMe  lieniia  and  rint  trust  to  the  patient  in 
any  way,  as  tlie  K)eal  are  often  inaskeil  \>\  tlie  severity  of  tlie  f^eiieral  symptoms,  and  the. 
local  eaiiso  is  thereby  overlooki-d. 

The  svmittoins  in  an  '•  old  hernia  "  are  less  acute  and  are  more  those  of  chronic 
ohstruetion  ;  they  arc  not,  however,  less  characteristic  whrii  vomltiiKj  has  sot  In.  In  all 
jirolialiilitv.  h'dore  this  symptom  appears,  the  patient  will  have  complained  of  some  gen- 
eral altdoniinal  uneasiness,  such  as  flatulence,  a  feelinj;  of  faintness,  nausea,  and  fulness, 
with  loeal  pain  in  the  hernia;  the  nausea,  however,  will  soon  be  followed  by  persistent 
eructations,  hice(tu<j:h,  and  vomiting;  in  most  of  the  cases  constipation  too  will  be  present, 
though  in  some  the  desire  to  go  to  stool  will  be  great  and  the  straining  severe.  The 
local  signs  of  strangulation  or  obstruction  are  often  so  slight  as  to  be  disregariled  by  the 
])atieut,  and  uidess  the  hernia  is  discovered  by  the  surgeon  his  attention  will  probably 
not  be  drawn  to  it  by  the  sufferer.  Thus,  at  Christmas,  llSTO,  I  reduced  a  femoral  hernia 
by  the  taxis  strangulated  for  a  hundred  hours  in  a  man  who  was  unconscious  of  its  pres- 
ence till  a  few  hours  before. 

If  the  obstruction  remain  unrelieved,  the  powers  of  the  patient  will  pmbaliiy  become 
prostrate  and  more  or  less  complete  collapse  will  show  itself,  with  a  feeble  pulse  and  cold 
clammy  skin.  The  vomiting  abso  may  diminish  in  intensity,  or  even  cease,  at  times 
remaining  only  as  a  passive  pouring  out  through  the  mouth  of  the  intestinal  contents. 
Pain  previously  severe  may  also  suddenly  disappear.  The  collapse,  indeed,  may  be  so 
great  that  the  parts  about  the  neck  of  the  sac  will  become  rela.xed,  and  the  hernia  may 
go  up  either  by  itself  or  by  the  gentlest  ])ressure ;  and  such  symptoms  indicate  a  serious 
collaj^se  of  the  general  power  of  the  patient  as  well  as  a  destruction  of  the  parts  strang- 
ulated. Under  these  circumstances  death  juay  be  looked  for,  either  from  the  shock  to 
the  nervous  system,  gangrene  or  death  of  the  strangulated  bowel,  rupture  of  the  bowel 
at  the  line  of  stricture,  fecal  extravasation,  or  peritonitis. 

"When  gangrene  of  the  bowel  is  the  cause  of  death,  the  collapse  may  be  as 
great  as  it  is  i'mm  shock,  althougli  of  greater  duration.      Death,  however,  is  slower. 

W^hen  rupture  of  the  bowel  with  fecal  extravasation  is  followed  by  collapse, 
it  will  have  been  preceded  by  .symptoms  of  local  or  general  peritonitis  or  by  a  sudden 
severe  abdominal  pain  ;  for  in  all  cases  of  strangulated  hernia  in  which  any  delay  in 
reduction  has  taken  place  symptoms  of  inflammation  of  the  protruded  parts,  of  local  peri- 
tonitis around  the  neck  of  the  sac.  and  subsequently  of  general  peritonitis,  will  be  sure 
to  .show  themselves. 

Strangulated  omental  hernia  is  characterized  by  the  same  symptoms  as  the 
intestinal,  though  less  marked  and  acute.  The  pain  is  not  so  severe  nor  the  vomiting  so 
constant,  constiftation  is  less  complete  and  insuperable,  while  the  constitutional  symptoms 
are  also  milder.  The  local  distress  is  likewise  inconsiderable,  the  tumor  feeling  harder, 
more  nodular,  and  like  to  an  obstructed  hernia,  permitting  manipulation  more  freely  than 
when  it  contains  intestine.  As  time  progresses,  however,  symptoms  of  inflammation  in 
the  hernial  tumor  will  .show  themselves  with  tho.se  of  local  peritonitis  ;  and  when  these 
appear,  they  are  as  severe  and  destructive  as  they  are  in  other  forms  of  strangulated 
hernia.     In  exceptional  cases,  however,  the  omentum  may  slough. 

A  strangulated  omental  hernia  requires,  consequently,  as  active  surgical  treatment  as 
any  other,  as  it  leads  to  the  same  end — a  fatal  peritonitis. 

Pathological  Changes  the  Result  of  Strangulation. 

These  are  the  same  when  they  take  place  within  the  abdominal  cavity  as  in  an  exter- 
nal hernia,  and  under  both  circumstances  the  first  eff'ect  of  the  partial  arrest  of  the  venous 
circulation  through  the  parts  is  congestion,  this  congestion  being  associated  with  its  usual 
accompaniment,  serous  effusion.  When  complete  arrest  has  taken  place,  the  congestion 
will  be  more  thorough,  the  surface  of  the  bowel  appearing  of  a  red  jiurple  or  blacki.sh 
hue,  and  the  tissues  themselves  thickened  from  efi"usion  into  their  meshes  or  blackened, 
wholly  or  in  .spots,  by  extravasated  blood  (Fig.  307).  When  they  have  been  much 
manipulated  by  the  taxis,  the  extravasation  of  blood  into  the  tissues  is  often  very 
marked,  the  degree  of  congestion  depending  upon  the  completeness  of  the  strangulation. 

When  the  .strangulation  has  been  acute  or  of  long  standing  and  an  inflammatory 
action  been  added  to  that  of  congestion,  the  bowel  will  be  not  only  swollen,  but  soft,  and 
the  natural  glLstening  aspect  and  elasticity  of  its  coats  will  have  become  changed  for  a 
dull  appearance  and  leathery  condition.  Its  serous  surface  may.  indeed,  be  covered  with 
a  layer  or  with  flocculi  of  lymph,  or  the  knuckle  of  intestine  may  be  wholly  or  in  part 


534 


ABDOMIXAL   IIKRMA. 


soft  and  gangrenous,  with  asli-colured  spots  on  its  surface,  and  even  perforations.     When 
the  bowel  dies  from  strangulation,  the  gangrene  will  be  of  the  static  kind. 

At  the  neck  of  the  sac  other  changes  will  also  be  found,  and  these  depend  materially 
upon  the  character  and  seat  of  the  constricting:  force.  Thus,  when  the  line  of  a  stran- 
gulation is  rigid  and  linear,  as  it  is  in  direct  inguinal  and  femoral  hernia,  the  knuckle  of 

Fig.  3U7. 


Extreme  Venous  Congestion  and  Interstitial  Hemorrhage  the  Effects  of  Severe  Strangulation  of  the  Bowel. 

(Drawing  4816.    Birkett.) 

Strangulated  bowel,  either  as  a  whole  or  in  part,  may  be  rapidly  destroyed  by  gangrene ; 
and  when  the  pressure  is  more  diffused  and  less  rapid,  as  in  large  inguinal  hernia,  ulcer- 
ation of  the  mucous  membrane  at  the  line  of  stricture,  even  to  perforation,  is  more  com- 
mon, the  grooved  or  sulcated  condition  of  the  serous  surface  in  the  line  of  stricture  being 
found  in  both. 

Within  the  abdomen  every  indication  of  peritonitis,  from  the  mere  greasy  condition 
of  peritoneum  to  fibrinous,  or  even  suppurative,  effusion,  may  be  met  with.  In  most 
cases  local  peritonitis  will  be  found  about  the  seat  of  hernia,  and  in  some  the  peritonitis 
will  be  general.  The  strangulated  portion  of  bowel  will  almost  always  be  found  at  the 
neck  of  the  sac,  if  not  adherent  to  it.  with  more  or  less  matting  together  of  the  neighbor- 
ing coils. 

That  this  peritonitis  is  to  be  directly  attributed  to  the  strangulation  of  the  intestine 
is  generalh'  acknowledged,  few  cases  of  strangulated  hernia  remaining  long  unrelieved 
without  local  or  general  peritonitis  making  its  appearance,  the  peritonitis  commencing  in 
tlie  bowel  above  the  seat  of  strangulation.  It  is  also  indisputable  that  this  peritonitis  is 
often  aggravated  and  at  times  caused  by  the  reduction  of  the  inflamed  and  injured  con- 
tents of  the  hernial  sac  into  the  abdominal  cavity,  but  to  assert  with  som.e  surgeons  that 
in  the  bulk  of  cases  it  is  the  return  of  the  intestine  into  the  abdomen  that  gives  rise  to 
the  peritonitis  is  an  assumption  which  facts  hitherto  known  do  not  bear  out. 

When  the  intestine  has  sloughed  wholly  or  in  part  and  discharged  itself  through  the 
wound,  an  artificial  anus  is  said  to  exist  :  and  this  result  is  far  more  common  after  femoral 
than  inguinal  hernia. 

When  the  bowel  subsequently  ulcerates  after  its  reduction,  either  at  the  line  of  stric- 
ture, as  it  may  in  inguinal  hernia,  or  at  the  centre  of  the  knuckle,  as  is  the  more  common 
in  femoral  hernia,  extravasation  of  feces  may  take  place,  half  of  the.se  cases  of  extravasa- 
tion being  either  general  into  the  peritoneal  cavity  and  fatal,  or  local  and  at  the  neck  of 
the  sac. 

The  following  facts,  published  by  me  in  Gio/s  Hasp.  Rep..  185G.  on  tlie  causes  of  death 
in  hernia,  will  tend  to  prove  these  points.  Out  of  17  cases  of  artificial  anus  after  hernia 
13  followed  femoral.  3  inguinal,  and  1  umbilical.  Out  of  15  cases  of  gangrenous  bowel 
11  were  femoral.  4  inguinal.  Hence,  out  of  ?j'l  cases  of  gangrenous  bowel.  24  were  fem- 
oral, 7  inguinal,  and  1  umbilical,  clearly  proving  that  gangrene  of  the  intestine  and  arti- 
jicial  anus  are  more  common  a  ft  rr  femoral  than   iiigninaJ  hernia. 

Of  15  cases  of  hernia  in  which  the  strangulated  bowel  was  found  perforated  10  were 
femoral  and  5  inguinal ;  in  4.  all  inguinal,  the  perforation  was  at  the  line  of  stricture  ;  in 


Ti:/:.iTMi:.\T  or  sTi:.\M;ri.  \ri:h  iii:i:si.\. 


535 


11  the  |M'rri>r;itinn  was  in  tin-  (('iilic  i.l"  tin-  knuckle.  In  licinii  li'mnral.  In  S  (jf  these  15 
cases  extravasatiiin  of  feees  was  preventetl  l»y  inHainniatory  exu<lati<iri  sealing'  the  aper- 
ture. Ill  7  it  existed,  hilt  ill  .')  only  of  these  was  it  jreiieral  ;  in  tlie  otlier  '1  it  was  |(jeal. 
or  these  7  oases,  in  '1  the  taxis  was  the  direet  cause,  in  1  ;iaii;rreiie,  hotli  hein^  cases  (jf 
i'eiiuu'al   hernia;   in  4  iilei-ratioii  at  the  line  of  stricture  was  the  cause,  all   heiii^  inguinal. 

Fmni  f/i<'sr  /'dcfs  il  in  rrlilrnt  "  llint  iilrrrntiini  in  the  lliif  of'  si rirlnrf  irit/i  frrnl  nrlrm-ii- 
siifinii  i\  iii'irr  /hi/miif  ill  iiit/ninni  than  in  fi'mond  /ifinin,  nm/  fhut  irlun  it  in  funnil  in  tlif 
hitter  it  i.<  t/meniff//  from  rn/tture  of   the  hoirel  from  forcilile  taris.^' 

As  a  result  of  u  strangulated  horniu  I  iiiust  mention  a  stricture  of  tlie  intestine  due 
to  contraction  of  the  howel  that  had  heeii  straiifjulated.  a  uni<|iie  example  of  which  took 
place  in  my  ])ractice  in  1S70  in  a  woman  ict.  ')'2  upon  whom  I  had  operated  for  stranjru- 
lated  fi'inoral  hernia  of  thirty  hojirs"  duration  witln»ut  opening  the  sac.  Convalescence 
followed  the  operation,  hut  ahoiit  the  .seventh  week  vomiting  appeared,  and  death  tor^k 
place  ill  the  eleventh  week,  from  intestinal  obstruction.  After  death  a  complete  .stricture 
of  a  knuckle  of  howel  was  found  (  V'tis.  ;»I>S). 


I'lfi.  .308. 


Disttnrltd  Bmirl 
ahoie  St  ri  rill  re 


Colli  rarteilBowd 
below  Stricture      ^\;if 

Strictuit.'  of  tlie  Small  Intestine  after  .^strangulated  Hernia. 

The  fluid  found  in  the  hernial  sac  varie.s  according  to  the  condition  of  its 
content.s.  In  the  early  period  of  strangulation,  when  the  venou.s  circulation  through  the 
contents  of  the  liernia  is  only  partially  arrested,  simple  serum  will  be  found.  When  blood 
stasis  is  more  marked,  the  serum  will  be  blood-stained.  "When  it  is  complete  and  blood 
has  been  extravasated  into  the  tissues,  lilood  elements  or  blood  it.self  will  be  found  in  the 
sac.  When  the  hernial  contents  are  inflamed,  flakes  or  flocculi  of  lymph  will  be  found 
floating  in  the  dark  fluid.  When  the  bowel  is  gangrenous,  the  fluid  in  the  sac  will  be 
fetid.  When  perforation  has  taken  place,  feces,  and  often  gas,  will  be  mixed  with  the 
fluid.  When  the  hernial  tumor  is  red.  infiltrated,  and  emphysematous,  the  surgeon  may 
safely  infer  that  sphacelus  of  the  gut  exists. 

Thus,  the  condition  of  the  fluid  in  and  the  external  aspect  of  the  sac  are  valuable  aids 
to  diagnosis  and  prognosis  in  strangulated  hernia. 


Treatment  of  Strangulated  Hernia. 

When  a  hernia  is  strangulated,  nothing  but  its  immediate  reduction  should  be  enter- 
tained, since  by  delay  the  venous  circulation  through  the  strangulated  bowel  honrfi/ 
increases  and  the  risks  of  static  gangrene  are  rapidly  increased.  In  the  surgeon,  indeed, 
delay  is  criminal.  This  may  be  done  by  manipulation,  or  by  what  is  technically  called 
'•  the  taxis,"  and.  when  this  fails,  by  '•  the  operation"  of  herniotomy. 

To  aid  the  surgeon  in  the  adoption  ofthe.se  means  the  u.se  of  an  anaesthetic  cannot  be 
too  highly  praised,  containing  as  it  does  within  it.self  all  the  advantages  of  every  other 
form  of  treatment  without  a  single  disadvantage.  It  renders  the  reduction  of  a  hernia  by 
the  taxis  a  gentle  and  comparatively  simple  measure,  and  certainly  a  tar  more  successful 
one  than  of  old.  It  facilitates,  also,  the  ojieration  of  herniotmny  on  the  failure  of  the 
taxis.  In  strangulated  hernia  the  value  of  an  am>?sthetic  is  so  great  that  I  would  urge, 
where  it  can  be  rendered  available,  that  the  taxis  should  never  be  employed  without  it, 
and  that  on  the  reduction  of  the  hernia  failing  to  be  accomplished  "  the  operation"  ought 
to  be  performed.  The  warm  bath,  the  administration  of  opium,  the  local  application  of 
ice.  are  poor  and  unreliable  remedies  for  strangulated  hernia,  since  they  encourage  delay, 
although  in  oliKtructed  or  inflamid  hernia  they  are  of  use. 

The  taxis  is  not  equally  successful  in  every  form  of  external  strangulated  hernia.    In 


536  ABDOMINAL  HERNIA. 

inguinal  cases  two-thirds,  at  least,  are  reduced  by  the  taxis,  a  large  proportion  of  these 
being  successfully  treated  with  the  patient  under  the  influence  of  an  an;i2sthetic  when  the 
taxis  without  an  anaesthetic  had  previously  failed.  Strangulated  old  are  also  more  suc- 
cessfully treated  by  the  taxis  than  recent  hernite,  and  more  particularly  when  the  recent 
cases  are  of  the  congenital  form. 

\n  femoral  hernia,  on  the  contrary,  the  taxis  is  not  half  so  successful  as  in  inguinal, 
and  it  is  much  more  fatal.  It  is  most  successful  in  "  recent,"  whilst  in  old  cases  it  seldom 
succeeds. 

In  umbilical  hernia  two-thirds  of  the  cases  are  reducible  by  the  taxis. 

The  Taxis. 

With  the  patient  under  the  influence  of  an  anaesthetic  and  placed  on  the  back,  the 
shoulders  raised,  and  the  legs  partially  flexed  and  rotated  inward,  in  oi'der  to  relax  all  the 
parts  that  can  possibly  aff"ect  the  neck  of  the  sac,  the  surgeon  should  steadily  grasp  with 
the  fingers  and  thumb  of  one  hand  the  neck  of  the  sac,  so  as  to  fix  it,  and  at  the  same 
time  prevent  the  contents  of  the  sac,  on  being  pressed,  from  bulging  round  the  orifice. 
With  the  other  hand  he  should  then  raise  the  tumor,  if  large,  and  gently  compress  it,  so 
as  to  empty  it  of  its  serous,  gaseous,  fecal,  or  venous  contents,  and  thus  lessen  its  size. 
Having  done  this,  he  should  draw  the  tumor  first  to  one  side  and  then  to  the  other,  with 
the  view  of  opening  the  constricted  lower  end  of  the  strangulated  gut,  to  allow  the  con- 
tents of  the  bowel  to  pass  onward.  (  Vide  Fig.  30G.)  He  should  remember  that  this  ca)tnot 
be  efi"ected  by  any  direct  pressure  upon  the  hernial  tumor  itself,  but  it  maj/  be  by  lateral ; 
for  if  the  slightest  movement  of  the  lower  or  constricted  end  of  the  knuckle  can  be  made 
in  the  direction  of  the  upper  or  distended  one,  the  lower  opening  will  probably  be  freed 
and  the  reduction  of  the  hernia  efi'ected  by  its  sndilen  rush  backward  into  the  abdominal 
cavity,  when  the  surgeon  may  be  assured  that  all  is  well. 

When  the  tumor  has  diminished  in  size  and  its  diminution  has  not  been  accompanied 
by  the  well-known  rushing  sensation,  a  feeling  of  doubt  should  ever  remain  in  the  mind  as 
to  the  result,  since  the  want  of  this  symptom  of  proper  reduction  should  suggest  the 
possibilit}'  of  a  rupture  of  the  bowel,  or  of  a  reduction  into  one  or  other  of  the  unnatural 
pouches  which  are  now  known  to  exist  under  certain  circumstances  at  the  neck  of  an 
inguinal  hernia. 

To  facilitate  reduction  Vi  gentle  kneading  movement  of  the  fingers  at  the  neck  of  the 
sac  may  be  made  in  inguinal  hernia,  as  well  as  a  steady  traction  downward  of  the  tumorj 
this  traction  rendering  the  neck  of  the  sac  a  straighter  channel  for  the  hernial  contents 
to  pass  through.  With  a  similar  object  the  sac  itself  may  at  times  be  pinched  up  with 
the  fingers  of  one  hand  and  drawn  downward.  Violence  in  manipulation  is  unjustifiable 
under  all  circumstances,  and  in  proportion  to  the  period  of  strangulation  as  indicated  by 
the  vomiting,  is  the  danger  increased.  In  femoral  hernia  also  it  is  comparatively  much 
more  injurious  than  in  inguinal,  for  not  only  may  the  bowel  be  ruptured  by  forcible 
taxis — an  accident  more  common  in  femoral  than  in  inguinal  hernia  {GuyaKej}.,  1856) — 
but  it  may  be  so  bruised  as  to  be  irreparably  injured  A  preparation  and  drawing  (Fig. 
307)  in  Guy's  Museum  show  such  extravasation  of  blood  into  the  strangulated  bowel  of 
a  femoral  hernia  as  to  cause  its  complete  death,  this  being  clearly  due  to  a  forcible  taxis. 

Where  evidence  exists  that  gangrene  of  the  contents  of  the  sac  has  taken  place,  or 
where,  indeed,  there  is  a  suspicion  of  such  a  result,  the  taxis  must  not  be  used.  When 
the  hernia  is  inflamed  or  has  been  much  manipulated,  the  same  advice  should  be  followed. 
In  recent  or  old  femoral  hernia,  where  fecal  vomiting  has  existed  for  some  hours,  the 
taxis  is  a  dangerous  practice,  and  in  all  old  cases  it  is  so  unsuccessful  that  reduction  by 
herniotomy  is  a  more  certain  and  safe  method.  If  there  be  hiccough,  the  taxis  is  inad- 
missible. The  taxis  may  succeed  without  an  antesthetic,  but  with  it  a  hernia  that  is 
capable  of  being  reduced  by  the  taxis,  as  a  rule,  returns  on  the  gentlest  manipulation  : 
and  when  such  a  result  does  not  follow,  force  will  be  not  only  unsuccessful,  but  injurious. 
When  the  taxis  succeeds,  vomiting  usually  disappears,  although  it  may  be  kept  up  to  a 
slight  extent  as  an  effect  of  the  anesthetic.  The  abdominal  dragging  pain  will,  however, 
be  at  once  relieved. 

Treatment  after  Reduction. — After  the  reduction  of  the  hernia  a  sponge  pad 
should  be  carefully  adjusted  over  the  neck  of  the  sac,  to  guard  against  its  re-descent ;  and 
when  the  patient  has  a  cough,  the  necessity  of  doing  so  is  increased,  as  I  have  known 
the  hernia  re-descend  and  a  renewal  of  all  the  symptoms  take  place  from  a  want  of  atten- 
tion to  this  point ;  indeed,  it  is  wise  to  adapt  a  pad  till  a  truss  has  been  obtained.      The 


THE    TAX  IS.  537 

patient,  iimliT  nil  (•ircunistiiiiccs,  sIkuiIiI  In-  kept  at  n-st  for  a  t'i'W  days  al'tiT  the  n-fliiction 
of  a  .straii<:ulati'(l  lu-riiia.  Tlic  diet,  too,  should  l>c  nutritious,  Imt  not  sidid.  ////  llir  hniriln 
harr  artnl  si>i>iiftiiii(>iis/i/,  and  no  aperiont  iiniK-r  any  l)Ut  cxoeptional  circunistaiices  sliould 
bi'  adniiiiistt'rcd.  for  the  Ixiwtds  will  to  a  certainty  act  a.s  soon  as  the  effects  of  their 
straiiLMilatioii  iiavc  jiassed  away  ainl  they  have  recovered  their  natural  tone.  If,  how- 
ever, al>ilo:ninal  symptoms  a|ipear  whicdi  can  he  attriliuted  to  a  want  of  the  natural  action 
of  the  liowcl,  an  enema  may  he  trivcn.  and  rejieated  with  advanta^re  when  rcfpiired. 
Stimulants  should  l>e  \ised  with  cijution.  When  the  howi-ls  have  acted  naturally,  the 
patient  may  be  ])ronounced  convalescent,  and  the  onlinary  diet,  etc.,  allowed. 

Where  an  aiiitsthetic  is  not  at  hand  or  cannot  readily  be  obtained,  a  ;rood  do.se  of 
opium,  such  as  a  <rrain  and  a  half  (»f  the  .solid  or  thirty  drops  of  the  tincture,  may  be 
given  to  an  adult  and  rejieated  ;  for  when  a  patient  with  an  old  obstructe<l  hernia  is 
brouirht  fully  under  the  influence  of  this  dru<:.  reduction  may  often  be  obtained  by  manipu- 
lation. In  the  very  earliest  luuirs  of  strantrulation,  before  vomitin<r  has  become  severe  or 
passed  beyond  stomach  vomitin<r.  this  practice  is  also  at  times  successful.  It  may  be 
tried,  moreover,  when  the  surgeon  cannot  obtain  the  patient's  consent  to  perform  herni- 
otomy and  reduction  has  not  been  effected  by  the  taxis  under  an  anjesthetic.  or  when 
time  has  necessarily  to  be  lost  in  making  arrangements  for  o[ierative  relief.  Fntler  the 
same  circumstances,  a  hot  huth  (!(!t°  F. )  may  be  used.  The  local  application  of  ice  should 
be  employed  in  cases  of  ohi  hernia  where  the  symptoms  are  more  those  of  obstruction 
and  delay  is  a  necessity  or  expedient.  In  omental  hernia  also  it  is  particularly  valuable, 
and  should  be  applied  over  the  whole  tumor  in  a  loose  bag  or  as  a  metallic  coil.  A  purga- 
tive is  never  admissible  with  a  strangulated  hernia. 

The  taxis  with  inversion  of  the  body,  the  legs  flexed,  pelvis  raised,  and 
shoulders  depressed,  has  been  succes.sful  in  causing  the  reduction  of  a  hernia,  the 
intestines,  by  their  weight,  drawing  upon  the  incarcerated  or  .strangulated  bowel  and 
helping  reduction.  On  a  bed  it  may  be  done  by  pillows  placed  below  the  pelvis ;  but  if 
one  of  Alderman's  chairs  or  a  lithotomy  couch  is  at  hand,  it  may  be  used.  Some  sur- 
geons, with  the  patient  in  the  recumbent  position  and  a  folded  sheet  placed  rouiTd  the 
abdomen  over  the  umbilicus,  have  forcibly  drawn  the  contents  of  the  abdomen  upward. 
Both  these  methods  are  founded  on  the  principle  of  withdrawing  by  position  and  force 
the  contents  of  the  sac  into  the  abdominal  cavity.  They  are  ^>ci.\-.s//^/// justifiable  when 
herniotomy  is  not  sanctioned  nor  an  auiosthetic  employed  and  delay  is  dangerous.  I 
cannot  recommend  them. 

The  taxis  should  never  be  employed  for  any  lengthened  period.  With  the  patient 
under  an  anaesthetic,  femoral  hernia  of  average  size  (that  of  a  walnut)  should  never  be 
manipulated  for  more  than  two  minutes ;  half  that  time  or  less  is  usually  sufficient  to 
effect  reduction  where  it  is  to  be  secured,  while  any  more  prolonged  effort  will  be  injuri- 
ous. The  taxis  .should  never  be  forcible.  In  large  femoral,  inguinal,  or  umbilical  herniae 
five  minutes  may  possibly  be  allowed,  but  the  (juarter  and  half  lutur  s  manipulation  so 
frequently  talked  about  is  dangerous  in  the  extreme.  It  is  from  this  fact,  coupled  with 
another — viz..  that  without  an  anjcsthetic  twice  the  force  is  needed — that  the  use  of  such 
is  to  be  recommended. 

The  reduction  of  a  hernia  bv  'jentJc  taxis  with  a  patient  under  an  anjesthetic  is  a 
simple,  rapid,  and  successful  operation.  The  reduction  of  hernia  hy  fore i/i/>'  or  prolonged 
taxis  without  an  anaesthetic  is  a  dangerous  and  far  less  successful  proceeding.  In  femoral 
hernia,  indeed,  herniotomy  had  far  better  be  employed.  Under  an  anaesthetic  the  taxis 
is  almost  always  successful  in  inguinal  hernia  not  of  the  congenital  form. 

When  the  taxis  has  failed,  nothing  but  an  immediate  operation  is  ju.stifiable.  The 
operation  is  not  of  itself  dangerous,  although  the  condition  that  demands  it  is  exceed- 
ingly so.  It  is  not,  and  should  not  be.  regarded  as  a  last  resource,  for  in  many  cases  it 
should  be  the  first.  W'hen  a  patient  is  hanging,  the  first  thing  any  one  does  is  to  cut 
the  rope  that  is  causing  strangulation  ;  and  no  other  means  are  admissible.  When  a 
piece  of  bowel  is  strangulated,  the  strangulating  medium  refjuires  division  to  give  it 
freedom,  the  doing  of  it  adding  nothing  to  the  danger  of  the  case.  The  danger  lies  in 
the  strangulation,  which  increases  every  minute. 

Herniotomy  or  Kelotomy 

remains  now  to  be  described ;  and  let  it  be  repeated  f/uit  it  is  to  he  performed  (JlrcctJi/  the 
redurtion  of  a  strangulated  hernia  hy  the  taxis  has  failed,  and,  if  an  ansesthetic  is  used, 
while  the  patient  remains  under  its  influence.    To  submit  a  patient  to  the  depressing  effects 


538  ABDOMINAL  HERXTA. 

of  an  anaesthetic  to  apply  the  taxis,  and  on  its  failing  to  allow  any  j)(_'ri(j(l  (if  time  to  pass 
before  re.sortins;  to  lierniotoniy.  is  a  practice  to  be  condemned.  It  would  be  better  for  the 
patient,  and  far  better  practice,  to  delay  the  application  of  the  taxi.s  till  an  anaesthetic  can 
be  obtained,  and  the  arrangements  for  operation  nnide  in  case  the  taxis  fails. 

The  objects  of  the  operation  are  to  liberate  the  strangulated  hernial  contents, 
and  in  a  general  way  to  return  them  into  the  abdominal  cavity,  exceptional  cases  occur- 
ring in  which  it  is  better  practice  to  leave  them  in  the  sac  wholly  or  in  part,  and  others 
in  which  it  is  impossible  to  reduce  them  ;  but  to  these  points  attention  will  be  directed 
farther  on. 

To  Kberate  the  strangulated  hernial  contents,  the  cause  of  the  strangu- 
lation must  be  divided;  and,  as  jireviously  shown,  this  may  be  found  either  in  the  tissues 
outside  the  sac,  in  the  neck  of  the  sac  itself,  or  in  the  contents  of  the  sac. 

When  the  cau.se  of  constriction  is  found  out.side  the  sac,  as  is  usual  in  femoral  hernia, 
the  opening  of  the  sac  is  rarely  needed,  division  outside  being  all  that  is  required. 

When  the  neck  of  the  sac  is  the  seat  of  obstruction  and  prevents  reduction,  an  open- 
ing into  it  sufficient  to  allow  of  its  division  is  all  that  is  necessary,  as  in  large  old  inguinal 
and  umbilical  hernia?. 

When  the  difficulty  lies  in  the  contents  of  the  sac,  the  surgeon  will  be  recjuired  to  lay 
the  whole  open  and  to  expose  it  in  order  to  its  removal.  But  it  should  be  remembered 
that  the  less  the  contents  of  a  hernia  are  exposed,  and  consequently  manipulated,  the 
better  are  the  results ;  also,  when  all  that  is  desired  can  be  secured  by  the  division  of  the 
tissues  outside  the  sac,  there  is  no  need  of  doing  more ;  and  that  when  the  division  of 
the  neck  of  the  sac  allows  of  the  reduction  of  the  hernia,  a  greater  exposure  of  the  con- 
tents of  the  sac  is  unnecessary  and  wrong,  for  in  hernia,  as  in  all  surgical  interference, 
the  surgeon  should  carry  out  his  objects  in  the  simplest  way  his  art  can  allow,  and  fehould 
never  allow  himself  to  do  more  than  the  absolute  neces.sities  of  the  case  demand.  ^leddle- 
some  surgery  is  always  bad,  but  in  hernia  it  is  too  often  fatal. 

These  remarks,  however,  are  only  entirely  applicable  to  cases  of  strangulated  hernia 
in  which  the  whole  contents  of  the  sac  are  reducible,  since,  when  some  portion  remains 
behind,  a  feeling  of  doubt  may  at  times  remain  as  to  the  thoroughness  of  the  reduction 
of  the  strangulated  portion  or  the  condition  of  what  is  left,  and  under  these  circumstances  it 
is  usually  advisable  that  the  sac  be  opened  and  explored ;  yet  it  is  better  to  do  so  after  the 
partial  reduction  of  the  hernia,  when,  in  all  probability,  the  strangulated  bowel  has  been 
reduced,  and  is  consequently  out  of  harm's  way,  than  with  the  whole  contents  of  the  sac 
in  siffi  and  when  they  may  be  exposed.  When  the  hernia  cannot  he  reduced  icithout  opening 
the  sac,  the  whole  must  necessarily  be  explored.  It  will  thus  be  seen  that  the  question 
of  opening  or  not  opening  the  sac  resolves  itself  into  the  neces.sities  of  the  individual 
case.  When  reduction  can  be  effected  without  it,  the  '•  minor"  operation  is  sufficient ; 
where  reduction  cannot  be  effected  b}-  the  ■•  minor"'  the  major"  operation  must  be  per- 
formed. 

The  surgeon  who  opens  the  sac  in  everf/  case  clearly  often  does  what  is  unnecessary. 
He  who  opens  it  only  when  reduction  cannot  be  effected  without  so  doing,  or  when  any 
uncertainty  exi.sts  as  to  the  condition  of  the  parts  contained  in  the  sac,  is  free  from  such 
an  error ;  "  and  although  we  dare  not  venture  to  say  that  some  of  the  fatal  eases  which 
have  occurred  after  opening  the  sac  might  have  terminated  diffei'ently  had  it  not  been 
incised,  we  do  not  hesitate  to  affirm  that  the  untoward  circumstances  stated  as  likely  to 
happen  when  the  sac  is  not  opened  have  not  occurred  "  (Birkett).  This  view  is  sup- 
ported by  my  analysis  of  126  fatal  cases  of  hernia  (Giif/'s  Rep.,  1856) — in  which  I 
proved  fairly  that  in  no  single  fatal  ease  could  the  opening  of  the  sac  have  had  the 
slightest  influence  in  retarding  or  pi-eventing  the  fotal  result — as  well  as  by  my  own  per- 
sonal experience.  The  surgeon  who  advocates  the  major  operation  in  most  cases  will  try 
the  taxis,  and,  I  take  it.  is  always  well  pleased  to  effect  the  reduction  of  a  hernia  by  such 
means.  The  operation  of  herniotomy  '•  external  to  the  hernial  sac"  differs  only  from  the 
taxis  in  the  skin  wound  ;  yet  in  what  way  the  necessity  for  that  wound  renders  the  taxis 
an  unsafe  measure  it  is  difficult  to  conceive.  It  would  be  as  reasonable  to  reject  the- 
administration  of  an  anjosthetic  for  the  renewed  application  of  the  taxis  in  eases  where 
the  taxis  had  failed  to  reduce  the  hernia  withoiit  its  aid  as  to  say  that  because  the  taxis 
had  failed  and  a  cutting  operation  is  demanded,  the  ocular  inspection  and  manipulation 
of  the  strangulated,  and  therefore  already  injured,  bowel  is  required.  To  argue  that  the 
liberation  of  a  strangulated  bowel  is  not  complete  until  it  has  been  carefully  examined, 
and  that,  moreover,  without  opening  the  sac,  a  hernia  that  is  strangulated  by  omental  or 
other  adhesions  or  by  the  neck  of  the  sac  may  be  reduced,  is  to  raise  objections  which,  if 


lli:i:SI()TnMY   oil    KEI.ornMY 


539 


upplicuMc  III  all.  all'  as  rnriiltlc  airaiiist  tlio  taxis  as  any  njn'ratiDii.  ami  an-.  imlciMl.  ol" 
littli"  \VL'i;(lit. 

'riie  i»itenitii)ii  of  lifriiiutniiiy  witliiml  ii|ii'iiinii  tin'  sac  has  hceii  ahly  a<lvo(;ateil  by  Petit, 
who  first  ailiipti'il  it  in  I  7  IS.  I»y  Miiiiii).  in  ITTH.  Astuii  Kry.  in  Is.'}.'),  Jjiiki-.  ami  otliors. 

Si)  i'ar  as  statistics  arc  nt'  value  towanl  the  M)liitii)n  of  this  matter,  they  are  in  I'avor 
of  not  njteninji  the  sac.  Thus,  out  of"  .")!•  caso  of  stran^rulateil  femoral  liernia  o|»erate<l 
upon  at  (luy's  Hospital  in  eii^lit  years  in  wiiicli  the  sac  was  <>i»n<'il.  the  mortality  was  00 
l)er  cent.,  ami  out  of  4.")  cases  in  which  the  sac  was  not  opi inil,  it  was  only  20  ]»er  cent., 
the  ilifierence  between  the  two  classes  of  cases  ljein<^  20  per  cent,  in  favor  of  the  minor 
oj)eration. 

Out  of!).")  cases  of  inj^uinai  liernia  in  which  the  sac  nnx  itjHucil.  00  per  cent,  dieil.  ami 
out  of  II  in  which  the  sac  was  not  opened.  2.  or  only  22  per  cent,  died,  the  difi'erence 
between  the  two  classes  in  inguinal  hernia  bein<r  40  per  cent,  in  favor  of  not  opeitin'/.  But 
it  must  be  remembered  that  as  a  rule  the  cases  in  which  the  sac  was  not  opened  were  of 
a  more  favorable  kind  than  those  in  which  it  icna. 

In  umbilical  hernia  it  is  a  rare  thinti',  however,  to  save  a  patient  after  openin;r  the  .sac 
and  exposinir  its  contciits,  thnu</h  when  this  is  not  dojie  a  good  result  may  be  looked  for. 

Whenever  the  taxis  is  applicable  to  a  .strangulated  hernia  and  fails,  herniotomy 
without  opening  the  sac  is  applicaltle,  and  where  reduction  is  effected  nothing  more  is 
needed.  Where  reduction  cannot  be  efiected  or  a  doubtful  something  remains  in  the  sac, 
where  the  contents  of  the  .sac  have  not  gone  back  with  their  normal  rush  or  the  symptoms 
persist  and  any  doubt  al)out  the  condition  of  the  parts  at  the  neck  of  the  sac  is  raised,  an 
exi)loration  of  the  sac  aii<l  its  neck  is  at>snlutely  neces.sary. 

Whenever  the  taxis  iS  inapplicable — that  is,  when  the  strangulation  has  been 
of  long  duration,  the  symptoms  severe,  fecal  vomiting  persistent,  and  the  local  as  well  as 
general  symptoms  indicate  the  probability  that  the  sti'angulated  gut  has  died  or  is  dying; 
whenever,  moreover,  during  the  application  of  the  taxis,  by  the  sudden  collapse  or  yield 
of  the  tumor  without  its  reduction,  the  fear  is  excited  of  .some  rupture  of  the  bowel  hav- 
ing taken  place, — herniotomy  by  the  minor  operation  is  inapplicable,  and  the  sac  must  be 
laid  open. 

Opekatikn. — The  patient,  having  been  brought  under  the  influence  of  an  anaesthetic, 
should  be  placed  with  the  shoulders  slightly  raised,  the  knees  Hexed  upon  a  pillow,  the 
integument  over  the  .seat  of  hernia  .sliaved  of  all  hair  and  well  washed  ;  an  incisson  should 
then  be  made  over  the  neck  of  the  sac — that  is,  in  inguinal  hernia,  along  the  line  of  the 
inguinal  canal,  from  the  internal  to  below  the  external  ring:  in  femoral,  over  or  on  the 
inner  side  of  the  crural  ring,  either  in  a  vertical  direction  or  in  the  course  of  Poupart's 

Fig.  309. 

A  B 


VnAilkalf 
Ring  ^ 


Eztenud 
Riivq 


Key's  Director  passed  beueatlx  the  Seat  of  Stricture 
of  a' Strangulated  Femoral  Hernia  outside  the  Sac 
beneath  the  Fascia  Propria.  (Taken  from  his 
work  on  Hi'inia.) 


Obturator 


Drawing  to  illustrate  the  Relative  Position  of  all 
the  Abdominal  Rings  from  within. 


ligament,  the  former  being  preferable.  In  this  incision  all  the  soft  parts  should  be  cut 
through  consecutively  down  to  the  sac,  each  layer  of  tissue  being  divided  the  full  extent 
of  the  wound,  while  all  vessels,  as  they  bleed,  should  be  twisted. 


540 


ABDOMINAL   HERN  FA. 


When  the  sac  lias  been  exposed,  the  seat  of  stricture  outside  its  neck  must  be  felt  for 
with  the  index  finger  ;  and  when  felt,  a  director  may  be  carefully  passed  beneath  it. 
Aston   Key's  flat  director,  shown  in  Fig.  30[),  a,  being  by  far  the  best. 

With   a   straight  or  curved  hernia  knife,  such  as  that  figured  (Fig.  310),  or  with   a 
niotome  (Fig.  310,  B),  the  .stricture  should  then  be  divided,  the  incision  upward  being 


Fig.  310. 


Hernia  Knife. 


Ilerniotoiue  Director.     \,  lihide  withdiuwn.     H,  Blade  expo.sod. 


heriuoiome  iny;.  oiu,  i>j,  me  .siricture  snouiu  men  oe  uiviuea,  tne  incision  npic<ir<i  being 

the  safest.  This  division  must  not 
be  too  free,  a  quarter  of  an  inch 
being  generally  ample  in  a  small 
hernia.  It  should,  under  all  cir- 
cumstances, be  only  enough  to  al- 
low of  the  return  of  the  hernia 
without  force.  It  is  better  to  have 
to  extend  it  than  to  make  it  too 
large  at  first.  The  stricture  hav- 
ing been  divided  outside  the  sac, 
reduction  by  the  gentlest  nianijiu- 
lation  can  then  be  attempted  ;  and 
when  the  contents  of  the  sac  go 
back  with  a  rush,  all  the  surgeon  needs  has  been  effected.  When  no  indications  of 
reduction  show  themselves  or  a  portion  of  the  contents  of  the  sac  has  disappeared,  but 
not  with  the  characteristic  jerk,  or  some  piece  has  been  left  behind,  the  sac  must  be 
opened.  To  open  the  sac  care  is  needed,  the  danger  of  carelessness  consisting  in  wound- 
ing the  bowel.  To  avoid  injury  to  the  contents  the  sac  may  be  nipjted  between  the 
thumb  and  finger  or  seized  with  forceps,  and,  being  slightly  raised,  opened  with  a  scalpel 
applied  laterally.  Through  this  opening  a  director  should  be  passed,  its  point  being  kept 
close  to  the  inner  surface  of  the  sac  toward  its  neck,  and  upon  it  the  sac  should  be 
divided  with  a  bistoury.  The  escape  of  fluid  usually  indicates  the  opening  of  the  sac, 
and  the  character  of  the  fluid  the  condition  of  its  contents.  But  fluid  does  not  always 
run  away  when  the  sac  is  opened,  and  at  other  times  the  escape  of  fluid  from  a  cyst  on 
the  hernial  tumor  may  mislead.  The  sac  having  been  opened,  its  contents  should  be 
examined;  and  in  doing  this  the  utmost  gentleness  must  be  employed.  When  a  hnucMe 
of  intesfiiie  is  present  and  is  neither  gangrenous  nor  perforated,  the  abdominal  cavity  is 
the  best  place.  It  may  be  black  from  congestion  and  spotted  from  eccliymosis  ;  it  may 
be  granular  from  lymph,  or  even  covered  with  fsdse  membrane  ;  but  as  long  as  it  pos- 
sesses its  living  resiliency,  is  not  fetid,  flaccid  like  wet  wa.sh-leather,  ruptured,  or  perfor- 
ated, it  should  be  returned. 

When  a  Icn'ge  qiutntity  of  tnjiircd  Intentinr  is  found  in  the  sac,  it  had  better  be  left,  the 
surgeon  simply  relieving  the  constriction  by  the  division  of  the  stricture.  To  do  this  a 
director  should  be  employed,  and  its  point  kept  close  to  the  inner  surface  of  the  sac  and 
away  from  the  bowel  ;  it  should  not  be  introduced  farther  into  the  abdominal  cavity  than 
is  required  to  ensure  the  safe  division  of  the  stricture  ;  when  the  knife  is  passed  along  the 
groove  of  the  director,  the  finger  of  the  operator  should  carefully  press  the  strangulated 
bowel  away  to  protect  it  from  injury.  The  finger,  however,  is  the  best  director,  and 
should  be  introduced  to  the  neck  of  the  sac,  with  the  knife  upon  it,  having  its  side 
pressed  into  the  pulp  of  the  soft  parts.  Both  having  thus  reached  the  neck,  the  knife 
may  be  carefully  turned  upward  and  the  tissues  divided,  the  point  of  the  finger  measur- 
ing the  extent  of  the  incision. 

When  a  herniotome  such  as  that  figured  (Fig.  310,  B)  is  used,  no  director  need  be 
employed. 

When  the  intestines  are  adherent  to  the  sac  or  to  one  another  by  filamentous  or  soft 
adhesions,  these  may  be  divided  ;  such  are,  however,  only  met  with  in  recent  hernia.  The 
fibrous  adhesions  of  old  hernijc  had  better  be  left  alone  and  the  hernia  considered  as  irre- 
ducible, the  surgeon  being  satisfied,  under  these  circumstances,  with  dividing  the  stricture 
and  thereby  relieving  the  .strangulation,  but  not  attempting  the  reduction  of  tlu;  hernia. 
If  a  fresh  piece  of  bowel  comes  down,  it  should  be  reduced  ;  but  the  old  hernia  ought  to 
be  left. 

The  strangulated  intestine,  under  all  circumstances,  should  be  handled  with  extreme 
delicacy.  An?/  drawing  down  of  the  horoel  to  examine  its  condition  should  be  avoided, 
since  such  an  act  can  do  no  good,  but  often  does  much  harm  in  tearing  away  adhesions 
that  would  have  sealed  an  ulcerated  orifice,  prevented  extravasation,  and  as.sisted  rejiair. 
Anj/  introduction  if  tiip  fimjcr  into  the  abdominal  cavity  save  under  exceptional  conditions 
is  also  to  be  condemned.      With  the  careful   return  of  the  bowel  within  the  neck  of  the 


UKHSInluMY    nU    Kl.l.nlnMY.  541 

sac  surgical  interfcri'iice  ought  to  c-«»a.sc.  Tlie  surgfoii  may  .satisfv  liiinself  that  such  an 
eiul  has  hceu  attained  witliout  probing  the  ahiloniinal  cavity  with  his  finger,  and  thus 
risking  life  hy  tearing  away  adhesions  and  undoing  in  a  moment  what  nature  by  her  own 
processes  had  probably  been  attempting  from  the  first  pirriod  of  strangulation — namely, 
to  shut  out  from  the  general  abdominal  cavity  what  might  prove  injurious  and  dangerous 
to  life. 

When  the  Iminl  is  t/,,ii/,  as  indicate(l  liy  its  flaccitlity  and  a>hy  color,  all  thought  of 
its  reduction  must  be  abandoned.  The  soft  parts  covering  in  the  sac.  with  the  sac  it.self, 
.should  be  freelv  laitl  open,  so  as  to  ex]>ose  the  whole  sloughing  mass,  mul  the  intmllnf  Ifj't 
f'l  iiiifiin .  to  ]»ass  into  what  is  called  an  "  artificial  anus.  '  The  neck  of  the  sac  may  be 
carefully  divided — not,  however,  with  the  view  of  relieving  the  strangulation,  for  the  gut, 
having  lu'conu-  gangrenous,  is  no  longer  strangulated,  but  with  a  view  of  allowing  the 
intestinal  oiuitents  to  escape  when  an  external  opening  takes  place,  and  should  life  be 
spared,  and  likewise  for  the  subsei|ueMt  retraction  of  tlif  bowel  toward  the  abdominal 
cavity,  to  efl'ect  a  natural  cure. 

No  free  incision  into  the  gangrenous  bowel,  no  stitching  of  the  intestine  to  the  mar- 
gin of  the  wound,  is  required,  as  feces  will  soon  find  their  way  through  the  opening  that 
has  been  made  by  the  artificial  anus,  and  the  surgeon  may  be  certain  that  within  the 
abdomen  sufficient  repair  has  gone  on  to  fix  the  intestine  that  had  been  strangulated  to 
the  neck  of  the  sac  and  thus  prevent  its  immediate  retraction  ;  for  it  must  be  remembered 
that  as  time  goes  on  this  retracting  process  is  precisely  that  which  nature  adopts  to  pro- 
cure a  spotitaneous  cure  of  an  artificial  anus. 

Within  recent  times  a  gangrenous  knuckle  of  bowel  lias  been  resected  (vide  Revue  de 
Chiniiyii.  May  10,  1888).  and  with  success.  When  this  operation  is  performed,  the 
bowel  above  and  below  the  constricte<l  portion  will  have  to  he  drawn  down,  resected,  and 
stitched  together  as  illustrated  in  Fig.  jJSrJ,  or  the  two  ends  of  the  resected  bowel  may  be 
retained  at  the  neck  of  the  sac  by  sutures  or  forceps. 

When  the  hoicel  is  jwrforatnl  hy  ulceration  or  ruptured^  and  the  <jpeniiig  is  not  large, 
the  neck  of  the  sac  must  be  incised,  as  in  an  ordinary  case,  and  the  intestine  that  appears 
reparable  replaced,  the  perforated  or  ruptured  portion  being  left  at  the  mouth  of  the  .sac. 
When  the  rupture  or  perforation  is  small,  there  is  no  objection  to  the  surgeon  suturing 
the  wound  and  replacing  the  gut  within  the  orifice  of  the  sac,  for  plastic  lymph  will  prob- 
ably be  poured  out  within  a  few  hours  and  the  parts  become  sealed  from  the  abdominal  cavity. 

When  the  hoivd  is  in  a  dimhtfnl  condition,  and  the  surgeon  is  ntjt  certain  whether  he 
can  .say  it  is  irreparably  dead  or  going  to  die,  the  abdominal  cavity  is  still  its  best  jilace, 
when  it  can  be  returned.  Aston  Key  advocated  this  plan  many  years  ago.  and  modern 
experience  has  not  disproved  its  value.  ''  The  danger  of  abdominal  extravasation  will 
not  be  increased  by  replacing  the  injured  bowel  within  the  neck  of  the  sac  ;  for  should 
sloughing  of  its  coats  ensue,  the  slough  may  be  walled  in  by  addition  of  the  surrounding 
peritoneum,  and  fecal  extravasation  be  prevented"'  (Key,  fini/s  Rep.,  1842). 

In  an  inquiry  in  185()  into  the  causes  of  death  in  hernia,  founded  on  an  analysis  of 
156  fatal  cases,  the  same  conclusion  was  arrived  at.  The  weight  of  evidence  led  me  then 
to  express  the  opinion  that  there  is  only  one  condition  of  intestine  in  which  its  reduction 
within  the  neck  of  the  sac  is  not  advantageous,  and  that  is  when  it  is  decidedly  ruptured 
by  gangrene  or  ulceration,  my  own  materials  tending  to  support  the  opinion  of  Mr.  A.ston 
Key.  as  stated  to  the  writer  in  1840,  ■•that  in  all  conditions  of  the  intestines  the  abdomen 
was  their  right  place." 

Mr.  Hutchinson,  who  believes  peritonitis  to  be  the  direct  result  of  the  reduction  of 
an  injured  bowel  into  the  abdominal  cavity,  advises  in  all  cases  that  the  damaged  gut.  if 
fouiul  in  a  bad  condition,  should  be  left  in  the  sac  ;  while  Mons.  Girard  goes  further, 
advising  the  contents  of  the  hernia,  under  all  circum-stances,  to  be  left,  the  surgeon  con- 
tenting himself  by  freely  dividing  the  stricture.  I  cannot  concur  in  this  practice,  nor 
with  the  principle  on  which  it  is  based. 

When  the  contents  cannot  be  returned,  on  account  of  adhesions,  the  neck  of  the  sac 
should  be  incised  and  the  case  left  to  nature.  In  large  umbilical  herniae,  also,  this  prac- 
tice is  valuable. 

When  omentum  is  found  in  the  sac  with  intestine  and  has  only  recently  descended,  it  may 
be  returned.  When  it  has  been  down  for  some  time,  is  irreducible,  and  is  only  a  small 
piece,  it  .should  be  left  alone,  the  omentum,  doubtless,  often  acting  as  a  plug  to  the  orifice 
of  the  sac.  When  it  is  diseased  or  in  large  quantities,  it  should  be  ligatured  in  two  or 
more  portions  and  cut  off.  the  ligatures  being  applied  as  near  to  the  neck  of  the  sac  as 
possible,  care  being  observed  not  to  disturb  the  parts  at  the  neck. 


542  ABDOMINAL  HERNIA. 

Simply  to  cut  off  the  omentum  and  to  tie  o^-  twist  the  vessels  is  risky,  the  omentum 
always  being  highly  vascular  and  small  vessels  being  apt  to  bleed  much  ;  indeed,  cases 
are  on  record  in  which  a  fatal  hemorrhage  supervened  after  this  practice.  When  diseased 
omentum  is  left  in  the  sac,  prolonged  suppuration  often  follows.  Whenever  intestine  and 
omentum  are  found  together  in  a  hernia,  much  care  is  required.  The  intestine  is  gener- 
ally to  be  sought  for  behind  the  omentum,  but  is  often  wrapped  up  in  it,  and  in  not  a  few 
cases  covered  by  an  omental  sac.  Under  all  these  circumstances,  the  intestine  should  be 
exposed  and  carefully  reduced,  care  being  taken  that  no  adhesions  at  the  neck  of  the  sac 
or  no  bands  bind  the  bowel  down  to  the  omentum,  thereby  keeping  up  the  strangulation. 
An  omental  sac  is  on  no  account  to  be  returned  into  the  abdomen  unopened.  Omental 
sacs  are  generally  found  in  femoral  hernia.  An  interesting  paper  by  Prescott  Hewett 
(^Med.-Glilr.  Traiix.,  1844)  may  be  referred  to  on  this  subject. 

It  has  been  my  practice,  and  that  of  most  of  the  surgeons  at  Guy's  Hospital  during 
the  last  three  or  four  years,  to  dissect  out  the  sac  after  the  operation,  stitch  up  its  neck,, 
and  excise  its  fundus,  this  measure  apparently  but  little,  if  at  all,  magnifying  the  opera- 
tion, and  being  successful  as  a  radical  cure. 

After-Treatment. — When  a  hernia  has  been  returned  into  the  abdominal  cavity^ 
the  more  the  case  is  left  to  nature,  the  better.     As  a  matter  of  precaution  after  the  ope- 
ration, as  after  its  rediiction  by  the  taxis,  when  the  wound  has 
Fig.  oil.  been  brovight  together  with  strapping  or  suture,  a  pad  may  be 

^\    adjusted  over  the  part  with  a  spica  bandage  (Fig.  311).     A 
\   sponge  is  the  best  form   of  a  pad. 

A  suppository  of  half  a  grain  of  morphia  or  more  should 
be  at  once  introduced  into  the  rectum,  and  repeated  in  an  hour 
should  pain  render  it  necessary  ;  a  little  ice,  too,  may  be  al- 
lowed for  the  patient  to  suck  when  thirst  is  great ;  but  the  less. 
that  is  taken  by  the  mouth,  the  better.  When  the  powers  are 
very  feeble,  brandy,  soda-water,  and  ice  may  be  given  in  small 
quantities. 

If  no  anaesthetic  sickness  complicate  the  case  after  the  first 
twelve  hours,  beef  tea,  arrowroot,  or  milk  may  be  given,  a  pint 
or  a  pint  and  a  half  in  the  twenty-four  hours  being  ample.  Stim- 
ulants should  be  allowed  as  the  powers  of  the  patient  indicate, 
but  always  with  caution. 
„  .     ,,     ,  On  the  second  day  the  wound  should  be  dressed,  some  sim- 

pie  dressing  being  all  that  is  usually  required,  the  lower  end 
of  the  wound  being  left  open  for  the  escape  of  fluid.  Should  pain  continue  and  symp- 
toms of  peritonitis  appear,  opium  should  be  given,  or  morphia  suppositories  twice  a  day 
or  more  frequently  ;  indeed,  the  patient  should  be  kept  under  the  gentle  influence  of 
opium  till  the  symptoms  are  relieved  ;  hot  fomentations  should  also  be  applied  to  the 
abdomen.  Purgatives  ought  never  to  be  given  if  the  bowel  has  been  bruised  or  other- 
wise injured  by  strangulation,  for  as  soon  as  it  has  recovered  its  tone  its  natural  action 
will  return,  and  any  goading  of  it  to  action  by  medicine  must  do  harm.  "A  bruised 
bowel,"  says  Aston  Key  (Grij/'s  Rep.,  1842),  "is  placed  by  nature  in  a  state  of  rest;  the 
exhaustion  of  the  nervous  energy  of  the  part  diminishes  in  the  muscular  tissue  the  dis- 
position to  contract.  Such  inactivity  of  the  Loicd  sJtouId  be  encoiirae/ed^  and  nejf  thwarted 
by  irritating  purgatives.  The  surgeon's  anxiety  to  procure  stools  should  yield  to  the 
evident  necessity  for  time  being  allowed  for  the  restoration  of  the  natural  powers  of  the 
injured  bowel. 

Three,  five,  ten,  or  even  twenty,  days  may  be  allowed  to  pass  without  any  action  of 
the  bowels  without  anxiety  or  without  purgatives,  so  long  as  no  other  indications  of  mis- 
chief show  themselves ;  but  during  this  time  only  liquid  food  is  to  be  given,  with  stimu- 
lants as  may  be  required.  When  some  local  distress  is  present  which  the  surgeon  can 
fairly  attribute  to  the  constipation,  an  enema  of  gruel  and  olive  oil  may  be  administered, 
which  may  be  repeated  if  necessary,  such  a  simple  intestinal  stimulant  being  usually  suf- 
ficient to  induce  the  bowel  to  act  should  it  have  recovered  its  tone.  \\"hen  the  bowels 
have  acted  naturally,  convalescence  may  be  declared  and  the  usual  diet  allowed. 

Any  violent  action  of  the  bowels  soon  after  the  operation  must  be  regarded  with 
anxiety,  and  in  the  aged  it  is  too  often  followed  by  a  fatal  collapse.  When  too  frequent, 
it  must  be  checked  by  opium.  The  patient  should  on  no  account  be  allowed  to  get  up 
and  walk  until  he  has  been  fitted  with  a  good  truss. 

It  occasionally  happens  that  after  the  reduction  of  a  hernia  by  operation   the  symp^ 


Disi >i.A(  HI)  iiijisL /•;.  543 

tonis  ol"  straiiL'iilatinii  persist  ami  the  suiL^cnii  is  in  flmilit  as  tu  their  eaiise.  Moreover, 
thi'  liiiwel  may  ii<»t  have  jroiie  ii|>  at  the  time  i»t'  the  o|ierati<m  with  the  usual  rush,  (ir  the 
suriretin  uiay  have  a  thmht  in  liis  miiul  as  t(i  its  ri^rlit  re»lueti(iii.  Ttnler  these  oircuiii- 
stances.  the  woiiiul  may  at  times  re(|uire  reitpeiiiuj;  ami  the  parts  at  the  neck  of  the  sac 
re-exi)hired.  since  the  ease  may  he  one  of  those  "  displaced  heriii;u  "  to  which  attention  is 
now  to  he  drawn. 

As  a  rule,  however,  the  persistency  of  the  .symptom.s  is  due  to  tile  ohstruction  caused 
by  the  injured  Kowi-l  or  to  the  anaesthetic. 

Multiple  Hernia. 

Wlu'U  tiro  or  Diorr  Itcniht  exist  with  syin]itiinis  of  straii^rulation,  the  one  that  on  care- 
ful examination  ajipears  to  be  the  most  temler  ouirlit  first  to  be  explored,  and  should  this 
operation  not  irive  relief  the  second  should  be  treated  in  a  like  manner:  indeed,  if  no  relief 
be  given  by  the  second  operation  and  a  third  hernia  exi.st,  it  should  also  be  explored,  for 
it  canmit  be  too  often  repeated  that  the  operati(»n  is  not  one  of  danger  when  compared 
with  the  necessity  of  the  case  that  demands  it.  Dupuytren  in  his  Liroiis  Oralis  has 
recorded  such  a  case.  In  the  third  part  of  my  CUniail  Snrycrij.  p.  204,  I  liave  likewise 
recorded  another  in  which  Mr.  Cock  was  the  o[)erator.  The  patient  was  a  man  ajt.  7U  ; 
the  left  side  was  first  explored,  but,  as  the  symptoms  continued,  the  right  was  operated 
upon  twelve  hours  later.  Both  herniae  were  old  inguinal ;  in  both  the  sac  was  opened, 
and  recovery  took  place.  In  the  ca.se  of  a  Jewess  set.  30  I  was  called  upon  to  .see.  with 
an  umbilical  and  double  femoral  hernias,  I  operated  on  the  right  femoral  for  strangu- 
lation, and  a  year  later  upon  the  umbilical,  with  success. 

Displaced  Hernia. 

No  eases  demand  closer  attention  than  these.  When  understood  and  appreciated, 
they  may  be  successfully  treated  ;  when  misunderstood,  they  are  sure  to  be  overlooked. 
Hence  it  may  be  accepte<l  as  a  fact  that  a  strangulated  hernia  with  its  sac  may  be  bodily 
reduced  within  the  abdominal  ring  and  behind  the  abdominal  parietes,  the  intestine  being 
.still  held  by  the  neck  of  the  sac  (Fig.  300).  This  form  was  first  described  by  the  French 
writers  as  reduction  en  bloc  or  en  masse,  and  by  ]Mr.  Luke  in  this  country  (^Med.-CJu'r. 
Trans.,  1843).  The  majority  of  ca-ses  reputed  to  be  of  this  nature  are,  however,  probably 
caused  by  other  lesions  of  the  sac,  and  the  credit  of  having  made  this  out  is  due  to  3Ir. 
Birkett,  in  an  able  paper  read  before  the  Royal  Med.  and  Chir.  Society  in  1859.  He 
describes  three  forms,  though  his  observations  apply  only  to  inguinal  hernia. 

There  are  four  varieties  of  displaced  hernia,  and  in  the  inguinal  they  are  mostly  found 
as  Complications  of  the  congenital  form. 

First  Form. — In  this  the  strangulated  hernia  with  its  sac  ma}-  be  bodil}-  reduced 
within  the  abdominal  ring  and  behind  the  abdominal  parietes ;  it  is  to  a  femoral  hernia 
that  this  accident  is  most  prone  to  occur,  but  it  may  do  so  to  an  inguinal.  It  is  the  true 
reduction  en  bloc  or  en  masse  of  the  French  writers  and  of  Luke.  Such  ca.ses  are,  how- 
ever, rare.  In  November.  1871,  I  had  this  fact  demonstrated  to  me  in  a  case  I  was  called 
to  see  by  Mr.  Berry  of  Pentonville.  It  was  in  a  lady  aet.  04  who  was  said  to  have  been 
ruptured  for  years,  and  had  worn  a  truss.  AVhen  I  saw  her,  she  had  been  vomiting  for 
a  week  and  a  tense  femoral  hernia  existed.  Under  chloroform  I  cut  down  upon  the  sac 
and  divided  the  neck  of  the  crural  ring,  and,  on  attemptnig  reduction  of  the  sacs  contents 
by  gentle  manipulation,  to  my  surprise  the  sac  with  its  contents  suddenly  disappeared 
into  the  abdomen.  By  a  little  abdominal  pressure  it  was  made  to  reappear,  and  it  did  .so 
in  the  same  sudden  way.  A  second  attempt  at  the  taxis  was  followed  by  the  same  result, 
and  renewed  [U'essure  upon  the  abdomen  with  a  like  reappearance.  For  the  sake  of  fully 
satisfying  myself  and  my  medical  friends  of  the  nature  of  the  case.  I  reduced  the  hernia 
en  HHf.v.vf  a  third  time,  and  then  found  some  little  difiiculty  in  securing  its  reappearance. 
When  I  did  so,  I  took  hold  of  the  sac  with  my  forceps,  carefully  opened  it.  and  exposed 
the  bowel  without  letting  the  .sac  go;  I  then  divided  its  neck  by  a  herniotome  and  reduced 
the  bowel,  keeping  the  sac  well  down.  On  the  second  day  the  bowels  acted,  but  the 
patient  subsecjuently  died  of  a  low  form  of  peritonitis.  In  this  case  the  whole  process 
of  reduction  f-n  mf(sse  was  demonstrated  most  clearly,  and  it  compelled  me  to  ask  the 
question  whether  the  same  result  might  not  have  taken  place  had  I  attempted  its  reduc- 
tion by  forcible  taxis  without  operation,  since  the  facility  with  which  the  sac  passed  up 
within  the  crural  ring  was  something  startling. 


544 


ABDOMINAL  HERNIA. 


In  Prep.  2508^",  (iuy's  Hosp.  Museum,  this  accident  may  be  seen.  It  was  taken 
from  a  woman  aet.  58,  and  my  friend  Mr.  Henry  Morris  showed  a  specimen  illustrating 
this  fact  at  the  Pathological  Society.      (See  Trans,  for  1871.) 

Second,  or  Charles  Bell's,  Form. — In  the  second  form  the  neck  of  the  sac 
becomes  detached  by  force  from  the  internal  abdominal  ring  and  pushed  upward  beneath 
the  abdominal  walls,  the  intestine  within  the  sac  being  strangulated  by  the  orifice  of  the 
sac.  This  variety  is  illustrated  by  Fig.  297,  and  still  better  in  Figs.  312  and  313,  which 
I  have  copied  from  page  48(J  of  the  first  volume  of  the  Medical  Gazette,  published  in  1828. 
The  case  formed  the  subject  of  a  lecture  by  Sir  Charles  (then  Mr.)  Bell.  It  occurred  in 
a  man  fet.  47  who  had  been  the  subject  of  a  right  scrotal  hernia  for  twenty  years.  The 
hernia  had  come  down  and  become  strangulated  three  days  before  he  was  seen,  but  had 
been  reduced,  or  rather  made  to  disappear.  The  .symptoms,  however,  continued,  and  death 
followed.  During  the  last  twenty-four  hours  of  the  patients  life  the  hernia  came  down 
repeatedly  during  the  day,  and  was  each  time  reduced  with  great  facility. 

After  death  the  hernia  was  found  to  be  in  the  scrotum,  strangulated  and  mortified 
(Fig.  312).  On  applying  pressure  to  it  "  the  intestine  could  very  easily  and  effectually 
be  pushed  through  the  external  abdominal  ring,  so  as  to  be  hid  from  sight.  On  looking 
to  the  inside,  however,  it  was  seen  that  the  portion  of  gut  had  cai-ried  the  neck  of  the 
sac  before  it  into  the  abdominal  cavity  (B,  Fig.  312),  and  the  duplicature  of  peritoneum 
which  hung  upon  the  inside  of  the  neck  of  the  sac,  being  unfolded,  had  formed  a  new 
.sac  for  the  intestine  in  the  inside  of  the  abdominal  muscles.  Thus,  the  fold  of  intestine 
was  pushed  through  the  external  ring,  through  the  spermatic  canal,  and  through  that 
part  which  is  described  to  be  an  internal  ring  (but  of  which  no  trace  could  be  seen),  and 
was  reduced  within  the  abdominal  muscles,  but  not  within  the  abdominal  cavity,"  the 
neck  of  the  sac  still  grasping  the  included  portion  of  gut  (B,  Fig.  313).  The  hernia  was 
also  clearly  of  the  congenital  form,  although  it  had  not  descended  as  far  as  the  testicle. 

The  two  drawings  (Figs.  312  and  313)  and  descriptions  are  as  originally  given 
by  Sir  C.  Bell. 

Fig.  312. 


Drawings  illustrating  the  .Second  Varieties  of  Displaced  Hernia. 

Fl<i.  :5I2. 
A  portion  of  the  abdominal  muscles,  with  the  peritoneal  lining. 
Tlie  strangulated  fold  of  intestine. 

The  testicle.    The  dark  lines  at  the  neck  of  the  .sac  represent  the  duplicature  of  the  peritoneum,  which,  being 
unfolded,  formed  a  sac  for  containing  the  intestine  when  reduced. 

Fio.  31:^. 

Peritoiit  imi  lining  the  abdominal  parietes. 

The  tumor  formed  when  the  strangulated  intestine  was  pushed  through  the  spermatic  canal  into  the  sac  formed 

by  peritoneum  in  tlie  inside. 
The  superior  portion  of  intestine.  , 

The  inferior. 
The  scrotal  hernial  sac. 
The  testicle,  with  the  vaginal  coat  opened. 


This  case  I  have  described  .somewhat  fully,  as  I  believe  it  to  be  the  earliest  on  record 
in  which  this  accident  has  been  clearly  made  out. 

Third  Form. — In  this  (Figs.  21)8  and  314),  "  as  the  effect  of  forcible  and  long- 
sustained  compression  of  the  hernial  tumor,  the  delicate  serous  membrane  of  the  sac  is 
rent,  burst,  or  torn,  and  the  hernia  makes  its  escape  through  the  aperture  into  the  sub- 
serous connective  tissue  ;  its  course  outside  the  peritoneal  sac  is  advanced  by  continued 
pressure,  and,  detaching  the  connections  of  the  neighboring  peritoneum,  it  forms  for 
itself  a  pouch  between  that  serous  membrane  and  the  internal  abdominal  fascia " 
(Birkett).  The  posterior  part  of  the  neck  of  an  inguinal  hernial  sac  is  the  usual  seat 
of  the  rupture,  and  the  position  of  the  artificial  sac  is  downward  and  outward.  The 
'•  congenital  "  form  of  hernial  sac  is  also  the  more  liable  to  the  accident.    (  Vide  Fig.  314.) 

The  indications  of  the  accident  having  taken  place  are  as  follows  (I  give   them  in 


niSl'I.ACKI)    IIIJISI.K. 


545 


Hirkctt's  \V(jrd.s)  :  "Tin'  liiiiiur  1m'i(»iiic,>  flaic'ul.  iimi  t  lifn-loic  smalltT  ;  tin-  Ijulk  of  iIk; 
tuniKi-  slowly  diuiiiii.slu's  :is  the  |»rt'.ssiire  is  rDiilimicd,  until  at  last  vt-ry  little,  if  anything, 
can  ))<.'  t'l'lt.  hut  the  .s;//v/<<(//  Imx  /'nllitl  In  I'l-^tfiinicr  (hut  sin/i/i  n  J>r/i  so  c/mrnrJt  ristir  u/  tlu 
esca/n  I,/'  till-  Itirnla  IVnni  the  irripe  iif  the  ninuth  of  the  .sac  as  it  enters  the  ahdoniinul 
cavity.  After  the  eflects  of  the  chloroform  have  passed  away  "//  tlf  si/nij>h,nis  u/  .sfnni'/ii. 
Infill  hnnil  nciii\  and  perhaps  with  increased  force.  Even  the  tumor  itself  may  reappear 
and  recede  on  tlu'  application  of  sliuht  pressure.' 

When  this  condition  is  found,  there  is  hut  one  form  of  practice  to  follow,  and  that  i.s 
the  exploration  of  the  .sac.  At  its  netHv  two  orifices  will  l)e  found,  oiu;  dippin«;  down  into 
the  artificial  .sac  and  the  second  into  the  ahdominal  cavity  ;  from  the  latter  the  howel  will  he 
seen  to  pa.ss  through  the  former  into  the  artificial  sac.  The  surgeon  must  then  draw  out 
the  bowel  from  the  .sac  throuj::li  its  false  orifice,  and,  havin<r  freely  divided  the  true  neck 
or  ahdominal  orifice  of  the  sac,  replace  the  intestine ;  and  '•  the  c.xerci.se  of  great  care 
and  caution  is  needed  to  prevent  the  entrance  of  the  hernia  once  more  into  the  abnormal 
space  oi'tside  the  peritoneal  cavity   '  (  liirkett). 


Tliird  Variety, 
luterstitial  Hernia,  witli  ruptured  neck  of  hernial  sac. 

Fourth  Form. — In  this  an  intermuscular,  interstitial,  or  intra-jxirietaJ  sac  ha.s  also 
been  described,  bciu^-  a  kind  of  diverticulum  from  the  inguinal  sac,  and  is  almost  always 
found,  according  to  Eirkett,  associated  witb  the  congenital  form  of  hernia.  The  sac  may 
be  found  in  the  anterior  abdominal  walls  in  an  upward,  outward,  or  inward  direction, 
mostly  behind  the  abdominal  muscles  in  front  of  the  abdominal  fascia,  though  in  some 
instances  in  front  of  the  external  oblique  muscle  beneath  the  skin.  Birkett  refers  to  a 
case  recorded  by  Scarpa,  and  to  a  second  by  Dr.  Fano. 

I  saw  an  example  of  this  in  1883  in  a  patient  of  Dr.  Kershaw  of  Surbiton.  The 
patient  was  over  sbcty  and  had  been  ruptured  for  years.  A  day  or  so  before  I  saw  him, 
in  attempting  reduction,  the  hernia  partially  left  the  scrotum,  and  a  swelling  appeared 
above  the  groin  and  steadily  increased  till  it  reached  nearly  to  the  umbilicus.  The  swell- 
ing, when  I  saw  it,  was  nearly  the  size  of  a  cocoanut,  soft,  and  resonant.  It  was  clearl}- 
bowel,  and  not  strangulated.  Ice  was  applied,  and  in  the  course  of  time  it  returned  into 
the  scrotal  sac  and  gave  rise  to  no  inconvenience. 

In  some  cases  the  sac  extends  to  the  iliac  fossa  and  rests  upon  the  iliacus  muscle, 
between  the  internal  abdominal  fascia  and  peritoneum,  or,  directing  itself  inward,  it  passes 
behind  the  horizontal  ramus  of  the  pubes  and  reaches  the  side  and  front  of  the  urinary 
bladder  (Birkett).  Fig.  299  illustrates  this  form  of  hernia,  but  Fig.  315  does  so  much 
more  clearly.  It  was  taken  from  a  preparation  now  in  Guy's  Museum,  which  was  removed 
from  a  man  aet.  36  upon  whom  I  operated  on  September  23,  18G9,  for  strangulated  hernia. 
The  man  had  been  ruptured  for  fifteen  years  and  had  worn  a  truss.  The  hernia  had 
descended  two  days  before  his  admission  into  Ouy's,  but  the  man  had  pushed  it  up  by 
manipulation  after  a  little  trouble,  though  it  did  not  go  up,  as  usual,  with  a  rush.  After 
its  reduction  vomiting  appeared  and  local  pain,  and  in  this  condition  he  was  admitted  into 
the  hospital. 

When  I  saw  him,  all  the  symptoms  of  strangulation  were  present.     No  hernia  was 

down,  but  there  was  some  fulness  at  the  internal  ring,  and  above  this,  toward  the  crest 

of  the  ilium,  a  tense  globular  swelling  could  be  felt.     This  swelling  I  explored,  and, 

having  laid  open  the  inguinal  canal,  I  exposed  the  empty  hernial  sac  (D.  Fig.  315),  with 

35 


646 


ABDOMINAL  HERNIA. 


Fig 


the  testicle,  showing  that  the  hernia  was  of  the  congenital  form.     I  then  passed  my  finger 
into  the  internal  ring,  and  came  against  a  knuckle  of  tense  distended  intestine.     I  enlarged 

the  opening,  and  this  intestine,  which  was 
of  a  dark  color,  but  still  glistening,  at  once 
protruded.  In  following  this  up  my  finger 
passed  downward  and  outward  into  a  dis- 
tinct cavity,  which  was  not  the  abdominal 
cavity  (C,  Fig.  315),  filled  with  bowel.  It 
was  a  distinct  sac  with  a  smooth  surface 
and  about  the  size  of  an  egg.  At  its  upper 
surface  it  communicated  with  the  hernial 
sac,  and  above  this  with  the  abdominal 
cavity.  I  then  increased  the  orifice  lead- 
ing into  the  abdominal  cavity,  drew  out  the 

Drawing  illustrating  the  Fourth  Variety  or  Intra-Parietal    Strangulated    bowel    from    the    iutra-Darictal 
A,  PeritoneunfHnLg^hSo^i^al^ltcles  (B).  '^f  ,  (^'^   ^^-i^^^^  ""'^    ^'"^"^'"f    '\  "^'?  '}'^ 

c,  intraparietai  sac  with  strangulated  bowel.  abdomen.     The  sac  was  clearly  placed  be- 

D,  Scrotal  hernial  sac  leading  down  to  testicle  (T).  i„j.i-i.  i-  ii.i.  ±\         -l. 

E,  Director  passed  from  the  congenital  scrotal  sac  through  low  the  internal  ring  and   between  the  ab- 

the  internal  ring.  ,  ^    ,,      •  .    ^     ^  dominal  musclcs  and  peritoneum.    The  man 

In  the  drawing  the  strangulated  bowel  has  been  introduced    -,•    ■•    n  •        ..'^        to         ^     ^  i- 

to  make  the  description  clearer.  died  iroiu  peritonitis  On  the  lourth  day,  his 

death  allowing  me  to  take  the  very  excellent 

preparation  from  which  Fig.  315  has  been  taken.     The  case  was  clearly  one  belonging  to 

Mr.  Birkett's  third  or  my  fourth  form,  an  intra-parietal  sac  (Fig.  315,  C)  existing  below 

the  internal  ring. 

The  disappearance  of  the  tumor  without  the  characteristic  jerk  and  the  persistence  of 
the  symptoms  indicate  all  these  forms.  The  treatment  in  all  is  the  same  as  that  described 
in  the  third  variety. 

Prognosis. — As  the  danger  of  a  strangulated  hernia  depends  upon  the  amount  of 
damage  the  intestine  has  sustained  by  the  strangulation,  so  the  amount  of  damage 
the  bowel  has  received  is  to  be  measured  by  the  intensity  of  the  strangulation  and 
its  duration.  A  tight,  unyielding  strangulation  such  as  usually  exists  in  a  recent  femoral 
or  in  a  congenital  or  direct  inguinal  hernia  does  more  harm  in  a  short  period  than  a  less 
tight  and  more  yielding  constricting  force,  such  as  is  met  with  in  an  old  oblique  inguinal 
hernia,  in  a  longer  period,  violent  taxis  adding  materially  to  the  danger  of  the  case. 

The  existence  of  peritonitis  before  the  reduction  of  the  hernia  is  always  an  unfavor- 
able sign,  as  it  is  not  likely  to  be  lessened  by  the  introduction  into  the  peritoneal  cavity 
of  a  portion  of  bowel  already  inflamed  and  altered  in  character.  A  hernia  in  an  other- 
wise healthy  subject,  that  has  not  been  strangulated  for  many  hours,  that  has  not  been 
injured  by  violent  manipulation,  and  has  been  reduced  by  the  "  minor"  operation,  will 
probably  do  well,  whereas  one  that  has  been  strangulated  for  days  or  been  subjected  to 
violent  taxis  will  probabl}''  do  badly. 

Where  disease  of  the  kidneys  or  of  other  viscera  exists  and  in  old  people,  the  prog- 
nosis is  always  unfavorable. 

A  case  in  which  the  intestine  has  been  freely  exposed  is  more  unfavorable  than  one 
in  which  no  exposure  has  taken  place,  and  any  excessive  manipulation  of  the  hernial 
contents  always  adds  to  the  danger. 

The  reduction  of  a  severely  damaged  intestine  is  more  liable  to  be  followed  by  a  bad 
result  than  where  little  injury  exists,  but  a  bowel  only  slightly  injured  in  an  aged  or 
unhealthy  subject  is  always  likely  to  do  badly. 

A  hernia  strangulated  in  its  first  descent  requiring  operation  is  always  far  more  fatal 
than  an  "  old  case." 

In  private  practice,  where  herniae,  as  a  rule,  are  discovered  and  treated  early,  good 
success  follows  herniotomy  ;  but  in  hospital  practice,  where  neglect  and  delay  combined 
have  had  their  influence,  treatment  is  very  unsuccessful,  nearly  one-half  the  cases  dying. 
At  Guy's  Hospital  the  average  period  of  strangulation  for  femoral  hernia  is  seventy-six 
hours  ;  of  inguinal,  fifty  ;  and  half  the  cases  that  die  after  the  operation  do  so  within 
forty-eight  hours,  the  injury  to  the  bowel  being  so  great  and  the  power  of  the  patient  so 
reduced  that  any  reaction  after  the  reduction  of  the  hernia  is  rendered  impossible. 
Under  these  circumstances,  the  worst  that  can  be  said  for  the  operation  is  that  it  fails 
to  cure. 


L\(;ri.\AL  ni:i:si.\.  547 

Inguinal  Hernia. 

Inguinal  hernia,  oi'  tlmi  Inrm  which  imitriKh-.s  tlinjii<:h  the  intornal  or  oxtcrnal 
abihniiiiKil  riiiLTS,  iiiclu(h'S  two-thirtls  of  all  cusl-s  of  ht-niia  and  ahout  half  of  all  cases  of 
straiij^iilatril  hrniia.  Two  out  of  three  eases  oi"  straiijiiilated  in;^uitial  hertiiu  are  reduci- 
ble by  the  taxis,  the  third  re((uiriii<;  operation.  In  hospital  practice  half  of  those  operated 
iijtoii  die,  operations  in  recent  cases  beitij;  most  fatal. 

An  inguinal  hernia  is  called  ohliijnc  when  it  passes  throuf:;h  the  internal  ring  and  along 
the  iiiLniinal  canal  downward  toward  the  scrotum  ;  dii-fct^  when  it  do(!S  not  pass  through 
the  internal  ring,  but  througli  the  external  in  a  direct  way. 

The  obli«|ne,  from  bi'ing  anatomically  jilaced  external  to  tin;  deep  epigastric  artery,  i.s 
called  i.i-itiiKil  (thllifur^  while  tluMlircct,  iVom  being  internal  to  the  same  vessel,  is  known 
as  tlu'  lute  null  (/iri'ft. 

When  the  obiicjue  has  not  passed  tlic  external  ring,  it  is  known  as  a  Itiilxmurclr  ;  when 
the  obli((ue  or  direct  has  passed  into  the  scrotum,  it  is  called  a  turolnl hrrnin  or  oscheocple. 

In  the  iililitiiit'  iii</in'iii(l  the  sac  of  the  hernia  may  be  the  natural  "  vaginal  process  of 
peritoneum  "  that  was  formed  on  the  descent  of  the  testicle  in  fuetal  life  and  has  not  clo.sed 
— /.<'.,  (/  cdiu/niifal  !<<ic  (Figs.  21(2,  2!>3,  29-4) — or  an  tiajidrcd  ><<ic  formed  by  the  gradual 
pouching  of  the  parietal  peritoneum  through  the  ring  (Fig.  29(5). 

In  the  ifiirrf  linjulndl  the  sac  is  alway.s  of  the  acquired  form. 

This  "  vaginal  tubular  process  of  peritoneum  "  which  communicates  above  at  the  inter- 
nal abdominal  ring  with  the  peritoneal  cavity,  and  V^elovv  is  in  clo.se  contact  with  and 
adherent  to  the  testicle,  lies  in  front  of  the  spermatic  cord,  and  before  birth,  or  soon  a^'ter, 
"  it  contracts  near  the  head  of  the  epididymis,  its  surftices  adhere  firmly  at  that  spot,  and 
thus  two  cavities  arc  formed."  The  inferior  one  forms  the  permanent  covering  to  the 
testis,  and  is  known  as  tlie  tunica  vaginalis  propria  testis.  The  superior  canal,  whci  no 
arrest  of  development  takes  place,  subse(|uently  contracts  till  the  canal  cea.ses  to  exist. 

When  an  arrest  of  development  occurs  and  the  abdominal  orifice  of  the  tubular  pro- 
cess remains  patent,  a  piece  of  ititestine  may  at  any  time  descend.  Wlien  the  v-liole  leuijth 
of  the  canal  is  open,  the  hernia  will  pass  down  at  once  into  the  scrotum  to  the  testicle, 
masking  its  presence  ;  and  in  this  way  the  congenital  hcrnid  of  Haller,  the  hrnia  of 
in/aiici/  of  3Ialgaigne,  or  the  hernia  into  the  vayinal  process  of  peritoneum  of  Birkett,  is 
formed  (Fig.  292). 

When  the  closure  of  the  canal  takes  place  higher  up — and  such  an  event  is  possible 
at  any  point  from  the  testicle  upward — the  descent  of  the  hernia  will  be  limited,  though 
its  nature  is  the  same,  the  only  difference  being  that  in  this  condition  the  testicle  will  be 
found  below  the  hernial  sac  at  a  variable  distance  and  separated  from  it.  To  this  form 
of  rupture  Birkett  has  given  the  name  o^  hernia  into  the  fnnindar  ptortion  of  the  vaginal 
process  (f  the  peritoneum  (Fig.  293  or  Fig.  .313). 

It  should  also  be  mentioned  that  it  is  not  uncommon  for  this  tubular  vaginal  process 
to  close  at  its  abdominal  orifice  at  the  internal  ring  and  yet  remain  more  or  less  open  as  a 
cavity  below,  and  under  these  circumstances  any  sudden  rupture  or  giving  wai/  of  the  clos- 
ing medium  will  be  followed  by  the  rapid  formation  of  a  hernia,  the  hernia  being  scrotal 
wholly  or  in  part,  lying  upon  or  separated  from  the  testicle,  according  to  the  absence  or 
position  of  any  point  of  closure.  This  form  of  hernia  differs  only  in  the  sudden  giving 
way  of  the  abdomimil  orifice  of  the  vaginal  process  from  those  last  described,  and  is  very 
common  in  young  adults. 

For  all  those  forms  of  hernia  in  which  the  sac  is  composed  of  the  natural  tubular 
Vaginal  process  of  peritoneum  the  term  congenital  form  of  hernia  would  probably  be  the 
best,  as  indicating  their  nature,  distinguishing  them  from  the  other  form,  rightfy  called 
the  acijitired. 

This  congenital  f(»rm  of  hernia  is  also  frcijuently  associated  with  some  malposition  of 
the  testicle,  such  as  its  non-descent  or  partial  descent. 

The  uifaiitHe  hernia  of  Hey  or  the  enct/sted  hernia  of  the  tunica  vaginalis  of  Sir  A. 
Cooper  is  an  acquired  hernia,  the  hernia  gradualli/ pushing  the  tissues  closing  the  orifice 
of  the  vaginal  ])rocess  of  peritoneum  downward  into  the  open  canal,  the  protruded 
parts,  together  with  the  sac,  being  contained  in  the  tunica  vaginalis  testis,  and  the  true 
sac  being  within  that  which  might  have  been  the  congenital  (Fig.  295). 

The  liour-glass  contraction  ff  a  scrotal  liernia  is  always  found  in  the  ''  congenital  form," 
and  is  due,  as  described  by  Birkett,  to  the  imperfect  closure  of  the  vaginal  sheath  above 
the  testicles,  where  union  of  its  walls  normally  takes  place.  Prep.  23G8  in  Guy's 
Museum  will  explain  these  cases,  also  Fig.  294. 


548  jyGUIXAL  HERNIA. 

The  acquired  form  of  inguinal  herniti,  oblique  and  direct,  i?-  nhrnys  dov:  in  its  forma- 
tion, the  pushing  downward  of  the  parietal  layer  of  peritoneum  by  the  protruding  viscera 
being  a  gradual  process,  thus  forming  a  marked  contrast  with  the  congenital  form.  In 
the  oblique  it  begins  as  a  slight  yielding  at  the  internal  ring,  and  in  the  direct  at  the 
external,  this  yielding  passing  into  a  "  pouching."  till  at  last  the  pouch  may  reach,  and 
even  fill,  the  scrotum.  In  the  early  stage  this  yielding  may  be  scarcely  perceptible,  but 
the  patient  it  will  give  rise  to  a  feeling  of  weakness,  and  often  of  pain,  on  any  abdominal 
muscular  exertion  being  made.  "When  a"  pouching'' — or.  according  to  ^lalgaigne.a  '-point- 
ing " — of  the  hernia  has.  commenced,  any  act  of  cougliing  or  straining  will  make  it  visible. 

"When  the  oblique  hernia  has  filled  the  inguinal  canal,  it  will  appear  as  an  ovoid  swell- 
ing above  Poupart's  ligament  {vile  Fig.  3U1)  beneath  the  tendon  of  the  external  oblique 
muscle.  AVhen  it  has  passed  through  the  external  ring,  the  long  axis  of  the  tumor,  and 
more  particularly  its  neck,  will  still  be  in  the  inguinal  canal  above  and  parallel  with  Pou- 
part's ligament  :  but,  having  escaped  from  beneath  the  external  oblique  muscle,  it  will 
appear  as  a  pyriform  scrotal  tumor  of  variable  size.  The  testicle  will  always  be  found 
below  and  distinct  from  the  sac.  the  cord  being  behind  the  tumor. 

In  the  direct  inguinal  form  in  which  the  pouching  of  the  hernial  sac  is  directly  behind 
the  external  ring  (Fig.  302),  there  will  be  no  inguinal  neck  such  as  exists  in  the  oblique, 
the  hernia  passing  directly  through  the  external  ring  down  into  the  scrotum.  This  form 
of  hernia  has  thus  a  more  globular  shape  than  the  oblique. 

When  the  ohlique  inguinal  is  reduced,  the  surgeon  can  pass  his  finger  through  the 
external  ring  along  the  inguinal  canal  upward  and  outward  into  the  internal  ring,  and 
thus  into  the  abdominal  cavity,  although  in  old  herniie  the  two  rings  are  brought  closer 
in  apposition  than  in  the  more  recent.  In  direct  inguinal,  the  finger,  having  passed  the 
external  ring,  seems  to  enter  at  once  into  the  abdominal  cavity,  the  opening  being 
directly  behind  the  external  ring,  and,  with  the  finger  passed  through  the  neck,  the 
external  border  of  the  rectus  muscle  may  be  felt  on  the  pubic  bones.  By  these  points  the 
diagnosis  between  the  acquired  oblique  and  the  direct  inguinal  can  be  made  out. 

With  respect  to  the  points  of  difference  between  the  ••  congenital  and  ■•  acquired 
form  of  oblique  inguinal  hei*nia  a  few  words  are  needed,  and  may  be  thus  epitomized  : 
The  ••  congenital "'  form  is  tht  hernia  of  infancy  and  young  adult  life ;  the  "  acquired.  " 
that  of  middle  life  and  old  age.  A  hernia  that  has  formed  >vddeidy  and  passed  at  ouce 
into  the  scrotum  is  probably  of  the  "  congenital,"  whereas  one  that  has  been  produced 
slowly  is  more  likely  to  be  of  the  '-acquired."  form.  "When  the  hernial  tumor  envelops 
the  testicle  and  renders  its  detection  impossible  or  difficult,  the  ••  congenital  form"  is  indi- 
cated ;  when  the  testicle  is  in  its  right  place  and  distinct  from  the  hernial  sac,  the 
"  acquired." 

A  hernia  with  a  long  tubular  neck  occupying  the  inguinal  canal  is  probably  of  the 
"  congenital  "  kind,  a  short  thick  neck  being  more  common  in  the  "  acquired." 

The  youth  of  the  patient,  the  rapidity  of  its  formation,  and  its  close  connection  with 
the  testicle  are  the  three  chief  points  characteristic  of  the  '•  congenital "'  form  of  hernia ; 
the  age  of  the  patient,  the  slowness  of  its  production,  and  its  distinct  separation  from 
the  testicle,  the  three  points  indicative  of  the  "  acquired." 

The  dlngnosis  of  an  inguinal  hernia  from  other  tumors  is  only  difficult  in  exceptional 
cases.  No  scrotal  tumor  beginning  in  the  scrotum  and  developing  upward  can  be  a 
hernia,  for  all  hernise  descend  toward  the  scrotum.  So.  when  a  distinct  separation  exists 
between  the  .scrotal  tumor  and  the  external  ring,  no  difficulty  in  diagnosis  ought  to  be 
experienced.  In  this  way  ordinary  hydroceles,  haematoceles.  and  all  diseases  of  the 
testicle  are  excluded. 

^Yhen  a  hydrocele,  however,  passes  through  the  external  up  to  the  internal  ring — a 
condition  by  no  means  uncommon  in  infancy  and  young  adult  life — when  the  vaginal 
process  of  peritoneum  is  only  closed  at  its  abdominal  orifice,  some  difficulty  may  be 
experienced:  but  in  the  absence  of  all  symptoms  of  hernia  the  translucency  of  the  tumor 
and  the  history  of  the  case — viz..  that  the  swelling  began  below  and  travelled  upward — 
are  sufficient  to  point  out  the  nature  of  the  affection. 

Cone/enital  hydroceles  into  the  vaginal  process  are  to  be  distinguished  from  congenital 
hernia  by  their  transparency,  by  the  gradual  filling  of  the  sac.  and  by  their  vibration  on 
percussion  :  whereas  a  hernia  is  opaque,  enters  the  sac  rapidly,  leaves  it  quickly,  and 
does  not  vibrate. 

An  encysted  hydrocele  of  the  cord  appears  as  a  tense,  fluctuating,  tran.sparent.  irreduci- 
ble tumor,  and  ought  not  to  be  confused  with  a  bubonocele  when  no  other  symptoms  of 
hernia  exist  bevond  the  swellinjir. 


Tin:  i:.\f>i':iL  crin:  of  iii:i:si.\.  549 

'I'lic  wniiiiv  f'ci'l  of  ii  ritn'cni-ilc  (ir  varicdso  sjic^niiatir  veins,  ami  the  fact  tliat  prc-suro 
siiHicicnt  to  keep  any  licriiia  in  position  with  tlu;  patient  erect  over  the  external  ring 
renders  the  varicose  veins  more  marked,  should  prevent  it  being  mistaken  for  a  lierniu. 
And  if  the  surgeon  wouhl  only  h">k  for  the  tw(t  testicles  in  every  case  of  scrotal,  or  even 
inguinal,  swelling,  he  could  not  fall  into  the  error  of  mistaking  an  undescended  testicle 
or  one  resting  at  the  internal  ring  or  iti  the  inguinal  canal  for  a  hernia  or  any  other 
disease. 

When  a  hernia  and  iiydrneelo  coi!xist,  sonic  dilhculty  may  he  experienced  in  the  diag- 
nosis :  l)ut.  as  ea(di  atfection  has  its  own  symptoms,  the  diagnosis  ought  not  to  he  very 
dittieult. 

Whenever  a  douht  in  diagnosis  is  felt  ahout  an  inguinal  tumor  and  symptoms  of  a 
strangulated  hernia  are  present,  the  golden  rule  in  suri:ery  should  be  observed,  and  the 
doubtful  tumor  exphu'ed. 

I  had  an  interesting  case  (February,  1872)  witli  the  Messrs.  Toulmin  of  Clapton 
illustrating  this  in  a  boy  fct.  4  who  had  an  acute  hydrocele  associated  with  a  sudden 
descent  of  a  hernia  into  the  vagina!  process  of  the  peritoneum  of  the  cord.  I  tapped  the 
hydrocele  and  left  the  inguinal  tumor,  thinking  it  might  be  possibly  a  hydrocele  of  the 
cord,  as  no  .symptoms  of  strangulated  bowel  were  present.  These,  however,  soon 
appeared ;  and  chloroform  was  given  with  a  view  of  exploring  the  tumor,  when,  by 
the  taxis,  the  hernia  was  happily  reduced,  and  the  boy  recovered. 

InquinaJ  hrrnia  in  very  common  in  flic  female  child;  indeed,  under  puberty,  it  is  the 
usual  kind,  and  is  always  of  the  "  congenital  form,"'  the  bowel  coming  down  into  the  open 
canal  of  Xuck.  It  is  found,  however,  at  all  periods  of  life,  though  as  a  direct  hernia  it 
is  only  seen  in  the  adult.  The  rupture  may  consist  of  the  ovary  and  descend  into  the 
labium.  It  can  be  recognized  by  the  same  symptoms  as  in  the  male,  and  should  be 
treated  on  the  .same  principles.     A  hydrocele  of  the  cord  may  be  mistaken  for  a  hernia. 

Tre.vt.ment. — A  reducible  inguinal  hernia  is  to  be  kept  up  with  a  truss,  whether  in 
the  infant,  child,  or  adult ;  the  truss,  too,  must  be  well  fitting,  exerting  sufficient  pressure 
to  keep  the  hernia  in  position,  hit  no  more.  In  the  adult  the  truss  should  always  be 
moulded  upon  a  cast  of  the  groin  taken  with  the  hernia  reduced.  Should  the  hernia 
come  down  when  the  truss  is  on,  it  ought  to  be  reduced  and  the  truss  reapplied.  The 
pressure  of  the  pad  in  the  oblique  form  should  be  over  the  internal.,  but  in  the  direct  over 
the  external.,  ring.  In  infants  a  complete  cure  is  often  obtainable  by  these  means  in  a 
year  or  so ;  and  if  no  descent  or  any  other  symptom  of  hernia  shows  itself  for  another 
year,  the  truss  may  be  left  off.  In  cases  of  hernia  occurring  after  infanc}"  it  is,  however, 
never  safe  to  leave  off  a  truss.  When  some  malposition  of  the  testis  complicates  a  case 
of  the  congenital  form  of  hernia,  care  must  be  taken  that  the  pad  of  the  truss  does  not 
press  the  testicle ;  and  when  the  testicle  and  hernia  are  both  in  the  inguinal  canal,  the 
only  truss  that  can  be  tolerated  is  one  made  upon  a  cast  of  the  parts  after  rest,  as  already 
advised  in  page  530. 

Irreducible,  inflamed,  obstructed,  and  strangulated  inguinal  herni;i3  are  to  be  treated 
on  the  principles  already  stated. 

A  strangulated  direct  inguinal  hernia  is,  however,  a  far  more  serious  affection  than 
the  ohlique,  the  sharp  unyielding  edge  of  the  ruptured  tendon  surrounding  the  neck  of 
the  sac  acting  as  rapidly  upon  the  strangulated  bowel  as  does  the  edge  of  Gimbernats 
ligament  in  femoral  hernia. 

When  a  hernia  cannot  be  kept  up  with  a  truss,  the  question  of  the  operation  for  the 
radical  cure  of  the  hernia  may  be'  entertained.  The  operation  has  its  dangers,  and  AVut- 
zer,  its  early,  and  Wood,  its  present,  advocate,  admit  that  a  truss  is  necessary  subse- 
quently throughout  life. 

The  Radical  Cure  of  a  Hernia. 

This  has  been  the  aim  of  surgeons  from  time  immemorial,  and  were  hernia  only  a 
mechanical  lesion  due  to  a  weakness  of  the  walls  through  which  it  protrudes  or  of  the 
neck  of  the  sac,  some  success  would  probably  have  attended  the  practice ;  but,  as  a  rup- 
ture is  more  probably  due  to  something  more  than  this,  it  can  hardly  be  expected  that 
any  very  good  result  should  have  been  obtained.  Gerdy,  Wutzer,  Rothmund,  Wells,  and 
Davies  have  all  tried  to  accomplish  this  by  plugging  the  mouth  of  the  sac  with  its  invag- 
inated  fundus,  Gerdy  fixing  the  invaginated  fundus  by  means  of  two  sutures ;  Wutzer, 
by  means  of  a  cylindrical  wooden  plug  passed  into  the  inguinal  canal  in  the  hollow  of 
the   invaginated   structures  up  to  its   neck,  and  a  grooved  wooden   pad  being  applied 


550 


INGUINAL  HERNIA. 


externally  over  the  first  to  hold  the  parts  in  position,  the  two  wooden  instruments 
being  held  together  by  a  needle  (which  is  enclosed  in  the  cylindrical  part  and  made  to 
pass  through  the  internal  ring  and  external  tissues)  and  a  screw  ;  the  plug  should  be 
retained  for  six  or  seven  days,  llothmund,  Wells,  Davies,  and  others  have  only  improved 
upon  Wutzer's  method.  Mr.  Birkett,  however,  tells  us,  on  the  authority  of  Dr.  Otto  Weber 
of  Bonn,  the  late  clinical  assistant  to  Wutzer,  that  Wutzer  is  stiil  of  opinion  that  his  opera- 
tion is  not  dangerous  when  properly  performed,  and  that  by  his  method  the  fundus  of  the 
invaginated  sac  may  be  made  to  adhere  to  its  neck ;  and,  as  a  consequence  of  this,  //'  the 
patient  continue  to  wear  a  trims  /or  fi/e,  a  return  of  the  hernia  may  he  avoided.  Dr.  0. 
Weber,  moreover,  writes  that  he  has  never  seen  any  of  the  so-called  ''  cured  cases  "  rad- 
ically cured  ;  that  the  plug  of  skin  is  by  degrees  entirely  drawn  out  again  ;  that  the 
external  and  internal  rings  are  not  closed  by  the  operation  ;  that  an  imperfect  cure  may 
be  effected  by  means  of  a  partial  closure  by  adhesion  of  the  internal  walls  of  the  neck 
of  the  sac  and  thickening  of  the  surrounding  tissues.  In  London  practice  it  is  also  well 
known  that  a  fatal  peritonitis  has  followed  the  attempt.  With  these  facts  before  us 
respecting  Wutzer's  operation,   I  cannot  recommend  it. 

Mr.  Wood  of  King's  College,  believing  that  Wutzer's  principle  of  practice  was  as 
wrong  as  his  practice  was  unsuccessful,  devised  in  1863  an  operation  by  which  the 
hernial  sac,  without  the  skin,  is  invaginated  into  the  canal,  and  the  hinder  and  inner 
walls  of  the  inguinal  canal  are  drawn  forward  by  means  of  sutures  and  fixed  to  the 
anterior  and  outer  walls. 

The  steps  of  the  operation  are  co^^ducted  as  follows  (they  are  taken  from  Druitt's 
Vade  Mecum  as  revised  by  Wood): 

The  patient  being  laid  on  his  back  with  the  shoulders  well  raised  and  the  knees  bent, 
the  pubes  cleanly  shaved,  the  rupture  completely  reduced,  and  chloroform  administered, 
an  oblique  incision  about  an  inch  long  is  made  in  the  skin  of  the  scrotum  over  the  fundus 
of  the  hernial  sac.  A  small  tenotomy  knife  is  then  carried  flatwise  under  the  uiargins  of 
the  incision,  so  as  to  separate  the  skin  from  the  deeper  coverings  of  the  sac  to  the  extent 
of  about  an  inch,  or  rather  more,  all  round.  The  forefinger  is  then  passed  into  the  wound 
and  the  detached  fascia  and  fundus  of  the  sac  invaginated  into  the  canal.  The  finger  then 
feels  for  the  lower  border  of  the  internal  oblique  muscle,  lifting  it  forward  to  the  surface. 
By  this  means  the  outer  edge  of  the  conjoined  tendon  is  felt  to  the  inner  side  of  the  fin- 
ger. A  stout  semi-circular  needle  mounted  in  a  strong  handle,  with  a  point  flattened 
antero-posteriorly  and  with  an  eye  in  its  point,  is  then  carried  carefully  up  to  the  point 
of  the  finger  along  its  inner  side  and  made  to  transfix  the  con- 
FiG.  316.  joined  tendon,  and  also  the  inner  pillar  of  the  external  ring. 

When  the  point  is  seen  to  raise  the  skin,  the  latter  is  drawn 
over  toward  the  median  line  and  the  needle  made  to  pierce  it 
as  far  outward  as  possible.  A  piece  of  stout  copper  wire,  sil- 
vered, about  two  feet  long,  is  then  hooked  into  the  eye  of  the 
needle,  drawn  back  with  it  into  the  scrotum,  and  then  detached. 
The  finger  is  next  placed  behind  the  outer  pillar  of  the  ring 
and  made  to  raise  that  and  Poupart's  ligament  as  much  as  pos- 
sible from  the  deeper  structures.  The  needle  is  then  passed 
along  the  outer  side  of  the  finger  and  pushed  through  Pou- 
part's ligament,  a  little  below  the  deep  hernial  opening  (inter- 
nal ring).  The  point  is  then  directed  through  the  same  skin 
puncture  before  made,  the  olfher  end  of  the  wire  hooked  on  to 
it,  drawn  back  into  the  scrotal  puncture,  as  before,  and  then 
detached.  Next,  the  sac  at  the  scrotal  incision  is  pinched  up 
between  the  finger  arid  thumb  and  the  cord  slipped  back  from 
it,  as  in  taking  up  varicose  veins.  The  needle  is  then  passed 
From  Wood.  across  behind  the  sac.  entering  and  emerging  at  the   oppo.site 

ends  of  the  scrotal  incision  (Fig.  310).  The  end  of  the  inner 
wire  is  again  hooked  on  and  drawn  back  across  the  sac.  Both  ends  of  the  wire  are  then 
drawn  down  until  the  loop  is  near  the  surface  of  the  groin  above,  and  are  twisted  together 
down  into  the  incision  and  cut  off'  to  a  convenient  length.  Traction  is  then  made  upon 
the  loop.  This  invaginates  the  sac  and  scrotal  fascia  well  up  into  the  hernial  canal.  The 
loop  of  wire  is  finally  twisted  down  close  into  the  upper  ])uncture  and  bent  down,  to  be 
joined  to  the  two  ends  in  a  bow  or  arch,  under  which  is  placed  a  stout  pad  of  lint.  The 
whole  is  held  steady  by  a  spica  bandage  (Fig.  311).  The  wire  is  kept  in  from  ten  to 
fourteen  days,  or  even  longer  if  the  amount  of  consolidation  is  not  satisfactory.     Very 


77//;    L'ADKWL    ('I'lll-:   OF   IIIJIMA.  551 

lillK'  sii|i|piir;itiiiii  usiiallv  I'nllnw.s,  lnit  jil'tcr  a  lew  days  the  jiarls  can- 1)0  felt  tliickciK-il  by 
udlu'sivc  (Icposit.  'IMic  wire  bt'coiin's  lnost'iicd  hy  iilcciatiuii  in  its  track  until  it  cuii  be 
uiitwisti'd  ami  withdrawn  iipirnri/.  In  this  (tjn'ratiitu  tlio  hernial  canal  is  clusi-d  al<Mi<;  its 
whole  length,  and  an  extended  adherent  snrlaee  is  obtained  to  resist  future  jiriitrusion. 

After  the  operation,  Wood  says,  a  horseshoe  pad  should  be  worn  i'or  a  lew  months; 
(I lid  titt'  truss  is  nut  In  hi  tliroini  nsiile  ir/ii:ii  //ir  jm/it  nf  is  iihoiif  to  hr  siihlirtnl  to  rioleiU 
sfniiiis  or  ti/tiuij.  This  is  important  to  remember,  thouLdi  it  tends  mutdi  to  do  away  with 
the  value  of  tlie  operation. 

Modifications  of  the  operation  art;  employed   for  infants,  etc. 

The  o|)eration  I  have  dt;scribed  is  a  subcutaiieous  one  and  i.s  infrenious.  It  has,  more- 
over,its  danLTors.  Wood  writes  he  has  operated  '.»?>'  times  with  4  deaths,  and  out  of  107 
cases  in  which  the  results  were  known  in  4.S  a  failure  followed  and  in  .')!(  a  satisfactory 
result  was  secured.  Thus,  in  the  most  favorable  lij-dit,  there  is  one  failure  to  one  success 
and  risk  to  life.  It  is  to  be  feared,  liowever,  that  a  lar<re  number  of  the.se  set-called  .satis- 
factory cures  are  only  so  when  they  leave  the  ojtcrator's  hands,  since  Kinjr<hjii's  Rrports 
of  the  City  of  London  Truss  Society  tell  us  that  within  ten  years  fifty  persons  who  had 
under<rone  siune  operation  for  the  radical  cure  had,  in  conse<)uence  of  its  failure.  a])plied 
for  trusses  :  and  this  number  is  large,  considering  the  surgeons  who  ])erform  this  ojteration 
are  not  numerous  nor  the  ca.ses  abundant. 

For  my  own  part,  I  believe  tlaat  where  a  hernia  can  be  kept  up  by  a  truss,  and  the 
patient  is  likely  to  remain  in  a  civilized  country  where  trusses  can  be  obtained,  an  opera- 
tion for  the  I'adical  cure  is  not  called  for.  To  risk  the  life  of  a  patient  on  the  theory  of  a 
cure,  when  a  truss,  as  a  matter  of  safety,  lias  to  be  worn  subsequent  to  the  operation,  is 
both  unfair  and  unsati.sfactory. 

When  a  hernia  is  reducible  and  (;annot  be  ke])t  in  ])lace  l)y  a  truss,  when  a  patient  is 
going  abroad  where  trusses  are  not  to  be  obtained  or  only  o])tained  at  too  great  a  cost,  the 
operation  for  the  radical  cure  may  be  undertaken.  Indeed,  under  these  circumstances,  I 
have  performed  Wood's  as  well  as  Wutzer's  operation  with  good  succes.s — that  is,  the 
patients  who  previously  could  not  keep  up  their  hernia,  on  account  of  the  great  size  of 
the  inguinal  ring,  were  enabled  to  do  so. 

In  the  '-congenital  form"  of  inguinal  hernia  there  seems  a  better  prospect  of  success 
following  the  operation  than  in  any  other,  and  a  better  basis  for  the  practice  ;  for,  '•  thus 
allowing  nature  to  guide  our  procedure,  we  must  make  it  a  rule  to  .select  those  cases  in 
which  her  efforts  have  failed,  and  by  acting  as  her  handmaid  we  may  reasonably  hope  to 
arrive  at  a  successful  result'   (Birkett). 

The  corkscrew  operation,  known  as  that  of  Mr.  Spanton  of  Hanley,  is  another  subcu- 
taneous operation  of  which  I  have  had  no  experience.  It  .seems  to  have  been  successful 
more  particularly  in  children,  and  is  worthy  of  an  extended  trial. 

Mr.  Spanton's  object  in  his  operation  is  to  fill  the  canal  itself  with  organized  tissues 
and  at  the  same  time  to  approximate  its  tendinous  boundaries.  The  operation  I  describe 
nearly  in  Mr.  Spanton's  own  words: 

The  instruments  required  for  the  operation  are  a  narrow-bladed  knife  for  making  the 
scrotal  incision,  dressing  forceps  ar>d  the  screw  instrument  (or  strephotome).  shaped  like 
a  corkscrew,  with  a  wide  spiral  which  tapers  somewhat  toward  its  base.  The  point  is 
flattened,  but  sharp,  .so  as  to  tran.sfix  the  tough  tissues  wnthout  tearing,  and  the  handle 
consists  of  a  movable  bar,  which  it  is  sometimes  convenient  to  leave  in  position,  .so  as 
effectually  to  steady  the  instrument.  In  cases  where  it  is  intended  to  use  a  ligature  by 
means  of  a  screw  a  glass  rod  perforated  with  two  holes  at  each  extremity  will  be  required 
for  fa.stening  the  ends  of  the  ligature.  The  patient  should  have  an  aperient  and  an  ordi- 
nary enema  previous  to  the  operation,  and,  if  necessary,  the  pubes  should  be  shaved.  The 
patient  being  anaisthetized,  the  operator,  standing  on  the  patient's  left,  makes  an  incision 
large  enough  to  admit  the"  forefinger  through  the  skin  of  the  scrotum  over  the  fundus  of 
the  hernial  .sac.  usually  an  inch  and  a  half  or  two  inches  below  the  pubic  sj)ine.  The  sac 
•with  the  fascial  tissues  covering  it  is  then  separated  from  the  skin  by  jiassing  the  knife 
or  handle  freely  around  the  internal  surface  of  the  wound,  until  a  sufficient  extent  of  it 
has  been  separated  to  permit  the  finger  easily  to  invaginate  the  sac  into  the  hernial  canal, 
which  is  readily  accomplished  by  pushing  the  .sac  with  the  left  forefinger  up  to  the  internal 
ring.  After  carefully  examining  the  condition  of  the  parts  within  reach  of  his  finger — 
especially  with  regard  to  the  ])osition  of  the  blood  vessels  and  the  boundaries  of  the  aper- 
ture— the  operator  retains  his  forefinger  in  the  inguinal  canal,  thereby  protecting  the 
spenuatic  cord,  which  lies  below  his  finger,  and  at  the  same  time  closing  the  internal  ring, 
so  as  to  prevent  any  protrusion  of  the  bowel.     Sometimes  with  a  very  patent  ring  it  ia 


552  FEMORAL  HERNIA. 

nect'Hsary  (or  ;in  nsHstant  to  place  his  finger  externally  on  the  groin  to  make  perfectly 
sure  of  this,  especially  if  there  is  any  cough  or  struggling.  It  is,  however,  wiser  to  wait 
a  few  moments  and  to  let  the  patient  become  (juiescent  before  proceeding  further.  Then, 
holding  the  "  strephotome"  firmly  in  the  right  hand,  the  surgeon  thrusts  the  point  through 
the  skin  of  the  groin  at  that  part  of  the  surface  which  corresponds  to  the  outer  pillar  of 
the  internal  ring,  which  is  also  pierced  by  the  point,  which  now  comes  in  contact  with  the 
left  forefinger.  Having  given  the  screw  a  turn,  the  point  is  made  to  pierce  the  invagin- 
ated  sac  and  pushed  on  through  the  internal  pillar  (conjoined  tendon)  as  high  up  as  can 
be  safely  reached,  the  left  forefinger  carefully  guarding  the  point  of  the  instrument 
throughout.  Another  turn  is  now  made,  causing  the  screw  to  pass  through  the  invagin- 
ated  tissues  and  across  the  pillars  of  the  external  ring  as  many  times  as  the  length  of  the 
canal  and  the  nature  of  the  case  will  permit.  The  left  finger  is  gradually  witlidrawn  as 
the  point  passes  downward  and  outward  through  the  opening  in  the  scrotum,  the  spermatic 
cord  lying  behind  and  slightly  compressed  by  the  gradual  tightening  of  the  hernial  canal. 
The  point  of  the  screw  is  then  protected  by  a  .small  india-rubber  ball,  and  the  handle  lies 
flat  on  the  outer  surface  of  the  abdomen.  The  scrotal  wound  is  closed  by  a  single  wire 
or  hair  suture.  A  pad  and  soft  bandage  are  then  applied  over  the  whole.  After  a  few 
days — usually  seven  to  ten — the  parts  become  sufficiently  consolidated,  and  the  screw  i.s 
then  removed  without  any  difficulty  and  an  oiled  pad  and  bandage  kept  applied  until  the 
parts  are  firm. 

If  a  continuous  ligature  is  preferred,  the  screw  with  a  large  eye  at  the  point  is  passed 
in  the  manner  already  described,  then  thi^eaded  v.nth  the  ligature  when  the  point  appears 
through  the  scrotal  opening,  and  the  screw  is  gradually  withdrawn  upAvard.  the  ligature 
following  its  track  and  occupying  its  place.  In  order  to  keep  the  ligature  tight,  each  end 
is  fastened  to  a  glass  rod,  which  lies  on  the  groin  until  the  parts  are  consolidated — ten  to 
fourteen  days  usually  ;  the  ends  are  then  cut  off  and  the  ligature  remains.  After  the 
operation  a  pad  should  be  worn  as  a  support  and  to  give  time  for  the  parts  to  become 
consolidated. 

The  most  satisfactory  cases  are  those  of  congenital  herni;e  in  the  young,  and  this  ope- 
ration is  especially  adapted  for  those  in  which  the  hernial  aperture  is  large  and  the  sac 
bulky  or  where  a  congenital  rupture  is  of  old  standing.  The  more  tissue  we  can  securely 
invaginate,  the  better  the  result,  as  a  rule  ;  and  when  the  pillars  are  soft  and  lax,  it  is 
easier  to  bring  all  the  parts  firmly  together  and  to  secure  a  firm,  unyielding  barrier. 
Experience  alone  can  teach  which  are  the  most  suitable  cases  for  each  operation.  Mr. 
Spanton  tells  me  that  he  has  operated  in  over  60  cases  and  has  had  no  death. 

Within  recent  times  an  oj^eio  operation,  a  method  by  dissection,  has  grown  in  favor, 
and  I  for  some  years  have  employed  it  in  preference  to  Wood's  operation.  It  consists  of 
cutting  down  upon  the  sac,  dissecting  it  out,  tying  its  neck  with  carbolized  gut  or  silk 
sutures,  excising  the  fundus  of  the  sac,  and  stitching  up  the  abdominal  rings  w'ith  good 
silk  or  wire  .sutures.  Where  omentum  is  present  I  cut  it  off,  after  ap]»lyiiig  a  ligature  to 
its  neck.  In  fact,  as  an  operation  for  the  radical  cure  of  a  hernia,  I  do  what  I  and  most 
of  my  colleagues  at  Guy's  have  for  years  done  after  an  operation  of  herniotomy  with 
good  success.  Wood  tells  me  he  has  recently  performed  a  like  operation  in  about  53 
cases  with  a  good  result.  This  open  operation  has  been  ably  advocated  by  Banks, 
Guenod  of  Basle,  Annandale,  Franks,  and  others.      Banks  employs  silver  sutures. 

References. — Banks,  Brit.  Med.  Journ.,  November  13,  1882;  Annandale,  Edln.  Med.  Jonrn.,\ol. 
xxvi. ;  GuENOD,  Thcae  de  Bade,  1881 ;  Franks,  Med.  Press,  January,  1884. 

Femoral  Hernia. 

This  forms  about  one-tenth  of  the  whole  number  of  cases  of  hernia,  and  about  forty 
per  cent,  of  all  cases  of  strangulated  hernia.  It  is  also  far  more  liable  to  become  stran- 
gulated than  inguinal,  and  less  likely  to  be  reduced  by  the  taxis.  The  taxis,  moreover, 
is  more  prone  to  produce  injury.  Thus,  one  out  of  three  cases  of  strangulated  femoral 
hernia  is  reducible  by  the  taxis,  two  being  operated  upon  ;  and  of  these,  forty  out  of  every 
one  hundred  die,  the  operation  after  "  recent  hernia  "  being  twice  as  fatal  as  it  is  after  the 
"  old,"  a  strangulated  femoral  hernia  going  on  more  rapidly  to  destruction  than  any  other, 
and  a  strangulated  "  recent  "  than  an  '•  old  "  hernia. 

Femoral  hernia  descends  from  the  abdominal  cavity  through  the  crural  ring  iii.sidr  the 
femoral  vessels.  The  free  margin  of  Gimbernat's  ligament  bounds  its  inner  side,  and  the 
sac,  which  is  always  "  acquired,"  pouches  downward  beru-ath  ]\)upart's  ligament  and 
emerges  through  the  saphenous  opening  to   the  inner  side  of  the  falcilbrm  process  of  the 


ii:m(h:m.  iiinxfA.  oo.'j 

fascia  lata.  'I'lii'  lnTiiia  fxpaiids  laliiallv,  n-stiiiL'  ii|miii  tliis  la«cia.  and  as  it  •■iilar;.'-('S 
turns  upward  dvci*  INiu|tan  s  lii^anK'nl,  tlicii  in  tlic  ilir«'<-ti(iu  dl"  tlic  cn-st  ol"  tlic  ilium,  very 
rarolv  sprcadinir  downward.  Its  Iiiult  diameter  will  lie  transverse,  and  imt  vertical.  Tlie 
neck  of  the  hernia  will  always  \'n\  onlsih  the  s|»ine  of  tin-  piihes  or  the  tendttii  oftlu!  lonj; 
abductor,  while  an  inj^uino-scrotul  or  laliial  hernia  will  always  he  loutul  insiJr  those 
points,  'riie  deeji  ejiij^astric  artery  and  vein  usually  lie  <uitside  tlur  neck  of  tlic  sac  and 
are  free  IVoin  harm  in  the  operation,  tlnui^di,  when  the  obturator  comes  ofl"  from  the  epi- 
gastric and  arches  over  the  neck  ol"  tiic  hernia  to  dip  down  on  its  inner  si(h'  toward  the 
obturator  loramen,  it  niav  be  ilivided  when  a  //w  incision  is  made. 

|{are  cases  of  femoral  hernia  occur  cxtcrinil  to  the  femoral  vessels,  as  related  by 
Partridirc  (/'if/i.  Sue.,  vol.  i.j,  as  well  as  throuL'h  (limbernat's  litrament.  or  with  a  divi-r- 
tieulum  tlirouirh  the  cribriform  or  superlieial  fascia.      (  I'/V/r  Hirkett.) 

l)i.\(JN'(isis. — The  points  alreaily  slated  will  enalde  the  stmleiit  t<i  distiuLMiish  a  femo- 
ral from  an  intruinal  hernia. 

A  /tstiiis  (ihxccss  dilates  on  couLrhinij;  and  disappears  or  diminishes  on  the  patient  lying 
down,  just  as  docs  a  hernia  ;  but  it  is  usually  placed  beneath  and  outsich'  instead  of  inside 
the  vessels.  Tt  is  often  accompanied  also  by  spinal  symptoms,  and  nu  niMuipulation  gives 
the  sign  of  fluctuation  from  above  to  below  I'oupart's  ligament. 

^4  ntrix  of  t]ie  fcmnnd  rein  may  also  in  a  nicasuve  simulate  a  hernia  ;  but  wherea.s,  in 
a  hernia,  with  the  patient  erect,  pressure  over  the  crural  ring  and  vessels  will  prevent  its 
descent,  in  varix  it  will  cause  its  enlargement. 

^4/1  iiiliirqcd  iflinul  ought  not  to  be  mistaken  for  a  rupture,  as  the  liistory  of  the  ca.«e 
and  concomitant  .symptoms  generally  mark  its  nature. 

Cysts  in  the  crural  ring  are  doubtless  difficult  to  diagno.se,  although  from  their  always 
being  in  the  same  spot  uiulcr  all  circumstaiu-i's.  and  from  their  not  being  influenced  by 
position,  coughing,  etc..  they  are  unlike  hernia.  When  associated  with  a  strangulated 
hernia,  they  may  complicate  the  case,  but  seldom  lead  to  error. 

Trkat.mknt. — Reducible  hernia  can  be  treated  by  a  truss,  the  [lad  pressing  in  the 
hollow  below  and  external  to  the  spinous  process  of  the  pubcs.  The  radical  cure  has 
been  ])erf(>rnu'(l  by  Wood.  Wells,  and  Davies,  but  it  cannot  be  recommended. 

Strangulated  femoral  hernia  reciuircs  the  most  prompt  attention,  for  the  parts 
constricting  the  neck  of  the  sac  are  so  unyielding  as  to  produce  in  a  .short  period  an 
amount  of  damage  which  is  too  often  irreparable.  Tn  the  application  of  the  taxis  the 
utmost  gentleness  .should  be  employed,  and  the  administration  of  an  anaesthetic  .should 
always  precede  the  attempt.  Tn  the  reduction  of  an  old  femoral  hernia  the  taxis  rarelv 
succeeds. 

In  reducing  a  femoral  hernia  by  the  taxis  the  surgeon  should  always  remember  tlie 
position  of  the  orifice  of  the  sac.  for  when  it  has  turned  over  Poupart's  ligament,  any 
pressure  on  the  tumor  can  only  do  harm.  The  tumor  should  be  gently  raised  bv  the  fin- 
gers and  drawn  slightly  downward  and  to  one  side  before  pressure  is  applied,  which  must 
be  of  the  mildest  kind.  If  the  slightest  disp<isition  to  yield  be  shown,  the  pressure  may 
be  continued,  because,  when  any  of  the  contents  of  the  sac  are  cTuptied.  the  probabilities 
of  the  reduction  of  the  whole  are  greatly  enhanced.  If  no  yielding  be  felt  in  the  parts, 
the  taxis  had  better  be  given  up  and  the  operation  performed. 

In  all  operations  for  femoral  hernia  the  reduction  of  the  hernia  without  opening  the 
sac  should  be  preferred,  and  in  "  recent "  hernia  this  "  minor  "  operati(m  is  generally  suc- 
cessful. The  incision  to  expose  the  sac,  consef|uently.  should  be  a  limited  one.  Ltike 
suggested  that  '•  a  fold  of  integuments  is  to  be  pinched  up  and  divided  by  transfixing  it 
with  a  narrow  blade,  so  that  the  incision,  when  the  skin  it;!  replaced,  shall  fall  perjiendicu- 
larly  to  the  body,  with  its  centre  opposite  to  the  depres.sion  which  indicates  the  seat  of 
strangulation."  But  this  plan  is,  in  a  measure,  dangerous,  as  I  have  seen  Mr.  Aston  Key 
with  the  point  of  his  knife,  in  perforating  the  skin-fold,  divide  all  the  tis>ues  outside  the 
sac,  and  even  the  sac  itself,  and  I  have  known  a  less  skilful  surgeon  open  the  bowel. 

Mr.  Gay  advises  '•  an  incision  rather  more  than  an  inch  long  to  be  made  near  the  inner 
side  of  the  neck  of  the  tumor.  The  sujierficial  fascia  to  be  divided,  and  a  director  or 
histouri  cache  introduced  down  to  the  neck  of  the  tumor  and  through  the  crural  ring  by 
the  least  amount  of  force,  arul  with  the  aid  of  a  little  gentle  compression  of  the  inner 
side  of  the  tumor  by  the  finger,  the  point  of  the  bistoury  may  be  insinuated  between  the 
sac  and  the  pubic  margin  of  the  ring;  the  edge  of  the  knife  is  then  to  be  turned  toward 
the  pubes,  and  by  projecting  the  blade  the  seat  of  stricture  in  that  direction  may  be  eff"ec- 
tively  divided."  When  a  director  is  used,  or  the  finger,  the  ordinary  hernia  knife  may 
be  applied  in  the  same  way. 


554  OBTURATOR  HERNIA. 

Nothing  can  be  more  satisfactory  than  tliis  operation  when  reduction  is  effected  by  it, 
and  it  should  always  be  attempted.  If"  it  fail  and  the  sac  has  to  be  opened,  no  harm  can 
possibly  have  been  caused  by  the  proceeding,  as  the  incision  can  readily  be  enlarged  if 
necessary,  the  sac  opened,  and  its  neck  divided.  Any  modification  of  the  incision,  how- 
ever, may  be  made.  The  essential  point  is  that  the  incision  should  be  of  such  a  nature 
as  to  allow  the  surgeon  to  reach  with  facility  the  neck  of  the  tumor.  In  operating,  the 
surgeon  must  also  remember  the  fascia  propria  or  fascia  that  is  external  and  superficial 
to  the  sac,  which  will  always  appear  as  a  well-defined  sac  on  the  division  of  the  soft  parts 
that  cover  it,  and  that  may  be  mistaken  for  the  true  sac.  On  its  division  a  layer  of  fat 
will  often  be  found  more  or  less  lobulated,  which  is  the  subperitoneal  fat,  and  beneath  it 
will  be  found  the  true  peritoneal  sac.  In  Gay's  operation,  as  already  described,  when  the 
parts  outside  the  fascia  propria  have  been  divided  and  the  hernia  cannot  be  reduced,  there 
is  no  objection  to  the  surgeon  dividing  the  neck  of  the  sac  upon  a  director  ;  and  when 
this  fails,  the  sac  mvist  be  fully  opened.  The  flow  of  a  stream  of  serum  will  probably 
attend  this  step,  and,  as  previously  stated,  the  nature  of  the  fluid  will  indicate  the  con- 
dition of  the  parts  within.  When  intestine  is  alone  seen,  the  director  may  be  carefully 
introduced  into  the  neck  of  the  sac  and  the  constricting  orifice  divided,  the  intestine  being 
then  reduced  with  the  gentlest  pressure.  When  omentum  covers  the  bowel,  it  should  be 
carefully  raised  and  unravelled,  and  when  an  omental  sac  exists,  it  must  be  torn  through 
or  carefully  divided  and  dealt  with  as  previously  explained.  The  neck  of  the  sac  should 
be  divided  outside  the  omentum.  The  less  the  parts  at  the  neck  of  the  sac  are  disturbed, 
the  better,  no  introduction  of  the  finger  beyond  the  neck  of  the  sac -being  necessary,  and. 
no  passing  of  the  director  or  hernia  knife  called  for  beyond  the  neck.  When  the  neck 
of  the  sac  has  been  divided  and  the  sac  has  subsequently  to  be  opened  to  ensure  the 
reduction  of  its  contents,  it  is  seldom  necessary  to  reintroduce  the  Vjistoury,  the  parts 
yielding  enough  to  the  finger  to  allow  of  the  replacement  of  the  hernial  contents ;  for  the 
less  the  neck  of  the  sac  is  divided,  the  better.  The  surgeon  should  always  be  careful 
that  the  hernia  is  not  reduced  within  the  crural  ring,  together  with  the  sac  ;  if  so,  the 
sac  must  be  brought  down  again,  opened,  and  held  in  situ  whilst  its  contents  are  returned. 
The  after-treatment  of  the  case  is  to  be  based  upon  the  principles  which  have  been 
already  laid  down. 

Obturator  Hernia, 

or  hernia  through  the  foramen  of  that  name,  deserves  a  notice,  as  its  successful  treatment 
can  only  follow  its  diagnosis.  It  is  more  common  in  females  than  in  males,  and  is  often 
unattended  by  any  external  evidences  of  its  existence.  Birkett  has  collected  twenty-five 
examples  of  this  affection,  though  in  fourteen  the  hernia  was  not  discovered  till  after 
death.  In  three  only  was  a  successful  operation  performed — by  Gbre  in  1851,  by 
Bransby  Cooper  in  1853,  and  by  Lorinson  in  1857.  Mr.  Copper's  case  I  had  the  good 
fortune  to  see. 

The  sac  of  the  hernia  is  always  "  acquired."  It  emerges  in  the  thigh,  beneath  the 
pectineus  and  between  the  abductor  longus  and  femoral  vessels.  The  hernia  is  conse- 
quently on  a  lower  level  than  the  femoi'al  and  comes  forward  instead  of  downward.  An 
obturator  hernia  is  not.  however,  always  to  be  felt,  and  a  diagnosis  has  consequently  to  be 
made  out  of  the  general  symptoms  ;  and  of  these  pain  in  the  course  and  distribution  of  the 
ohturator  verve  is  the  most  marked.  It  is  not,  however,  always  present.  In  several  of  the 
recorded  cases,  during  the  development  of  the  hernia  the  pain  described  as  "  spasmodic 
contraction  of  the  abdominal  muscles  "  existed  ;  and  this  fact  is  explained  by  Birkett  in 
recalling  the  association  there  is  between  this  nerve  and  the  muscular  filaments  distributed 
on  the  abdominal  muscles,  all  being  branches  of  the  lumbar  plexus.  Birkett  also  observed 
that  movement  of  the  hip-joint  in  the  affected  side  excites  or  aggravates  the  pain,  so  does 
deep  local  pressure  and  pelvic  examination,  either  ^jer  varjinam  or  rectum.  In  the  follow- 
ing case,  however,  which  came  under  my  care  in  1875,  none  of  these  symptoms  were 
present,  though  a  fixed  pain  in  the  left  iliac  fossa  existed.  Susan  G ,  ost.  05,  a  mar- 
ried woman,  was  admitted  under  my  care  into  Guy's  Hospital  on  the  2()th  May,  1875. 
She  had  enjoyed  excellent  health  till  1871,  when  one  morning,  after  considerable  exertion, 
she  experienced  great  pain  in  the  left  side  and  was  able  to  sit  down  only  with  difficulty. 
The  medical  man  who  saw  her  said  she  had  a  hernia,  but  that  it  had  gone  up.  Her  health 
after  this  remained  indifferent,  though  she  was  able  to  go  about  till  six  months  before  her 
admission,  when  she  passed  no  motion  for  nine  days  and  was  very  sick.  Purgative 
draughts,  however,  acted  upon  the  bowels  very  freely,  and  she  convalesced.  She  then 
continued  well  until  ten  days  before  her  admission.      At  that  time  no  motion  had  passed 


oiiTiHAini;  iu:i:\i.\. 


555 


fur  ten  (lavs;  she  had  coiit  iiiiiall  V  viiiiiitcil,  luciknl  very  imlicaltliy.  much  i-muciuti>d  and 
vdhiwisli.  was  oAd  and  cdlhipscd,  tlif  altihiiiH'ii  liciiii:  Minifwhat  distt-mh-d,  with  vi.^ihle 
cciils  (d'  small  iiiti'stinc  and  jn'ristalsis.  Slu-  alstj  complaiiiiMl  ul"  dilbiM-d  ahiluminal  pain. 
Nil  L'rowth  coiild  1)1'  deti'ctt'il  in  the  ivctiim.  Opium  wa.s  atlmiMisitTcd  and  warm  Joummi- 
tatitins  applieil  t(»  the  ahddincn  with  ndiid",  and  al'tcr  lour  days  tin;  howids  acted  twice 
.spimtancnusly  ;  antl  sul)sci|ucntly  she  had  repeated  l()r)se  evacuations.  She  left  the  liu.s- 
jiital  convalescent,  thouirli  much  emaciated,  on  June  1.'),  1S7.').  nineteen  days  after  her 
admission.  She  was.  however,  readmitt«'d  on  Deceniher  litl  of  the  same  year,  huviri;^ 
remained  (juite  well  till  December  ','>,  thouirh  for  the  last  three  months  she  had  heen  in 
much  reduced  circumstances.  On  December  '.i  .she  was  ajrain  violently  sick  and  had  much 
])ain  in  the  Ay'  sii/r  of  the  abdomen,  which  was  increased  on  passin;z  a  motion.  The 
bowels  were  confined  and  the  feces  small.  She  had  now  a  double  femoral  reducible  rup- 
ture. IL^r  abdomen  was  natural,  and  a  rectal  examination  showed  nothing;  abnormal. 
She  was  placed  under  the  influence  of  opium,  when  the  sickness  cea.sed  and  the  bowels 
acted,  (^)n  January  (!.  however,  the  symptoms  returned.  She  was  ajrain  sick  and  liad 
much  pain  in  the  left  side  of  the  abdomen,  while  the  tenijjerature  n»se  to  101°  F.  From 
that  time  she  irradually  sank.  The  bowels  were  ncjt  ai^ain  relieved  ;  the  abdomen  became 
tvmpanitic  and  the  vomitinii'  cea.sed  only  a  few  days  before  death,  which  toi>k  j)lace  on 
February  4.  with  incrt-asinij  exhaustion.  She  had  at  no  time  anythin<r  like  obturator 
pain,  and,  tliouuh  all  the  regions  of  hernia  were  carefully  exanuned,  nothing  was  noticed 
to  suggest  the  disease 

Antiipm/  III/  Dr.  <i(>o(Ih<irt. — The  )>ody  was  very  emaciated  ;  there  was  no  marked  di.s- 
tension  of  the  abdomen  :  the  peritoneum  was  injected  all  over.  A  little  pu.s  was  smeared 
over  the  coils  in  the  neighborhood  of  the  cjvcum,  and  in  the  pelvis  two  ounce.s  of  pus  or 
more  had  gravitated  to  the  bottom  of  Douglas's  pouch.  No  evident  source  of  the  pus 
could  be  discovered,  though  it  is  probable  that  it  arose  from  periontitis  due  to  overdisten- 
sion of  the  bowel.  The  small  intestine  was  only  moderately  distended,  but  crammed  with 
pultaceous,  yellow,  fecal  contents,  and  the  coats  were  somewhat  thickened.  Following  it 
ilownwaRl,  the  distension  continued  till  two  feet  from  the  c;vcum,  where  a  piece  of  the 
bowel  passed  through  the  left  obturator  foramen  (Fig.  318).  Below  this  the  intestine 
was  very  contracted.  The  aperture  in  the  obturator  foramen  was  not  large,  and  the  inte.s- 
tine  did  not  api)ear  to  be  nipped  in  any  way.  A  knuckle  of  bowel  was  in  the  sac,  but 
the  pas.sage  onward  would  not  allow  of  the  introduction  of  the  little  finger.  The  bowel 
Avas  intimately  adherent  to  the  sac  throughout,  so  that  on  opening  the  latter  the  bowel  was 
wounded.  The  included  bowel  was  grayish,  but  neither  gangrenous  nor  inflamed.  The 
mesentery  was  somewhat  thickened  at  its  neck  and  within  the  bowel  were  some  old  ulcera- 
tions, as  judged  from  the  amount  of  thickening  of  the  edges  of  an  ulcer  found  at  the 
neck  of  the  hernia.  The  ulceration,  however,  w-as  not  within  the  neck,  but  rather  on  the 
opposite  unincluded  surface  of  the  intestine.  The  sac  pushed  the  obturator  nerve  and 
vessels  well  to  the  outer  side  and  to  its  upper  part,  with  the  exception  of  one  branch  of 
artery  which  ])assed  to  the  thigh  on  the  inner  side. 

The  obturator  muscle,  which  was  in  front  of  the  sac.  had  to  be  scraped  away  to  get 
at  it.  The  sac  was  of  nodular  shape  and  about  two-thirds  of  an  inch  in  diameter  (Fig. 
317).  It  caused  no  fulness  externally  on  the  thigh.  This  was  looked  for  particularly, 
because  the  protrusion  was  fir.st 
discovered  from  the  inside.  In 
addition  to  the  hernia,  another 
coil  of  bowel  (small  intestine 
considerably  higher  up)  was  ad- 
herent by  a  strong  band  at  the 
hernial  neck,  and  about  this  the 
distended  coils  had  twisted  in  a 
peculiar  and  indescribable  man- 
ner ;  yet  no  obstl-uction  had  re- 
sulted therefrom,  the  distension 
continuing  both  above  and  below 
it.  A  slight  femoral  protrusion 
also  existed  on  both  sides.  On  '^"'"''^  ""'"^  ^"f 
the  right  side  a  little  omentum  obturator  Hernia. 

was  adherent  at   the  neck  of   the  E.xternal  Mew.  internal  vtew. 

sac,  and  by  its  adhesion  dragged  down  the  pyloric  orifice  of  the  stomach  and  the  textures 
in  the  porial  fissure. 


Fig.  317. 


Fig.  318. 


556 


UMBILICAL  HERNIA. 


Death  in  this  case  was  clearly  due  to  chronic  inte.-^tinal  obstruction  caused  by  the 
adhesions  of  the  bowel  to  the  hernial  sac.  The  only  special  symptom  worthy  of  ntHice 
was  the  fixed  pain  in  the  left  side  of  the  abdomen,  above  Poupart  s  ii<rament. 

Treatment. — The  taxis  can  hardly  be  expected  to  be  a  successful  proceeding  in 
obturator  hernia,  the  sac  beins  so  low  down  in  the  thigh  and  so  little  under  control. 
Nevertheless,  it  .should  be  tried,  with  the  adductors  relaxed  Vjy  means  of  steady  pressure 
applied  downward  in  the  hollow  of  the  thigh  and  inward  between  the  adductors. 

To  explore  the  parts  an  incision  should  be  made  below  Pouparts  ligament  and  to  the 
inner  side  of  the  femoral  vein,  down  to  the  pectineus  muscle,  which  may  then  be  divided. 
If  no  sac  appear  and  the  obturator  foramen  covered  by  its  muscle  be  reached,  the  fibres 
of  this  muscle  must  then  be  separated  and  the  obturator  canal  found  ;  for  a  .small  hernia, 
as  proved  by  the  case  I  have  recorded,  may  be  hidden  completely  by  the  muscle.  When 
a  sac  is  felt,  the  parts  constricting  it  must  be  divided  by  a  knife  and  its  content.** 
reduced.     The  obturator  nerve  should,  if  possible,  be  avoided. 


Umbilical  Hernia. 

This  may  be  a  congenital  or  an  acquired  affection,  and  is  common  in  children  from 
want  of  closure  of  the  umbilicus.  It  is  far  from  rare  in  fat  women  and  in  others  who  have 
had  many  children.  It  is  also  met  with  in  men.  forming  five  per  cent,  of  all  cases  of 
liernia  and  six  per  cent,  of  cases  of  strangulated  hernia. 

The  Congenital  Form. — Children  are  occasionally  born  with  a  hernial  protrusion 
of  some  of  the  abdominal   viscera  into  the  umbilical  cord,  the  covering  of  the  vi.scera 

consisting  of  the  thin  translucent  sheatli 
Fig.  319.  of  the  cord  ;  this   deformity  is  probably 

due  to  an  arrest  of  development.  Among 
the  few  examples  of  this  affection  that  I 
have  seen  was  one  in  which  the  liver  pro- 
jected, and  in  it  the  serous  covering  sub- 
sequently granulated,  contracted,  and  so 
pressed  the  parts  back  into  their  normal 
position  that  a  recovery  followed.  Fig. 
ol9  represents  the  case  in  the  fifth  month. 
In  the  case  of  a  male  child  one  day  fild 
in  which  a  hernia  into  the  cord  the  size 
of  a  small  egg  existed,  and  through  the 
thin  walls  of  which  the  caecum  with  its 
appendix  was  clearly  visible,  I  pressed  the 
bowel  back  with  my  finger  and  thumb, 
stitched  up  the  cord  at  its  umbilical  ori- 
fice with  some  deep  sutures,  and  ligatured 
the  cord  itself  at  the  apex  of  the  congenital  translucent  hernial  sac  ;  and  complete  recov- 
ery followed  without  any  bad  symptoms.  The  child  was  alive  and  well  two  years  after 
the  operation.  The  case  was  brought  to  me  on  June  16,  1876,  by  an  old  dresser.  Dr. 
W.  Cock  of  Peckham.  The  practice  adopted  in  the  case  is  that  which  I  advise  to  be 
followed. 

The  Acquired  Form. — In  the  acquired  form  of  hernia  the  sac  is  always  formed, 
in  both  the  infant  and  tlie  adult.  Vjy  the  pushing  forward  of  the  p)arietal  abdominal  layer 
of  peritoneum.  The  jtarts  covering  it.  Vjeing  occasionally  very  thin,  are  only  integument 
and  fascia,  the  internal  abdominal  fascia  being  over  the  true  sac  ;  at  times  the  tumor 
attains  a  large  size,  and,  as  it  generally  increases  (hAcnuard,  the  surgeon  must  look  for 
the  neck  of  the  sac  at  its  upper  part.     These  hernias  at  times  assume  odd  .shapes. 

Treatment. — When  in  an  infant  and  reducible,  a  cure  may  with  .some  confidence  be 
promi.sed ;  indeed,  with  the  majority  of  cases  in  young  life,  an  opening  "in  the  navel  will 
contract  if  care  be  observed  to  fix  with  good  strapping  &  flat  elastic  ring  or  pad  covered 
with  leather  over  the  part.  A  convex  pad  tends  to  keep  the  ring  open.  A  belt  or  truss 
in  early  life  is  a  delusion,  since  it  never  keeps  its  place.  In  lieu  of  a  pad.  it  is  an  excel- 
lent plan  to  pinch  up  the  integument  over  the  hernia  with  the  thumb  and  finger  and  then 
to  turn  the  folds  sideways  upon  the  umbilical  opening,  fixing  it  in  its  position  by  water- 
proof strapping,  the  folded  integument  Vjy  this  method  acting  as  a  pad  and  assisting 
recovery. 

Messrs.  Lee,  Barwell.  and  Wood  have  suggested  an  operation  for  the  closure  of  the 


I'oiiit    of 
Attar  lime /it    of  cord- 


Congenital  Umbilical  Hernia. 


VMitii.K'M.  in:n\f.i.  r,r,7 

uinl)ili»'al  orifu-c  :  Init  siifli  a  iiicasiiic  caiiiiut  Ik-  r.MniniiMiKli'd.  sinco  to  ri>k  lifi-  imm'ce.s- 
sarily  lor  an  aHi-ctioii  tlial  i>  im>>tly  i-iiralilc  \>\  liiiic  ami  natural  |iri)ee.s.st'H  assisted  liy  art 
is  hardly  justitiaMf. 

Adult  patii'iits  with  n-tliicililc  vi-iiiral  heniia  should  also  wt-ar  somk;  incchaiiical  appli- 
ance, such  as  a  riiij;  truss;  aiitl  an  irreducilili-  rupture  should  he  protected  l»v  a  truss 
luude  upon  a  cast  of  the  rujilure  when  at  its  smallest,  after  a  day  or  so  rest  in  hed. 

When  tlu'se  tumors  arc  hir^e  and  irrcducihle,  they  trive  rise  to  trouhlcsume  ahdoiniiial 
.symptoms.  They  supply,  indeed,  the  hest  examples  seen  of  so-called  olotructed  hernia; 
feces  and  Hat  us  enter  the  incarcerated  intestine  and  remain  immovable,  eausinir  naus(!a, 
colicky  pains,  and  constipation.  Kest  in  the  horizontal  position,  the  local  application  of 
euld,  a  udod  inema  to  empty  the  lower  liowel.  and  a  ])urjr<'  to  clear  out  the  upper,  will 
often,  under  these  circumstances,  pmve  of  ^ircat  l)cnefit,  and  should  he  tried  in  all  ea.se.s. 

When  symptoms  of  stran<:;ulatioii  e.\i.>t,  such  measures,  however,  must  not  he  thought 
of.  The  taxis  should  then  he  emjdoyed,  and  with  a  patient  under  an  aiuusthetic,  as 
a  rule,  it  proves  successful.  In  ajiplyini;-  it  to  a  larire  tumor,  where  it  is  ]irohal»le  a  fresh 
descent  of  intestine  has  taken  place  and  the  symptoms  are  due  to  its  stran<rulation,  the 
surgeon  should  examiiu;  the  tumor  carefully,  to  discover  if  oim  part  is  more  tense  than 
another,  as  then  the  taxis  should  ])e  applied  to  the  tense  in  preference  to  the  other  jjart. 
On  several  oecasiiuis,  by  adopting  this  practice,  I  liave  been  able  to  reduce  the  strangu- 
lated porti(Ui  of  the  contents  of  a  hernia  with  complete  success.  When  vomiting,  consti- 
pation, local  pain,  and  an  absence  of  impulse  in  the  tumor  are  persistent,  the  reduction  or 
freedom  of  the  mass  from  strangulation  by  operation  must  be  ent(;rtained. 

When  herniotomy  is  called  for,  it  is  a  matter  of  immen.se  imjtortance  that  no  manipu- 
hition  of  the  contents  of  the  .sac  should  take  place,  because,  when  the  sac  is  opened  and 
the  parts  exposed,  it  is  an  exceptional  occurrence  for  a  cure  to  follow,  no  cases  of  hernia 
under  these  circumstances  being  more  fatal  than  the  umbilical.  When  the  .sac  is  not 
opened,  however,  so  as  to  expose  its  contents,  or  only  opened  at  its  neck  to  allow  of  the 
division  of  the  strangulating  orifice,  a  good  result  may  be  expected. 

In  many  cases  in  which  I  have  adopted  this  practice  a  good  result  followed,  the 
oldest  patient  being  seventy -four  years  of  age,  with  strangulation  of  five  days"  standing. 

In  irreducible  hernia  of  large  size  and  of  long  standing,  when  reduction  of  the  con- 
tents of  the  sac,  as  a  whole,  cannot  be  expected,  and  there  is  no  evidence  of  strangulation 
within  the  sac  by  some  of  its  contents,  the  surgeon  should  be  satisfied  with  relievinsr  the 
strangulation  by  dividing  the  neck  of  the  sac  and  leaving  the  case  to  nature.  To  explore  the 
whole  sac  and  to  expose  the  irreducible  bowel  to  the  air  and  manipulation  are  unnecessary  as 
Avell  as  fatal.  1  had  a  case  in  1874  with  Dr.  Brockwell  of  Sydenham  in  which,  in  a  lady, 
an  irreducible  hernia  of  .seven  years'  standing  became  strangulated ;  I  simply  divided  the 
neck  of  the  sac  and  left  the  parts  alone.  After  two  days  the  whole  contents  of  the  sac 
returned,  and  a  rapid  and  complete  recovery  took  place.  I  have  followed  this  practice  on 
several  occasions  with  a  similar  result.  A  double  sac  is  found  at  times  in  umbilical 
hernia.  Some  time  ago  I  was  called  on  to  operate  in  such  a  case.  The  woman  was  aged 
forty-four  and  had  been  ruptured  for  years,  the  hernia  being  irreducible.  She  came 
under  my  care  at  Guy's  with  symptoms  of  two  days'  strangulation.  The  rupture  was 
clearly  inflamed,  the  slightest  manipulation  causing  intolerable  jjain.  Under  chloroform 
I  cut  down  upon  the  tumor  and  found  two  distinct  sacs,  their  orifices,  which  were  placed 
laterally,  being  .separated  by  a  piece  of  dense  fibre  tissue.  One  contained  a  mass  of 
omentum  ;  the  second,  intestine,  which  was  black  from  congestion  and  covered  with 
lymph.  The  orifices  of  the  sacs  were  freely  divided  and  their  contents  left,  but  the 
patient  died,  and  no  examination  after  death  was  allowed.  In  another  case  I  found 
i^trangulated  bowel  in  a  small  omental  sac  introduced  into  an  irreducible  hernia. 

Ventral  hernia  is  a  term  applied  to  any  protrusion  through  the  abdominal  walls 
not  belonging  to  the  usual  forms.  Most  of  these  herniae  are  found  in  the  linea  alba 
above  the  navel.  One  of  the  largest  I  ever  saw  was  over  the  right  iliac  fossa  and  fol- 
lowed a  rupture  of  the  abdominal  muscles  caused  by  a  fall  of  twenty  feet  upon  the 
handle  of  a  pump ;  it  was  the  size  of  a  man's  hand  and  strangulated.  By  the  taxis  I 
reduced  the  mass,  and  by  the  use  of  ice  locally  and  opium  internally  the  man  recovered. 
He  had,  however,  subsequently,  to  wear  a  pad  to  supjxut  the  part. 

After  the  operation  of  ovariotomy  a  very  large  protrusion  may  take  place  if  a  good 
belt  be  not  worn.  The  same  may  arise  after  the  weakening  of  the  abdominal  walls  from 
abscess. 

When  the  hernia  takes  place  below  the  xiphoid  cartilage,  is  is  called  epigastrir,  and 
in  the  loins  lumbar.     Birkett  quotes  two  such  cases.     In  1875  I  saw  an  example  of  the 


558  HERNIA. 

epigastric  form  with  Mr.  Treves  of  Margate  in  a  lady  aet.  (IS  who  had  at  the  same  time 
an  irreducible  umbilical  hernia.  .Symptom.*  had  existed  for  one  hundred  and  eight  hours 
when  I  operated,  and  the  bowel  slipped  back  unseen  on  dividing  the  parts  at  the  neck  of 
the  sac.      The  patient,  however,  sank. 

Perineal  hernia  descends  in  fr(3nt  of  the  rectum  and  appears  in  the  perinajum, 
and  is  most  common  in  women.  When  the  hernia  descends  outside  the  vagina,  along  the 
ramus  of  the  ischium,  it  shows  itself  in  the  labium — lnhial  ov  piuhndal hernia ;  and  when 
it  appears  in  the  vagina,  vaginal  hmila. 

Vaginal  and  labial  herniae  may  be  mi.stakeu  for  the  raucous  cysts  of  those  parts,  but 
the  herni?e  are  reducible ;  and  when  irreducible  or  strangulated,  they  give  rise  to  symp- 
toms indicative  of  these  conditions.  The  cysts  are  only  local  affections  and  cause  no 
general  symptoms.  They  are  tense,  elastic,  globular  tumors  fixed  in  the  tissues,  and 
have   no  neck  pa.<sing  upward  into  the  pelvis. 

Ischiatic  hernia  is  a  hernia  through  the  sciatic  notch,  above  or  below  the  pyri- 
formis  muscle.  The  gluteus  maximus  muscle  covers  it  in,  but  as  the  hernia  enlarges  it 
may  appear  below  the  lower  border  of  that  muscle.  Dr.  F.  C.  Crosse  in  September,  1873 
(^Dnblin  Journal  of  Medical  Science^,  has  recorded  an  interesting  example  of  this  kind  in 
a  woman  aet.  40.  The  tumor  occupied  the  lower  border  of  the  right  gluteal  fold  ;  it  was 
the  size  of  a  foetal  head,  soft  and  pulpy  to  the  touch,  dull  in  parts,  tympanitic  in  others, 
and  coughing  gave  an  impulse  to  it.  It  was  treated  by  a  truss.  When  a  rupture  of  this 
sort  becomes  strangulated,  an  operation  must  be  performed,  the  surgeon  making  such  an 
incision  as  will  best  expose  the  tumor  and  its  neck. 

Diaphragmatic  hernia  is  met  with  as  the  result  of  an  accident  (traumatic)^ 
and  is  generally  fatal ;  it  has  been  alluded  to  under  the  heading  of  "  Abdominal  Injuries." 
page  491.  It  may  ahso  be  the  result  of  some  "  congenital  "  defect  or  the  pushing  of  the 
abdominal  viscera  through  a  natural  or  other  opening  in  the  muscle  (acquired  form).  It 
rarely  calls  for  surgical  aid. 

On  Trusses. 

A  truss  is  an  instrument  employed  for  the  purpose  of  preventing  the  descent  or 
enlargement  of  a  hernia.  It  is  composed  of  a  pad,  to  be  placed  over  the  seat  of  the 
hernial  protrusion,  and  a  spring  or  belt,  to  keep  it  in  position.  Any  truss  that  will  keep 
up  the  hernia  under  all  circumstances  and  does  not  cause  pain  or  lasting  discomfort  is 
probably  beneficial.  Every  truss  that  fails  to  carry  out  this  object  should  be  condemned. 
An  instrument  with  a  too  feeble  spring  is  a  delusion  and  a  snare,  but  one  that  is  too 
powerful  may  tend  to  do  more  eventual  harm  than  present  good  by  causing  absorption 
of  the  abdominal  parietes,  upon  which  it  presses,  and,  as  a  consequence,  enlargement  of 
the  opening  through  which  the  hernia  descends.  For  the  same  reason  a  pad  that  is 
unduly  convex  is  also  to  be  condemned. 

A  pad.  to  be  efficient  and  comfortable,  should  be  moulded  upon  a  cast  of  the  part  to 
which  it  is  to  be  applied,  since  no  two  groins  are  alike.  When  this  is  done,  the  most  per- 
fect and  most  comfortable  truss  is  provided  (Fig.  304). 

Every  subject  of  a  hernia,  young  or  old,  male  or  female,  .should  wear  a  truss,  and  in 
a  good  proportion  of  cases,  particularly  of  the  young,  a  cure  may  take  place — that  is, 
the  neck  of  the  sac  may  close.  But  even  after  a  cure  or  an  apparent  cure  has  taken 
place  it  is  well,  for  the  sake  of  safety,  to  wear  the  instrument,  as  cases  are  far  from 
infrequent  when  a  supposed  cure  has  taken  place,  and  after  the  lapse  of  years  a  sudden 
descent  has  occurred,  jeopardizing  life.  This  is  the  more  common  in  the  congenital  form 
of  hernia. 

The  truss  should  be  Avorn  all  day,  from  the  act  of  rising  out  of  bed  to  that  of  retir- 
ing, as  its  object  is  to  prevent  the  descent  of  the  hernia  under  any  sudden  act  of 
exertion,  and  with  the  truss  off  it  is  impossible  to  guarantee  that  any  such  may  not  be 
made.  Some  patients  habitually  remove  their  trusses  when  they  are  sitting  in  their 
drawing-room,  but  this  practice  is  to  be  condemned,  since  I  have  more  than  once  been 
called  upon  to  treat  a  strangulated  hernia  which  came  down  during  some  unguarded  act 
under  these  circumstances ;  and  it  is  in  these  unguarded  moments  that  the  truss  is  cal- 
culated to  be  of  so  much  benefit. 

When  the  truss  is  first  applied,  it  will  doubtless  cause  some  inconvenience  ;  with  the 
moulded  truss  this  is  very  slight.  The  use  of  plenty  of  starch  or  violet  powder,  the 
bathing  of  the  point  of  pressure  with  some  spirit  and  water,  and  attention  to  keep  it  very 
dry  are  excellent  remedies  for  any  little  local  source  of  discomfort. 

The  Pad. — This  should  be  regulated  according  to  the  size  of  the  hernial  aperture, 


o.v  TiiUssEs:  559 

a  small  nponintr  r('(|iiirin<;  a  small  pad  ami  a  larL'c;  rtpeninp:  :i  larjro  one.  The  pad  shouM 
always  nvcrlap  t'nr  alioiit  halt'  an  iiwli  all  round  the  hernial  aperture,  and  in  larfre  lieriiiiu 
for  ludre.  It  should  he  adapted  to  the  individual  <rroin  and  he  made  flat  or  concave, 
aocordini;  to  its  anatomy.  It  should  also  he  so  adapted  to  its  spriuL'  as  to  keep  its  place 
under  all  circumstanet-s. 

In  in<ruinal  hernia  it  should,  mon-over,  he  so  fixed  to  the  sprinjr  as  to  t^xert  a  pressure 
at  rij^rht  anjrles  to  the  plane  of  the  hernial  aperture.  Thus,  in  larj^'e  jtendulous  hellie.s  the 
pressure  may  he  upward  or  inward  and  upward,  hut  in  thin  suhjects  directly  hackward. 
In  femoral  rujiture  the  pressure  should  always  he  hackward,  in  order  to  close  the  crural 
riiifr.  Any  truss  that  applies  its  pressure  only  in  one  direction  must  fail  in  it.s  purpo.se  in 
a  lar«;o  nuniher  of  cases.  It  is,  indeeil.  in  this  curve  of  the  spring  or  direction  in  which 
the  pressure  of  the  pad  is  emjdoyed  that  the  chief  diflference  in  the  great  varietie.s  of 
trusses  is  found. 

Some  pads  are  rigidly  attached  to  the  spring  that  holds  them  in  position,  while  others 
are  connected  by  means  of  movahle  joints  of  different  construction.  Salmon  and  Ody's 
well-known  truss  has  a  hall-and-socket  joint,  as  has  the  excellent  Champion  truss  of 
America. 

The  spring  of  a  truss  is  a  matter  of  importance,  although  not  so  much  as  the  pad 
and  the  direction  of  the  line  of  pres.sure.  Its  strength  should  be  carefully  regulated 
according  to  the  requirement.s  of  the  individual  case.  It  ought  to  be  strong  enough  to 
keep  the  pad  in  position  and  prevent  the  descent  of  the  hernia  under  all  circuni.stances, 
but  not  so  strong  as  to  cause  pain.  The  French  spring  consists  of  a  coil  like  that  of  a 
watch-spring,  is  always  in  action,  and  pres.ses  inward.  The  German  form  is  more  rigid 
and  inelastic  and  holds  the  pad  firmly  in  its  place,  thereby  resisting  the  protrusion  of  the 
hernia  under  any  expulsive  effort.  The  English  makers  employ  a  variety  of  springs.  A 
too  rigid  one.  as  the  German,  is  not  to  be  recommended,  whilst  the  French  is  also  objec- 
tionable, its  action  being  too  severe  and  con.stant. 

The  best  is  that  which  holds  the  pad  in  position,  keeps  it  there  under  all  movements, 
counteracts  any  expulsive  action  of  the  hernia,  and  causes  little  if  any  discf)n)fort.  The 
lighter  it  is.  under  these  circumstances,  the  better  and  the  closer  it  is  adapted  to  the  body, 
the  more  comfort  it  affords. 

The  only  truss  that  has  no  circular-body  spring  and  is  kept  in  position  bv  a  band  i.s 
the  Moc-main  lever.  The  pressure  is  kept  up  by  means  of  a  thigh-strap  attached  to  a 
small  spring-lever  connected  with  the  pad.  Such  a  truss  is  doubtless  comfortable,  as  its 
action  is  not  enough  to  produce  inconvenience  ;  but  it  is  not  safe  under  mo.st  circum- 
stances. In  old  people,  where  the  inguinal  rings  requii-e  only  a  little  support  it  may  be 
u.sed  ;  but  in  the  middle-aged,  when  the  hernia  has  a  tendency  to  come  down,  it  is  a  dan- 
gerous and  unreliable  instrument. 

In  oblique  inguinal  hernia  the  pad  of  the  truss  should  be  placed  orer  the  infernal 
ring  fin</  cuiuil.  and  not  over  the  external  ring,  the  object  being  to  give  support  to  the 
weak  internal  ring :  in  direct  inguinal,  it  is  placed  over  the  external  ring.  In 
femoral  hernia,  when  the  crural  arch  is  natural  and  not  relaxed,  a  small  pad  may 
be  employed  over  the  neck  of  the  sac  ;  but  when  the  arch  is  relaxed  and  movable,  a 
large  pad  so  adjusted  as  to  press  upon  the  ligament  itself  is  required.  After  the  opera- 
tion of  herniotomy  for  crural  hernia  this  f^ict  is  worthy  of  attention  ;  for  when  a  free 
division  of  Gimbernats  ligament  has  been  made,  the  neck  of  the  sac  is  alwavs  large  and 
the  ligaments  relaxed. 

Varieties  of  Truss. — To  give  a  description  of  every  variety  of  truss  is  needless. 
Egrf>(  tnn^x  is  in  all  respects  rigid,  and  keeps  its  place  when  once  fitted.  Cohss  truss  is  very 
good,  is  light,  and  has  a  thin  metallic  pad  covered  with  leather  and  acted  on  by  spiral  rings. 
When  properly  adapted,  with  a  not  too  convex  pad,  it  gives  elastic  pressure,  but  is  not 
so  well  calculated  to  retain  a  hernia  under  violent  exertion  as  another  truss  with  a  more 
solid  pad.  the  elastic  pad  being  apt  to  yield  and  allow  the  hernia  to  descend.  This  objec- 
tion applies  to  all  elastic  pads,  although  air  or  water  pads,  in  some  cases,  are  very  com- 
fortable and  valuable,  particularly  in  the  healthy  aged  subject. 

Among  the  trusses  with  solid  pads  Wood's  must  be  mentioned.  Thev  are  made  bv 
Matthews,  with  flat  pads,  composed  of  wood,  ivory,  or  vulcanite,  an  india-rubber  water- 
bag  being  occasionally  applied  to  the  surface  of  the  pad.  They  are  held  in  position  by  a 
spring  that  encircles  the  body.  The  size  of  the  pad  varies  with  the  nature  of  the  hernia 
and  the  size  of  the  hernial  aperture.  For  oblique  inguinal  hernia  the  pad  is  of  an 
obliquely  curved  horseshoe  shape,  the  outer  limb  over  Poupart's  ligament  being  shorter 
than  the  inner,  and  the  spermatic  cord  and  pubic  spine  lying  in  the  cleft.     The  curve  of 


560  HERNIA. 

the  horseshoe  is  placed  over  the  inner  hernial  aperture.  For  direct  inguinal  or  umbilical 
hernia  the  pad  is  made  the  shape  of  an  ovate  ring,  with  a  hole  corresponding  to  the  her- 
nial opening  in  the  centre.  For  femoral  hernia  the  pad  is  egg  shape.  Newsom's  truss 
has  a  thin  round  wire  spring  and  a  hard  pad,  which  is  very  comfortable  when  well  adapted. 
The  truss  of  Dr.  C.  Edwards  of  Cheltenham  is  good,  the  pad  being  so  arranged  that  it 
may  revolve  as  well  as  slide  on  the  spring  when  required.  Those  of  Salt  of  Birmingham 
and  of  L'Estrange  are  also  good  instruments.  Down,  late  Milikin,  of  St.  Thomas's 
street,  S.E.,  makes  also  an  excellent  truss,  with  a  pad  which,  being  movable  upon  a  ball- 
and-socket  joint  is  readily  adapted  to  any  case. 

The  Vjest  truss,  without  doubt,  is  the  one  already  alluded  to.  with  a  pad  made  upon  a 
cast  of  the  groin  of  the  individual  requiring  it.  and  fa.stened  to  a  spring  with  adjustments 
like  those  of  the  American  Champion  truss,  as  made  for  me  by  Messers.  Krohne  (page  530). 

The  Main  Objects  of  a  Truss. — Whatever  truss  is  selected  to  be  of  use.  it  must 
answer  to  a  nicety  tlie  i>urpu.-e  fi>r  which  it  is  required.  The  pad  should  be  adapted  to 
the  abdominal  hernial  orifice  or  to  the  hernial  tumor  itself,  and  not  below  it.  The  amount 
of  pressure  applied  to  the  pad  ought  to  be  carefully  regulated,  as  well  as  its  direction, 
and  enough  employed  to  keep  the  pad  in  position  under  all  circumstances  without  causing 
pain,  a  slight  force  applied  in  the  right  direction  being  of  more  value  than  a  greater  mis- 
directed. 

The  pad  may  be  flat,  concave,  or  .slightly  convex,  and  made  of  a  solid  or  elastic  mate- 
rial. A  metal  one  with  wash  leather  taking  the  shape  of  the  parts  is  the  best.  Sand  pads 
covered  are  of  value,  as  they  can  be  moulded  to  fit  more  comfortably  and  accurately  than 
many  others.  For  an  irreducible  hernia  (not  scrotal)  the  pad  should  always  be  framed 
upon  a  cast  of  the  hernial  tumor,  taken  when  at  its  smallest,  after  rest.  No  other  pad 
will  keep  its  place. 

To  Test  the  Value  of  a  Truss. — The  patient  should  be  made  to  cough  and 
strain,  and.  wlieu  possible,  to  jump.  He  should  be  placed  on  the  edge  of  a  chair  with 
his  legs  apart,  or  made  to  stoop  forward  with  his  knees  apart  and  his  hands  resting  on 
his  knees,  and  then  to  cough,  these  positions  tending  more  than  any  other  to  relax  the 
lower  parts  of  the  abdomen  and  to  loosen  the  truss.  When  the  hernia  by  the.se  means 
fails  to  descend  or  to  excite  in  the  patient  a  sensation  of  weakness  in  the  region  of  one 
of  the  abdominal  rings,  the  truss  is  probably  efficient.  The  patient  should  be  taught, 
under  all  circumstances,  what  the  truss  is  expected  to  do.  and  be  made  to  understand  the 
danger  he  will  incur  if  it  fail  in  its  purpo.se;  as  well  as  the  necessity  of  again  seeking  advice. 

The  surgeon,  moreover,  should  always  take  upon  himself  the  responsibility  of  seeing 
that  the  truss  fits,  and  not  rest  satisfied  by  sending  his  patient  to  buy  a  truss  where  he 
likes  and  of  what  kind  he  likes ;  he  should  also  tell  the  maker  what  is  wanted,  and  not 
leave  him  to  find  it  out. 

To  Measure  for  a  Truss. — The  following  points  should  be  noticed — viz.,  the 
nature  of  the  licniia.  the  size  of  tlie  hernial  aperture,  the  side,  or  if  double.  The  circum- 
ference of  the  pelvis  should  also  be  given  one  inch  below  the  crest  of  the  ilium,  and  the 
girth  of  the  body,  commencing  and  ending  at  the  hernial  orifice,  as  well  as  the  distance 
from  the  hernial  aperture  to  the  iliac  spine.  The  surgeon,  moreover,  should  always  indi- 
cate to  the  maker  the  directions  of  the  pressure  required  by  the  pad.  and  this  should 
always  be  made  out,  when  the  patient  stands,  by  a  digital  examination.  In  pendulous 
and  fat  subjects  with  inguinal  hernia  it  may  be  upward,  backward,  and  inward;  in  thin 
subjects,  simply  backward.  In  femoral  rupture  the  plane  of  the  crural  ring  is  horizontal 
and  may  be  closed  by  a  backward  pressure.  No  general  rules  can  be  laid  down,  though 
this  is  a  point  upon  which  the  whole  value  of  the  truss  depends. 

To  estimate  the  force  required  to  keep  the  hernia  in-  position  is  a  difficult  matter. 
Up  to  the  present  time  the  only  true  test  is  that  of  trial.  Mr.  Wood  has  had  an  inge- 
nious pressure-gauge  made  for  the  purpose,  which  may  pos.sibly  turn  out  of  value  (Brit. 
Med.  Joiirn..  October  12.  1871).  Mr.  Holthouse  has  "^likewise  invented  a  skeleton  truss 
which  promises  to  be  of  use  for  indicating  the  length  and  shape  of  the  spring  required 
and  the  correct  angle  at  which  the  pad  should  be  fixed. 

Extra  Spare  Truss. — Patients  who  are  liable  to  employ  at  times  great  muscular 
exertion  .should  have  two  trusses — one.  for  ordinary  wear,  with  a  sufficient  press  power  to 
keep  the  hernia  in  position  ;  and  the  second  with  an  increase  of  power,  which  is  to  be  put 
on  when  occasion  demands.     They  should  also  have  extra  bathing  trus.^es. 

When  a  Double  Truss*  is  to  be  Used.— When  any  tendency  exi.sts  for  a 
double  hernia,  as  indicated  by  a  bulging  of  the  opposite  ring  or  a  sense  of  weakness  on 
making  exertion,  a  double  truss  should  be  worn  ;   indeed,  in   inguinal   hernia.  I  believe 


MM.rnllMATlOSS. 


5<;i 


that  a  double  truss  should  always  W  fuiployctl.      It  is  at  least  as  coinfortahle  as  a  single 
one,  besides  being  an  extra  iinitectioii  il'  well  adjusted;  certainly  it  can  do  no  hann. 

BlKKKTT,  HohiifK'n  Sygf.,  vol.  11.,  M  cm!.,  1HS.'{;  Mol.-Chir.  TranM.,  18'>9. — BkvanT,  Gny'i*  JieiimlR, 
185(»;  (.'tin.  Sun/.,  part  '.i,  IKOl.— (."ooI'Kk's  Suri/lnil  Did.,  Htli  ed.— (iAV,  On  Hnni'i,  184H.— I*.  IIi:\v- 
ETT,  Mftl.-i'liir.  'J'idiis.,  1S44. — IlrTclllXsoN,  Loml.  IIoxp.  Hep.,  IWo. — J.x.MKS,  0;t  Urrnln,  1K.V.». — 
Aston  Ki:y,  On  Ifirnia,  IS.S.'i;  (iiii/'s  li'i,.,  1S4'2. —  KlN(il)oN,  Mt<l.-('ltir.  Tnuis.,  ISdJ.  — LcKK,  Mnl.- 
Chir.  VVdjis.,  vols.  x.wl.  and  xxxi.— L.\  wiiK.NCi:,  On  liuplnrtK,  IS:{.'),  .')lli  (•<!.  -Sti;imii;ns,  On  Oli.-<liitrle/l 
Hnnia,  IX'l'J. — ScAKTA,  Wisliart's  cd.,  1.S14. — Wakd,  (Jn  Slranyiduted  Hernia,  18o4. — Wool),  On  Jiup- 
ttire,  18(53. 


Fig.  320. 


CITAPTF/R    XVT. 
SURGERY    OF   TIIK    ANTS   AM)    IlKCTrM. 

Malformations. 

The  anus  and  rectum  are  not  rarely  the  seat  of  congenital  malformations,  which  show 
themselves  in  a  variety  of  forms.  In  one  the  anus  is  imperforate,  the  rectum  being  either 
partially  or  wholly  deticient ;  in  a  second  the  anus  exists  in  its  normal  condition,  but  opens 
into  a  cu/-(h-s(u\  the  rectum  being  partially  or  wholly  deficient  (Fig.  3llU)  ;  and  in  a  f/iird 
the  anal  orifice  is  absent,  the  rectum  opening  into  the  bladder,  urethra, 
vagina,  or  other  abnormal  position.  And  it  will  be  observed,  says  Mr. 
Curling,  to  whom  wc  are  indebted  for  the  bulk  of  our  information  on 
this  subject  (Mrd.-Chir.  Trans.,  vol.  xliii.),  that  .the  classification  of 
these  im])erfections  is  founded  on  states  that  can  generally  be  recog- 
nized during  life,  although,  unfortunately,  the  conditions  of  the  ter- 
minal portion  of  the  intestinal  canal  and  its  relation  to  the  parts 
around  cannot  be  predicated  with  any  certainty,  since  in  the  first  two 
classes  of  cases  of  imperforate  anus  or  of  anus  opening  into  a  cnl-de- 
snc  the  intestinal  canal  may  terminate  in  a  blind  pouch  at  the  brim 
of  the  pelvis,  the  rectum  being  wholly  wanting  ;  or,  as  in  the  third 
class,  an  imperfect  rectum  ma}"^  form  and  show  itself  as  a  short  sac 
descending  to  the  floor  of  the  pelvis,  or  to  the  neck  of  the  bladder  ■^'tiiiiiar') 
in  the  male  or  the  commencement  of  the  vagina  in  the  female.  An  ^^--!5S^ 
explanation  of  these  difterent  conditions  is  to  be  found  in  the  fact  ^^"n'^/J,^,  ^^^^a  c«/wS 
that  these  malformations  are  clearly  due  to  some  failure  in  the  foetal  above  the .\nus.  (Prep, 
development  and  to  the  want  of  junction  of  the  two  ends  of  the  rectal  ""  '  '"'  * 
tube.  The  anal  portion  of  the  bowel,  which  develops  from  below,  grows  uj)ward.  while 
the  intestinal  descends  from  above  ;  and  these  two  parts  subsequently  advance  and  in  a 
natural  condition  unite,  the  membranous  diaphragm  at  the  point  of  their  junction  disaji- 
pearing  at  a  later  period  by  interstitial  aVjsorption.  When  a  failure  in  this  uniting  pro- 
cess takes  place,  the  second  class  of  congenital  imperfection  is  formed ;  when  the  failure 
occurs  at  an  early  period  of  development  the  two  ends  of  the  approaching  tubes  will  be 
far  distant,  and  when  at  a  later  period  they  may  be  in  closer  contact.  The  closure  of  the 
anal  orifice  is  due  to  a  firm  adhesion  of  the  integument. 

Sometimes  the  blind  pouch  in  which  the  intestinal  canal  terminates  is  connected  with 
the  anal  integument  or  with  the  anal  cul-de-sac  by  a  cord  prolonged  from  the  bowel  above, 
and  it  seems  po.ssible,  from  Curling's  and  MM.  Goyrand  and  Friedberg's  observations,  that 
such  cases  are  caused  by  an  obliteration  of  the  bowel,  which  was  originally  w^ell  formed, 
from  some  intra-uterine  inflammatory  action,  instances  being  on  record  where  the  mus- 
cular tissue  of  the  intestine  was  clearly  traced  into  the  cord.  Where  the  upper  bowel 
communicates  with  the  urinary  or  vaginal  pas.sages,  it  is  owing  to  the  incomplete  sepa- 
ration of  the  natural  cloaca  that  exists  during  the  development  of  those  parts. 

A  clear  understanding  of  the  way  in  which  these  deformities  are  caused  will  explain 
the  difiiculties  that  are  met  with  in  their  treatment. 

Treat.mext. — On  the  birth  of  every  child  the  condition  of  the  different  outlets  of  the 
body  should  invariablv  be  examined;  and  even  when  the  anus  appears  normal,  a  digital 
examination  should  be  made  on  the  second  day  if  the  bowels  have  failed  to  act,  as  many 
an  infant's  life  has  been  lost  for  the  want  of  this  attention  and  the  consequent  postpone^ 
ment  of  surgical  relief  till  too  late  a  period. 
36 


562 


SURGERY  OF  THE  ANUS  AND  RECTUM. 


In  the  shnpleat  cases,  when  the  anus  is  closed  by  a  tliin  membrane  and  the  bulging  of 
the  distended  rectum  indicates  its  nature,  a  cautious  central  incision  through  the  soft  parts 
should  at  once  be  made ;  and  a  good  result  is  generally  obtained,  the  power  of  the  anus 
usually  l)eing  complete.  Mr.  11.  Harrison  of  Liverpool  records  the  case  of  a  child  who 
was  born  with  an  imperforate  anus,  and  was  successfully  operated  upon  in  the  anal  region 
thirty-three  days  after  birth  {Lancet,  February  26,  1876). 

In  the  more  complicated  cases,  where  the  anus  is  closed  or  absent  and  no  Judging  of  the 
hoicel  exists,  where  the  surgeon  has  no  means  of  making  out  the  true  position  of  the  ter- 
minal end  of  the  bowel,  a  cautious  incision  may  be  made  over  the  .spot  in  which  the  anus 
ought  to  be  found,  the  finger  of  the  left  hand  acting  as  a  pilot.  The  incision  may  be  free 
as  long  as  it  is  carried  upward  and  backward  toward  the  sacrum,  and  not  forward  toward 
the  urethra  or  vagina.  It  must  not,  however,  be  made  too  high.  Where  there  is  not  suf- 
ficient room  to  carry  out  this  practice,  the  coccyx  may  be  cut  away. 

When  these  means  fail,  all  further  attempts  must  be  relinquished.  Blindly  to  intro- 
duce a  knife  or  a  trocar  and  canula  upward  with  the  vain  hope  of  puncturing  the  distended 
bowel  is  a  practice  to  be  unhesitatingly  condemned.  Mr.  Curling's  figures,  too,  prove  that 
the  perineal  exploratory  operation,  unless  undertaken  with  great  care,  does  more  harm  than 
good,  though  when  skilfully  performed  it  is  followed  by  considerable  success. 

In  the  treatment  of  the  second  class  of  cases,  when  the  rectum  terminates  above  in  a  cul- 
de-sac,  an  exploratory  operation  may  be  made  as  just  described  ;  but  the  uncertainty  as  to 
the  true  position  of  the  bowel  rendei's  any  operative  proceeding  hazardous.  When  the 
two  tubes  are  in  contact  and  separated  only  by  their  membranous  ends,  as  in  the  case 
illustrated  (Fig.  320),  a  good  result  may  be  expected ;  but  when  they  are  far  apart,  no 
such  success  can  be  anticipated.  j\Ir.  Curling  in  his  table  gives  31  examples  of  this  class 
of  cases.  In  27  an  attempt  was  made  to  reach  the  bowel,  in  16  with  success,  while  10 
of  these  subsequently  recovered. 

When  the  bowel  is  opened  in  any  of  these  cases  and  is  not  far  from  the  anus,  the  sur- 
geon should  use  all  fair  endeavors  to  draw  down  the  intestine  to  the  margin  of  the  external 
opening  and  fasten  it  with  sutures  to  the  skin.  He  cannot  often,  however,  succeed  in 
accomplishing  this,  the  bowel  being  rarely  found  at  a  less  distance  than  an  inch  from  the 
perinaium  ;  but  when  possible,  the  advantages  of  the  practice  are  great.  Where  this  can- 
not be  attained,  repeated  ^dilatation  of  the  perforated  bowel  is  absolutely  essential  to  main- 
tain its  patency,  as  otherwise,  like  all  artificial  openings,  its  subsequent  contraction  will 
take  place.  The  introduction  of  a  finger  once  or  twice  a  week  is  sometimes  sufficient  for 
this  purpose,  and  in  several  cases  I  have  had  under  care,  where  the  tendency  to  contract 
rapidly  was  marked,  the  introduction  of  a  large  sea-tangle  tent  answered  admirably,  the 
tent  being  placed  in  water  for  a  few  minutes  beforehand,  to  make  it  swell. 

When  the  anus  opens  in  an  abnormal  position,  as  in  the  vagina,  and  the  anus  made  by 
the  surgeon  is  established,  there  is  a  natural  tendency  for  the  abnormal  opening  to  close, 

several  cases  being  on  record  in  which  this  result 
ensued.  Three  have  occurred  in  my  own  prac- 
tice. When  success  has  followed  any  operative 
procedure  in  these  cases,  it  is  important  that  close 
attention  should  be  paid  to  the  condition  of  the 
bowel  for  many  years,  and,  indeed,  for  the  whole 
of  life,  because  there  seems  reason  to  believe  that 
the  bowel  which  forms  the  upper  cid-de-sac  has 
but  little  muscular  power  and  is  liable  to  dilate 
under  fecal  collection,  as  well  as  to  become  para- 
lyzed, death,  under  these  circumstances,  taking 
place  from  obstruction.      In  Fig.  321  this  fact  is 

illustrated.     It  was  taken  from  William  L ,  aet. 

26,  who  had  been  operated  upon  as  an  inftmt  for  an 
imperforate  rectum.  He  died  in  June,  1874,  from 
exhaustion  and  peritonitis  following  intestinal  ob- 
struction, this  obstruction  being  clearly  due  to  the 
narrowing  of  the  rectum  at  the  seat  of  the  early 
operation^     At  the   post-mortem   the  rectum  was 

Enormous   Dilatation   of  the   Rectum   following     f„,,„fl    i„    oppnnv    half   the    abdominal    cavitv,  and 
Obstruction  due  to  the  Contraction  of  an  Arti-     lOUncl    tO    0CCUp>    na  I    uie    aouomiudi    tdwi,) ,  a.  « 

ficiai  Opening  made  into  an  Imperforate  Rec-    y^as  thirteen  inches  louii'  and  eleven  in  circumier- 

tum  Twenty-Six  Years  previously.  ^^^^        j^^   ^.^jj^  ^^^.^    ^^^.^^    ^-^^^^  ^^  ^j^j^j.  ^^  ^^^, 

ural,  more  particularly  the  peritoneal  coat. 


Fig.  321. 


Dilate^ 
Rectuni 


Wlii-n  tlu'  I'xploraton  :iiio-]M'riii;i';il  oiM-ratiun  has  failed  to  <;ive  rclii-f  or  wlicn  it  is 
iiH'xiit'<liL'iit  to  iiiakf  the  atti'iiipt  from  the  very  hackwanl  position  of  the  fjenital  or;:aii. 
other  measures  must  l)e  a(hiptetl  ;  ami  of"  these  tlu-  fipeiiiri;.'  ol'the  large  intestine  throu^ih 
the  aliilomiiial  wall  is  eertainly  the  best.  M.  Kochard,  in  the  Mi'miiin-a  ilc  l Arinliniii- 
lmpniitlf  <!)■  .)/r/////rtr  (  I.S.')i)),  <rives  ten  authentic  sueeessfiil  cases  of  Littre's  operation 
in  the  ^roin  for  this  afi"eeti(»n.  Holmes  informs  us,  in  his  admirable  work  On  tlir  Sun/iiul 
DisntacK  i>j  Chllihiii,  that  he  ha<l  n<tt  met  with  the  aeeount  of  any  permamMitly  successful 
operation  since  the  publication  of  llochanl's  paper.  (Juersant  opened  the  colon  in  the 
<;roin  eleven  times  in  succession,  and  once  in  the  loin,  without  savinj;  a  patient,  (iiraldes, 
however,  had  one  ca.se  in  which  a  child  lived  two  niontlhs  and  a  lialf.  and  then  died  from 
another  cause. 

The  operation,  to  be  successful,  must  be  undertaken  early,  before  the  infant  is 
exhausted  and  peritonitis  has  set  in.  Delay  is  justifiable  only  when  the  bowel  is  not 
distended  and  the  symptoms  not  in   any   way   ur<rent. 

With  respect  to  the  form  of  o])eration,  that  known  as  liittre's  is  proliablv  the  best — 
viz.,  openiiiLC  the  bowel  in  the  <;roin.  The  left  groin  is  usually  selected,  (iiraldes  having 
shown  from  dissection  that  in  thirty  infants  operated  on  for  imperforation  the  intestine 
was  found  on  the  left  in  all  (^XmirraH  Diet,  dr  Mill,  et  de  ('hirnnj.  pratiqnei^.  1804). 
Huguier  has.  however,  recommended  the  right,  on  account  of  the  frequent  bend  in  the 
colon  toward  the  right  groin  and  the  absence  of  the  rectum  in  these  cases.  I  have  on 
three  occasions  performed  Huguier's  operation  with  temporary  success.  In  the  last  case, 
operated  upon  in  December,  1870,  the  child  (a  male)  was  twelve  days  old  before  relief 
was  souglit,  and  he  lived  eight  days,  dying  from  chronic  peritonitis,  which  had  evidently 
existed  before  the  operation.  The  artificial  anus  had  been  made  in  the  lower  part  of  the 
large  intestine  ;  and  had  the  operation  been  performed  at  an  earlier  period  good  succes.s 
would  probably  have  been  attained.  The  question  of  side  is,  therefore,  still  sub  jndicp. 
Amussat's  operation  in  the  loin  is  rightly  put  aside  in  these  ca.ses,  on  account  of  the  nat- 
ural looseness  of  the  colon  at  this  part  in  children  and  the  very  usual  oblique  turn  of  the 
colon  after  its  splenic  flexure.  Figures  likewise  favor  this  conclusion,  since,  out  of  four- 
teen instances  in  which  Littres  operation  was  performed,  nine  recovered,  whereas  two  only 
out  of  seven  recovered  al'ter  the  lumbar  operation. 

The  operation  itself  has  been  described  in  page  508  ('•  Enterotomy  "). 

In  the  trmtmeut  of  the  third  r/ff.s-.s  of  casics^  where  the  rectum  opens  into  the  vagina,  the 
surgeon  may  lay  open  the  rectum  from  the  position  of  the  natural  anus,  having  previously 
passed  a  director  into  the  vaginal  orifice  of  the  gut  as  a  guide,  drawing  down,  when  pos- 
sible, the  bowel  and  fastening  it  to  the  integument  by  sutures,  as  originally  performed 
with  success  by  Amussat.  As  a  guide  to  the  perinatal  incision  a  bent  probe  may  be 
passed  into  the  vaginal  orifice  of  the  bowel  and  the  end  turned  toward  the  perinfeum, 
cutting  down  carefully  upon  it.  I  have  done  this  with  success  on  four  occasions,  and  in 
all  stitched  the  bowel  to  the  margin  of  the  integument,  forming  a  good  anus.  In  two 
cases  the  vaginal  orifice  subsequent^  closed.  In  two  that  were  operated  on  several  years 
ago  the  patients  have  good  control  over  their  motions,  while  the  vaginal  fecal  fistula  seems 
to  be  contracting,  liquid  motions  alone  passing. 

In  exceptional  instances  the  deformity,  though  persisting,  seems  to  cause  no  inconve- 
nience. Ricord  has  recorded  one  {Gaz.  de.f  Hop..  18(53).  in  which  the  woman  was  married 
and  her  husband  was  (juite  unconscious  that  anything  abnormal  about  the  parts  existed. 
Le  Fort  has  recorded  a  second,  in  which  the  woman  was  married  and  had  had  three  chil- 
dren, the  malformation  having  been  accidentally  di.scovered  in  an  examination  for  some 
suspected  disease  of  the  bowel. 

"  In  such  cases  as  these,"  adds  Holmes,  "  the  termination  of  the  rectum  in  the  vagina 
mu.st  be  tolerably  free,  and  there  must  either  be  an  external  sphincter  or  the  internal 
sphincter  must  be  hypertrophied." 

When  the  bowel  empties  itself  into  the  bladdn-  or  urethra,  the  case  is  very  hopeless, 
though  the  prospects  of  a  successful  issue  are  better  under  the  latter  than  under  the 
former  conditions.  An  exploratory  operation  in  the  region  of  the  anus  mav.  however, 
be  made  with  the  usual  caution,  in  the  hope  of  reaching  the  intestine,  which  when  found 
may  be  dissected  away  from  its  attachments  and  brought  down  to  its  normal  position. 
On  the  failure  of  this  operation  Littre's  should  be  ])erformed.  Mr.  Curling  has  related 
a  successful  case  of  Littres  operation  in  a  boy  eight  years  of  age  who  had  a  good  anua 
in  the  groin,  yet  suffered  from  the  occasional  passage  of  feces  into  the  urinary  passages. 

By  way  of  summar\-  the  following  conclusions  may  be  given  : 

1.   In  all  but  exceptional  cases  of  imperforate  anus,  obstructed  rectum,  or  misplaced 


564  SURGERY  OF  THE  ANUS  AND  RECTUM. 

anus  an  exploratory  operation  in  the  normal  anal  position  and  an  attempt  to  bring  the 
bowel  into  its  right  place  should  be  made,  success  following  the  attempt  in  nearly  half 
such  cases. 

2.  Such  exploratory  operations,  however,  to  be  successful,  should  be  undertaken  early 
and  conducted  with  great  caution,  the  line  of  puncture  or  incision  being  upward  and  back- 
ward toward  the  sacrum. 

3.  When  these  means  fail  or  are  inapplicable,  the  intestine  must  be  opened  in  the 
groin  (enterotomy),  it  being  still  an  open  question  whether  the  right  or  the  left  side 
ought  to  be  selected,  though  the  latter  is  the  usual  one. 

4.  When  an  artificial  anus  has  been  made,  its  constant  dilatation  is  a  necessity. 

For  further  information  on  this  subject  refer  to  Curling's  paper,  Med.-Otir.  Trans.,  vol.  xliii., 
and  French  edition  of  Holmes's  Surf/ical  Disea.'ies  of  Children,  by  Dr.  Larcher. — Bodexhamer, 
Wm.,  On  Malformations,  Wood,  New  York,  1860. — Ashton,  On  Rectum,  3d  ed.,  1860. — Cripps,  St. 
Bartholomtvf  s  Ho><p.  Reports,  1882. 

Injuries  of  the  Rectum. 

The  anal  orifice  and  lower  part  of  the  rectum  may  be  wounded  by  accident  from  falls 
or  by  design ;  and  when  this  occurs,  hemorrhage  is  a  common  result.  Repair,  however, 
rapidly  goes  on  in  these  regions,  and  with  the  arrest  of  bleeding  by  either  securing  the 
divided  artery  or  pressure  and  some  simple  dressing  a  good  result  may  be  anticipated. 

In  1876  a  severe  example  of  this  kind  came  under  my  cai'e  at  Guy's  Hospital  in  a 
boy  set.  12  who  was  impaled  upon  a  rail,  the  iron  spike  entering  the  pelvis  on  the  inner 
side  of  the  right  tuberosity  of  the  ischium,  perforating  the  rectum  about  two  inches  up, 
and  lacerating  the  anterior  wall  of  the  rectum  and  base  of  the  bladder.  The  injury  was 
followed  by  collapse  and  attended  with  hemorrhage.  I  saw"  him  directly  after  the  acci- 
dent, and  made  a  free  incision  into  his  bladder  as  for  lithotomy,  in  order  to  secure  a  free 
passage  for  the  urine,  it  being  clear  that  the  recto-vesical  peritoneal  pouch  was  lacerated. 
Some,  though  not  severe,  peritonitis  followed,  and  feces  passed  per  anwn  as  well  as 
through  the  external  wound.  On  the  sixteenth  day  I  consequently  gave  opium,  to  lock 
up  the  bowels,  with  the  view  of  making  a  splint,  as  it  were,  of  the  feces,  and  to  keep  the 
rectum  and  intestinal  wound  quiet.  Success  followed  the  practice,  and  the  wound  in  the 
bowel  closed.  After  four  days  the  bowels  were  opened  by  a  do.se  of  castor  oil,  and  con- 
valescence became  established. 

In  parturition  the  rectum  is  sometimes  laid  open  by  a  rupture,  either  alone  or 
with  the  perinajum  ;  and  when  this  occurs,  the  rent  ought  to  be  brought  together  at 
once,  for  if  this  practice  be  not  adopted  a  plastic  operation  subsequently  will  have  to  be 
performed.  Cases  are  also  on  record  in  which,  during  parturition,  the  child's  head  passed 
into  the  rectum  and  was  delivered  per  annm.  M.  Queme  (^Revue  de  Cliirurgic^  1882) 
cites  seven  cases  of  this  kind. 

Laceration  from  Act  of  Defecation. — In  the  act  of  defecation  small  lacera- 
tions of  the  anus  are  not  uncommon  when  the  motions  are  very  large  or  hard. 

Treatment. — In  the  milder  forms  of  laceration  of  this  kind,  cleanliness  and  laxa- 
tives, as  a  rule,  are  sufficient  to  allow  the  parts  to  heal.  In  some  instances  the  rent  does 
not  heal  and  the  case  becomes  one  of  fissured  anus  or  painful  ulcer  of  the  rectum.-  and 
should  be  dealt  with  accordingly. 

Wounds  of  the  rectum  inflicted  by  the  surgeon,  as  a  rule,  heal  readily,  as  is  fairly 
proved  by  the  cases  of  fistula  in  ano  treated  by  operation  and  the  recto-vesical  operation 
for  stone.  The  puncture  made  in  the  operation  of  tapping  the  bladder  jjer  rectum  for 
retention  also  heals  quickly. 

It  is  well  to  remember  that  the  rectum  may  be  wounded  by  the  passage  of  a  bougie, 
enema  syringe,  or  the  introduction  of  an  O'Beirne's  tube.  Guy's  Museum  contains  speci- 
mens illustrating  all  these  forms  of  injury,  and  at  St.  Bartholomew's  there  is  a  specimen 
of  perforation  of  the  rectum  by  a  metallic  clyster  pipe  through  which  gruel  was  injected 
into  the  pei'itoneal  cavity. 

Rupture  of  the  rectum  may  occur  during  a  violent  eff"ort  at  defecation,  but  there 
is  no  evidence  to  show  that  such  an  accident  can  occur  when  the  bowel  is  healthy.  In 
the  majority  of  cases  in  which  it  has-  taken  place  some  prolapse  of  the  rectum  was  present. 
The  rupture  is  usually  in  a  vertical  direction.  It  is  known  by  the  sudden  appearance  of 
a  mass  of  small  intestine  protruding  through  the  anus,  following  a  sharp  abdominal  pain 
the  result  of  an  eff'ort  at  defecation. 

H.  Mayo  {Dis.  of  Rect.,  1833)  relates  the  case  of  a  lady  who  during  a  violent  eff'ort 


7>/.s7;.i>/>  oy-  Till-:  .\srs  asd  iiinrrM.  5G5 

at  iK'Tccation  frit  soinotliiii'r  ^ivo  wny,  and  (jii  the  fnllowin;;  inoniiii;/  discovcrcfl  W'Ca's  in 
her  vasiiia.  An  exaniinatinii  n-vcalctl  a  rent  two  inches  up  the  bowel  large  enough  to 
aUow  the  e:;-'  nf  the  linirfr  to  pass  fioni  the  rfctiiin  into  tht;  vagina. 

Foreign  Bodies  in  the  Rectum. 

Those  may  he  intnxlueeil  tVoni  irif/mnf,  citlier  fVnin  mischief  or  from  accident,  and 
trouhh'  may  he  experienced  in  their  removal,  their  shajte  and  jiositioii  influencing  the 
result.  More  commonly,  however,  they  have  been  swallowed  and  have  passed  down  the 
canal,  becoming  caught  or  impacted  in  the  rectum.  They  are  not  unfref|Uently  the  eau.se 
of  anal  abscess,  bones,  pins,  bristles,  etc.,  being  constantly  found  in  the  rectum  under 
these  circumstances.  Stones,  hairs,  or  husks  may  likewise  form  concretions  that  are 
foreign  bodies.  When  large  foreign  bodies  have  been  introduced  into  the  rectum  or  con- 
cretions or  solid  mas.ses  of  feces  become  there  impactedj  an  anaesthetic  should  be  given 
to  allow  of  their  removal,  care  being  taken  not  to  injure  the  walls  of  the  bowel  more  than 
can  be  helped,  since  cases  are  on  record  where  the  i'oreign  body  has  passed  into  the  peri- 
toneal cavity.  With  the  patient  under  the  influence  of  an  an.'esthetic  the  sphincters 
become  so  rela.xed  as  to  allow  of  the  introduction  of  large  instruments,  or  even  the  intro- 
duction of  the  hand  to  guard  the  bowel  and  remove  the  foreign  body.  JJottles,  pots,  cups, 
corks,  rings,  jHMicil-cases,  bougies,  sticks,  stones,  etc.,  have  been  impacted  in  these  regions, 
and  considerable  care  is  needed  in  their  removal,  to  prevent  injury. 

TuKATMKNT. — The  injection  of  plenty  of  warm  oil  before  the  attempt  greatly  facili- 
tates the  operation.  Lithotomy  scoops  or  forceps  are  likewise  valuable,  but  the  ingenuity 
of  the  surgeon  is  necessary  in  every  case  to  apply  the  best  means  to  carry  out  the  end  in 
view.  Linear  rectotomy  may  be  performed  whenever  it  is  called  for.  and  occasionally  the 
foreign  body  may  have  to  be  removed  by  laparotomy.  M.  Verneuil  related  such  a  case 
at  the  Societe  de  Chirurgie,  June,  1880.  It  was  that  of  a  man  aet.  40  who  introduced  a 
piece  of  wood  into  his  rectum  to  arrest  a  dysenteric  discharge.  A  few  days  later,  after 
the  introduction  of  the  hand  into  the  rectum  had  failed  to  reach  the  foreign  body,  a 
median  abdominal  incision  was  made  and  the  foreign  body  pressed  downward,  when  it  was 
seized  and  removed  after  the  rectum  had  been  incised  from  the  anus.  The  man  made  a 
rapid  recovery.  Dr.  Thorndike  of  Boston,  United  States,  also  records  a  successful  case 
in  which  a  large  stone  was  removed  from  the  peritoneal  cavity  after  having  passed  into  it 
through  a  ruptured  rectum  (AV^>.  of  City  Uoi^p.,  1882). 

A  large  collection  of  such  cases,  with  their  treatment,  is  given  by  ^L  Morand  in 
Memoirs  of  the  Frnich  Academy  of  Snrrjerjj^  vol.  iii.,  by  Ashton  in  his  work  Ou  thf  Rec- 
/H»j,and  by  Poulet  in  a  general  treati.se  on  foreign  bodies  in  surgical  practice  (New  York, 
1880). 

Diseases  of  the  Anus  and  Rectum. 

These  have  only  recently  received  sufficient  attention  from  the  great  body  of  surgeons, 
and,  as  a  consequence,  have  been  too  often  allowed  to  fall  into  the  hands  of  "quacks;" 
and,  although  able  and  respectable  specialists  have  since  rescued  tliis  important  cla.ss  of 
case^s  from  their  hands,  much  remains  to  be  done  by  the  profession  as  a  whole  to  bring 
the  diseases  of  these  parts  into  their  right  position — that  is,  into  the  hands  of  the  general 
practising  body  of  the  profession.  Again,  in  no  class  of  cases  are  so  many  mistakes  met 
with,  and  these  almost  always  arise  from  a  want  of  proper  local  examination  of  the  parts. 
The  anus  or  rectum  is  either  unlocked  at  or  unexamined  from  some  mistaken  notions  of 
delicacy,  or  badly  examined  from  want  of  knowledge  or  want  of  inclination.  But  such 
should  not  be,  and  every  patient  who  complains  of  anything  like  persistent  symptoms  in 
those  regions  should  be  as  carefully  examined  as  he  or  she  would  be  were  any  other  locality 
equally  affected.  To  do  this  some  nicety  is  required,  and  to  help  the  student  the  follow- 
ing hints  n)ay  be  acceptable. 

Examination  of  a  Patient. — The  best  position  is  on  the  side,  with  the  legs  well 
drawn  up  and  the  thighs  flexed  upon  the  abdomen,  the  hips  being  brought  to  the  edge  of 
the  bed  or  couch  in  a  good  light ;  the  surgeon,  with  one  hand  having  uncovered  the  parts 
sufficiently  to  expose  them,  may  then  raise  the  upper  buttock,  and  in  doing  this  the  anus 
conies  well  into  view  ;  in  operations  this  may  be  done  by  an  as.sistant.  When  an  abscess 
exists,  it  will  then  be  seen  ;  if  a  fistula  be  present,  its  external  orifice  will  be  apparent. 
Fissures,  warts,  condylomata,  or  fleshy,  flattened,  cutaneous  vegetations  or  cancerous 
tubercles  will  also  be  at  once  recognized. 

Pendulous  loose  folds  of  skin  about  the  anus  will  suggest  the  former  existence  of 


566 


SURGERY  OF  THE  ANUS  AND  RECTUM. 


external  hemorrhoids  ;  blue,  turgid,  venous  projections,  their  present  existence.  A  tightly 
contracted  and  rigidly  drawn-up  anus,  as  a  rule,  means  some  painful  ulcer  of  the  part, 
and  a  patulous  anus  through  which  flatus  or  discharge  passes  without  the  patient's  wish 
too  often  indicates  extensive  rectal  ulceration  or  stricture. 

Intcrmd  piles,  when  prolapsed,  will  appear  as  turgid,  vascular,  mucous  projections 
covered  with  mucus  or  blood,  surrounded  by  everted  integument  more  or  less  oedematous; 
prolapsus  recti,  as  a  greater  or  less  annular  projection  of  smooth  or  rugous  mucous  mem- 
brane, with  a  central  intestinal  orifice.  A.  polypus  projecting  will  appear  as  a  cherry,  sur- 
rounded by  healthy  structures.  All  these  points  are  taken  in  at  a  glance  and  understood. 
A  digital  examination  should  then  be  employed,  to  confirm  or  refute  the  suggestions  thus 
taken  in  by  the  eye.  To  do  this  well  the  index  finger  must  be  thoroughly  anointed  with 
lard  or  ointment,  it  being  a  good  plan  previously  to  fill  the  nail  with  a  piece  of  soap.  It 
should  then  be  applied  to  the  anus  and  the  patient  told  to  bear  down,  as  in  doing  this  the 
sphincter  is  relaxed.  The  surgeon  can  then  with  ease  and  without  pain  introduce  his 
finger.  When  an  ulcer  exists  at  the  anus,  pain  will  be  caused  by  and  spasmodic  resistance 
off"ered  to  the  introduction  of  the  finger,  and,  with  the  pulp  of  the  finger  slowly  moved 
round  the  anus,  the  ulcer  will  probably  be  felt.  It  should  be  stated,  however,  that  in 
many  cases  this  ulcer  will  be  seen  by  a  careful  drawing  down  of  the  skin  of  the  anus  till 
the  margin  of  the  mucous  membrane  becomes  visible.  A  spongy  nodular  feel  of  the 
mucous  membrane  just  within  the  sphincter  will  suggest  internal  hemorrhoids ;  a  local,- 
tender,  and  raw  surface,  the  probability  of  a  simple  ulcer ;  a  circular,  indurated  raw  sur- 
face, that  of  a  syphilitic  sore ;  while  a  cancerous  ulcer  is  known  by  an  infiltrated  nodular 
and  thickened  surface.  A  stricture  within  two  inches  of  the  anus  can  always  be  detected 
by  its  annular  form  or  the  obstruction  which  it  causes.  AVhen  a  healthy  piece  of  bowel 
separates  the  anus  from  the  stricture  or  ulceration,  the  probability  of  the  disease  being 
cancerotis  is  rendered  great.  When  no  such  healthy  tissue  exists,  syphilitic  disease  is 
rendered  probable.  A  digital  examination  will  always  detect  the  presence  of  scybala  or 
impacted  feces,  and  also  the  encroachment  of  uterine  or  pelvic  tumors  in  women  and 
prostatic  tumors  in  men.  To  confirm  these  opinions  thus  formed,  a  speculum  may  be 
used,  which  should  be  introduced  well  warmed  and  greased  in  the  same  way  as  the  finger. 
Mr.  Curling  says,  "When  the  mischief  is  high  up  in  the  rectum,  let  the  patient  stand  on 
the  left  leg,  with  the  right  thigh  and  leg  bent,  the  foot  resting  on  a  chair.  Tell  the 
patient  to  .strain.  This  action  will  then  force  the  parts  down."  I  have  found  this  method 
of  examination  serviceable. 

Mr.  Allingham  "  advises  the  prone  position,  with  the  hips  well  elevated  upon  hard  pil- 
lows, to  such  an  inclination  that  the  intestines  will  gravitate  toward  the  diaphragm,  so 
that  when  expiration  takes  place  the  rectum  becomes  patulous  and  you  can  see  as  far  as 
the  sigmoid  flexure  perfectly  distinctly."  This  mode  of  examination,  he  infoi'ms  us,  was 
suggested  by  Dr.  Marion  Sims  (^Oii  Diseases  of  the  Rectum,  1882.)  • 

The  speculum  represented  in  Fig.  322,  as  made  for  me  by  Krohne,  is  the  one  T  prefer. 

Fig.  322. 


A  nest  of  three, 


Rectal  .Speculum. 

Two  adapted  for  use. 


The  practice  of  iutroducinrj  the  whole  hand  into  the  rectum  has  been  frequently  adopted 
by  several  good  surgeons,  and  from  my  own  personal  experience  I  believe  it  to  be  of 
value,  more  particularly  for  diagnostic  purposes,  in  cases  of  suspected  disease  of  the  rec- 
tum above  the  brim  of  the  pelvis,  in  pelvic  or  abdominal  aff"ections.  In  the  female  patient 
it  is  more  readily  performed  than  in  the  male.  The  operation,  however,  is  neither  easy 
nor  free  from  risk,  .since  laceration  of  the  rectum  has  been  recorded.  It  should  be  per- 
formed with  the  patient  under  the  influence  of  an  anaesthetic  and  with  extreme  slowness 
(five  minutes  may  well  be  spent  in  pas.sing  the  sphincter  ani)  ;  the  hand  should  be  well 


FISSURK  AM>    I'M S FIJI.    UlJ'hi:    OF   TUE  ANUS.  ',07 

greased  and  iiitindnccd  with  a  s<Ti'\viii^'^  iimtidii.  Wlicti  tlic  hand  has  passed  witliin  tlic 
rectum,  imudi  eare  is  rf(|iiin'd  ;  and  wlu-u  tlie  narr<»\VMess  of"  tlie  gut  i'nrbids  easy  advance, 
no  lorce  shouhl  he  eni|doyed,  lor  hy  force  tlie  peritoneal  covering  of"  the  howel  has  been 
rujitured.  With  the  hand  in  the  rectum  the  jtarts  above  the  brim  <d"  the  pelvis  may  be 
readily  examined;  indeed,  the  kidneys  have  been  felt,  and  pulsation  in  the  larger  branches 
of  the  abdominal  a(trta  can  be  traced,  and  conse<juently  controlle(i. 

With  these  brief  general  remarks.  I  now  proceed  to  treat  id"  the  special  affections. 

Fissure  and  Painful  Ulcer  of  the  Anus. 

This  most  distressing  affection  produces  more  misery  than  any  other  loeal  disease  with 
which  I  am  ac(|iiainted.  and  nsnders  the  natural  act  (d"  defecation  an  agoidzing  one.  of"teii 
'■  causing  great  dro])s  of  jicrspiration  to  course  down  the  temples."  It  is  usually  caused 
by  the  meidianical  sjditting  of  the  orifice  of  the  anus,  from  the  passage  of  a  large  or 
indurated  motion  at  the  junction  of  the  mucous  membrane  of  the  bowel  with  the  skin, 
although  it  is  not  always  traceable  to  such  a  cause.  In  .some  instances  it  seems  to  owe 
its  origin  to  scratching  the  parts  when  highly  irritable.  It  is  usually  a  disease  of  adult 
life  and  common  to  both  .se.\cs,  though  it  has  been  found  in  children  even  so  young  as  a 
year  and  a  half  {^Hrit.  Med.  Juitrn.,  June  G,  1874).  It  is  met  with  as  often  in  the  healthy 
as  in  the  feeble  sul))ect  ;  but  where  it  has  been  allowed  to  go  uncontrolled,  it  soon  tells 
upon  the  strongest  patient.  Constipation,  high  feeding,  sedentary  habits,  and  want  of 
local  cleaidiness  are  the  common  causes,  but  anything  that  sets  uji  irritation  in  the  intes- 
tines is  likely  to  produce  it  ;  and  when  once  started,  unless  treated  with  discrimination, 
it  may  go  on  for  years  ;  indeed,  it  is  by  no  means  unusual  to  hear  that  the  .symptoms 
have  been  endured  for  two.  four,  or  even  six,  years.  It  generally  manifests  its  presence 
by  some  local  uneasiness  in  the  act  of  defecation,  this  uneasiness  passing  on  to  more  or 
less  severe  pain.  This  pain,  as  a  rule,  is  experienced  during  the  passage  of  the  motion, 
but  in  some  instances  it  comes  on  after  the  lapse  of  a  few  minutes,  or  even  an  hour  or 
more,  after  the  act,  and  may  last  a  few  minutes  or  hours.  When  it  passes  away,  the 
patient  is  easy  till  the  same  cause  excites  the  same  symptoms.  The  motions  will  often 
be  streaked  with  a  line  of  pus  or  blood  and  diminished  in  size,  sometimes  being  flattened, 
at  others,  pipe-like ;  and  this  diminution  is  produced  by  the  spasm  of  the  sphincter,  the 
size  of  a  motion  Ijeing.  in  disease  as  in  liealth,  greatly  determined  by  the  condition  of  the 
sphincter. 

On  examing  the  anus  the  first  fact  that  strikes  the  observant  eye  is  the  unnatural 
resistance  the  patient  makes  on  separating  the  buttocks,  and,  on  doing  this,  the  powerful 
contraction  of  the  sjdiincter  that  will  be  visible.  On  attempting  to  introduce  the  finger 
considerable  resistance  will  be  encountered,  and  the  greatest  pain  caused  if  the  surgeon 
persevere  in  his  attempt. 

The  .symptoms  and  local  signs  of  the  afi'ection  are,  indeed,  so  characteristic  that  the 
true  nature  of  the  ca.se  can,  as  a  rule,  be  diagnosed  without  the  aid  of  a  digital  internal 
examination,  and  a  careful  external  examination  will  often  reveal  the  presence  of  an  ulcer 
on  the  verge  of  or  within  the  sphincter;  when  within,  the  outer  border  only  will  be  visi- 
ble. The  ulcer  is  usually,  though  not  invariably,  placed  at  the  posterior  margin  of  the 
anus,  and  is  rarely  larger  than  a  sixpence,  if  so  large.  When  recent  it  will  be  soft  with 
slightly  elevated  edges,  and  when  of  long  standing  indurated  with  an  irregular  surface, 
small  jiolypoid  growths  fringing  its  border.  The  ulcers  are  at  times  multiple,  in  excep- 
tional cases  involving  the  bowel  higher  up.  It  is  an  affection  of  the  mucous  and  submu- 
cous tissue  and  painful  only  from  its  position,  besides  being  obstinate  in  healing  from  its 
connection  with  the  sphincter  ani.  Simple  fissures  of  the  anus  rarely  involve  other  than 
the  mucous  meml)rane  and  skin  around  the  parts  and  are  often  associated  with  piles, 
though  occa.sionally  with  small  polypi.  Ulcers  are  often  hidden  from  view  when  piles  or 
folds  of  skin  exist  about  tlie  anus,  but  pain  indicates  their  presence. 

In  women  this  affliction  is  so  often  associated  with  reflective  uterine  symptoms  as  to 
be  frequently  overlooked,  and  in  men  urinary  irritation  may  mask  the  disease. 

Reflected  nerve  pains  in  the  perinaMim  and  down  the  leg,  as  in  sciatica,  or  in  the  loins, 
as  in  lumbago,  etc.,  are  often  induced  by  the  affection. 

Tre.\t.mext. — Happily  for  patients,  the  treatment  of  this  disease  is  as  successful  as  it 
is  simple.  Simple  fissures  are  readily  treated  by  the  administration  of  a  laxative,  the 
local  application  of  the  nitrate  of  silver  or  of  lead  lotion  mixed  with  the  extract  of  opium, 
and  local  cleanliness,  with  simple,  nutritious,  and  unstimulating  diet.  When  the  parts 
are  indolent  or  syphilis  is  suspected,  black  wash  may  be  used,  or  calomel  dusted  over  the 


568  SURGERY  OF  THE  ASUS  AND  RECTUM. 

part  or  applied  as  an  ointment  of  five  grains  to  a  drachm  of  lard.  In  other  cases  the 
application  of  mercurial  ointment  with  the  extract  of  belladonna  gives  relief.  Injections 
of  the  decoction  of  rhatany  twice  a  day,  or  of  an  enema  composed  of  a  drachm  each  of 
the  extract  and  tincture  of  rhatany  in  five  ounces  of  water,  are  sometimes  of  great  use, 
as  also  is  an  ointment  ten  grains  of  iodoform  to  the  ounce. 

When  a  larger  nicer  exiafs  and  is  quite  recent,  the  same  treatment  may  be  employed  ; 
but  when  the  ulcer  has  existed  for  any  time  and  has  a  hard  base,  it  is  quite  exceptional 
for  a  cure  to  take  place  by  these  means,  the  surgeon  being  hardly  justified  in  making  the 
attempt  when  he  has  at  hand  such  an  efficient  means  as  the  division  of  ilie  base  of  the  uher 
vith  the  snperfcial  fihrea  of  the  external  sphincter.  This  can  be  done  in  many  cases  by  the 
introduction  of  the  finger  with  a  probe-pointed  bistoury  pressed  flat  upon  it  and  introdu- 
cing them  to  the  upper  margin  of  the  ulcer,  and  then  turning  the  edge  of  the  knife  toward 
the  surface  of  the  ulcer  and  incising  it.  Boyer,  who  first  suggested  this  principle  of  treat- 
ment, advised  the  free  division  of  the  sphincter,  but  Copland  and  Brodie  introduced  the 
minor  operation,  which  in  the  bulk  of  cases  is  sufficient  to  effect  a  cure.  In  very  chronic 
instances  Beyer's  operation  may  be  demanded.  When  an  anaesthetic  is  given,  a  speculum 
may  be  used ;  and  the  ulcer,  being  exposed,  should  be  divided  by  a  sharp  bistoury,  tran.s- 
fixing  the  tissues  at  the  base  of  the  ulcer  on  cutting  inward.  The  essential  point  of  prac- 
tice to  observe  is  the  free  division  of  the  base  of  the  ulcer  down  to  healthy  tissue,  the 
mode  of  doing  it  being  unimportant.  When  any  fold  of  skin  or  pile  exists  near  the  ulcer, 
it  should  be  removed.  The  forcible  dilatation  of  the  sphincter  and  its  laceration  with  the 
thumbs  in  the  rectum,  as  practised  abroad,  is  a  barbarous  treatment  compared  with  the 
above,  though  when  a  patient  is  under  an  anaesthetic  it  may  be  followed. 

After-Treatment. — In  the  after-treatment  the  bowels  must  be  kept  slightly  loose, 
and  for  this  purpose  nothing  equals  in  value  a  mixture  of  one  ounce  of  olive  oil  rubbed 
down  with  forty-five  grains  of  cai'bonate  of  potash  and  mixed  with  seven  ounces  of  pep- 
permint or  chloroform  water,  one  ounce  being  given  two  or  three  times  a  day,  to  produce 
a  soft  evacuation.  Indeed,  before  as  well  as  after  the  operation  this  mixture  should  be 
employed ;  when  it  fails,  enemata  ought  to  be  used.  The  diet  should  be  simple  and  rest 
maintained  till  the  cure  is  complete,  for  where  this  rule  has  not  been  observed  I  have 
known  the  ulcer  become  so  indolent  as  to  require  a  second  division,  which  under  other 
circumstances  is  rarely  required.  Tonics  are  often  of  value  during  the  convalescing 
period. 

Spasm  of  the  sphincter  is  not  a  disease,  but  a  symptom,  caused  by  reflected 
irritation  from  some  rectal,  uterine,  or  other  local  affection.  It  may  be  a  small  or  super- 
ficial ulcer  beyond  the  verge  of  the  anus ;  the  presence  of  worms,  the  existence  of  a 
small  polypus,  or  some  other  local  cause  of  iri'itation  of  the  mucous  membrane  lining  the 
bowel  will  be  found  after  careful  investigation. 

The  same  remarks  are  also  applicable  to  neuralgia  of  the  rectum,  though  it  is 
quite  reasonable  to  believe  that  a  pure  neuralgia  may  occur  of  this  part,  as  of  any  other. 
Yet,  as  a  rule,  it  is  caused  by  reflected  irritation  from  some  nerve  with  which  the  part  is 
connected,  and  the  surgeon  should  clinically  so  regard  it.  It  is  said  to  be  common  in 
gouty  subjects,  and  can  certainly  be  relieved  by  free  purgation.  At  times  it  is  caused  by 
malaria  and  cured  by  large  doses  of  quinine. 

Anal  Abscess  and  Fistula  in  Recto. 

The  two  subjects  of  anal  abscess  and  fistula  in  recto  are  classed  together,  as  the  latter 
disease  is  almost  always  preceded  by  the  former,  though  a  large  number  of  cases  of  anal 
abscess  recover  without  passing  into  a  fistula.  Of  my  notes  of  230  consecutive  cases  of 
the  two  diseases,  43  commenced  and  ended  as  anal  abscess,  while  the  remaining  193  were 
treated  as  fistula  in  recto  ;  74  of  these  cases  were  females  and  162  males,  men  being  evi- 
dently more  liable  than  women  to  this  affection.  It  rarely  occurs  in  children,  though  I 
have  successfully  treated  a  case  in  a  male  child  four  months  old,  and  a  second  in  one  of 
fifteen  months  ;  in  the  latter  the  fetor  of  the  discharge  was  very  great. 

Of  the  causes  of  this  disease  little  positive  information  can  be  given,  because,  as  a 
rule,  the  abscess  is  obscure  in  its  origin  and  slow  in  its  progress  and  repair,  some  patients 
even  professing  to  have  been  uncon.scious  of  its  existence  till  it  was  about  to  burst.  In 
other  cases,  however,  it  is  very  acute  in  its  action,  and  very  painful. 

That  an  anal  abscess  must  always  result  from  some  ulceration  of  the  bowel  within 
the  sphincter  is  an  opinion  which  can  scarcely  be  regarded  as  true,  there  being  no  evi- 
dence to  support  such  a  view ;  and  the  fact  that  so  many  as  43  out  of  236  cases  of  anal 


.I.V.I/.    Al!sri:ss  AM)   FIsrri.A    IS  llF.rro,  509 

aliscoss  rfcovcii'il  witliout  t'Mriniiii;  a  listiilu  ^dcs  far  to  prove  its  error.  It  is  not  unfair, 
tlu'rcforc,  to  iiil'iT  that  in  nianv  cases  it  de]>etKls  uiM)n  a  (liH'ereiit  cause. 

in  iistnia  in  recto  tiiis  ar;j,iunent  tniist  lu;  e(|ually  stronj^,  since  it  is  frenerally  heliev(!<l 
that  this  ath'ction  is  merely  the  .se(|uel  of  tlie  anal  ahseess  ;  we  niu.st,  cuiise<|uently,  h>oii 
for  some  other  and  more  irt'iieral  cause  than  tiiat  ordinarily  received — namely.  |ierforation 
of  tlie  l)o\vel  from  uiceratifui. 

Thi'  mechanical  irritation  oi'  a  foreij:;n  hody  is  douhtless  an  occasional  cause,  it  being 
bv  no  means  uncommon  f(tr  a  suriietm  to  remove  i'rom  the  anus,  when  o])(!nin<r  an  abscess, 
a  jtiece  of  Hsh-h(UU',  bristle,  or  other  foreiiiii  body.      Quit(!  n^-ently  I  removed  a  pin. 

These  atl'ections  may  occur  at  any  period  of  life,  though  I  have  .seen  a  fistula  in  a 
child  fnui'  months  old.  and  in  the  majority  (d'  instances  it  is  found  in  adults  betw(!en 
twentv  and  forty  years  of  age.  i>r.  Jiipsconib  of  St.  Albans  related  a  case  to  me  which 
took  iilace  in  his  jiractice  that  was  congenital,  the  mother  having  conceived  when  worry- 
ing al)out  hi'r  husband,  who  was  suffering  from  fistula.  It  is  very  common  to  be  informed 
that  the  Kstula  had  existed  for  .several  years  before  surgical  aid  is  sought. 

With  respect  to  the  connection  between  phthisis  and  fistula  it  is  difficult  to  give  any 
positive  information.  During  the  eight  years  that  I  was  registrar  at  (luy's  I  iufjuired 
carefully  iuto  this  point  in  every  ease,  but  had  only  ?t  out  of  193  in  which  either  hjcniop- 
tysis  or  other  symptom  of  marked  phthisis  was  present.  In  the  majority  of  cases  the 
patients  presented  no  more  severe  cachectic  symptoms  than  is  usually  met  with  in  other 
liospital  patients,  and  I  confess  to  being  somewhat  doubtful  as  to  the  fact  that  fistula  in 
recto  is  a  common  conse((uenee  of  phthisical  disease.  When,  however,  fistula  and 
phthisis  are  associated,  the  former  is  usually  of  a  bad  form. 

When  a  fistula  has  two  openings,  one  externally  and  the  other  into  the  bowel,  it  is 
called  conipletc.  When  there  is  an  external  but  no  internal  opening  to  be  found,  it  is 
known  as  the  blind  external ;  when  an  internal  but  no  external,  blind  internal. 

That,  as  a  rule,  an  internal  opening  exists  is  now  scarcely  doubted,  although  at  times 
there  may  be  great  difficulty  in  finding  it.  M.  Ribes  in  1819  examined  the  bodies  of 
seventy-five  people  who  died  with  fistula,  and  in  all  he  found  an  internal  opening;  in 
nearly  all  this  was  placed  just  within  the  sphincter,  but  in  no  instance  was  it  higher  than 
half  an  inch.  Modern  surgeons  now  accept  these  facts.  The  pus  that  forms  in  these 
parts  is  very  offensive  at  times,  as  often  from  the  absorption  of  fetid  gases  through  the 
mucous  membrane  as  from  the  mixture  of  feculent  matter.  In  a  large  number  of  ca.ses 
the  discharge  has  no  fecal  odor. 

It  should  always  be  remembered  that  an  anal  fistula  may  accompany  severe  rectal 
di.sease,  such  as  stricture  or  ulceration,  or  that  it  may  be  connected  with  disease  of  the 
pelvic  bones,  etc.  In  the  case  of  an  old  man  with  an  enormous  abscess  Vjetween  the  base 
of  the  bladder  and  the  rectum  constitutional  symptoms  were  very  severe  till  two  deep 
incisions  were  made  on  either  side  of  the  perinteum,  giving  exit  to  a  quantity  of  pus, 
when  an  excellent  recovery  ensued.  In  this  instance  it  was  a  question  whether  the  pros- 
tate gland  was  in  fault,  but  no  other  symptoms  of  such  a  complication  could  be  ascer- 
tained. 

Treatment. — In  cases  of  anal  abscess  free  incision  is  the  best  practice,  which  should 
be  made  as  soon  as  fluctuation  can  be  felt  e^^ternally  or  through  the  bowel.  Deep-.seated 
abscesses  in  these  regions  .eliould  not  be  left  to  natural  processes  to  open.  When  the 
abscess  is  in  front  of  the  anus  and  rectum,  an  early  opening  may  be  called  for.  on  account 
of  the  retention  of  urine  to  which  it  may  give  rise.  The  incision  should  be  made  from 
without  inward  in  a  line  radiating  toward  the  anus.  In  deep-seated  abscesses  one  or  two 
fingers  may  be  inserted  well  into  the  rectum  and  the  abscess  pressed  forward  before  the 
incision  is  made,  a  sharp  straight  bistoury  being  the  best  instrument  to  use.  A  piece  of 
oiled  lint  should  be  in.serted  into  the  wound  and  kept  there  for  a  day. 

In  a  case  I  saw  in  1872,  owing  to  the  neglect  of  making  an  early  opening,  emphysema 
and  phlegmonous  inflammation  of  the  perinacum,  scrotum,  and  penis,  and  of  the  abdomen 
even  up  to  the  axilla,  took  place,  a  free  communication  evidently  existing  between  the 
bowel  and  the  abscess.  The  patient  died  from  the  constitutional  irritation  of  the  disease. 
The  sloughing  of  the  cellular  tissue  was  very  extensive,  and  the  fetor  of  the  sloughs  was 
something  to  remember. 

After  the  abscess  has  been  opened  the  j^atient  should  be  kept  at  rest  in  the  horizontal 
posture,  some  antiseptic  dressing  applied  to  the  wound,  and  the  most  perfect  cleanliness 
ob.served,  laxatives  being  given  when  the  motions  are  hard,  and  also  tonics  to  improve  the 
health. 

When  ajistida  exists,  the  best  operation  is  its  division  into  the  bowel,  the  action  of  the 


570 


SURGERY  OF  THE  ANUS  AND  RECTUM. 


Fig.  323. 


sphincter  ani  having,  doubtless,  a  powerful  influence  in  retarding  repair.  The  bowels 
should  previously  be  cleared  by  a  mild  purge  two  days  before  the  operation,  and  an  enema 
given  on  the  morning  of  its  performance.  The  patient  should  be  placed  on  the  side  upon 
which  the  fistula  exists,  with  the  legs  well  drawn  up,  and  brought  to  the  edge  of  the  bed 
or  couch.  An  assistant  should  separate  the  buttocks.  The  surgeon  ought  then  to  intro- 
duce a  fine  probe-pointed  grooved  director  into  one  of  the  fistulous  openings  and  with  the 
greatest  gentleness  guide  it  through  the  fistula.  Anything  like  force  will  excite  re>sist- 
ance  on  the  part  of  the  sphincter  to  its  introduction  and  cause  pain.  When  the  end  of  the 
probe  p'asses  into  the  bowel  through  the  internal  opening,  all  that  is  required  has  been 
effected  ;  and  if  difficulty  be  experienced  in  doing  this,  the  well-greased  index  finger  of  the 
opposite  hand  can  be  carefully  inserted  into  the  rectum  and  the  internal  opening  felt  for, 
through  which,  when  found,  the  end  of  the  pi'obe  can  readily  be  guided  into  the  bowel. 

When  no  internal  opening  exists  (a  rare  condition), 
the  director  must  be  forced  through  the  bowel  at  the 
upper  part  of  the  sinus. 

As  soon  as  the  director  is  felt  in  the  rectum  the 
patient  should  be  told  to  strain,  the  surgeon  at  the 
same  time  with  his  index  finger  hooking  its  end  down- 
ward. By  these  means  the  director  will  be  made  to 
protrude  from  the  anus,  when  the  whole  of  the  tissues 
bi"idged  over  can  be  readily  divided  (Fig.  323). 

When  the  fistula  runs  high  up  and  much  force  is 
called  for  to  turn  the  probe  out  of  the  anus,  it  is 
better  to  pass  a  speculum  and  to  divide  the  fistula. 
When  a  long  sinus  runs  up  by  the  side  of  the 
bowel,  it  should  be  laid  open  through  a  speculum,  to 
leave  it  alone  not  being  a  safe  practice  ;  for,  although 
in  some  cases  a  cure  may  take  place,  in  many  the  dis- 
charge into  the  rectum  will  continue  and  but  little 
good  will  have  been  effected  by  the  external  opera- 
tion. The  pi-esence  of  this  internal  discharging  fistula 
is  generally  indicated  by  the  appearance  of  pus  upon 
the  motion. 

When  many  sinuses  exist,  they  should  be  laid 
open,  although  it  is  not  necessary  to  divide  the  sphincter  in  more  than  one  place,  as  a 
double  division  of  the  sphincter  is  apt  to  be  followed  by  incontinence. 

After-Treatment. — After  operation  the  wound  should  be  well  plugged  with  dry 
cotton-wool  down  to  the  bottom,  and  no  careless  introduction  of  the  plug  will  suffice.  By 
this  measure  all  bleeding  can  be  controlled,  and  any  amount  of  f  ressure  applied  by  means 
of  a  T-bandage.     When  no  bleeding  exists,  only  a  moderate-sized  plug  is  necessary. 

On  the  second  day  the  dressing  may  be  removed,  there  being  no  occa.sion  to  reintro- 
duce the  plug,  a  piece  of  oiled  wool  or  lint  gently  introduced  to  absorb  discharge  being 
all  that  is  required.  The  wound  should  be  kept  clean.  When  indolent,  it  can  be  stimu- 
lated by  some  lotion  of  nitric  or  carbolic  acid,  terebene,  or  tincture  of  iodine,  tonics  and 
good  diet  being  also  valuable.  The  horizontal  position — not  in  bed,  but  on  a  sofa — must 
be  maintained,  however,  till  the  parts  are  healed. 

In  the  hlhid  internal  fistula  a  guide  to  the  external  wound  may  often  be  found  by  means 
of  a  bent  probe  hooked  through  the  internal  opening,  and  the  case  treated  as  any  other. 

When  severe  bleeding  complicates  the  case,  a  speculum  may  be  passed  and  the  vessel 
seized  and  twisted.  Where  this  cannot  be  done  the  rectum  may  be  well  plugged  wnth  a 
sponge  saturated  in  alum;  but,  as  a  rule,  a  well-applied  pad  and  pressure,  adjusted  with 
a  T-bandage,  are  sufficient  to  control  it. 

A  piece  of  ice  put  into  the  centre  of  a  cup-sponge  and  applied  to  the  anus  not  only 
arrests  bleeding,  but  gives  great  comfort  in  this,  as  in  almost  all  anal  operations. 

When  a  cutting  operation  is  inexpedient,  as  in  "  bleeders,"  or  when  the  patient  will 
not  submit  to  it,  the  division  of  the  fistula  with  a  metallic  wire  heated  by  the  galvanic 
cautery  is  a  faultless  method.  Indeed,  in  all  cases  of  fistula,  where  this  apparatus  can 
be  obtained,  it  is  the  best  means.  It  readily  divides  the  tissues,  the  two  ends  of  the  wire 
being  made  to  project  through  the  two  orifices  of  the  fistula,  thus  burning  their  way  out 
with  a  sawing  movement.  There  is  little  pain  at  the  time,  and  scarcely  any  after,  with 
no  loss  of  blood,  and,  what  is  more,  no  need  of  subsequent  dressing,  as  a  cauterized  sur- 
face must  heal  by  granulation. 


Grooved  Probe  passed  through  Anal  Fistula 
before  its  Divisiou. 


III.MonininlDS,   (III   I'lLKS.  571 

When  this  plan  cannot  he  Inlhiwctl,  the  treatment  hy  li^'atnre  has  hoen  adopted.  Mr. 
Luke  revived  the  |)raetice  in  1S45,  hut  it  has  now  fallen  into  desuetude.  Were  I  ealled 
on  to  adopt  the  praetice.  1  should  use  an  iiidia-ruhher  lijrature. 

In  rare  eases  fistula  may  he  treated  hy  injiu'tion,  a  daily  iiijection  of  the  sinus  with 
some  tincture  of  iodine,  sulphate  of  zinc,  or  nitrate;  of  silver  haviufr  heen  followed  hv  a 
cure;  yet  suidi  cases  are  too  exceptional  to  justily  the  recommendation  of  such  treat- 
nieiil. 

W'luii  llie  patients  condition  is  sneli  ;..<  lo  i'orhid  any  hope  of  repair  in  the  wound 
takiiiu  place,  the  operation  for  fistula  should  he  set  aside;  hut  the  existence  of  pulmonarv 
mischii'f,  if  not  far  advanced,  is  no  ar<rumcnt  ajrainst  its  adoption  :  nay,  it  may  he  mad<,' 
use  of  as  an  arirument  in  favor  (d"  surj^ical  interference,  recent  investigations,  as  already 
alluded  to  in  an  early  chai)ter,  having  indicated  that  the  long  existence  of  .suppuration  is 
liahlc  to  set  up  tuherculous  disease.  Practically,  however,  it  is  undoubtedly  true  that 
tistula  nuiy  he  divided  and  heal  in  far  from  healthy  subjects,  and  the  general  health 
improve  after  tlie  operation. 

There  is  no  need  to  keep  the  bowels  locked  up  after  an  operation  for  fistula. 

Hemorrhoids,  or  Piles. 

In  a  clinical  point  of  view,  ihese.may  be  divided  into  tlie  hlrcding  and  the  non-hlpfd- 
iii</.  The  former  are  generaly  the  itifmial,  and  composed  of  a  highly  vascular  tissue 
involving  the  mucous  membrane  of  the  rectum  and  the  submucous  tissue,  with  enlarged 
arteries  and  veins.  Where  the  arterial  element  predominates,  the  tumor  has  a  bright-red 
strawberry  aspect ;  where  the  venous,  a  dusky  hue.  They  are  cloisely  allied  to  naevoid 
structure  and  discharge  arterial  blood. 

The  non-bleeding,  or  external,  piles  are  composed  of  the  loo.se  folds  of  skin 
that  surround  the  anus,  or  a  varico.se,  inflamed,  or  ruptured  vein.  When  inflamed,  these 
folds  become  oedematous  and  infiltrated  with  organized  inflammatory  products,  and  appear 
as  fleshy  growths  of  various  degrees  of  density.  The  venous  hemorrhoids  also  become 
swollen  and  appear  as  bluish,  tense,  and  painful  tumors.  When  in  an  active  state,  they 
may  encroach  upon  the  mucous  membrane  of  the  rectum  and  a])pear  as  large  as  a  walnut, 
but,  as  a  rule,  they  are  about  the  size  of  a  nut.  They  rarely  give  rise  to  much  annoy- 
ance when  cleanliness  is  observed,  but  under  other  circumstances  they  cause  much  local 
irritation.  When  swollen  or  inflamed,  however,  they  give  great  distress,  from  the  sensi- 
tive condition  of  the  skin  at  these  parts.  Plxternal  piles  also  are  occasionally  the  cause  of 
hemorrhage,  the  blood  at  times  coming  direct  from  an  ulcerated  vein  and  then  being  venous. 
At  other  times  it  will  be  profuse,  but  its  exact  seat  is  not  so  evident.  The  flow  comes 
from  between  the  pendulous  flaps  of  .skin,  and  ceases  when  they  have  been  removed. 

The  TREATMENT  of  external  piles  is  simple,  and  excision  is  the  only  radical  cure. 
The  pendulous  flaps  of  skin  that  surround  the  anus  may  be  removed  with  a  pair  of  sharp 
scissors,  the  tumor  having  been  drawn  forward  with  a  pair  of  forceps.  These  incisions 
should  be  made  in  lines  radiating  toward  the  anus.  When  coagulated  blood  has  been 
poured  out  into  the  pile  and  a  tense,  painful  tumor  exi.sts,  it  may  be  punctured  or  laid 
open  with  a  lancet,  bleeding,  when  it  occurs,  being  easily  arrested  by  cold  and  moderate 
pressure.  AVhen  the  pile  is  inflamed,  leeching  often  gives  comfort,  and  the  application 
of  a  poultice  covered  with  the  extract  of  opium  gives  relief  When  the  part  suppurates, 
the  abscess  may  be  opened. 

In  the  early  stage  of  the  affection  local  cleanliness  and  abstinence  from  highly-seasoned 
food  and  strong  wines  are  mostly  sufticient,  the  bowels  being  kept  clear  by  enen)ata  or 
the  occasional  dose  of  a  mild  aperient,  such  as  the  compound  rhubarb  pill,  before  dinner, 
some  saline,  purgative  water,  or  an  electuary.  When  local  irritation  exists,  an  ointment 
composed  of  e({ual  parts  of  zinc,  nitrate  of  mercury,  and  subacetate  of  lead  is  very  valu- 
able ;  some  recommend  the  compound  gall  ointment.  An  ointment  of  zinc  and  the 
extract  of  belladonna  is  very  useful. 

Internal  piles  are  very  insidious  in  their  growth — so  insidious,  indeed,  that  bleed- 
ing is  often  the  first  symptom  that  attracts  notice.  On  inquiry,  however,  it  may  gener- 
ally be  made  out  that  constipation  has  been  the  normal  condition,  and  that  irritation 
about  the  anus,  with  a  feeling  of  heat  and  fulness  in  the  parts,  had  previou.sly  existed. 
These  piles  often  appear  after  parturition.  When  the  parts  inflame,  there  will  be  throb- 
bing, and  pain  in  defecation  ;  when  they  protrude,  there  will  be  one,  two,  three,  or  more 
masses  of  thickened  mucous  membrane  with  n{X3Void  structure,  presenting  either  a  smooth 
and  tense  or  a  reticulated  surface.     Sometimes  there  will  be  oozing  of  blood  from  the 


572 


SURGERY  OF  THE  ANUS  AND  RECTUM. 


Internal  Hemorrhoids. 


whole  surface,  or  the  bh^od  may  spurt  from  a  distinct  orifice.  The  blood  is  almost  always 
red  and  arterial,  and  the  mucous  projection  is  surrounded  by  skin  more  or  less  pendulous, 
oedematous,  or  infiltrated  with  inflammatory  products  (Fig.  324). 

When  the  parts  are  not  inflamed,  this  hemorrhoidal 
mass  may  protrude  only  during  defecation  and  return 
naturally  or  after  a  little  pressure.  When  the  disease 
has  been  of  long  duration,  the  pile  may  protrude  on 
the  slightest  exertion,  even  on  the  patient  assuming 
the  ei-ect  posture  or  on  coughing,  the  whole  mucous 
membrane  of  the  rectum  often  participating  in  the 
prolapse  and  adding  to  the  discomfort. 

The  jmin  attending  the  development  of  these  piles 
varies  vastly,  small  hemorrlioids  often  giving  rise  to 
severe  local  distress,  while  the  larger  cause  but  little. 
An  inflamed  pile  is,  however,  always  painful,  and  a 
prolapsed  inflamed  one  the  most  of  all.  Where  pain 
is  excessive  and  more  particularly  felt  after  defecation, 
there  is  a  strong  probability  that  a  Jissure  or  an  ulcer 
complicates  the  case. 

The  amount  of  Jiemorrliage  bears  no  proportion  to 
the  extent  of  the  disease.  In  one  of  the  worst  cases 
of  hemorrhage  T  ever  saw,  in  which  a  lady  was  blanched  and  almost  pulseless,  the  pile 
was  not  larger  than  half  a  nut  ;  it  was  of  the  reticulated  kind,  and  the  blood  spurted  out 
from  a  vessel  as  large  as  the  radial  artery.  On  the  removal  of  the  pile  a  complete  recov- 
ery ensued  On  the  other  hand,  it  is  remarkable  to  what  an  extent  the  local  disease  may 
develop  in  some  cases  without  producing  excessive  bleeding. 

The  bleeding,  as  a  rule,  takes  place  after  the  action  of  the  bowels  and  covers  the 
motion  ;  occasionally  it  precedes  it ;  but  in  many  instances  it  is  quite  independent  of  all 
action  of  the  bowels,  blood  flowing  on  the  patient  assuming  the  erect  posture  or  at  odd 
times  without  any  such  cause. 

The  amount  of  blood  said  to  have  been  lost  vinder  these  circumstances  is  somewhat 
remarkable,  writers  upon  these  subjects  relating  the  loss  of  three  "  chamberpotfuls," 
"  eight  or  nine  pounds,"  etc.  Doubtless  in  many  of  these  accounts  there  is  exaggeration  ; 
still,  all  surgeons  must  at  times  be  astonished  at  the  loss  of  blood  that  takes  place  in  these 
cases  daily,  sometimes  for  years,  but  with  little  apparent  interference  with  the  general  health. 
The  discharge  of  a  thick  mucus  from  the  anus  is  a  frequent  accompaniment 
of  this  aff"ection  ;  and  when  ulceration  complicates  the  case,  the  secretion  is  of  a  muco- 
purulent character. 

Urinary  irritation,  and  at  times  retention,  in  both  male  and  female  subjects, 
and  in  women  WOmb  COmphcationS,  often  add  to  the  distress. 

Nerve  pains  passing  upward  to  the  loins,  hips,  and  round  the  sacrum,  or  even 
downward  to  the  heel  and  sole  of  the  foot,  are  likewise  met  with.  Brodie  gives  a  case  in 
which  the  heel  pain  was  the  most  prominent  feature. 

What  are  called  dyspeptic  symptomS  are  almost  always  present,  the  assimilat- 
ing organs  suffering  as  well  as  the  circulatory  and  nervous  systems. 

This  aff"ection  is  usually  met  with  after  puberty.  In  early  life  men  are  probably 
more  liable  to  it  than  women,  but  after  forty-five  both  appear  equally  liable. 

Constipation  has  probably  an  important  influence  in  causing  the  disease,  and  cer- 
tainly in  increasing  it ;  but  sedentary  occupations  and  high  living  appear  to  have  a 
stronger  eff"ect.  In  the  prosperous  classes  of  society  this  malady  is  comparatively  com- 
mon, although  in  the  poor  daily  hospital  experience  does  not  help  to  confirm  the  notion 
that  it  is  rare.  Whatever  tends  to  retard  the  flow  of  blood  from  the  hemorrhoidal  veins, 
such  as  pregnancy  and  abdominal  tumors,  aggravates  the  disease  ;  and  whatever  tends  to 
keep  up  irritation  in  the  rectum,  such  as  drastic  purgatives,  worms,  and  pungent  food, 
acts  in  a  similar  manner. 

A  pile  may  be  mistaken  for  a  polypus,  but  the  smooth,  firm  surface  and  pedunculated 
form  of  the  latter  will  reveal  its  true  nature.  Again,  a  ring  of  piles  might  be  confounded 
with  prolapse  of  the  rectum,  but  the  uniform  smooth  and  generally  non-bleeding  surface  of 
the  latter,  with  its  broad  attachments,  ought  to  be  enough  to  prevent  falling  into  the  error. 
External  piles,  when  ulcerated,  may  also  assume  very  much  the  aspect  of  venereal 
anal  outgrowths,  which  can  be  made  out  only  by  the  history  of  the  case  and  other  clini- 
cal symptoms. 


SUItdlCAL    rUEATMEST  OE   llEM<>J:J:ilnfI)S.  .073 

Finally,  it  must  iint  Kr  I'lUL'^uttcii  llial  IiciiinrrlKtiils  may  he  iiii'itiy  a  r"(»iisfiqueiict'  of 
another  disease.  mu-Ii  as  .stricture  ol'  tin-  rectum. 

TllKATMKNT. — All  piles  (lit  not  re(|uire  removal.  In  llie  early  periml  of  their  growth 
thi'V  may  'jl'  so  sueeessfully  treated  hy  what  is  <'allc<l  imllinlirr  treatment  as  to  reiirler 
more  active  measures  unnecessary,  ami  in  the  very  eacht;clie  ami  diseased  it  may  not  h«; 
CXjietlieiit  to  do  more  than  relieve,  althoujrh  it  must  he  added  that  uidess  orj^anic  disease 
exists  to  threaten  life  there  are  lew  ;reneral  conditions  of  a  patient  that  forhid  the  removal 
of  a  severe  bleediiiLi  pile.  A<rain.  when  jtile.s  occur  in  plethoric  subjects  who  are  pcirhap.s 
what  has  been  described  as  ajioplectic  or  gouty,  and  an  attack  of  them  is  preceded  by 
constitutional  disturbance  and  tollowed  by  relief;  the  surgeon  should  be  careful  in  clieck- 
ing  suddeidy  the  flow  of  blood,  as  such  a  measure  is  undoubtedly  sttnietimes  followed  by 
alarming  constitutional  symptoms,  though  such  cases  are  rare. 

The  /xil/inlirr  {)r  f/eiitinf  treatment  of  piles  means  attenti<tn  to  diet,  the  giving  up  of 
high  living  and  strong  drinks,  beer  and  spirits  in  particular  being  avoided,  and  the  taking 
of  simjtle  nutritious  food  in  moileration. 

The  bowels  should  be  regulated  by  the  mistura  olei,  already  described  (p.  508).  or  by 
castor  oil,  rhubarli  and  magnesia,  or  s(jme  saline  medicine  or  mineral  water,  such  as  Vichy, 
Frietlrichshall.  or  Pullna.  an<l  when  these  fail  by  enemata.  Indeed,  the  daily  enema  of 
cold  water  or  the  use  of  the  rectum  plug,  through  which  cold  water  is  allowed  to  flow,  is 
of  great  value.  Violent  purgation,  more  particulary  by  aloes  and  colocj'nth,  should  be 
avoided.  Some  prescribe  copaiba,  but  its  nauseous  <jualities  forbid  its  general  use.  The 
confections  of  senna  or  sulphur  are  useful,  and  that  of  black  pepper  (Ward's  paste)  has 
been  always  popular.  A  mixture  of  confection  of  senna  5J,  confection  of  sulphur  ^, 
powdered  guaiacum  ^ij,  and  treacle  is  very  beneficial.  The  compound  liquorice  powder 
is  of  great  use.  Dr.  Cleland  recommends  (Fract  it  loner,  January,  1870)  the  use  of  the 
li«(Uor  bismuthi  ."^ij.  mixed  with  .^i  of  starch,  as  an  enema,  to  be  used  at  night  in  prolapsus 
recti.  In  ])iles,  in  both  the  child  and  the  adult,  drachm  doses  of  glycerine  combined  with 
fifteen  grains-  of  citric  acid  and  some  vegetable  bitter  three  times  a  day  may  be  administered. 

When  the  secretions  of  the  liver  and  intestines  are  unhealthy,  a  little  blue  pill  or  gray 
powder  and  chalk  at  bedtime  is  sometimes  of  use,  some  bicarbonate  of  potash  in  gentian 
or  calumba  assisting  recovery. 

Absolute  local  cleanliness  should  always  be  observed,  and  the  recumbent  position 
assumed  after  defecation,  the  prolap.sed  pile  being  always  reduced  at  once  by  gentle 
pressure.  By  these  diff"erent  means  an  attack  of  piles  may  pass  away  never  to  return,  or 
to  return  only  after  a  long  interval ;  but  even  in  the  worst  cases  relief  may  be  given. 

When  the  piles  are  inflamed,  the  application  of  leeches  occasionally  gives  great  relief, 
bleeding  being  encouraged  by  hot  fomentations  ;  such  means,  however,  are  rarely  called 
for.  the  complete  washing  out  of  the  lower  bowel,  rest,  and  fomentations  being  generally 
sufficient.  In  some  cases  the  application  of  ice  in  a  cup-sponge  gives  more  relief  under 
these  circumstances  than  any  other  remedy. 

When  the  prolap.sed  internal  piles  are  strangulated  by  the  sphincter  spasmodically 
contracting  around  the  mass,  sloughing  of  the  whole  may  take  place.  Under  these  cir- 
cumstances great  pain  is  caused  by  the  tension  of  the  parts,  and  on  one  occasion  I  was 
tempted  to  cut  off  with  scissors  some  of  the  projecting  portions,  when  the  relief  was  so 
marked  that  T  would  repeat  it  under  the  .same  circumstances ;  to  adopt  this  practice  with 
safety,  the  pile  must  be  in  the  condition  that  precedes  its  death.  When  this  sloughing  takes 
place,  a  cure  may  follow.     During  the  sloughing  process  a  poultice  is  the  best  application. 

The  mucous  discharge  from  the  bowel  in  long-existing  piles  can  be  met  only  by  ene- 
mata and  the  application  of  astringents,  such  as  an  ointment  of  tannic  acid  ten  grains  to 
the  ounce,  of  gall  and  opium,  or  of  extract  of  rhatany  half  a  drachm  to  the  ounce  of 
lard  or  spermaceti.  The  occasional  introduction  of  a  suppository  of  tannic  acid  into  the 
rectum  is  likewi.se  a  valuable  expedient,  and  an  enema  of  alum  or  tannin  five  grains  to 
the  ounce  is  also  .serviceable.  Allingham  speaks  highly  of  an  ointment  of  the  persul- 
phate of  iron  half  a  drachm  to  one  drachm  of  the  unguentum  cetacei,  or,  as  a  lotion, 
twenty  grains  to  an  ounce. 

Surgical  Treatment. 

Unless  the  general  condition  of  the  patient  forbids,  all  piles,  external  or  internal, 
should  be  removed,  not  only  when  they  give  local  annoyance,  but  when  by  the  hemor- 
rhage produced  they  disturb  the  general  health  of  the  patient  and  induce  weakness.  To 
accomplish  this  many  means  are  at  our  disposal. 

External  hemorrhoids  ought  to  be  removed  by  abscission. 


574 


SURGERY  OF  THE  ANUS  AND  RECTUM. 


Internal  piles  ought  never  to  be  excised,  but  destroyed  by  the  galvanic  or  actual 
cautery,  crushing,  or  the  ligature.  In  the  hands  of  many  surgeons  the  ligature  still 
holds  Its  ground,  but  with  as  many  it  has  been  nearly,  if  not  altogether,  superseded  by 
crushing  or  the  cautery.  I  have  used  the  ligature  only  in  exceptional  cases  for  at  least 
twenty  years.  In  a  few  cases  nitric  acid  is  of  service.  In  Paris  a  plan  of  treatment 
has  been  successful  which  claims  attention,  as  it  receives  the  support  of  M.  Verneuil. 
It  consists  of  forced  anal  dilatations,  either  by  the  thumbs  of  the  surgeon  or  by  means 
of  a  dilator,  the  piles  withering  after  one  full  dilatation  of  the  anus  ( Union  Medicale, 
March  6,  1877). 

The  Ligature. — The  patient,  having  made  the  hemorrhoidal  tumors  protrude  by 
straining  over  a  stool  containing  hot  water  or  by  an  enema  of  warm  water,  should  be  placed 

on   his   side,  with   his   legs  drawn 
Fig.  325.  up  and  the  parts  well  brought  into 

view  by  an  assistant  separating 
the  buttocks.  The  surgeon  should 
then  grasp  the  base  of  the  tumor 
that  is  to  be  ligatured  by  a  pair  of 
forceps  (Figs.  325,  326)  and  sepa- 
rate the  pile  from  the  skin  and 
submucous  tissue  by  scissors,  sub- 
sequently transfixing  it  with  a 
needle  armed  with  a  double  silk  or 
hempen  ligature.  He  should  then 
divide  the  coi'd  and  tie  the  pile 
tightly  in  halves,  cutting  off  with 
scissors  at  least  half  of  the  strangu- 
lated portion  before  finally  tighten- 
ing the  second  ligature  ;  a  second 
or  third  mass  should  be  similarly 
treated  ;  the  ends  of  the  ligature 
should  then  be  cut  off  and  the  whole  returned  within  the  sphincter.  The  surgeon  should 
be  careful  to  include  in  his  ligature  all  the  diseased  tissue  ;  and  when  this  has  not  been 
done  with  the  forceps,  it  is  better  to  pass  a  needle  or  tenaculum  through  the  base  of  the 
pile  higher  up,  and  loop  a  ligature  round  it,  than  to  remove  the  forceps  and  reapply  it. 
He  should  also  take  care  not  to  include  any  of  the  external  skin. 

The  ligatures  may  be  expected  to  separate  about  the  seventh  or  tenth  day,  and  they 
should  always  be  allowed  to  slough  off. 

Apter-Treatment. — After  the  operation  an  opiate  may  be  given, 
or  a  full  dose  of  chloral  (half  a  drachm).  The  bowels  should  be  left 
undisturbed  for  at  least  two  days,  when  a  dose  of  castor  oil  or  other 
purge  may  be  administered,  or,  better  still,  an  enema.  The  horizontal 
position  must  be  maintained  throughout  the  case.  If  oedema  of  the 
parts  follow,  ice  may  be  applied,  or  a  lotion  of  lead  and  opium ;  bella- 
donna rubbed  down  with  glycerine  at  times  gives  relief.  Until  the 
bowels  act  the  diet  should  be  simple,  nutritious,  but  not  stimulating. 
This  operation  is  successful  and  has  no  special  danger,  though  it  is  per- 
haps more  tedious  than  the  treatment  by  cautery. 

The  Cautery. — When  internal  piles  require  removal,  the  clamp 
and  the  cautery  are  means  I  generally  employ  ;  and  the  thermo  or  gal- 
vanic cautery  is  preferable  to  "the  actual.  Cusack  of  Dublin  suggested 
this  practice  in  1835,  but  Henry  Lee  and  Henry  Smith  have  done  more 
to  establish  it  than  any  other  surgeons.  It  is  adopted  as  follows :  The 
patient  having  been  prepared  for  the  ligature  and  the  piles  protruded, 
the  anus  is  to  be  dilated  forcibly,  with  the  view  of  allowing  free  manip- 
ulation of  the  piles,  as  well  as  of  preventing  subsequent  spasm  of  the 
sphincter.  Each  mass  is  then  to  be  seized  seri<ifini  witk  the  vulcellum 
forceps,  drawn  down  and  secured  at  its  base  by  clamps  (that  represented 
in  Fig.  327,  a  modification  of  Curling's,  being  as  good  as  any),  the 
upper  end  of  the  clamps  presenting  toward  the  anus.  The  projecting 
half  of  each  mass  must  then  be  exit  off  with  scissors,  the  surface  wiped 
dry,  and  the  cautery,  heated  to  a  white  heat,  applied  to  the  surface ; 
the  whole  projecting  portion  being  burned  down  to  the  level  of  the  clamp ;  a  dense  eschar 


Fig.  327. 


si'Rt;i<:i/.  Tin:  AT  mi:  ST  or  ni:M<)i;i;nn/i)s.  575 

is  tliu>  tnriiicil.  W'licii  tlif  ilicrinu  i>v  ii;il\  .iiiic  caiihTy  caiinot  Iti-  lijid,  tin-  actual  cautery 
must  lie  cuipluvcil,  a  second  hciiiL:  at   liainl  t(t  us(!  as  tlie  first  cools. 

'I'lic  eschar  is  luori'  soliil  aixl  liiiii  alter  the  theniio  or  ;;alvaiiic  than  after  the  actual 
cautery  ;  it  is  likewise  follo\ve(l  liy  less  pain,  the  heat  hein^'  so  intiMise  as  to  destroy  all 
scnsihility.      Aiuple  ex|>erieuce  with  hoth  has  convinced  nie  ol"  this  fact. 

As  eacli  mass  is  destroyi'd  the  clani|i  should  he  removed,  care  ljein<^  taken  not  to  dis- 
turl)  the  eschar.  When  all  have  lieen  treated,  the  wIkjIc  projecting  mass  may  he  returned 
into  the  rectum  with  the  Hn<;er  well  j^reased,  it  being  a  good  plan  at  this  moment  to  intro- 
duce a  sup])ository  of  opium  or  morphia  to  soothe  pain. 

AFTKU-'ruK.VT.MENT. — Patients  should  he  kept  at  rest  for  at  least  two  week.s  after  this 
operation,  hut  thi-y  will  often  he  an.\ious  to  go  al)out  much  sor)ner,  saying  that  they  feel 
ipiite  well.  A  fortnight  is  the  aviTage  titne  for  convalescence,  hut  a  week  in  good  cases 
.seems  suHicient.  In  one  of  the  worst  ca.ses  of  internal  ])iles  I  ever  treated  I  applieil  the 
clamp  to  four  masses  and  l)urned  them  down  as  described  with  the  galvanic  cautery. 
After  the  first  day  all  pain  had  gone  ;  on  the  fourth  the  bowels  acted  naturally  without 
the  slightest  inconvenience,  and  in  a  week  the  man  was  up,  no  single  drawback  having 
taken  place.      Such  a  ca.se,  however,  is  e.Kceptionally  good  even  for  the  cautery. 

The  al'ter-treatment  is  the  same  as  in  ligature,  the  local  a])plication  of  ice  perhaps  giv- 
ing greater  comfort. 

Ignipuncture. — In  not  a  few  examples  of  internal  hemorrhoids  where  one  or  two 
sessile  masses  alone  existed  I  have  by  means  of  a  speculum,  without  the  aid  of  a  clamp, 
applii'd  the  galvanic  or  thermo  cautery  to  their  surfaces  direct,  and  in  others  I  have 
merely  punctured  them  in  two,  three,  or  more  places,  according  to  their  size,  taking  care 
to  rotate  rather  than  pull  on  the  cautery  in  its  removal.  Nothing  but  good  results  have 
followed  the  ])ractice,  and  I  am  disposed  to  think  that  in  such  cases  it  is  the  best  to 
adopt.  Mr.  Reeves  has  recently  strongly^  advocated  this  method.  A  good  sound  eschar 
forms  at  once,  and  on  its  removal  a  recovery  takes  place. 

Demarquay  (Gar:,  dr  Pan's,  18(J0)  merely  passed  a  hot  iron  over  the  surface  of  the 
pile  to  produce  a  superficial  eschar.  He  advised  also  linear  ecrasement  where  the  piles 
only  protrude  on  deiecation  and  can  be  replaced,  and  where  the  sphincter  is  not  relaxed 
nor  the  mucous  membrane  of  the  rectum  prolapsed.  In  all  other  cases  he  prefers  the 
cautery. 

Treatment  by  Crushing. — This  method  was  introduced  into  practice  by  Mr.  G. 
Pollock  {Ld licet,  July  o,  1880)  and  a  clamp  suggested  by  Mr.  Benham  employed. 

The  instrument  is  to  be  adjusted  as  in  the  operation  for  cautery,  and  the  protruding 
pile  cut  off  with  scissors.  The  clamp,  which  is  very  strong,  is  left  on  the  pile  for  one 
minute.  Messrs.  Pollock  and  Allingham  have  employed  this  method  of  crushing  very 
largely,  and  speak  favorably  of  it.  It  is  said  to  be  safe  and  to  be  followed  by  less  pain 
than  other  methods.  I  have  followed  this  practice  in  only  a  few  cases,  but  have  no  rea- 
son to  prefer  it  to  the  cautery. 

Treatment  by  the  Subcutaneous  Injection  of  Carbohc  Acid. — This 

method  has  been  employed  freely  in  America,  and  apparently  with  success.  It  is  appli- 
cable to  internal  piles  alone,  and  one  pile  should  be  treated  at  a  time,  about  a  week  being 
allowed  between  the  operations.  About  one  to  six  drops  of  a  solution  of  one  part  of  car- 
bolic acid  in  thirty  of  olive  oil  or  glycerine  should  be  injected  with  a  hypodermic  .syringe 
into  the  pile,  which  turns  white,  and  in  successful  cases  withers  without  pain  or  sloughing. 
An  ointment  of  vaseline  should  be  smeared  well  over  the  parts  around  the  pile,  to  guard 
against  any  injury  from  the  dropping  of  the  fluid.  The  majority  of  cases  treated  in  this 
way.  according  to  Dr.  Andrews  of  Chicago,  are  cured  rapidly. 

When  nitric  acid,  is  used,  the  patient  should  be  prepared  and  treated  in  the  same 
way  as  for  the  cautery  ;  the  acid  should  be  applied  with  a  piece  of  wood  to  the  diseased 
surface.  The  spoon-shaped  clam))  forceps  are  probably  the  best  to  use  under  these  cir- 
cumstances. After  the  application  of  the  acid  the  parts  should  be  well  oiled  and  returned. 
This  practice  was  suggested  by  Dr.  Houston  of  Dublin  in  1857.  To  small,  flat,  straw- 
berry-looking internal  hemorrhoids  this  plan  of  treatment  is  applicable,  but  is  not  so  satis- 
factory as  the  cautery.  I  never  now  employ  it.  Ulcerating  piles  may  be  treated  in  the 
same  way  as  others. 

When  a  fissure  or  painful  ulcer  coexists  with  hemorrhoids,  its  base  should  be  divided 
before  the  operation  for  hemorrhoids  is  undertaken,  or,  what  is  better,  lacerated  by  forci- 
ble dilatation  of  the  anus. 

In  operating  on  internal  piles  the  surgeon  must  be  careful  not  to  take  the  everted, 
and  possibly  oedematous,  skin  that  encircles  the  mucous  hemorrhoidal   mass  for  external 


576  SURGERY  OF  THE  ANUS  AND  RECTUM. 

piles  and  remove  it.  This  should  on  no  account  l>c  touched.  Pendulous  external  hem- 
orrhoids can  also  be  taken  away  at  the  same  time. 

In  rectal  operations,  when  an  anaesthetic  is  employed,  the  patient  requires  to  be 
brought  completely  under  its  influence.  It  is  probably  advisable  to  use  anaesthetics  in 
all  cases. 

Local  anaesthesia  in  these  operations  is  worse  than  a  delusion  except  for  the  removal 
of  external  piles,  but  it  is  of  use  to  assist  their  reduction  when  inflamed  and  edematous, 
and  to  give  relief  after  operation. 

The  danger  of  operating  is  but  small,  though  fatal  cases  have  followed  both  the  liga- 
ture and  the  cautery ;  the  advocates  of  the  latter  say  it  is  safer  than  the  former.  Mr. 
Henry  Smith  had  only  four  deaths  in  four  hundred  cases  operated  on  by  the  actual 
cautery. 

Prolapsus  Recti. 

This  is  met  with  in  every  degree  of  severity,  from  the  mere  protrusion  of  a  ring  of 
mucous  membrane  through  the  anus  (Fig.  328)  to  the  prolapse  of  even  a  foot  of  etdire 

bowel.     In  children  a  mild  form   is  very  common  ;  it  is 
ifiG.  6^».  usually  a  symptom  either  of  some  urinary  irritation,  such 

as  a  stone,  or  of  a  long  or  adherent  prepuce ;  worms,  con- 
stipation, dysentery,  a  poli/pus,  or  any  rectal  irritation 
may  likewise  induce  it,  as  may  a  cough  in  very  feeble 
subjects  where  the  sphincter  has  lost  its  tone.  One  of 
the  worst  cases  I  have  seen  in  an  adult  was  due  to  the 
existence  of  a  villous  polypus  high  up  the  rectum  ;  the 
straining  accompanying  the  affection  and  the  hemorrhage 
were  very  severe,  but  a  rapid  recovery  ensued  on  the 
removal  of  the  growth.  In  another  case,  that  of  a  lady, 
where  the  bowel  had  come  down  for  sixteen  years, 
accompanied  with  daily  hemorrhage,  and  in  which  walk- 
ing was  rendered  impossible  from  the  extent  of  prolapse 
'"'.■'"'  (about  six  inches  of  bowel),  the  removal  of  the  mucous 

„   ,         I.    f^  membrane    in    three    portions    by    clamp    and    cautery 

rapidly  effected  a  cure.  To  ascertain  the  true  cause  of 
the  affection,  consequently,  is  the  first  aim  of  the  surgeon,  the  treatment  being  then  com- 
paratively simple.      On  its  removal  the  prolapse  rapidly  disappears. 

Treatment. — Whenever  the  bowel  comes  down,  it  should  be  returned;  and  this  can 
usually  be  effected  by  placing  the  patient  in  the  recumbent  posture  and  pressing  with 
oiled  fingers  flat  upon  the  part.  In  children  the  utmost  gentleness  should  be  employed, 
for  with  pain  resistance  is  produced,  and  with  it  increased  difficulty  in  reduction.  Under 
all  circumstances  the  patient  should  be  kept  in  the  recumbent  posture.  The  bowels 
should  in  children  be  relieved  lying  down,  and  in  adults  the  horizontal  posture  ought 
always  to  be  assumed  after  natural  relief.  Brodie  advised  nocturnal  relief  of  the  bowels 
to  be  encouraged  with  this  object.  When  the  parts  have  been  down  for  some  time,  the 
greatest  trouble  is  often  experienced  in  their  reduction  ;  indeed,  sometimes  it  is  impos- 
sible, although,  with  the  patient  antBsthetized,  success  may  attend  the  gentlest  efforts 
when  forcible  attempts  had  previously  failed.  When  the  bowel  has  been  reduced,  a  good 
pad  or  sponge  fastened  on  with  a  T-bandage  will  keep  it  in  place,  or  the  nates  may  be 
fastened  together  with  some  good  bands  of  strapping.  When  the  bowel  is  inflamed  or 
ulcerated — a  condition  that  soon  occurs  in  chronic  cases  when  the  patient  goes  about — 
some  slight  scarification  may  be  called  for ;  but  the  application  of  cold  in  the  form  of 
ice  is  probably  the  best  treatment.  In  obstinate  cases  in  children  the  free  application  of 
the  nitrate  of  silver  in  stick  to  the  whole  mucous  surface,  previously  wiped  with  lint  and 
subsequently  mopped,  is  often  followed  by  its  reduction  and  retention.  I  have  never  seen 
this  practice  do  harm,  and  one  application  has  often  cured  the  disease.  The  injection  of 
three  or  four  ounces  of  Vater  made  astringent  with  tannic  acid  in  the  proportion  of  three 
grains  to  the  ounce,  or  with  tincture  of  iron  ten  drops  to  the  ounce,  or  of  the  infusion 
of  krameria  or  decoction  of  oak  bark,  with  or  without  alum,  after  the  bowels  have  been 
relieved,  is  a  valuable  adjunct;  in  adults  the  tannic  acid  suppository  twice  a  day  is  use- 
ful, as  also  the  application  of  the  tannic  acid  glycerine  before  its  reduction.  A  mixture 
of  the  solution  of  the  perchloride  of  iron  with  two  of  glycerine  is  likewise  a  good  appli- 
cation. Costiveness  should  never  be  allowed,  either  enemata  being  used  to  keep  the 
bowels  empty  or  the  mildest  laxatives,  as  rhubarb,  castor  oil,  or  some  natural  saline 


I'ni.vrrs  OF  ruF.  iiFrrr.M.  577 

water,  as  tlic  I'ulliia  or  I'licilriclisliall,  'I'o  ^ivi'  the  lj<»\vcl  toin;,  tonics,  as  a  rule,  are 
n'(|uiro(l,  mix  voinica  l)i'iiiir  prohalily  tlic  Ix'st,  cither  almic  or  in  comhinatiMU  with  iron. 
1  have  never  eiii|thiyi'(l  this  (IriiL,^  in  chihlren,  as  the  siinph'r  tonics  usually  sutiicc,  thijujifh 
some  suri;eoMs  speak  hit^hly  "i"  it.  In  cliililrtMi,  as  an  alt(!rativc.  rhubarb,  soda,  ami 
caluiuba  mixed  arc  to  \w  rceomniended.  In  mor»3  severe  eases  (»f' prolapse  the  upplicatioii 
of  nitric  aeid  in  vertical  strips  is  very  valuable,  or,  what  is  l)etter,  the  thernio  eauterv, 
similarly  aj)plied.  In  l>ad  cases  it  may  be  necessary  t<i  remove  three  or  four  vertical  folds 
of  mucous  membrane  with  the  clamp  and  cautery,  as  for  piles.  Kew  operatiojis  in  sur- 
i;ery  are  more  successful  than  this;  and  althoutrh  in  children  it  is  jirobably  never  rcfjuired, 
yet  in  adults  it  should  never  be  rejected  exce])t  for  the  same  causes  as  operations  for  lien»- 
orrhoids.  In  very  extreme  ca.scs  of  j)rolapse  tlic  linear  cauterization  of  the  prolap.sed 
bowel  may  be  advantageously  employed. 

The  treatment  of  such  a  case  wouli'  be  jirecisely  similar  to  tliat  laid  down  in  the  last 
section  for  piles. 

Polypus  of  the  Rectum. 

This  is  not  so  rare  a  disease  as  authors  would  lead  us  to  believe.  In  the  adult  it  is 
so,  comparatively,  but  in  tlie  child  it  is  thi;  priiuip'il  rmise  of  hcmorrluiffe  from  the  bov)el, 
and  from  this  fact  cases  of  polypus  have  been  doubtless  put  down  as  those  of  piles. 
These  iirowths  arc  ji;enerally  found  in  children  under  ten  years  of  age,  and  in  male  more 
commonly  than  in  female  subjects,  since  out  of  18  consecutive  cases  14  were  in  males,  13 
in  children  under  ten,  and  5  in  adults.  These  growths  vary  in  size  from  that  of  a  pea  to 
that  of  a  large  cherry  ;  they  grow  from  the  submucous  tissue  and  are  covered  bv  mucous 
membrane.  When  far  beyond  the  reach  of  the  sphincter  and  small,  they  })robal)ly  do  not 
cause  any  inconvenience,  tliough  when  large  they  may  give  rise  to  straining  of  the  bowel, 
to  prolajisus  recti,  and  even  to  intussusception.  One  of  the  worst  examples  of  prolapsus 
recti  I  have  ever  been  called  upon  to  treat  was  due  to  the  presence  of  a  til)rous  polypus 
situated  some  inches  up  the  bowel  of  a  man  fifty  years  of  age  who  had  suffered  from  it 
for  twenty  years.  He  was  cured  by  the  removal  of  the  growth.  Mr.  l\)llock  (  Holmes's 
Si/sf.,  vol.  iv.  ed.  2)  has  given  a  case  in  which  intussusception  took  place,  and  in  a  case 
of  my  own  the  same  result  ensued.  As  it  nears  the  sphincter  local  irritation  and  hem- 
orrhage are  produced,  the  growth  appearing  often  at  the  anus  as  a  pink  or  red  cherry. 
Blood  sometimes  flows  from  the  anus  only  during  defecation,  at  other  times  quite  inde- 
pendently of  it.  When  the  polypus  is  low  down,  there  is  usually  with  the  blood  a  free 
discharge  of  mucus. 

Whenever  a  child  is  brought  with  these  symptoms,  a  local  examination  should  be 
made  ;  and  to  do  this  efficiently  the  surgeon  should  sweep  his  finger  well  into  the  rectum 
completely  round  the  walls  of  the  bowel.  By  doing  this  the  polypus  will  be  dragged 
from  its  attachment  and  its  pedicle  made  tense.  Sometimes  several  polypi  exist  together. 
I  have  on  one  occasion  removed  three.  They  are  made  up  of  fibro-cellular  tissue,  being 
more  or  less  fibrous  according  to  the  age  of  the  patient ;  in  the  adult  the  fibrous  element 
predominates. 

When  polypi  have  been  discovered,  their  removal  is  the  only  correct  practice.  In 
children,  when  I  detect  them  with  the  finger,  I  generally  manage  to  hook  them  down, 
and  in  so  doing  break  them  off.  I  have  never  seen  any  bleeding  follow  this  measure. 
On  several  occasions,  when  I  have  brought  the  growth  external  to  the  sphincter,  the 
action  of  the  muscle  has  broken  it  away ;  and  in  this  manner,  doubtless,  many  cases  of 
polypi  are  naturally  cured.  When  they  do  not  break  off',  a  ligature  may  be  applied  to 
the  pedicle  and  the  growth  cut  off  beyond  the  knot.  In  adults  the  ligature  should 
always  be  employed. 

On  the  removal  of  the  disease  the  symptoms  disappear ;  but  when  they  continue,  a 
second  ]iolypus  will  generally  be  found. 

Papillary  or  villous  growths  are  occasioiu\lly  met  with  in  the  rectum,  as  in 
other  ))arts  of  the  large  intestine  ;  and  when  low  down,  they  give  rise  to  violent  .straining 
and  hemorrhage.  This  straining  may,  indeed,  give  rise  to  an  intussusception  of  the  bowel 
or  to  prolapsus  recti.  This  was  well  exemplified  in  the  case  of  a  woman  xt.  43  whom  I 
had  under  my  care  in  June,  1867.  She  had  suffered  from  prolapsus  recti,  with  more  or 
less  bleeding  after  every  motion,  for  twenty  years,  the  straining  at  times  being  most  dis- 
tressing. When  I  saw  her.  the  bowel  was  down  for  about  nine  inches ;  blood  was  then 
passing,  and  the  pain  was  great.  I  made  a  careful  exaiuination,  but  failed  to  find  any- 
thing. I  reduced  the  prolapsus  and  prescribed  rest.  On  my  second  visit,  with  the  bowel 
only  down  a  very  little.  I  examined  her  again,  and  with  mv  finger  could  just  touch  a  new 
37  ' 


578 


SURGERY  OF  THE  AXUS  AND  RECTUM. 


growth.     With  a  pair  of  long  fenestrated  forceps  I  took  hold  of  it  and  l)roiight  it  down 
finding  a  splendid  specimen  of  the  villous  polypus.      I  put  a   ligature   round  its  base   at 


Fig.  :r29. 


Fig.  330. 


Fig.  .330. — Vertical  section  of  Polypus  through  the  line  a.  Fig. 
.329,  showing  vascular  simple  and  compound  villi  covered  witl» 
a  columnar  epithelium,  large  vessels  in  the  base  on  which  the 
villi  rest,  and  sections  of  tlie  follicles  of  Lieberkiihn.  This 
section  represents  half  the  thickness  of  a  lobule  of  the  poly- 
pus seen  by  1 4-inch  power.  (Dr.  ^loxon's  Report  on  Villotts 
Growth,  with  drawings.) 


In 


Villous  Polypus  of  Rectum. 

once  and  cut  off  the  growth.  No  single 
unfavorable  symptom  subsequently  ap- 
peared ;  all  her  former  troubles  at  once 
vanished,  and  a  complete  recovery  en- 
sued. In  June,  1870,  this  woman  was 
still  well.  The  growth  is  illustrated  in 
Fig.  329,  and  its  microscopical  appear- 
ances in  Fig.  330. 

Condylomata  are  also  very  com- 
mon about  the  anus,  and  are  mostly,  but 

not  always,  syphilitic,  the  irritation  of  dirt  being  probably  sufficient  to  produce  them 
children  they  seem  to  come  from  the  irritation  of  worms. 

Treatment. — Cleanliness,  the  application  of  nitrate  of  silver,  and  the  dusting  of 
their  surfaces  with  calomel  or  oxide  of  zinc  generally  produce  a  rapid  cure.  Vegetations 
due  to  the  irritation  of  acrid  discharges,  such  as  gonorrhoea  or  syphilis,  require  to  be 
excised. 

W^arty  grovrths  are  also  met  with  about  the  anus,  as  on  other  cutaneous  surfaces. 
Sometimes  they  grow  to  a  great  extent,  and  then  require  excision.  I  have  removed  a 
mass  the  size  of  a  fist. 

Pruritus  ani  should  generally  be  looked  upon  as  a  symptom  of  some  rectal  or  intes- 
tinal irritation,  constipation,  or  rectal  disease.  It  is  always  a  source  of  great  distress,  the 
most  distressing  cases  being  those  in  which  the  symptoms  occur  at  night  in  bed,  preventing 
sleep.  The  best  application  I  know  for  its  relief  is  a  cold  sponge,  and,  having  dried  the 
parts,  the  ointment  made  of  equal  parts  of  zinc,  nitrate  of  mercury,  and  subacetate  of 
lead  ointments.  Zinc  and  opium  ointment  is  also  beneficial.  The  application  of  cold 
through  the  rectum  plug  may  also  be  recommended.  These  remedies,  however,  only 
relieve  the  symptom ;  in  order  to  cure  it  the  cause  must  be  found  out  and  removed.  If 
ascarides  be  the  cause,  Agnew  advises  an  injection  of  carbolic  acid  and  olive  oil  (one  part 
to  six),  and  in  obstinate  cases  an  enema  of  bromide  of  potash  .^ss  dissolved  in  cosmoline 
giv ;  in  nocturnal  pruritus,  iodoform  gr.  iij  or  iv  as  a  .suppository.  When  due  to  the 
presence  of  minute  cracks  and  fissures,  a  solution  of  nitrate  of  silver  gr.  x  to  xx  in  an 
ounce  of  spirits  of  nitre  is  good. 


Ulceration  of  the  Rectum  and  Stricture. 

The  painful  ulcer  of  the  anus  or  anal  orifice  of  the  rectum  has  been  already  noticed, 
and  it  remains  for  us  to  con.sider  briefly  such  other  forms  of  ulceration  of  the  rectum  as 
are  met  with  in  practice.  They  may  be  described  as  simple,  si/phil'dic,  and  cancerous. 
Simple  ulceration  is  by  no  means  unfrequent ;  and  when  not  involving  the  anus,  it  gives 
rise  to  symptoms  which  are  usually  looked  upon  as  dysenteric.  The  passage  of  lumpy 
feces  with  blood  and  muco-purulent  discharge  is  the  chief  symptom.  The  rapid  passage 
of  the  intestinal  contents  through  the  sigmoid  flexure  and  rectum  gives  rise  to  a  slight 
griping  pain,  but  beyond  this  there  are  few  general  symptoms.  On  examining  a  rectum 
under  these  circum.stances  a  single  ulcer  will  probably  be  found,  but  occasionally  others. 
It  may  be  somewhat  indurated  at  its  edges,  though  its  base  is  not  so  as  a  whole.  It  is 
often  circular,  and  at  times  surrounding  half  the   rectum,      [n  the  case  of  a  bov  act.  16 


iij'EiiATios  OF  riii:  nhciTM  A.\n  sruicrriii:.  ,-,79 

under  my  t rfatinciit  the  siirlacc  ol'tlic  ulcer  was  su  rnxliilar  that  I  <lioul<l  li.ive  suhpeeted 
its  euiieiM'ous  nature  had  I  uiet  with  it  in  an  adult,  hut  in  this  instaiiee  it  had  existed  i'ur 
many  mduths,  and  the  granulations  had  assumed  a  ixtlypoid  nature.  It  ended  in  a 
recovery.  These  simple  ulecrs  are  also  likely  to  y»erforate  the  hhulder  and  to  induce 
recto-vesical  fistula.  1  liave  had  five  such  cases,  and  in  four  ccdotomy  was  performed 
with  success,  the  operation  takin>r  away  tlie  chief  source  of  distre.s.s — viz.,  the  passaf^e  of 
feces  with  the  urine — |)ndonj;in;;  lil'e.  and  ajtparently  allowin^-^  the  ulcers  to  heal.  (  Vidr 
paper  by  author,  ('liiiivnl  Sue,  ISTli. ) 

Trk.vT.MK.NT. — These  cases  can  he  treate(l  hy  jreneral  means,  such  as  a  careful  rejru- 
lation  of  the  diet,  alkaline  medicines  with  tonics,  the  administration  of  laxatives,  such  as 
the  mistura  olei,  to  cause  and  maintain  a  .soft  cfnidition  of  the  feces,  and  the  daily  adminis- 
tration of  a  small  two-ounce  enema  of  starch  and  ojiium  or  simple  oil.  The  recumbent 
position  should  lie  maintained  as  much  as  possible. 

Tnder  these  circumstances  a  jrood  recovery  frenerally  takes  [ilace. 

When  these  ulcers  involve  the  anus,  they  give  ri.se  to  the  same  painful  symptoms  as 
the  painful  ulcer  of  the  anus  and  must  be  treated  in  a  similar  way — viz.,  by  divisifin  of 
the  superfiii:il  Hlncs  nf  the  >phincter. 

Syphilitic  disease  of  the  rectum  is  a  more  common  affection  and  is  met  with 
in  both  sexes,  though  more  fretjueiitly  in  women  than  in  men,  the  disea.se  apparently 
creeping  IVom  the  vagina  to  the  rectum.  Occasionally  it  is  due,  doubtless,  to  direct  intro- 
duction of  the  poison.  It  appears  as  a  more  or  less  extensive  ulceration  of  the  lower  two 
inches  of  the  rectum,  and,  as  a  rule,  involves  the  anus,  as  well  as  passing  higher  up  the 
rectum.  It  is  a  disease  of  the  mucous  and  submucous  tissues,  and  is  indicated  in  its 
early  stage  by  a  syiongy  induration  of  these  tissues,  and  later  by  ulceration  and  the  dis- 
charge of  a  highly  irritating,  sero-purulent.  or  sanguineous  discharge  and  by  a  patulous 
anus.  The  anus  itself  may  also  be  the  seat  of  the  lateral,  flattened,  fleshy,  cutaneous 
outgrowtli  so  common  in  syphilis,  or  it  may  be  ulcerated.  It  is  generally  a  di.sease  of 
young  adult  life  and  associated  with  some  syphilitic  history. 

8v.MPTOM.s. — There  is  almost  always  some  pain  in  the  act  of  defecation,  some  looseness 
of  the  bowels  and  discharge  of  blood,  .pus,  or  mucus.  Anal  or  vaginal  fistulas  sometimes 
complicate  the  case.  In  neglected  cases,  where  cicatrization  has  gone  on  with  spreading 
ulceration,  there  may  be  constipation  and  some  stricture ;  indeed,  as  a  cause  of  stricture 
of  the  rectum,  this  syphilitic  disease  is  by  no  means  unusual. 

Treat.mext. — Recognizing  its  .syphilitic  origin,  large  doses  of  the  iodide  of  potassium 
ought  to  be  given — five  grains,  gradually  increased  to  ten  or  twenty,  three  times  a  day — 
in  some  bitter  infusion  or  bark  ;  but  when  tonics  are  indicated,  they  may  be  given  in 
combination.  The  bowels  should  be  kept  slightly  loose  by  the  daily  dose  of  olive  oil  or 
castor  oil,  so  regulated  as  not  to  purge,  and  the  daily  employment  of  an  enema  of  starch 
or  gruel,  with  or  without  oil,  to  keep  the  parts  clean  and  free  from  the  irritation  of  feces. 

The  recumbent  posture  should  likewise  be  observed,  and  simple,  nutritious,  but  not 
bulky,  food  taken. 

Locally,  absolute  cleanliness  is  essential.  Where  contraction  exists  or  is  taking  place, 
the  daily  introductiotj  of  a  bougie  anointed  with  some  mild  mercurial  ointment  such  as 
the  unguentum  metallorum  may  be  used,  but  for  the  patient  the  daily  introduction  of  a 
candle  similarly  anointed  is  preferable,  candles  being  made  of  all  sizes.  Nothing  like 
mechanical  dilatation  should  be  thought  of,  as  it  is  dangerous  in  the  extreme.  By  these 
means  a  cure  may  be  effected,  though  such  can  only  be  complete  after  the  treatment  of 
months.  In  very  neglected  or  severe  cases  a  cure  is  almost  hopeless  without  colotomy. 
I  have  had  some  striking  examples  under  my  care  illustrating  well  the  advantages 
of  this  operation.  The  recognition  of  the  disease  as  syphilitic  is  the  main  point  of 
importance. 

Foreign  authors  describe  chancroid  disease  of  the  rectum  as  venereal,  and  not  syphili- 
tic ;  but  in  this  country  it  is  hardly  recognized.  Such  may,  however,  be  found  amongst 
the  cases  described  as  simple  ulceration. 

Cancerous  ulceration  of  the  rectum,  usually  epithehal,  sometimes  vil- 
lous, rarely  carcinomatous,  is  generally  met  with  two  or  three  inches  up  the  bowel.  It 
occasionally  occurs  higher  up  and  beyond  the  reach  of  the  finger  in  the  rectum,  and  occa- 
sionally lower  down,  nearer  the  anus  or  involving  it.  It  is  remarkably  insidious  in  its 
origin  and  uncertain  in  its  progress,  giving  rise  at  first  only  to  such  symptoms  as  are  usu- 
ally put  down  to  con.stipation,  for  this  symptom  is  the  most  prominent  feature,  while  the 
occasional  pain  and  bearing  down  or  straining  are  looked  upon  as  the  result  of  the  consJti- 
pation.     In  a  general  way,  it  is  only  when  some  blood  or  sero-purulent  fluid  has  pas.sed, 


580  SURGERY  OF  THE  AXUS  AXD  RECTUM. 

with  or  without  a  motion,  that  surgical  aid  is  sought  ;  and  it  is  under  such  circumstances 
that  the  surgeon  discovers,  on  making  a  local  examination,  that  such  a  serious  disease 
exists. 

The  cancerous  ulcer  can  rarely  be  overlooked  and  occurs  as  an  indurated,  nodular, 
irregular  mass.  In  its  early  stage  the  surface  may  be  smooth  ;  in  a  later,  irregular,  from 
ulceration  ;  the  discharge,  which  is  generally  very  often.sive.  is  made  up  of  broken-up  tis- 
sue, blood,  and  thin  pus.  The  disease  involves,  as  a  rule,  the  whole  circumference  of  the 
bowel ;  at  others,  only  a  part.  It  is  always  associated  with  a  narrowing  of  the  canal, 
which  will  go  on  to  cause  its  complete  occlusion.  It  generally  attacks  patients  pa.st  mid- 
dle life,  but  it  may  be  found  in  the  young.  I  have  seen  it  in  a  boy  aet.  15,  and  in  Sep- 
tember, 1871,  I  attended,  with  Mr.  Turner  of  Bermondsey.  a  girl  aet.  IS  who  had  had 
insuperable  constipation  for  seven  weeks.  I  opened  her  colon  in  the  n'>jJit  loin  with  great 
relief,  and  she  was  up  and  about  in  six  weeks.  She  died  ten  months  after  the  operation 
(June,  1872)  with  a  rectum  complete!}/  occluded  from  cancerous  disease,  and  with  second- 
ary tubercles  in  the  pelvic  peritoneum.  The  disease  was  examined  at  the  Pathological 
Society  by  the  committee  on  morbid  growths,  and  was  found  by  Dr.  Hilton  Fagge  and 
Dr.  Goodhart  to  be  of  a  cancerous  nature,  confined  to  the  peritoneum  and  ovarv.  and 
only  leading  to  sti'icture  of  the  bowel  by  a  secondary  process  of  contraction.  The  stric- 
ture has  an  ulcerated  surface,  but  the  mucous  membrane  did  not  show  any  cancerou.s 
elements  (Trans.  Path.  Soc.  1875). 

Treatment. — Palliative  treatment  can  alone  be  thought  of.  such  as  the  maintenance 
and  improvement  of  the  general  health  by  diet  and  tonics  ;  the  removal  of  all  local  causes 
of  irritation  by  the  use  of  laxatives,  to  render  the  motions  more  liquid,  and  consequently 
more  easy  for  evacuation  ;  and  the  relief  of  pain  by  the  use  of  enemata  of  starch  and 
opium  or  by  morphia  suppositories. 

In  the  very  early  stage  of  the  affection,  before  ulceration  has  taken  place,  the  use  of 
bougies  may  be  justifiable  and  useful,  but  when  ulceration  exists  they  are  injurious  and 
dangerous.  When  the  ob.struction  becomes  a  symptom  of  importance,  surgical  treatment 
will  have  to  be  thought  of;  but  this  will  be  considered  under  the  heading  "Stricture  of 
the  Bowel." 

Complications  of  Ulceration. — All  cases  of  ulceration  of  the  rectum  may  go  on 
to  cause  stricture  :  the  cancerous  cases  to  a  certainty  must,  the  syphilitic  often  do.  and 
the  simple  may  when  extensive.  The  two  latter  cause  a  cicatricird  stricture  resulting 
from  the  contraction  of  the  cicatricial  tissue  in  the  mucous  and  submucous  tissue,  the 
first  producing  a  stricture  by  simple  increment.  Thej-  may  also  be  complicated  with 
deep-seated  abscesses  and  fistulje  and  with  hemorrhoids.  The  surgeon  should,  therefore, 
always  be  careful,  when  treating  these  affections,  to  examine  the  rectum  minutely,  as  it  is 
only  too  common  to  meet  with  cases  that  have  been  subjected  to  useless  operation  for 
piles  and  fistula  when  these  affections  were  the  results  of  a  far  more  serious  disease,  such 
as  stricture  or  ulceration  of  the  rectum. 

Again,  any  of  these  forms  of  ulceration  may  extend  into  the  bladder  or  urethra.  I 
have  had  five  examples  of  such  cases  of  vesico-intestinal  fistula  under  my  care  in  males 
and  one  in  a  female,  in  all  of  which  the  agonies  of  a  foreign  body  in  the  bladder  were 
added  to  those  produced  by  the  ulceration,  and  in  the  four  male  cases  complete  relief  was 
afforded  by  colotomy.  In  three  of  these  the  ulceration  seemed  to  be  of  the  simple  kind. 
In  another  the  existence  of  rectal  ulceration  was  first  revealed  by  a  sudden  rush  of  urine 
through  the  rectum  after  an  attack  of  retention. 

I  have  seen  many  cases  of  recto-vaginal  fistula  as  a  consequence  of  syphilitic  and 
cancerous  di.sease. 

Stricture  of  the  Rectum. 

In  the  majority  of  cases  this  is  caused  by  cancerous  disease ;  in  many  it  is  the  result 
of  an  inflammatory  process,  simple  or  svphilitic,  from  the  cicatrization  of  deep-seated  and 
extensive  ulceration  ;  in  others  it  is  due  to  the  contraction  of  inflammatory  material  poured 
out  in  the  submucous  tissue  :  in  exceptional  instances  it  may  arise  from  contraction  of  the 
parts  external  to  the  bowel  after  pelvic  cellulitis :  and  Curling  quotes  a  case  where  it  was 
the  direct  result  of  an  injury. 

In  all  these  conditions  the  calibre  of  the  intestine  is  gradually  or  rapidly  encroached 
upon,  till  at  last  complete  obstruction  takes  place.  The  stricture  may  appear  after  death 
as  an  anmdar  contraction  of  the  bowel  with  adventitious  material  in  the  submucous 
tissue  and  hypertrophy  of  the  muscular  coat,  looking  very  like  a  so-called  scirrhous 
pylorus,  or  as  a  thickened,  ulcerated,  irregular  mass  of  cancerous  material  infiltrating  all 


STiucrriir:  or  riii:  /:i:<rrM. 


681 


Stricture  of  Rectum. 
(32.5iJ<-',  (juy's  Hosp.  Mifs.) 


tin-  li.ssufs  ol'  llic  liKWcl  altliiui^li  rarely  cxti-iKiiiij:  IicY'MkI  two  or  tlin-c  inclics  in  li'ri;:lli. 
Tlu-  Ixiwi'l  iibdVf  the  stricture  will  ul\v;iys  lit-  tlilatcd,  at  times  even  to  riipl  iiriii;:.  ulceration 
of  tile  colon  lieiii^'  a  very  common  conse(juence  ot"  tlie  <lilatation. 
IJelow  the  stricture  there  will  olteii  he  found  pcfluiiculated,  flerthy, 
or  cancerous  <:rowths.      These  points  are  well  seen  in  Ki^.  \\\\\. 

It  has  heen  already  |)ointe(l  out  that  fistula,  isehio-reetal,  vesi- 
cal, or  va>:iiial,  ahscesses,  and  hemorrlinids  are  conminM  accom- 
yianinicnts  of  stricture. 

The  disease,  taken  as  a  whole,  is  twice  as  common  in  women  as 
in  men,  and  I  found  from  my  own  notes  that  W'l  out  of  4S  consec- 
utivi'  casi's  were  of  the  former  sex.  Hut  syphilitic  stricture  i- 
more  common  in  the  female,  and  cancerous  in  the  male.  Curlin;;. 
in  »|Uotinjr  t!7  cases  of  cancer,  jxives  44  in  males.  In  my  4S  cases 
2(»  were  found  in  suhjects  under  thirty,  1.')  of  these  hein<;  women, 
and  mostly,  if  not  all,  .syphilitic;  22  were  in  subjects  over  forty, 
half  heiuir  men,  the  majority  of  these  being  probably  cancerou.s. 

The  approach  of  the  disease  is  very  insidious,  whatever  may 
he  its  origin  or  nature,  and  the  symptoms  are  generally  such  as 
have  been  given  under  the  heading  of  '•  Cancerous  Ulceration  of 
the  Bowel." 

OniatiiKtiliiH  is  the  one  early  symptom,  and  it  is  not  till  some 
ulcerati(jn  has  commenced,  either  at  the  stricture  or  above  it,  that 
others  a{)pear.  Of  these  the  most  common  are  diarrhced  with 
lumpy  stools  containing  blood,  pus.  or  mucus;  sfrnitu'iif/  at  stool  and  a  sf/isafion  <>J  hnni- 
ing'in  the  part  afterward  ;  at  last  a  complete  stoppage,  abdominal  distension,  and  dyspeptic 
symptoms. 

An  examination  with  the  finger  carefully  introduced  into  the  rectum  will,  as  a  rule, 
at  once  reveal  the  true  nature  of  the  ca.se ;  for  about  two  inches  up  the  bowel  the  nar- 
rowing will  usually  be  felt,  with  or  without  ulceration,  or  the  infiltration  of  the  part  with 
new  ti.ssue.  Sometimes  the  .stricture  is  beyond  the  reach  of  the  finger,  and  then,  prob- 
ably, Vty  pressure  upon  the  abdomen  above  the  pelvis  with  the  free  hand  or  by  the  intro- 
duction of  the  hand  into  the  rectum,  the  disease  may  be  felt. 

When  the  stricture  is  annular,  it  is  probably  cicatricial  or  fibrous,  possibly  cancerous. 

When  ('plthell(d  or  positively  cancerous,  it  will  be  infiltrated  with  a  nodular,  irregular 
mass  of  new  ti.ssue,  which  may  be  breaking  down  and  ulcerating ;  and  occasionally  the 
mass  can  be  felt  externally  at  the  brim  of  the  pelvis,  over  the  left  iliac  fossa. 

When  si/jt/n'/(fi(\  the  ulceration  will  pntbably  extend  upward  from  the  anus,  and  such 
anal  integuniental  outgrowths  as  have  been  already  mentioned  will  exist. 

In  ordinary  cases  of  cancerous  stricture  there  is  an  inch  of  healthy  rectum  between 
the  stricture  and  the  anus,  though  in  exceptional  instances  and  where  disease  is  extensive 
the  anus  is  involved. 

In  advanced  ea.ses  the  anus  will  appear  patulous,  and  on  separating  the  buttocks  a 
red.  a  brickdust-colored,  feculent  discharge  may  run  out ;  wind  will  also  pass  without 
effort. 

To  the  flat,  tape-like,  or  figured  feces  which  some  authors  regard  as  being  character- 
istic of  this  disea.se  I  concur  with  Curling  in  not  ascribing  much  importance,  .«;ince  such 
a  condition  of  motion  is  not  uncommon  even  in  a  state  of  health  when  the  bowels  are 
irritable  ;  besides,  many  other  conditions  of  the  pelvic  parts  may  give  rise  to  the  same 
thing.  When  a  patient  never  pa.s.«es  a  well-formed  motion,  large  or  small,  the  case  looks 
suspicious;  and  when,  on  the  other  hand,  a  large  well-formed  stool  is  occasionally  seen, 
the  probabilities  of  a  stricture  existing  are  very  slight. 

The  examination  of  a  diseased  rectum  with  a  tube,  flexible  or  otherwise,  with  or  with- 
out injection,  requires  the  greatest  care  and  gentleness,  as  the  gut  is  easily  perforated  or 
ru]itured:  moreover,  the  surgeon  may  be  misled  to  suspect  obstruction  where  none  exists 
by  the  end  of  the  instrument  striking  against  the  sacrum  or  being  caught  in  a  fold  of 
mucous  membrane. 

It  must  also  be  remembered,  in  examining  a  rectum  for  a  supposed  stricture,  that  its 
calibre  may  be  more  or  less  completely  encroached  upon  by  pelvic  tumors,  uterine,  ova- 
rian, prostatic,  hydatid,  or  bony.  Some  few  years  ago  I  had  a  case  with  Dr.  DeAth  of 
Buckingham  in  which  a  hydatid  tunmr  caused  complete  obstruction  to  the  rectum  as 
well  as  to  the  bladder,  and.  although  the  latter  organ  was  emptied  on  the  evacuation 
of  the  hydatid  contents,  the  patient  died   unrelieved   from  an   enormously  over-distended 


582  SURGERY  OF  THE  ANUS  AND  RECTUM. 

and  ruptured  colon  (Trans.  P,ith  Socicfy,  1886).  In  April,  1870,  I  saw,  with  Mr.  Phillips 
of  Leinster  Stjuare,  a  mo.st  intere.sting  case  of  complete  ob.struction  of  the  bowel.s  in  a  lady 
set.  46,  caused  by  the  presence  of  a  large,  loose,  cancerous  growth  hanging  from  the  peri- 
toneum into  the  pelvis,  covering  in  the  promontory  of  the  sacrum.  The  tumor  had  been 
regarded  by  an  eminent  {thysician-aceoucheur  as  uterine.  Colotomy  was  performed  with 
great  relief,  but  death  took  place  on  the  third  day,  from  collapse  caused  by  a  sudden  rup- 
ture of  the  tumor  and  escape  of  its  softened  contents  into  the  peritoneal  cavity.  In 
March,  1875,  I  also  opened  the  descending  colon  of  a  boy  a3t.  18  for  complete  obstruction 
of  the  rectum  from  a  cancerous  tumor  that  filled  the  pelvis  and  the  abdomen  as  high  as 
the  umbilicus.  The  boy  survived  the  operation  two  months,  dying  from  other  causes 
than   obstruction. 

Treatment. — It  is  so  rare  for  a  surgeon  to  be  consulted  about  a  stricture  of  the 
rectum  till  either  the  ulcerative  stage  has  set  in  or  almo.st  complete  obstruction  has  taken 
place  that  he  has  few  opportunities  of  testing  the  value  of  dilatation  of  the  stricture, 
since  this  practice  is  clearly  useless,  if  not  injurious,  under  these  circumstances.  In  cica- 
tricial or  inflammatory  strictures,  however,  it  is  the  only  form  of  practice  upon  which 
reliance  can  be  placed. 

Dilatation  should  be  effected  by  mechanical  means,  but  applied  with  caution  ;  forcible 
dilatation  is  inadmissible.  Many  instruments  have  been  invented  for  the  purpose,  but 
the  elastic-gum  bougie  is  the  favorite.  I  have,  however,  known  so  much  harm  to  follow 
its  use  that  I  have  abandoned  it  and  prefer  the  sponge-tent,  by  which  a  stricture  can  be 
dilated  in  a  painless  and  less  dangerous  way.  When  it  does  not  produce  any  irritation,  a 
second  and  larger  may  be  passed  in  two  days  ;  but  when  irritation  is  .set  up,  the  repetition 
of  the  operation  should  be  postponed  till  it  has  subsided.  By  these  means  a  simple  stric- 
ture may  be  checked  in  its  progress,  and  even  dilated,  though  rarely  cured.  This  prac- 
tice may,  however,  prolong  life  for  years.  Mr.  Curling  gives  a  case  in  which  he  believes 
he  cured  an  annular  stricture  in  a  lady  set.  24  by  incisions  and  dilatation.  I  can  record  a 
case  which  occurred  in  a  lady  agt.  30  who  some  years  before  had  had  what  she  called 
dysentery.  When  I  saw  her,  the  rectum,  about  one  inch  from  the  anus,  was  narrowed  by 
a  diaphragmatic  stricture  which  would  only  admit  a  probe.  I  incised  this  in  three  direc- 
tions and  kept  it  dilated  with  bougies.  Three  years  later,  when  she  died,  no  evidence  of 
stricture  could  be  made  out.  Another  case  in  whicii  for  two  years  a  lady  has  been  in 
complete  comfort  after  the  operation  has  come  under  my  care. 

M.  Verneuil,  in  the  Gazette  Mediade  de  Paris  for  January,  1873,  has  advocated  the 
operation  of  rectotomy  for  the  cure  of  stricture.  This  operation  consists  in  an  incision  by 
means  of  a  blunt-pointed  bistoury  introduced  flatwise  through  the  stricture,  guided  by  the 
index  finger  of  the  left  hand,  and  the  divi.sion  of  the  entire  thickness  of  the  strictured 
bowel  downward  and  in  the  median  dorsal  line,  through  the  anus  and  the  sphincter,  the 
free  division  of  this  muscle  evidently  playing  as  important  a  part  in  giving  relief  as 
the  division  of  the  stricture.  Drs.  C.  Lente  (American  Journ.  of  Med.  Sciences,  July, 
1873)  and  C.  B.  Kelsey  of  Xew  York  (Neir  York  Med.  Jovrn.,  March,  1880)  have  also 
advocated  a  like  practice,  at  the  same  time  adopting  an  anterior  as  well  as  posterior  incis- 
ion in  non-malignant  strictures.  Dr.  Kelsey's  paper  shows  that  where  the  disease  is 
quite  low  down  and  within  easy  reach  of  the  finger  this  operation  gives  almost  as  much 
relief  as  colotomy. 

This  dilatation,  however,  is  only  a  means  to  an  end  ;  and  that  end  is  to  secure  an  open- 
ing for  the  passage  of  the  intestinal  contents.  Enemata  are  valuable  aids  to  efl"ect  this 
purpose,  the  daily  washing  out  of  the  bowel  with  gruel  and  oil  or  the  daily  use  of  mist, 
olei  with  manna,  confection  of  senna  with  sulphur,  or  any  other  gentle  laxative  that  the 
patient  by  experience  has  found  to  suit,  giving  great  relief.  Cod-liver  oil  in  full  doses 
often  acts  as  a  laxative  as  well  as  a  tonic.  Care,  too,  should  be  observed  in  the  introduc- 
tion of  the  tube  ;  for  in  a  cancerous  bowel  perforation  is  very  liable  to  occur,  and  even 
in  a  healthy  one  this  accident  has  taken  place.  The  Guy's  Museum  contains  a  prep. 
(1877'*")  in  which  the  colon  was  perforated  by  a  bougie  thirteen  inches  from  the  anus  for 
an  imaginary  stricture,  and  a  second  (1877-°)  in  which  an  O'Beirne's  tube  perforated  the 
rectum  five  inches  from  the  anus  in  an  attempt  to  pass  it  up  the  healthy  bowel  to  give 
relief  in  a  case  of  obstruction  after  the  reduction  of  a  hernia. 

How  far  it  is  safe  to  allow  a  patient  to  pass  a  bougie  for  himself  or  herself  is  another 
question.  I  am  disposed  to  think  it  is  unwise  to  allow  it  when  the  bougie  is  solid,  hav- 
ing seen  great  irritation,  and  consequently  harm,  follow  the  practice,  and  in  several  cases 
deep-seated  suppuration.  Curling  has  given  a  case  where  the  patient  caused  his  own 
death  by  perforating  the  bowel  half  an  inch  in  extent  above  the  stricture.      I  have  con- 


j:.\cjsi().\  or  rui:  i.nwi:/:  i:\n  or  riir.  rectum.  583 

.s('(|iifiitly  liffii  ill  tlic  li;il)it   (if  iiistnictiiij::  my  patients  tu   use  lullnw  imikUcs  as  I)i»u(^ie8, 
ami  liavi'  l)ffii  satisliftl  with  the  pracliic. 

'I'litTc  cimics  a  time,  liowi'vcr.  when  tliis  tn-atiiifiit  l»v  iliialatiun  ccuhiis  to  Ix;  ht-iiftioiul 
»ir  wlicii  it  is  associated  with  mih-li  distress,  as  wliuii  thi-  stricture  has  dostid  or  ulceratcid. 
I'lidcr  thc.-c  circumstances  the  i|uestiou  of  r.irislnii  of  this  disease  or  of  the  operation  of 
e()h>totiiy  may  l»e  coiisiih-red.  'I'he  former  operation  may  he  disi-ir-sed  hiter  on.  'I'he  hitter 
;;ives  comfort  to  a  ih'i;ree  tliat  sometimes  astonishes  and  always  j^ratities;  it  prohjn^s  life 
and  adds  materially  to  its  comfort,  and  little  more  than  this  can  hi;  said  of  most  operations  ; 
nitU'cover.  it  is  not  fmml  to  be  practically  associated  with  such  inconvenience  as  sur^^eons 
of  old  have  theoretically  attributed  to  it.  Hut  it  should  not  b(!  postponed  till  the  powers 
of  life  have  become  so  exhausted  as  to  render  poor  tlic  chances  of  recovery  from  the  ope- 
ration, or  till  th(>  ciocum  or  lar<;e  intestitie  has  l)econ»e  so  distended  as  to  be  much  damaged 
or  iuHamed.  It  shouhl  be  undertaken  as  scjon  as  it  is  clear  that  the  disease  has  i»aHsed 
beyoiul  the  ri'acdi  of  local  treatment  and  the  n'cneral  powers  of  the  patient  ava  hftginnlnf/  to 
fail,  CM'  as  soon  as  the  local  distress  finds  no  relief  from  jialliative  measures  and  a  downward 
course  is  evidently  a)»proachinu'.  Tin;  ditiiculties  of  colot<imy  are  not  great,  nor  are  its 
dangers  numerous;  when  Kiisiirccs!<fii/j  it  has  often  been  nuide  so  by  delay  in  its  perform- 
ance, from  the  want  of  power  in  the  patient,  or  from  the  secondary  effects  of  the  disease 
on  the  alxlomiiial  viscera.  When  iiinxf  siicrtss/iilj  it  gives  immediate  relief  to  most  of  the 
•symptoms  and  makes  life  worth  retaining  ;  when  Ini.sf  so,  it  lessens  pain  and  renders  endur- 
able what  remains  of  life.  The  operation  is  now  established,  and  creditably  so  to  surgical 
art,  although  it  must  be  admitted  that  in  the  general  way  it  is  apt  to  be  postponed  until 
too  late  a  period  to  demonstrate  its  full  value. 

Excision  of  the  Lower  End  of  the  Rectum. 

This  operation  lias  but  recently  received  attention  in  this  country  as  a  means  of  cure 
for  cancerous  and  other  strictures  of  the  rectum,  although  practised  abroad  by  Lisfranc 
and  others  fifty  years  ago.  It  has,  however,  been  performed  by  Billroth,  l)y  Dr.  Levis  of 
Pennsylvania,  and  by  other  surgeons.  Billroth  reports  that  he  lost  19  out  of  45  cases  of 
this  operation,  and  that  tlie  majority  of  liis  cases  were  unsatisfactory.  Cripps's  statistics 
are  more  satisfactory  ;  he  records  also  (Jacksonian  prize  essay  1877)  that  in  23  cases 
defecation  was  subsecjuently  normal,  in  0  that  feces  could  be  retained  when  not  too  fluid, 
and  in  7  that  there  was  incontinence.  With  these  facts,  it  is  clear  that  the  operation  for 
the  removal  of  cancerous  or  other  disease  of  the  rectum  by  excision  is  a  justifiable,  and 
possibly  a  beneficial,  measure,  and  that  it  should  be  undertaken  when  the  disease  is  local 
and  can  be  so  defined  and  isolated  as  to  come  within  the  reach  of  the  surgeon's  skill. 

It  is  clearly  inapplicable  when  the  disease  has  extended  high  up  and  the  parts  around 
the  rectum  are  infiltrated  with  cancerous  disease.  I  quite  accord  with  this  view,  and  have 
acted  upon  it  in  four  cases,  all  females,  with  good  success.  All  survived  the  operation — 
one  for  t\vo  years,  when  a  return  took  place,  and  the  patient  died  from  visceral  cancer ; 
one  lived  fourteen  months,  and  two  are  now  alive,  twelve  and  thirteen  months  after  the 
operation,  and  in  comparative  comfort. 

It  would  seem  that  about  two  and  a  half  to  three  inches  of  rectum  may  be  removed 
with  .safety,  and  that  when  the  bladder  is  fairly  distended  and  traction  is  made  upon  the 
rectum  the  peritoneal  pouch  is  less  likely  to  be  drawn  down  with  it  than  when  the  bladder 
is  empty.     I  have  satisfied  myself  upon  these  points  by  experiments  upon  the  cadaver. 

Operation. — After  a  metallic  bougie  has  been  introduced  into  the  bladder  to  serve  as 
a  guide  to  the  position  of  the  urethra  and  to  steady  it,  an  incision  is  to  be  made  from  the 
base  of  the  scrotum  to  the  coccyx,  encircling  both  sides  of  the  anal  aperture.  The  hand 
of  the  operator  may  then  be  introduced  behind  the  bowel  into  the  hollow  of  the  sacrum, 
in  order  to  tear  the  rectum  loose  from  its  posterior  attachments.  By  means  of  the  finger 
and  a  pair  of  scissors  the  adhesions  all  around  the  rectum  where,  on  account  of  the  disease, 
it  may  be  firmly  attached  to  the  prostate  gland  and  neck  of  the  bladder,  should  be  broken 
up.  The  cancerous  gut  should  next  be  carefully  dissected  from  these  parts,  exposing  to 
view  the  prostate  and  the  lower  part  of  the  bladder  ;  all  bleeding  vessels  should  be  care- 
fully ligatured  or  torsed  as  soon  as  divided,  and  sutures  pas.sed  through  the  rectum,  above 
the  proposed  line  of  incision.  These  should  not,  however,  be  fastened,  but  left  in  posi- 
tion, to  give  perfect  control  over  the  parts.  When  the  rectum,  including  the  cancerous 
portion,  has  been  thus  carefully  and  thoroughly  isolated,  it  should  be  drawn  down  and 
separated  by  means  of  scissors:  there  is  no  advantage  to  be  gained  by  stitching  the  gut 
to  the  surrounding  integuments.     After  the  operation  a  good  drainage-tube  should  be 


584  SURGERY  OF  THE  ANUS  AND  RECTUM. 

introduced  well  into  the  posterior  part  of  the  sacral  cavity,  and  sutures  employed  to  bring 
the  integuments  together.     The  wound  should  be  kept  clean  by  daily  irrigation. 

Atony  of  the  Colon  and  Dilatation  of  the  Rectum. 

These  conditions  are  not  unfrequently  met  with  in  practice.  In  old  people  the  colon, 
for  want  of  power,  often  becomes  enormously  distended  with  feculent  matter  from  gradual 
accumulation,  and  this  condition  frequently  causes  death.  In  some  cases  it  gives  rise  to 
the  idea  of  stricture  of  the  rectum,  and  every  surgeon  must  have  been  called  to  cases  in 
which  impacted  feces  in  the  rectum  and  colon,  associated  with  the  discharge  of  small, 
loose,  offensive  motions,  mixed  with  mucus,  and  sometimes  wuth  blood,  have  misled  the 
attendant.  Some  years  ago  I  was  asked  to  see  a  lady  over  seventy  who  had  been  bed- 
ridden for  six  months  and  was  supposed  to  be  dying  from  constipation  and  stricture  of 
the  rectum,  nothing  but  small,  lumpy,  and  loose  motions  having  passed.  Xo  disease 
whatever  existed  beyond  the  impacted  rectum  and  distended  colon  from  atony  of  the 
bowel  from  old  age.  The  masses  were  mechanically  removed  by  means  of  the  lithotomy 
scoop  and  enemata  of  oil,  etc.,  and  she  lived  four  years  afterward  and  died  .simply  of  old  age. 

Treatment. — In  this  form  of  constipation  the  value  of  nux  vomica  is  well  seen,  a 
pill  composed  of  half  a  grain  of  the  extract  with  half  a  grain  of  belladonna,  twice  a  week 
or  oftener,  giving  tone  to  the  intestine  and  acting  as  a  purge. 

In  women  especially  who  have  been  in  the  habit  of  neglecting  their  bowels  and  allow- 
ing the  rectum  to  be  a  closed  receptacle  for  feculent  matter  the  cavity  not  only  becomes 
much  distended,  but  seems  to  lose  the  power  of  contracting  and  expelling  its  contents.  I 
had  some  years  ago,  at  Gruy's,  a  case  illustrating  these  points.  The  rectum,  on  examina- 
tion, feeling  like  a  loose  bag,  large  enough  to  admit  a  fist,  was  always  full,  having  evi- 
dently lost  all  power  of  expulsion.  The  woman  in  young  life  had  neglected  her.«elf.  and 
in  middle  age  could  not  overcome  the  effects  of  such  neglect.  By  daily  enemata  of  cold 
water  to  wash  out  the  bowel,  and  the  subsequent  injection  of  an  astringent  liquid  such  as 
the  decoction  of  bark  and  alum,  with  the  daily  use  of  a  pill  containing  half  a  grain  of 
extract  of  nux  vomica  mixed  with  gentian,  a  complete  recovery  took  place. 

The  Administ.ration  of  Food  and  Medicine  by  the  Rectum. 

Physiologists  have  Jong  known  that  water  and  certain  forms  of  food  and  medicines  are 
absorbed  by  the  rectum,  and  physicians  have  acted  upon  this  knowledge,  though  possibly 
the  physiological  fact  .has  not  been  utilized  so  fully  as  it  deserves. 

It  has.  however,  such  an  important  bearing  for  good  u])on  surgical  practice  that  it 
would  be  well  to  regard  the  rectum  as  a  second  stomach,  and  in  certain  cases  to  use  the 
one  for  nutritive  or  medicinal  purposes  as  a  substitute  or  accessory  for  the  other.  I  have 
for  years  acted  upon  this  principle,  and  have  every  reason  to  be  satisfied  with  the  result. 
Indeed,  in  any  case  of  disease  or  injury  in  which  nutriment  is  essential  and  the  stomach 
refuses  to  receive  or  retain  food,  I  have  never  hesitated  to  resort  to  the  nutrient  enema. 

I  do  so  also  in  cases  of  abdominal  injury  or  disease  in  which  it  is  inexpedient  to  give 
the  stomach  or  small  intestines  work  to  do.  In  aged  patients,  after  injury  or  operation, 
when,  from  shock,  the  stomach  seems  incapable  of  doing  its  duty,  as  well  as  in  all  cases 
of  persistent  vomiting,  whether  after  the  use  of  ansesthetics  or  otherwise,  it  gives  time 
for  the  stomach  to  regain  its  tone.  The  use  of  the  nutrient  enema  for  a  few  hours  often 
tides  over  a  slight,  and  for  days  over  a  great,  difficulty,  as  without  doubt  it  supplies  food 
to  the  body  almost  as  well  as  the  usual  meal,  and  does  so  under  circumstances  in  which 
the  latter  cannot  or  ought  not  to  be  administered.  In  a  case  I  had  with  Dr.  Parsons 
Smith  of  Addiscombe  life  was  entirely  maintained  for  fifteen  weeks  by  its  use.  and  I 
could  adduce  others  in  which  its  beneficial  influence  was  most  marked.  Dr.  Flint  of 
New  York  has  published  one  case  in  which  life  was  sustained  for  fifteen  months  by  this 
method,  and  he  adds  that  during  five  years  the  patient  had  depended  almost  entirely 
upon  it.  In  cases  of  unconsciousness  from  anaesthetics  or  otherwi.se  this  practice  should 
be  followed  in  preference  to  any  other,  as  it  seems  more  than  probable  that  under  these 
circumstances  any  fluid  which  it  is  attempted  to  pour  into  the  mouth  passes  into  the 
Jungs  rather  than  into  the  oesophagus,  and  consec{uently  hastens  death. 

Directions  for  Use. 

The  bowels  should  be  emptied  by  a  simple  enema  before  the  nutrient  one  is  intro- 
duced. 


DIRKCriOSS  FOR    USE.  585 

The  nutrient  ciicnia  sIkhiM  Ik-  used  cvt-ry  four  nr  six  li(*iirs,  and  should  not  consist  of 
mor»'  than  four  nr  six  ouiut-s. 

Thf  matt-rial  shuuKl  he  Ifpid  and  intmducrd  slmrlif,  as  the  rectum  repudiates  any 
Hudden  distension. 

After  its  administration  a  najikin  shouhl  he  jircsscd  against  the  anu^  until  tin-  disjio- 
sition  to  expel  it  has  passed  away. 

When  tile  expulsive  tendency  is  great,  five  or  ten  drops  of  the  tincture  of  opiutn  may 
be  atlded  tn  the  enema  ;   indeed,  under  all  circumstances,  it  is  of  advantage. 

At  times  the  enema  is  retained  better  when  introduced  some  six  inches  into  the  rectum 
than  when  only  just  within  the  sphincters. 

When  injections  are  badly  tolerated  at  first,  they  may  at  times  be  well  retained  if  they 
are  j>ersisted  in. 

The  best  materials  for  these  enemata  are  milk,  eggs,  meat  juices,  with  pancreas  or 
pancreatic  emulsion.  These  may  be  employed  at  different  times,  since  it  is  a  mistake  to 
kee}»  t(»o  long  to  one  kind. 

Milk  and  eggs,  alternating  with  one  of  meat  juice  and  pancreas,  seems  to  be  pref- 
erable. 

I>arby's  peptonized  fluid  meat  is  very  good. 

As  a  meat  emulsion  Kaufmann's  mixture  is  excellent,  composed  of  a  pound  of  minced 
or  scraped  beef,  a  third  of  a  pound  of  fresh  pancreas,  and  half  a  pint  of  cold  water,  the 
whole  allowed  to  macerate  for  three-quarters  of  an  hour,  gradually  raised  to  the  boiling 
point,  and  boiled  for  two  minutes.  The  mixture  will  then  have  been  reduced  to  the  con- 
sistence of  a  thick  soup. 

Wlien  this  mixture  is  not  at  hand,  good  beef  tea  or  mutton  broth  may  be  employed,  to 
which  Liebigs  extract  of  meat  may  be  added. 

In  making  beef  tea  or  broth  long  boiling  does  no  good.  A  pound  of  finely-minced 
meat  macerated  in  half  a  pint  of  cold  water  for  three  or  four  hours  will  give  an  excellent 
mixture ;  and  if  the  whole  is  well  shaken  for  half  an  hour,  nearly  the  .same  result  is 
obtained. 

Chi  several  occasions  I  have  found  Slingers  (of  Yorkj  nutrient  suppo.sitories  of  great 
use. 

Rectal  medication  in  its  way  is  as  valuable  as  alimentation,  more  particularly 
when  morphia,  opium,  or  mercury  is  prescribed,  the  former  drug,  administered  after  an 
operation  Vjefore  the  influence  of  the  anae.sthetic  has  passed  ofi".  doing  more  to  calm  the 
patient  and  give  rest  than  any  other  method,  more  particularly  in  cases  of  abdominal 
surgery. 

The  mercurial  suppository  employed  twice  a  day  acts  on  .syphilitic  patients  in  such  a 
quiet  and  beneficial  way  as  to  lead  me  to  look  upon  it  as  the  best  method  of  bringing  any 
one  under  the  influence  of  the  drug. 


SURGERY  OF  THE  RESPIRATORY  SYSTEM. 


CHAPTEK    XVII 


SURGICAL   AFFECTIONS   OF   THE   NOSE. 

Congenital  and  other  Defects  of  the  Nose. 

The  nose  may  be  congenitally  absent  or  fissured,  as  illustrated  in  Fig.  52 ;  the  nostrils 
may  likewise  be  congenitally  or  otherwise  occluded  from  cicatricial  contraction  after  ulcer- 
ation or  small-pox  ;  and  for  these  defects  surgery  may  be  successfully  called  into  requi- 
sition either  to  establish  an  orifice  or  to  prevent  its  contraction. 

Wounds. 

Incised  and  lacerated  wounds  of  the  nose  generally  progress  well,  on  account  of  the 
freedom  of  its  vascular  supply.  The  edges  of  any  wound  should  consequently  be  brought 
carefully  together  and  fixed  with  sutures,  even  if  the  part  be  nearly  or  wholly  separated 
from  the  body.  For  this  purpose  very  fine  silk  ought  to  be  used  and  great  care  exer- 
cised in  the  accurate  adjustment  of  the  parts,  a  suture  being  passed  through  the  cartilages 
when  they  have  been  divided.  In  the  case  illustrated  in  Fig.  332,  where  the  nose  was 
nearly  cut  off,  the  edges  of  the  wound  were  adjusted,  and  a  good  recovery  followed. 

Fracture  of  the  Nose. 

This  accident  is  not  uncommon  and  may  be  simple  or  compound.  It  may  likewise  be 
followed  by  little  or  great  deformity,  the  amount  depending  much  upon  the  care  and  skill 


Fig.  332. 


Fig.  333. 


Drawing  illustrating  the  Repair  after  an  Incised 
Wound  ol  the  Nose. 


Forceps  and  Nos 


•  Truss  for  Treatment  of  Deformed 
Nose. 


with  which  the  broken  bones  have  been  readjusted.  When  displacement  has  taken  place, 
the  surgeon  must  restore  the  misplaced  bones  by  external  manipulation,  aided  by  pressure 
applied  from  within  the  nasal  cavity  by  means  of  the  blades  of  the  ordinary  dressing  for- 
ceps or  a  steel  probe.  When  the  parts  have  been  restored  to  their  natural  position, 
or  as  nearly  so  as  is  possible,  care  must  be  observed  that  no  external  pressure  is 
employed  by  which  they  can  be  displaced.  Plugging  of  the  nostrils  is  useless. 
.  68t;         . 


A7'/7MA7V. 


587 


WluMi  little  or  IK)  (lis|)Ia<H'iiiont  exists,  nothing;  Itetter  is  re(juire<l  tliiiii  the  applifation  of 
culd-watiT  (Ircssiiiir,  <»r  |ti'rlia|»s  ice,  for  the  first  ft!\v  hours,  as  these  hones  rapidly  reunite. 

Dr.  li.  1>.  .^Iaslt^  of  Mrooklyu,  I'nitcd  States,  has  sujrjrested  the  use  of  a  wire  suture 
])assed  transversely  through  the  nose  to  keep  depressed  IVaetures  in  jtosition  (Annals  of 
All, If.  (iiiil  Siny.  Sotirfi/,  ISSO). 

When  the  foree  has  heen  .severe  anil  direct  tipnn  the  nose,  fraeture  of  the  skull  may 
(•oni]>li(ate  the  ea.se — fraeture  either  of  the  ethmoid  bone  forniinir  the  floor  of  the  base  of 
the  skull,  as  has  been  illustrated  in  the  ehapter  (ju  injuries  (jf  the  skull  (Fijr.  "')),  or  frac- 
ture of  the  frontal  l)one.  This  latter  form  may  be  generally  recognized  by  swelling  and 
crepitation  of  emphysema  about  the  forehead  or  the  crepitus  of  the  fracture  with  displace- 
ment, etc.  ('a.ses  of  fracture  of  the  frontal  .sinus  require  no  special  treatment,  and  gen- 
erally do  well. 

In  children  the  cartilage  of  the  nose  may  be  displaced  from  the  nasal  bones  in  conse- 
<iuence  of  an  injury,  and.  unless  replaced,  permanent  deformity  and  obstruction  \vill 
ensue.  The  surgeon,  conse(|uently,  wlieii  this  accident  takes  ])lace,  shouM  do  his  best  to 
restore  the  misjdaced  parts  and  to  keep  them  in  ajtposition,  although  some  difficulty  is 
often  experienced  in  its  accomplishjuent. 

With  the  view  of  ])reventing  or  correcting  deformity,  Mr.  W.  Adams  has  suggested 
that  tlie  broken  or  bent  septum  should  be  straiglitened  by  strong  plate-bladed  forceps 
(Fig.  XV^,  B)  and  the  broken  na.sal  bones  raised,  these  parts  sub.sequently  being  main- 
tained in  position  by  an  ivory  clamp,  and  the  side  of  the  nose  pressed  into  place  by  a 
nose  truss  (Fig.  333,  A)  connected  with  a  forehead  plate  (a)  and  band  (h).  The  plates 
(c)  are  shaped  according  to  the  outline  of  the  nose  and  are  made  to  diverge  by  rotating  a 
central  controlling  screw,  the  pressure  of  the  plates  being  regulated  by  two  circular 
springs.  The  ivory  clamp  must  be  worn  day  and  night  for  three  or  four  days  after  the 
deformity  has  been  corrected,  and  the  nose  truss  for  some  months  during  the  day. 

Epistaxis. 

Bleeding  from  the  no.se  is  an  occurrence  of  eon.siderable  frequency,  and  when  not  too 
free  or  lasting  rai'ely  requires  surgical  interference.  It  may  be  the  result  of  an  injury — 
trauimitlc — or  associated  with  some  cancerous  affection  or  fibrous  growth  from  the  base 
of  the  skull  or  other  local  cause,  or  it  may  be  the  direct  consequence  of  .some  fulness  of 
the  vessels  of  the  head  or  heart  disease.  It  is  found  also  as  a  kind  of  passive  exudation 
in  an;\?mic  and  cachectic  subjects  after  purpura  or  from  hepatic  disea.se,  and  also  as  supple- 
mentary to  the  catamenia. 

Trkat.mknt. — With  a  view  to  successful  treatment,  the  cause  of  the  bleeding  mu.st 
be  ascertained.  ^Vhen  traumatic,  it  usually  stops  without  aid.  AVben  due  to  plethora 
of  the  vessels  from  any  cause,  it  is  often 

salutary,  and  should  be  checked  only  when  Fig.  33-1. 

too  copious  or  lasting.  AVhen  of  a  passive 
nature,  it  is  serious,  since  anaemic  feeble 
subjects  cannot  bear  loss  of  blood,  and  the 
loss  tends  to  aggravate  its  cause.  In  one 
case,  therefore,  saline  purgatives  may  be 
of  value ;  in  another,  iron  in  full  doses, 
or  gallic  acid  in  gr.  v  or  gr.  x  doses.  As 
to  its  treatment  no  definite  rules  can  be 
laid  down,  it  being  a  common  accompani- 
ment of  so  many  different  conditions,  local 
and  general.        • 

W' hen,  however,  life  is  threatened  by 
its  severity,  real  or  comparative,  the  sur- 
geon is  bound  to  interfere.  The  head 
should  be  kept  raised  and  cold  applied  by. 
means  of  ice  to  the  nose  and  frontal  si- 
nuses. A  steady  stream  of  some  cool  saline 
li(|uid  (a  teaspoonful  of  carbonate  of  soda 
and  common  salt  to  a  pint  of  water  being 
as  good  as  any)  passed  through  the  nostril 
is  a  very  effectual  mode  of  treatment.  For 
this  purpose  the  double-action  india-rubber 
enema  apparatus  with  a  nose-piece  to  introduce  into  the  nostril  may  be  employed,  or  Dr. 


iSt/filwn  (uZm: 
with  Wd{/ht 


Nasal  Douche. 


688  SURGICAL  AFFECTIONS  OF  THE  SOSE. 

Ra.<ch"s  vaginal  syphon  douche,  applied  as  in  Fig.  334.  the  patient  V»reathing  at  the  time 
through  the  mouth,  which  .should  he  kept  wide  open.  Prof.  AVeber  of  Halle  having  dis- 
covered years  ago  that  while  the  patient  is  breathing  through  the  mouth  the  soft  palate 
completely  closes  the  posterior  nares  and  does  not  permit  any  fluid  to  pass  into  the 
pharynx.  The  popular  methods  of  placing  the  patient  in  the  erect  piosture  and  raising 
both  arms  above  the  head  may  likewise  be  tried,  as  they  are  unquestionably  good.  If 
these  measures  fail,  the  nostril  or  nostrils  mu.st  be  plugged. 

Plugging  Nose. — To  do  this  effectually  some  skill  is  necessary ;  to  do  it  otherwise 
is  usek>>.  if  lint  injurious.  To  plug  from  the  anterior  nares  alone  is  to  trifle  with  the 
hemorrhage  and  merely  to  mask  the  escape  of  blood  as  well  as  to  direct  it  down  the 
pharynx,  under  which  circum.stances  severe  loss  of  blood  may  take  place  without  know- 
ledge. To  perform  the  operation  of  plugging  effectually,  a  plug  of  lint,  cotton-wool,  a 
sponge  tent,  or  compressed  sponge,  an  inch  and  a  quarter  long  and  an  inch  wide,  should 
be.prepared  and  fastened  in  the  middle  by  a  double  piece  of  strong  .silk  or  whipcord,  an 
end  about  six  inches  long  being  left  on  one  side,  and  two  ends  or  a  loop  a  foot  long  on 
the  other.    With  Bellocq  s  canula  (Fig.  335),  a  long-eyed  probe,  or  an  elastic  catheter  a 

loop    of    the    same    material    should    be 
Fig.  335.  p)assed    into    the    nose    along    its    floor 

through  the  posterior  nares  into  the 
pharynx,  and  caught  either  by  the  fin- 
gers or  forceps.  This  end  should  then 
be  fastened  to  the  long  ends  on  the  plug 
and  the  instrument  withdrawn  through 
the  nostril.  The  plug,  having  been  well 
oiled,  is  then  to  be  drawn  into  the  month 
by  applying  traction  upon  the  ligatures 
protruding  from  the  nostril,  tilted  with 
Bellw^'s  Canula  for  Plugging  Nostrils.  the  finger  behind  and  above  the  soft  pal- 

ate, and  carefully  adjusted  or  wedged  into 
the  posterior  nares,  by  which  means  the  escape  of  blood  into  the  pharynx  will  be  pre- 
vented. The  two  cords  hanging  from  the  anterior  nares  are  then  to  be  separated  and  the 
nasal  cavity  filled  with  compressed  sponge,  lint,  or  cotton-wool,  which  should  be  intro- 
duced between  them,  the  whole  mass  being  made  secure  by  tying  the  two  cords  across 
the  plug  that  has  been  introduced  in  front  and  fastening  them  in  a  bow.  to  allow  of  unfas- 
tening. When  any  styptic  is  deemed  necessary,  the  .sponge,  cotton-wool,  or  lint  intro- 
duced into  the  anterior  nares  may  be  saturated  with  the  solution  of  the  perchloride  of 
iron,  tannin,  matico,  or  a  concentrated  sohition  of  alum.  By  this  means  the  p»ossibility 
of  any  escape  of  blood  from  either  opening  of  the  nose  can  be  effectually  prevented  and 
the  most  dangerous  epistaxis  absolutely  controlled.  To  remove  the  apparatus,  the  knot  at 
the  anterior  nares  should  be  undone  and  the  anterior  plug  taken  out.  the  posterior  being 
readih"  drawn  from  its  position  by  means  of  the  short  end  attached  to  it  in  the  pharynx, 
which  may  be  left  hanging  down  the  patients  throat.  The  plug  should  not  be  left  in 
more  than  three  or  four  days,  but  may  be  reintroduced  if  necessary,  the  surgeon,  in  doing 
so,  taking  care  to  preserve  in  situ  the  two  pieces  of  cord  that  have  been  passed  along  the 
floor  of  the  nose.  The  inflating  nasal  india-rubber  plug  of  Mr.  H.  C.  Howard  is  like- 
wise good  for  plugging  purposes.  It  can  readily  be  inflated  when  in  position,  and  as 
readily   removed   (Brit.   Med.  Joum.,   1881,   p.   8I;'G). 

Lipoma — or,  more  correctly,  Hypertrophy  , 

of  the  nose — is  a  readily  recognizaV>le  aff"ection  and  is  a  disease  of  the  .skin  and  subcuta- 
neous tissue  (not  of  the  cartilages),  in  which  the  follicles  may  or  may  not  participate.  It 
is  confined  to  the  apex  and  the  ala^  of  the  organ.  The  enlargement  is  sometimes  general ; 
at  others  the  swellings  are  pendulous,  lobulated.  and  loose.  The  capillaries  of  the  part 
are  sometimes  congested,  giving  the  growth  a  purplish  hue.  As  a  rule,  it  is  painless  and 
causes  only  mechanical  annoyance  It  interferes  at  times  with  vision  and  the  functions 
of  the  nose.  and.  moreover,  wounds  vanity. 

Treatment. — Nothing  but  the  removal  of  the  growth  can  be  suggested,  which  can 
be  done  without  dantrer  and  with  no  great  difficulty.  The  redundant  mass  is  to  be  dis- 
f;ected  off",  care  being  observed  not  to  encroach  upon  the  nostril.  This  is  best  done  by 
introducing  the  little  finger  or  a  spatula  into  the  nostril  and  shaving  the  redundant  mass 
off  the  cartilage  with  a  scalpel.    Any  bleeding  that  ma}-  take  place  can  usually  be  checked 


Rirf.ynsrory, 


589 


by  c'lild,  styptics,  or  torsion;  tho  woiiml  thai  is  li-f't  should  he  ullowtMi  to  granulate.  Th»5 
surgt'on  should  ho  (raref'ul  not  to  take  away  too  much  <ir  to  gu  too  deep,  hut  to  leave  Houie 
oovcriuir  to  tlic  cartilai^es.  Tl>e  disease  rarely  returns.  The  late  Mr.  Hey  ot"  Leed.s  was 
the  first  to  pcrf'iirni  the  operation  described. 


Lupus. 

This  afVcction  is  more  common  on  the  iiose  than  in  any  otlu^r  part  of  the  body  and  is 
often  very  destructive — so  much  so,  indeed,  as  to  destroy  the  whole  or<^an.  it  is,  how- 
ever, more  amenable  to  treatment  than  is  usually  supposed.  Too  often  it  is  described  as 
a  strumous,  ami  therefore  constitutional.  atfe(;tion,  and  rcfrarded  as  incurable.  It  would 
be  well,  however,  if  surijeons  would  i»ractically  rej^ard  it  iiKjre  as  a  local  disca.se, 

Tkkat.mknt. — The  best  local  treatment  is  its  entire  destruction,  which  may  be  effected 
by  serapini;  away  the  diseased  tissue  with  ;i  blunt  ktiil'c  or  the  handle  of  a  scalpel,  followed 
by  the  aiiidication  of  carbolic  acid  (Ui  ,•        ...  ,.  _ 

lint  to  tile  expo.sed  surface,  hy  excision 
or  tile  free  application  of  the  galvano- 
or  thermo-eautery.  One  of  the  wor.st 
cases  of  lupus  of  the  iio.se  that  I  have 
seen  was  that  illustrated  in  V\g.  ',i',H). 
It  had  existed  for  years,  and  was  cured 
in  a  month  after  one  tree  application 
of  the  galvanic  cautery,  every  ulcerat- 
ing tubercle  of  unhealthy  tissue  being 
freely  destroyed. 

Tonic  treatment  also  must  not  be 
neglected,  while  as  a  palliative  appli- 
cation cod-liver  oil  is  very  beneficial. 
Arsenic  is  also  highly  commended  by 
Messrs.  Hunt  and  others,  and  Don- 
ovan's solution  when  there  is  an}- 
syphilitic  taint. 

The  lupus  iion-exedens  may  be  regarded  as  an  early  stage  of  the  lupus  exedens  ;  both 
have  a  i)apular  origin  and  become  tubercular,  the  tubercles  ulcerating  at  a  later  stage. 


Lupus  of  Nose,  with  the  Outline  of  a  Tlaj)  for  a  New  Nose. 
(From  life.) 


Epithelial  Cancer  and  Rodent  Cancer 

may  attack  the  nose,  the  former  usually  appearing  at  first  as  a  wartv  growth,  which  sub- 
seijuently  ulcerates;  the  latter  as  a  firm,  uncolored.  solitary  nodule,  which  excoriates, 
then  scales  and  bleeds,  and  finally  ulcerates,  deepening  and  extending  the  scabbed  excor- 
iation. In  the  epithelial  cancer  the  margin  (»f  the  sole  is  more  irregular  and  thicker  than 
in  the  rodent  ulcer,  although,  until  the  lymph  glands  are  affected,  it  is  somewhat  difficult 
to  distiiigui.sh  between  the  two.  Indeed,  the  epithelial  cancer  may  be  for  long  undistin- 
guishable  from  the  rodent  cancer.  The  treatment  of  both,  however,  consists  in  the  total 
destruction  of  the  ulcerating  surface  and  its  edges  by  cautery,  escharotics.  or  the  knife. 
I  have  treated  many  of  the  epithelial  forms  by  means  of  the  galvanic  cautery  with  grat- 
ifying success.     The  disease,  like  other  cancers,  is,  however,  liable  to  return. 


Rhinoscopy. 

1'he  examination  of  tlie  nasal  cavity  may  be  made  through  the  nostrils  by  means  of 
a  .speculum,  and  for  the  purpose  reflected  sunlight  is  the  best,  or,  this  failing,  reflected 
artificial  light  must  be  employed.  The  posterior  iiares  can  Ite  examined  by  means  of  a 
mirror  introduced  behind  the  soft  palate,  after  the  same  fashion  as  in  laryngoscopy,  the 
parts  being  reflected  from  the  mirror,  which  is  illuminated  by  sun-  or  artificial  light.  The 
best  aid  may  also  be  obtained  by  means  of  the  finger  introduced  through  the  mouth  behind 
the  soft  palate.  Czermak  speaks  highly  of  the  value  of  a  small  mirror  introduced  throutih 
the  nostril,  which  should  be  well  illuminated.  I  have,  however,  found  all  the  help  I  wanted 
in  digital  examination  and  posterior  rhino.scopy,  taking  care  to  draw  forward  with  great 
gentleness  the  soft  palate  by  means  of  forceps.  This  method  of  examination  is.  how- 
ever, at  times  difficult. 


590  SURGICAL  AFFECTIONS  OF  THE  NOSE. 

Diseases  of  the  Nostrils  causing  Obstruction. 

These  are  very  cunnuon,  and  for  such  the  surgeon  is  often  consuhed.  In  the  infant 
such  a  condition  may  be  the  result  of  congenital  syphilis,  which  will  be  indicated  by  the 
history  of  the  case  and  the  concomitant  symptoms.  The  muffles  in  infancy  are  very  cha- 
racteristic, and  should  always  direct  the  practitioner  to  look  out  for  some  syphilitic  aflec- 
tion.  In  isolated  cases  such  a  symptom  may  be  the  only  one  of  hereditary  syphilis,  and 
by  proper  treatment  it  may  be  cured  without  any  other  complication  making  its  appear- 
ance, although  as  a  rule,  if  looked  for,  some  cutaneous  aifection  will  be  observed,  a  grain 
of  gray  powder  with  three  or  four  grains  of  dried  soda  twice  a  day  generally  proving 
quite  sufficient  to  cure  the  disease.  When  the  mother  is  suckling,  the  child  may  be 
physicked  through  the  mother,  taking  five  or  more  grains  of  the  iodide  of  potassium  with 
quinine  half  an  hour  before  suckling  three  times  a  day. 

Warty  growths  are  sometimes  met  with  at  the  orifice  of  the  nostril,  causing 
obstruction.      They  are  to  be  cured  by  the  removal  of  the  growths. 

Foreign  Bodies  in  the  Nasal  Cavity. 

When  a  child  suflers  from  any  obstruction  to  the  nasal  cavity,  and  particularly  when 
such  is  one-sided,  the  presence  of  a  foreign  body  should  be  suspected ;  and  the  prac- 
titioner in  such  instances  should  never  allow  himself  to  be  misled  by  the  absence  of  a  his- 
tory of  its  introduction,  since  instances  are  not  uncommon  where  some  foreign  hody  has 
been  left  in  the  nasal  canal  for  months.  A  child  four  years  of  age  came  under  my  care  who 
had  suffered  from  all  the  miseries  of  an  obstructed  nasal  passage  for  eight  months  from 
the  presence  of  a  plum-stone.  Many  remedies  had  been  tried,  but  without  effect,  the 
foreign  body  being  unsuspected.  Its  removal  was  rapidly  followed  by  convalescence. 
Ulcerations  of  the  mucous  membrane  from  the  inflammation  excited  by  the  foreign  body 
may  tempt  the  surgeon  to  overlook  the  nature  of  the  case.  He  should  therefore  remem- 
ber that  such  a  disease  as  ulceration  of  the  nose  in  children,  except  at  the  immediate 
orifice,  is  by  no  means  common,  and  that  the  probabilities  of  its  being  excited  by  a  for- 
eign body  are  very  great.  When  only  one  nostril  is  affected,  the  diagnosis  is  more  sure. 
The  removal  of  these  bodies  when  firmly  impacted  requires  some  care,  and  the  adminis- 
tration of  an  anaesthetic  cannot  be  too  highly  recommended,  particularly  when  the  child 
is  young.  A  firm,  hook-bent  probe  introduced  down  the  floor  of  the  nose  may  be  passed 
with  facility  behind  the  foreign  body,  or  a  noose  of  wire,  twisted  or  not,  inserted  along 
the  septum  and  half  turned,  will  generally,  after  one  or  two  attempts,  hook  out  the  offend- 
ing body.  In  some  cases  a  pair  of  forceps  will  suffice.  Gingerbread  and  other  soft  mate- 
rials may  have  to  be  scooped  out  and  the  nose  well  syringed.  I  have  never  known  any 
good  result  from  syringing  this  cavity  when  any  solid  body  has  become  impacted,  except 
for  the  sake  of  cleanliness.  Mechanical  means  always  succeed  and  are  the  simplest,  par- 
ticularly when  the  child  is  under  the  influence  of  an  anfesthetic.  In  older  children  and 
in  adult  life  obstruction  to  the  nasal  passage  may  be  produced  by  many  diseases.  When 
the  presence  of  a  foreign  body  is  the  cause,  a  true  history  of  the  case  will  generally  be 
given,  and  thus  the  surgeon  is  more  likely  to  arrive  at  a  just  conclusion  as  to  the  charac- 
ter of  the  disease. 

Nasal  Calculi,  or  Rhinolithes. 

Such  cases  have  been  recorded ;  I  have  seen  but  one  instance,  and  that  proved  to  be 
due  to  the  introduction  of  a  foreign  body.  It  occurred  in  the  practice  of  Mr.  B.  Duke 
of  Clapham.  On  examination  by  Dr.  Stevenson  the  calculus  was  found  to  consist  of  75 
per  cent,  of  earthy  carbonates  and  phosphates,  and  25  per  icent.  of  organic  matter  with 
cotton-wool.  They  may  be  small  or  so  large  as  to  obstruct  the  nostril.  Obstruction  and 
more  or  less  pain  are  said  to  be  the  chief  symptoms,  and  occasionally  a  copious  discharge 
of  mucus  or  pus.  The  calculus  can  be  detected  on  examination;  and  when  found,  it 
should  be  removed  by  douche,  snare,  or  forceps.  Cases  are  on  record  in  which  the  con- 
cretion was  crushed  before  removal. 

Polypus  Nasi. 

This  is  a  common  affection,  and  may  be  found  in  one  or  both  nostrils  of  the  old  or 
young.  It  may  be  of  a  simple  mucous  or  fibrous  structure  or  it  may  be  of  a  malignant 
nature.     The  mucous  are  by  far  the  more  common  forms,  and  are  not  difficult  to  recog- 


roLvrrs  yAsr. 


rm 


Fig.  338. 


nize ;  they,  as  a  rule.  s|>riii<r  f'nuii  tho  middle  ttirltiiiatcd  Imrn'  and  from  its  poiSterior  por- 
tion, thoii';li  tlu'V  may  jrr<t\v  fVum  other  j>arts.  I  have  removed  oidy  <»ne  from  tin-  septum. 
They  are  sehhtm  reco^ni/.ed  in  an  early  eimdition,  since  they  cause  no  pain  and  hut  little 
inconvenience.  A  slijiht  e.\cess  of  discharjie  is  the  earliest  symptom,  and  this  is  frener- 
ally  rejrarded  as  heinjr  the  result  of  "  cold ; '  hut  when  this  secretion  is  examined,  it  will 
he  ohserved  to  he  more  serous  than  is  found  to  exist  in  an  ordinary  coryza.  In  excep- 
tional eases  the  .serous  flow  may  he  very  free.  .Sir  J.  i'ajjret  has  recorded  (  Cfiu.  Soc. 
TVans.,  Vol.  xii.)  a  case  in  which  this  symptom  existed  and  where  after  death  fine  polypoid 
growths  were  found  in  the  antrum.  The  disehar<:e.  eontiiiuin;:.  may  at  last  cause  some 
anxietv  to  the  ]>atient  ;  and  if  the  surireon  he  consulteil.  a  careful  examination  with  a 
speculum  should  he  instituted,  when  a  jiolypus.  or  rather  a  frinfre  of  polypi,  will  often  he 
ohserved  on  the  maririn  u\'  the  middle  turhinated  bone. 

Trkat.mk.nt. — When  the  di.<ease  has  heen  made  out,  removal  of  the  growth  is  the 
only  efl'ectual  treatment.  Tonics  and  local  astringents  may  for  a  time  retard  its  growth, 
hut  rarely  effect  a  cure.  The  use  of  tannin  as  a  snuff  has  heen  very  successful  in  my  hands 
in  causing  the  sloughing  off  of  even  the  largest  polypi  (Lancef, 
February,  18G7).  but  the  remedy  is  uncertain  ;  it  is,  however, 
always  of  value  in  destroying  the  smaller,  and  thus  in  check- 
ing the  progress  of  tlie  disease.  Of  late  years  I  have  em- 
ployed a  spray  composed  of  ecjual  parts  of  alcohol  and  a  ten- 
grain  solution  of  Vjoracic  acid  to  the  ounce  of  water,  the  alco- 
hol withering  the  small  growths. 

I  have  had  several  instruments  made  to  apply  the  tan- 
nin, but  the  bent  glass  tube  is  as  good  as  any.  It  is  modified 
from  one  made  by  a  patient  for  his  own  use.  and  answers  well. 

The  tannin  is  put  into  the  small  receptacle  in  the  upper  half,  that  end  of  the  tube  being 
inserted  into  the  nostril,  and  the  other  into  the  mouth,  and  the  patient  then  blows  tannin 
into  his  nostril. 

Tiie  removal  of  the  softer  kinds  of  polypi  should  always  be  by  abruption.  Some  sur- 
geons employ  a  long  pair  of  narrow  well-made  forceps,  which  fix  the  pedicle,  and  then  by 
a  slight  twist  and  some  force  the  removal  of  the  growth  is  effected.  When  the  polypus 
hangs  far  back,  the  introduction  of  the  finger  into  the  mouth  and  behind  the  fauces  facil- 
itates its  removal.  The  best  instrument  known  is  the  ''  noose.  '  and  that  illu.strated  in 
Fig.  339  is  the  form  I  prefer.     It  is  so  constructed  that  a  loop  of  wire  introduced  along 


Fig.  339. 


Removal  of  Nasal  Polypus  by  Koose. 


the  septum  and  half  turned  can  be  made  to  pass  over  the  polypus  and  encircle  its  pedun- 
cle. The  loop  is  then  drawn  home,  the  growth  strangled  at  its  neck  and  abrupted.  By 
these  means  the  polypus  is  removed  as  a  whole  and  V)leeding  is  prevented ;  consequently, 
by  the  use  of  this  instrument,  the  nose  can  generally  be  cleared  at  one  operation.  In 
some  cases  I  have  cured  the  disease  by  cutting  off  with  a  long  pair  of  scis.sors  the  turbi- 
nated bone  from  which  these  polypi  grow.  A  few  days  after  the  removal  of  the  polypi 
by  the  snare,  tannin  as  a  snuff  or  the  alcohol  and  boracic  acid  lotion  used  as  a  spray  may 
be  employed. 

In  severe  cases  in  which  this  treatment  has  been  employed  with  but  poor  success, 
Rouge's  operation,  as  suggested  by  him  for  the  treatment  of  certain  cases  of  oza?na  in 
1873.  may  be  performed,  the  operation  consisting  in  the  elevation  of  the  upper  lip  and 
soft  parts  of  the  nose  from  their  os.seous  attachments  by  means  of  an  incision  made 
beneath  the  lip  through  the  mucous  membrane  where  it  is  reflected  from  the  lip  into  the 


592 


SURGICAL  AFFECTIONS   OF  THE  NOSE. 


gums,  the  lip  and  nasal  cartilages  by  these  means  being  so  freed  from  their  attachments 
as  to  allow  the  surgeon  to  lift  them  up  as  a  whole  toward  the  forehead,  and  thus  reach- 
ing the  nasal  cavity  for  purposes  of  exploration  or  operation.  To  give  more  room,  the 
septum  nasi  may  retjuire  to  be  separated  from  its  base.  After  the  operation  the  parts 
readily  fall  into  position,  and  should  be  kept  there  by  strapping.  No  deformity  or  vis- 
ible scar  follows  the  operation. 

The  mucous  form  of  polypus  seems  to  be  more  common  in  men  than  in  women  and 
is  a  disease  of  young  adult  life.  I  have  known  it,  however,  to  appear  in  a  man  aged 
seventy-five. 

The  firmer  and  fibrous  forms  of  polypi  are  by  no  means  so  common  as  the 
mucous,  and  seldom  spring  from  the  turbinated  bones.  They  grow  more  frequently  from 
the  upper  and  posterior  portion  of  the  nasal  cavity,  from  the  top  of  the  pharynx  and  the 
posterior  nares,  and  have  a  periosteal  origin.  They  do  not  make  their  appearance  so 
early  in  life  as  the  mucous,  are  far  more  serious  in  their  nature,  and  more  difficult  to 
treat,  on  account  of  their  position;  and  when  removed,  they  rarely  return. 

Treatment. — The  best  mode  of  treatment  is  to  ligature  them  through  the  nose  by 
means  of  a  loop  of  whipcord  or  wire  passed  through  the  nostril  into  the  pharynx  and 
slipped  over  the  growth.  When  this  operation  cannot  be  performed,  the  nostril*  may  be 
laid  open,  to  give  room  for  manipulation,  or  it  may  be  necessary  to  remove  the  nasal  pro- 
cess of  the  superior  maxillary  bone  or  displace  the  body  of,  but  not  remove,  the  upper 
jaw  itself  to  reach  the  tumor.  In  1865  I  removed  a  large  tumor  of  this  kind  which 
completely  obstructed  the  posterior  nares  of  a  boy  ajt.  l-t  by  the  ligature  introduced 
through  the  nostril  (Path.  Trans.,  vol.  xviii.),  and  in  1868,  I'removed  a  second  from  a 
lad  aet.  18  in  the  same  way.  In  1872,  in  another  case,  I  took  away  a  portion  of  the 
upper  jaw  to  get  at  a  tumor  of  the  spheno-maxillary  fossa  which  filled  up  the  nostril 
from  behind.  In  1883  I  removed  by  evulsion  from  a  man  who  was  dying  from  bleeding 
a  large  growth  from  behind  the  palate  and  posterior  nares,  but  with  a  fatal  result,  the 
growth  having  sprung  from  the  base  of  the  skull  and  invaded  the  cranium.  Some  of 
these  polypi  grow  from  the  antrum  and  press  inward.  The  surgeon  should  bear  this  fact 
in  mind  in  examining  a  case,  as  it  may  materially  afteet  his  treatment. 

Cancerous  tumors  of  the  nose  are  found  in  practice,  although  not  frequently. 
They  may  attack  the  body  of  the  organ,  as  seen  in  Fig.  340,  or  grow  from  within  and 
press  forward  or  backward,  filling  in  the  anterior  or  posterior 
nares,  when  they  are  difficult  to  diagnose.  They  are  perhaps 
more  common  in  the  old  than  in  the  young,  although  two  cases 
have  pas,sed  under  my  care  in  patients  under  thirty.  They  are 
generally  associated  with  bleeding,  from  either  the  nose  or  the 
pharynx.  When  they  grow  from  within,  their  removal,  when 
possible,  is  an  expedient  practice,  if  only  to  give  relief;  and 
this  can  be  done  much  in  the  same  way  as  in  the  other  varieties 
of  polypi. 

Conditions  simulating  Polypus. — The  conditions  of 

the  nasal  cavity  which  are  not  infrequently  mistaken  for  poly- 
pus are  numerous.  Many  such  have  passed  under  my  notice, 
the  patients  applying  for  the  removal  of  such  a  growth,  when 
in  reality  no  growth  existed. 

Malformation  of  the  septum  nasi  is  one  of  the  most 

common  deformities  of  the  nose.  In  it  the  septum  projects  into 
either  the  right  or  the  left  nostril,  causing  more  or  less  obstruc- 
tion to  respiration  and  leading  a  superficial  observer  to  believe 
in  the  presence  of  some  new  growth.  This  deformity  may  some- 
times be  the  result  of  an  injury;  and  when  so,  there  is  generally  some  lateral  twist  of 
the  nose  itself.  The  knowledge  of  the  existence  of  such  a  condition  is  quite  sufficient  to 
prevent  any  careful  surgeon  falling  into  this  error.  For  the  relief  of  this  deformity  an 
attempt  may  be  made  by  Adams's  forceps  to  loosen  the  septum  and  to  fix  it  in  a  better 
position,  or  comfort  may  be  given  by  admitting  air  through  a  perforation  of  the  septum 
made  by  cutting  forceps. 

A  chronic  inflammation  and  thickening  of  the  mucous  lining  of 

the  nose  is  another  condition  which  may  be,  and  frequently  is,  mistaken  for  jiolypus. 
In  it  the  patient  complains  of  difficulty  in  respiration  and  feels  that  there  is  something  in 
the  nose  which  mechanically  impedes  that  function.  On  examining  the  cavity  a  smooth, 
projecting,  and  firm  outgrowth  will  be  observed  on  its  outer  wall,  which  may  be  regarded 


Fig.  340. 


Cancer  of  Nose. 


OZ.KSA.  o!>3 

tts  a  jxilvpus,  Imt  wliicli  is  really  <'iily  I  lie  lower  tiirhiiiatetl  l)i)tU!  covered  by  a  thiekened 
u'deniatoiis  nr  iiiHaiiieil  iiiiieniis  iiieiiihraiie.  In  a  ease  such  as  this,  if  a  little  ean;  he 
taken  ill  sit'tiiij,'  its  liisturv.  it  will  pniltalily  he  t'lMiiid  that  an  i(hstrii(;tioti  to  the  respira- 
tiun  will  ho  the  uiily  syiiiiitniii  of  iiii|Mirtaiice  ;  there  will  he  no  senms  discliarge,  such  as 
is  so  copious  ill  cases  of  polypi,  altli()iii;h  there  may  he  a  discharj^e  of  tenacious  mucus; 
yet  tills  is  not  common,  since  the  seeretiiiL'  I'linelinii  nl"  the  mucous  mcmhrane  in  these 
cases  will  ireiierally  he  found  diminished  and  a  iinat  dryness  present,  accompanied  by  a 
lo.'.s  of  the  sense  of  smell. 

TuKATMKNT. — The  hcst  treatment  in  such  examples  is  the  constitutional  in  the  form 
of  ionics,  usin«r  that  which  appears  to  he  most  suited  to  the  jiciieral  wants  <d"  the  patient's 
system.  Some  sli«rlit  stimulating:;  lotion,  such  as  the  sulphate  or  chloride  of  zinc,  or 
nitrate  (d'  silver  <d"  the  streiiirth  of  two  j.n-ains  to  the  ounce,  may  at  times  he  re<|iiire(l.  but 
constitutional  means  alone  are  generally  sufficient.  Itemoval  (jf  the  turbinated  bom;  for 
this  afi'ection  has  been  advocated  and  perlormed  by  some  surgeons.  1  have  ailopted  the 
practice  in  some  obstinate  cases  with  marked  success. 

It  is  worthy  <d'  observati(ni  that  this  disease  is  at  times  confined  to  the  mucous  mem- 
brane over  the  lower  turbinated  bone,  and  for  reasons  which  1  am  unable  to  explain. 

The  septum  may  likewise  be  the  seat  of  inflammation,  either  acute  or  chronic  ;  and, 
as  a  result,  great  swelling  of  the  soft  parts  covering  it  in  will  be  pre.sent,  giving  rise  to 
obstruction.  When  pus  e.xists,  an  early  opening  is  advantageous.  In  .some  cases  a  per- 
forating ulcer  may  appear ;  in  others,  exfoliation  of  the  cartilage.  I  have  removed  from 
a  boy  a  rmliliiijlnnii^i  i>>ifi/roicf/i  from  the  septum  which  obstructed  the  nostril,  which  had 
a  base  the  size  of  a  si.xpence. 

Oz^NA. 

This  term  is  applied  to  a  large  and  important  class  of  cases  where  an  oflFensive  dis- 
charge, or  rather  smell,  is  the  common  symptom,  which  is  due  to  many  different  morbid 
conditions. 

It  has  been  said  that  this  offensive  smell  is  the  result  of  some  morbid  secretion  of  the 
part,  but  my  own  experience  has  not  furnished  me  with  any  information  tending  to  con- 
firm such  an  idea,  and  I  believe  that  the  fetor  is  generally,  if  not  always,  the  result  of  the 
decomposition  of  retained  mucus.  At  one  time  it  may  be  associated  with  inflammation  or 
ulceration  of  the  mucous  membrane,  and  at  another  with  some  diseased  bone  the  result  of 
syphilis  or  otherwise.  Under  all  circumstances  the  disease  is  an  insidious  one,  and  many 
months  have  usually  elapsed  before  it  comes  under  the  notice  of  the  surgeon  or  medical 
adviser. 

SvMl'TOMS. — Tiie  patient  at  first  believes  the  symptoms  to  depend  upon  an  ordinary 
catarrh,  the  discharge  from  the  nose  being  thick,  but  not  offensive,  and  the  sense  of  smell 
more  or  less  impaired.  If  these  symptoms  continue,  the  health  of  the  sufferer  often 
declines  ;  and  the  physician  is  consulted  on  account  of  want  of  power,  the  local  symptoms 
assuming  a  secondary  importance.  If  the  nose  be  examined  at  this  time,  as  it  should  be, 
with  a  speculum,  to  obtain  a  good  view  of  the  whole,  the  only  visible  morbid  condition 
may  be  either  intense  congestion  of  the  mucous  membrane,  which  will  not  be  much,  if  at 
all,  thickened,  or  some  ulcer,  this  congestion  of  the  mucous  membrane  being  associated 
with  excess  of  secretion  and  the  ulcer  with  a  variable  discharge.  When  dead  bone  exists, 
a  probe  will  detect  it. 

Treatment. — In  the  majority  of  cases  the  only  correct  and  satisfactory  treatment  is 
the  constitutional.  When  the  general  condition  of  the  body  is  improved,  the  local  disease 
will  disappear.  To  this  end  the  hygienic  conditions  by  which  the  patient  is  surrounded 
should  be  considered.  If  tonics,  as  quinine  or  iron,  are  indicated,  they  should  be  admin- 
istered;  the  secretions  also  should  be  attended  to.  and  all  external  and  internal  causes 
which  may  prove  detrimental  to  health  removed.  The  hctt/  treatment  consists  in  absolute 
cleanliness  and  the  removal  of  all  retained  secretions  ;  for  this  purpose  there  is  nothing 
equal  to  the  use  of  the  douche  (Fig.  334)  with  saline  medicated  lotions.  The  inhalation 
of  steam  will  at  times  assist  the  removal  of  the  secretion  and  relieve  the  state  of  fulness 
of  the  part  of  which  some  patients  so  much  complain,  especially  if  the  discharges  have  a 
tendency  to  desiccate,  adhere  to  the  mucous  lining,  and.  as  a  consequence,  to  putrefy, 
since  it  is  this  putrefaction  of  the  retained  muco-purulent  secretion  on  which  essentially 
depends  the  condition  denominated  ozxna.  Medicated  lotions  are  sometimes  required, 
such  as  iodine  or  boracic  acid  lotion  ten  drops  or  grains  to  the  ounce.  Condy  s  fluid, 
carbolic  acid,  the  sulphate  or  chloride  of  zinc,  or  nitrate  of  silver,  in  the  strength  of 
:iS 


594  SURGICAL  AFFECTIONS   OF  THE  NOSE. 

about  one  grain  to  the  ounce  of  water.  The  inhalation  of  the  fumes  of  iodine  is  always 
useful. 

When  ozaena  is  associated  with  some  ulceration  of  the  passage — an  ulceration  that 
may  be  seen  through  the  speculum,  and,  if  not  seen,  suspected  to  exist  when  an  occa- 
sional escape  of  a  blood-stained  niuco-purulent  secretion  takes  place — tonics  are  still 
called  for,  with  cleanliness  locally,  topical  stimulants  being  employed  when  simpler  means 
have  failed  or  when  great  indolence  of  the  part  is  present. 

These  cases  are,  however,  very  obstinate,  and  much  time  is  frequently  required  to 
bring  about  a  cure,  several  months  being  often  not  long  enough  ;  but  the  fetor,  which  is 
the  chief  symptom  of  annoyance  to  the  suiferer,  may  speedily  be  removed  by  the 
mechanical  and  local  means  already  suggested,  and  so  the  worst  feature  of  the  disease 
becomes  destroyed  and  the  mental  as  well  as  the  physical  comfort  of  the  patient  .secured. 

When,  however,  this  inflammatory  action,  and  perhaps  ulceration,  is  allowed  to  con- 
tinue, a  diff'erent  result  will  ensue ;  the  bone  itself  may  become  involved,  and  as  a  result 
necrosis  follow.  In  so-called  .strumous  subjects  this  condition  is  not  infrequent.  I  have, 
however,  no  evidence  to  give  that  such  a  necrosis  is  always  the  result  of  the  extension 
of  the  inflammation  from  the  soft  parts  around  the  bone  to  the  bone  itself.  In  many 
cases,  I  believe,  if  not  in  the  majority,  the  disease  originates  in  the  bones. 

Necrosis  of  bone  in  the  nose  is  not  an  unfrequent  condition,  and,  as  such,  is 
another  cause  of  the  disease  described  as  ozseno.  It  is  found  in  children  as  well  as  in 
adult  life,  and  may  be  the  result  of  injury,  extension  of  disease  from  the  soft  parts  cover- 
ing the  bones,  or  associated  with  the  so-called  strumous  diathesis  or  with  the  .syphilitic 
poison.  Occasionally  it  takes  place  without  any  such  distinct  cause,  when  it  is  described 
as  idiopathic,  it  being  well  known  that  inflammation  of  bone  may  arise  jjer  se. 

When  oz^ena  is  the  result  of  necrosed  bone,  the  fetor  is  generally  of  a  peculiar  cha- 
racter, such  as  is  well  known  to  accompany  diseased  bone  ;  and  under  these  circumstances, 
by  careful  examination  with  the  speculum'  or  probe,  bare  bone  will  often  be  detected,  by 
which  the  nature  of  the  disease  becomes  tolerably  evident.  In  early  life  I  believe  that 
inherited  syphilis  is  a  more  frequent  cause  of  this  affection  than  is  generally  suspected, 
and  this  opinion  has  been  confirmed  by  the  presence  of  other  marked  symptoms  in  some 
cases,  such  as  old  skin  diseases,  syphilitic  teeth,  or  keratitis. 

Diagnosis. — To  form  a  correct  opinion  in  all  cases  of  ozrena,  a  careful  history  of  the 
case  must  be  obtained  and  well-known  symptoms  not  overlooked  ;  for  unless  an  accurate 
knowledge  of  the  ease  can  be  acquired,  the  treatment  adopted  must  be  doubtful,  and  con- 
sequently unsuccessful. 

Treatment. — When  the  presence  of  necrosed  bone  has  been  made  out  as  the  cause 
of  the  disease  called  ozaena.  it  is  tolerably  evident  that  the  patient  will  not  recover  until 
the  fetid  bone  has  been  removed,  or  rather  has  exfoliated.  To  this  end  the  preservation 
of  perfect  cleanliness  by  means  of  a  douche  or  syringe,  with  or  without  .stimulating  or 
antiseptic  lotions,  may  be  employed,  and  tonics  should  be  administered.  If  syphilis, 
either  hereditary  or  acquired,  is  the  apparent  cause,  our  remedies  must  be  modified  to  the 
general  requirements  of  the  patient.  Mercurials  are  seldom  necessary,  although  in  chil- 
dren suffering  from  this  disease,  where  the  hi-stor}'  and  other  symptoms  of  congenital 
syphilis  are  present,  I  have  given  them,  associated  with  tonics,  with  marked  benefit,  and 
in  obstinate  cases  in  adult  life  such  a  combination  may  also  be  employed.  The  perchlo- 
ride  and  green  iodide  have  proved  the  best  forms  in  my  experience,  and  when  combined 
with  tonics,  such  as  quinine,  bark,  or  iron,  are  invaluable.  I  generally  prescribe  the 
perchloride  with  bark  and  the  iodide  in  pills  at  bedtime,  the  patient  taking  at  the  same 
time  the  syrup  of  the  iodide  of  iron  and  the  iodide  of  potassium  in  some  bitter  infusion, 
such  as  quassia.  If  mercurials  are  not  indicated  or  required,  the  combination  flf  the 
iodides  of  iron  and  potassium  cannot  be  too  highly  valued. 

In  strumous  subjects,  perfect  local  cleanliness,  and  perhaps  stimulants,  accompanied 
with  tonics,  as  cod-liver  oil,  quinine,  or  iron  alone  or  in  combination,  generally  suffice. 
In  exceptional  cases  an  operation  may  be  required  for  the  removal  of  the  dead  bone,  and 
where  by  forceps  the  bone  cannot  be  taken  away  Rouge's  operation  (vide  p.  591)  may  be 
performed. 

Disease  of  the  Frontal  Sinus. 

The  frontal  sinuses,  as  part  of  the  nose,  are  liable  to  many  of  its  diseases.  Acute  or 
chronic  catarrhal  inflammation  is  by  no  means  uncommon,  both  giving  rise  to  a  dull  heavy 
pain  over  the  forehead,  which  the  inhalation  of  the  fumes  of  half  a  grain  or  more  of 
opium  thrown  on  a  hot  piece  of  metal  often  speedily  relieves. 


DrsTi:.\'srf)y  of  tiii:  fiiostm.  sisus. 


595 


Acute  suppuration  ol"  (Im'sc  siiius»'s  is  (icc.'i.si'niaily  met  with,  and  is  atton<lr(l  with 
BeviTO  local  and  j^ciicral  syiuptimis.  I'lidcr  these  circuiustuiiccs  the.'  application  u\'  tlie 
trephine  to  the  outer  sh«'ll  of  hone  may  he  re<|uireil.  Nc^crosis  of  tlie  hones  covcrin;^  in 
the  sinuses  may  exist,  and  the  latter  are  also  lialdc  to  fracture.  New  growths  may  like- 
wise be  fouml  in  this  locality,  cancerous,  myeloid,  or  hony,  the  Ivory  nxsrutix  yroutlm  being 
more  fre(|uently  found  in  the  air-cells  of  the  frontal  bone  and  nasal  fossjc  than  in  any 
other  loc-ality.  From  modern  investigations  they  appear  to  have  a  periosteal  origin  and 
soon    become  loose.      Ill    Hilton's  well-known    case    the   growth    sloughed   away.      In  the 


I'K,.  .{41. 


Fig.  342. 


Enostosis  of  Frontal  .'^inus. 


il.t'izt 


Enostosis  after  Removal. 


case  of  niv  own.  from  which  Figs.  :>41  and  842  were  taken,  the  osseous  mass  was  evidently 
dying  when  it  was  removed.  It  had  been  growing  in  the  frontal  sinus  of  a  man  aet.  24 
for  four  years,  and  had  gradually  encroached  upon  the  orbit.  I  enucleated  it  from  its 
bed  by  means  of  an  elevator,  after  having  taken  away  the  layer  of  frontal  bone  that 
covered  it  in.  A  good  recovery  ensued  {Guys  Hoi^pitdl  Reports^  1873-74).  M.  Olivier's 
treatise  upon  the  subject,  published  in  Paris  in  1869,  gives  all  the  facts  known  about  such 
growths. 

In  all  tumors  occupying  the  centre  of  the  frontal  region  in  children  the  possibility 
that  anv  one  mav  be  a  hernia  of  the  brain   atul  its  membranes  should  be  borne  in  mind. 

Distension  of  the  frontal  sinus  is  an  affection  not  sufficiently  known  ;  indeed, 
it  has  been  described  only  by  Lawson  and  Higgens.  It  shows  it.self  as  a  chronic  swelling 
or  expansion  of  the  bone  near  the  inner  angle  of  the  orbit  above  the  lachrymal  sac.  and 
is  attended  at  times  with  pain  of  a  dull  aching  character.  Occasionally  the  affection  is 
painless  or  the  pain  is  intermittent.  Sometimes  with  the  swelling  there  is  some  watering 
of  the  eye,  and  in  rare  cases  the  eyeball  is  pu.shed  outward.  Injury  is  said  by  Lawson 
to  be  its  common  cause,  but  in  the  three  cases  I  have  seen  it  come  on  of  it.self.  When 
injury  has  been  the  cause,  it  was  probably  a  fracture,  the  fracture  bringing  about  a 
closure  of  the  communication  between  the  middle  meatus  of  the  nose  and  frontal  .sinus. 
The  .swelling  contains  a  more  or  less  purulent  tenacious  fluid. 

Distension  of  the  frontal  sinus,  writes  Higgens.^  "  has  probably  no  early  symptoms. 
There  is  at  no  time  .severe  pain,  nor.  indeed,  any  until  the  disease  has  far  advanced." 
Indeed,  it  is  probable  that  the  disease  is  not  to  be  recognized  until  the  orbital  wall  of  the 
.sinus  begins  to  bulge  or  the  bone  has  so  thinned  as  to  allow  the  distended  .sinus  to  appear 
as  a  soft  fluctuating  swelling  with  a  raised  Vjony  and  dearly-defined  margin.  In  one  of 
my  cases  this  condition  was  very  niarked. 

Diagnosis. — When  the  swelling  is  hard  and  bony,  it  may  be  mistaken  for  an  osseous 
growth,  such  as  is  figured  in  Fig.  341.  When  it  is  soft  and  fluctuating,  it  may  be 
regarded  as  an  ab.scess  connected  with  the  lachrymal  sac.  When  the  bone  has  thinned 
and  gives  a  crackling  sensation  on  pressure,  or  when,  as  noted  above,  a  .soft  fluctuating 
swelling  surmounts  an  elevated  bimy  ridge,  its  true  nature  is  rendered  probable ;  and 
when  the  tumor  varies  in  .size  at  different  times  of  the  day.  the  diagnosis  is  certain,  this 
variation  in  size  being,  according  to  Higgens,  "  due  to  the  fluid  becoming — when  the 
patient  lies  down — evenly  diffu.sed  throughout  the  sinus,  whilst  it  gravitates  to  the  part 
after  the  erect  position  has  been  maintained  for  a  few  hours." 

'  Guy's  Hogp.  JRep.,  vol.  xxv.,  1881. 


596  SURGICAL  AFFECTIONS  OF  THE  NOSE. 

Treatment. — There  is  but  one  kind  which  can  brinp;  about  a  cure,  and  that  is  the 
free  opening  of  the  swelling  and  its  efficient  drainage  into  tlie  nose,  wliich  should  be  guar- 
anteed by  the  introduction  of  rubber  tube.  The  cavity  should  be  washed  out  daily  with 
some  antiseptic.  In  two  of  my  three  cases  a  cure  was  effected  by  these  means  after  the 
lapse  of  months.     In  one  case  the  sinus  through  the  forehead  is  still  open. 

Rhinoplastic  or  Taliacotian  Operations. 

Gaspar  Tagliacozzi.  or  Taliacotius,  professor  of  anatomy  and  surgery  in  the  University 
of  Bologna,  was  the  first  to  bring  these  operations  into  notoriety,  and  they  have  conse- 
quently been  named  after  him.  He  was  not.  however,  the  originator  of  the  operation,  as 
he  himself  refers  to  earlier  men,  such  as  A.  Pare  and  others,  who  have  recommended  it ; 
but  he  was  the  first  to  practise  it  with  much  success,  and  quite  deserves  the  fame  that 
attended  his  efforts.  His  principal  work,  published  in  15!»7  at  Venice,  only  two  years 
before  his  death,  gives  the  histories  of  the  cases  in  which  he  operated. 

His  method  consisted  essentially  in  taking  a  flap  of  skin  from  the  arm  and  transplant- 
ing it  to  the  nose,  and  so  restoring  that  organ  to  its  normal  appearance  where  there  had 
been  any  loss  of  substance. 

Modern  surgeons,  instead  of  following  the  great  Italian  example,  generallv  prefer  to 
adopt  the  Indian  method  and  take  the  integument  from   the  forehead.     The   operation  is 

by  no  means  common.     It  may  be  undertaken   to  restore 
Fig.  .34.3.  the  nose  wholly  or  in   part,  and  the  amount  of  healthy 

integument  required  for  this  purpose  will  be  regulated  by 
the  want.  The  ingenuity  of  the  surgeon,  too,  will  be 
taxed  in  every  case  to  adapt  his  operation  to  its  special 
requirements.  He  must,  however,  always  be  careful  to 
give  himself  abundance  of  new  material ;  and,  having  sat- 
isfied himself  of  the  wants  of  the  individual  case,  and 
that  the  parts  upon  which  he  is  about  to  operate  have 
long  lost  all  traces  of  disease,  he  can  then  map  out  upon 
the  centre  or  lateral  portion  of  the  forehead  of  the  patient 
that  portion  of  integument  he  proposes  to  transplant,  hav- 
ing planned  it  beforehand  on  a  piece  of  paper,  plaster, 
or  wash-leather.  The  shape  required  for  a  nose  and 
columna  will  be  such  as  is  indicated  in  Figs.  337  and  343, 
the  flap  measuring  three  inches  in  each  diameter.  The 
surgeon  shall  then  make  raw  the  whole  surface  of  the  old 
nose  to  which  the  flap  is  to  be  united,  cutting  a  deep 
groove  close  down  to  the  bones  bounding  the  nasal  cavity  for  the  reception  of  the  new 
flap.  A  sponge  may  then  be  firmly  pressed  upon  this  raw  surface  to  arrest  the  bleeding, 
while  the  surgeon  proceeds  to  dissect  up  the  integument  he  had  previously  marked  out 
upon  the  forehead.  In  doing  this  care  should  be  observed  not  to  bruise  or  otherwise 
injure  this  borrowed  skin.  The  inci.sion  should  be  clean  and  extend  down  to  the  bone. 
The  flap  should  be  dissected  up  boldly  and  freely,  care  being  observed  to  leave  a  good 
neck,  through  which  the  circulation  can  be  maintained,  and  to  make  it  long  enough  to 
allow  of  its  being  turned  round.  For  this  purpose  it  is  a  good  practice  to  make  the  inci- 
sion on  the  side  to  which  the  twi.st  is  to  be  made  a  little  longer  than  the  other. 

When  all  bleeding  has  ceased,  the  frontal  flap,  with  the  external  surface  still  upper- 
most, should  be  turned  half  round  and  applied  to  the  nasal  raw  surface,  to  wdiich  it  is  to 
be  carefully  stitched,  the  columnar  portion  being  well  pressed  down  into  the  groove  made 
for  it  and  fixed.  The  new  nostrils  ought  to  be  supported  by  oiled  cotton-wool  or  lint,  and 
the  surface  covered  with  the  same  sort  of  material,  to  maintain  its  warmth.  The  gaping 
wound  on  the  forehead  can  then  be  brought  together  as  far  as  possible  by  means  of  strap- 
ping and  left  to  heal  by  granulation,  the  operation  of  skin-grafting  expediting  repair.  The 
sutures  may  be  removed  on  the  second  or  third  day.  For  the  next  month  the  greatest 
care  is  requisite  in  the  dressing  of  the  wound  and  in  keeping  the  nostrils  up  with  a  plug, 
the  one  suggested  by  Langenbeck  being  the  best,  and  as  soon  as  the  new  flap  has  consol- 
idated the  neck  of  integument  at  the  root  of  the  nose  may  be  divided.  In  the  case  illus- 
trated (Fig.  344)  such  a  practice  was  not  called  for.  I  operated  upon  it  in  1872  with  an 
excellent  result.  When  the  formation  of  the  columna  is  required,  Li.ston's  plan  is  the 
one  generally  employed,  and  is  thus  described  in  his  own   words  : 

"  Restoration  of  the  columna  is  an  operation  which,  in  this  and  other  civilized  coun- 


iniisoi'i.AsTic  ()i'i:ii.\ri()ss. 


597 


I'lO.  344. 


^ 


tri«'s,  must  Im'  more  rri>(|iiciitly  r(M|uin'(l  than  llio  rcstoratinn  of  the  wlinh;  nose.  This 
latter  oju'ratioii  came  tn  he  praetiscMl  in  cniisciiiictife  of  tin;  frcfjiicricy  of  tnutilutioiis 
as  a  ]>iiiiisliiii*'iit,  Imt  llic  |iiMiisliiiiciit  for  suiiic  ol'  mir  sins  is  Iclt  to  nature,  and  she 
generally  n-lciits  liet'ori'  the  wholi'  of  the  orjiaii  disuf)- 
poars.  This  coliinina  is  fre(|iMMitly  destroyed  hy  ulct-ra- 
tion.  Tiu'  deformity  produced  hy  its  loss  is  not  far  short 
of  that  caused  l»y  destruction  of  the  whole  n«)se.  Map- 
pily.  after  the  ulceration  has  heeii  cheeked  the  jiart  .mm 
be  renewed  neatly,  safely,  and  without  much  sufferiiiL'  i  ■ 
the  patient.  The  operation  whicdi  I  have  practised  suc- 
cessfully f'lr  some  years  and  in  many  instances  is  thus 
perfonni'd  :  The  inner  surface  of  the  apex  is  first  pared. 
A  sharp-|tointed  histoury  is  then  passed  thr(»uu:h  the  upp(!r 
li|> — previously  stretched  and  raised  hy  an  assistant — close 
to  the  ruins  of  the  former  columna  and  ahout  an  ei<.dith 
of  an  inch  on  one  side  of  the  nn'sial  line.  The  inci.xion  is 
continued  down  in  a  strai;rht  directittn  to  the  free  mar<rin 
of  the  lip,  and  a  similar  one,  parallel  to  the  former,  is  made 
on  the  opposite  side  of  the  mesial  line,  .so  as  to  insulate  a 
flap  about  a  quarter  of  an  inch  in  breadth  and  conipo.sed 
of  skin,  mucous  membrane,  and  interposed  substance.  The 
fnenulum  is  then  divided  and  the  prolabium  of  the  flap  re-  Appearance  of  Face  after  Formation  of 
moved.  In  ordtn*  to  tix  a  new  cnlumna  firmly  and  with  accu- 
racy in  its  ]»roper  place,  a  sewintr-needlc  is  pa.s.sed  from  without  through  the  apex  of  the  nose 
and  obliquely  tliroui^h  the  extremity  of  the  elevated  flap  ;  a  few  turns  of  thread  over  this 
suflice  to  approximate  and  retain  the  surfaces.  It  is  to  be  observed  that  the  flap  is  not 
twisted  round,  as  in  the  operation  already  detailed,  but  simply  elevated,  so  as  to  do  away 
with  the  risk  of  failure.  Twisting  is  here  unnecessary,  for  the  mucous  lining  of  the  lip, 
forming  the  outer  surface  of  the  columna,  readily  assumes  the  color  and  appearance  of 
integument  after  exposure  for  some  time.  The  fixing  of  the  columna  having  been  accom- 
plished, the  edges  of  the  lip  must  be  neatly  brought  together." 

The  sutures  can  be  removed  on  the  third  or  fourth  day,  when,  as  a  rule,  the  parts  have 
cicatrized.  The  ultimate  result  of  the  case  depends  materially  upon  the  care  be.stowed 
upon  its  after-treatment.  In  the  case  illustrated  in  Fig.  344,  which  I  operated  upon  sev- 
eral years  ago,  a  gratifying  result  ensued,  the  bridge  of  the  no.se  requiring  no  second  ope- 
ration. Dr.  Lichtenberg  has  had  within  the  last  few  years  some  very  successful  cases, 
and  the  late  Mr.  Skey  had  some  excellent  results  in  his  practice.  I  saw  one  that  he  had 
operated  upon  years  before,  which  was  very  excellent.  It  is  well,  however,  to  remember 
Mr.  Skey's  advice  when  he  says,  ••  Let  it  be  the  patient  who  urges  the  operation."' 

Of  late  years  Langenbeck  has  suggested  the  propriety  of  dis.secting  up  the  periosteum 
from  the  frontal  bone  with  the  skin  flap,  so  as  to  give  a  bony  nose,  but  it  is  a  question 
how  fiir  this  osteorhinoplasty  is  an  advantage.      The  operation  has  not  found  much  favor. 

When  only  one  ala  has  to  be  re.stoi'ed,  the  flap  may  be  taken  either  from  the  nose 
itself  or  from  the  cheek,  the  particulars  of  the  plan  being  left  to  the  ingenuity  of  the 
surgeon  to  determine. 


CHAPTER    XVIII. 


SURGICAL    AFFECTIONS    OF    THE    LARYNX    AND    TRACHEA. 

The  larynx  and  windpipe  may  be  contu.sed  from  external  injury,  or  the  cartilages  and 
trachea  rings  fractured,  the  nature  and  .severity  of  the  symptoms  following  these  accidents 
varying  with  the  character  and  the  amount  of  injury  ;  some  years  ago  a  case  came  under 
my  care  in  which  the  tlnjrnUl  cartilage  was  fractured  obliquely  across  the  body.  The  acci- 
dent was  attended  with  much  bleeding  and  cough,  but  these  soon  disappeared,  and  an 
excellent  recovery  ensued.  In  1877.  Dr.  A.  Corley  of  Dublin  recorded  a  case  in  which, 
after  death,  the  second,  third,  and  possibly  the  fourth,  cartilages  of  the  trachea  were  frac- 
tured and  projected  unevenly  into  the  tube,  associated  with  suppuration  around  a  necro.<ied 


698  SURGICAL  AFFECTIONS  OF  THE  LARYNX  AND   TRACHEA. 

cricoid  cartilage.  The  preparation  was  taken  from  a  woman  ajt.  ?A\  who  had  been  squeezed 
in  the  throat  some  weeks  before,  and  was  admitted  into  the  Richmond  Hospital  with  dysp- 
noea, stridulous  breathing,  congestion  of  the  face,  and  external  signs  of  inflammation  about 
her  throat,  and  for  which  tracheotomy  had  been  unsuccessfully  performed.  There  is  more 
danger  when  the  cricoid  cartilage  is  involved  than  when  the  thyroid. 

The  trachea  may  also  be  completely  divided  snhcMtaneously.  I  saw  this  in  June,  1876, 
at  Guy's  Hospital,  in  the  case  of  a  man  ajt.  47  who  was  crushed  between  a  barge  and 
the  side  of  a  vessel,  the  prow  of  the  barge  striking  his  neck.  The  accident  was  followed 
by  dyspncjea  and  some  emphysema  of  the  neck,  but  the  symptoms  were  not  urgent  so  long 
as  the  erect  position  was  maintained,  but  the  recumbent  was  impossible.  The  man  lived 
fifty  hours  and  died  quietly.  After  death  the  trachea  was  found  to  be  completely  severed 
below  the  thyroid  body,  the  two  ends  being  separated  for  an  inch  and  a  half,  while  the 
lower  end  was  below  the  innominate  vein. 

There  was  no  external  bruise  to  denote  the  severity  of  the  injury. 

Wounds  of  the  Throat. 

These  are  generally  made  by  the  hand  of  the  suicide,  and  consequently  have  a  double 
interest,  the  dangers  of  the  local  injury  being  complicated  with  the  peculiar  mental  con- 
dition of  the  sufferer.  It  is  essential,  therefore,  for  the  surgeon  to  dwell  seriously  before- 
hand upon  the  necessities  of  these  cases,  in  order  that  he  may  be  prejiared  to  act  with 
decision  in  the  hour  of  danger. 

In  the  majority  of  cases  of  '•  cut  throat  "  the  wound  is  only  of  a  superficial  nature 
and  simply  involves  skin  or  skin  and  muscle,  and  does  not  implicate  either  the  pharynx 
or  the  respiratory  tract.  These  cases  require  no  other  local  treatment  than  that  usually 
employed  for  skin  wounds,  such  as  sutures  and  some  simple  dressing. 

When  the  wound  is  of  a  deeper  character,  it  may  penetrate  into  the  pharynx  and  air- 
passages  or  involve  the  deep  vessels,  the  dangers  of  the  case  being  much  determined  by 
the  position  of  the  wound. 

My  colleague,  Mr.  Durham,  in  an  able  article  in  Holmes  s  Surgenj  (8d  ed.),  shows  that 
of  232  uns,elected  cases  the  wound  was 

Above  the  hyoid  bone  in 

Througli  the  thyro-hyoid  membrane  in        ....         . 

Througli  the  thyroid  cartilage  in 

Througli  the  crico-thyroid  membrane  in      ....         . 
Into  tlie  trachea  in        ........         . 


J/ 

cases. 

80 

" 

42 

" 

36 

u 

57 

li 

The  respiratory  tract  was  opened  in  about  two-thirds  of  the  cases. 

In  all  cases  of  cut  throat  hemorrhage  as  the  direct  result  of  a  divided  or  wounded 
artery  or  vein  is  to  be  apprehended  ;  and  although  from  the  deep  position  of  the  carotid 
artery  and  jugular  vein  these  vessels  in  the  majority  of  cases  escape  injury,  yet  when 
they  are  divided  death  is  usually  rapid.  Partial  or  complete  division  of  some  of  the 
branches  of  these  vessels  is,  however,  not  unfrequent. 

A  man  in  Guy's,  aet.  21,  in  a  fit  of  despondency  cut  his  throat,  and  died  from  profuse 
hemorrhage  into  the  lung  before  help  could  be  obtained.  The  blood  was  found  after 
death  to  have  come  from  a  divided  superior  thyroid  artery.  An  inmate  of  St.  George's 
divided  the  left  common  carotid  artery  and  wounded  the  internal  jugular  vein  with  a  pen- 
knife, and  died  before  the  house  surgeon  could  arrive.  "A  gentleman  who  committed  sui- 
cide by  cutting  deeply  between  the  os  hyoides  and  thyroid  cartilage  partially  divided  the 
external  carotid  artery  on  the  right  side  just  as  it  was  given  off;  the  flow  of  blood  was 
immense,  and  he  was  found  dead  within  ten  minutes  of  the  infliction  of  the  wound  " 
(Fothergillian  prize  essay  for  1836,  by  my  father,  the  late  Mr.  T.  E.  Bryant).  In  Guy's 
Museum  (Prep.  1711'*)  the  left  interinil  jugular  vein  may  be  seen  divided,  the  cut  being 
between  the  thyroid  and  cricoid  cartilages  and  proving  speedily  fatal.  Prep.  171 P  shows 
division  of  the  inferior  thyroid  artery. 

Blood  may  flow  into  the  trachea  and  suddenly  or  slowly  cause  asphyxia  ;  it  may 
coagulate  over  the  orifice  of  the  larynx  with  the  same  result.  Mr.  Le  Gros  Clark  has  also 
shown  (Surg.  Diag..  1870)  how  air  may  enter  the  circulation  through  a  partially-divided 
vein  a-nd  destroy  life  in  twenty-four  hours. 

When  the  incision  is  above  the  hyoid  bone  and  deep,  the  tongue  may  be  divided,  and 
the  loosened  portion,  by  falling  over  the  orifice  of  the  larynx,  may  cause  sudden  death 
by  suffocation.     In  wounds  of  this  description  the  surgeon  should  consequently  guard 


woiWDs  OF  TIIJ-:  'niiioAT.  599 

n<;ainst   tlu*  )tossil)ilil y  i)f'  tlii^^  ('(mtiiiirciicy  by  pas.sitiL!;  a  thread  throufrh   the  ton«]^ue  and 
ilrawiiiir  it  forwartl. 

Whi'ii  the  eiit  is  jnat  iiliurr  titr  tliijroiti  niiillitif)-,  the  e|ti<rhjttis  may  he  »livi(hMj,  and 
this,  t'allinir  into  the  hiryiix.  may  eause  fatal  (lys|»n<L'a.  To  jtrevcnt  tliis  u  stiteh  should 
he  iiisiTted  into  the  divided  ]i(irlioii  and  the  parts  adjusted.  'J'he  same  result  may  take 
plaee  when  any  portiun  of  the  oritiee  of  tlu-  larynx  lias  heen  detaehed.  Indeed,  all  loose 
bodies  likely  to  obstruct  respiration  should  be  tixed.  Emphysema  is  by  no  means  an 
uneommon  eomplicration  of  eut  throat  when  the  respiratory  traet  has  been  opened,  and  is 
not,  as  a  rule,  a  dauji,erous  oeeurrencc.  It  is  more  common  when  the  external  wound  is 
small. 

liitlamniatiiiM  of  tiic  air-tulifs  aii<l  lunu's  i.>  tin-  .^rciindary  <laiiL't'r  of  wounds  of  the 
throat  involvinu:  the  air-|)assai;cs  :  and  when  the  jdiarynx  or  (esopha<:us  has  been  opened, 
this  risk  is  airtrravated  l>y  the  ])ossibh'  iiitroduetion  oi'  f(»od  into  the  trachea.  It  '' was 
the  eause  of  death  in  17  out  of  21  fatal  eases  of  eut  throat  ei^nsecutively  treated  at 
Ouy's  Hospital  in  whieh  tlie  more  immediate  effects  oi'  the  injury  had  Vjeen  survived" 
(Durham).  Purulent  inKltration  of  the  cellular  tissue  of  the  neck  may  also  ensue,  or 
avlenui  of  the  glottis,  and  at  a  later  date  the  air-pas.saires  may  be  obstructed  V^y  the  cica- 
trization of  the  wound  or  the  contraction  of  the  trachea.  In  excejttional  cases  a  perma- 
nent fistulous  openin«>-  may  be  left. 

The  immediate  danger  of  a  wound  in  the  throat  con.sequently  depends  (1)  on  the 
quantity  of  blood  lost;  (2)  on  the  risk  of  suffocation  from  blood  flowing  into  the  air- 
tube  ;  (;})  the  danger  of  suffocation  by  tissues  divided  and  partially  separated  from  their 
connections  obstructing  the  larynx.  The  secondary  dangers  are  those  of  oedema  of  the 
larynx  and  inflammation  of  the  air-passages,  and  later  on  from  sub.setjuent  obstruction  of 
the  divided  tube  l)y  the  contraction  of  new  tissue  around  it  or  the  growtli  of  exuberant 
granulations  round  the  wound. 

Treatment. — The  first  duty  of  the  surgeon  under  all  circumstances  is  to  arrest  Jiem- 
orrJid;/'.  Arteries  ought  to  be  ligatured  or  twisted,  .so  also  all  deep  veins  when  moderate 
pressure  fails  to  check  the  flow  of  blood.  A  wounded  artery  or  vein  should  be  ligatured 
above  and  below  the  wound.  To  tie  up  an  opening  in  a  large  vein  with  a  lateral  ligature 
is  bad  practice. 

To  find  the  bleeding  vessel,  the  wound  may  have  to  be  enlarged.  The  internal  jugu- 
lar vein  may  be  ligatured  with  a  good  prospect  of  a  successful  result.  Durham  states 
that  out  of  72  cases,  48  recovered.  Gross  has  demonstrated  the  .soundness  of  the  prac- 
tice ( Amer.  Journ.  of  MetL  Sci.,  1867). 

The  second  duty  of  the  surgeon  is  to  prevenf  suffocutuju.  He  should  see  that  the 
respiratory  orifice  is  kept  clear  of  blood  or  of  any  divided  structure,  such  as  the  tongue  or 
epiglottis.  Coagula  ought  to  be  speedily  removed  and  respiration  encouraged  by  artificial 
means  when  natural  processes  have  failed. 

When  the  larynx  or  trachea  has  been  wounded,  the  aim  of  the  surgeon  should  be  to 
keep  the  divided  ])ieces  of  the  tube  in  continuity,  and  not  to  allow  the  upper  portion  to 
overlap  the  lower  and  thus  obstruct  the  resi)iration  ;  at  the  same  time,  care  must  be 
taken  to  keep  the  wounded  parts  sufiiciently  open  to  allow  of  the  escape  of  the  uiucus, 
which  is  always  profuse,  and  to  permit  the  free  ingress  of  air. 

If  the  wound  is  very  extensive  and  difficulties  arise  in  carrying  out  the  above  indica- 
tions, sutures  may  be  introduced ;  but  it  mu.st  be  left  to  the  surgeons  judgment  to  decide 
when  they  may  be  necessary,  according  to  the  exigences  of  the  individual  case.  In  large 
wounds,  where  the  parts  cannot  be  kept  together,  a  suture  is  often  of  immense  benefit ; 
and  sutures,  when  applied,  should  be  put  in  firmly,  including  often  the  whole  thickness 
of  the  tissues.  Their  object  can  only  be  to  fix  the  divided  parts  in  position  and  prevent 
any  mechanical  obstruction  to  the  I'cspiratory  act  by  their  sudden  movement.  To  do 
this  effectually,  the  measures  employed  should  be  boldly  executed.  The  head  should  be 
kept  forward  b\'  the  application  of  bandages,  and  water  dressing  applied  to  the  wound 
itself;  constant  attention  is  demanded  of  the  nurse  to  keep  the  wound  clear  of  discharge 
and  to  see  that  no  obstruction  to  the  breathing  take  place.  The  atmosphere  the  patient 
breathes  should  be  kept  warm  and  made  moist  by  the  introduction  of  steam,  and  the 
wound  covered  with  muslin.  The  clo.sest  attention  should  be  paid  to  the  patient  by  a 
skilful  nurse,  and  every  mental  and  bodily  want  or  weakness  cared  for.  As  regards 
nourishment,  abundance  .should  always  be  provided,  although  it  is  not  such  an  easy  task 
for  the  patient  to  take  it. 

When  the  pharynx  or  oesophagus  is  extensively'  opened,  the  patient  should  never  be 
allowed  to  swallow,  but  be  fed  by  means  of  a  tube  passed  through  either  the  nose  or  the 


600  SURGICAL  AFFECTIONS  OF  THE  LARYXX  AXD   TRACHEA. 

mouth  (and  not  through  the  wound)  and  directed  with  the  fingers  carefully  down  the  throat 
into  the  lower  portion  of  the  oesophagus.  Through  this  beef  tea,  eggs,  brandy,  and  other 
liquid  nourishment  such  as  the  symptoms  indicate  may  be  periodically  administered.  I 
have  an  instance  before  me  of  this  kind,  and  where  the  patient  was  kept  alive  by  such 
means  for  nearly  six  weeks,  the  tube  having  been  passed  through  the  nose.  At  the  end 
of  this  time  he  was  able  to  swallow,  and  recovery  ensued.  When  acting  as  dresser  to  the 
late  Mr.  Aston  Key,  I  had  a  case  where  the  wound  was  inflicted  through  the  trachea, 
dividing  the  cesopliagus.  In  this  instance  the  man  was  fed  twice  daily  through  a  tube 
passed  through  the  mouth  and  directed  with  care  into  the  lower  oesophageal  opening ; 
this  practice,  being  carried  on  for  many  weeks,  was  rewarded  by  recovery.  The  plan  of 
treatment  just  indicated,  however,  is  only  rational,  and  is  such  as  any  surgeon  would 
naturally  suggest.  All  complications,  such  as  suppuration  in  the  cellular  tissues  around 
the  wound,  bronchitis,  or  broncho-pneumonia,  ai'e  to  be  dealt  with  as  they  arise.  Some 
have  suggested  the  propriety  of  tracheotomy  in  severe  cases  of  cut  throat,  so  as  to  allow 
the  wound  to  be  closed.  I  am  unable,  however,  to  see  the  advantages  offered  by  this 
practice  in  ordinary  cases,  although  in  wounds  involving  the  epiglottis  or  upper  part  of 
the  larynx,  when  inflammatory  oedema  appears  as  a  secondary  result,  causing  obstruction 
to  respiration  and  threatening  life,  there  is  no  doubt  as  to  the  wisdom  of  the  practice. 
These  cases,  however,  are  uncommon. 

Among  the  most  remote  dangers  of  such  wounds  the  mechanical  ob.struction  of 
exuberant  granulations  ought  to  be  mentioned,  likewise  some  narrowing  of  the  air-pas- 
sage from  contraction  of  the  cicatrix,  and  tracheal  fistula.  These  results  are  common  to 
traumatic  and  surgical  wounds  of  the  part.  In  Prep.  1711".  Guy^>  Hosp.  Museum, 
taken  from  a  patient  who  had  lived  for  many  years  after  a  wound  which  had  involved 
both  the  trachea  and  oesophagus,  both  the  trachea  and  oesophagus  are  much  contracted 
above  the  opening  and  in  a  less  degree  below.  In  1873  I  was  called  upon  to  perform 
tracheotomy  on  a  man  get.  57  who  had  cut  his  throat  through  the  thyroid  cartilage  .six- 
teen months  previously  ;  for  eight  or  ten  months  he  had  been  suffering  from  gradually- 
increasing  difficulty  of  breathing  due  to  the  contraction  of  the  air-passage,  and  this 
patient  has  ever  since  been  obliged  to  wear  the  canula.  In  the  seventh  volume  of  the 
Clin.  Soc.  Trans,  an  interesting  case  of  the  kind  has  been  recorded  by  Mr.  H.  Lee. 

Foreign  Bodies  in  the  Windpipe. 

There  are  few  accidents  which  excite  more  anxiety  and  alarm  to  a  looker-on  than  the 
passage  of  a  foreign  body  into  the  larynx  or  trachea,  since  the  unfortunate  subject,  in  the 
midst  of  appai'ent  health  or  happiness,  is  suddenly  forced  to  make  violent  .struggles  for 
life.  To  the  spectator  death  seems  imminent,  and  in  the  surgeon  no  less  painful  feelings 
are  excited ;  for  unless  by  his  ail  timely  relief  can  be  afforded,  the  danger  which  is 
apparent  becomes  real  and  death  is  almost  a  certainty. 

The  majority  of  the  victims  of  such  an  accident  are  children,  although  adults  are  not 
exempt  from  such  a  contingency. 

A  foreign  body  may  be  inhaled  at  any  moment,  a  sudden  inspii'ation  being  sufficient 
when  the  mouth  is  full  or  holds  a  foreign  body  which  is  smooth,  light,  or  small,  such  as 
a  seed,  fruit-stone,  bead,  bean,  nut,  or  coin.  Vomited  matter  may  likewi.se  be  drawn  by 
inspiration  into  the  air-tubes  by  patients  in  a  state  of  unconsciousness,  as  when  drunk, 
under  an  anaesthetic,  or  in  an  epileptic  fit.  Foreign  matter  may  likewise  find  an  entry  into 
the  respiratory  tract  through  a  fistulous  opening  between  the  oesophagus  and  trachea  the 
result  of  simple  or  cancerous  ulceration.  The  body  may  be  lodged  at  the  orifice  of  the 
larynx  (Fig.  345).  and  thus  cause  sudden  asphyxia,  or  pass  into  the  rima  or  ventricle, 
where  it  may  be  arrested  and  give  rise  to  spasm  or  cause  oedema,  and.  as  a  consequence, 
more  or  less  gradual  obstruction.  It  may  likewise  pass  into  the  trachea  or  bronchi,  the 
right  bronchus  being  its  most  common  seat,  and  become  either  impacted  or  remain  mova- 
ble. The  size  and  the  shape  of  the  foreign  body  determine  many  of  these  points  ;  for, 
whilst  a  large  one  will  naturally  be  arrested  at  the  orifice  of  the  larynx,  a  small  one  will 
probably  pass  through.  A  jagged  and  light  bod}-  such  as  a  seed  or  piece  of  nutshell 
would  be  more  likely  to  be  caught  in  the  rima  than  a  small  round  body  such  as  a  bean. 
A  light  body  will  remain  movable,  whereas  a  heavier  one  may  become  impacted. 

A  piece  of  meat  may  become  impacted  in  the  rima  glottidis  and  cause  instantaneous 
death  (Prep.  Guy's  Hosp.  Mus.  1710). 

In  the  case  of  a  child  set.  2?  on  whom  I  unsuccessfully  operated  in  1864,  a  date-stone 
was  found  impacted  in  the  right  bronchus,  while  its  upper  end  was  pressing  against  the 


FftnEiax  nnniF.s  is  riii:  wisin'iri':. 


GO] 


Vu..  :;10. 


J. 


uiising  Death. 
(Taken  Irom  a  child  eleven 
months  old.     Prep.  1710^.) 


Date-Stone  Impacted  in 
Right  Bronchus,  i  I'rep. 
1717'*.) 


leftside  (if  the  traclica  ;iii(l  «'xritinf:  ulccnitidii  (  Fijr.  iilti).  Tlic  child  livccl  four  days. 
In  aiKttlicr  case.  rciMirdt'd  in  my  Clliiicul  Snnji  n/.  I'art  TT  m  Ihhii  \v:i<  firtnly  itiipaoted  in 
the  riijht  hroiicliiis,  (•aii.^iiii';  ctunplt'tc 
obstnicticin  ti>  the  ri,Ldit  \n\\]i. 

Till'  fact,  |Miiiited  out  by  Ooodall 
of  Duldiii.  that  tlic  septum  at  the 
divisidu  of  the  tracliea  is  somewhat 
to  the  left  of  the  median  line,  is  jiroh- 
ably  the  ex|ilaiiati(in  of  the  riirht 
bronchus  beinj;  UKire  fre(|iictitly  the 
peat  of  the  foreiirn  body  than  tin- 
left.  The  hiitrer  size  of  the  ri<rht 
bronclius  doubtless  favors  this  tend- 
ency. 

The  sv.Ml'Tci.Ms  which  attend  the 
entrance  of  a  foreign  body  into  the 
air-passajrres  are  somewhat  character- 
istic, although  those  that  follow  are 
often  ob.scure.  The  most  typical  is 
a  violent  convulsive  cough  coming  on  pone  in  i.arvnx, 
ahnipf/i/,  followed  by  difficult  respira- 
tion and  a  feeling  of  suffocation,  this 
spasmodic  cough  being  likely  to  recur  at  intervals  on  any  movement  and  as  long  as  the 
foreign  body  is  loose. 

AV'hen  the  foreign. body  is  lodged  near  the  rima  and  impacted,  the  voice  is  altered  in 
character,  ichistling  or  sfri'/ii/oiia,  and  there  may  be  some  tenderness  of  the  larynx  on 
manipulation,  or  pain.  When  an  extraneous  body  is  in  the  ventricles,  the  spasmodic 
deVangement  to  which  it  gives  rise  too  often  proves  speedily  fatal.  In  children  rapid 
suffocation  is  a  common  result  of  such  a  cause,  death  being  more  frequent  from  spasm 
of  the  glottis  than  from  mechanical  obstruction  by  the  foreign  body,  though  when  the 
body  is  fixed  in  the  larynx  chronic  obstruction  often  comes  on  from  the  oedema  of  the 
larynx  excited  by  its  presence. 

When  the  breathing  of  the  patient  is  at  times  natural  and  at  others  disturbed  by  a 
paroxysm  of  cough  or  dyspnoea,  and  when  these  symptoms  are  brought  on  by  any  move- 
ment or  violent  respiratory  effort,  it  is  probable  that  the  foreign  body  is  loose  in  the 
trachea  or  in  one  of  its  divisions  ;  indeed,  patients  are  conscious  occasionally  of  the 
movement  of  the  body.  When  by  auscultation  it  can  be  made  out  that  air  enters  one 
lung  freely  and  the  other  feebly,  the  exact  seat  of  impaction  of  the  foreign  body  is  indi- 
cated, and  the  amount  of  dyspncea  present  will  depend  upon  the  tightness  of  the  impaction. 

When  the  extraneous  body  has  passed  through  the  larynx  into  the  trachea,  there  may 
be  long  intervals  of  repose  between  the  attacks  of  laryngeal  spasm,  but  any  spa.sm  may 
prove  fatal. 

Many  cases  are  now  on  record  in  which  foreign  bodies,  particularly  coins,  have  been 
impacted  in  a  bronchus  and  have  given  rise  to  no  urgent  symptoms  for  years.  Dupuy- 
tren  in  one  of  his  lectures  given  in  1833  relates  a  case  where  a  coin  was  known  to  have 
been  in  the  air-passage  for  ten  years  without  producing  any  very  distressing  effects,  and 
was  found  after  death  to  occupy  a  tubercular  excavation.  Professor  Gross  gives  a  case 
in  which  a  portion  of  bone  is  said  to  have  been  coughed  up  after  having  been  retained 
for  sixty  years.  Cases  such  as  the.se.  however,  should  never  allow  the  surgeon  to  rest 
satisfied  or  permit  a  foreign  body  to  remain  in  the  air-passages,  for  so  long  as  it  does 
death  may  at  any  moment  be  suddenly  produced  by  convulsive  laryngeal  spa.sm.  or  more 
slowly  by  broncho-pneumonia. 

Difficulty  of  breathing  is  not  uncommon  as  a  consequence  of  the  arrest  of  food  in  the 
oesophagus  or  lower  part  of  the  pharynx,  and  at  first  sight  the  surgeon  might  think  that 
the  symptoms  are  due  to  the  presence  of  some  foreign  body  in  the  air-passage.  When 
doubt  exists,  the  patient  should  be  made  to  swallow;  in  laryngeal  obstruction  no  difficulty 
will  be  experienced  by  the  act.  whereas  in  pharyngeal  it  will  be  impossible.  Under  other 
circumstances  a  probang  may  be  carefully  introduced  into  the  oesophagus,  and  in  every 
case  a  careful  exploration  of  the  throat  and  pharynx  with  the  finger  should  be  made. 
When  the  foreign  body  is  impacted  in  the  pharynx  and  cannot  be  removed,  and  laryngeal 
spasm  threatens  life,  the  windpipe  may  require  to  be  opened.  The  surgeon  should  always 
hesitate  to  employ  force  in  pressing  a  foreign  Ijody  downward. 


602  SURGICAL  AFFECTIONS  OF  THE  LARYNX  AND   TRACHEA. 

Treatment. — Given  the  diagnosis  of"  a  foreign  body  in  the  windpipe,  the  duty  of  the 
surgeon  plainly  is  to  endeavor  to  remove  it.  There  should  be  no  deviation  from  this  res- 
olution, because  so  long  as  a  foreign  body  remains  in  the  air-passage  sudden  death  from 
spasm  of  the  larynx  is  imminent,  and  the  first  spasm  may  prove  fatal,  the  spasm  being 
produced  by  any  movement  of  the  foreign  body.  The  surgeon  should  never  allow  him- 
self to  be  misled  by  the  mildness  of  the  symptoms  nor  by  the  knowledge  that  in  rare 
instances  foreign  bodies  have  remained  in  the  passage  for  years,  and  even  then  been 
expelled,  since  such  cases  are  exceptional.  The  accident  is  one  that  will  inevitably 
destroy  life,  although  it  must  be  doubtful  at  what  time  or  in  what  form  danger  may 
appear. 

In  all  urgent  cases  in  which  spasm  of  the  larynx  threatens  life  tracheotomy  should  be 
performed,  because  with  an  opening  in  the  trachea  fatal  spasm  is  impossible,  and  the  sur- 
geon may  then  proceed  to  investigate  the  case.  In  cases  in  which  life  appears  to  be 
extinguished  the  same  practice  should  be  adopted,  artificial  respiration  being  subse- 
quently maintained.  Should  the  symptoms  point  to  the  larynx  as  the  seat  of  the 
impaction,  the  upper  orifice  should  be  closely  examined  by  the  finger  introduced 
through  the  mouth,  and  a  full-sized  bougie  or  catheter — or,  what  is  better,  a  small 
piece  of  sponge  held  by  forceps  or  fixed  on  a  handle — introduced  from  below  through 
the  wound  into  the  larynx.  By  these  measures  most  foreign  bodies  caught  and  impacted 
in  the  larynx  itself  may  be  removed.  In  exceptional  cases  where  these  measures  fail  the 
surgeon  may  be  called  upon  to  lay  open  the  larynx.  The  laryngoscope  at  times  will  be 
an  invaluable  aid  in  guiding  to  the  position  of  the  foreign  body  and  in  eft'ecting  its  extrac- 
tion. It  is  only  applicable,  however,  in  adults.  When  the  position  of  the  foreign  body 
is  known,  its  removal  may  be  facilitated  by  curved  forceps. 

Laryngotomy  is  scarcely  applicable  to  these  cases,  the  majority  being  found  in  chil- 
dren. In  children  the  opening  in  the  trachea  should  always  be  as  high  as  possible,  and 
there  is  no  objection  to  dividing  the  cricoid  cartilage  {larynijo-tracheotomy^  to  reach  the 
larynx.  When  the  foreign  body  is  so  fixed  in  the  larynx  as  to  be  immovable  by  tlie 
means  suggested,  the  thyroid  caitilage  must  be  laid  open  by  increasing  the  incision 
upward.  In  doing  this  the  larynx  will  be  fully  exposed  and  the  removal  of  the  body 
facilitated.  When  the  foreign  body  has  passed  the  larynx  and  is  in  the  trachea,  a  free 
opening  should  be  made  tow  down  in  the  passage ;  and  when  this  is  done,  it  not  unfre- 
(jucntly  happens  that  the  foreign  body  is  expelled.  Should  this  not  happen  and  the. 
foreign  Ijody  is  heavy  and  smooth,  the  patient  may  be  inverted  and  succussion  employed 
— that  is,  the  patient  should  be  patted  sharply  on  the  back  or  shaken  with  the  view  of 
dislodging  it.  But  this  proceeding  should  not  be  employed  until  the  trachea  has  been 
opened.  Should  the  foreign  body  be  light,  it  may  possibly  be  extracted  by  means  of  the 
"  sucker"  figured  352  at  page  609.     The  rubber  tube  for  this  purpose  should  be  long. 

Some  surgeons  advise  the  introduction  of  forceps  or  other  instrument  through  the  wound 
into  the  trachea  for  the  removal  of  the  foreign  body,  and  in  recent  times  success  has  follow- 
ed the  practice.  Thus  in  May,  1876,  Mr.  Maunder  extracted  by  means  of  a  loop  of  silver 
wire  through  an  opening  made  in  the  trachea  a  glass  sleeve-link  from  the  left  bronchus 
of  a  boy  a3t.  13.  Mr.  Hulke  in  August,  1876,  hooked  out  of  the  right  bronchus  of  a 
woman  aet.  37  the  outer  tube  of  a  tracheotomy  canula  by  means  of  a  piece  of  German 
silver  wire  bent  into  a  hook,  and  Mr.  Lucas  on  November  16,  1877,  removed  by  means 
of  forceps  the  same  kind  of  thing  from  the  left  bronchus  of  a  man  aet.  57,  the  tube  hav- 
ing been  in  the  bronchus  for  seven  weeks. 

Fig.  347  represents  an  excellent  pair  of  forceps  for  this  purpose.  It  was  made  for 
Dr.  S.  D.  Gross  of  Louisville  before  1854,  and  is  taken  from  his  book  on  Foreign  Bodies 

Fig.  347. 


Gross's  Trachea  Forceps 


in  the  Air-Passages.  "They,"  as  described  by  him,  "are  composed  of  silver,  and  are  a 
little  upward  of  eight  inches  in  length.  The  handle  is  considerably  curved  on  the  flat 
and  has  two  rings  for  the  thumb  and  finger.  The  blades,  which  are  rounded  and  very 
slender,  are  five  inches  long  and  terminate  each  in  a  fenestrated  extremity  nine  lines  in 


SCALD    OF   rUK   LAUYSX.  (103 

len^tli  l»y  tliriT  lines  in  width,  tlit;  milt;r  siirt'iicc!  heiiii:  siiiouth  uiid  coiivox,  tlii;  iiiiicr  Hut 
anil  sliiilitly  serrated.  Tlie  blades  when  shut  sli;<htly  overhip  eaeh  other.  The  weight 
of  the  instrunient  is  a  little  over  five  drachms.  The  instnini(!iit.  hein<r  long  and  slender, 
may  he  used  as  a  prohe  ;  heini;  eomposi-d  of  silver,  it  may  he  hent  at  any  point  and  in 
any  direetion  ;   and  heing  delieate,  it  eannot  impede  the  jtassage  of  air  durinj^  its  u.se.' 

When  these  means  fail  to  remove  the  foreiirn  l)ody.  the  jiatient  must  he  lel"t,  hut  the 
wound  in  the  air-tuhe  should  l>e  kept  open. 

If  the  foreij;ii  hody  be  in  the  laryn.\,  the  eanula  may  be  introduced;  liut  when  in  the 
trachea  or  bronchus,  its  retention  is  injurious,  as  it  prevents  the  escape  of  the  substance. 
Under  tliese  circumstances  Hilton's  suggesti(jn  to  form  a  transverse  valvular  openiiif^  in 
the  trachea  is  undoubtedly  the  best,  since  it  readily  allows  the  escape  of  tlie  foreign  body 
when  impelled  against  its  surface.  The  cutting  out  of  a  portion  of  the  trachea  is  (piite 
unnecessary.  A  better  practice  consists  in  making  some  provision  for  the  tracheal  wound 
to  be  held  open  by  hooks,  by  some  such  apparatus  as  Golding-Bird's  tracheal  dilator.  In 
one  case  in  which  the  trachea  was  deep  1  managed  to  keep  the  traclieal  wound  open  by 
means  of  a  divided  ring  of  strong  wire  embracing  the  neck,  its  two  ends  being  made  to 
liook  into  the  opening  in  the  air-passage  and  acting  as  retractors.  In  anotlier  I  licld  the 
wound  apart  by  means  of  a  wire  instrument  made  on  the  principle  of  the  eye  speculum. 
When  efforts  fail  at  one  time  for  the  removal  of  the  body,  they  nuiy  be  successful  at 
another.  Mr.  Urunel's  well-known  case  is  one  in  point.  Mr.  Durhaui  informs  us,  from 
an  analysis  of  G3G  cases  <tf  foreign  bodies  in  the  air-passages,  that  death  resulted  in  41 
per  cent,  when  no  operation  twas  performed,  and  in  23  per  cent,  when  operative  measures 
were  resorted  to,  and  lience  the  chances  are  greatly  in  favor  of  the  latter  practice.  The 
foreign  body  having  been  removed,  the  chief  danger  has  passed.  There  may  be  some 
inflammation  of  the  air-passage  as  a  result  of  the  irritation  of  the  foreign  body,  but  this 
usually  subsides  on  the  removal  of  its  cause ;  in  exceptional  instances  it  may  prove 
troublesome,  if  not  fatal.  The  nature  of  the  substance  has  also  much  influence  in  deter- 
mining this  result,  smooth  bodies  being  sliglitly  irritating,  while  jagged  are  more  so.  The 
operation  of  tracheotomy  doubtless  does  something  toward  aggravating  the  tendency  to 
inflammation.  Such  a  complication  sliould  be  treated  on  rational  principles,  but  in  the 
majority  of  instances  the  inflammation  will  subside  spontaneously  on  the  removal  of  the 
oftending  body.  Water  dressing  to  the  wound  and  a  warm,  moist  atmosphere  are  the 
two  essential  points  of  practice  to  be  attended  to  after  the  removal  of  the  cause,  and,  as  a 
rule,  convalescence  speedily  follows.  Antcsthetics  ought  always  to  be  administered  in 
these  cases  when  operative  interference  is  called  for. 

Scald  of  the  Larynx. 

This  somewhat  common  accident  is  engendered  amongst  the  poor  from  the  habit  of 
feeding  their  children  out  of  a  teapot.  The  child,  when  thirsty  and  alone,  being  accus- 
tomed to  drink  from  the  '•  spout,"  tries  the  same  experiment  with  the  kettle  of  boiling 
water,  and  scalds  the  pharynx  and  orifice  of  the  larynx,  so  that  anlenia  of  the  part  fol- 
lows, in  the  same  manner  as  a  blister  ari.ses  by  the  application  of  boiling  water  or  steam 
to  any  other  tissue. 

The  symptoms  caused  by  such  an  accident  appear,  as  a  rule,  very  speedily,  and  the 
small  chink  of  the  glottis  soon  closes ;  as  a  consequence,  a  fatal  result  ensues  unless  early 
relief  can  be  obtained. 

Sv.MPTOMS. — In  some  cases  the  mouth,  with  the  soft  palate,  tongue,  and  fauces,  will 
be  found  swollen  and  vesicated.  There  will  also  be  difficulty  in  swallowing,  and  also 
alteration  in  the  character  of  the  voice.  The  respiration  rajiidly  becomes  affected  and  a 
spasmodic  croupy  cough  appears,  with  .stridulous  breathing.  These  symptoms  may 
become  gradually  or  rapidly  worse,  and  may  be  complicated  with  attacks  o^  spasmodic 
dyspnoea  at  long  or  short  intervals  ;  but  when  these  attacks  appear,  the  condition  is 
extremely  dangerous,  as  any  spasm  may  prove  fatal.  A  somewhat  .similar  result  may- 
arise  from  the  intentional  or  accidental  swallowing  of  any  corrosive  poison  or  acid  or  from 
the  inhalation  of  a  flame. 

Treatment. — In  a  fair  proportion  of  these  cases  little  other  treatment  than  a  warm 
bed.  the  application  of  a  hot  sponge  to  the  larynx,  and  the  inhalation  of  warm  moist  air 
is  ever  needed ;  the  symptoms  sub.side  as  rapidly  as  they  appear,  three  or  four  days  see- 
ing the  worst  of  the  ca.se  :  and  in  these  mild  cases  the  laryngeal  symptoms  are  probably 
never  severe.  When  laryngeal  symptoms  exist,  accompanied  by  spasm,  the  case  assumes 
a  threatening  aspect ;  indeed,  the  first  spa-sm  may  be  the  last.     I  have  notes  of  the  case 


604  SURGICAL  AFFECTIONS  OF   THE  LARYNX  AND   TRACHEA. 

-'  of  a  child  in  whom  the  symptoms  were  so  slight  that  no  anxiety  was  felt,  but  a  single 
spasm  took  place  two  hours  and  a  half  after  the  accident  and  put  an  end  to  life. 

When  symptoms  are  severe,  the  operation  of  tracheotomy  should  be  performed  ; 
indeed,  I  am  disposed  to  recommend  this  operation  in  every  case  in  Avhich  the  symptoms 
are  progressing  and  laryngeal  spasms  coexist.  To  postpone  it  too  long,  till  the  lungs 
become  gorged  with  blood,  and  consequently  disposed  to  inflammatory  action,  and  the 
powers  of  the  patient  are  depressed,  is  a  timid,  and  certainly  unsuccessful,  practice.  In 
the  opinion  of  many  good  surgeons,  I  know,  it  is  thought  desirable  to  pospone  operative 
interference  as  long  as  possible — "to  watch  and  wait."  In  this  I  do  not  agree.  When 
laryngeal  spasms  exist  with  mechanical  obstruction,  nothing  but  opening  the  windpipe 
places  the  patient  in  safety.  Out  of  9  cases  consecutively  treated  by  tracheotomy  5 
recovered.  The  statistics,  however,  of  my  colleague,  Mr.  Durham,  are  less  favorable,  35 
out  of  51  cases  terminating  fatally. 

In  some  instances  the  scarification  or  puncturing  of  the  oedematous  opening  of  the 
larynx  and  epiglottis  gives  great  relief.  I  have  been  accustomed  to  do  this  by  means  of 
an  ordinary  tenaculum  or  mounted  needle.  Mr.  Tudor,  formerly  of  the  Dreadnaught, 
has  invented  a  useful  instrument  for  the  purpose,  called  an  epiglottome.  The  puncture.^ 
into  the  oedematous  tissue  may  be  free  and  never  seem  to  do  "harm.  Drs.  Wallace  and 
Bevan  of  Dublin  have  spoken  very  strongly  in  favor  of  the  calomel  treatment,  two  or 
three  grains  being  given  every  hour  until  the  symptoms  are  relieved,  and  Dr.  Croly  uses 
inunction  at  the  same  time.  Other  surgeons  speak  well  of  antimony,  and  doubtless  it  is 
a  drug  that  should  always  be  given  in  doses  of  one,  two,  er  three  minims  of  the  anti- 
monial  wine  every  quarter  of  an  hour  until  some  efi'ect  has  been  made  upon  the  disease, 
and  then  at  longer  intervals.  The  best  local  application  to  the  larynx  is  the  hot  sponge. 
A  blister  over  the  upper  part  of  the  sternum  sometimes  does  good,  and  in  exceptional 
cases  leeches  to  the  larynx  may  be  used.  The  time  required  by  all  these  remedies  to  pro- 
duce their  eff"ects  is  too  long  and  their  action  is  too  uncertain  to  allow  the  surgeon  to 
depend  upon  them  in  acute  cases;  as  accessories  to  the  treatment  they  are  of  use," but  as 
means  of  preventing  death  when  obstruction  exists  and  spasms  are  frequent  they  are  not 
to  be  relied  upon.  When  an  operation  is  performed,  it  should  be  tracheotomy.  Laryn- 
gotomy  is  inapplicable  and  too  near  to  the  disease.  Anaesthetics  may  be  given  without 
fear. 

Diseases  of  the  Larynx  requiring  Tracheotomy. 

Since  the  introduction  of  the  laryngoscope  our  knowledge  of  the  disease  of  the  larynx 
has  so  much  increased,  and  the  treatment  of  its  diff'erent  affections  so  much  improved, 
that  the  subject  has  become  somewhat  extensive — so  extensive,  indeed,  that  enterprising 
members  of  our  profession  have  contrived  to  turn  it  into  a  specialty.  This  is  a  subject 
of  regret  in  a  certain  sense,  as  it  tends  to  make  the  bulk  of  the  profession,  and  with  it  the 
student,  look  upon  laryngeal  affections  as  difficult  subjects  of  investigation  and  beyond 
the  reach  of  average  skill.  This  is  not,  however,  in  any  way  correct,  for  the  use  of  the 
laryngoscope  or  throat  speculum  is  no  more  difficult  than  that  of  any  other  iri.strument. 
To  use  it  neatly  and  efficiently  requires  skill  and  some  practice,  but  the  same  efforts  are 
also  essential  to  every  other  surgical  investigation. 

The  first  laryngoscope  was  introduced  to  the  profession  in  1829  by  the  late  Dr.  B.  G. 
Babington  of  Guy's  Hospital,  who  under  the  term  "  glottiscope  "  invented  an  instrument 
composed  of  a  mirror  fixed  to  a  wire  handle,  which,  being  fixed  against  the  palate  whilst 
the  tongue  was  depressed,  enabled  him  to  view  the  upper  part  of  the  larynx.  Garcia, 
the  singer,  in  1855  gave  an  impulse  to  the  idea  by  throwing  the  sun's  rays  into  the  back 
of  his  mouth  by  means  of  a  mirror  held  in  his  left  hand,  and  so  from  a  dentist's  reflector 
introduced  into  his  mouth  he  could  witness  the  movements  of  his  larynx  in  the  looking- 
glass.  But  to  Drs.  Czermak  and  Turck  is  unquestionably  due  the  credit  of  having  applied 
this  mode  of  investigation  in  a  scientific  way  to  the  diagnosis  of  laryngeal  disease.  They 
employed,  however,  artificial  illumination  instead  of  solar,  adopting  the  practice  of  Helm- 
holtz  in  ophthalmoscopic  operations. 

The  ordinary  mode  of  application  of  the  instrument  is  very  simple.  The  patient  sits 
with  his  back  to  a  good  light ;  that  of  the  sun  is  the  best,  but  a  moderator,  gas,  or  electric 
lamp  will  suffice.  The  lamp  should  be  in  a  line  with  the  patient's  face  and  on  his  right 
side  ;  the  surgeon,  with  the  mirror  fastened  round  his  head,  faces  the  light  and  reflects  it 
on  the  patient.  The  patient  is  then  directed  to  open  his  mouth,  protrude  his  tongue,  and 
hold  it  with  a  handkerchief;  a  warmed  mirror  is  then  introduced  to  the  back  of  the 
fauces,  while  the  tongue  at  this  time  is  depressed.     The  rays  of  light  from  the  frontal 


/'//. I n y.\(;j:. il  a I'lKcrioys  unsrit iicrisu  nil-:  iu:si'ira tios. 


005 


HjiiTor  aiv   tlu'ii   inailc  tu  fall  upon   tlic   mirror  in  tlii'  pliarynx,  and  with  a  litlh?  arrange- 
mont  tlu'  glottis  anil  all  the  parts  arouml,  ahovi;  or  hi'low,  may  be  fari'lully  examined. 

The  pharyntroal  mirror  may  also  he  well  illuminated  hy  simply  projectint^  the  rays  of 
light  tVum  a  large  retieetor  fastened  heind  a  gas  or  moderator  lamp,  as  seen  in  Fig.  34b. 

Fiu.  348. 


Laryngoscopie  Examination. 


I  have  employed  this  method  for  many  years,  and  found  it  more  effectual  than  any 
other. 

It  is  impos.sible  in  the  following  chapter  to  give  a  full  description  of  all  the  different 
affections  to  which  the  larynx  is  liable,  nor  would  it  be  consistent  with  the  object  I  have 
in  view,  since  laryngeal  affections  come  as  much  under  the  notice  of  the  physician  as  of 
the  surgeon,  and  the  latter  is  consulted  only  when  medicine  has  failed  to  relieve  symp- 
toms and  evidence  exists  of  some  progressive  aflPection  which,  by  causing  obstruction  to 
the  respiratory  process,  threatens  life.  In  the  following  chapter  I  propose,  therefore,  to 
consider  the  diseases  of  the  larynx  in  their  surgical  aspect  only,  and  to  view  them  simply 
in  their  relation  to  tracheotomy  or  other  operative  interference. 

In  a  general  way  it  may  be  asserted  that  tracheotomy  may  be  called  for  under  any 
circumstances  in  which  obstruction  exists  to  the  respiratory  act.  such  as  in  pharyngeal 
affections  mechanically  affecting  the  larynx;  in  laryngeal  disease,  acute  or  chronic,  inflam- 
matory or  otherwise;  or  in  tumors  pressing  from  without  upon  the  windpipe  in  some  part 
of  its  course.  It  may  also  be  possibly  required  for  some  temporary  purpose  connected 
with  operative  surgery,  to  ensure  the  maintenance  of  the  respiratory  act  during  the 
removal  of  a  large  pharyngeal  or  maxillary  tumor. 


Pharyngeal  Affections  Obstructing  the  Respiration. 

Abscesses  about  the  pharynx  or  tonsils  at  times  cause  laryngeal  obstruction,  and 
such  a  complication  should  be  treated  by  puncturing  the  abscess  with  a  guarded  bistoury. 
Inflammatory  and  ulcerating  affections  of  the  throat,  more  particularly  those  called  diph- 
theritic, are  apt  to  spread  to  the  larynx  and  set  up  a  laryngitis. 

Tumors  of  the  pharynx  or  tonsils  are  occasionally  met  with  pres.sing  upon  the 
larynx  and  interfering  with  its  functions  ;  a  cyst  may  develop  at  the  back  of  the  tongue 
in  front  of  the  epiglottis  and  by  its  size  almost  close  the  laryngeal  orifice,  or  a  naso-pha- 
ryngeal  tumor  may  so  press  downward  as  not  only  to  threaten  life  by  suffocation,  but  to 
cause  death.  In  a  large  naso-pharyngeal  tumor  I  had  to  treat  the  former  condition  was 
met  with,  but  relief  was  given  by  the  removal  of  the  growth.  In  another  case,  one  of 
cancerous  tumor  of  the  pharynx  above  the  soft  palate,  occurring  in  a  boy  aet.  18,  and 
which  rapidly  recurred  after  its  removal,  death  ensued  from  suffocation,  tracheotomy 
having  been  rejected.  Suffocation  from  simple  enlargement  of  the  tonsils  I  believe  to  be 
unknown,  although  it  has  occurred  from  cancerous  disease. 


606  SURGICAL  AFFECTIOXS  OF  THE  LARYXX  AND   TRACHEA. 

Affections  of  the  Larynx  requiring  Tracheotomy. 

Inflammatory  affections  can  never  exist  long  without  causing  some  closure  of  the 
glottis,  thereby  endangering  life.  In  acute  laryngitis  of  catarrhal  origin,  in  membranous 
and  in  diphtheritic  croup,  a  few  hours  may  be  sufficient  to  produce  this  effect,  from  either 
oedema  of  the  larynx,  suppuration  of  the  larynx,  or  the  effusion  of  a  false  membrane.  In 
all  the  result  is  the  same — mechanical  closure  of  the  glottis  complicated  with  spasm — and 
in  all  the  important  question  presents  itself  as  to  whether  medical  treatment  can  be  suf- 
ficient to  check  the  disease  or  surgical  aid  in  the  way  of  operative  interference  is  required. 
Trousseau,  our  great  authority  in  this  matter  of  tracheotomy  in  croup,  maintained  strongly 
that  the  earlier  the  operation  is  performed  the  greater  are  the  chances  of  success,  that  it 
ought  to  be  performed  before  death  is  imminent,  and  that,  to  whatever  degree  asphyxia 
may  have  proceeded,  it  ought  to  be  tried,  for  in  the  most  desperate  cases  there  is  a  chance 
of  success  provided  the  local  lesion,  the  croup,  constitutes  the  chief  danger  of  the  disease. 
In  these  views  I  entirely  concur ;  they  are  physiologically  sound  and  clinically  correct. 
Indeed,  the  operation  should  be  performed  in  all  cases  when  the  disease  is  steadily  pro- 
gressing and  is  unaffected  by  medical  treatment,  and  it  should  be  undertaken  h^fore 
asphyxia,  carbonaemia,  or  severe  blood  poisoning  has  taken  place.  To  operate  before 
any  evidence  of  deficient  oxygenation  of  the  blood,  as  shown  by  lividity  of  the  lips,  etc., 
exists  would  be  bad  practice,  and  to  postpone  operative  interference  when  such  lividity 
is  present  is  to  throw  away  a  chance.  With  retraction  of  the  epigastrium  and  intercostal 
spaces  and  supraclavicular  depression  in  inspiration,  with  or  without  cyanosis,  any  delay 
would  be  dangerous.  It  is  a  clinical  fact  that  in  a  large  number  of  cases  the  extension 
of  disease  is  arrested  by  the  operation,  though  when  the  lungs  have  become  gorged  with 
blood  unfit  for  circulation  by  too  protracted  delay  in  operating  a  successful  issue  can 
hardly  be  looked  for. 

In  chronic  laryngitis,  whether  tubercular,  syphilitic,  or  otherwise,  tracheotomy 
may  be  required  to  prevent  impending  death  or  as  a  means  of  cure.  For  the  first  indi- 
cation it  should  not  be  postponed  too  long,  for  ''too  long  '  often  means  "too  late,"  .some 
spasmodic  attack  carrying  off  the  patient.  When  these  attacks  consequently  appear  and 
recur,  tracheotomy  should  be  performed. 

TracJieolomy  as  a  means  of  cure  in  chronic  inflammatory  laryngeal  affections  is  not 
sufficiently  practised.  •'  It  has  been  hitherto  generally  performed  in  the  class  of  cases  to 
which  I  have  just  alluded — to  rescue  patients  from  the  danger  of  impending  suffocation, 
and  to  prolong  life  when  threatened  from  laryngeal  disease ;  and  yet  it  must  have  struck 
most  men,  when  watching  cases  which  have  been  operated  upon  under  these  circum- 
stances, how  rapidly  all  laryngeal  symptoms  disappear  and  ulcerative  action  undergoes  a 
reparative  process,  both  in  the  pharynx  and  larynx,  after  a  new  passage  has  been  obtained 
for  the  respiratory  act  and  complete  quiescence  of  the  parts  has  been  secured  by  means 
of  tracheotomy."  I  have  a  strong  opinion,  therefore,  that  it  would  be  wise  to  perform 
the  operation  in  ulcerative  laryngeal  affections  at  an  earlier  period  than  has  hitherto  been 
practised,  witha  view  of  arresting  the  progress  of  the  disease,  and  probably  of  saving  the 
larynx  as  a  respiratory  and  vocal  organ,  anticipating  the  time  when  the  operation  may  be 
demanded  for  the  purpo.se  of  preventing  impending  suffocation.  In  the  first  volume  of 
the  Clinical  Society's  Transactions  I  published  some  cases  illustrative  of  these  views,  and 
my  more  recent  experience  has  confirmed  them.  It  should  not  be  performed  in  the  very 
early  period  of  the  disease,  whilst  any  reasonable  hope  exists  that  by  medical  or  local 
treatment  a  successful  result  may  be  secured,  but  it  should  be  undertaken  in  all  cases  of 
progressive  disea.se  when  local  and  general  treatment  have  failed  to  make  any  impression 
on  the  local  affection. 

Tumors  of  the  larynx  are  not  very  uncommon.  Children  are  liable  to  suffer 
from  warty  growths  of  the  rima  or  the  surrounding  parts,  and  in  adults  epithelial  tumors  , 
are  likewise  met  with.  Cancerous  growths  involving  the  larynx  are  also  on  record.  Mr. 
Holmes,  in  his  admirable  work  On  Children's  Diseases,  informs  us  that  out  of  twenty- 
eight  cases  of  tumor  of  the  larynx  which  he  tabulated  from  the  Transactions  of  the  Patho- 
logical Society,  seven  were  cancerous.  He  also  points  out  the  fact  that  in  cases  of  tumors 
of  this  region  life  is  threatened  by  the  occasional  fits  of  spasmodic  dyspnoea,  the  patient 
being  often  well  in  the  intervals ;  and  when  these  recur  very  severely,  it  becomes  neces- 
sary to  perform  tracheotomy. 

When  warty  growths  exist  and  it  is  impossible  to  remove  them  from  above  by  means 
of  the  forceps  or  snare,  aided  by  the  laryngoscope,  the  larynx  may  be  laid  open  fearlessly 
in  the  middle  line  and  the  tumor  removed.     I  did  this  in  1871,  in  a  child  aet.  3,  for  exten- 


IU:()\ril()-l(i.][)  \    rilACllF.o'l'oMW    I.MiY\<;(>r()MY.  f)07 

sivc  vviirtv  (liscasc  (if  tlu'  cpiirlultis  and  glottis  with  coinidctt!  .siic-t;f.<.s,  and  my  collcafriics, 
Mr.  Durliam  and  Mr.  Davics-Collcy,  Iiav(!  dnnt-  tlic  .same.  I  Iiavo  also  hy  tin-  opcralidii 
of  tracdu'otomv  iindnn^L'd  for  many  niontlis  tlic  lil'c  id'  a  man  wlio  had  a  cancerous  hiryn- 
peal  tumor  ohstrucliny:  respiration. 

Tracheotomy  may  also  he  recjuircd  for  tumors  of  the  neck  pressinj;  upon  the  larynx. 
I  have  hecn  called  u]ton  to  operate  under  tliese  circumstances  on  three  occasions.  It  may 
likewise  he  demanded  for  intrathoracic  tumors,  ancurisnjal  or  otherwise,  on  account  of 
sudden  larynireal  spasm  due  either  to  pressure  (»n  the  recurrent  laryngeal  nerve  or  to 
compression  (tf  the  traidica,  Dr.  Hristowe  haviuir  vvell  sh<iwn  {St.  Thoiixis's  JIosji.  /i'<j>., 
vol.  iii.,  1S72)  ''that  destruction  of  the  functional  activity  of  one  recurrent  laryn;rcal 
nerve  is  marked  }>y  paralysis  of  tlx^  corresponding  vocal  cord,  which  can  be  recognized  by 
means  of  the  laryngoscope,  by  impairment  of  the  musical  (piality  of  the  voice,  and  (prob- 
ably) by  some  difficulty  of  swallowing,  owing  to  the  tendency  of  fcjod  to  slip  into  the 
laryn.x,  but  is  not  necessarily  attended  with  stridor  or  dyspmea  ;  and,  in  the  second  jdace, 
that  compression  of  the  trachea  involves  stridor  and  difficulty  of  breathing,  which  is  often 
paro.xysmal  and  liable  to  end  in  sudden  death,  but  that  it  does  not  of  itself  interfere  with 
perfect  intonation,  excepting  only  in  so  far  as  it  may  render  the  voice  weak  by  diminish- 
ing the  supply  of  wind  to  the  vocal  organs." 

Excision  of  the  Larynx. 

This  operation  was  first  performed  by  P.  H.  Watson  in  180(5,  and  later  by  Billroth  of 
Vienna  in  1S73,  for  cancerous  disease,  Heine  of  Prague,  Moriz  Schmidt  of  Frankfort-on- 
the-Maine,  Langenbeck  of  Berlin,  Caselli  of  Milan,  and  Gussenbauer  of  Prague,  but  the 
success  that  has  attended  it  is  not  such  as  to  lead  me  to  recommend  the  operation.  The 
operation  can  be  performed  by  making  a  transverse  inci.sion  parallel  to  and  above  the 
hyoid  bone  and  a  vertical  one  at  a  right  angle  to  it  over  the  larynx,  the  dissection  of  the 
larynx  being  made  from  above.  Dr.  Foulis  of  Glasgow  has,  however,  performed  this 
operatit)n  upon  a  man  set.  28  for  recurrent  papillary  sarcoma  with  success.  In  the  ope- 
ration he  left  the  epiglottis  {Lancef,  1877,  vol.  ii.,  and  1878,  vol.  i.). 

Bronchotomy,  Tracheotomy,  Laryngotomy. 

Any  opening  made  by  the  surgeon  into  the  windpipe  is  called  hroiwhotomi/  ;  when 
between  the  thyroid  and  cricoid  cartilages,  it  is  called  hirijngotom]/ ;  when  below  the  cri- 
coid into  the  trachea,  trach<otom]i ;  and  when  the  incision  includes  the  cricoid  cartilage 
and  upper  rings  of  the  trachea  it  is  called  lari/ ago-tracheoto my .  In  all  these  operations 
the  object  is  the  same — either  to  admit  air  into  the  lungs  when  some  obstruction  exi.sts 
in  or  above  the  larynx,  or  to  facilitate  the  removal  of  a  foreign  body  or  morbid  growth. 
Dismissing  the  general  term  ''  bronchotomy  "  from  our  consideration,  the  latter  two  ope- 
rations claim  our  notice  and  are  applicable  in  two  different  classes  of  cases.  When  the 
cause  of  obstruction  is  a  I >f iva  t\iG.  larynx,  laryngotomy  may  be  performed  ;  when  in  the 
larynx,  tracheotomy  or  laryngo-tracheotomy  should  always  be  preferred.  For  the 
removal  of  a  foreign  body  or  new  growth  tracheotomy  is  the  better  operation,  the  incis- 
ion at  times  being  extended  either  upward  into  the  larynx,  through  the  cricoid  and  thy- 
roid cartilages,  or  downward  as  far  as  needed.  For  both  operations  anaesthetics  may  be 
safely  administered,  unless  asphyxia  be  profound,  when  it  is  not  required. 

Laryngotomy  is  not  an  operation  to  be  performed  on  children,  the  crico-thyroid 
space  at  an  early  period  of  life  being  too  small  to  allow  of  a  free  opening  being  made  into 
it.  It  is  only  applicable  in  adults  when  obstruction  to  respiration  exists  above  the  rima 
glottidis,  such  as  that  caused  by  an  impacted  mass  of  food  or  some  pharyngeal  growth. 
For  tetanus  or  any  other  spastnodic  affection  of  the  lar^^nx  threatening  life  it  may  like- 
wise be  employed,  as  well  as  in  operations  on  the  palate,  pharynx,  etc..  in  which  it  is 
advisable  to  ensure  the  free  passage  of  air  into  the  lungs  during  manipulation,  although 
under  these  latter  circumstances  tracheotomy  and  the  use  of  Dr.  Trendelenburg's  plug 
are  to  be  preferred  (Fig.  228). 

To  perform  the  operation,  the  patient  should  be  placed  on  the  back  with  the  thorax 
raised,  shoulders  drawn  down,  and  head  extended.  The  operator  should  stand  on  the 
patient's  right  side  and  feel  for  the  thyroid  cartilage,  at  the  lower  border  of  which  the 
windpipe  is  to  be  opened.  To  do  this  a  vertical  incision  is  to  be  made  in  the  median 
line,  about  one  inch  long,  cutting  through  all  the  tissues  covering  in  the  crico-thyroid 
membrane.     The  membrane  should  then  be  opened  transversely  with  a  knife.    The  crico- 


608 


SURGICAL  AFFECTIONS  OF  THE  LARYNX  AND   TRACHEA. 


thyroid  arteries  cross  this  space,  and  may  possibly  be  divided,  giving  rise  to  some  little 
hemorrhage.  Sir  W.  Fergusson  has  recorded  a  case  narrated  to  him  by  Professor  Turner 
of  Edinburgh  in  which  a  fatal  hemorrhage  occurred  from  these  vessels.  Such  a  danger 
i.'i.  however,  very  remote. 

Tracheotomy  is  by  no  means  a  simple  operation,  but  under  all   circumstances  is 
delicate,  requiring  coolness  and  caution,  and  when  performed  hurriedly  is  too  often  made 

Fig.  349. 


Operation  of  Tracheotomy. 

difficult,  and  even  dangerous.  In  very  young  children  it  is  always  troublesome.  The 
surgeon  may  at  times  be  called  upon  to  be  rapid  in  his  movements,  but  never  should  be 
hurried.  As  the  result  of  hurry  many  are  the  mistakes  that  might  be  enumerated,  such 
as  wounding  of  the  innominate  or  carotid  artery,  the  opening  of  the  oesophagus  through 
the  trachea,  the  puncturing  of  the  spine  through  both  these  tubes,  etc. 

The  patient  should  be  placed  as  in  laryngotomy.  while  the  surgeon  stands  on  the 
right  side.  The  different  points  in  the  neck  must  then  be  made  out  and  the  existence  of 
any  large  vein  in  the  line  of  incision  looked  for,  and,  if  present,  avoided.  The  best 
position  for  opening  the  trachea  is  half  an  inch  below  the  cricoid  cartilage  or  below  the 
isthmus  of  the  thyroid  gland ;  but  this  is  not  a  point  of  so  much  importance  as  some 
surgeons  would  lead  us  to  suppose.  In  infants  it  may  be  disregarded.  An  incision 
about  two  inches  long  may  then  be  made  through  all  the  soft  parts  covering  the  trachea. 
This  may  be  done  rapidly  when  needed,  deliberately  when  possible,  care  being  taken  at 
the  same  time,  by  means  of  reti-actoi-s,  not  to  displace  the  parts.  During  this  step  of  the 
operation  the  surgeon's  left  index  finger  should  be  his  guide,  and  it  should  be  steadily 
kept  over  the  trachea  till  the  rings  are  felt,  while  it  will  also  intimate  the  presence  of  any 
arteries  near  the  tube  or  in  the  line  of  incision.  The  rings  once  recognized,  the  trachea 
may  be  opened  with  the  knife,  its  edge  being  turned  upward,  and  the  opening  made  par- 
allel with  the  nail  of  the  left  index  finger,  which  is  in  the  wound.  When  the  windpipe 
has  been  opened,  air,  blood,  and  mucus  will  at  once  bubble  up.  The  canula  with  its 
pilot  should  then  be  introduced  into  the  trachea  through  the  opening  which  the  left  index 
finger  has  covered,  this  finger  acting  all  through  as  a  guide  and  director,  and.  lastly,  as  a 
plug  to  the  wound  till  the  canula  has  been  introduced.  The  eye  of  the  operator  should 
be  directed  to  the  end  of  his  left  index  finger. 

In  opening  the  trachea  some  prefer  to  use  the  hook  to  draw  it  forward,  and  in  cases 
in  which  much  bleeding  exists  or  the  trachea  is  very  deep  it  may  be  employed.  I  have, 
however,  rarely  used  it,  having  more  confidence  in  the  use  of  the  left  index  finger  as  a 
guide  throughout. 

Some  employ,  also,  a  dilator  to  keep  the  wound  open  till  the  tube  is  introduced,  while 
others  prefer  to  open  the  trachea  with  a  sharp  trocar.  The  former  practice  is  unnecessary 
and  the  latter  dangerous,  as  a  sharp  trocar  ma}*  perforate  the  trachea  altogether  and 
enter  the  oesophagus — an  accident  I  have  known  to  occur,  or,  if  it  slip  by  the  side  of  the 
windpipe,  the  large  vessels  will  be  endangered.  With  respect  to  the  canula.  Fuller's 
bivalve  has  hitherto  met  with  general  approval,  and  Durham's  "  lobstei'-tail "  canula 
(Fig.  350)  has  been  much  liked,  though  the  best  by  far  is  the  ball-and-socket  instrument 


nnoyciioToM y,  th.k  iir.oro)! v,  i..\i: vsaoroM v. 


609 


(Fij;.  .'{')!  )  I  had   iiiaiU'  soiiu-  years  ap),  its  ^'n-at    ailvantajrc  ooiisistiii^'  in  tlic   luuliility  nf 
the  till)!'  with  the  trachea,  the  neck  jdate  Ijeinj;  fixed. 

When    this  eanuhi  is  made  ol"  aliiininiuni,  ^real  advantaf^es  are  jraiiud,  an  aliiiiiininni 
instrument  \vei_t:hin,:;  mdy  sixty  <:rains,  when  a  Hilver  one  weighs  tw<i    Inindn-d  and  sixty. 


F  ui.  350. 


Ifiirhain's  riiniilii  iiixl  I'ilol. 


Indeed,  the  aluminium  is  liiihter  hy  ten  grains  tlian  the  vuh-anite.  Tlio  rigid  tuVjo.  wlien 
re(|uired  t(»  l)e  w(trn  lor  h)Ug,  too  often  excites  ulceration  by  the  pressure  of  its  free  end 
on  the  trachea,  which  may  extend  into  the  innominate  artery.     Mr.  Morant  Baker  has 


i-i(i.  :rji. 


Fig.  352. 


Hrvaiit's  <,'amila 


A,  Full  lenjith. 


B,  Shortened. 


Tracheal  Aspirator  for  the  Removal  of  Mucus, 
J>ynii)h,  or  possibly  a  Foreign  Hotly,  from  the 
Air-l'assages. 


recently  introduced  into  practice  a  tube  made  of  vulcanized  red  india-rubber  which  seems 
to  answer  well,  and  may  be  employed  on  the  second  or  third  day  after  the  operation  has 
been  performed.  Every  metal  canula  should  be  double,  and  every  canula  fixed  in  position 
by  a  piece  of  silk  or  tape  passed  through  the  shield  and  fastened  round  the  nape  of  the 
neck. 

After-Treatment. — After  the  operation  the  atmosphere  of  the  room  should  be  kept 
warm  and  moist  by  the  admission  of  steam,  care  being  taken  that  the  air  is  not  saturated 
with  vapor.  The  wound  ought  to  be  kept  clean  ;  strapping  and  sutures  are  rarely 
required ;  water  dressing  or  sweet  oil  is  probably  the  best  local  application.  Great  care 
should  be  observed  to  keep  the  orifice  of  the  canula  free  from  mucus  and  the  inner  tube 
clean,  a  "  sucker  "  (Fig.  352)  composed  of  a  rubber  bottle,  glass  tube,  and  rubber  spout 
small  enough  to  enter  the  canula,  and  long  enough  to  pass  down  the  trachea  if  required, 
being  always  at  hand  for  the  purpose.  This  instrument  does  away  with  the  nasty  and 
dangerous  practice  of  sucking  by  the  mouth.  After  the  operation  a  piece  of  muslin  should 
be  placed  over  the  tube,  to  prevent  the  entrance  of  foreign  bodies. 

Complications. — If  the  operation  should  be  complicated  by  hemorrhage,  the  sur- 
geon must  not  be  alarmed.  When  arterial,  it  must  be  arrested  before  the  trachea  is 
opened,  either  by  the  application  of  a  ligature  or  by  torsion  ;  if  venous,  the  sooner  the 
trachea  is  opened,  the  better,  for  a  few  good  inspirations  do  more  to  relieve  the  venous 
congestion  which  is  almost  always  present  when  tracheotomy  is  demanded  than  any  other 
attempt  to  check  bleeding.  As  soon  as  the  tube  has  been  introduced  the  patient  may  be 
rolled  over  on  his  side,  to  allow  the  blood  to  run  away  from  the  tracheal  wound.  A  piece 
of  sponge  applied  with  some  pressure  over  the  wound  is  generally  enough  to  arrest  all 
venous  bleeding,  unless  some  large  venous  trunk  has  been  opened.  I  have  never  known 
hemorrhage  of  this  kind  to  be  so  copious  as  to  interfere  with  the  operation,  or  to  be  so 
persistent  as  not  to  cease  readily  on  its  completion.  If  the  surgeon  stops  his  operation 
till  bleeding  has  ceased,  he  will  too  often  wait  till,  with  the  life  of  his  patient,  the  neces- 
sity of  the  operation  has  ]iassed  away. 

Opening  of  the  Trachea. — There  can  be  little  doubt  that  in  patients  after 
puberty  the  trachea  should  generally  be  opened  below  the  isthmus  of  the  thyroid  gland, 
but  in  infants  and  young  children,  where  the  trachea  is  deeply  placed  and  the  neck  fat 
39 


610  SURGICAL  AFFECTIONS  OF  THE  LARYNX  AND   TRACHEA. 

and  short,  the  nearer  the  opening  is  to  the  cricoid  cartihitre,  the  better.  For  several  years 
I  have  been  in  the  habit  of  opening  the  trachea  immediately  below  the  cricoid  ring,  and 
never  have  hesitated  to  divide  the  latter  when  more  room  is  reqnired.  In  many  instances 
I  have  gone  through  the  isthmus  of  the  thyroid,  and  never  had  any  reason  to  regret  it ; 
nay,  I  am  almost  tempted  to  believe  that  the  dangers  of  its  division  are  really  theoretical, 
and  practically  may  be  disregarded.  Of  this  I  am  convinced — that  the  nearer  the 
tracheal  opening  is  to  the  lower  border  of  the  cricoid  ring,  the  better  is  the  operation. 
If  the  opening  be  too  small  at  the  first  puncture,  a  second  should  be  made  rather  than 
grope  about  with  retractors  and  instruments  to  find  the  original  opening.  The  tracheal 
tube  need  not  be  very  large,  for  Mr.  Marsh  has  demonstrated  (*SV.  Barth.  Hasp.  Repoi-t, 
vol.  iii.)  that  the  rima  glottidis  is  the  smallest  part  of  the  air-tube.  In  dividing  the  soft 
tissues  and  fascia  on  the  trachea  care  should  be  taken  to  do  so  freely,  to  guard  against 
the  mediastinal  emphysema  which  Dr.  Champneys  has  shown  to  be  such  a  common  cause 
of  death  after  tracheotomy  (Med.-Chir.  Trans.,  1882  and  1883),  from  the  escape  of  air 
beneath  the  deep  cervical  fascia. 

Under  all  cii'cumstances  the  operation  should  be  completed,  and  even  in  apparently 
hopeless  cases  artificial  respiration  should  be  kept  up  through  the  wound.  Mr.  Holmes 
has  recorded  a  case  of  Mr.  Tatum's  in  which  it  was  maintained  for  two  hours  with  ulti- 
mate success. 

When  tracheotomy  has  been  performed  for  thyroidal  tumors  pressing  upon  the 
trachea,  the  sui'geon  should  have  at  hand  a  long  perforated  tube  small  enough  to  be 
introduced  through  the  canula,  as  the  tumor  may  so  overlap  the  trachea  as  to  cause 
obstruction  below  the  point  at  which  the  operation  is  performed.  For  the  want  of  such 
an  instrument  I  lost  a  patient  whom  I  saw  with  Sir  Risdon  Bennett,  while  by  its  aid  I 
was  enabled  to  save  another  for  several  days,  the  elastic  tube  being  pressed  through  the 
canula,  past  the  obstruction,  into  the  lungs.  I  have  had  such  a  tube  adapted  to  my 
canula  as  a  pilot  to  introduce  it.  It  is  almost  needless  to  say  that  the  canula  should  be 
removed  from  the  trachea  as  soon  as  respiration  has  been  re-established  by  the  natural 
passage,  and  that  it  should  on  no  account  be  left  in  more  than  three  months.  When 
required  longer,  a  new  one  should  be  substituted,  since  the  canula  rapidly  undergoes 
oxidization  in  the  trachea  and  becomes  liable  to  break.  In  a  patient  of  my  own,  where 
the  tube  had  been  worn  six  months,  half  its  circumference  close  to  the  neck  shield  had 
been  destroyed,  and  the  slightest  violence  would  have  broken  the  instrument  in  the 
trachea.     The  vulcanite,  and  probably  the  aluminium,  canula  is  good  for  constant  use. 

Mr.  T.  Smith  in  an  excellent  paper  (Med.-Chir.  Tnms.,  1865)  has  given  a  good  sum- 
mary of  the  obstacles  to  the  re-establishment  of  natural  respiration  after  tracheotomy, 
and  he  has  shown  that  the  chief  causes  are  a  narrowing  of  the  passage  of  the  larynx  by 
granulations  around  the  canula,  and  the  impairment  or  loss  of  those  functions  of  the 
muscles  of  the  larynx  which  regulate  the  admission  of  air  through  the  rima.  There  may 
likewise  be  a  persistence  of  the  original  cause  which  necessitated  the  performance  of  the 
operation,  the  effects  of  the  original  disease,  or  the  closure  of  the  vocal  cords  from  the 
cicatrization  of  old  ulceration.  In  three  cases  now  under  my  observation  in  which  trache- 
otomy has  been  performed  for  chronic  ulceration  of  the  larynx  the  rima  has  so  contracted 
as  to  be  impervious  in  two,  and  in  one  the  opening  is  so  small  as  to  be  insufficient  for 
respiration,  although  enough  for  speaking  purposes. 

To  help  the  surgeon  to  judge  of  the  patency  of  the  glottis,  Luer  has  invented  a  bullet 
valve  to  be  adapted  to  the  orifice  of  the  canula,  and  Mr.  T.  Smith  an  india-rubber  one 
which  seems  equally  efficient  and  is  a  simpler  instrument.  Either  may  be  employed,  as 
anything  that  helps  to  decide  when  the  canula  may  be  removed  with  safety  is  of  value. 


FRACTrilKI)   lllliS.  <;il 


CHAI^TKIl    XTX. 

SUKCKi;  V     OK    Til  K    ('II  KST. 
Contusions. 

The  chest  is  liable  to  be  contused,  and  severe  contusions  are  not  unfroquently  fol- 
lowed by  extensive  effusions  of  blood.  The  swelling  under  these  circumstances  occurs 
suddenly  after  the  injury  and  ajipears  with  the  discoloration  of  a  bruis(\  Those  cases,  as  a 
rule,  do  well  if  left  aloiu',  the  e.xtravasated  bhtod  beconiin<;  absorbed,  but  in  exceptional 
examples  the  blood  may  break  down  aiul  give  rise  to  supj)urati(»n. 

Tkk.vtmknt. — When  the  contusion  is  slight,  the  apj)licatiou  of  a  cold  lead  lotion  is 
all  that  is  necessary,  and  in  more  severe  examples,  where  extravasation  is  great,  there  is 
nothing  equal  to  the  application  of  cold,  in  the  form  either  of  the  metallic  tube  (Fig.  9) 
or  of  ice.  In  obstinate  cases  the  use  of  some  stimulating  liniment  hastens  recovery,  and 
the  administration  of  tonics  is  always  of  value. 

When  the  effused  blood  breaks  down  and  suppuration  ensues,  the  abscess  must  be 
opened  ;  but  the  surgeon  need  be  in  no  hurry  to  conclude  that  the  effused  blood  is 
incapable  of  being  absorbed  nor  that  pus  has  formed,  since  it  is  a  familiar  fact  that 
blood  may  remain  fluid  in  the  tissues  for  a  long  period  and  yet  be  eventually  removed  by 
absorption. 

Rupture  of  the  Pectoral  Muscle 

is  an  accident  which  may  take  place  from  a  forcible  strain  applied  to  the  muscle  when 
unprepared  for  action  or  from  external  violence.  I  have  seen  a  case  in  which  the  muscle, 
from  the  forcible  drawing  back  of  the  arm,  was  nearly  torn  across  about  its  centre,  in 
which  the  fingers  could  be  inserted  between  the  divided  ends  of  the  torn  muscle,  and 
there  was  much  effusion  of  blood.  In  that  case  the  arm  was  bound  to  the  side  by  a 
bandage  and  ice  locally  applied,  and  three  months  subsequently  some  power  existed  in 
the  muscle.  The  amount  of  repair  which  is  to  be  expected  in  these  cases  depends  upon 
the  severity  of  the  injury  and  the  care  with  which  the  parts  are  kept  in  position  during 
its  progress.  As  a  general  rule,  the  two  ends  of  the  divided  muscle  should  be  kept  in 
contact  for  at  least  two  months  before  movement  is  allowed.  This  accident  is  not  rare  in 
children  from  forcible  dragging  of  the  arm. 

Fractured  Ribs 

form  about  a  tenth  part  of  the  cases  of  fracture  admitted  into  a  large  hospital.  This  acci- 
dent is  less  common  in  children  and  young  adults  than  in  subjects  past  middle  age,  on 
account  of  the  elasticity  of  the  ribs.  In  the  aged  the  ribs  become  so  brittle  that  they 
break  under  slight  external  violence,  and  in  rare  cases  from  the  violence  of  a  cough.  I 
have  seen  this  occur  in  two  patients  between  sixty  and  seventy  years  of  age,  the  one  a 
male  and  the  other  a  female  ;  in  neither  were  there  any  signs  of  disease,  and  both  of  the 
persons  are  now  alive. 

Fractured  ribs  are  not  uncommon  accidents  in  lunatic  asylums,  and  generally  ari.se 
from  direct  violence,  though  it  would  be  wrong  to  assume  that  they  are  always  the  result 
of  ill-treatment,  as  patients,  when  much  excited,  will  unconsciously  inflict  most  serious 
injuries  on  themselves;  and  it  has  been  proved  that  the  bones  of  many  of  the  insane  are 
in  an  abnormally  brittle  state.  This  is  especially  true  in  the  disease  known  as  "  general 
paralysis  of  the  insane."  Dr.  Campbell  Brown  of  Liverpool  has  analyzed  the  ribs  of 
general  paralytics,  and  states  that  '■  the  ratio  of  organic  constituents  to  earthv  matters  is 
much  greater,  while  the  ratio  of  lime  to  phos]>horic  acid  is  distinctly  less,  in  the  ribs  of 
paralytics  than  in  those  of  healthy  adults.  There  are  the  same  differences  between  the 
composition  of  healthy  ribs  and  those  of  paralytics  as  between  the  composition  of  the 
adult  large  bones  and  those  of  the  fuetus.  And  generally  the  composition  in  cases  of 
paralysis  approaches  that  observed  in  cases  of  osteo-malacia."  Some  striking  cases  bear- 
ing on  this  subject  are  recorded  by  Dr.  Hearder  in  the  Jmini.  of  Mental  Sci.  for  1871. 

In  the  majority  of  cases,  the  injury  being  the  result  of  direct  violence,  the  fracture 
takes  place  at  the  part  struck,  and  so  the  ribs  are  often  driven  in.    In  the  minority,  where 


612  SURGERY  OF  THE  CHEST. 

it  is  due  to  indirect  violence  such  as  that  caused  by  a  crush  or  squeeze,  the  ribs  generally 
give  way  about  their  middle  and  three  or  more  become  injured,  both  sides  being  not 
unfrequently  involved.  When  the  bones  are  merely  broken,  it  is  called  a  simple  fracture  ; 
but  when  complicated  with  a  wound  communicating  with  the  fracture,  compoinid.  When 
the  ends  of  the  broken  ribs  are  driven  inward,  the  pleura  costalis  or  the  lung  itself  may 
be  torn  and  the  heart  or  pericardium  or  abdominal  viscera  injured.  In  an  analysis  of  136 
consecutive  cases  which  I  made  when  registrar  at  Guy's,  108  were  uncomplicated,  and 
of  these  8  only  had  secondary  inflammation  ;  28  were  complicated  fractures :  of  these  6 
died  at  once  from  fatal  collapse,  16  were  complicated  with  emphysema,  3  with  emphy- 
sema and  haemoptysis,  and  3  with  extensive  injury  to  the  lung  and  secondary  inflamma- 
tory symptoms.  Two  of  these  cases  subsequently  died  from  old-standing  disease.  Frac- 
tured ribs  on  the  right  side  are  often  complicated  with  laceration  of  the  liver. 

When  a  rib  is  broken,  the  serous  lining  of  the  chest,  the  pleura  costalis,  is  probably 
injured,  and  the  danger  of  the  accident  lies  in  the  secondary  inflammation — pleuritis — 
which  may  follow  ;  and  this  occurred  in  8  of  the  108  cases  just  alluded  to.  In  a  case 
recently  seen,  which  proved  fatal  from  other  causes,  the  pleura  was  unimpaired,  but  a 
quantity  of  blood  was  eff"used  into  the  soft  parts  outside  the  pleura  from  laceration  of  an 
intercostal  artery.  When  the  lung  is  injured,  as  indicated  by  emphysema  or  haemoptysis, 
pneumonia,  which  happens  in  about  7  out  of  every  22  cases,  is  the  danger  to  be  feared. 
Ca.ses  that  die  from  fatal  collap.se  offer  the  accident  generally  do  so  from  hemorrhage  due 
to  extensive  laceration  of  the  thoracic  or  abdominal  viscera.  In  gunshot  fractures  a  por- 
tion of  the  ribs  may  be  detached  and  driven  into  the  lung. 

Simple  fracture  is  a  serious  accident  only  in  subjects  who  are  the  victims  of  some 
chronic  chest  aff"ection,  when  from  the  broken  ribs  the  patients  are  unable  to  expectorate, 
and  asphyxia  is  favored. 

Fractures  complicated  with  injury  to  the  lung  are,  however,  more  serious.  When 
severe,  they  are  directly  dangerous  from  the  shock  to  the  system  and  the  hemorrhage  that 
frequently  attends  them,  and  indirecfhj  so  from  the  fact  that  the  slightest  lung  wound  is 
liable  to  be  followed  by  inflammation  of  the  lung  itself  or  of  the  pleura. 

Fractured  ribs  generally  unite  in  about  a  month,  and  where  they  have  not  been  kept 
quiet  considerable  callus  may  be  thrown  out  or  a  false  joint  formed. 

Diagnosis. — Pain  at  the  seat  of  injury,  aggravated  by  sternal  pressure  and  associated 
with  a  peculiar  catch  in  the  breath  of  the  patient  and  the  general  avoidance  of  anything 
like  a  full  inspiration,  is  a  somewhat  characteri.stic  symptom  of  a  fractured  rib,  more  espe- 
cially when  it  .shows  itself  at  once  after  direct  or  indirect  violence.  At  times,  too,  the 
patient  will  complain  of  a  grating  in  the  part,  and  on  the  application  of  the  hand  over  the 
seat  of  injury,  if  the  patient  be  made  to  cough,  crepitus  will  be  felt,  this  crepitus  being 
caused  by  the  friction  of  the  ends  of  the  broken  bone.  When  the  seat  of  fracture  is 
beneath  a  thick  layer  of  muscles  or  fat,  this  symptom  may,  however,  escape  detection  ; 
nor  should  it  be  too  closely  sought  after  when  others  indicate  the  nature  of  the  injury,  as 
the  manipulation  required  to  elicit  this  sign  is  sometimes  considerable,  and  any  approach 
to  violence  or  over-manipulation  is  always  injurious. 

When  eniphysenia  complicates  the  case,  as  indicated  by  a  more  or  less  diff"used 
puflPy  swelling  which  crackles  on  pressure,  there  will  be  no  doubt  as  to  the  lung  having 
been  injured,  since  this  symptom  is  caused  by  the  escape  of  air  from  the  lung  into  the 
cellular  tissue  about  the  seat  of  fracture.  This  may  be  either  local  or  general ;  when 
associated  with  hftnvopfiji'is,  it  is  fair  to  infer  that  the  lung  has  been  penetrated,  the  sever- 
ity of  the  mischief  being  gauged  by  the  extent  of  the  emphysema  and  the  amount  of  the 
haemoptysis. 

In  rare  cases  the  emphysema  lasts  for  days.  In  a  case  under  care  in  October,  1881, 
it  remained  for  seventeen  days  after  the  accident ;  the  patient  recovered. 

Emphysema  may  be  met  with  as  the  result  of  chest  injury  without  fracture  of  the  ribs, 
as  evidenced  by  the  case  of  a  boy  aet.  5  who,  having  had  the  wheel  of  a  cart  pass  across 
his  shoulders,  was  admitted  in  1883,  within  a  few  minutes  after  the  accident,  into  my  ward 
at  Guy's  with  universal  emphysema  and  such  difficulty  of  respiration  that  death  appeared 
imminent.  The  boy's  body  and  neck  appeared  like  a  tight  .sausage.  To  let  out  the  air 
I  punctured  the  integuments  over  the  child's  body  with  a  small  knife  an  eighth  of  an  inch 
wide,  and  the  air  whistled  out  of  the  openings  with  enough  force  to  blow  out  a  lighted  wax 
taper.  The  relief  aff"orded  by  the  operation  was  marked,  for  the  child  steadily  went  on  to 
a  complete  recovery.  There  was  no  hjemopty.sis  in  this  case  or  evidence  of  fracture  of  the 
ribs.  The  child  also  cried  naturally,  the  fact  fairly  proving  that  neither  the  larynx  nor 
the  trachea  was  lacerated.     Yet  the  opening  into  the  air-passages  must  have  been  very 


riiAcrriii:!)  in  us.  613 

free  to  ^^ive  rise  to  sucli  rapiil  ami  ticiicnil  i'm|iliys<'iiiii.  TIk-  ri-licf  jriven  hy  tlu;  (ijn'ra- 
tion  *A'  |»iiiic'turiii;^  the  skin  is  a  |niiiit  in  ri'inciiilicr  (/inf.  JAr/.  ./'>»/•/*.,  Jamiarv  2tJ, 
ISSl). 

TitKAT.MKNT. — Tlin  (iltjcct  of  the  siir^M'oii  in  tilt"  treat  iiiciit  ni'  a  .simple  Tract  lire  nf  tlie 
thorax  is  to  niaiiitaiii  the  rihs  at  rest,  which  sh(nihl  he  efl'ected  l)y  the  u|)iilicati(jii  of  strips 
of  strmiir  adhesive  phister  two  iiich(!S  l)roa<l,  exteii(iiii<r    from  the 
sternmii  to  the   spine,  and    from    at    h-ast    three    iiicdies   ahove   to 
thret'   inches  heh)W   the  seat  of  injury. 

Till-  )tfril>s  s/i'iii/i/  III  iijijilii  (I  frnni  In  loir  ii/nnird  nml  nl  tin  i  nd 
of  i.rjn'ntti(i>i^  and  eacli  one  shouhl  he  made  to  cover  half  of  tiiat 
wliieii  jireeeded  it  (  Kiir.  ;};')!>).  My  this  method  the  movements 
of  the  broken  rihs  are  restrained  without  thos(!  of  the  o])positc 
side  lieint;  interfi-red  with.  It  is,  moreover,  in  both  comfort  and 
erticiency.  far  superior  to  the  ohl  method  of  encirclin<;  tiie  chest 
with  a  Hannel  roUer;  indeed,  it  generally  affords  speedy  relief  to 
all  symptoms.  When  the  case  is  complicated  with  emphysema, 
or  even  with   ha-moptysis,  the  same  treatment  should  be  carried  ''^  e 

out;  tor  in  these  more  severe  cases  the  necessity  of  maintaining  strapping  m  Fracture  of  Kiiw. 
the  immol)ility  of  the  ribs  is  just  as  necessary  as  in  the  less  severe. 

In  rare  casi's  in  which  much  displacement  has  occurred  a  sheet  of  felt  or  <rutta-percha 
made  soft  by  hot  water  and  moulded  to  the  part  is  of  ,<rreat  value,  the  mould  being  subse- 
([uentlv  fixed  liy  stra])])iini'  as  described. 

The  patient  should  be  ke])t  (|uiet,  though  not  necessarily  in  bed,  and  abundance  of 
bland,  nutritious,  but  unstimulatiiig,  I'ood  given,  with  sedatives  if  re(|uired  ;  of  the  latter, 
chloral  in  half-drachm  doses  is  probably  the  best,  though  morphia  or  Dover's  powder  is 
also  good.  When  couirh  or  any  symptoms  of  infiammation  of  the  pleura  or  lungs  appear, 
antimonial  wine  in  do.ses  of  thirty  minims  for  an  adult  every  four  or  six  hours  in  .some 
saline  mixture  is  a  most  valuable  remedy.  When  chest  complications  are  .severe  and 
orthoi)n(.ea  with  a  sense  of  suffocation  from  pulmonary  congestion  threatens  life,  venesec- 
tion should  be  practised.  Local  treatment  by  it.self  was  sufficient  in  lOU  of  the  136  cases 
above  mentioned. 

In  a  case  of  severe  injury  to  the  chest  that  came  under  my  care  some  time  ago, 
caused  by  the  passage  over  it  of  the  wheels  of  a  heavily-laden  cart,  fracture  of  five  or 
six  ribs  and  dislocation  of  the  clavicle  occurred,  associated  with  collapse,  intense  dyspnoea, 
and  lK\3moptysis  ;  I  bled  the  patient  twice  in  twelve  hours,  and  each  time  with  immediate 
relief,  the  case  going  on  to  a  good  recovery.  In  it  the  severe  dyspnoea  and  venous  con- 
gestion, the  rapid  and  hard  pulse  that  came  on  as  soon  as  the  collapse  of  the  accident  had 
passed  away  and  tlie  circulation  had  been  restored,  too  surely  pointed  to  an  excessive 
engorgement  of  the  lungs,  and  indicated  that  if  relief  were  not  afforded  absolute  suffoca- 
tion would  si)eedily  ensue  by  the  patient's  own  highly-carbonized  blood.  At  such  a  crisis 
antimony,  however  beneficial  in  simpler  cases,  could  not  be  trusted,  as  there  was  no  time 
for  it  to  take  effect.  Under  these  circumstances  bleeding  was  performed,  and  as  the  blood 
flowed  life  seemed  gradually  to  return  :  the  laborious  breathing  became  quiet  and  sub- 
dued ;  the  deadened  and  congested  eye  bright  and  natural ;  the  pulse,  from  being  full  and 
hard,  softer  and  less  bounding ;  and  the  boy's  feelings,  released  from  the  impression  that 
death  was  nigh  at  hand,  became  more  hopeful  and  resigned ;  and  as  a  spectator  I  felt 
such  a  hope  was  valid  and  that  success  might  crown  our  efforts.  After  the  lapse  of  twelve 
hours,  however,  the  symptoms  returned,  and  the  repetitiiMi  of  the  bleeding  was  followed 
by  a  repetition  of  all  its  benefits.  The  antimony  then  came  in  to  complete  the  cure  ;  by 
the  double  venesection  the  pulmonary  vessels  had  been  relieved  of  their  congestion,  while 
the  antimony,  in  acting  upon  the  circulation,  perfected  the  cure  by  preventing  a  return 
of  the  former  threatening  symptoms.  The  benefits  arising  from  the  treatment  adopted  in 
this  case  have  such  a  lasting  liold  on  my  memory  that  I  cannot  too  strongly  recommend 
the  practice  thus  pursued,  and  the  more  .so  as  I  have  seen  it  equally  successful  in  other 
cases. 

Bleeding  is  now  rarely  performed,  and  at  Guy's  Hospital  I  believe  it  is  rarer  tlian  any 
capital  operation.  In  the  case  of  lacerated  lung,  however,  when  urgent  dyspnoea  makes 
its  appearance  and  the  powers  of  the  patient  do  not  forbid  it,  I  know  of  nothing  which 
gives  greater  relief  to  the  patient  or  greater  satisfaction  to  the  practitioner.  Bleed  with 
no  sparing  hand,  letting  it  flow  freely  in  a  full  stream,  and  as  it  flows  the  symptoms  will 
gradually  disappear.  When  relief  has  been  obtained,  arrest  the  flow  immediately,  as 
syncope  can  do  only  harm.     The  aim  should  be  to  make  an  impression  through  the  sys- 


614  SURGERY  OF  THE  CHEST. 

temic  circulation  upon  the  pulmonary.  The  patient  should  be  carefully  watched  and  the 
operation  repeated  if  the  symptoms  return,  and  if  necessary  even  for  a  third  time.  The 
antimonial  treatment,  however,  must  not  be  neglected.  The  object  of  the  bleeding  is  to 
relieve  immediate  symptoms  and  to  give  time  for  the  antimony  to  take  effect,  because, 
when  the  patient  has  been  brought  fully  under  its  influence,  all  danger  may  be  said  to 
have  disappeared ;  few  patients  die  from  secondary  inflammation  of  the  lungs  when  once 
fairly  under  the  influence  of  antimony. 

Fracture  of  the  sterno-COStal  cartilages  is  a  rare  accident.  I  have  seen 
but  few  cases  ;  in  one  of  the  seventh  rib,  which  had  resulted  from  a  direct  blow,  a  false 
joint  existed.  In  a  recent  case,  in  which  the  cartilage  of  the  right  second  rib  was  driven 
in  by  direct  violence,  no  harm  followed.  These,  which  are  said  to  unite  generally  by 
bone,  can  be  treated  in  the  same  way  as  fractured  ribs. 

Dislocation  and  fracture  of  the  sternum  are  likewise  rare  accidents,  and 
the  majority  of  them  are  complicated  with  other  injuries,  especially  of  the  head  and 
spine;  they  were  found  in  4  out  of  5G  fatal  cases  of  injury  to  the  spine  at  Guy's  Hos- 
pital. The  sternum  yields,  owing  to  the  violent  descent  of  i\\e  chin  against  the  manu- 
brium. Fractured  sternum  is  also  occasionally  met  with  as  a  complication  of  fractured 
ribs.  When  fracture  takes  place,  it  is  generally  transverse  and  oblique  from  before  back- 
ward, the  lower  fragment  being  found  projecting.  Only  rare  examples  exist  of  a  vertical 
fissure.  When  the  upper  portion  of  bone  is  displaced,  it  is  generally  displaced  backward. 
Kivington  in  an  able  paper  {Med.-Chir.  Trans.,  1874)  has  fairly  shown  that  displacement 
occurs  in  preference  to  fracture  when  an  arthrodial  joint  exists  between  the  manubrium 
and  gladiolus. 

Diagnosis. — When  deformity  is  present  from  displacement  of  bones,  the  diagnosis  is 
easy  ;  and  when  this  does  not  exist,  pain  in  the  part,  aggravated  by  a  full  inspiration  and 
crepitus  on  the  application  of  the  hand,  is  the  chief  symptom. 

Treatment. — The  treatment  must  be  the  same  as  for  fractured  ribs — namely,  the 
recumbent  position  and  strapping  over  the  part,  complications  being  dealt  with  as  they 
arise.  I  have  lately  had  under  care  a  man  who  fi-om  a  blow  from  the  pole  of  a  wagon 
had  the  upper  two  inches  of  the  body  of  the  sternum  displaced  inward  from  the  manu- 
brium and  costal  cartilages ;  the  bones  partially  recovered  their  position  in  three  weeks, 
and  the  man  got  well. 

Dislocation  of  the  ribs  requires  notice,  although  little  can  be  said  about  the 
subject.  It  is  rarely  if  ever  an  accident  ^^er  se  ;  and  when  it  occurs,  it  is  part  of  a  more 
severe  injury,  such  as  fracture  of  the  spine  or  complicated  fracture  of  the  ribs.  The  same 
remarks  apply  to  dislocation  of  the  ribs  from  the  cartiha/es  and  of  the  cartilages  from  the 
sternum.     Practically,  all  these  cases  should  be  dealt  with  like  fractures. 

Wounds  of  the  Chest. 

The  main  point  to  be  determined  in  such  cases  as  these  is  whether  the  wound  is  super- 
ficial or  has  penetrated  the  pleura  ;  for  if  the  former  obtains  slight  cause  for  anxiety 
exists,  but  if  the  latter  the  accident  is  grave. 

When  the  wound  is  penetrating,  the  extent  of  the  penetration  and  the  organ  penetra- 
ted have  to  be  determined.  Is  the  pleura  alone  wounded — a  rare  injury — or  is  the  lung 
involved?  Is  the  heart  injured  or  any  of  the  great  vessels — the  intercostal  or  internal 
mammary  artery?  Many  of  these  points  can  be  determined  only  by  a  knowledge  of  the 
kind  of  weapon  employed,  its  subsequent  appearance,  the  direction  of  the  force,  and  the 
anatomical  knowledge  of  the  surgeon  ;  and  even  then  the  difficulties  of  these  cases  are 
often  great,  as  witnessed  in  a  recent  memorable  trial  (Flora  Davy).  When  emphysema 
and  haemoptysis  are  present,  they  may  be  accepted  as  clear  indications  of  a  wounded  lung. 
Emphysema  alone  is  always  a  suspicious  symptom,  though  it  may  occur  to  a  limited 
extent  in  non-penetrating  punctured  wounds  that  traverse  the  soft  tissues  outside  the 
thorax  ;  while  the  absence  of  haemoptysis  is  no  proof  that  the  lung  has  escaped  injury. 
When  blood  and  air  bubble  through  the  wound  and  air  passes  freely  from  it  or  a  portion 
of  lung  protrudes,  there  is  no  room  for  doubt  as  to  the  nature  of  the  injury  ;  but  these 
cases  are  exceptional.  In  the  majority  the  diagnosis  is  ever  uncertain,  since  there  are 
no  definite  individual  symptoms  by  which  injury  to  the  lung  is  to  be  diagnosed.  The 
surgeon  in  his  anxiety  to  make  out  the  point  must  never  be  induced  to  probe  the  wound 
or  to  explore  it  with  a  finger,  nor  should  he  test  the  condition  of  the  lung  by  making  his 
patient  cough  to  expel  air  through  the  thoracic  opening.  Indeed,  he  should  throw  aside 
all  direct  or  manipulative  modes  of  investigation  and  trust  to  the  indirect. 


n'oiwns  or  Tin:  cuhsr.  <J15 

Tilt'  t/iiTit  offi'cts  of  n  jK'iu'tratiiii;  wnuiid  arc  liciiKirrhajrc  ii)ti»  the  chest  or  hjuino- 
tliorax.  ciMphyscnia,  pnciiiiHi-tlinrax,  ami  hernia  ot"  the  lllllL^  'l'li«"  s<ri,ii</iin/  results  arc 
those  of  iiiHaminatioii,  sinli  :i>  |il(iirisv  or  ]iiieiiiiioiiia.  li  V'lio-l  liorax.  oi-  eiii|iyciiia,  with 
tlu'ir   coiise((iiciices. 

l*K«»(iN()sis. — The  prognosis  is  always  imiavoraliie  ami  shoiiM  he  guardeil,  more  par- 
ticularly when  the  wound  is  peuctratiug ;  hut  when  a  wtn-k  has  passed  without  any 
unfavorahle  symptoms  appearing,  a  more  ]»romising  and  decided  tone  may  he  assumed. 

TuKATMKNT. —  In  all  sus-^tccted  or  ohvious  penetrating  chest  wounds  the  utnu>st  gen- 
tleness should  he  employed  and  complete  (|uiet  enforced,  as  any  deviatifiu  from  this  prac- 
tice may  disturh  nature's  reparative  jiroeess,  disarrantre  clot,  and  excite  overacti(»n  or 
iuHammation.  The  external  wound  should  he  carefully  cit'aiifi/  tinil  rloiit<f  ainl  all  foreign 
hodies  rcmove(l.  Tlie  ))atient  should  he  placed  in  the  reciimhent  position  and  on  no 
account  allowed  to  stir.  lie  should  he  fed  on  the  sini]»lest  nutritious  food,  and  for  the 
tirst  two  or  three  days  this  should  he  cold  ;  ice  and  milk  I'orm,  with(jut  douht,  the  hest 
mixture.  The  collajtse  which  often  follows  the  injury  need  not  excite  alarm  urdess  it  he 
protracted  or  severe  ;  for  when  the  result  of  hemorrhage,  it  is  not  only  a  salutary  measure, 
but  the  only  means  the  surgeon  looks  to  for  the  arrest  of  hemorrhage,  as  he  himself  is 
powerless  to  interfere.  If  blood,  however,  accumulate  in  the  chest  and  by  its  mechanical 
pressure  threaten  life,  .some  means  must  be  found  for  its  evacuation,  either  through  the 
original  wound  or  l)y  the  operation  of  tapping  or  by  an  incision  of  the  thorax.  The  indi- 
cations should  he  very  decided  before  the  surgeon  interferes,  as  the  extrava.satcd  hlood 
rajndlv  coagulates,  and  consecjuently  is  difficult  to  remove.  The  same  renuirks  hold  good 
when  air  accumulates  or  is  pent  up  in  the  pleural  cavity. 

The  symptoms  that  attend  reaction  should  l)e  carefully  watched,  and  anything  like 
excess  of  action,  as  indicated  by  increased  difficulty  in  respiration,  cough,  or  a  rapid 
pulse,  ought  to  be  met  by  the  administrati(tn  of  antimony  in  half-drachm  doses  of  the 
wine  with  some  saline  every  three  or  four  hours. 

If  the  lungs  become  gorged  with  blood  and  asphyxia  threatens,  venesection  is  as  valu- 
able a  remedy  in  these  cases  as  it  has  been  shown  to  be  in  those  of  fractured  ribs.  Dr. 
Macleod  tells  us  that  in  the  Crimea  the  cases  of  gunshot  wounds  of  the  chest  that  did 
the  best  were  tho.se  in  which  early  and  repeated  l)leedings  were  had  recourse  to.  Pain 
must  be  relieved  by  anodynes,  chloral  being  better  than  opium. 

Hernia  of  the  lung,  or  pueumocele,  is  a  rare  consequence  of  a  punctured  wound 
of  the  thorax.  I  have  seen  but  one  example,  where  the  tumor  was  on  the  left  side, 
external  to  the  nipple,  and  about  the  size  of  a  walnut.  The  mass  was  left  In  sifii  and 
gradually  withered.  When  the  hernia  is  recent,  however,  and  the  lung  healthy,  its 
reduction  is  generally  considered  to  be  the  best  practice ;  but  when  of  long  standing  and 
diseased,  it  had  better  be  left  alone.  Its  removal  by  ligature  or  the  knife  has  likewise 
been  recommended,  successful  cases  having  been  recorded  of  all  forms  of  practice.  In  a 
case  which  came  under  my  care  at  Guy's  in  187(5,  of  fracture  of  the  sternal  ends  of  the 
left  third  and  foi.rth  ribs  by  the  man  i'alling  upon  the  blunt  end  of  .some  wooden  palings, 
in  which  the  bones  were  driven  in  without  wounding  the  integuments,  a  hernia  of  the 
lung  took  place  the  size  of  a  duck's  egg ;  but  an  excellent  recovery  followed  the  reduc- 
tion of  the  hernia  and  the  persistent  application  of  pressure.  A'elpeau  has  recorded  an 
instance  of  hernia  of  the  lung  following  the  healing  of  a  wound.  The  tumor  in  such  a 
case  is  covered  with  integument,  and  is  called  "  the  consecutive  variety  of  hernia."'  In 
such  a  ease  all  that  can  he  done  is  to  ]irotcct  the  lung  from  injury  hv  a  shield. 

Laceration  of  the  lung  without  fracture  of  the  ribs  is  an  accident  of 

occasional  occurrence,  and  1  have  recorded  an  instance  in  Gnij'x  Reports  for  1800  ari.sinir 
from  extreme  pressure  upon  the  ela.stic  ribs  of  a  boy  ret.  7.  I  saw  another  ca.se  in  180!), 
in  a  child  a;t.  4  who  had  been  run  over.  The  rent  was  on  the  lateral  side  of  the  right 
lung  and  ran  from  its  apex  to  base.  The  ribs  of  the  same  side  were  broken  at  their 
angles  far  behind  the  seat  of  rupture.  Poland  also,  in  liis  excellent  article  on  the  chest 
in  //o/we.-j'.s  Sioycr//.  has  quoted  several  others.  M.  Grosselin's  explanation  of  its  cause  is 
probably  correct — viz.,  '•  that  at  the  time  of  the  injury  when  the  chest  su.stains  the  vio- 
lence, the  lungs  are  suddenly  filled  and  distended  with  air  by  a  full  inspiration,  and  the 
air,  prevented  from  escaping  by  occlusion  of  the  larynx,  thus  becomes  pent  up  in  the 
lung  tissue,  and,  the  lung  not  being  able  to  recede  from  the  superincumbent  pressure,  its 
tissue  necessarily  gives  way."  The  symptoms  of  this  injury  are  much  the  same  as  have 
been  mentioned  in  the  paragraph  on  wounds  of  the  lung,  while  the  treatment  must  be 
similar. 

Severe  compression  of  the  chest  may  likewise  cause  laceration  of  the  heart 


016  SURGERY  OF  THE  CHEST. 

or  large  vessels;  also  brain  symptoms,  such  as  uncoiiseiousness,  epistaxis,  and  hemorrhage 
into  the  orbit  beneath  the  conjunctiva  and  eyelids  ;  and  in  a  singular  case  which  I  recorded 
in  the  same  volume  of  the  Gia/a  Rep.  as  that  of  the  boy  just  quoted  paralysis  of  the  mus- 
cles of  deglutition  and  of  the  larynx,  which  lasted  for  two  days. 

Abscesses  are  frequently  found  about  the  chest,  and  in  rare  instances  may  be  due 
to  the  discharge  through  the  lung  of  a  foreign  body.  Thus  Dr.  Wilks  recorded  at  the 
Pathological  Society  on  November  1,  1881,  a  case  of  a  child  in  which  an  ear  of  corn  was 
discharged  from  an  abscess  situated  in  the  left  suprascapular  region.  A  recovery  fol- 
lowed. No  history  could  be  obtained  as  to  how  the  foreign  body  entered  the  lung.  It 
was  probably  inhaled. 

When  abscesses  are  situated  beneath  the  pectoral  muscles,  they  are  very  obstinate. 
They  may  be  confined  to  the  cellular  tissue  of  the  part  and  connected  with  the  subpectoral 
glands  or  associated  with  ruptured  mu-scle  or  inflammation  of  the  periosteum  or  bone. 

When  connected  with  the  muscles,  they  must  be  opened  and  the  parts  kept  quiet  by 
binding  the  arm  to  which  the  muscle  belongs  to  the  side,  as  each  movement  of  the  muscle 
retards  recovery. 

When  due  to  pe?-/o.sA?7?'s-  or  ostitu^  they  are  frequently  syphilitic,  and  are  more  com- 
monly situated  over  the  sternum,  though  any  of  the  ribs  may  be  affected.  Under  these 
circumstances  constitutional  treatment  is  essential,  and  the  iodide  of  potassium,  in  grad- 
ually-increasing doses,  from  five  to  ten  grains,  in  some  tonic  such  as  bark,  is  the  best 
medicine.  If  the  bone  dies  (necrosis),  the  dead  portion  must  be  removed  when  nature 
proves  herself  incompetent  to  throw  off  the  srqHesfrmji. 

When  sinuses  exist  about  the  thorax,  the  surgeon  should  always  be  alive  to  the  fact 
that  they  may  be  due  either  to  an  empyema  which  has  naturally  discharged  itself  or  to  a 
snhstertidf  absceas,  which  is  making  its  way  through  the  intercostal  spaces.  The  history 
of  the  case  will  be  found  to  be  the  only  correct  clue  to  the  diagnosis.  In  both  instances 
a  free  opening  into  the  abscess  and  the  washing  out  of  its  cavity  are  required. 

Tumors  of  the  chest  are  not  uncommon,  but  come  more  under  the  notice  of  the 
physician.  Malignant  and  other  tumors,  however,  may  arise  external  to  the  ribs ;  and  I 
have  seen  several  cases  of  exostosis  from  the  ribs,  and  one  of  enchondroma.  No  surgical 
interference  was  called  for.  Exostosis  from  the  first  rib  may  press  upon  the  branches  of 
the  brachial  plexus  and  give  rise  to  some  pain,  or  upon  the  subclavian  artery  or  vein  and 
produce  obstruction.     In  some  cases  these  exostoses  have  been  removed. 

Deformities  of  the  chest  are  mo.stly  due  to  spinal  curvatures,  though  the  con- 
tracted or  compressed  thorax  with  the  projecting  sternum  of  childhood  (pigeon-breast) 
is  frequently  found  where  some  long-continued  obstruction  to  natural  respiration,  such  as 
enlarged  tonsils,  exists.  This  is  not,  however,  permanent  in  a  large  number  of  cases, 
since  children  who  are  the  subjects  of  it  "grow  out"  of  the  deformity  ;  as  their  general 
condition  improves  the  cause  is  removed  and  their  powers  strengthen.  It  is  commonly 
found  in  rickety  subjects,  and  is,  without  doubt,  occasionally  the  result  of  enlarged  tonsils. 

Deformity  of  the  chest  may  be  due  to  an  old  pleurisy. 

Tapping  the  Chest. 

When  air  accumulates  in  the  chest  ( j^ncumo-fhora.r)  as  a  consequence  of  either  dis- 
ea.se  or  accident,  causes  pressure  on  the  lung,  and  interferes  with  the  respiratory  process 
so  as  to  create  alarm,  the  tapping  of  the  chest  (paracentesis  thoracis)  with  a  small  trocar 
and  canula  fitted  with  a  valve  may  be  called  for.  When  blood  accumulates  (Jiscmo-fhorax), 
producing  similar  alarming  symptoms,  and  the  blood  is  mixed  with  air,  and  it  is  clear  that 
life  will  be  extinguished  if  relief  be  not  afforded,  the  blood  and  air  must  be  let  out ;  and 
for  this  purpose  it  is  probably  the  best  operation  to  make  an  incision  into  the  thorax 
where  no  wound  previously  existed,  or  to  enlarge  a  small  wound  when  present.  To  give 
relief  with  a  trocar  and  canula  is  always  a  difficult,  and  often  an  impossible,  task,  on 
account  of  the  coagulum.  When  s^crvm  presses  upon  the  thoracic  contents  (Jit/dro-fho- 
?Yf.x)  and  requires  surgical  interference,  the  trocar  and  canula  with  the  aspirator  are 
beyond  doubt  the  best  instruments  to  employ,  great  care  being  observed  to  exclude  air. 
The  object  under  all  these  circumstances  is  to  remove  the  pressure  from  the  lung  in  the 
most  effectual  way  by  the  withdrawal  of  the  compressing  material.  When  pus  exists 
(empi/emd),  surgeons  are  not  quite  decided  as  to  the  best  means  to  be  employed,  although 
all  are  agreed  as  to  the  propriety  of  drawing  it  off.  A  generalized  empyema  rarely  points 
externally;  a  localized  one  does  so  frequently.  For  diagnostic  ])urposes  the  aspirator  may 
be  a  valuable  instrument,  as  it  is  for  the  first  emptying  of  a  localized  empyema  ;   but  for 


T.\i'i'iS(;   rill-:  ciiiisr.  dlT 

a  coiicnil  I'liipyiMiia  tin*  practice  ol'  as|»iratiiiLr  is  not  to  he  advocated,  siiico  iiothiiif^  less 
tliaii  IVi'i'  (lraiiiai.M'  is  likely  tn  siifcfcd.  as  a  ircncral  ruli'.  Tu  tap  hy  incaiis  of  the  aspi- 
rator iir  the  trocar  and  caiiula  jrivt's  temporary  relief,  Itiit  docs  not  cure  the  disease,  lor 
which  more  eHicieiit  measures  are  re<|Mired.  For  my  own  part,  I  helieve  that  when  pus 
80  presses  upon  the  luntrs  and  interferes  with  the  respiratory  proeesH  as  to  call  for  sur- 
gical interference  the  pus  must  he  let  out  hy  nu'ans  of  a  IVee  opening,  the  opening  ^jcing 
hirge  enough  to  ])ermit  of  the  free  escape  of  all  fluid  through  a  drainage-tube.  The 
introiluetion  of  drainage-tuhes  hy  M.  Cliassaignae  has  heen  of  gnjat  service  in  the  treat- 
ment of  empyema.  Hr.  (Joodfellow  and  Mr.  de  Morgan — early  advocates  of  their  use  in 
this  country — passed  the  ]»ertorated  india-ruhher  tuhe  through  the  canula  upon  a  long 
iron  prol)e,  and  hrought  it  out  of  a  second  opening  in  the  lower  and  i»ost(?rior  part  of  the 
chest,  this  second  opening  heing  made  with  a  scalpel  u|)on  the  cxtre-mity  of  the  probe 
pressed  against  the  lower  intercostal  space.  The  perforated  tulte  conse(|U(.'ntly  passed 
as  a   seton   through  the  chest   and   allowed  the  free  csca|)e  of  any  fluid  in   its  cavity. 

I  have  never  adopted  this  |)ractice  in  the  way  here  detailed,  heing  satisfied  with  a 
free  o])ening  into  the  thora.x,  with  either  a  .scalpel  or  a  large  trocar  and  canula.  and  the 
introduction  of  a  drainage-tuht;  into  the  thorax  either  through  the  canula  or  otherwise 
and  the  subse(|uent  daily  washing  out  of  the  cavity  with  a  solution  of  iodine.  Sub- 
aqueous drainage  may  lie  employed.  In  May,  LS""),  I  followed  the  former  practice  in 
the  case  of  a  gentleman  :ct.  o7  whom  I  saw  with  Dr.  Rowlands  of  Carmarthen,  and  drew 
off  tliree  (juarts  of  pus  from  his  left  chest  through  a' free  opening,  and  subsequently  passed 
a  drainage-tube  into  the  cavity.  In  three  months  convalescence  ensued,  and  in  another 
month  he  was  quite  well,  the  lung  on  the  aff"ected  side  having  expar)ded.  Itideed.  I  quite 
coincide  with  Dr.  (ioodhart  (Gni/'s  IIosj).  R<p.^  1877)  that  "if  drainage  is  decided  upon, 
notliing  short  of  perfect  drainage  is  safe  for  the  patient;"  and  to  this  end  the  opening 
into  tlie  th(jrax  must  be  free  and  the  cavity  of  the  chest  kept  well  emptied,  either  by 
irrigation  or  by  wliat  has  been  described  as  subaqueous  drainage,  which  should  be  carried 
out  as  follows:  "Having  determined  on  the  spot  at  which  i)uncture  of  the  chest  is  to 
be  made,  a  trocar  and  canula  are  taken,  the  bore  of  which  is  alxiut  five  millimetres.  A 
length  of  several  feet  of  black  or  red  india-rubber  tubing  which  will  slip  easily  through 
the  canula  is  placed  ready  at  hand;  the  chest  is  then  tapped  and  the  trochar  withdrawn, 
and  as  tlie  fluid  comes  in  full  stream  by  the  canula  the  india-rubber  tubing  is  pushed 
along  the  latter  into  the  che.st  as  far  as  neces.sary — usually  four  or  five  inches.  The 
canula  is  then  witlidrawn  over  the  tube,  leaving  the  one  end  of  the  latter  in  the  chest, 
while  the  other  or  free  end  is  kept  under  water  by  the  side  of  the  bed.  The  tube  then 
acts  as  a  syplion." 

This  plan  of  drainage  is  not.  however,  very  complete;  for  out  of  30  cases  in  which  it 
was  employed,  as  reported  by  Dr.  Goodhart,  in  18  imperfect  drainage  had  to  be  recorded, 
and,  as  this  is  a  method  which  professes  to  drain  away  pus,  it  cannot  be  said  to  have 
proved  successful. 

In  young  people,  where  the  ribs  are  elastic,  good  results  may  be  looked  for ;  but  in 
the  old,  where  the  ri))s  are  rigid,  no  contraction  can  be  expected. 

The  Operation. 

In  tapping  the  chest  for  air,  serum,  or  pus  the  following  points  should  be  observed : 
"Where  the  signs  of  disease  are  most  marked,  there  the  puncture  should  be  made.  When 
the  chest  is  full  of  fluid,  the  eighth  or  ninth  intercostal  space  should  be  cho.sen.  just  in 
front  of  the  angle,  or  the  seventh,  midway  between  the  sternum  and  spine.  This  latter 
spot  can  always  readily  be  found  by  drawing  a  line  with  a  string  round  tlie  body  on  the 
level  of  the  nipple,  and  midway  between  the  sternum  and  spine  this  line  will  cut  the 
proper  intercostal  space.  At  this  spot,  close  to  the  lower  rib,  a  small  incision  should  be 
made  through  the  skin  and  fascia  with  a  lancet  or  scalpel,  and  through  this  the  trocar  and 
canula.  warmed  and  oiled,  should  be  introduced  ;  the  trocar,  as  .soon  as  it  has  jierforated 
the  chest,  should  be  withdrawn,  the  canula  being  jiushcd  more  home.  When  the  ojicra- 
tion  has  been  performed  for  air  or  serum,  a  small  instrument  should  be  employed  and 
great  care  used  to  prevent  the  admission  of  air.  For  this  purpose  there  is  no  better 
instrument  than  the  pneumatic  aspirator  of  Dr.  Dieulafoy  or  one  of  its  modifications,  and 
Dr.  Bowditch  of  Boston,  I'nited  States — a  staunch  supporter  of  this  practice — reports 
(Pracfifioiin-.  April,  1873)  that  during  twenty-four  years  and  in  270  operations  he  had 
never  seen  any  injury  done  by  the  aspirator.  As  a  substitute  one  of  the  canulas  may  be 
used  fitted  with  a  stop-cock  or  valve,  to  prevent  the  admission  of  air. 


618  SURGERY  OF  THE  CHEST. 

When  the  chest  requires  opening  for  the  discharge  of  blood  or  pus,  a  free  incision  or 
large  canula  should  be  resorted  to.  I  prefer  an  incision,  and  make  it  large  enough  to 
admit  my  little  finger,  and  subsequently  a  large  india-rubber  drainage-tube.  Trousseau 
strongly  advises  the  operation  of  tapping  when  serous  effusion  fills  the  cavity,  as  indicated 
by  auscultation  and  percussion  ;  when  oppression  of  breathing  also  exists,  it  may  be 
urgently  needed ;  but  this  oppression,  adds  he,  is  one  of  the  most  deceitful  of  signs,  and 
its  absence  ought  not  to  inspire  too  great  a  feeling  of  security,  as  by  refraining  from 
interference  we  run  the  risk  of  losing  patients  whom  the  operation  would  assuredly  have 
saved.  In  empyema  he  fixes  in  the  canula  and  draws  off  the  fluid  every  twenty-four 
hours,  injecting  the  chest  with  a  solution  of  iodine,  one  part  of  the  tincture  in  six, "every 
two,  three,  or  four  days. 

It  should,  however,  be  recorded  that  sudden  death  has  taken  place  after  thoracentesis 
for  pleuritic  effusion  or  empyema,  although  evidence  is  wanting  to  prove  that  any  distinct 
relation  exists  between  the  operation  and  death,  since  cases  are  on  record  in  which  sud- 
den death  ensued  in  the  normal  course  of  cases  of  pleuritic  effusion.  Trousseau  has 
recorded  examples  of  the  latter  kind,  and  Drs.  Cayley  and  Broadbent  of  the  former  {Clin. 
Societi/^  1877). 

Apncea,  or  so-called  Asphyxia. 

Death  from  asphyxia,  in  the  common  acceptation  of  the  term,  means  death  from 
either  the  cessation  of  the  respiratory  process  or  the  want  of  the  ordinary  respiratory 
medium  (oxygen),,  the  heart  ceasing  to  act  after  the  cessation  of  the  respiratory  process. 
Etymologically,  it  means  an  absence  of  pulse.  The  more  correct  term  is  "  apncea."  It 
is  caused  by  whatever  interferes  with  the  admission  of  the  air  into  the  lung — by  such  acts 
as  (iwwiiiiu/  and  hanging,  by  diseases  that  mechanically  block  up  the  air-passages  or  excite 
.spasm  of  the  larynx,  by  any  external  or  internal  condition  of  the  thorax  that  prevents 
the  admission  of  air  into  its  cavity  or  interferes  with  its  expansion,  by  the  want  of  the 
respiratory  medium,  or  by  the  inhalation  of  toxic  vapors. 

Under  some  circumstances  the  asphyxia  is  rapid  or  acute ;  in  others,  chronic.  In 
accidental  cases  it  is  chiefly  the  former ;  in  di.sease,  the  latter.  In  both,  however,  the 
result  is  the  same,  the  blood  not  being  decarbonized  as  it  should  be,  and  what  Dr.  Cleve- 
land has  rightly  called  carbonaemia  ensuing.  Special  symptoms  may  depend  entirely 
upon  the  nature  of  the  asphyxiating  cause,  but  the  ultimate  effects  are  the  same  in  each. 
In  all,  whether  slow  or  rapid,  there  are  congestion  and  lividity  of  the  face.  In  all  the 
heart  continues  to  beat,  though  laboriously,  after  respiration  has  ceased,  the  action  becom- 
ing gradually  less  distinct,  till  it  stops  altogether.  It  is  possible  for  the  heart  to  continue 
its  action  from  two  to  four  minutes  after  the  last  respiratory  effort. 

After  death,  it  has  generally  been  thought  the  cerchral  irxseia  would  be  found  gorged 
with  blood.  Ackenian  has  shown,  however,  that  this  condition  is  present  only  when  the 
head  of  the  subject  has  been  kept  lower  than  the  rest  of  the  body,  and  that  death  by 
suffocation  is  always  connected  with  an  exsanguine  state  of  the  cerebral  vessels.  The 
right  side  of  the  heart  and  great  vessels  will  be  full  of  black  blood,  whilst  the  Ir/t  side  will 
be  found  empty  ;  and  the  whole  arterial  blood  will  be,  as  the  venous,  of  a  dark  color. 
All  the  abdominal  viscera  will  be  engorged  with  blood. 

The  lungs,  in  cases  of  hanging  and  mechanical  obstruction,  pi'esent  no  characteristic 
appearance,  but  in  those  of  drowning  they  will  be  njore  or  less  filled  with  water  or  the 
drowning  medium  and  incapable  of  collapsing,  and  will  feel  heavy  and  doughy  to  the 
touch.  The  air-tubes,  moreover,  will  be  choked  with  a  sanious  foam  composed  of  blood, 
water,  mucus,  ;<nd  often  foreign  matter  churned  up  with  the  air  of  the  lungs.  Frothy 
water  mixed  with  blood  will  also  pour  out  of  any  section  of  the  lung.  These  points  were 
clearly  stated  by  the  committee  of  the  Roy.  Med.  and  Chir.  Society  on  suspending  ani- 
mation, and  recorded  in  the  Transactions  for  1862. 

Drowning. 

Hoin  long  a  Iniman  bring  mat/  he  nndcr  irater  and  i/et  recover  is  an  important  question, 
but  the  answer  depends  upon  many  considerations.  Dr.  Sanderson  believes  he  has  demon- 
strated by  experiments  that  in  animals  the  duration  of  life  turns  upon  the  amount  of  air 
confined  in  the  chest  at  the  time  of  immersion — that  when  the  animal  on  immersion  fills 
its  chest  with  water  by  an  inspiratory  effort,  death  is  most  rapid  ;  but  if  the  chest  be  full 
of  air  at  the  time,  and  no  such  inspiratory  effort  takes  place,  life  may  be  prolonged  for 
several  minutes.     The  occurrence  of  syncope  at  the  moment  of  immersion,  whether  from 


Tni:ATMi:yT  of  M'S(t:.\,  m:  AsriivxiA. 


»;i9 


fright,  sluK'k,  or  jtrcvious  injury,  is  ciiiisiMjUi'iitly  ii  happy  iifcidciit,  the  vospiratorv  act 
being  niatt-rially  diininislit'd  l)y  the  jsyncupc.  ■  If  a  pcrs<in  he  eoinph'tely  .suhnierged," 
writes  Dr.  \V.  (J.  Ilarh-y  in  llnlnutss  Si/sfrm,  ''and  the  entrance  of  water  to,  and  exit  of 
air  from,  the  lungs  not  prevented,  we  believe  that  recovery  would  he  impossible  after  two 
minutes.  On  the  ctther  hand,  if  the  air-passages  were  closed  against  the  entrance  of 
water  and  the  chest  kept  i'ull  of  air,  we  see  no  reason  for  thinking  that  a  human  being 
would  perish  either  more  slowly  or  more  fjuickly  than  a  dog  placed  under  similar  circum- 
stances— namely,  in  iVom  four  to  five  minutes.  " 

Death  by  sfraiKfufn/inn  is  due  to  asphyxia  alone,  and.  as  a  rule,  is  homicidal,  being 
consetjuently  often  complicated  with  other  injuries. 

Death  by  /idiiifin;/  is  of  a  mixed  form,  since,  in  addition  to  the  strangulation  by  the 
Cord,  there  is  the  added  traction  on  it  by  the  weight  of  the  falling  body. 

J/i(iii/iiii/  cau.ses  death,  according  to  Dr.  A.  Taylor,  "  commonly  fnjin  a})n<ea,  but  some- 
times froui  apoi)lexy,  caused  by  pressure  on  the  jugular  vein,  being  preceded  by  c<^nvul- 
sions,  often  lasting  for  many  minutes,  but  in  all  jmtbability  not  accompanied  by  m(jre 
than  UKunentary  pain.  Occasionally  there  is  found  displacement  or  fracture  of  the  first 
or  second  of  the  vertebne,  with  com[(ression  of  the  spinal  marrow.  This  cause  of  death 
is  only  likely  to  be  ob.served  in  corpulent  or  heavy  persons,  when  a  long  fall  is  allowed 
by  the  cord,  and  is  seldom  met  with  in  judicial  executions."  This  latter  fact  is  supported 
by  the  observations  of  Dr.  Barker  of  Melbourne,  who  informed  Professor  Haught(jn  of 
Dublin  that  in  fifty-four  post-mortem  examinations  of  criminals  hanged  according  to  the 
old  or  "  short-drop  "  system,  in  not  a  single  ca.se  was  there  dislocation  or  fracture  of  the 
neck.  Tn  the  following  plan,  however,  introduced  by  Dr.  Barker,  this  dislocation  was  the 
rule.  Dr.  llaughton  (juotes  his  words  (J/cW.  TimcA  and  Guz.^  June  21,  1871)  :  "  I  have 
the  knot  put  about  two  inches  from  the  spine,  so  that  when  it  is  tightened  by  the  weight 
of  the  body  the  knot  comes  on  the  vertebr;e  ;  by  the  fall  the  body  has  an  impetus  for- 
ward, the  resistance  being  at  the  beam  to  which  the  rope  is  fa.stened.  The  knot  acts  as 
a  fulcrum  to  i)ush  the  head  forward.  By  this  arrangement  I  have  found  in  all  ca.ses 
there  was  a  dislocation  and  fracture  of  the  cervical  .spine  and  pressure  on  the  cord,  lacer- 
ation of  the  muscles  of  the  larynx,  and  generally  fracture  of  the  hyoid  bone,  death  being 
always  sudden  and  complete  ;  no  long  drop  is  required."  To  the  Irish  and  American 
long-drop  system  there  are  grave  objections.  When  the  cord  is  crushed,  death  is  instan- 
taneous ;  when  not  so  injured,  life  may  be  prolonged  for  some  minutes — usually  about 
three  ;  but  there  is  no  evidence  to  believe  that  the  period  may  be  extended  to  ten.  Con- 
scious life,  under  both  circumstances,  probably  is  soon  lost,  rarely  extending  beyond  the 
thrte  minutes. 

When  the  cord  is  not  injured,  Taylor  computes  that  life  may  be  restored  after  five 
minutes  of  suspension,  and  Tardieu,  an  eminent  French  writer,  gives  a  similar  period. 


Treatment  of  Apncea,  or  Asphyxia. 

All  obstruction  to  the  passage  of  fresh  air  to  and  from  the  lungs  is  to  be  at  once,  so 
far  as  practicable,  removed,  all  froth  and  mucus  to  be  cleansed  from  the  mouth  and  nos- 
trils, and  all  tight  articles  of  clothing  to  be 

at  once  taken  away  from  the  neck  and  chest.  Fig.  .354. 

In  slight  cases  of  temporary  apnoea  the  treat- 
ment is  as  in  syncope,  dropping  the  head, 
which  should  be  low  in  all  cases,  a  dash  of 
cold,  or  alternately  of  cold  and  hot,  water 
to  the  face,  or  a  smarting  slap  upon  the  epi- 
gastrium, generally  sufficing  to  revive  the 
patient.  When  this  proves  useless,  artifi- 
cial respiration  should  be  instantly  com- 
menced. 

The  methods  of  artificial  respiration 
which  have  been  successively  in  use  are 
those  of  the  late  Drs.  Marshall  Hall  and 
Silvester,  but  I  believe  the  best  method  to 
be  the  one  more  recently  advocated  by  Dr. 
Benjamin    Howard    of   New    York.     This 

"  direct  method."  as  the  author  calls  it.  was  first  published  in  the  form  of  a  prize  essay 
by  the  American  Medical  Association  in  1871,  and  has  since  been  adopted  by  the  United 


620 


SURGERY  OF  THE  CHEST. 


Fig.  355. 


Artificial  Respiration  by  Direct  Method. 


States  Government  Life-Saving  Service,  the  Life-Saving  Society  of  New  York.  etc.  It  is 
eminently  .simple  and  effective,  and  is  to  be  applied  in  the  treatment  of  the  drowned  as 
follows,  the  rules  having  been  drawn  up  for  me  by  Dr.  Howard  : 

Rule  1.  For  Ejection  and  Drainage  of  Fluids,  etc.  from  the  Stomach  and 
Lungs.  Position  of  Faiient. — Face  downward  with  forehead  re.sting  upon  the  fore-arm 
or  wrist,  to  keep  the  mouth  from  the  ground,  and  a  hard  roll  of  clothing  beneath  the 
epigastrium,  which  .should  be  the  highest  point,  while  the  mouth  is  the  lowest  (Fig. 
354). 

Position  and  Action  of  Operator. — With  the  left  hand  well  spread  out  upon  the  base 
of  the  thorax,  to  the  left  of  the  spine,  and   the  right  hand  upon  the  spine,  a  little  above 

the  left  and  over  the  lower  part  of  the 
stomach,  the  operator  should  with  a  for- 
ward motion  throw  upon  them  all  the 
weight  and  force  the  age  and  sex  of  the 
patient  will  justify,  ending  this  pressure 
of  two  or  three  seconds  with  a  sharp 
push,  which  helps  to  jerk  him  back  to 
the  upright  position.  And  this  move- 
ment should  Vje  repeated  two  or  three 
times,  according  to  the  period  of  sub- 
mersion and  other  indications. 

Rule  2.  Position  of  Operator. — ^^In 
a  kneeling  posture,  astride  patient's 
hips  ;  his  hands  upon  the  chest,  so  that 
the  ball  of  each  thumb  and  little  finirer 
rests  upon  the  inner  margin  of  the  free 
border  of  the  costal  cartilages,  the  tip 
of  each  thumb  near  or  upon  the  zy- 
phoid,  and  the  fingers  fitting  into  the  corresponding  intercostal  spaces ;  the  elbows  firmly 
fixed,  making  them  one  with  the  sides  and  hips  ;  then — To  Perform  Artificial  Respi- 
ration. Position  of  Patif-nt.  Rip  or  strip  clothing  from  the  waist  and  neck.  Face 
upward  :  shoulders  slightly  declining  over.  Hard  roll  of  clothing  placed  beneath  thorax  ; 
the  head  and  neck  bent  back  to  the  utmost,  with  the  hands  on  the  top  of  the  head  (one 
twist  of  handkerchief  around  the  crossed  wrists  keeping  them  there)  (Fig.  355). 

The  operator,  pressing  upward  and  inward  toward  the  diaphragm,  using  his  knees  as 
a  pivot  and  throwing  his  weight  slowly  forward  two  or  three  seconds  until  his  face  almost 
touches  that  of  the  patient,  should  end  with  a  sharp  push,  which  helps  to  jerk  him  back 
to  the  erect  kneeling  position.  He  should  then  rest  three  seconds  and  repeat  this  bellows- 
blowing  movement  as  before,  continuing  it  at  the  rate  of  seven  to  ten  times  a  minute, 
taking  the  utmost  care,  on  the  occurrence  of  a  natural  gasp,  gently  to  aid  and  deepen  it 
into  a  long  breath  until  respiration  becomes  natural.  When  practicable,  the  tongue 
•should  be  held  firmly  out  of  one  corner  of  the  mouth  with  the  thumb  and  forefinger 
armed  with  dry  cotton  rag. 

Avoid  all  impatient  vertical  pushes ;  the  force  upward  and  inward  must  be  increased 
gradually  from  zero  to  the  maximum  the  age,  sex,  etc..  may  indicate.  Abandon  no  ca.se 
as  hopeless  within  an  hour's  useless  effort. 

In  the  application  of  this  method  to  ca-^^es  of  stiUhirth  the  child  lies  along  the  left  hand 
of  the  operator,  the  ball  of  whose  thumb  takes  the  place  of  the  hard  roll  of  clothing  .seen 
in  Fig.  355.  Over  this  the  shoulders  decline,  the  head  falling  back,  with  the  arms,  if 
convenient,  on  either  side  the  face.  The  buttocks  and  thighs  are  supported  by  the 
operator's  fingers. 

Thus  the  operator  has  the  prominent  little  thorax  completely  within  the  grasp  of  his 
right  hand  with  firm  counter-pressure  behind,  enabling  him  to  apply,  locate,  distribute, 
direct,  or  alternate  his  pressure  as  he  pleases. 

The  advantages  Dr.  Howard  claims  for  this  method  over  other  methods  are:  1st.  It  pro- 
vides for  ejection  and  drainage  of  fluids,  etc.  from  the  stomach  and  lungs,  and  in  such  a 
way  that  each  motion  for  ejection  induces  an  alternate  inspiration.  2d.  It  excludes  the 
tongue  from  the  pharynx  without  manipulation.  3d.  It  secures  elevation  of  the  epiglot- 
tis and  a  post-oral  air-way  from  the  glottis  to  the  nares.  4th.  It  includes  a  remedy 
against  syncope  and  cerebral  ansemia.  5th.  It  obtains  a  more  general  expansion  of  the 
thorax.  6th.  It  effects  a  thoracic  compression  which  is  more  complete,  better  distributed, 
directed,  and  regulated.     7th.  It  is  done  by  one  person  and  can  be  applied  instantly  on 


Tin:.\TMi:sT  of  ai\\(KA,  on  aspjivxia.  021 

the  spot  wliorevor  tlif  patit-iit  is  fomul.      Sth.    It  is  more  easily  understoofl  l)y  the  illiter- 
ate, is  less  liiti^uiii^'  to  the  tiperator,  and  is  free  from  iiimeeessary  motion  or  violenee. 

When  respiration  is  re-estahlished,  maintain  the;  t«'m]teratnre  ol"  the  hody  hy  friction, 
warm  Idankets,  and  when  possible  l»y  warm  water  (1(M»°  V.)  or  air  hath,  keeping:  the  head 
where  a  eirculation  of  ])ure  air  niay  he  maintained.  As  soon  as  the  patient  can  swalhiw 
give  warm  milk,  beef  tea,  tea,  or  eoff'ee,  with  a  tahlespoonful  of  .some  spirit;  or  these  may 
be  injeeted  by  the  stomach-pump.  When  respiration  is  restored,  put  the  patient  into  a 
warm  bed  witli  hot  bottles  to  his  feet  and  encourage  sleep,  but  let  him  be  watched  in  ca.se 
of  secondary  or  '.elapsing  apnwa  ;  at  the  slightest  .symptoms  of  which,  let  friction,  and 
even  artificial  respiration,  be  re-employed.  (Jive  V(jlatile  stimulants,  such  as  tlie  spiritus 
amnion i:t>  aromaticus. 


SURGERY  OF  THE  URINOGENITAL  SYSTEM. 


CHAPTEK     XX. 

DISEASES   OF   THE   KIDNEY.— STONE.— NEPHROTOMY. 

Malformations  of  the  kidney  have  more  scientific  than  surgical  interest,  yet 
they  may  have  an  important  surgical  bearing ;  for  when  any  accident  from  external 
violence  or  internal  irritation  happens  to  a  single  or  imperfect  organ,  the  life  of  a  patient 
is  more  likely  to  be  jeopardized  than  when  it  is  normal.  In  a  case  recorded  on  page  -189 
this  fact  was  illustrated.  When  a  kidney  is  single,  it  is  usually  large  and  sometimes  has 
the  form  of  a  horseshoe  ;  when  it  assumes  a  central  position,  with  the  convexity  of  the 
curve  downward,  it  may  be  regarded  as  a  double  organ,  the  vessels  entering  from  above 
in  their  normal  way.  A  kidney  may  also  hold  a  position  nearer  the  pelvis,  or  even  lie  in 
the  pelvis  ;  it  may  be  "movable"  or  "floating."  At  times  the  adult  kidney  maintains  the 
lobulated  character  it  possessed  in  foetal  life.  A  kidney  when  loosely  connected  may 
appear  as  a  movable  abdominal  tumor,  and  in  exceptional  cases  be  the  seat  of  much  dis- 
tress.    In  such  operative  surgery  may  be  required.      (Vide  '"  Nephrorraphy,"  page  031.) 

The  diseases  of  the  kidney  are  generally  regarded  as  belonging  to  the  physi- 
cian, but  I  need  hardly  add  that  a  thorough  knowledge  of  renal  pathology  is  as  requisite 
to  the  surgeon  as  it  is  to  the  medical  practitioner,  for  without  such  a  knowledge  he  will 
be  able  neither  to  recognize  the  different  conditions  of  the  urine  with  its  deposits  nor  to 
appreciate  their  significance.  He  will  likewise  be  as  unfit  to  decide  upon  the  propriety 
of  an  operation  of  expediency  as  to  understand  the  risks  of  one  of  necessity  ;  for  the 
existence  of  kidney  disease,  as  a  rule,  is  enough  to  debar  the  surgeon  from  performing 
any  operation  other  than  that  required  to  save  life,  and  in  such  operations  it  renders  the 
prognosis  most  unfavorable,  since  kidney  disease  is  well  known  to  be  the  chief  cause  of 
death  after  operations. 

As  a  rule  of  practice  the  condition  of  the  kidney,  as  expressed  by  the  character  of  the 
urine,  should  be  made  out  in  all  cases  in  which  an  operation  is  thought  of,  and  more 
particularly  in  operations  upon  the  urinary  organs. 

Nephritis. 

Inflammation  of  the  kidney  associated  with  suppuration  of  the  organ  has  long  been 
recognized  as  a  common  consequence  of  obstructive  disease  of  the  urinary  passages.  But 
it  may  occur  as  a  consequence  of  local  injury,  or  as  an  acute  attack  upon  a  chronically 
diseased  organ,  or  as  a  consequence  of  pyi^elnia  or  other  cause.  It  is  also  very  common 
as  a  sequel  to  Bright's  disease  of  the  kidney — that  is,  to  disease  of  the  secreting  structure 
of  the  organ — in  consequence  of  some  local  .source  of  irritation  in  any  part  of  the  urinary 
passages.     Bright's  disease  by  itself  is  not  a  suppurative  disease. 

Suppurative  nephritis  may  occur  as  an  acute  or  as  a  chronic  affection,  though  more 
frequently  as  an  acute  upon  a  chronic  disease.  After  death  a  kidney  thus  affected  may 
appear  enlarged,  with  its  substance  more  or  less  filled  with  suppurating  cavities.  When 
the  inflammatory  action  is  confined  to  the  mucous  lining  of  the  pelvis  of  the  organ,  it  is 
called  pi/e/itis.  At  times  the  kidney  is  a  mere  cyst  or  shell  containing  pus  and  broken- 
down  tissue,  and  in  extreme  cases  the  kidney  and  parts  around  form  one  large  suppurat- 
ing cavity.  This  condition  is  not  rare  as  a  consequence  of  the  breaking  up  of  tubercu- 
lous matter,  and  then  it  is  usually  symmetrical. 

Symptoms  and  Diagnosis. — When  after  an  injury  in  the  loins,  or  in  the  course  of 
some  obstructive  vesical,  urethral,  or  calculous  affection,  a  patient  is  seized  with  rigors. 

022 


m:  I 'I  I  urns. 


G2;J 


Via.  3')f;. 


severe  pain  and  t»'ii<len)Oss  in  tlic  linnltar  rcjrioii,  fcltrilc  <listiirliaiipe,  nausea,  vomiting, 
scanty.  Iiiijli-folorcd,  ami  jiDs.silily  lilctoily,  urine,  and  irrital)lc  liladilcr.  ttcnfr  iifjihrilin  may 
be  suspected.  When  riiri>rs  recur  rrc(|uently  and  tliere  is  suppression  of"  urine  with  renal 
casts  or  pus  in  the  urini-.  su|>puration  ottlie  oriran  is  to  he  diairnoscd  ;  and  when  to  these 
symptoms  are  added  severe  (h'pression,  anasarca,  and  hrain  .^yniptnms  passing  on  to  coma, 
unuinic  poi.sonintr  may  safely  he  expected. 

Hut  chronic  nephritis  is  a  more  common  afl'cction  than  the  acute;  indeed,  unlcs.s 
from  accideiil,  the  acute  is  uenerally  a  se(|uel  to  the  chronic.  Kidney  di.sea.se  i.s  a  coiu- 
luon  eonsei|uence  of  long  standing  or  neglected  blad- 
der or  uretiiral  mi.schief.  When  a  stone  has  existed 
for  any  period  in  the  hladihr  and  has  set  up  inflam- 
mation of  that  (U'gan,  when  iVom  prostatic  disease  the 
same  result  ensues,  or  when  from  stricture  the  urin- 
ary organs  have  been  sul)jected  to  irritation  and  dis- 
tension from  retained  urine,  the  ureters,  and  later  on 
the  pelvis  of  the  kidney,  and  subse(|uently  the  'iecret- 
ing  structures  of  the  kidneys  tlu'mseives,  becotne  in- 
flamed by  extension  from  the  blarlder.  T'nder  these 
circumstances  every  gradation  of  dilatati(»n,  inflam- 
mation, or  suppuration  of  the  whole  urinary  pas.sages 
may  be  found  ;  the  bladder  may  be  enormously  thick- 
ened and  inflamed ;  the  ureters  dilated,  tortuous, 
thickened,  and  stippurating  ;  the  pelvis  of  the  kidney 
expanded  and  filled  with  pus — pijf.'Utis — and  the  kid- 
ney itself  more  or  less  undergoing  disorganizing 
changes  (Fig.  o5'V). 

Symptoms. — The  symptoms  of  changes  such  as 
these  are  not  very  definite.  In  all  long  stttudtHg 
examples  of  obstructive  urinary  aifections  some  of 
them  may  be  suspected ;  so  also  in  all  cases  of 
neglected  stone,  particularly  when  bladder  symptoms 
are  marked ;  in  cases  in  which  the  urine  is  albumi- 
nous, pale-colored,  and  smoky,  or  tinged  with  blood ; 
when  it  contains  pus  in  suspension,  varying  in  quan- 
tity at  different  times,  or  shreds  of  lymph  ;  when  a  Suppurative  Disease  of  the  Kidnevs,  Dilata- 
diill      -ichino-    min     is    nrpspnt    in    tbp    Initio     sbontintr       tion  of  Ureters,  Hypertrophy  of  Uie  Bladder, 

auii,  acning  pain    is    present   in  tne  loins,  snooting     e,c_^  tjjg  gtiect  of   Urethral  obstruction, 
round  the  hips  into  the  groin  and  down  to  the  testi-     (Drawing  ses^s,  Guy's  Hosp.  Mus.) 
cles  ;  when  vomiting  is  constant  and  persistent,  and  the 

digestive  organs  do  their  work  badly  ;  and  when  sleep  is  diSicult  to  secure  or  superseded 
by  a  general  drowsiness. 

Dla.(}N'osis. — Under  these  circumstances  chronic  kidney  disea.se  may  ftiirly  be  diagnosed, 
with  or  without  suppuration  in  the  organ  or  around  it. 

When  anasarca  .sets  in  or  brain  symptoms  from  uncmic  poisoning  a])pear,  the  diagnosis 
is  clear. 

"When  rigors  are  frequent,  even  when  not  well  marked,  when  lumbar  pain  is  constant 
and  increased  on  pressure,  when  on  manipulation  evidence  exists  of  some  deep-seated 
lumbar  swelling  and  fluctuation  is  distinctly  or  indistinctly  to  be  made  out,  abscess  of  the 
kidnnj  is  fairly  indicated.  W^hen  with  these  a  sudden  discharge  in  the  urine  of  large 
quantities  of  pus  takes  place  with  relief  to  the  local  symptoms,  it  is  probable  that  the 
abscess  has  discharged  itself  through  the  ureter ;  when  the  lumbar  pain  becomes  more 
intense,  the  swelling  more  marked  and  prominent,  and  fluctuation  more  distinct,  it  is 
probable  that  the  ureter  has  become  obstructed  and  the  renal  abscess  is  making  its  way 
through  the  loin  externally  ;  and  many  cases  are  on  record  in  which,  after  the  di.scharge 
of  the  abscess  by  natural  or  surgical  means,  a  recovery  has  ensued.  Indeed,  stones  have 
been  taken  away  from  or  discharged  from  the  kidney  in  this  way  with  a  good  result. 

Kcnal,  like  perirenal,  ab.seesses  are,  however,  prone  to  make  their  way  through  the 
diaphragm  into  the  lung  or  into  the  colon  :  and  cases  are  recorded  where  they  burrowed 
downward  and  appeared  below  Pouparts  ligament  or  in  the  pelvis.  In  these  ca.ses  the 
symptoms  simulate  spinal  disease,  the  thigh  being  flexed  upon  the  pelvis,  this  symptom 
attended  with  lumbar  pain  or  tenderness,  being  very  constant  in  nephritic  as  in  perine- 
phritic  abscess.  Dr.  Bowditch  of  Boston  was  the  first  to  draw  attention  to  the  fact  in 
1869  and  1870. 


624  DISEASES  OF  THE  KWyEY—STOyE—yEPHROTOMY. 

Treatment. — When  acute  nephritis  originates  from  a  blow  or  from  the  irritation  of  a 
renal  calculus,  complete  rest  in  the  horizontal  posture  in  a  warm  bed  is  absolutely  essen- 
tial, with  milk  diet  and  the  moderate  use  of  simple  diluents,  as  milk  and  water  or  barley 
water.  Poppy  fomentations  to  the  loins  always  give  comfort,  and  when  the  pain  is 
severe  leeching  is  beneficial ;  cupping  has  been  recommended  and  is  of  use.  The  bowels 
should  always  be  well  cleared  out  by  some  .simple  medicine,  such  as  castor  oil  or  an 
enema.  All  medicines  that  act  upon  the  kidney,  as  salines  or  turpentine,  all  external 
applications,  such  as  blasters,  should  be  carefully  avoided ;  and  for  this  same  reason 
stimulants  ought  not  to  be  given. 

The  action  of  the  skin  should  be  encouraged  by  outside  warmth,  and  the  hot-air  bath  or 
steam  bath,  applied  to  the  patient  in  bed,  is  a  valuable  means  to  this  end ;  a  hot  bath  is 
a  good  substitute.     Calomel  and  antimony  cannot  be  recommended. 

When  the  case  passes  into  the  chronic  stage,  counter-irritation  becomes  of  value,  and, 
as  this  cannot  be  obtained  by  means  of  blisters,  since  cantharides  act  powerfully  on  the 
kidneys,  mustard  may  be  employed,  or  a  piece  of  lint  saturated  with  a  mixture  of  chloro- 
form and  alcohol  should  be  applied  to  the  loin  and  covered  with  oil  silk.  Dry  cupping 
also  is  of  great  value. 

When  acute  nephritis  supervenes  upon  the  chronic  form,  the  result  of  long-standing 
disease  of  the  urinary  organs,  or  after  operation,  the  whole  aim  of  practice  must  be  to 
soothe,  relieve  pain,  and  keep  life  going.  Nothing  like  mechanical  interference  with  the 
urinary  passages  must  be  thought  of  Retention  of  urine  should,  of  cour.se,  be 
relieved,  but  the  utmost  gentleness  ought  to  be  employed  in  the  manipulation.  These 
cases  are,  as  a  rule,  very  hopeless. 

In  chronic  nephritic  the  result  of  local  disease  there  can  be  little  doubt  that  the  best 
practice  is  the  removal  of  the  cau.se.  When  a  stone  in  the  bladder  has  set  up  the  mis- 
chief, it  should  be  removed,  and  by  that  mode  which  induces  the  least  local  irritation. 
When  a  stricture  of  the  urethra  has  been  the  cause,  it  should  be  dilated,  for  as  long  as 
the  local  cause  of  the  disease  exists  no  recovery  can  be  looked  for.  When  calculus  in 
the  kidney  is  the  local  irritant,  the  surgeon's  aim  must  be  to  allay  local  irritation  by 
keeping  the  patient  quiet  and  administering  soothing  remedies,  the  alkaline  potash  salts 
being  prescribed  where  the  urine  indicates  uric-acid  calculus,  and  the  mineral  acids  when 
the  urine  is  phosphatic.  The  removal  of  the  .stone  by  operation  may  also  be  entertained. 
(Vide  •' Nephro-Lithotomy,"  p.  628.) 

When  suppuration  of  the  kidney  takes  place,  with  or  without  a  calculus,  and  any 
external  evidence  /jf  the  abscess  exists,  the  kidney  .should  be  cut  down  upon  by  a  lumbar 
incision,  the  abscess  freely  opened  and  drained  after  irrigation.  (  Vide  •■  Nephrotomy," 
p.  628.) 

When  the  urine  is  full  of  pus,  the  preparations  of  buchu  are  of  undoubted  value, 
and  the  mineral  acids  or  the  preparations  of  iron  of  use.  Warm  baths  and  diaphoretics, 
to  induce  free  action  of  the  skin,  and  by  these  means  to  relieve  the  kidney,  with  a  sup- 
ply of  simple  nutritious  food,  and  stimulants  only  when  absolutely  required,  make  up  the 
treatment. 

Perinephritis  is  an  affection  that  must  be  recognized,  and,  although  it  may  be 
more  frequently  found  in  connection  with  suppuration  of  the  kidney,  it  is  at  times  inde- 
pendent of  it.  It  is  indicated  by  a  sudden  pain  in  the  loin,  fever,  and  subsequently 
lumbar  sicdliuij^  with  frequently  cedema  of  the  integuments  of  the  loin.  The  pain  is  at 
times  constant  and  persistent,  while  at  others  it  may  appear  and  then  disappear  for  an 
uncertain  interval,  to  recur  spontaneously  in  all  its  severity.  The  urine  in  an  uncompli- 
cated case  is  generally  natural,  and  if  at  all  altered  scanty,  renal  symptoms,  so  called, 
being  absent.  When  the  case  is  left  to  nature,  the  inflammation  may  attack  the  chest 
and  induce  a  fatal  plem-i.sy.  or  the  abscess  may  burst  into  the  bowel  or  externally,  bur- 
rowing beneath  the  fascia  covering  the  psoas  muscle  and  .showing  itself  in  the  thigh  or 
pointing  to  the  loin.  The  surgeon  should  not.  however,  leave  these  cases  to  nature,  but 
cut  down  upon  the  abscess  or  lumbar  swelling,  as  in  colotomy,  at  the  outer  border  of  the 
quadratus  lumborum  muscle,  and  evacuate  the  pus  as  soon  as  sufficient  evidence  exists 
of  its  presence ;  from  this  treatment  a  good  result  may  be  looked  for.  (  Vide  paper  by 
Dr.  Bowditch,  Am.  Journ.  of  Med.  Science,  1871.) 

HEMATURIA 

is  a  symptom  met  with  in   many  diver.se  conditions,  the  hemorrhage  being  limited  or 
profuse.     It  may  come  from  one  or  both  the  kidneys  or  any  other  part  of  the  urinary 


ii.KM.\rri:i.\.  025 

passage,  eitli<>r  as  u  result  of  S(»iim»  coiistilutiDiuil  cause,  such  as  the  lieuiorrlia^ie  diatlie-' 
sis,  or  stuue  u»i»rl)i»l  coiulitiiin  of  tlu-  Mood,  as  in  jMirpura,  scurvy,  smallpox,  the  |ila;iue, 
or  fever.  It  uiay  likewise  he  parasitic.  Profuse  renal  h.-eiuaturia  takes  jdace  occasion- 
ally »«  all  intennittent  atVection.  It  may  likewise  follow  an  injury  or  ilisea.se  of  the 
kiilney,  ureter,  hladder,  prostate,  vas  deferens,  or  urethra.  In  surgical  jiractice  the 
hoinorrhaire  is  more  Jre(|Ucntly  due  to  sonu-  local  cause,  yet  the  practitioner  should  he 
alive  to  the  fact  that  it  may  orijrinate  from  a  constitutiomd  one  or  from  the  use  of  such 
druf^s  as  turpentiiu'  or  eantharides. 

|{kn.vI,  IlKMtiKKIlACiK. — If  the  InniorriiaLie  follow  an  aciidi  lit.  the  diagnosis  is  .sel- 
dom ditliciilt  ;  for  when,  after  an  injury  to  the  loin,  hlood  is  jiassed  mixed  with  tlie  urine, 
it  may  he  inferretl  that  the  kidney  has  heeii  injured  ;  and  when  slender,  cylindrical,  ]»ale 
pieces  of  tihrin  are  .seen  in  the  urine,  the  surj^eon  may  he  sure  that  they  come  from  the 
kidney,  these  clots  havintr  hceii  moulded  in  the  uret(!r  and  washed  down  from  the  kidney 
by  the  urine.  Blood  also,  wiicii  iiitiniately  mixed  with  tiie  urine,  has  jirohahiy  ii  renal 
origin. 

The  jiassajxe  of  a  stone  down  the  ureter  is  also  attended  hy  hemorrhajre.  whicdi  is  rarely 
profuse,  and  is,  moreover,  frenerally  aecomjianicd  hy  severe  colicky  pain  shooting  down  the 
groin  and  scrotum  of  the  affected  side,  with  a  retracted  testicle.  When  blood  comes  from 
a  diseased  kidney,  it  is  mixed  with  the  urine,  as  in  cases  of  accident,  and  may  be  slight  or 
profuse  in  <|uantity  ;  but  the  nature  of  the  affection  or  its  being  due  to  calculus  will  have 
to  be  determined  by  the  history  of  the  case,  the  existence  of  lumbar  pain  or  tenderness, 
and  a  close  examination  of  the  urine.  In  cancer  of  the  kidney  pain  rarely  extends  to  the 
testicle. 

Parasitic  HsBinaturia. — 'fhis  is  common  in  Egypt,  Syria,  and  at  the  Cape,  and  is 
now  known  to  be  due  to  the  presence  of  a  parasite  first  discovered  l>y  Bilharz  in  1851. 
Dr.  Zancarol  of  Alexandria  describes  it  as  "  Bilharzia  lucmatobia."  The  disea.se  is  found 
only  in  weakly  subjects  and  those  who  drink  foul  water  or  the  undistilled  water  of  the 
Nile.  Its  early  symptoms  are  the  appearance  of  blood  at  the  end  of  micturition,  its  pas- 
sage being  acc(jmpaiiied  and  followed  by  pain,  frequent  micturition,  and  ana?mia.  With 
the  parasite  there  is  cystitis,  whicli  will  go  on,  and  at  last  give  rise  to  dilated  ureters  and 
diseased  kidneys. 

Dr.  Zancarol  ascribes  the  frequency  of  stone  in  the  bladder  in  Egypt  to  the  presence 
of  the  parasite. 

The  urine  of  patients  the  subjects  of  this  disease  contains  blood  and  mucus,  but  is  of 
norn^al  specific  gravity.  The  ova  of  the  parasite  itself  are  to  be  found  in  it  in  an  active 
condition  for  twenty-four  hours  after  it  has  been  pa.ssed.  They  are  ovoid  in  shape,  cili- 
ated, and  YT^  of  an  inch  in  diameter.  The  worm  itself  never  passes  with  the  urine.  It 
is  filiform  and  three  or  four  lines  in  length.  A  full  description  of  the  worm  may  be  found 
in  the   Trans,  of  the  Path.  Soc,  December  !),  1SS2. 

Little  can  be  said  about  treatment  beyond  that  Dr.  Wastobet  of  Beyrout,  Syria,  records 
(^Lancet.  December  i>,  1882)  a  case  cui'ed  by  one-drachm  doses  of  the  oil  of  turpentine  in 
milk  three  times  a  day  in  twenty-four  days. 

Vesical  or  prostatic  hemorrhage,  either  from  injury  or  disease,  chiefly  shows 
itself  as  blood  clots  mixed  with  the  urine,  the  former  passing  either  before  or  after  the 
latter.  The  blood  at  first  may  fill  the  bladder,  but  after  some  days  the  urine  will  only  be 
stained  with  blood.  When  the  clot  has  broken  up.  more  or  less  discolored  irregular  coag- 
ula  with  fimbriated  edges  will  pass  with  the  urine,  these  coagula  being  very  characteristic 
of  blood  clot.  They  may  pa.ss  ;>e/'  urethrani  as  rolled-up  masses,  but  when  floated  out  in 
water  will  present  their  natural  shape ;  blood  that  has  been  retained  within  the  bladder 
for  any  time  will  impart  to  the  urine  a  porter-like  aspect. 

AVhen  blood  flows  at  the  end  of  micturition  in  small  quantities,  squeezed  out.  as  it 
were,  by  the  bladder,  a  calculus  or  prostatic  disease  may  be  suspected  :  but  the  same  con- 
dition is  also  occasionally  met  with  in  the  irritable  bladder  of  goiiorrha'a  or  after  the  pa.s- 
sage  of  "gravel." 

When  a  cancer  of  the  bladder  or  prostate  or  a  villous  growth  exists,  pieces  of  broken-up 
tissue  may  be  detected  by  the  microscope  in  the  bloody  urine.  In  these  cases,  too.  the 
hsematuria  will   be  intermittent. 

Urethral  Hemorrhage. — When,  after  an  injury  to  the  periiKeum  or  pelvis  or  a 
sudden  muscular  strain,  pure  blood  flows  from  the  urethra  unmixed  with  urine,  urethral 
mischief  may  be  suspected. 

Urethral  hemorrhage  irrespective  of  injury,  may  proceed  from  a  chancre,  acute  gonor- 
rhoea, or  an  impacted  stone.     It  may  follow  over-exertion  or  the  straining  associated  with 

40 


626  DISEASES  OF  THE  KIDNEY.— STONE.— NEPHROTOMY. 

the  retention  of  urine  or  sexual  intercourse.  It  may  likewise  take  place  after  the  forcible 
bending  of  an  erect  penis  in  a  chordee  or  during  some  sudden  muscular  exertion  from  a 
rupture  of  the  vas  deferens,  as  pointed  out  by  Hilton,  and  in  rare  cases  it  may  occur  with- 
out any  known  cause,  the  blood  flowing  from  the  penis  unaccompanied  by  any  symptom 
of  disease.     I  have  recorded  two  such  cases  {Clin.  Sun/.,  Chapter  47). 

Urethral  hemorrhage  as  a  result  of  catheteri,sm  is  also  common,  and  it  may  be  caused 
by  the  introduction  of  some  foreign  body  into  the  urethra. 

It  should  also  be  remembered  that  bile  when  concentrated,  indigo,  or  other  rare  con- 
stituents of  the  urine,  from  diet  or  otherwise,  may  simulate  the  presence  of  blood,  as  may 
the  black  urine  which  results  from  the  external  or  internal  use  of  carbolic  acid  when 
ab.sorbed  in  poisonous  doses.  This  symptom,  however,  soon  disappears  on  the  omission 
of  the  remedy.  In  a  case  under  my  care  in  1871,  of  a  man  who  had  a  weak  sore  the  size 
■of  a  crown  piece,  which  had  been  dressed  with  an  oily  lotion  of  carbolic  acid  one  part  to 
forty,  the  black  urine  appeared  after  the  second  dres.sing  associated  with  brain  symptoms 
and  collapse  of  the  general  powers  which  I  thought  must  prove  fatal.  The  symptoms, 
however,  speedily  disappeared  on  withdrawing  the  drug,  and  a  recovery  ensued.  In  a 
case  under  my  care  five  years  ago  a  boy  xt.  9  was  unintentionally  kept  in  a  semicomatose 
state  for  two  months  by  the  application  of  a  lotion  of  carbolic  acid  (one  part  to  a  hundred) 
to  a  small  sore,  the  brain  recovering  its  healthy  condition  on  the  omission  of  the  lotion. 
The  poisonous  action  of  the  carbolic  acid  was  detected  through  the  urine,  which  was  occa- 
sionally black. 

Treatment. — The  disease  or  condition  that  gives  rise  to  the  blood  in  the  urine 
requires  treatment  more  than  the  .symptom  itself,  but  at  times  the  bleeding  is  so  pro- 
fuse as  to  threaten  life.  Renal  hemorrhage,  when  profuse,  may  be  checked  by  gallic  acid 
in  full  doses,  gr.  v  to  gr.  x,  three  times  a  day,  acetate  of  lead,  tincture  of  ergot,  or  maticO; 
opium  being  generally  a  valuable  addition,  and  in  extreme  cases  the  spirit  of  turpentine, 
absolute  rest  in  the  horizontal  po.sition,  and  cold  milk  diet  should  be  also  adopted. 

Hemorrhage  from  the  bladder,  when  persistent,  may  be  checked  by  the  application  of  a 
bag  of  ice  over  the  pubes  and  to  the  perinaeum,  by  cold  or  astringent  injections  into  the 
rectum,  with  rest  and  opium.  There  is  no  neces.sity  to  pass  a  catheter  or  to  interfere  with 
the  clot  so  long  as  the  urine  flows  and  retention  does  not  occur,  the  urine  at  the  natural 
temperature  of  the  body  being  a  good  blood  solvent.  A  clot  of  blood,  when  bathed  with 
urine,  as  a  rule,  disintegrates  in  the  course  of  a  few  days,  when  it  may  be  passed  without 
help.  Any  disturbance  of  the  clot  when  first  formed  will  probably  tend  rather  to  encour- 
age than  to  .stop  bleeding;  consequently,  no  unnecessary  catheterism  should  be  employed. 
When  retention  exists,  the  .symptoms  become  urgent,  and  opium  administered  either 
by  the  mouth  or,  what  is  preferable,  by  the  rectum  fails  to  give  relief,  the  passage  of  a 

lartre-sized  catheter  and  the   use 
Fig.  357.  of  an  exhau.sting  syringe,  such  as 

Clover  invented  for  use  after  lith- 
otrity  (Fig.  357),  or  the  aspirator 
may  be  called  for ;  yet  these  meas- 
ures should  be  employed  only 
when  an  absolute  necessity  exists 
and  opium  in  full  doses  fails  ta 
give  relief. 
Clover's  Syringe,  as  Improved  bv  Maunder.  Urethral    hemorrhage    rarely 

continues  for  any  time  or  requires 
for  its  treatment  more  than  rest  in  the  horizontal  posture,  unless  caused  by  some  lacera- 
tion of  the  urethra  or  more  severe  injury. 

Suppression  op  Urine 

is  the  result  of  renal  disease,  from  which,  the  kidneys  ceasing  to  fulfil  their  functions,  the 
constituents  of  the  urine  are  left  in  the  blood  and  give  rise  to  coma,  and  pos,sibly  to  con- 
vulsions and  death.  Urtemia  or  uraemic  poisoning  is  then  said  to  be  the  cause  of  death. 
It  may  occur  at  any  stage  of  kidney  disea.se,  and  not  uncommonly  follows  an  operation 
performed  on  a  patient  the  subject  of  such  an  affection  ;  it  is  a  result  to  be  taken  into  cal- 
culation before  undertaking  any  operation  where  albuminous  urine  exists. 

In  exceptional  cases,  however,  suppression  of  urine  occurs  when  no  such  chronic  mis- 
chief can  be  detected,  coming  on  suddenly,  as  it  often  does,  without  cau.se,  and  leaving  as 
suddenly  without  any  reason.     I  once  saw  a  musician  who  secreted  no  urine  for  sixty 


SToxr:  r\  riii:  Kiitsi'V.  c,27 

hours,  and  tlicii  jiassotl  what  sofiucil  to  ho  a  natural  <juaiitity  ;  liis  only  other  syiiijttom.s 
wort'  those  of  slijrht  levcrishiicss  aiul  heailathc.  In  sucli  cases  the  hot-air,  vapor,  or 
warm   liath   is  tho   best   remedy. 

Stone  in  the  Kidney 

is  not  an  iinconiinon  artVotii>M.  and  is  irenerally  painful  and  often  fatal.  At  times,  how- 
ever, lar<:e  stones  arc-  found  in  tlie  kidney  after  death  which  gave  no  .si<.'ns  of  their  exist- 
ence durini;  life.  When  the  stone  hecnnies  impacted  in  the  oriran  and  ceases  to  be  mov- 
able, it  does  not  trive  rise  to  any  marki-d  symptoms,  and,  comparatively  speakinir,  ceases 
to  interfere  with  life;  more  fre»|uently.  however,  it  often  excites  much  local  irritation,  if 
not  suppuration,  and  usually  kills  by  destntyinir  the  kidney  by  convertintr  it  into  a  sup- 
puratiiiLT  cyst.  Small  stones  are  constantly  formed  in  the  kidney  and  passed  throu<rh  the 
ureter  into  the  bladder.  Large  st<»nes  may  so  increase  as  to  form  a  cast  of  the  pelvis  of 
the  kidney  (Fig.  •i78i.  and  at  times  attain  enormous  dimensions. 

The  SYMPTo.Ms  of  stone  in  the  kidney  are  a  tendency  to  rigor,  lumbar  pain,  increased 
by  riding  or  any  jolting  of  the  body,  the  pain  passing  dttwn  the  groin  into  the  testicle  of 
the  affected  side  and  causing  its  retraction,  irritable  bladder,  and  blood  in  the  urine.  Irri- 
tabilitv  of  the  bladder  may  be  the  uu\\  symptom  of  renal  disease.  When  the  stone  enters 
the  ureter,  the  inguinal  and  testicular  pain  becomes  increased  and  a  colicky  pain  appears, 
attended  often  with  sickness,  and  even  collapse,  the  bladder  becoming  more  irritable  and 
the  urine  more  bloody.  When  the  stone  passes,  all  these  symptoms  suddeid}'  cease,  the 
bladder  irritation  probably  alone  remaining.  As  time  goes  on  and  the  local  irritation 
becomes  worse  some  suppuration  in  the  kidney  may  occur.  As  long  as  the  ureter  remains 
open  and  pus  makes  its  escape  into  the  bladder  the  symptoms  are  not  urgent;  but  .should 
the  ureter  become  closed  by  the  stone  or  some  inflammatory  change,  the  pus  will  collect 
and  give  rise  to  lumbar  renal  abscess.  At  times  this  lumbar  swelling  may  be  felt ;  indeed, 
in  thin  subjects,  with  one  hand  in  the  lumbar  and  the  other  in  the  hypochondriac  region, 
a  calculus  may  by  palpation  even  be  made  out  in  the  kidney ;  this  examination  will  be 
made  occasionally  with  advantage  when  the  patient  is  under  an  anaesthetic.  The  lumbar 
swelling  may  so  increase  as  to  form  a  large  cystic  abdominal  tumor.  When  the  ureter  is 
obstructed,  this  result  will  take  place  more  rapidly  than  when  it  is  open,  from  the  accu- 
mulation of  pus ;  but  when  it  is  open,  the  pus  flows  into  tlie  bladder  and  passes  with  the 
urine  as  turbid  urine.  When  allowed  to  .settle  in  a  porringer  or  glass,  its  presence  will  be 
readily  detected.  Pus  poured  into  the  bladder  from  the  kidney  or  elsewhere  is  mixed 
with  but  little  mucus,  but  when  formed  in  the  bladder  is  mixed  with  much.  Pus  and 
mucus  secreted  from  the  bladder  is  constant  in  the  urine ;  when  from  the  kidney,  it  may 
be  intermittent.  Dr.  Owen  Rees  has  pointed  out  the  value  of  the  tincture  of  galls  added 
guttatim  to  the  urine  of  patients  who  may  be  suspected  to  be  suffering  from  renal  cal- 
culus, this  tincture  producing  an  immediate  flocculent  precipitate  of  a  light-brown  color 
when  any  of  the  extractive  matters  of  the  blood  are  present  (Bi-it.  Med.  Joitrn.,  October 
21,  1876.  p.  518).  He  also  asserted  that  a  heavy  and  continued  pain  over  the  sacrum 
may  be  the  only  prominent  clinical  symptom  of  this  affection. 

Treatme.nt. — When  a  stone  has  formed  in  the  kidney,  the  happiest  result  is  its  pas- 
sage into  the  bladder;  which  end  can  be  facilitated  by  the  administration  of  diluents, 
particularly  water,  as  well  as  alkaline  preparations  of  potash,  such  as  the  citrate,  tartrate, 
or  bicarbonate.  When  strong  evidence  exists  of  local  irritation,  opium  or  henbane, 
given  by  either  the  mouth  or  the  rectum,  is  a  valuable  drug;  while  a  subcutaneous  injec- 
tion of  morphia  over  the  affected  kidney  at  times  acts  most  beneficially.  Fomentations 
about  the  loin  and  groin  or  the  warm  bath  also  give  much  relief. 

When  the  stone  is  passing  down  the  ureter,  the  same  practice  is  to  be  followed,  a 
warm  bath  and  a  full  dose  of  opium  often  relaxing  the  parts  and  favoring  the  passage  of 
the  stone.  The  administration  of  an  anjesthetic  by  inhalation  may,  when  the  pain  is 
severe,  under  these  circumstances,  also  be  tried.  In  a  case  I  was  called  upon  to  see, 
where  extreme  agony  existed,  instantaneous  and  permanent  relief  followed  the  practice, 
the  stone  having  passed  during  the  inhalation  of  the  chloroform. 

When  the  stone  has  become  impacted  in  the  kidney  and  gives  rise  to  periodical 
attacks  of  pain  and  constant  unea-siness.  each  attack  being  worse  than  the  last,  important 
questions  occur  to  the  surgeon  :  Is  it  to  be  allowed  to  remain,  where  it  may  in  all  prob- 
ability set  up  irremediable  disease  if  not  destruction  of  the  kidney  ?  or  is  an  attempt  to 
be  made  to  remove  it  by  surgical  operation  ?  The  answer  at  the  present  day  is  very 
decided :  The  surfreon  should  remove  the  stone. 


628  DISEASES  OF  THE  KIDNEY.— STONE.— NEPHROTOMY. 

RENAL  SURGERY. 

This  branch  of  surgery  has  reached  a  definite  position  ;  and  if  it  rises  in  value  as  it 
has  risen  in  interest,  a  wide  surgical  field  has  indeed  been  opened.  It  is  to  Simon  of 
Heidelberg  that  we  are  indebted  for  its  birth,  in  that  he  in  ISGU  first  designedly  reiuoved 
a  kidney  with  success.  He  did  so  for  a  urinary  fistula  of  the  ureter  which  had  resulted 
from  an  ovariotomy. 

Since  then,  writes  Clement  Lucas  in  an  able  article  (^British  Med.  Journ..  September 
29.  1883),  '•nephrectomy  (removal  of  the  kidney)  has  been  performed  upward  of  a  hun- 
dred times.  Kejjhrotomy,  or  incision  and  drainage  of  the  kidney,  has  become  a  much 
more  frequent  operation,  and  renal  lithotomy,  }iephro-Ut]iotomy,  has  been  successfully 
extended  to  cases  where  no  tumor  or  sinuses  exist ;"  and  the  credit  of  this  last  triumph 
must  be  given  to  my  friend  3Ir.  Henrv  ^lorris.  (See  Trans.  Clinical  Society,  vol.  xiv. 
p.  30,  1881.) 

A  fourth  operation,  named  neplirorrapliy .  must  also  be  mentioned — an  operation  first 
performed  by  E.  Hahn  of  Berlin  (  Centralblatf  fiir  Chirurgie.  July,  1881) — which  consists 
in  cutting  down  upon  and  exposing  a  movable  or  floating  kidney  and  stitching  it  to  the 
edges  of  the  parietes  of  the  lumbar  wound. 

Last,  but  not  \e?L?,t.  jiaracentesis  of  the  kidney  claims  a  notice. 

Upon  each  and  all  of  these  surgical  proceedings  a  few  observations  will  be  made. 

Paracentesis  of  the  KroNEY. 

This  operation  is  valuable  for  diagnostic  as  well  as  for  curative  purposes,  and  it  may 
be  performed,  either  by  way  of  aspiration  or  by  means  of  a  trocar,  in  cases  in  which  it 
is  well  to  be  assured  of  the  presence  or  absence  of  fluid  in  any  given  dull  lumbar 
swelling. 

In  hvdronephrosis,  or  dropsy  of  the  kidney,  brought  about  by  the  retention  of  urine 
in  the  pelvis  of  the  kidney  from  obstruction  of  the  ureter,  in  those  rare  examples  of  iso- 
lated serous  or  blood  cysts  of  the  kidney,  and  hydatid  cysts,  this  operation  is  particularly 
valuable. 

For  the  diagnosis  of  pyonephrosis  it  is  equally  of  use.  and  even  where  the  tumor  may 
turn  out  to  be  of  a  solid  nature  a  fine  aspirating  needle  is  not  likely  to  be  followed  by  harm. 

The  best  position  for  tapping  the  right  kidney  "  is  one  halfway  between  the  last  rib 
and  the  crest  of  the  ilium,  between  two  and  two  and  a  half  inches  behind  the  anterior 
superior  spine  of  the  ilium"  (Morris,  Med.-Chir.  Trans.,  vol.  lix.  p.  242),  and  for  the  left, 
according  to  Mr.  .J.  Thomson  of  Nottingham,  '-the  interval  between  the  last  two  ribs 
near  their  anterior  extremities"  (^Patli.  Soc.   Trans.,  vol.  xiii.). 

Nephrotomy,  or  an  incision  into  the  pelvis  or  substance  of  the  kidney,  is  called 
for  in  cases  of  abscess  of  the  organ,  whether  from  stone  or  from  tubercle,  or  of  pyone- 
phrosis from  whatever  cause,  and  for  hydronephrosis  and  hydatid  when  the  .simple  opera- 
tion of  paracentesis  has  failed  to  bring  about  a  cure.  It  essentially  consists  of  exposing, 
opening,  irrigating,  and  draining  the  abscess  cavity  in  the  same  way  as  any  other  abscess 
cavity  should  be  treated. 

I  have  followed  this  in  practice  on  many  occasions,  having  in  a  man  cut  down  upon  a 
suppurating  kidney  and  evacuated  several  ounces  of  pus  with  marked  benefit,  and  in 
another  opened  and  drained  a  large  suppurating  renal  cyst  through  the  left  loin. 

On  August  31,  1876,  I  likewise  cut  down  upon  the  right  loin  of  a  lady  a?t.  27  whom 
I  saw  in  consultation  with  Dr.  Moore  and  Mr.  Pocock  of  Brighton,  with  a  swelling  which 
we  diagnosed  as  renal,  and  evacuated  three  pints  of  fetid  pus.  the  lady  making  a  good 
recovery.  In  1877  I  cut  into  the  left  loin  of  a  woman  with  a  lumbar  swelling  and  let 
out  a  quart  of  pus  with  marked  benefit,  my  finger  readily  passing  into  the  dilated  pelvis 
of  the  kidney,  and  in  1883  I  opened  the  right  kidney  of  a  man  which  twelve  years  before 
had  been  seriously  injured,  and  evacuated  eighty-six  ounces  of  fetid  pus.  subsequently 
irrigating  with  iodine  water  and  syringing  the  cavity.      He  was  well  in  three  months. 

The  operation  in  its  several  steps  should  be  the  same  as  that  described  for  lumbar 
colotomy,  the  kidney  being  readily  reached  and  dealt  with  through  such  an  incision  as 
was  there  indicated.- 

NephrO-lithotomy,  writes  Henr}'  Morris,  who  was  the  first  surgeon  who  design- 
edly cut  down  upon  a  kidney  to  remove  a  stone  (see  C'h'ji.  Soc.  Trim.'i..  vol.  xiv.  p.  30, 
1881  j,  ''  should  unhesitatingly  be  done  in  all  cases  in  which  .symptoms  of  renal  calculus 
continue  uninfluenced  by  medical  treatment  and  are  sufficiently  severe  to  interfere  mate- 


I'AiiAChWTh'sis  or  Till:  KinsEY.  029 

riiilly  with  tlic  (•(Hiifort  and  usoi'iiliicss  ol"  the  |i!iticiit'.s  lii'c  If  for  scvcnil  numtlis  a  jicrMon 
has  Itccii  siiliji'ct  t(»  iiiKrc  <tr  less  cdnstaiit  |iairi  in  one  loin  and  alon^'  the  ureter,  and  \n'.r 
haps,  also,  in  the  tcsticU'  of"  thu  sanu-  side,  it"  then;  have  hcen  rcicnrrinjr  attacks  oi"  rnial 
colic,  and  csjicciaUv  it  with  tlicsi-  symptoms  there  is  occasional  li:i>matiiria  (»r  the  urine  is 
constantly  char'red  with  a  little  pus  or  albumen,  wc  have  the  conditions  not  only  justify- 
ing, hut  demandini;-.  an  explorati<ui.  It",  in  addition  to  these  symptoms,  a  small  calculus 
or  a  little  ealeulous  matter  has  heen  j)asscd  y>''/"  /*/V7/;/v»///,  there  is  almost  absolute  cer- 
tainty of  the  presence  ot"  a  stoiu'  ;  at  the  same  time,  it  uiust  be  recognized  that  symptom!- 
stronirlv  suggestive  of  renal  ealculus  arise  trom  other  causes  than  stone.  " 

()l'KUATl(»N. — I  give  this  in  the  words  of  Mr.  .Morris:  ''An  incision  is  made  four  and 
a  half  inches  in  length  parallel  with,  and  three-<|uarters  of  an  iiudi  below,  the  last  rib. 
The  structures  divided  are  the  sanu'  as  in  ne]ilMotoniy.  If  the  r|Ua<lratus  lumborum  be 
so  wide  as  to  contract  the  d«'ep  jtart  of  the  wound,  its  outer  edge  nuiy  be  incised  to  the 
extent  ot"  half  iw  three-<|uarters  of  an  incli.  All  bleeding  ves.sels  having  been  twi.sted 
and  hemorrhage  (piite  stayed,  the  assistant  should  stretch  the  edges  of  the  wound  widely 
apart  by  suitable  retractors,  and  the  ojierator,  with  two  jiairs  of  dissecting  forceps,  tears 
through  the  perirenal  fat.  As  he  approaches  the  back  of  the  kidney  there  will  be  some- 
times noticed  a  difference  in  the  character  of  this  fat,  that  immediately  in  contact  with 
the  kidney  being  finer  in  te.xture  and  of  a  delicate  primrose  color.  If,  from  the  presence 
of  the  stone,  there  has  been  inflammation  in  the  tissues  around  the  kidney,  thi.s  appear- 
ance will  not  be  expected,  and  the  whole  of  the  tissue  will  probably  be  dense  and  tough. 

'•  When  the  kidney  has  been  fairly  reached,  the  index  finger  should  be  passed  care- 
fully over  the  whole  of  the  posterior  surface  of  the  organ,  including  its  pelvis,  and  any 
inequality  of  surface  or  increased  hardness  or  resistance  at  any  particular  spot  should  be 
searched  for.  During  this  tactile  exploration — indeed,  throughout  the  whole  of  the 
examination  of  the  kidney — the  abdominal  walls  of  the  patient  should  be  well  supported 
by  an  assistant  or  well-arranged  pillows,  so  that  the  kidney  should  not  be  pushed  forward 
by  the  exploring  finger.  If  nothing  suggestive  of  the  presence  of  a  .stone  is  thus  felt, 
the  kidney  .should  be  freely  exposed  to  view  by  drawing  aside  the  edges  of  the  wound, 
and  a  fine  needle  .should  be  passed  into  the  renal  substance.  This  should  be  done  in  a 
systematic  way  and  in  several  places,  if  the  stone  be  not  at  once  struck,  introducing  the 
needle  here  and  there,  so  as  to  puncture  in  succession  the  several  calyces  of  the  kidney, 
in  one  or  other  of  which  experience  tells  us  the  stone  usually  rests.  If  in  the  course  of 
the  digital  exploration  some  one  .spot  gives  more  re,si.stanee  than  the  rest,  this  should  be 
first  punctured,  but  otherwise  the  puncturing  should  be  done  in  a  well-planned  manner. 
On  this  point  I  would  lay  great  stress,  as  it  is  quite  possible  to  puncture  in  a  dozen  places 
and  yet  to  miss  the  calculus. 

"  If  by  this  means  the  calculus  is  not  detected,  the  search  should  not  be  given  up 
until  the  fingers  of  the  right  hand  are  passed  round  the  outer  edge  of  the  kidney,  and 
the  front  surface  t"elt  over  in  the  same  way  as  the  posterior.  Whilst  doing  this,  in  order 
to  give  counter-resistance  to  the  exploring  finger,  the  kidney  may  be  pressed  against  the 
psoas  muscle  or  be  squeezed  between  the  finger  and  thumb.  Despite  all  these  means,  a 
calculus  may  escape  detection.  I  have  recently  removed  by  lumbar  nephrectomy  a  healthy 
kidney  for  a  calculus  the  size  of  a  marble  imbedded  in  it,  but  which  I  could  not  localize. 
The  man  recovered  well,  but  the  loss  of  a  good  kidney  is  a  very  regrettable  feature  in 
the  case.  The  kidney  becomes  very  hard  and  tough  under  the  prolonged  irritation  of  a 
stone,  so  that,  whilst  the  whole  organ  feels  firmer  than  natural,  any  slight  difference  in 
the  degree  of  resistance  of  one  part  is  more  difficult  to  appreciate.  This  hardness  of  the 
renal  substance  should  make  the  surgeon  very  sus]»icious  of  a  calculus,  and  future  experi- 
ence will.  I  think,  encourage  him,  when  this  condition  is  present,  not  to  be  satisfied  either 
that  no  stone  exists  or  that  nephrectomy  must  be  performed  until  he  has  made  such  an 
incision  into  the  kidney  as  will  open  each  of  the  calyces.  Kidney  wounds  are  known  to 
heal  readily,  aiul,  whiLst  the  risk  of  such  an  incision  would  not  ecjual  that  of  nephrec- 
tomy, the  subsequent  condition  of  the  kidney  would  be  preferable  to  the  possession  of 
oidy  one  of  these  organs. 

••  Having  detected  the  stone  by  one  or  other  of  the  methods  above  described,  the  over- 
lying parts  of  the  kidney  should  be  cut  into  with  a  probe-ended  straight  bistoury,  and 
then  with  a  scooping  movement  of  the  finger,  introduced  through  the  incision,  the  stone, 
unless  a  branched  or  very  large  one,  can  be  raised  to  the  surface  of  the  parietal  wound 
on  the  point  of  the  finger ;  or  a  pair  of  forceps  might  be  passed  into  the  kidney  by  the 
side  of  the  knife  and  the  stone  seized  and  withdrawn.  The  finger  is,  however,  much  to 
be  preferred  ;   and  if  the  incision  is  small,  as  it  ought  to  be.  the  finger  serves  the  purpose 


630  DISEASES   OF  THE  KIDSEY.— STONE.— XEPHREVTOMY. 

of  plugging  the  reiuil  woiiiul,  whilst  it  hicerates  tlie  renal  tissue  to  the  necessary  extent. 
By  this  plan  the  hemorrliage  is  minimized,  and  the  rent  made  with  the  finger  heals  as 
readily  as  the  cut.  When  equally  convenient  to  reach  the  stone,  it  is  much  best  to  opet 
the  secreting  structure,  and  not  the  pelvis,  of  the  kidney.  The  wound  in  the  former 
heals  better  than  in  the  latter,  and  the  chance  of  a  urinary  fistula  is  much  less.  If  the  cal- 
culus be  large  and  branched,  it  may  possibly  be  requisite  to  break  it  up  into  two  or  more 
fragments  and  remove  the  fragments  separately.  I  have  known  this  done  in  a  suppurat- 
ing kidney,  but  it  is  not  probable  that  a  stone  will  attain  such  a  size  as  to  require  break- 
ing before  removal  without  having  in  its  growth  more  or  less  destroyed  the  kidney 
structure.  A  stone  one  ounce  in  weight  has  been  removed  entire  from  a  kidney  not 
markedly  enlarged  nor  the  seat  of  advanced  suppuration  (Bennett  May,  Clhi.  Soc.  IVans., 
1883). 

AFTER-TREATMENT. — The  after-treatment  is  very  simple :  a  drainage-tube  should  be 
left  in  the  back  part  of  the  wound,  and  the  rest  should  be  closed  by  sutures.  For  a  time, 
of  course,  the  whole  or  greater  part  of  the  urine  secreted  by  the  injured  kidney  Avill  be 
discharged  through  the  loin,  but  after  gradually  diminishing  this  may  be  expected  to 
cease  altogether  in  from  three  to  four  weeks. 

''  These  loin  wounds  usually  heal  very  quickly.  In  nephrotomy,  as  in  nephro-lithoto- 
my,  some  simple  dressing,  such  as  lint  soaked  in  terebene  and  oil  or  spread  with  boraeie 
ointment,  should  be  applied  over  the  wound,  and  the  drainage  tube  should  pass  through 
this  and  be  covered  with  a  thick  pad  of  absorbent  cotton-wool,  iodoform,  or  Lister's  gauze, 
retained  in  place  by  a  light  bandage.  The  dressings  will  require  frequent  changing,  as 
they  soon  become  saturated  with  the  urine.  To  keep  the  bedding  dry,  a  large  pad  of 
finely-powdered  German  moss  peat  should  be  placed  beneath  the  loin  to  receive  and  absorb 
the  urine,  Avhich  it  readily  does. 

Dangers  of  Operation. — The  dangers  of  nephro-lithotomy  are  not  great,  so  far 
as  we  can  judge  from  present  experience.  The  operation  hitherto  has,  it  appears,  been 
uniformly  successful,  but  the  number  of  cases  as  yet  recorded  is  but  few.  1.  Jleinorihar/e 
from  the  wounded  kidney  is  not  likely  to  be  serious  if  the  plan  suggested  above  be  fol- 
lowed. There  may,  perhaps,  be  a  formidable-looking  gush  on  fir.st  dividing  the  tissue, 
as  in  Mr.  Beck's  case,  but  compression  with  the  finger  or  a  sponge  will  soon  check  it. 
2.  Cellulitis  may  follow  the  operation,  but  with  due  jirecaution  as  to  antiseptic  cleanliness 
and  drainage  this  will  almost  certainly  be  escaped.  It  may,  however,  occur,  and  I  am 
aware  of  one  case  in  which  extensive  suppurative  cellulitis  followed  an  exploratory  incis- 
ion in  search  of  a  renal  calculus  ;  pus  burrowed  downward  to  the  pelvis  and  upward 
until  the  abscess  burst  into  the  lung,  and,  though  the  patient  ultimately  recovered,  he 
nearly  lost  his  life.  3.  Roial  abxcess  might  possibly  follow  the  operation  as  the  result  of 
wounding  an  organ  already  long  irritated  by  the  presence  of  a  calculus.  I  do  not  know 
of  its  having  occurred,  and  it  is  much  more  probable  that  any  morbid  change  started  by 
the  calculus  would  be  checked  and  repaired  by  the  removal  of  the  cause — a  result  which 
is  pi'overbially  known  to  occur  in  other  tissues  of  the  body.  4.  A  renal  fistula  or  a  mere 
superficial  purulent  fi.stula  may  follow ;  but,  though  the  chances  are  against  it,  such  a 
result  would  be  a  welcome  substitute  for  the  ceaseless  pain  and  chronic  invalidism  of  the 
condition  which  it  replaces. 

Nephrectomy. — This  operation  has  been  successfully  performed  at  intervals  for 
years — in  some  cases  on  account  of  injury  and  in  others  b}'  mistake,  renal  tumors  having 
been  removed  as  ovarian  ;  but  Simon  of  Heidelberg  was  the  first  surgeon  who  design- 
edly performed  it,  and  with  success,  by  the  lumbar  operation. 

Dr.  Brant  of  Klausenburg  on  June  7,  1872,  removed  the  left  kidney  of  a  man  a?t.  27, 
which  had  escaped  from  the  loin  through  an  opening  caused  by  a  stab  four  days  before. 
He  tied  its  pedicle  in  two  portions  with  a  silken  ligature,  and  recovery  took  place  without 
a  bad  symptom  (  Wirner  Med.  Hoc//.,  November  29,  1873). 

On  December  2,  1873,  Dr.  A.  Cam])bell  of  Dundee  removed  the  kidney  that  was  the 
subject  of  cystic  disease  through  an  abdominal  incision,  having  mistaken  it  for  an  ovarian 
tumor,  and  the  patient,  who  was  a  Avidow  ost.  49,  made  a  good  recovery.  The  pedicle  was 
ligatured  with  carbolized  catgut  (Edin.  Med.  Jouni.,  July,  1874). 

Nephrectomij  may  be  performed  by  an  abdominal  or  lumhnr  incision,  and  there  can  be 
no  question  that  the  latter  is  the  right  one  to  select  in  all  ca.ses  in  which  the  kidney  is 
small  and  yet  sufficiently  diseased  to  justify  its  removal. 

The  abdominal  incision  should  be  reserved  for  large  tumors  which  cannot  be  taken 
away  by  the  lumbar. 

Lumbar  ntphrectuiny  is  at  all  times  a  serious  operation,  and  is  only  to  be  undertaken 


j'AJi.\cj:\Tj:sfs  OF  riir:  kidshy.  G."il 

after  inature  corisidonitinii.  "  It  is  mily  pennissiKh',"  .says  Siiiioii,  'Mvlien  a  patient's  life 
is  sfrimisly  tliivateiuMl  hy  tliseasi-  ami  all  Dtlicr  rciiicdirs  have  failed."  It  should,  Iidw- 
evor,  he  entertained  when  one  oriran  is  seriously  disorj:ani/ed  fnjui  ealeiiltis  or  other 
cau.se.s,  and  when  the  minor  operation  of  nephrotomy  has  failt'd  or  seem.s  inapplicable; 
when  the  ovfjau  is  the  seat  of  a  tumor  otherwise  incurahle  or  the  subject  of  urethral 
urinary  fistula  sericmsly  interfering  with  life  s  duties.  It  .seems  likewise  applicable  to 
certain  examples  of  ruptured  or  wounded  kidney  in  which  nature  cannot  be  expected  to 
briuLT  alioiit  or  has  faili'd  to  secure  repair. 

It  should  never  be  undertaken  uidess  evidence  exists  as  to  tin-  probaliilifv  of  the 
other  kidney  being  healthy,  as  evinced  by  the  normal  condition  of  the  urine  as  to  i|uan- 
tity  and  t|uality,  and  the  absence  of  albumen  over  and  alxne  what  can  be  explaine<l  by 
tile  presence  of  pus  due  to  the  disease  of  the  atleeted  organ. 

It  does  not  ajij)ear  to  be  ap])licable  to  disorganization  oi'  the  kiilnev  from  tuberculous 
disease,  such  an  aflection  being  usually  double. 

The  operation  itself  should  be  made  much  upon  the  same  lines  as  that  of  nepliro- 
lithot(»my. 

Should  more  room  be  rojuired  in  the  incision,  it  can  be  gained  by  a  vertical  cut  made 
at  right  angles  to  the  spinal  end  of  the  wound,  thi.s  incLsion  not  only  facilitating  the 
removal  of  the  kidney  and  the  application  of  ligatures  to  its  pedicle,  but  being  very 
favorable  for  drainage. 

The  kidney  should  be  enucleated  by  the  finger,  and  this  is,  as  a  rule,  readily  eflfected. 
Where  difficulty  is  felt  the  capsule  may  be  left. 

The  pedicle  should  be  secured  ])y  means  of  a  double  ligature  of  silk  passed  on  a  long 
and  strong  aneurism  uecdle,  and  it  is  well  to  tie  the  ureter  and  vessels  separately.  The 
kidney  should  next  be  well  dragged  out  of  the  wound,  and  to  facilitate  tliis  the  lower 
ribs  should  be  forcibly  drawn  upward.  If  the  ligatures  do  not  appear  to  he  .securely 
tied,  a  second  one  should  be  put  on  ;  before  the  kidney  is  separated  the  pedicle  should  be 
cut  through  with  scissors. 

All  bleeding  points  should  at  once  be  .seized  as  they  present  themselves  and  secured 
either  by  ligature  or  forceps.  All  the  ligatures  should  be  cut  short.  Any  wound  of  the 
peritoneum  should  be  sutured.  The  wound  should  then  be  treated  as  any  other  deep 
wound — that  is,  well  washed  out  with  iodine  water  and  drained.  Enough  sutures  should 
be  introduced  into  the  wound  to  keep  the  parts  together,  but  a  free  outlet  should  be  left. 
A  large  pad  of  ab.sorbent  cotton  and  gauze  may  then  be  adjusted  over  the  loin,  to  absorb 
discharge,  and  the  patient  left  alone  for  natures  reparative  powers  to  bring  about  a  cure. 
The  simplest  food  is  the  best ;  the  nearer  a  milk  diet  can  be  maintained,  the  better.  Con- 
valescence has  been  generally  secured  in  about  four  weeks. 

Abdominal  ncp/iircfoin//  is  to  be  entertained  only  when  the  lumbar  is  ina])plicable  ; 
and  had  I  to  do  it,  I  should  use  the  incision  which  approaches  that  illustrated  in  Fig, 
UiO,  the  upper  enil  of  the  incision  being  made  to  pass  more  obli(|uely  below  the  last  rib. 
Langenbuch  of  Berlin  makes  his  along  the  outer  border  of  the  rectus  abdominis,  the  mid- 
point of  the  incision  corresponding  to  the  umbilicus. 

All  the  details  of  the  operation  are  to' be  conducted  with  all  the  care  observed  in  an 
ovariotomy. 

The  statistics  of  the  operation  up  to  the  present  are : 

Out  of  90  cases  well  reported,  54  recovered  and  42  died.  Of  these,  46  were  made  by 
the  abdominal  incision,  of  which  half  died ;  whereas  of  the  50  made  by  the  lumbar,  31 
recovered  and  19  died.  The  result  of  the  operation  seems,  however,  to  turn  nujre  upon 
the  disease  denumding  it.  Thus,  of  IS  ca,ses  for  cancer,  9  died  ;  of  10  ca.ses  for  floating 
kidney.  0  died  ;  of  7  for  urethral  fistula,  all  lumbar,  0  recovered,  1  died. 

Nephrorraphy  is  an  operation  undertaken  for  the  relief  and  fixation  of  a  kidney 
which  is  freely  mnn/h/r  behind  the  peritoneum.  It  is  clearly  inapplicable  to  such  rare 
cases  as  are  found  to  possess  a  mesonephron  and  are  Jf'xitin;/  kidneys.  It  should,  how- 
ever, be  undertaken  only  in  exceptional  cases.  It  consists  in  a  lumbar  incision  as  for 
nephrotomy,  after  the  exposure  of  the  kidney,  which  is  greatly  aided  by  an  assistant 
pressing  it  well  to  the  wound  from  the  abdomen  ;  the  ca])sule  and  cortex  should  be  firmly 
stitched  by  six  or  more  sutures  to  the  margins  of  the  lumbar  wound,  the  wound  sub.se- 
t|uently  being  left  to  granulate.  The  operation  was  first  performed  by  Hahn  of  Berlin 
in  1881,  and  it  has  been  repeated  by  Langenbuch,  Martin.  Kiister,  Esmarch.  Weir.  JN'ew- 
man,  and  others  with  sufficient  success  to  justify  its  adoption  in  such  exceptionally  trou- 
blesome and  painful  cases  of  the  aflection  as  are  occasionally  met  with. 

The  OPERATION,  up  to  the  exposure  of  the  kidney,  is  the  same  as  that  of  nephrotomy, 


632  DISEASES  OF  THE  BLADDER  AND  PROSTATE. 

and  later  on  consists  in  the  application  of  strong  catgut  sutures  between  the  renai  capsule 
and  the  margins  of  the  lumbar  wound.  The  kidney  by  this  process  is  stitched  back  to 
the  loin,  where  it  becomes  ultimately  fixed.  The  wound  after  this  should  be  dressed  so 
as  to  heal  by  granulation.  The  operation  of  nephrectomy  for  this  affection  is  hardly 
justifiable. 

For  papers  on  this  subject  refer  to  Thomas  Smith's,  Mecl.-Chir.  Trans,  for  1869 ;  to  Lucas's, 
British  Med.  Journal.  September  29,  188-3  ;  to  Hexry  Morris's,  Aahhurst's  Iniernatwnal  EncyclopcBd. 
of  Surgery,  vol.  v.;  CzERXY  of  Heidelberg,  Tram.  Internat.  Med.  Conrjress,  1881,  vol.  ii.,  p.  249;  BAR- 
KER, Trans,  of  Med.-Cfiir.  Soc,  vols.  Ixiii.  and  Ixiv. ;  Hahx,  Centralhlattfur  Chirurgie,  July  23,  1881  ; 
American  Journal  of  Med.  Science,  January,  1873,  July,  1874,  also  paper  by  Harris,  1882;  David 
Newman,  M.  B.,  Glasgow  Med.  Journal,  August,  1883;  Dr.  Weir,  Xew  York  Med.  Gazette,  1884. 


CHAPTER    XXI. 

DISEASES   OF   THE   BLADDER   AND   PROSTATE. 

Irritable  Bladder. 

Almost  every  disease  of  the  urinary  organs  from  the  kidney  downward  manifests  its 
presence  by  some  bladder  symptom,  and  that  symptom  is  usually  what  is  called  an  irri- 
table bkidder — that  is,  the  patient  passes  urine  more  frequently  than  natural,  with  or 
without  pain. 

Such  a  .symptom  may  indicate  some  slight  deviation  from  the  healthy  relations  that 
ought  normally  to  exist  between  the  bladder  and  its  contents,  or  the  presence  of  a  severe 
if  not  fatal  organic  disease.  It  may  be  a  result  of  some  irritation  of  the  glans  penis  asso- 
ciated with  retained  subpreputial  secretion  or  an  adhesion  between  the  glans  and  prepuce, 
or  it  may  be  due  to  a  serious  cerebral  or  .spinal  affection.  It  may  indicate  kidney,  blad- 
der, pro.static,  or  urethral  disease,  and.  in  many  instances  it  is  the  one  symptom  that  has 
induced  the  patient  to  seek  advice.  The  irrhaJtle  hbiddcr.  therefore,  though  only  a  symp- 
tom, is  clinically  an  important  one,  and  demands  elucidation  at  the  commencement  of  a 
chapter  on  bladder  affections. 

Irritability  of  Bladder  in  Children. — ^\'llen  tliis  symptom  is  well  njarked  in 
a  male  child,  the  condition  of  the  penis  should  first  receive  attention,  since,  if  the  prepuce 
be  long  or  adherent  to  the  glans  penis,  and  the  secretion  from  Tyson's  glands,  from  want 
of  cleanliness,  have  accumulated  and  become  indurated,  there  will  be  strong  reason  to 
believe  that  the  irritability  of  bladder  is  the  direct  product  of  these  apparently  simple 
causes ;  for  any  of  these  conditions  of  the  penis  are  sufficient  to  produce  every  degree  of 
bladder  irritation,  and  a  cure  can  be  obtained  only  by  their  removal.  To  secure  this  end 
all  retained  secretion  .should  be  taken  away,  adhesions  between  the  glans  penis  and  pre- 
puce carefully  separated,  and,  if  the  prepuce  be  long,  circumcision  performed.  If,  how- 
ever, on  a  careful  examination,  no  such  conditions  are  to  be  observed,  the  state  of  the 
bladder  should  be  inquired  into,  and  for  this  purpose  a  sound  passed  Tan  instrument  with 
a  bulbous  extremity  being  preferred)  (Fig.  385)  ;  and  if  a  stone  be  detected,  the  cause 
of  the  symptom  will  be  cleai'ly  explained,  as  well  as  the  practice  to  be  followed.  It  must 
be  remarked,  also,  that  if  a  calculus  be  the  cause,  a  careful  inquiry  will  probably  detect 
the  pi-esence  of  other  symptoms,  such  as  pain  after  micturition.  ha?maturia,  and  an  occa- 
sional interruption  to  the  flow  of  urine,  the  intermitting  urinal  flow  being  very  character- 
istic of  the  presence  of  a  .stone,  although  all  these  symptoms  may  be  present  in  irritable 
bladder  from  an  adherent  prepuce.  When  the  .stone  cannot  be  felt,  it  is  not  at  once  to 
be  assumed  that  no  such  cause  exi.sts ;  for  on  a  .subsequent  examination  it  may  readily  be 
discovered,  the  calculus  having  been  probably  covered  by  one  of  the  folds  of  mucous 
membrane  of  a  partially-contracted  bladder.  If,  however,  a  second  examination  fail  to 
strike  it,  the  condition  of  the  bladder  should  receive  attention  ;  and  if  to  the  sound  its 
mucous  lining  feels  rough  and  the  presence  of  the  instrument  cause  more  or  less  pain  and 
a  desire  to  micturate,  the  urine  will  probably  be  found  altered  in  character,  and  after 
standing  will  show  a  cloudy  deposit  of  mucus,  if  not  of  pus,  the  latter  deposit  being  very 
rare,  however,  in  young  subjects. 

Treatment. — Under  these  circumstances  the  general  health  of  the  child  will  require 
attention,  as  it  may  happen  that  some  slight  aperient  or  alterative  or  an  alkaline  mixture 


ii:i:ir\i:i.i:  i:i..\i>i>er.  r,,T{ 

of  potash.  (»r  perhaps  a  t  mic,  may  he  rt'(piin'tl,  the  ((lijoct  Ix'iiig  t<t  make  the  miric  as 
uiiirritatiiig  as  possiliK-,  ami  thc'rel)y  to  aUow  the  vesical  mucous  iiR-mhraiu-  tr»  return  to 
its  iioruial  eoiidition.  Rest,  also,  as  fur  as  it  is  possihle  to  be  secured,  should  he  eulbreed. 
The  diet  ought  to  he  of  the  simplest  uature  and  meat  <riven  in  moderation,  since  it  will 
prohahlv  he  found  that  the  urine  is  unnaturally  loath-d  with  lithates,  if  not  with  lithie 
acid;  and  this  tendency  to  the  deposition  of  such  ingredients  would  he  increased  hy  the 
free  administration  of  animal  food.  When,  however,  a  case  of  irritahle  bladder  in  a  child 
presents  itself  in  which  none  of  flic  conditions  alluded  to  are  found,  and  in  which  the 
penis,  urethra,  and  Madder  appear  ])crfectly  natural,  the  state  of  the  rectum  shruild  be 
in(|uired  intti.  tlu'  presence  of  worms,  and  more  particularly  of  ascarides,  being  (piite  suf- 
ficient to  produce  an  irritable  condition  of  the  urinary  organs.  These  may  be  removed 
by  a  jalap  purge  or  an  enema  of  .some  bitter  vegetable  infusion  such  as  (piassia,  but  the 
condition  of  the  digestive  a]iparatus  will  re(|uire  attention,  as  influencing  the  presence  of 
worms. 

Excluding  tin-  presence  of  a  stone  as  a  cause  oi'  irritable  bladder  in  young  children, 
and  in  obstinate  cases  the  probability  of  some  villous  growth,  thi.s  aftection  is  not  (me  of 
serious  importance  if  its  true  cau.se  can  be  accurately  recognized,  since  the  conditions 
upon  which  it  depends  are  easily  remediable,  and  the  irritability  of  the  bladder  rapidly 
disa]ipcars  on  their  removal. 

Irritability  of  Bladder  in  the  Adult. — In  adult  life  this  symptom  cannot  be 

regarded  in  such  a  favorable  light  as  in  a  child,  since  it  is  too  often  as.sociated  with  con- 
ditions which  are  of  a  very  serious  nature  and  are  by  no  means  readily  removed,  although 
in  the  adult,  as  in  the  chifd.  a  congenital  or  an  acquiri'd  phimosis,  with  a  contracted  pre- 
putial orifice  or  adhesions  between  the  prepuce  and  the  glans  penis,  is  a  sufficient  condi- 
tion to  produce  this  symptom. 

,4s  a  siymptom  of  africfiire  the  irritable  bladder  is  not  without  its  value,  and.  as  a  rule, 
it  indicates  considerable  narrowing,  as  well  as  probably  a  contraction,  which  has  been  .so 
gradual  in  its  progress  as  to  escape  notice  until  this  irritability  of  bladder  enforced  more 
accurate  observation  and  induced  the  patient  to  seek  advice.  It  must  be  regarded  as  a 
result,  therefore,  of  a  urethral  stricture  which  can  be  relieved  only  by  the  removal  of  its 
cause.  Doubtless  it  is  produced  by  some  chronic  inflammatory  action  of  the  vesical 
mucous  membrane,  and  as  such  requires  treatment — viz.,  the  dilatation  of  the  stricture, 
absolute  rest,  and  the  administration  of  alteratives. 

As  a  symptom  o^  enlarged  proatnte  (or  of  atony  of  the  bladder  in  the  aged  in  whom  no 
prostatic  enlargement  exists)  this  irritability  of  bladder  is  a  complication  of  serious  import, 
for  in  both  classes  of  cases  it  is  due  to  a  want  of  power  on  the  part  of  the  bladder  to 
empty  its  contents — in  the  one  case  from  a  mechanical  obstruction  caused  by  the  pros- 
tatic tumor,  in  the  other  from  a  loss  of  power  in  the  parts,  the  residual  urine  under  both, 
partially  decomposing,  becomes  ammoniacal,  and  in  this  way  acting  as  an  irritant  to  the 
mucous  membrane  of  the  bladder,  thereby  giving  rise  to  the  irritability. 

The  treatment  of  these  cases  is  not,  therefore,  a  task  of  difficulty,  the  removal  of  the 
residual  urine  and  the  prevention  of  its  subsequent  retention  by  the  cautious  emplovment 
of  a  catheter  being  the  most  important,  together  with  the  frequent  washing  out  of  the 
bladder  with  warm  water  or  water  medicated  by  some  solution  of  morphia,  opium,  quinine, 
boracic,  or  nitric  acid. 

The  recognition  of  the  cause  of  the  symptom,  however,  is  the  main  point  to  be  remem- 
bered, the  practice  to  be  followed  readily  suggesting  itself  when  the  cause  is  understood. 
As  a  sign  of  gravel  an  irritable  bladder  is  of  importance,  and  a  careful  examination  of  the 
urine  will  determine  its  true  meaning.  As  a  symptom  of  calculus  in  the  bladder  it  is 
constant  and  valuable,  although  in  some  cases  of  stone  it  is  extraordinary  how  little  irri- 
tation the  presence  of  a  calculus  wmII  produce.  As  a  sign,  also,  of  organic  disease  of  the 
bladder,  irritability  must  not  be  passed  over.  The  obscurity  of  this  class  of  cases  is.  how- 
ever, very  great,  and  the  correctness  of  diagnosis  must  rest  upon  the  combination  of 
many  symptoms,  none  being  of  greater  value  than  another.  In  women  this  .symptom  is 
a  common  accompaniment  of  uterine  affections,  while  in  both  sexes  it  is  often  associated 
with  rectal  disease. 

Last,  but  not  least,  this  irritability  may  be  the  product  of  a  renal  affection,  the  urethra 
and  bladder  being  perfectly  sound.  When,  therefore,  bladder  .symptoms  exist  and  a 
careful  examination  fails  to  discover  any  disease  in  the  bladder  or  urethra,  it  may  fairly 
be  assumed  that  some  renal  affection  is  the  cause.  But  a  careful  chemical  and  micro- 
.scopical  examination  of  the  urine  is  alone  sufficient  to  enable  the  surgeon  to  arrive  at 
anvthinc  like  a  correct  diagnosis. 


634 


DISEASES  OF  THE  BLADDER  AND  PROSTATE. 


Irritability  of  bladder  may  also  be  produced  by  some  cerebral  or  spinal  disease,  but 
the  fact  can  merely  be  alluded  to  in  these  pages. 

The  passage  of  a  large  quantity  of  urine,  as  in  diabetes,  should  not  be  mistaken  for 
irritability  of  bladder. 


Inflammation  of  the  Bladder, 

Cystitis  is  a  common  consequence  of  stone,  prostatic  disease,  stricture,  or  gonorrhoea, 
and  is  usually  chronic  or  subacute,  the  more  acute  symptoms  mostly  supervening  upon  the 
chronic.  As  an  cicute  idiopathic  disease  it  has  been  described  by  authors,  but  clinically 
such  cases  are  very  rare.  The  most  acute  are  those  occurring  in  gouty  subjects  as  a 
catarrhal  affection. 

The  c/(ro»/c  form  is  the  direct  consequence  of  local  irritation  produced  by  the- presence 
of  a  tumor,  stone,  or  other  foreign  body,  although  it  is  found  whepever  the  flow  of  urine 
is  interfered  with  from  either  prostatic  disease  or  urethral  obstruction,  the  bladder  in  these 
cases  being  irritated  by  the  retained  and  decomposed  urine  as  well  as  by  its  own  ineffec- 
tual attempts  to  evacuate  its  contents.  A  similar  result  likewise  ensues  when  the  bladder 
is  paralyzed  and  unable  to  expel  its  contents  from  overdistension,  spinal  injury,  or  disease. 
It  is  under  these  circumstances  the  more  acute  forms  of  cystitis  and  the  worst  pathologi- 
cal conditions  are  found. 

Subacute  cystitis  is  commonly  the  result  of  gonorrha?a,  the  inflammation  of  the 
urethra  spreading  to  the  bladder. 

The  seat  of  the  inflammation  is  the  mucous  membrane,  which  becomes  rough,  cov- 
ered with  flakes  of  adherent  lymph  and  phosphatic  secretion,  thickened,  and  at  times 
ulcerated,  and  in  the  acute  forms  of  the  affection  detached  in  fragments  or  as  a  whole 
and  thrown  off  as  a  slough.  This  latter  condition  is  generally  met  with  in  the  bladder 
of  the  paralytic  and  in  women  who  liave  had  their  bladders  much  distended  from  retention. 
It  is  probably  as  much  due  to  the  deficiency  of  nerve  supply  as  to  the  intensity  of  the 
inflammatory  mischief,  rough  catheterism  having  often  too  much  to  do  M'ith  it. 

In  chronic  cases  the  walls  of  the  bladder  become  greatly  hypertrophied  from  over- 
action,  thick  muscular  bands  being  visible,  and  where  the  obstruction  to  the  exit  of  the 

urine  has  been  of  long  standing  this  thickening  of 
Fig.  358.  the  walls  of  the  bladder  is  associated  with  its  dila- 

tation. Under  these  circumstances  it  is  common 
to  meet  with  sacular  dilatations  of  the  mucous 
membrane,  the  mucous  lining  of  the  bladder  be- 
coming pressed  outward  as  a  hernia  between  the 
bands  of  muscular  tissue  forming  the  walls  of  the 
organ.  These  pouches  are  usually  small,  though 
in  exceptional  cases  (as  seen  in  Fig.  358)  they 
may  be  double  the  size  of  the  bladder  itself.  Into 
one  of  these  pouches  a  stone  may  occasionally  fall 
and  rest,  thereby  becoming  encysted.  At  times 
these  sacculi  are  multiple. 

Sacculi  of  the  bladder  are  met  with  chiefly  in 
male  subjects  ;  they  were  found  in  20  out  of  3000 
post-mortem  examinations  made  at  Guy's;  in  11 
cases  of  stricture,  5  of  stone,  1  of  spinal  disease,  1  of  enlarged  prostate.  In  1  the  cause 
was  not  clear.  My  friend  Dr.  Hale  "White  recorded  these  facts  with  a  case  met  with  in 
a  woman  at  the  Path.  Society,  March,  1883. 

Symptoms. — When  the  disease  is  subacute,  the  symptoms  are  irritability  of  bladder 
and  inability  to  retain  urine,  the  desire  to  pass  water  being  often  associated  with  its 
uncontrollable  passage.  The  act  of  micturition  is  attended  with  pain  and  followed  by 
straining,  blood  being  frequently  squeezed  out  by  the  forcible  contraction  of  the  oi'gan. 
Pain  is  mostly  present  above  the  pubes,  in  the  perinreum  and  penis,  often  over  the  sacrum 
and  in  the  groin.  With  these  local  symptoms  there  may  be  those  of  more  or  less  severe 
febrile  disturbance. 

The  urine  will  be  found  to  vary  in  character  according  to  the  cause  of  the  disease. 
When  it  has  originated  from  the  extension  of  a  gonorrhoeal  inflammation  of  the  urethra, 
it  will  be  cloudy  from  the  presence  of  mucus,  or  even  of  pus,  and  at  times  stained  with 
blood,  this  blood  having  been  passed  dui'ing  the  act  of  straining  at  the  end  of  mictu- 
rition. 


Sac 


Sacculated  Bladder. 
(Prep.  2087",  Guy's  Hosp.  Mus.) 


IM'J.AMMATIUS   OF   'J'] IK   ni.AhDER. 


G35 


[n  other  cases  of  cliroiiic  discasi;  (nilnnhnl  n/stlliH)  the  uriiit!  will  l)e  inixcfj  with 
^ravi.^h,  viseid,  r()|)y  mueiis  or  niiicit-punili'iit  fluid,  whi(di  so  sticks  to  the  hoituiu  of  tlie 
diaiiilier-vessel  ami  toirether  as  to  fall  like  a  ^lutiimus  mass  when  tiinieil  out.  'I'he  urine 
will  jtnd)ii]»ly,  in  ehmnie  eases,  he  alkaline  nr  ammoniacal;  in  subacute,  acid  ;  in  ne;^lected 
cases  the  diseharf^e  of  mucus  hecoines  (iiiirmnus.  and  |diips|diate  of  lime  ollen  becomes 
mixed   with  the  mucus  and   Ibrms  stmie. 

When  ulceration  of  the  bladder  is  present,  all  the  symptoms  are  afrKravattvl  and  the 
local  pain  is  severe.  Hleedinj;  is  a  connnon  accomjianiment,  the  blood  being  mixed  with 
the  contents  of  the  bladder  and  ])assed  either  as  dark-colored  urine  or  as  clots  of  blood. 

In  the  cystitis  of  <;onorrlnea  it  is  pr(jbal)le  that  the  mucous  membrane  about  tlie  neck 
of  the  bladder  is  alone  affected  ;  in  the  nnjre  chronic  cases  of  disease  the  whole  surface 
and  submucous  tissue  are  involved. 

Tkk.VTMKNT. — Whatever  may  be  the  local  cause  of  the  cystitis,  the  local  symptom.^ 
re((uire  attention,  althoutrh  in  order  to  (tbtain  a  cure  the  removal  of  the  cause  is  most 
essential. 

Rest  in  the  horizontal  posture,  hot  fomentations  or  the  hot  bath,  simple  diluents  such 
as  barley  water,  linseed  tea,  milk  and  water,  with  alkalies,  as  the  salicylate  of  soda,  citrate, 
or  bicarbonate  of  potash,  in  ten-<?rain  doses,  three  times  a  day.  and,  abtn'e  all.  sedatives, 
are  most  essential.  Of  the  sedatives  hyoscyamus  is  the  best,  in  half-drachni  or  drachm 
doses  of  the  tincture  every  two  or  three  hours ;  and  where  this  is  not  enough  opium  may 
be  substituted,  but  where  the  kidneys  are  diseased  opium  should  always  be  given  with 
great  caution.  The  morphia  suppo.sitory  is  an  excellent  remedy  ;  so  is  an  enema  of 
starch  with  opium.  The  bowels  should  be  relieved  by  enemata  in  preference  to  purga- 
tives, although,  when  severe  constipation  is  present,  a  good  mercurial  purge  is  often  of 
value  ;  leeches  to  the  perin.'cum  are  sometimes  serviceable. 

AVhen  retention  of  urine  complicates  the  case,  catheterism  is  called  for  :  and  an  ela.stic 
catheter  should  be  used,  with  the  utmost  gentleness. 

In  clironic  cases  the  infusions  of  buchu.  uva  ursi,  pareira.  or  senega,  and  benzoic  acid 
in  ten-grain  doses  are  excellent  remedies  ;  the  tincture  of  cubebs  or  cijpaiba  at  times  acts 
also  beneticially  ;  the  triticum  repens,  in  the  form  of  a  decoction,  two  ounces  to  the  pint, 
is  also  a  valuable  drug.  When  gout  is  the  assignable  cause,  colchicum.  with  five-grain 
doses  of  the  carbonate  of  lithia,  sometimes  acts  as  a  charm,  and  in  some  cases  of  gonor- 
rhoea! cystitis  the  same  good  effect  is  often  experi- 
enced. AVhen  stone  is  the  cau.se,  it  should  be  re- 
moved ;  when  stricture  coexists,  it  must  be  dilated ; 
when  enlarged  prostate  or  atony  of  the  bladder  in 
the  aged  is  the  cause  of  the  cystitis,  it  is .  essential 
to  keep  the  bladder  empty  by  the  introduction  of  a 
catheter  once  or  twice  daily  ;  in  severe  cases  the  blad- 
der should  be  washed  out  by  either  a  stream  of  tep- 
id water  or  medicated  solution.  Boracic  acid,  ten 
grains  to  the  ounce  of  water,  is  the  best  form.  Mr. 
T.  W^.  Nunn  speaks  highly  of  a  solution  of  two  grains 
of  quinine  in  two  and  a  half  ounces  of  water  wnth  a 
drop  of  diluted  sulphuric  acid.  W^hen  the  urine  is 
fetid,  Condy's  fluid  or  a  few  drops  of  tincture  of  iodine, 
carbolic  acid,  or  of  one  part  of  thymol  dissolved  in 
seven  of  glycerine  may  be  added  to  the  water. 

In  w'ashing  the  bladder  the  greatest  gentleness 
should  be  observed  ;  to  force  fluid  into  the  l)ladder 
by  a  syringe  is  dangerous,  unless  in  skilled  hands, 
while  to  introduce  more  than  three  or  four  ounces  of 
■fluid  is  unnecessary.  The  best  method  is  by  means 
of  the  irrigating  can  or  a  piece  of  india-rubber  tub- 
ing, two  or  three  feet  long,  fitted  to  the  top  of  the 
catheter  after  its  introduction,  and  the  gradual  pour- 
ing of  the  water  or  .solution  made  warm  through  a 
glass  funnel  fitted  to  the  other  end.  The  tubing  can 
be  raised  to  increase  the  pressure  of  the  fluid,  or  de- 
pressed, according  to  the  necessities  of  the  case,  the 
bladder  resenting  the  slightest  distension  by  its  contraction  and  by  the  expulsion  or  ele- 
vation of  the  fluid  into  the  funnel.     By  these  means  no  harm  can  possibly  accrue  to 


Fig.  359. 


Mode  of  Washing  Out  the  Bladder.  (^The  irri- 
gator can  may  be  substituted  for  the  jug 
and  hand.) 


636  DISEASES  OF  THE  BLADDER   AND  PROSTATE. 

an  inflamed  bladdei",  and  the  most  atonic  bladder  can  be  emptied  as  with  a  syphon  (Fig. 
359). 

After  the  fluid  has  been  inti'oduced  and  left  for  two  or  three  minutes  it  should  be 
withdrawn,  and  fresh  fluid  poured  in  where  necessary,  the  funnel  being  depressed  below 
the  level  of  the  bed  for  emptying  the  bladder.  Anodyne  solutions  are  said  not  to  be  of 
much  use  in  these  cases,  but  I  have  been  in  the  habit  of  introducing  half  a  grain,  more 
or  less,  of  morphia,  with  apparent  advantage,  after  the  washing  out  of  the  bladder.  When 
the  washing  out  of  the  bladder  increases  the  irritation,  it  should  be  discontinued.  At  times 
a  double  catheter  is  of  use,  the  injection  flowing  down  one  side  and  the  contents  of  the 
bladder  out  of  the  other. 

In  the  inflamed  bladder  associated  with  atony  the  tincture  of  the  perchloride  of  iron 
is  a  valuable  drug,  or  the  dilute  nitro-muriatic  acid  given  in  twenty-minim  or  half-drachm 
doses  three  times  a  day  ;  but,  in  a  general  way,  alkalies  are  called  for,  the  urine  naturally 
secreted  being  acid,  and  so  as  it  is  poured  into  the  inflamed  bladder  becomes  an  irritant. 
The  diet  under  all  circumstances  should  be  nutritious,  but  unstiuiulating,  alcohol  being 
given  carefully,  according  to  the  patient's  powers.  In  all  cases,  however,  of  inflamed 
bladder  the  surgeon  ought  to  remember  its  cause,  which  is  generally  due  to  some  obstruc- 
tion to  the  flow  of  urine  or  local  cause  of  irritation,  and  for  a  cure  the  removal  of  its 
cause  is  essential. 

Ulceration  of  the  Bladder. 

This  is  rarely  the  result  of  ordinary  cystitis,  though  it  may  occur  in  the  paralyzed 
organ,  and  is  met  with  after  death  where  catheterism  has  been  frequently  employed  and 
in  cases  of  stone.  It  is  likewise'  found  in  tuberculous  subjects,  from  the  breaking  down 
of  tuberculous  material,  as  well  as  in  cancer.  The  disease  is  indicated  by  the  same 
symptoms  as  exist  in  inflamed  bladder,  with  more  local  distress,  more  blood  in  the  urine, 
and  greater  pain  after  micturition.  There  is  usually  also  much  constitutional  depression 
and  want  of  power.  I  have  seen  two  cases  in  which  extravasation  of  urine  above  the 
pubes  resulted  from   this  disease,  one  of  which  recovered  and  the  other  died. 

Treatment. — The  indications  for  treatment  are  similar  to  those  for  cystitis,  opium 
being  freely  used  as  a  suppository  or  an  enema.  All  mechanical  interference  should  be 
avoided  unless  absolutely  called  for,  and  then  it  should  be  of  the  gentlest  kind.  It  is  a 
question,  however,  whether  in  the  severer  forms  median  perineal  cy.stotomy  would  not  be 
a  sound  practice  ;  the  urine  would  then  flow  away  as  secreted  and  a  chance  given  to  the 
bladder  to  recover  itself;  at  any  rate,  the  operation  would  give  relief.  I  have  done  this 
on  several  occasions  with  success. 

Tubercular  Disease  of  the  Bladder. 

This  is  a  rare  although  a  real  aff"ection.  and  is  confined  to  young  middle  age.  It  is 
generally  associated  with  the  same  disease  of  the  kidneys,  prostate,  vesiculac  seminales, 
and  testicles,  and-  shows  itself  as  a  deposit  of  tuberculous  matter  in  the  mucous  and  sub- 
mucous tissue,  which  when  it  breaks  down  forms  an  ulcer.  It  is  usually  accompanied 
with  symptoms  of  irritable  bladder  and  painful  micturition,  the  latter  symptom  being 
more  common  when  ulceration  has  taken  place. 

Rest  in  the  horizontal  posture  is  essential  in  this  as  in  all  bladder  affections,  anodynes, 
tonics,  and  nutritious  food  being  of  great  value.  My  friend  the  late  Mr.  Poland  told  me 
that  in  a  case  of  tubercular  disease  of  the  bladder  attended  with  ulceration  (which  was 
under  Mr.  Aston  Key's  care  when  he  was  a  dresser,  about  1840),  where  the  suffering  was 
severe,  Mr.  Key  suggested  the  propriety  of  laying  the  bladder  open  as  in  lithotomy,  and 
thus  allowing  the  urine  to  flow  off"  as  soon  as  it  reached  the  bladder.  The  patient,  how- 
ever, was  too  fiir  exhausted  from  advanced  lung  disease  to  allow  of  its  performance.  3Ir. 
Key  stated  that  in  another  case,  where  the  disease  had  not  made  so  much  progress,  he 
should  not  hesitate  in  performing  the  operation.  The  bladder  in  this  one  was  found 
almost  stripped  of  its  mucous  membrane,  and  what  remained  was  studded  with  tubercu- 
lar deposits.  Mr.  Key  called  it  phthisis  of  the  bladder.  At  the  present  day  Mr.  Aston 
Key's  suggestion  of  cystotomy  would  probably  be  performed. 

Tumors  of  the  Bladder. 

A  bladder,  anatomically  being  constructed  of  mucous  membrane,  fibrous  and  muscu- 
lar tissue,  may  be  the  seat  of  papillomata,  the  innocent  villoits  groxcth  ;   myxomata,  or 


<:A\ci:iis. 


(\:u 


iiuiCDUs  polypus  ;    i-'IHKomata,  or  liliiniis  ;;ro\vtli  ;    MVOMATA,  or  niUHcular.      ("<»iit;iiiiiiig, 
likrwisi',  as  it   tltu-s,  (•])itlu'lial   ami   (M»iiiu'ctivi'-tissiU'  I'lcinciits,  it  may  he   tlie  sultji'i-t  of 


I'll  ;  aixl  to  this  list   i>kk.M(jII) 
intraiiiiiral  or  polypoid.      The 


I'm.  360. 

Thlckentd  Mall  of  IHaJJrr 


'         "    ;  '  Mir  roscopic 

Villous  Growth  in  Bladder,  with  llyper- 
irophied  Walls  of  the  Ur(,'aii.  (From 
drawing  ;5()S''3,  (Juy's  Hosp.  Mus.; 


KlMTIIKMAl,    CANCKIl,  as   Wi'll    as  of   a    SAKCOMATUIS    «iK(»\V 

tiiiiiors  mav  hi'  adtli-d.  Any  one  of  these  <xro\vths  may  he 
papillomata  are  tiuiiul  in  ehihireii  as  well  as  in  adnlts. 
The  other  forms  of  tumor  helonjr  more  to  the  iniddie-aLM-d 
or  old.  (Irowths  are  as  eonim<iM  in  the  teinale  as  in  the 
male  sex. 

The  papillomatous  me  mostly  j»eduneulati;d.  vil- 
lous, and  sinuli.  Many  are  sessile  and  multiple.  When 
single,  they  are  <;euerally  attached  to  the  hase  of  the  hlad- 
dor — that  is,  to  the  trig(»ne  and  orifices  of  the  ureters,  when 
at  times  their  long  villous  ends  or  |)rolongations  of  natural 
villi  are  carried  by  the  urine  stream  into  the  urethra, 
where  they  may  be  broken  off  and  exjielled  or  cause 
obstruction. 

In  exeeptiiiiial  eases  the  miicims  surface  of  the  bladder 
may  bi-  nn)re  or  less  covered  with  these  villous  or  sessile 
papillomatous  growths  ;  indeed,  instances  are  on  record 
where  the   ureters  or  calyces  of  kidneys  were  involved. 

These  growths  are  benign  and  of  slow  growth  ;  they 
may  last  for  six  or  more  years. 

Fig.  8G0  well  illustrates  the  ordinary  appearance  of 
this  variety  of  tumor,  with  the  changes  brought  about  in 
the  bladdi'r  from  its  presence. 

The  myxomata,  fibromata,  or  myomata  are 

mostly  single  tumors  and  develop  as  pidypoid  or  irregular- 
.shaped  outgrowths,  the  expulsive  action  of  the  bladder  doubtless  doing  much  toward 
making  the  growths  polypoid.  They  affect  both  sexes  equally,  and  are  more  frequent 
during  young  than  old  life ;  they  may  grow  from  any  part  of  the  bladder,  but  generally 
from  the  trigone. 

In  Fig.  'M\\  the  disease  was  extensive.  It  was  described  by  Sir  A.  Cooper  as  '-tumor 
of  the  mucous  mem1)rane  of  the  bladder  everted,  polypoid  excre.scences  producing  .symp- 
toms of  stone."  Fibrous  and  myomatous  tumors  are,  however,  rare.  In  1883  I  had  a 
man  ;ct.  6(»  under  care  with  a  fibrous  growth  springing  from  the  fundus;  it  had  caused 
symptoms  for  four  years. 

Cancers. 

These  are  generally  of  the  epithelial  form,  but  examples  of  the  hard  and  soft  varieties 
have  been  recorded.  They  are  generally  sessile  and  infiltrating  the  walls  of  the  bladder, 
but  they  may  assume  the  villous  shape.  The  affections  may  be  primary  ;  more  commonly, 
in  women,  the  bladder  becomes  involved  by  the  extension  of 
di.sease  from  the  uterus,  and  in  men  from  the  rectum.  Under 
all  circumstances  the  disease  is  one  of  middle  or  advanced  age. 

In  the  notes  of  a  case  before  me,  however,  the  disease 
appeared  in  a  man  aet.  28;  in  ten  others  the  ages  varied  from 
48  to  (J!t. 

Symptoms. — All  bladder  tumors  give  rise  to  much  the  same 
series  of  symptoms,  which  may  be  brought  under  three  head- 
ings— namely.  irritahUily  of  bladder,  passing  on  to  incontinence, 
hstmntnild,  and  puin. 

The  irritability  may  be  very  slow  in  its  increase,  intermittent 
in  its  action,  or  rapidly  progressive.  In  the  majority  of  tumors 
it  is  the  earliest  sign  ;  in  the  villous  or  papillomatous  it  rarely 
appears  till  other  evidence  of  bladder  trouble,  such  as  hajma- 
turia,  shows  itself.  When  it  has  appeared,  it  usually  steadily 
increases  in  severity,  till  at  last  the  bladder  refuses  to  retain 
urine  and  incontinence  ensues. 

The  progress  of  villous  disease  is  usually  slow,  but  it  may 
be  rapid.  Thus,  in  one  case  of  villous  growth,  the  notes  of  which  are  before  me.  in  a  man 
ret.  87,  the  irritability  of  bladder  and  h;vmaturia  had  been  gradually  increasing  in  severity 
for  eight  yea r^.  and  after  death  the  mucous  lining  of  the  bladder  was  found  covered  with 


Fig.  361. 


Polypoid  Outfirnwtiis  ifiin  Mu- 
cous Menihrane  of  Bladder. 
(Preparation  21042^5,  (iuy's  Mu- 
seum.) 


638  DISEASES  OF  THE  BLADDER  AXD  PROSTATE. 

a  growth,  and  the  walls  of  the  bladder  were  so  thickened  that  when  removed,  empty  of 
urine,  it  was  as  large  as  a  coeoanut ;  whilst  in  a  second  case,  which  occurred  in  a  man  a?t. 
70.  there  had  been  symptoms  for  only  tv;o  months,  and  the  first  was  haematuria.  No  pain 
or  difficulty  in  micturition  had  appeared  till  five  days  before  his  admission  into  Guy's.  He 
died  from  suppurating  kidneys.  In  this  case  the  disease  was  localized  to  the  trigone  of 
the  bladder. 

It  is  to  be  remarked  also  that  in  villous  disease  there  may  be  intervals  of  days,  and 
sometimes  weeks,  between  the  attacks  of  haematuria.  the  urine  between-whiles  being  nor- 
mal.    In  cancerous  disease  these  intervals  are  rare. 

It  need  hardly  be  said  that  the  urine  should  be  most  carefully  examined  in  all  these 
cases  and  its  sediment  and  clots  washed,  for  in  one  case  a  small  fragment  of  villous  growth 
may  often  be  found  in  it.  and  in  another  mas^e.f  of  epithelial  or  spindle-.shaped  cells — not 
isolated  cells,  however  numerous — when  the  diagnosis  will  be  complete. 

With  the  same  view,  when  a  catheter  has  been  passed,  the  contents  of  the  instrument 
should  be  well  washed  and  examined.  I  have  on  several  occasions  found  pieces  of  growth 
in  the  instrument,  and  in  the  case  of  a  female  child  who  had  .several  attacks  of  haematuria 
I  caught  in  the  eye  of  mv  catheter  a  small  villous  growth,  pulled  it  awav.  and  cured  the 
child.  .  .  ,  ., 

Ultzmann  (  VilhHs-Ueher  Hematuric,  1878)  has  described  a  condition  of  urine  met  with 
in  villous  growths  which  he  considers  diagnostic.  It  consists  of  a  coagulating  of  the  urine, 
which  seems  free  from  blood,  into  a  glutinous  mass  soon  after  it  has  been  passed,  the  mass 
consisting,  apparently,  of  fibrine.  A.  Stein  of  New  York,  in  his  able  memoir  on  bladder 
tumors  (ISSlj.  confirms  the  observation.  It  would  .seem  as  if  in  some  cases  liquor  san- 
guinis exudes  from  the  villi,  and  in  others  blood. 

Hhf:maturia.  or  the  passage  of  blood-stained  urine,  or  blood  in  abundance  or  in  clots, 
is  a  constant  .symptom,  and  in  the  villous  growth  it  is  usually  the  earliest.  In  such  it  is 
also  very  intermittent — that  is.  it  may  appear  to-day  and  not  reappear  for  three  or  four 
months.  The  same  may  be  said  of  other  growths,  but.  as  a  rule,  when  ha?maturia  has 
appeared  with  them,  it  is  persistent.     It  is.  however,  usually  a  later  symptom. 

The  blood  generally  shows  itself  toward  the  end  of  micturition,  the  stream  of  urine 
being  at  first  clear,  and  then  toward  the  end  red.  In  exceptional  cases,  however,  the  blood 
may  pass  first. 

The  po.sition  of  the  growth  must  have  much  to  do  with  this  symptom,  growths  about 
the  trigone  being  more  liable  to  bleed  when  the  bladder  contracts  than  the  same  situated 
nearer  the   fundus. 

In  exceptional  cases  of  tumor  of  the  bladder  there  is  no  hematuria. 

Pain  is  not  a  constant  symptom  of  this  disease,  although  uneasiness  from  frequent 
micturition  may  be  troublesome  ;  pain  becomes  more  marked  as  the  irritability  of  bladder 
increases  and  inflammation  shows  itself,  and  in  the  later  stages  of  trouble  it  may  become 
intense. 

The  pain  is  usually  felt  in  the  penis  after  micturition,  but  a  dull  suprapubic  pain  is  by 
no  means  an  uncommon  symptom  of  bladder  growth. 

Pain  over  the  sacrum  and  in  the  perinaeum  and  rectum,  and  pains  shooting  down  the 
thigh,  are  not  rare.  Lumbar  pains  are  of  frequent  occurrence  toward  the  close  of  the 
case. 

Diagnosis. — From  what  has  been  said  as  to  .symptoms  it  will  be  gathered  that  it  is 
in  exceptional  cases  alone  a  true  diagnosis  if  any  special  vesical  growth  can  be  made  out, 
although  when  haematuria.  steadily-increasing  irritability  of  bladder,  and  pain  are  present,, 
and  these  symptoms  are  unrelieved  by  treatment,  the  diagnosis  of  a  local  vesical  cause 
may  fairly  be  made.  A  bimanual,  vaginal,  and  suprapubic  combined  examination  will 
often  prove  of  great  value  in  aiding  diagnosis  in  women  and  in  men.  The  same  method 
applied   through  the  rectum  may  be  equally  serviceable. 

But  for  a  completely  satisfactory  digital  exploration  of  the  bladder  a  full  dilatation 
of  the  female  urethra  is  absolutely  essential,  and  a  central  perineal  urethral  incision  in 
the  male,  by  which  the  membranous  portion  of  the  urethra  is  opened  to  allow  of  direct 
digital  exploration,  is  equally  called  for. 

Sounds  and  catheters  are  of  use.  but  they  are  of  uncertain  value,  and  more  particu- 
larly when  compared  with  '•  direct  digital  bimanual  exploration,"  as  strongly  advocated 
by  Sir  H.  Thompson. 

Treatment. — Little  more  than  palliative  treatment  has  hitherto  been  generally 
employed  in  these  cases,  as  bladder  tumors  have  been  little  understood.  Yet  an  old 
surgeon  of  Guy's  (Warner)  in  17-47  incised  the  urethra  of  a  woman  aet.  23  who  was  suf- 


CASrJJls. 


iy.io 


ferinj^  from  a  |)<ilyiHi.s  ami  put  a  ligatiiru  nmiid  the  fuMluiiflc  of  a  f:rowtIi  the  size  of  a 
turkey's  c'ltl;  with  comnlt'ic  success;  Dessault,  after  rcmoviiifr  a  stone  from  a  male,  suc- 
cessfully twisted  ort' a  jiolyjtus  that  he  iound  in  tiie  Idaddcr  ;  ami  Mr.  Hirkett  ( M'd.-Cliir. 
Trails.,  1S5S).  in  a  strikinjr  example  of  the  disease  occurring'  in  a  female  child  :et.  '>, 
applied  a  liirature  to  the  j:rowth,  hut  the  patient  died  with  suppuratin;.-^  kidney  the  effect 
of  the  disease;  anil  in  many  eases  the  ])ractieahility  of  successful  operative  interference 
is  not  diseourafiimr. 

I  also  ill  lSt)4  removed  a  villous  <;rowtli  from  a  woman  s  hladder  with  the  ecraseur 
with  complete  success.  Other  cases  may  also  be  found  in  .sur^'ical  literature  in  which 
operative  interference  has  been  emj)loyed,  and  niore  particularly  in  women.  In  male  sub- 
jects the  instances  are  very  few.  Civiale  in  1^21  used  to  crush  vesical  growths  with  the 
lithotrite  with  some  success,  and  Covillard,  according  to  Crosse  {dinar//  Fonudfions, 
1885),  was  the  first  to  perform  designedly  perineal  cystotomy  for  a  tumor  with  success. 
Crosse  ro])eated  the  o])eratioii  in  1S;{4,  Billroth.  Volkman,  and  Kocher  in  1874.  Humphrey 
in  1877,  and  Davies-Colley  in  1S8(I.  At  the  iire.><ent  time  Thompson  has  ably  advocated 
it.  Suprapuliic  cystotomy  has  been  employed  in  still  fewer  cases.  In  considering  the.se 
operations  it  is  always  to  be  remembered  that  a  case  of  bladder  tumor  when  left  to  nature 
can  have  but  one  ending,  and  that  is  death.  Every  rec(»very.  therefore,  aptly  writes 
Thompson,  ''is  a  clear  gain."  In  all  cases  of  persistent  Vjladdcr  irritation  and  hit'inaturia 
in  which  the  cau.se  is  doubtful  a  full  exploration  of  the  bladder  in  the  ways  previou.sly 
suggested,  by  urethral  dilatation  in  the  female  and  a  perineal  incision  into  the  mem- 
branous portion  of  the  urethra  in  the  male,  should  Vje  undertaken. 

Should  no  tumor  be  found,  the  injurious  effects  of  the  operation  may  be  put  down  as 
very  slight ;  should  one  be  found  to  exist,  its  removal  will  probably  be  effected.  Thomp- 
son writes  that  out  of  27  explorations  he  found  and  removed  growths  in  12  cases,  and 
that  5  of  them  were  effectually  cured. 

The  growth,  when  discovered,  should  be  removed  by  scoop  ecraseurs  or  forceps  of 
different  shajtes  and  sizes.  Thompson  uses  cutting  as  well  as  crushing  forceps.  The 
latter  are  probably  the  safer  and  most  efficient  {vt>/f:  Fig.  3(J2). 

Fig.  362. 


Thompson's  Bladder  Forceps. 

When  the  whole  growth  can  be  removed,  so  much  the  better ;  but  should  this  not  be 
possible,  the  surgeon  may  console  himself  with  Thompson's  opinion  that  *•  a  complete 
ablation  of  the  growth  is  not  absolutely  essential  to  success ;  that  as  cicatrization  takes 
place  this  process  by  degrees  leads  to  solidification  of  the  tissues  at  the  point  at  which 
evulsion  was  made."  In  female  subjects  the  operation  is  far  easier  than  it  is  in  the  male. 
In  both,  however,  it  should  be  considered  and  adopted  in  an}"  case  of  suspected  tumor. 
When  any  difficulty  is  experienced  in  finding  or  removing  the  growth,  it  may  be  well  to 
leave  the  case  alone  for  twenty-four  hours,  as.  from  a  case  related  to  me  by  my  friend 
Mr.  H.  Morris,  it  .seems  that  when  a  bladder  containing  a  growth  is  drained  the  growth 
itself  may  be  partially  extruded  through  the  wound  by  the  natural  expulsive  action  of 
the  bladder,  when  it  can  be  readily  seized  and  treated. 

Under  certain  circumstances  a  suprapubic  operation  might  be  preferable  to  the  per- 
ineal ;  for  example,  when  the  growth  is  at  the  fundus  or  very  large.  In  a  case  of  my 
own  of  fibrous  growth  in  the  fundus  I  regretted  that  I  had  not  chosen  it. 

The  surgeon,  when  considering  any  operation  upon  the  bladder,  should  remember  that 
its  position  is  capable  of  undergoing  great  changes ;  that  in  the  adult,  when  flaccid,  it  lies 
behind  and  below  the  level  of  the  symphysis;  and  that  when  moderately  distended  it  may 
be  uncovered  with  peritoneum  for  about  one  inch  at  its  upper  and  anterior  surface.  He 
should  likewise  be  aware  of  what  Dr.  J.  (t.  Garson  of  the  College  of  Surgeons  has  demon- 
strated {Ellin.  Med.  Jiiurn..  October,  1878)  when  the  rectum  is  di.stended  with  a  rubber 
oval  bag  measuring  when  full  ten  inches  in  circumference  (the  size  of  a  man's  hand) — 
that  the  bladder  is  raised  out  of  the  pelvis  into  the  position  it  occupies  in  the  new-born 
child,  and  that  under  such  circumstances  the  bladder  is  uncovered  above  the  symphysis 


640 


DISEASES  OF  THE  BLADDER  AND   PROSTATE. 


for  about  three  inches.  It  would  seem  by  Garson's  experiments  that  the  bladder  is  raised 
out  of  the  pelvis  by  stretching  the  prostatic  portion  of  the  urethra  to  nearly  double  its 
ordinary  length,  and  that  with  the  elevation  of  the  bladder  its  posterior  peritoneal  cover- 
ing is  considerably  raised,  Douglas's  pouch,  which  is  normally  about  two  and  a  half  to 
three  inches  from  the  anus,  being  raised  to  three,  four,  and  even  more,  inches.  My  own 
observations  with  the  rectal  dilator  upon  the  cadaver  support  Dr.  Garson's  views. 

The  bearing  of  these  facts  upon  suprapubic  bladder  operations  is  palpable. 

For  distending  the  rectum  an  oval  india-rubber  bag  ten  inches  in  circumference,  with 
a  metal  perforated  tube  for  introducing  and  filling  purposes,  may  be  employed  (Fig.  303). 

Fig.  363. 


Rectal  Dilator. 


Dermoid  tumors  of  the  bladder  are  of  rare  occurrence  ;  and  when  tliey 
occur,  they  are  probably  ovarian  in  their  origin,  and  are  discharged  through  the  bladder. 
In  exceptional  cases  they  may  have  a  bladder  origin — that  is,  may  have  been  developed 
within  the  walls  of  the  bladder  and  at  a  later  stage  broken  down,  ulcerated  into  it,  and 
been  then  discharged. 

In  the  following  ca.se  this  explanation  seems  to  be  the  only  reasonable  one. 

A  married  lady  aet.  30,  the  mother  of  two  children,  came  into  my  hands  on  June  30, 
1883,  to  be  operated  upon  for  some  hemorrhoidal  trouble  ;  she  then  complained  of  slight 
bladder  irritability  of  a  few  days'  standing.  Previous  to  this  she  could  hold  her  water 
for  hours ;  indeed,  on  hunting-days  she  could  do  so  for  eight  or  ten.  I  regarded  the  blad- 
der symptom  as  one  associated  with  her  rectal  trouble. 

After  the  operation  the  symptoms  continued,  and  on  July  10,  without  any  apparent 
cause,  intense  fever  and  constitutional  disturbance  appeared,  and  on  the  11th  her  bladder 
symptoms  became  intensified. 

On  the  12th  some  urethral  obstruction  occurred,  and  on  examination  with  a  view  to 
relieve  it  I  removed  a  bundle,  the  size  of  a  penholder,  of  fine  hairs  covered  with  phos- 
phates from  the  urethra  (Fig.  364,  A),  which  bundle  is  now  in  the  museum  of  the  Eoyal 


Dermoid  Growth  removed  from  the  Bladder  with  hairs  f  A)  covered  with  plio.s|)hatic;  concretion.  B,  First  part  removed 
C,  Pedicle  wiih  ligature.    D,  Growth  and  pedicle  finally  removed. 

College  of  Surgeons.     With  the  removal  of  this  all  constitutional  symptoms  disappeared. 
The  bladder  irritability,  however,  lasted,  and  for  the  next  six  weeks  small  phosphatic  cal- 


i>i:nM()ii>  TiMijiis  or  riii:  iu.addiji. 


<M1 


illy  assi.stiiijr  nic-  witli  Mr,  II. 

mctlira  raiiidly  ililatc<l  with 
I  tlifii  introduced  iiiv  tinker 


culi,  t'oriiiftl  i»ti  li>iiL^  ami  short  hairs,  were  Ikmm^  fVc<|ii('iitly  passed.      Soiin-  of  thcsi-  liairs 
were  a  loot  hxii;  ;   the  majority  were,  however,  short. 

On  several  oeeasions  I  washeil  the  hladder  <Mit  with  relict'.  Karly  in  Septeinher  the 
])atient  was  fairly  eoinfortahh' ;  she  eoiild  hold  her  urim-  for  hours  and  pass  it  without 
pain.  She  then  left  liondon.  Suddenly,  however,  towanl  tin-  en<l  of  the  month,  all  her 
severe  symptoms  ret urnecl.  ami  with  aiz;.;ravation.  The  urine  hrcame  <diarL'»*d  with  mucuts, 
and  likewise  with  Mood. 

Karlv  in  ()etid>cr  I  >:iw  licr  aizain.  when  >lic  wa>  pa^siuLi  nia^^c*  ol'  ]diosphatie  concre- 
tion foniinl  nil  liairs.  with  urine  riill  nt'  mucus  and  pu>.  .\  hladder  e.xpluration  wa.s  then 
arraULjed. 

On  (Jetoher  "Jit  this  was  jierioriiied.  Sir  II.  Tliomp-un  ki 
Morris. 

For  a  lull  examination  an  amesthetic  wa.s  given,  and  the 
tlie  small  iustninu'iit  1  am  in  the  habit  of  using  (Fig.  4."{Sj. 
into  the  hlaildcr,  and  at  once  came  down  upon  a  mass  of  phospatic  concretion  matted  on 
hair.  This  I  removed,  and,  having  done  so,  discovered  hanging  from  the  upper  wall  or 
fuiulus  of  the  bladder  a  polypoid  outgrowth  about  one  in(di  and  a  half  long,  the  pedicle 
of  which  apjiareutly  came  out  of  a  kind  (d' annular  depression  in  the  walls  of  the  bladder. 
These  facts  were  likewise  recognized  by  Sir  II.  Thomp.stui.  1  then  seized  the  growth  with 
a  pair  td'  Thompsons  fenestrated  forceps  (Fig.  'MVl)  and  drew  it  well  down,  and  having 
done  .so,  applied  to  its  pedicle  a  ligature  of  chroniicized  catgut. 

Sir  H.  Thompson  then,  whilst  I  held  the  growth  forward,  cut  oif  its  summit,  whicli 
measured  three-quarters  of  an  inch  across  (Fig.  304,  B).     This  turned  out  to  be  what  it 
appeared  at  the  time — a  piece  of  coarse  but  perfect  skin  with  sweat  and  .sebaceous  glands 
and  hair  follicles.     A  few  hairs  were  on  the 
surface,  but  the  bulk  of  them  liad  been  re- 
moved (Fig.  8(55). 

After  the  operation  all  the  liladder  symp- 
toms were  relieved  for  a  few  days;  they  then 
increased,  but  were  again  relieved  when  the 
pedicle  with  its  ligature  came  away  on  the 
tenth  day  (Fig.  8()4,  C).  After  this  every- 
thing went  on  well  for  a  few  days  till  the  cat- 
amenia  ai)peared,  when  bladder  troubles  re- 
turned and  rapidly  increased ;  indeed,  they 
soon  became  as  bad  as  ever. 

On  November  17  another  exploration  was 
made  of  the  bladder,  when  it  was  found  that 
the  pedicle  of  the  growth  which  had  been  left 
had  much  increased,  and  had  apparently  jiro- 
truded  as  far  again  as  ever  from  the  annular 
ring  in  the  bladder  which  was  noticed  at  the 
first  operation. 

The  polypus  was  consecjuently  again  seized 
and  drawn  down,  and  as  Sir  H.  Thomp.son  was 
about  to  apply  a  ligature  to  its  pedicle  the 
whole  thing  came  away  with  the  forceps  in 
my  hands.  The  growth  removed  was  as  large 
as  that  which  existed  at  the  first  operation, 
and  it  came  away,  pedicle  and  all  (Fig.  304,  D). 

After  the  operation  the  annular  ring  no- 
ticed was  very  distinct,  and  into  this  the  finger  was  pas.sed  with  ease.     I  need,  however, 
hardly  add  that  neither  I  nor  Sir  H.  Thompson  was  too  curious  as  to  where  it  led. 

With  this  operation  all  trouble  ceased.  The  bladder  in  two  days  was  well  able  to 
retain  its  contents.  In  three  days  all  blood  and  mucus  disappeared  from  the  urine.  In 
a  week  the  urine  was  normal.  At  the  end  of  two  weeks  from  the  operation,  with  the 
exception  of  a  little  soreness,  no  bladder  symptoms  existed,  and  WMtliin  one  month  the 
patient  was  as  well  as  she  had  ever  been  in  her  life.  She  is  now  as  if  she  liad  never  had 
a  bladder  trouble. 

Remarks, — I  believe  this  tumor  to  have  originated  from  a  dermoid  cyst  whicli  had 
been  implanted  in  the  walls  of  the  bladder  during  the  patient's  foetal  life  :  that  it  began 
to  undergo  chansjes  in  its  interior  a  few  days  before  she  came  into  my  hands  for  rectal 
41  " 


7  Muscular 


Microscopical  .Appearances  of  a  Section  of  the  Skia 
covering  the  I>eriuoid  Tumor. 


642  DISEASES  OF   THE   BLADDER  AND  PROSTATE. 

mischief;  that  the  tumor,  then  acutely  inflamed,  gave  rise  to  the  severe  constitutional 
symptoms  mentioned  and  opened  into  the  vesical  cavity  ;  that  at  its  opening  it  discharged, 
firstly,  the  mass  of  fine  long  and  short  hairs  covered  with  a  very  thin  layer  oi'  ])hosphatic 
deposit,  and,  secondly,  the  innumerable  larger  masses,  or  rather  calculi,  which  were  sub- 
sequently passed  or  removed;  that  for  a  time,  the  cyst  having  partially  discharged  it- 
self, the  bladder  trouble  subsided,  and  when  it  reappeared  it  was  from  the  formation  of 
almost  a  calculus  upon  the  remaining  hairs  which  the  dermoid  cyst  then  contained  ;  that 
this  cyst  then  began  to  turn  inside  out,  and  from  the  ex]>ulsive  action  of  the  bladder  to 
become  polypoid;  that  at  the  first  operation,  when  the  bulk  of  the  projecting  growth  was 
removed,  this  process  was  not  completed,  such  having  taken  place  only  at  the  second. 

In  support  of  these  views  Dr.  Goodhart's  following  report  of  the  preparation  will  be 
read  with  interest : 

"  The  specimens  submitted  to  me  were  a  rounded,  knob-like  piece  with  a  truncated 
end,  which  had  been  removed  at  the  first  operation,  and  an  elongated,  somewhat  irregular- 
shaped  mass,  presumably  the  stalk  from  which  the  first  piece  had  been  removed.  Both 
had  long  dark  hairs  growing  from  them  in  considerable  numbers,  and  these  were  mostly 
thickly  covered  with  a  shell  of  yellowish  phosphatic  matter. 

"A  section  of  the  knob  showed  it  to  consist,  apparently,  of  a  layer  of  thickish  skin, 
with  a  quantity  of  tough  fibrous  tissue  beneath  it  (Fig.  HG5).  The  opinion  furnished  by 
the  naked  eye  was  quite  borne  out  by  microscopical  examination.  No  lengthy  descrip- 
tion need  be  given  of  it,  as  a  very  truthful  drawing  of  a  part  of  the  section  has  been 
made  by  Miss  Boole,  which  will  show  at  once  that  the  growth  is  composed  of  perfect 
skin.  At  <t  I)  c  is  the  epidermal  layer,  with  its  horny  layer  at  a,  the  intermediate  layer 
at  b,  and  the  mucous  layer  at  c :  below  this  comes  a  thick  layer  of  fibrous  tissue,  </,  which 
has  been  reduced  in  the  drawing  to  allow  of  the  introduction  of  the  deeper  part.  At  e  is 
a  sebaceous  gland ;  at  /  a  section  of  a  hair  cut  obliquely  and  surrounded  by  its  cuticular 
sheath  ;  while  at  ff  are  seen  sections  of  sweat  glands. 

"The  only  question  that  arises  from  the  appearances  is  as  to  the  existence  or  not  of 
striped  muscular  fibres. 

"  In  many  parts  of  the  section  are  broad  bands  (a  piece  of  one  is  shown  at  /()  which 
look  very  much  like  muscular  fibre,  but  the  striati(Ui  is  nowhere  distinct  enough  to  pro- 
nounce with  any  certainty.  I  am  inclined  to  regard  them  as  an  embryonic  form  of  mus- 
cle midway  between  the  striped  and  unstriped  varieties.  But,  however  this  may  be,  the 
nature  of  the  growth  is  clearly  similar  to  what  upon  the  surface  of  the  body  would  be 
called  molluscum  fibrosum — that  is  to  say,  a  polypoid  overgrowth  of  the  corium  and  sub- 
cutaneous tissue,  covered  by  the  epidermal  layers. 

"  In  the  urinary  bladder,  naturally,  the  first — and,  indeed,  the  one — question  is  how 
such  an  excrescence  could  get  there,  and  I  believe  that  only  one  answer  to  that  question 
has  any  degree  of  probability  attached  to  it. 

"  It  has  been  suggested  that  it  is  some  congenital  growth,  like  a  hairy  mole  upon  the 
skin  ;  but  taking  into  account  the  history,  which  conclusively  establishes  that  the  patient 
was  perfectly  free  from  any  vesical  trouble  of  any  kind  until  recent  date,  and  knowing 
that  hair  in  the  bladder  always  provokes  a  deposition  of  phosphates  and  causes  extreme 
worry  and  cystitis,  it  is  inconceivable  that  this  growth  has  been  in  the  bladder  any  length 
of  time.  It  must,  therefore,  have  come  from  the  outside.  The  history,  again,  points 
strongly  toward  this  conclusion,  for  the  first  symptoms  were  those  of  high  fever  and  sub- 
sequent cystitis.  I  take  it,  therefore,  as  probable  that  at  that  time  some  inflammation 
occurred  around  this  growth,  situated  outside  the  bladder,  that  ulceration  occurred  in  the 
bladder  and  the  polypus  escaped  into  the  cavity,  and  that  when  once  there  it  immediately 
provoked,  as  such  a  growth  might  be  expected  to  do,  the  intense  cystitis  that  then 
happened. 

"  When  we  further  have  to  decide  whence  the  growth  sprang,  the  facts  of  the  case 
are,  I  think,  quite  unmistakable ;  for  before  the  growth  had  been  detected  a  mass  of  hair 
had  been  discharged  from  the  bladder,  with  a  quantity  of  phosphatic  matter  (?  fatty 
matter).  This  surely  indicates  that  a  dermoid  cyst  had  opened  into  the  bladder,  and  the 
growth  in  question  was  no  doubt  a  .sprout  from  its  wall.  Whether  the  dermoid  cyst 
sprang  from  the  ovary,  as  is  naturally  moxt  probable,  or  came,  as  is  not  unknown,  from 
some  other  part  of  the  pelvis,  there  is  no  evidence  in  the  preparation  to  determine." — 
James  F.  Ooodhart. 

Atony  of  the  bladder  is  a  want  of  muscular  power  in  the  bladder  to  expel  its 
contents,  as  a  result  of  overdistension  from  either  compulsory  retention  or  organic  obstruc- 
tion, or  from   some  cerebral  disturbance  or  from   fever,  etc.      It  has  been  often   falsely 


yj:sj(  '().L\Ti:sTi.\. i  /.  i  isri  'la .  vA.i 

di'Hcribod  as  paralysis  uf  tin-  Itladdcr ;  Imt  wlicrcas,  in  jtaralysis,  tho  |f)ss  of  j)r)WiT  is  due 
to  a  want  nt'  iicrv*-  supjily,  in  atuny  it  is  the  ri-sult  of  want  of  ninscular  p(»W('r  due  to 
exhaustion  or  overstretehinj:.  It  may  he  assoeiated  with  retention  (jr  witli  ineontinetice, 
the  latt«'r  eondition  showin-;  itself  when  tlie  hladiler  is  overeharired.  the  drihhlinj:  of 
urine  heini;  a  mere  overflow. 

TuKATMK.NT. — As  the  eaiise  of  atony  of  the  bladder  i>  muscular  exhaustion,  so  the 
treatment  «-onsists  in  jriving  the  or<;an  muscular  repose,  which  can  be  done  by  catheter- 
ism.  Where  the  atony  is  not  very  complete,  the  dra\vin<^  off  of  the  urine  twice  a  day 
may  suffice  t<i  allow  the  or^^an  to  recover  its  tone  and  to  act  naturally  ;  but  when  the 
atony  is  extreme,  it  may  be  necessary  to  introduce  a  catheter  into  the  bladder  and  to 
fasten  it  there,  the  urine  beiuLC  allowed  to  run  away  as  .secreted  throuj!;h  a  tube  fixed  on 
the  eiul  of  the  catheter.  By  this  means  the  most  complete  rest  can  be.  given  t(»  the 
organ.  Where  the  bladder  is  sluggish  in  resuming  its  functions,  tonics  such  as  ir(»n  may 
be  given,  with  the  local  injection  into  the  bladder  of  .some  stimulant,  as  cold  water, 
diluted  nitric  acid,  or  tincture  of  iron  in  the  proporti<»n  of  four  to  ten  drops  to  the  ounce; 
but  catheterism  ahuie,  as  a  rule,  is  enough,  these  cases  generally  reccjvering  unless  the 
cause  has  been  acting  for  too  long  a  period.  W^hen  recovery  is  slow,  an  electric  shock 
through  llif  |iclvis  is  uftcii  beneficial. 

Paralysis  of  the  bladder  is  a  far  more  serious  affection  than  atony,  since  the 
want  of  power  is  due  to  deficiency  in  nerve  supply  ;  which  deficiency  may  be  partial  or 
complete.  It  is  met  with  whenever  the  spinal  cord  is  injured  or  diseased,  as  in  brain 
shocks  or  disease,  in  reflected  irritation  from  disea.se  about  the  rectum,  uterus,  etc.,  and 
after  any  operation  upon  these  parts.  It  may  be  caused  also  by  a  severe  mental  shock  or 
the  general  depression  from  a  fever. 

Tre.\t.me.\t. — The  cause  of  the  paralysis  in  these  cases  must  always  have  an  import- 
ant influence  on  the  practice  of  the  surgeon,  but  the  necessity  of  keeping  the  bladder 
empty  is  essential  under  all  circumstances  ;  for  this  purpose  a  soft,  full-sized  elastic  cath- 
eter had  better  be  passed  two  or  three  times  a  day,  the  greatest  gentleness  being  observed 
in  the  manipulation.  When  anything  like  cystitis  is  present,  it  should  be  locally  treated 
by  washing  out  the  bladder,  etc.,  as  already  indicated.  To  leave  a  catheter  in  the  blad- 
der is  not  desirable.  When  professional  aid  is  not  always  at  hand,  a  nurse  may  at  times 
be  entrusted  with  a  full-sized  vulcanized  india-rubber  catheter  without  a  stylet  and 
allowed  to  pass  it ;  it  has  simply  to  be  pushed  down  the  penis,  and  can  do  no  harm.  In 
fever  cases  the  plan  is  a  good  one. 

Hysterical  retention  is  not  rarely  met  with  in  women,  and  is  difficult  to  treat. 
Catheterism  is  to  be  resorted  to  only  when  necessity  compels,  hysterical  patients  usually 
micturating  when  the  pain  of  retention  calls  loudly  for  relief.  The  cold  douche  over  the 
lower  part  of  the  abdomen  is  a  good  local  remedy  for  the  affection,  and  not  too  plea.sant 
for  the  patient  to  wish  for  its  repetition.  Moral  treatment  is  always  called  for  in  these 
cases,  and  is  more  needful  than  surgical  interference. 

Vesico-Intestinal.  Fistula. 

This  is  sometimes  met  with,  and  it  is  probable,  in  the  majority  of  cases,  that  the 
ulcerating  process  commences  in  the  bowel  and  involves  the  bladder  in  a  secondary 
way. 

Symptoms. — It  usually  first  manifests  its  presence  by  the  passage  of  wind  with  the 
water,  some  little  irritability  of  bladder  having  previously  existed ;  feces,  liquid  or  solid, 
soon  follow,  giving  rise  to  fetid  urine  and  severe  bladder  symptoms,  the  pain  of  foreign 
material  in  the  bladder  being  very  marked  when  the  large  intestine  or  rectum  is  involved; 
the  liquid  motion  of  the  small  intestine  does  not  appear  to  give  ri.se  to  the  same  local  dis- 
tress as  the  solid. 

DlAGNOSLS. — There  is  no  difiiculty  in  recognizing  this  mixture  of  urine  and  intestinal 
contents.  When  flatus  pas.ses  per  uref/iram,  the  ct)ndition  may  be  suspected  ;  when  the 
urine  has  a  fecal  odor  and  color,  the  condition  gives  rise  to  something  more  than  a  sus- 
picion; and  when  solid  feces  are  visible,  the  diagnosis  is  certain.  In  doubtful  cases  the 
microscoj)ical  examination  of  the  sediment  of  the  urine  will  readily  reveal  its  nature.  At 
times  the  feces  may  obstruct  the  ui'ethra  and  cause  retention. 

In  looking  into  the  history  of  these  cases  there  will  usually  be  found  some  bowel 
symptoms,  some  diarrhoea  or  dysenteric  affection,  some  symptoms  of  stricture  or  cancer 
of  the  bowel ;  and,  although  this  afi'ection  may  be  found  associated  with  cancerous  disease, 
it  seems  more  frequently  to  be  the  result  of  the  simple  perforating  ulcer  of  the  bowel. 


644  DISEASES   OF  THE  BLADDER  AND   PROSTATE. 

Treatment. — When  a  fecal  fistula  has  once  formed  betw(;en  the  bowel  and  bladder, 
the  hopes  of  an  unaided  natural  cure  are  very  feeble  ;  when  solid  motions  are  mixed  with 
the  urine,  but  little  can  be  done  except  by  an  operation  to  palliate  the  suffering  that  is 
produced.  For  a  time  the  bladder  may  be  emptied  of  its  contents  and  by  being  washed 
out  freed  of  its  local  irritant,  but  the  truce  can  be  only  for  a  limited  period,  another 
action  of  the  bowel  being  to  a  certainty  followed  by  a  fresh  entry  of  feculent  material 
into  the  bladder,  with  all  its  evil  effects. 

When  liquid  motions  or  small  intestine  contents  communicate  with  the  bladder,  the 
symptoms  are  not  nearly  so  distressing,  and  the  necessity  for  interference  is  thereby 
diminished. 

The  only  means  the  surgeon  has  at  his  disposal  by  which  relief  can  be  afforded  is 
colotomy  ;  and  when  the  rectum  is  the  seat  of  the  disease,  whether  cancerous  or  other- 
wise, lumbar  colotomy  ought  to  be  performed.  By  it  the  feces  are  diverted  from  their 
unnatural  channel  and  discharged  through  the  loin,  and  all  the  miseries  of  bladder  com- 
plication are  effectually  relieved.  When  the  ulceration  is  of  a  simple  kind,  there  is  some 
prospect  of  its  closing ;  when  of  a  cancerous  nature,  such  a  result  cannot  be  expected ; 
but  under  both  circumstances  a  large  amount  of  relief  is  immediately  afforded  and  life 
prolonged. 

I  have  had  four  cases  of  vesico-intestinal  fistula,  in  which  this  operation,  lumbar  colo- 
tomy, has  been  performed  with  marked  success ;  one  lived  six  years  after  the  operation, 
and  died,  aet.  70,  from  ruptured  heart ;  the  second  is  still  alive  and  well,  eleven  years 
after  the  operation  ;  the  third  died  four  months  after  the  operation,  from  kidney  dis- 
ease. Mr.  Holmes,  Mr.  C.  Heath,  and  Mr.  Pennell  of  Rio  have  had  similar  cases.  (For 
further  information  vide  Holmes's  paper,  Med.-Clrir.  Trans.,  18GG-67,  and  case,  with 
remarks,  by  author,  Brif.  and  Foreign  Qnarterly,  January,  1869;  and  Clin.  Soc.  Trans., 
1872.) 

Incontinence  of  Urine 

is  met  with  under  two  very  different  conditions — in  the  one  during  sleep,  when  the  will 
of  the  patient  is  in  abeyance,  the  neck  of  the  bladder  ceasing  to  act,  from  want  of  power, 
and  giving  rise  to  nocturnal  incontinence  ;  in  the  other  the  incontinence  is  only  a  result  of 
overdistension  and  is  a  mere  overflow.  The  first  form  is  common  in  children,  the  second 
in  adults.  Incontinence,  however,  in  both  the  child  and  the  adult,  may  be  due  to  bladder 
irritation  from  the  presence  of  a  stone  or  other  foreign  body,  and  it  will  then  exist  during 
the  day  rather  than  at  night.  It  may  also  follow  the  operation  of  lithotomy  from  injury 
to  the  sphincter  of  the  neck  of  the  bladder. 

Incontinence  in  the  child  is  a  very  troublesome,  and  often  a  very  obstinate, 
affection.  It  is,  notwithstanding,  generally  curable,  and  even  in  very  bad  cases,  as 
puberty  approaches,  the  symptom  disappears,  though  in  exceptional  instances  the  infirm- 
ity continues  in  after-life.  The  child  is  generally  brought  to  the  surgeon  because  he 
"  wets  his  bed,"  when  too  often  the  history  reveals  the  painful  fact  that  punishment  has 
been  severely  tried  before  professional  advice  was  sought ;  and  it  is  needless  to  add  that 
by  such  a  process  no  cure  can  be  effected.  In  many  instances  the  habit  is  in  a  measure 
induced  by  a  want  of  attention  in  the  parents  to  take  up  the  child  during  the  long  hours 
of  the  night. 

Tre.\t>ient. — When  the  prepuce  is  very  long  or  adherent,  circumcision  should  be 
performed. 

When  the  urine  is  chemically  wrong  in  any  of  its  constituents,  remedies  must  be 
given  to  correct  the  faults,  and  a  limpid  watery  urine  in  a  child,  as  in  an  adult,  is  always 
an  irritant. 

With  respect  to  medicines,  the  tincture  of  iron  is  doubtless  the  best,  and  next  to  it 
belladonna  in  the  form  of  either  the  tincture  or  the  extract,  but  in  some  instances  the 
combination  of  the  two  is  excellent. 

I  have  tried  and  been  disappointed  with  full  doses  of  chloral  given  at  bedtime.  It 
acts  at  times  wonderfully  well,  but  at  others  appears  useless.  When  employed,  it  should 
be  given  on  an  empty  stomach.  Tonics  are  the  right  medicines,  one  form  often  succeed- 
ing where  another  fails,  iron,  quinine,  nux  vomica,  and  zinc  being,  as  a  rule,  better  than 
belladonna.  The  tonics  by  day  and  a  night-dose  of  belladonna  have  sometimes  proved 
of  value. 

The  bowels  should  always  be  attended  to  and  the  presence  of  worms  considered,  and 
it  is  well  to  have  the  bowels  relieved  at  night  before  going  to  bed.  When  the  child  is 
not  too  young,  cold  baths,  with  or  without  salt,  should  be  used ;  and  every  means  should 


ryrLAMMATiox  of  riii:  i'i:nsT.\Ti-:.  045 

lu"  I'liiplovftl  to  iiiaiiitaiii  the  <r«'iu'ral  licaltli.  altlnMij:li  it  must  lie  aiMcfl  that  cliiMrcii  who 
hibor  under  thi.s  intirniity  are  rarely  teilth-  and  caehcciic  The  chihl  .should  he  eiieoura^ed 
to  sleep  on  his  side  in  |»ret'erenee  to  his  haek,  and  lor  tliis  end  a  handkerehief  with  a  knot 
in  it  may  be  fastened  round  the  pelvis,  the  knot  hein^'  adjusted  over  the  sacrum. 

|)r.  W.  Steaven.son  reeords  (Ji/it.  Mnl.  Jnuni..  January  (i,  1HH3)  cases  of  lr('i|U('iit 
micturition  treated  hy  eU'etrieity  with  the  most  henefieial  results.  In  these,  one  elec- 
trode, in  the  form  of  a  spinal  disc,  was  connected  with  the  positive  pole  of  the  battery 
and  ap])lied  to  the  lumbar  rei.non.  and  the  other  electrode  was  applied  ab(»ve  the  pubes 
or  to  the  peri:!;tMim  ;  throuu:h  lhe.se  a  weak  current  was  passed  for  a  few  minutes  daily. 
Ivclicf  of  the  symptoms  from  the  C(»inmencement  of  tlu'  trcatmi-iit  and  l>y  coinpjctc  cure, 
usually  within  a  furtniiilit.  have  been  the  results. 

In  cases  of  extreme  obstinacy  some  surL^Mms  ajijdy  a  solution  of  nitrate  of  silv«'r  ten 
<;rains  to  the  ounce  t<»  the  neck  of  the  bladder,  and,  it  is  said,  with  advanta<:e.  (Jthers 
apply  mechanical  means  to  prevent  the  flow  of  urine,  such  as  an  india-ruliber  rin<:r  around 
the  penis,  or  cover  up  the  urethral  or  preputial  orifice  by  a  layer  of  collodion,  (iood 
reports  have  been  <riven  of  these  practices.  I  cannot  say  that  I  think  well  of  any  such 
means  and  have  never  adopted  them,  as  they  seem  wrong  in  principle. 

Xvcturuid  incontinence  in  a  child  generally  means  atony  of  the  sphincter,  while  incon- 
tinence duriuLT  the  </"//  suirirosts  bladder  irritation,  generally  a  stone  or  urethral  obstruction. 

Incontinence  in  the  adult,  as  already  stated,  means,  as  a  rule,  overfulness  of 
the  bladder,  the  real  condition  being  one  of  retention  from  some  obstructive  urethral  or 
prostatic  disease,  bladder  atony,  or  paralysis.  It  may,  however,  be  due  to  stone  or  to  a 
preceding  lithotomy.  In  women  it  may  be  associated  with  some  uterine  displacement  or 
disturbance,  some  urethral  disease  or  injury.  In  men  and  women  severe  spine  disease 
may  cause  it. 

Treatment. — To  treat  it  the  cause  mu-st  be  ascertained,  and  the  introduction  of  a 
catheter  is  probably  a  sound  practice  to  follow  as  the  first  means  of  investigation,  since  it 
settles  at  once  the  question  of  retention  and  often  detects  tlie  true  cause,  thereby  giving 
a  clue  to  the  treatment  to  be  adopted — viz.,  the  removal  of  the  cause. 

True  incontinence,  however,  is  met  with  in  severe  cases  of  general  or  local  paralysis, 
in  functional  derangement  of  the  cord  from  venereal  exces.ses.  and  still  more  frequently 
from  self-abuse,  such  patients  often  complaining  of  '•  inability  to  stop  the  flow  of  urine 
when  commenced.'  It  is.  however,  seen  in  old  people  with  prostatic  enlargement,  the 
tbii'd  lobe  being  enlarged  and  pi'ojecting  forward  between  the  lateral  lobes,  so  as  to  open 
out  the  neck  of  the  bladder  and  render  it  constantly  patent,  the  incontinence  being  due 
to  overflow  the  result  of  retention. 

In  these  ca.ses  the  use  of  a  urinal  is  the  only  remedial  means  at  the  surgeons  com- 
mand, except  in  those  caused  by  venereal  excesses,  when  tonics,  cold  bathing,  and  abso- 
lute abstinence  from  all  injurious  habits  may  effect  a  cure. 

DISEASES   OF  THE  PROSTATE. 

The  diseases  of  the  prostate  gland  are  of  importance.  Placed,  as  the  gland  is,  at  the 
neck  of  the  bladder  and  at  the  commencement  of  the  urethra,  on  the  one  hand  it  may 
suffer  as  a  consequence  of  urethral  disease,  and  on  the  other,  when  di.sea.«ed.  it  may  give 
rise  to  bladder  symptoms  of  considerable  severity.  Thus,  as  a  conseijuence  of  urethral 
di.sease.  gonorrh(jea,  or  stricture,  it  may  inflame  or  suppurate  and,  mechanically  interfering 
with  the  flow  of  urine,  cause  retention.  It  may,  indeed,  undergo  nearly  complete  destruc- 
tion from  supj)uratioii.  the  direct  conse(|uence  of  stricture,  and  possibly  of  extravasation. 
When  enlarged  from  hypertrophy,  stone,  cancer,  or  any  other  cause,  it  may  mechanically 
interfere  with  the  flow  of  urine,  and  so  give  rise  to  bladder  symptoms  or  bladder  disease 
of  no  slight  severity,  and  later  on  cause  incontinence  from  overflow  by  the  special  direc- 
tion of  the  growth. 

Inflammation  of  the  Prostate. 

This  is  usually  due  to  the  extension  backward  of  a  gonorrhoeal  inflammation  or  to  the 
presence  of  a  stricture.  It  may  arise,  too.  as  a  complication  of  cy.stitis  from  the  irritation 
of  a  calculus,  the  passage  of  a  sound,  or  the  application  of  caustics.  It  is  also  not 
unknown  as  an  idiopathic  affection  in  gouty  subjects  and  in  those  who  indulge  in  sexual 
excesses. 

Symptoms. — It  is  generally  ushered  in  with  pain  in  the  perinieum  and  bladder  irrita- 


646  DISEASES  OF  THE  BLADDER  AXD  PROSTATE. 

tion,  the  act  of  micturition  being  attended  and  followed  by  pain,  and  often  tenesmus. 
Defecation  eea.ses  to  be  a  painle-ss  act,  and  is  attended  with  uneasiness,  sometimes 
with  difficulty,  and  at  last  with  distress.  On  manipulating  the  perinaeum  a  deep-seated 
fulness  will  be  felt,  and  on  passing  the  finger  into  the  rectum  the  prostate  will  be  found 
enlarged,  spongy,  and  painful :  rigors  probably  will  form  one  of  the  general  symptoms, 
with  febrile  disturbance,  which  will  vary  in  severity  according  to  the  acuteness  of  the 
aifection. 

If  the  inflammation  advances  to  abscess,  a  throbbing  pain  at  the  neelc  of  the  bladder 
will  be  felt,  with  a  constant  desire  to  go  to  stool,  and  retention  of  urine  is  almost  .sure  to 
occur. 

If  left  alone,  the  abscess  will  probably  burst  into  the  urethra  and  discharge  itself 
externally,  with  immediate  and  marked  relief;  while  in  other  cases  it  may  open  into  the 
rectum.  It  sometimes  happens  that  the  abscess  is  ruptured  during  the  passage  of  a 
catheter  to  relieve  retention  or  during  a  rectal  examination. 

When  the  disease  is  acute,  the  local  as  well  as  the  general  .symptoms  will  be  severe ; 
but  when  chronic,  they  will  be  less  marked,  though  not  less  characteristic. 

As  a  result  of  acute  inflammation  chronic  disease  is  often  left,  as  indicated  by  pain  in 
passing  water,  irritability  of  bladder,  a  thin  urethral  discharge,  cloudy  purulent  urine, 
and  perineal,  pelvic,  and  anal  pain,  which  is  increased  on  exercise  or  excitement.  There 
mav  be  at  times  some  little  loss  of  power  in  emptying  the  bladder,  pain  in  sexual  inter- 
course, or  frequent  nocturnal  emissions. 

Treatment. — When  the  symptoms  are  acute,  few  remedies  give  more  relief  than  the 
application  of  fifteen  or  twenty  leeches  to  the  perina?nm.  followed  by  a  hot  hip  bath  and 
the  subsequent  application  of  a  linseed  poultice  made  with  the  decoction  of  poppies  or 
mixed  with  the  extract  of  opium.  A  good  purge  should  also  be  resorted  to.  and  alkalies 
given,  with  sedatives  such  as  morphia  or  opium,  allay  pain. 

When  retention  of  urine  complicates  the  case,  a  catheter  must  be  passed,  a  catheter 
coude  being  the  best :  but  the  warm  bath  and  opium  should  first  have  been  employed,  as 
the  introduction  of  a  catheter  under  such  circumstances  is  always  painful  and  may  do 
harm.  When  required,  an  elastic  instrument  which  has  been  well  softened  and  oiled 
should  be  selected.  Rest  in  the  horizontal  posture  should  be  observed  and  liquid  diet 
given. 

When  an  abscess  has  formed  and  there  is  evidence  of  deep-seated  perineal  suppura- 
tion, an  incision  in  the  median  line  of  the  perinfeum  should  be  made  ;  and,  indeed,  if 
suppuration  has  not  taken  place,  the  operation,  by  lessening  tension,  will  be  followed  by 
relief  to  the  .symptoms. 

When  the  abscess  has  opened  naturally,  no  surgical  interference  is  usually  required, 
although  in  exceptional  cases,  where  one  abscess  is  followed  by  another  and  the  deep  parts 
about  the  gland,  instead  of  undergoing  repair,  are  becoming  more  involved,  a  perineal 
incision  should  be  made.  When  the  suppuration  is  the  result  of  a  stricture  and  has 
probably  been  caused  by  extravasation,  the  propriety  of  dividing  the  stricture  and  laying 
open  the  perineum  down  to  the  prostate  cannot  be  questioned. 

In  chronic  inflammation,  whether  the  sequel  of  the  acute  or  not.  when  attended  with 
suppuration,  the  practice  already  advised  should  be  followed.  When  no  suppuration 
exists,  but  only  enlargement,  counter-irritation  by  means  of  small  perineal  blisters  is  of 
great  use,  and  the  elevation  of  the  pelvis  with  a  pillow  at  night  is  also  valuable.  Tonics, 
as  a  rule,  are  required,  with  the  iodide  of  potassium.  The  bowels  should  never  be  allowed 
to  be  confined,  the  best  laxatives  being  some  saline  medicine  or  one  of  the  natural  mineral 
waters,  such  as  Vichy  or  Pullna.  All  mechanical  interference  with  the  prostate  should 
be  avoided  and  the  nocturnal  emissions  treated  on  general  principles,  and  not  as  being 
due  to  a  local  cause,  tonics,  generous  living,  and  fresh  air  doing  more  toward  hastening 
recoverv  than  anything  else.  Over-exercise  must  be  avoided  and  sexual  excitement  for- 
bidden. 

Abscesses  occasionally  occur  around  the  prostate  and  give  rise  to  very 

many  of  the  same  symptoms  as  a  prostatic  abscess.  They  are  more  apt.  however,  to 
make  their  way  toward  the  po.sterior  part  of  the  perinseum  into  the  ischio-reetal  fossa. 
As  soon  as  they  are  recognized  they  should'  be  opened  by  one  or  two  deep  incisions  in 
front  of  the  anus  on  either  side  of  the  median  line.  On  one  occasion  I  let  out  by  two 
incisions  about  a  pint  of  pus  that  had  accumulated  in  this  part,  and  produced  complete 
retention  of  urine  for  several  days.  Immediate  relief  and  a  good  recovery  followed  the 
operation. 


nvriinTUnriiY  m-  riii:  i'iiostati:.  047 


Hypertrophy  of  the  Prostate. 


This  is  a  giMieral  ttTiii  a|>|ili«'(I  to  a  clinuiif  fiilar<r<'iii»'iit  nt"  tlic;  ^laiid  which  is  not 
iiitlamiiiati»ry.  hut  is  <;fin'iallv  hdifvctl  to  ht-  a  coniiiinii  <oiisci|U(mic('  of"  ohl  a;r«;  ;  itidceil, 
it  has  hi'i'ii  reiranh'd  as  a  part  ol'a  ^rciuTal  sciiih-  chaiiiro.  l'athohi;_'iral  iii\  i'sti;.'utio!is,  how- 
ever, havt'  tauirht  us  tliat,  altliouj^'h  tliis  is  an  atlV-ctioii  of  advanced  lite,  it  is  iti  no  way  a 
neeessary  atteiichmt  on  ohl  a^re,  the  vast  majority  of  old  men  havin;^  nothing'  of  the  kind. 

When  present,  it  is  usually  met  witli  in  suhjeets  over  si.xly.  I'lionipson  has  not  met 
witli  an  e.xamph^  under  the  aj^e  (tf  fifty-four,  and  after  many  dis.sections  of  the  pro.states 
of  elderly  men  he  found  an  appreciahle  eidargement  of  the  organ  in  one-tliird  of  the  cuhch, 
but  only  in  one-third  of  tliese  wa.s  it  enough  to  cause  .symptom.s  during  life. 

l'.VTii(»L(»(iY. — The  di.sea.se  i.s  generally  believed  to  be  a  hypertropliy  or  overgrowth 
of  natural  tissues,  and  in  a  certain  ])roportion  of  instances  this  is  doubtless  the  case;  but 
in  others  the  enlargi'nient  is  clearly  caused  by  the  development  of 
distinct  glandular  tumors  embedded  within  the  structure  of  tlie 
gland,  which  may  be  si|ueezed  out  of  the  organ  u]>on  division  of 
the  tissues  covering  them  in.  They  are  sometimes  merely  covered 
by  the  capsule  of  the  prostate,  while  at  others  they  are  well  ])laced 
within  its  structure  ;  at  times  they  are  single,  at  others  multiple, 
and  rarely  give  rise  to  any  otiier  than  mechanical  symptoms. 
When  tliese  growth.s  are  situated  in  what  is  called  the  third  lobe 
of  the  prostate,  they  give  rise  to  .symptoms  of  obstruction  and 
bladder  irritation  ])reci.sely  similar  to  those  caused  by  the  genuine 
enlargement  or  hypertrophy  of  the  gland  itself.  The.se  fibrous  (jr 
glandular  tumors  are  analogous  to  those  found  in  the  uterus.  This 
hypertrophy  is  now  known  to  be,  as  shown  by  Ellis  and  others,  a  I 
mere  increase  in  the  natural  fibrous,  muscular,  and  glandular  struc-  " 
ture  of  the  organ.  The  enlargement  is  mostly  general,  and  as  long 
as  the  vesical  or  third  lobe  is  not  materially  enlarged  or  the  urethra 
encroached  upon  it  is  extraordinary  to  what  a  size  the  prostate  may 
attain  without  giving  rise  to  any  special  symptoms.  It  is.  indeed,  '^tbf  ofX^olme'wIJh 
only  when  the  so-called  third  lobe  increases  bladder-ways  and  inter-  Dilatation  and  Hypertro- 
feres  mechanically  by  its  size  or  the  direction  of  its  growtb  with  ^  ^  ** 
the  act  of  micturition  that  any  marked  symptoms  are  produced.  In  the  preparation  from 
which  Fig.  36G  was  taken  this  condition  is  w'ell  shown. 

The  effect  of  an  enlargement  of  the  prostate  upon  the  urethra  is  very  variable.  At 
one  time  the  prostatic  urethra  will  be  elongated  to  twice  or  more  its  normal  length,  while 
at  another  it  will  be  tortuous,  this  condition  being  caused  by  an  unequal  enlargement 
of  the  lateral  lobes.  In  a  third  class  the  urethra  will  be  more  or  less  obstructed.  In 
the  bladder  other  changes  are  found,  and  the  sudden  projection  upward  of  the  ve.sical 
or  third  lobe  is  the  most  common  ;  yet  when  with  this  there  is  an  enlargement  of  one  or 
other  of  the  lateral  lobes,  a  greaft  irregularity  of  the  urethra  is  the  result. 

This  enlargement  of  the  prostate  may  so  derange  the  course  of  the  muscular  fibres 
about  the  trigone  of  the  bladder  as  to  produce  a  bar  or  ridge  that  mechanically  interferes 
with  micturition,  (luthrie  and  Mercier  have  described  such  a  bar  as  occurring  independ- 
ently of  these  changes,  the  bar  consisting  of  the  elastic  structure  and  mucous  meiubrane 
of  the  neck  of  the  bladder.  Thomp.son  also  asserts  that  in  ''  very  exceptional  instances 
the  bar  is  undoubtedly  to  be  met  with."  I  have  never  known  such  a  bar  as  that  last 
described,  and  give  it  onlj-  on  the  authority  of  the  names  quoted.  It  is  .said  to  occur 
earlier  in  life  than  prostatic  enlargements  and  to  give  rise  to  similar  symptoms.  Hyper- 
trophied  prostates  are  sometimes  met  with  measuring  four  inches  in  diameter,  and  are 
common  at  half  that  size.  They  have  been  found  to  weigh  ten  or  twelve  ounces,  the 
normal  weight  of  the  pro.state  being  four  and  a  half  drachms. 

Symptoms. — So  long  as  the  vesical  orifice  of  the  urethra  is  not  mechanically 
encroached  upon  prostatic  enlargement  may  proceed  to  an  extreme  degree  without 
giving  rise  to  any  definite  symptoms,  and  retention  of  urine  is  very  often  the  first 
feature  that  attracts  notice.  But  under  these  circumstances  it  generally  will  be  found 
that  the  patient  has  had  for  some  time  a  difiiculty  in  micturition,  that  the  bladder  has 
hesitated  to  contract  when  the  desire  to  pass  urine  manifested  itself,  and  that  either  there 
has  been  less  force  in  the  expulsion  of  the  fluid  than  formerly  or  the  water  has  •flowed  in 
a  more  languid  stream. 

Irritability  of  the  bladder  will  generally  be  present,  the  act  of  passing  urine  being 


648  DISEASES   OF  THE  BLADDER  AXD  PROSTATE. 

raj>idly  followed  by  the  desire  to  do  so  again,  and  the  difficulty  of  the  act  gradually 
increasing. 

As  the  disease  progresses  a  feeling  of  weight  and  fulness  in  the  perinaeum  and  of 
irritation  about  the  rectum  will  soon  appear,  the  rectal  irritation  and  the  irritability  of 
bladder  increasing  equally,  till  at  last  the  two  acts  of  defecation  and  micturition  take 
place  together,  the  violent  straining  and  tenesmus  giving  rise  to  prolapse  of  the  rectum 
or  piles  and  leading  the  patient  to  believe  that  the  bowel  complication  is  the  cause  of  his 
disease,  if  not  the  disease  itself. 

At  a  still  later  period,  and  as  the  result  of  the  bladder  being  unable  to  empty  itself,  a 
residuum  of  urine  remains  behind,  and  the  bladder  consequently  gradually  expands  from 
its  accumulation  and  becomes  exhausted  by  its  ineffectvial  expulsive  efforts.  The  urine, 
moreover,  at  the  same  time  decomposes  and  acts  as  a  direct  irritant  to  the  mucous  mem- 
brane of  the  bladder.  In  this  way  inflammation  of  the  bladder,  and  subsequently  incon- 
tinence from  the  overflow  of  a  distended  organ,  is  produced,  this  inconvenience  existing 
day  and  night. 

The  ultimate  result  of  this  aff"ection  left  to  nature  is  the  same  as  that  of  all  obstructive 
urethral  diseases  :  from  the  pressure  of  retention  the  bladder  sufters  first,  and  subsequently 
the  ureters  and  kidneys ;  oi'ganic  renal  disease  is  thus  set  up  and  the  powers  of  life  are 
gradually  sapped  by  exhaustion,  death  being  often  hastened  by  severe  bladder  symptoms, 
haematuria,  or  ura?mic  poisoning. 

A  physical  examination  of  a  patient  laboring  under  this  disease  will  probably  reveal  » 
bladder  more  or  less  distended,  and  the  passage  of  a  catheter,  even  after  the  patient  has, 
to  the  best  of  his  belief,  emptied  his  bladder,  will  prove  the  presence  of  several  ounces  of 
urine  which  may  be  ammoniacal,  this  change  in  the  urine  being  produced  by  its  partial 
decomposition  from  its  retention  and  admixture  with  the  mucus  of  the  bladder.  In  neg- 
lected cases  the  urine  will  be  fetid  and  may  contain  blood.  The  passage  of  the  catheter 
will  also  reveal  the  nature  of  the  obstruction  at  the  neck  of  the  bladder. 

On  passing  a  finger  into  the  rectum  the  enlarged  prcstate  will  be  felt,  and  in  some 
cases  may  nearly  fill  the  pelvis.  "When  pus  or  fluid  exists,  fluctuation  will  be  detected 
and  when  inflammation,  pain.  To  make  this  examination  nicely  the  finger  should  be  well 
anointed,  and  at  the  moment  of  its  introduction  the  patient  should  be  told  to  bear  down. 
It  should  be  remembered,  however,  that  to  appreciate  any  abnormal  condition  of  the  gland 
it  is  necessary  to  be  familiar  with  its  normal  state. 

As  a  consequence  of  this  afi'ection  and  of  the  change  produced  in  the  urine,  a  pho.s- 
phatic  calculus  may  form  ;  but  its  presence  is  often  masked  by  the  symptoms  of  the  dis- 
ease. When,  however,  there  is  increased  pain  after  micturition,  pus  and  blood  in  the 
urine,  and  extreme  pain  in  the  penis,  a  calculus  may  be  suspected ;  and  when  fragments 
of  phosphatic  deposit  pass,  the  suspicion  is  confirmed.  In  all  long-standing  cases  of  pros- 
tatic disease  with  bladder  symptoms  the  presence  of  a  stone  should  be  suspected,  although 
when  present  it  is  often  difficult  of  detection,  from  being  protected  by  the  enlarged  i)ros- 
tate,  behind  which  it  usually  lies. 

A  patient  with  enlarged  prostate  is  liable  to  retention  from  any  sudden  chill,  overdis- 
tension of  the  bladder,  mental  emotion,  or  fatigue;  indeed,  such  accidents  usually  reveal 
the  presence  of  the  afi'ection. 

Treatment. — Medicine  has  no  influence  in  checking  the  progress  of  this  disease  or 
in  causing  absorption  of  the  enlarged  organ.  l)ut  surgery  can  do  much  in  the  way  of  pal- 
liating the  symptoms  that  are  the  direct  result  of  the  enlargement  and  neutralizing  its 
evil  effects. 

The  most  essential  point  is  to  secure  the  complete  evacuation  of  the  bladder's  con- 
tents, and  also  to  see  that  no  residuum  of  urine  remains  in  the  bladder  to  irritate  the 
organ  and  decompose,  thereby  setting  up  cystitis.  This  should  be  done  by  the  passage 
of  a  catheter.  In  early  cases  where  but  little  bladder  irritation  exists  the  passage  of  the 
instrument  once  a  day  may  suffice ;  but  when  the  residual  urine  is  in  any  quantity  and 
the  bladder  has  lo.st  some  of  its  power  of  contraction,  the  introduction  of  an  instrument 
two  or  three  times  in  the  twenty-four  hours  may  be  necessary,  and  in  woi'se  cases,  where 
the  bladder  has  lost  all  power  of  contraction  on  account  of  its  overdistension  from  chronic 
retention,  it  may  be  neces.sary  or  expedient  to  tie  a  catheter  in  the  bladder  and  leave  it 
there  for  a  time.  The  surgeon  must  remember,  too.  that  instrumental  aid.  though  valu- 
able, is  a  necessary  evil,  and  .should  not  be  resorted  to  more  frequently  than  the  necessi- 
ties of  the  case  demand. 

Where  instruments  are  required,  a  flexible  full-sized  catheter  is  the  best.  When 
silver  instruments  are  employed,  one  with  a  large  curve  should  be  selected,  the  back  of 


iiYi'Kirnioriiv  <>/    riii:  rnosTATi:.  649 

the  t-atlutfr  lidiii;:  iiiuiv  readily  ovor  tliu  ciilar^'cd  vesical  <ir  third  lobe  of  the  prostate 
than  a  shorter  one.  To  assist  in  the  introduction  of  any  instrument  into  the  bladder,  the 
pass-a<re  id'  the  index  tinker  of  the  surfj^eon's  left  hand  fully  into  the  rectum  is  an  excel- 
lent aid,  and  under  all  circumstances  the  pelvis  of  the  patient  should  be  well  raised  on  a 
pillow. 

W  iicii  an  elastic  iiist niMiciit  i>  used  and  sonic  difliculty  experienced  in  ridinj;  over  the 
olistruction,  success  may  (jften  be  achieved,  as  soon  as  the  end  of  the  instrument  lias 
reatdicd  the  vesical  end  of  the  urethra,  by  the  withdrawal  id"  the  stylet  with  one  hand  and 
the  pressure  of  the  catheti'r  into  the  bladder  with  the  other.  Force  should  never  be 
employed,  <reiitlc  manipulation   and  care  almost   always  sufficing  to  secure  success. 

When  the  disease  is  chronic  and  the  necessity  of  catlieterism  is  j»ro)iablv  jiermanent, 
the  patient  should  be  taiitrht  to  pass  a  gum  elastic  catheter  for  himself,  a  few  lessons  and 
a  little  coiifiilence  ])eing  all  required  for  the  purpose. 

AVheii  the  bladder,  from  overdistension,  has  lost  all  power  and  it  is  necessary  that  it 
should  have  complete  rest  to  allow  it  time  to  recover  its  tone,  a  catheter  may  be  fastened 
in  ;  and  if  the  instrument  sets  up  much  bladder  irritation,  a  good  compromise  may  be 
found  in  the  practice  of  leaving  it  in  at  night  and  removing  it  during  the  dav.  When 
the  introduction  of  the  in.strument  is  attended  with  great  difficulty,  it  may  be  expedient 
to  leave  an  instrument  in  for  some  days;  but  under  these  circumstances  the  bladder 
should  be  washed  out  through  the  catheter  daily. 

The  vulcanized  india-rubber  catheter  is  a  good  form  to  employ  for  this  purpose, 
although  at  times  it  cau.ses  more  urethral  irritation  than  the  gum  elastic.  A  winged  or 
other  self-retaining  catheter  may  be  employed  when  difficulties  are  experienced  with  keep- 
ing in  the  simpler  form. 

When  retention  is  present  and  catheterism  impossible,  the  surgeon  may  be  called  upon 
to  puncture  the  bladder  juey  rectum  or  to  aspirate  it  above  the  pubes  in  order  to  give 
relief.  When  severe  cystitis  exists  and  the  agony  of  catheterism  becomes  unendurable, 
a  clean  perineal  incision  into  the  membranous  portion  of  the  urethra  and  the  introduction 
into  the  neck  of  the  bladder  of  a  soft  catheter,  to  enable  the  urine  to  flow  away  as  secreted, 
is  a  desirable  measure. 

General  Treatment. — With  the  local  treatment  of  this  aiFection  the  general  must 
not  be  neglected,  although  in  importance  it  is  quite  .secondary.  When  cystitis  exists,  it 
must  be  treated  upon  the  principles  previously  laid  down.  The  general  condition  of  the 
patient  must  be  maintained  by  means  of  good  diet  and  sufficient  stimulants.  The  skin 
should  l»e  kept  warm  and  all  sudden  chills  avoided ;  the  bowels  kept  open,  but  not  loose  ; 
pain  should  be  relieved  by  sedatives  and  sleep  secured  by  hypnotics :  tonics  are  often 
called  for.  the  preparations  of  iron  being,  as  a  rule,  the  best. 

Exercise  should  be  taken  when  there  is  no  inflammation  of  the  bladder  or  other  reason 
to  forbid  it,  walking  and  driving  being  the  best  foi-ms ;  and  under  these  circumstances 
the  local  distress  from  the  affection  may  be  rendered  ver}'  light  and  life  prolonged  for 
many  years  with  comfort. 

Patients  wuth  this  affection  should  once  a  day.  as  a  matter  of  habit,  pass  urine  on 
their  hands  and  knees,  the  bladder  in  this  way  having  more  power  to  evacuate  its  con- 
tents ;  and  the  mucus  and  other  more  solid  contents,  which  otherwise  would  lie  behind 
the  prostate,  are  got  rid  of  with  greater  certainty. 

Atrophy  of  the  prostate  is  often  found  in  the  aged  and  in  the  young,  and  in 
rare  cases  it  is  due  to  suiue  arrest  in  its  development.  In  the  majority  it  is  genuine 
atrophy  or  fibroid  degeneration,  probably  caused  in  some  by  syphilis.  Such  a  condition, 
however,  does  not  give  rise  to  any  symptoms  by  which  it  can  be  recognized  during  life, 
nor  is  it  a  cause  of  any  distress. 

Calcuh  of  the  prostate  are  not  rare,  and  may  be  found  embedded  in  the  organ 
as  small  .stones  varying  in  size  from  a  grain  of  sand  to  bodies  of  much  larger  dimensions. 
They  are  often  very  numerous,  are  sometimes  amorphous,  but  are  generally  laminated. 
Wollaston  says  they  are  composed  of  eighty-four  per  cent,  of  phosphate  of  lime,  one-half 
per  cent,  of  carbonate  of  lime,  and  fifteen  per  cent,  of  animal  matter. 

••  The  prostrate  gland,  like  other  glands,  is  liable  to  an  inspissation  of  its  secretion, 
producing  small  yellow,  sometimes  red,  pale  or  colorless  bodies  scattered  throughout  the 
follicular  structure.  These  at  first  are  said  to  con.sist  entirely  of  organic  matter,  which 
Virchow  believes  to  be  derived  from  a  peculiar  insoluble  protein  substance  mixed  with 
the  semen,  but  sooner  or  later  these  formations  ai"e  believed  to  irritate  the  mucous  mem- 
brane, causing  phosphatic  depositions  which  beconu'  encrusted  upon  the  organic  matter, 
and  thus  the  genuine  prostatic  calculi  are  formed '"  {Pu/and). 


650 


DISEASES   OF  THE  BLADDER  AND   PROSTATE. 


Fig.  367 


Prostate 
Prostate- Vesical  Calculus. 


Symptoms. — AVhen  embedded  in  the  organ  and  not  interfering  in  any  way  with  the 
urethra,  they  cause  no  symptoms ;  when  encroaching  upon  the  urinary  passage,  they  may 
cause  obstruction,  but  certainly  must  give  rise  to  urethral,  and  probablj'  to  bladder, 
irritation.  They  are  accompanied  occasionally  by  ulceration  and  suppuration  of  the 
surrounding  parts. 

A  prostatic  calculus  may  project  into  the  urethra  and  increase  the  urethral  portion, 
subsequently  extending  backward  into  the  bladder  and  forming  a  prostato-vesieal  cal- 
culus. In  Guy  s  Hospital  Refjorts^Y  1857 
a  case  reported  by  Poland,  with  references 
to  others,  will  be  found  (Fig.  3G7).  The 
calculus  has  a  dumb-bell  shape.  In  all 
these  cases  the  urethra  is  usually  per- 
vious, the  passage  of  a  sound,  however, 
as  a  rule,  detecting  its  presence,  a  grating 
sensation  being  experienced  in  the  passage 
of  the  metal  instrument  over  the  stone, 
but  no  ring  will  be  heard.  A  large  pros- 
tatic calculus  may  also  be  felt  per  rectum. 
Treatment. — When  a  prostatic  calcu- 
lus gives  rise  to  sufficient  symptoms  to 
indicate  its  presence  and  by  its  size  is 
likely  to  prove  troublesome,  it  should  be 
removed  by  a  perineal  section,  by  such  an 
operation  as  median  lithotomy,  the  incision 
stopping  short  of  the  bladder  when  the  stone  does  not  involve  it.  In  this  way  Dr. 
Barker  (vide  Druit's  Vocle  Mecinn)  removed  a  large  stone  nearly  five  inches  in  diameter 
with  success.  When  the  stone  or  stones  give  rise  to  few  symptoms  of  importance,  they 
should  be  left  alone  ;  occasionally  they  pass  nsitni-My  per  vrefh ram.  The  greatest  argu- 
ment against  operation,  unless  absolutely  essential,  is  found  in  the  fact  that  these  calculi 
are  mostly  multiple  and  often  exist  in  both  lobes  of  the  prostate. 

Cancer  of  the  prostate  occurs  but  seldom,  and  is  generally  of  the  soft  kind ; 
indeed,  as  Dr.  Walshe  .stated  in  1846.  '•  the  evidence  of  the  occurrence  of  true  scirrhus 
of  the  prostate  is  defective.  ' 

Symptoms.' — The  symptoms  are  those  of  enlargement,  and  increase  rapidly  in  severity, 
the  disease  being  attended  with  more  frequent  and  profuse  hemorrhage  than  the  ordinary 
hypertrophy.  The  blood  follows  the  straining  which  attends  the  act  of  micturition,  and 
appears  as  pure  blood :  after  catheterism  it  is  often  profuse.  The  disease  may  be  pri- 
mary, but  is  commonly  secondary.  It  cannot  exist  for  any  time  without  giving  rise  to 
glandular  enlargements  in  the  groin  or  along  the  iliac  vessels,  when,  as  a  rule,  the 
patients  powers    rapidly  yield. 

Treatment. — The  treatment  is  only  palliative,  the  surgeon  dealing  with  symptoms. 
All   instrumental  interference   should  be  of  the  gentlest   kind  and  as  little  as  possible. 
Pain  must  be  relieved  by  opium  and  the  general  powers  maintained  by  good  nourishment' 
and  stimulants. 

Tubercle  of  the  prostate  probably,  as  a  rule,  only  occurs  as  a  part  of  a  general 
tuberculo.sis.  and  until  the  deposit  is  breaking  up  or  by  its  presence  is  producing  some 
suppurative  action  it  gives  rise  to  no  symptoms  by  which  it  can  be  recognized.  It  is  too 
often  associated  with  renal  or  bladder  disease,  and  the  local  pro.static  mischief  is  lost  in 
the  more  general  afiection.  It  is  quite  possible  that  some  of  the  cases  of  so-called  idio- 
pathic abscess  of  the  prostate  are  the  result  of  the  breaking  down  of  this  deposit,  but 
there  are  no  clinical  data  to  enable  the  surgeon  to  diagnose  the  presence  of  this  disease, 
and  there  are,  consequently,  none  other  than  general  rules  of  treatment  to  be  mentioned. 


S'KJMC  IS   Tin:  l',l.MHH:ii^   A. SI)   ITS   Tni:.\TMi:sT. 


051 


CII  A  V'VV:  II     XXII 


STONK    IN    TlIK    iJLADhKi;.    AM»    ITS    TKKAT.M  K.NT. 


HkK(»i<k  p:issiii<;  til  tlu;  suhjoet  of  stoiu;  in  the  hlatlder  it  aiipL'ur.s  desirable  to  con.sider, 
llioutrli  hrii'Hy,  tliat  of  urinary  deposits,  or<;anie  and  inorganic,  as  the  value  of  a  sound 
kiiowled<;i'  of  what  the  urine  may  contain,  either  in  snsj/fiisu/n,  in  Hfthit inn.  or  \u  pr'  fipi'fn- 
fiuii,  is  to  the  surgeon  as  indispensable  for  successful  practice  as  to  the  physician. 

The  student  should  reinenil)er  that  healthy  urine  is  a  clear  acid,  amber-color  Huid 
with  a  specific  gravity  of  HtliO  to  lO.'^O;  that  in  one  thousand  jiarts  !)54.Hl  consist  of 
water,  45.11)  of  .solid  matters.  These  solid  matters  are  made  up  as  follows:  I'rca.  21.57  ; 
uric  acid,  0.3(1 ;  extractives,  such  as  creatine,  creatinine,  .xanthine,  hippuric  acid,  ammo- 
nia, sarcine,  pigment,  unoxidizcd  stuphur.  jthosphorus.  mucus,  etc.,  (i.53 ;  chlorine.  4.57; 
sulphuric  acid,  l.))!;  |diosphoric  acid,  2.((!( ;  ))Otash,  1.4(1;  soda,  7.1!>:  lime,  0.11  ;  mag- 
nesia, 0.12.  lie  should  further  remember  that  after  drinking  or  after  a  meal  the  urine  i.s 
altered  by  the  nature  of  the  diet  and  probably  diluted,  and  that  the  best  sample  of  urine 
to  examine  is  that  passed  in  the  morning  before  breakfast — the  "  urina  sanguinis  "  of 
Prout ;  when  this  urine  contains  any  ingredient  in  excess  or  in  deposit,  some  important 
derangement  of  the  system  exists.  When  any  of  the  constituents  of  the  urine  are  in 
excess,  the  balance  which  normally  exists  between  them  and  that  keeps  them  in  solution 
is  disturbed,  and,  as  a  consequence,  some  depo.sit  takes  place.  When  this  excess  consist.s 
of  the  safiiif  matters  of  the  urine,  such  as  those  of  potash  or  soda,  urinary  deposits  and 
stone  are  less  liable  to  form,  on  account  of  their  solubility,  than  when  the  excess  is  found 
in  the  alkaline  earths;  for  the  salts  of  lime  and  magnesia  are  most  insoluble,  and  conse- 
quently, when  in  excess,  .soon  show  themselves  as  gravel  or  calculi.  For  the  same  reason, 
uric  acid,  being  very  sparingly  soluble,  is  a  very  common  urinary  deposit  and  is  a  con- 
stituent of  most  stones.  When  blood  or  pus  is  found  in  the  urine,  the  surgeon  has  to 
discover  its  source.  Is  the  origin  of  the  blood  urethral,  prostatic,  vesical,  or  renal  ?  Has 
the  pus  been  secreted  by  the  bladder  or  been  poured  into  it  from  the  kidneys  or  other 
part  of  the  urinary  tract  ?  Is  the  salt  the  result  of  some  excessive  supply  of  its  chemi- 
cal constituents,  some  deficiency  in  the  working  power  of  the  machinery  of  the  body,  or 
some  accidental  circumstance  ?  Are  the  kidneys  themselves  at  fault  ?  or  is  it  that  they 
are  called  upon  to  excrete  morbid  products  which  have  accumulated  in  the  blood  from 
organic  or  functional  disturbance  of  other  portions  of  the  body  upon  which  the  existence 
of  healthy  blood  depends?  All  these  points  have  to  be  determined  in  dealing  with  any 
case  of  urinary  deposit,  and  in  the  special  works  devoted  to  the  subject  can  be  found  all 
that  is  necessary  to  guide  the  student. 

What  I  seek  to  impress  here  is  that  urinary  deposits  are  not  themselves  diseases  or  to 


Fig.  3GS. 


Fig.  369. 


Epithelium  from  Urinary  Passages. 


.Spermatozoa  and  Vaginal  Epithelium. 


be  dealt  with  as  such.  They  are  always  to  be  accepted  as  indications  of  disease,  func- 
tional or  organic,  in  some  of  the  working  organs  or  other  parts  of  the  machinery  of  the 
body. 


652 


STONE  IN  THE  BLADDER,   AXD  ITS   TREATMEXT. 


Fig.  370. 


Oily  Cads 


The  reader  is  referred  for  all  special  information  on  these  points  to  the  works  of  Bird, 
Beale.  Owen.  Rees.  Pavy,  Bence  Jones,  William  Roberts,  Thudichum,  \'oLrel,  and  Has- 
sall. 

Healthy  urine  ought  to  be  quite  clear.  It  may.  however,  be  slightly  hazy,  from 
mucus  or  frum  tlie  deposition  of  urates  in  cold  weather,  without  being  abnormal.  When 
any  deposit  has  been  merely  suspended  in  the  urine,  it  will  commence  subsiding  as  soon 
as  the  urine  has  passed.  These  deposits  are  mostly  organic  and  derived  from  the  kidneys 
themselves  or  the  urinary  passages.  They  may  consist  of  epithelium  cells,  columnar 
or  tessellated,  from  those  parts,  with  more  or  less  mucus.   (  IVrA-  Fig.  i^iis.j 

Blood  corpuscles  or  clots,  crystals  of  hfematin,  or  pus   cells,  may  be  found. 
Renal  Casts. — -Waxy,  granular,  oily,  bloody,  or  purulent   (Fig.  :^70). 
The  urine,  under  all  the.se  circumstances,  is  albuminous,  and  the  best  tests  for  albu. 
men  are  the  following : 

Nitric  Acid  Test. — To  test  for  albumen,  the  urine  should  be  boiled  and  enough 
strong  nitric  acid  added  to  give  the  resulting  liquid  an  acid  reaction. 
Any  precipitate  remaining  after  this  treatment  must  be  albumen. 
A  delicate  mode  of  employing  this  te.st  is  to  place  a  few  drops  of  nitric  acid  in  a  tube 
and  then  pour  the  urine  carefully  upon  it,  so  that  the  two  liquids  do  not  mi.x  ;  or  the 

reverse  process  may  be  adopted.  If  albumen  is 
present,  an  opalescent  zone  will  appear  at  the 
plane  of  contact  of  the  fluids.  If  the  proportion 
is  small,  several  minutes  may  elapse  before  its 
appearance.  A  quantitative  estimate  of  the 
amount  of  albumen  sufiicient  for  clinical  pur- 
poses may  be  obtained  by  noting  the  amount  of 
precipitate  to  the  liquid  employed,  but  a  more 
accurate  estimate  may  be  formed  by  the  use  of 
Roberts's  dilution  method,  described  in  the  Lan- 
cet, vol.  i.,  1876,  p.  .313. 

Picric  Acid  Test. — This  test,  as  recom- 
mended by  Dr.  (1.  Johnson,  is  used  as  follows  : 
Fill  a  test-tube  six  inches  long  with  four  inches 
of  urine,  and  upon  this  pour  an  inch  of  the  picric 
acid  solution  (six  or  seven  grains  to  the  ounce), 
so  as  to  mix  only  with  the  upjier  layer  of  the 
urine. 

If  albumen  is  present,  a  cloud  or   coagulum 
of  albumen   will  appear  as  far  as  the  yellow  color  of  the  test  solution  extends. 

If  the  tube  be  allowed  to  stand,  the  precipitated  albumen  will  gravitate  and  form  a 
film  or  deposit  at  the  junction  of  the  colored  and  unstained  portion  of  the  urine.     The 

turbid  portion  of  the  liquid  must  then  be  boiled  ;  and 
if  the  precipitate  is  permanent,  it  must  be  albumen. 

Dr.  Pavy's  Ferrocyanide  of  Potassium 
Test,  in  -which  the  Spirit  Lamp  is  not  re- 
quired.— Add  to  the  susijected  urine  a  sniull  quan- 
tity of  a  solution  of  citric  acid.  If  this  causes  a  pre- 
cipitate of  urates,  add  a  little  hot  water,  which  will 
redissolve  it ;  then  add  some  solution  of  ferrocyanide 
of  potassium  ;  and  if  albumen  is  present,  it  will  be 
precipitated,  and  nothing  else,  as  far  as  is  known, 
will. 

It  must  be  added  that  in  all  methods  of  testing 
any  initial  turbidity  of  urine  from  the  presence  of 
urates  must  be  got  rid  of  by  heat.  It  should  also  be 
ascertained  that  the  patient  is  not  taking  cubebs  or 
copail)a.  for  all  the  oleo-resins  are  thrown  down  by 
acids.  Prior  boiling  of  the  liquid  will  also  obviate 
fallacy  from  this  cause, 
pellets  and  Oliver's  test  papers  are  trustworthy. 

At  times  the  dehria  of  kidney  structure  or  cancer  products  may  be  found. 

Spermatoza  (Fig.  309),  sarcinse,  or  hydatids  may  likewise  be  present, 
these  materials  can  be  made  out  only  by  the  microscope. 


Urinarv  Casts. 


Fig.  371. 


Urates. 


For  bedside  purposes  Pavy' 


All 


yrtjsj-:  /.v  77/a;  iu.M>i)i:n,  asd  its  thiiatmkst. 


(>r);i 


ITriiii'  cniitaiiiiiij^  blood  is  i-ithcr  it<l  ur  sinn/.y  ;  tliat  coiitaiiiiii;.'  bile,  <liirk  nr  olive- 
brown,      lilttcli  urine  is  cuninionly  the  result  of  tlie  |iois<inoiis  al(s<ir|itii(ri  oi'  carliolii-  aeid. 

Pus,  wlien  |)oure(l  into  the  urinary  passafxt',  Ims  usually  little  mucus  with  it  ;  that 
seereted  hv  the  Madder  is  j:;reatly  mixed  with  it.      {'undent  urine  is  always  alhundnous. 

The  urates  generally  appear  as  "  hriek-dust  "  or  "  red  jrravel  deposits.  Wiien  they  do 
so,  as  soon  as  the  urine  has  eoided  down  there  is  j^enerally  some  diminution  in  the  watery 
constituents  of  the  urine  with  I'ehrile  dist urhanee.  When  they  are  deposited  some  hours 
al'ier  mieturitiou,  iiurea.sed  acidity  id'  the  urine  is  indicated,  from  ehanj^e.s  in  tlu;  pif^ment 
or  extractives,  the  acids  heinj;  ]ir(d)ahly  the  lactic,  acetic,  and  hutyrie.  A  drop  of  acid 
jiddeil  to  such  urine  will  cause  the  settlement  of  the  deposit  (\'\]i.  -jTI).  Urates  are  dis- 
solved hy  heat  and  alkalies. 

Uric  acid  apjtears  in  transparent  urine  oi'  a  ycdlow  color  and  is  usually  <le]»osited 
shiwiv-  Tilt'  crystals  are  variously  I'ormed,  and  (diiefiy  rhomhie,  with  the  an<rles  routided 
off  or  lo/.eniic-shaped  (Fij^.  372).  They  are  soluhle  in  potash  or  soda,  hut  insoluhle  in 
mineral  acids. 

Oxalate  of  lime  is  ]»rol)a])ly  secreted  under  the  same  circumstances  as  the  uric 
acid  and  has  tlu;  same  patlioloi;ieal  siiiiiitication.  ])r.  Parkes  held  this  view,  and  believed 
tluvt  it  may  he  a  substitution  I'or  the  excretion  of  tlic  carbolic  acid  of  the  lunjrs.  It 
appears  as  octahedral  crystals  or  dumb-bell  like  bodies  (Fig.  373)  which  are  in.soluble  in 


Fig.  872. 


Fig.  373. 


Uric  Acid. 


Oxalate  of  Lime. 


acetic  acid  and  alkalies,  though  soluble  in  the  mineral  acids,  such  as  the  nitric,  without 
effc'rvesceiice. 

The  phosphates  appear  as  the  amraoniaco-magnesian  phosphate,  the  phosphate  of 
magnesia,  and  the  phosphate  of  lime. 

The  first  occurs  in  the  form  of  beautiful,  colorless,  transparent  prisms  or  in  foliaceous 
or  stellar  prisms.     It  is  supposed  to  be  deposited  as  a  consequence  of  the  decomposition 


Fig.  374. 


Fig.  37-3. 


Phosphates. 


of  urea,  and  is  first  .seen  upon  the  surface  of  the  urine  as  an  iridescent  pellicle  (Fig.  374). 
It  is  soluble  in  acetic  acid,  but  not  by  heat. 


654 


STONE  IX  THE  BLADDER,   AND  ITS  TREATMENT. 


The  phosphates  of  magnesia  and  lime  occur  as  white  gravel,  usually  amorphous,  at 
times  crystalline.  They  are  mostly  found  in  alkaline  urine  mixed  with  pus  or  mucus 
(Fig.  375).     They  are  insoluble  by  heat,  but  soluble  in  acetic  or  the  mineral  acids. 


Fig.  376. 


Fig. 


Tyrosine  and  Leucine. 


Cystine. 


Tyrosine  appears  in  the  form  of  fine  needles  or  stars  of  a  greenish-yellow  color 
(Fig.  o76).  When  treated  with  nitric  acid,  urine  containing  it  becomes  of  a  deep-orange 
color,  and  on  evaporation  of  deep-yellow.  A  solution  of  soda  dropped  upon  this  flake 
produces  a  red  tinge. 

Cystine  occurs  in  colorless  hexagonal  plates  (Fig.  377)  or  light  fawn-colored  amor- 
phous depo.sit.  and  is  soluble  in  ammonia  and  hydrochloric  acid,  insoluble  in  acetic  acid. 

Potash  dissolves  all  deposits  except  the  phosphates  and  oxalate  of  lime. 

Heat  dissolves  only  the  urates  of  the  urine. 

Hydrochloric  acid  dissolves  all  except  uric  acid. 

"  Perfectly  healthy  urine  should  show  no  appreciable  deposit ;  when,  however,  it 
becomes  concentrated  from  deficiency  of  the  watery  excretion,  then  the  uric  acid  is 
thrown  down  in  the  form  of  a  urate.  This  may  occasionally  occur  within  the  body,  but 
far  more  frequently  after  the  urine  has  been  voided ;  sometimes,  however,  this  change 
ensues  so  rapidly  that  the  urine  is  erroneously  supposed  to  have  been  passed  in  that  con- 
dition. The  presence  of  a  solid  body  in  any  part  of  the  urinary  tract  favors  deposition 
very  much,  and  hence  urine  which  would  otherwise  remain  clear  may  yield  a  deposit  to 
any  substance  previously  present  in  the  same  tract,  and  may  thus  add  considerably  to  an 
already  existing  calculus.  The  appearance  of  the  numerous  layers  so  frequently  seen 
around  a  central  nucleus,  in  both  renal  and  vesical  calculi,  is  thus  easily  explained. 
When,  however,  the  urine  becomes  further  altered  in  composition — if,  for  example,  a  free 
acid  is  either  excreted  with  the  urine  or  rapidly  generated  in  it  through  the  setting  up  of 
the  lactic  fermentation — the  uric  acid  becomes  liberated  from  its  state  of  combination, 
and  in  a  form  more  or  less  altered  by  the  presence  of  colloid  matters  is  deposited  on  a 
previously  existing  calculus,  or  is  passed  as  separate  rhomboidal  crystals  or  in  aggregated 
masses,  constituting  gravel  or  sand.  I  should  feel  disposed  to  confine  the  name  of  '  sand' 
or  '  gravel '  exclusively  to  such  deposits,  which,  I  believe,  .seldom  form  the  nucleus  or 
become  the  starting-point  of  any  calculus.  I  may  add  that  urine  possessing  these  cha- 
racters is  frequently  voided  for  months  and  years  without  the  occurrence  of  any  apprecia- 
ble inconvenience  to  the  patient.  It  is  true  that  a  calculus  may  be  augmented  by  con- 
tact with  such  urine,  but,  as  I  have  said,  it  seldom  originates  in  this  way.  Gravel  or 
sand  consists  of  uric  acid,  previously  in  a  state  of  solution,  which  has  become  precipitated 
by  the  occurrence  of  some  change  in  the  urinary  excretion."  "  It  would,  however,  appear 
probable  that  the  initial  step  in  the  formation  of  a  calculus  is  the  exudation  of  some  col- 
loid mucus  or  some  other  albuminoid  substance  into  the  urinary  passages.  Into  this 
colloid  urates  or  oxalate  of  lime,  or  both,  are  precipitated,  and,  combining  with  it.  form 
molecular  aggregations  of  a  globular  character,  which  constitute  the  foundation  of  the 
subsequent  growth"  (Garrod,  LnmJeian  Lectures,  1883). 

When  any  of  the  inorganic  deposits  just  described  mass  together  either  by  themselves 
upon  any  nucleus  of  organic  matter,  such  as  blood  or  a  foreign  body,  a  stone  is  the 
result.  This  stone  may  form  in  the  kidney  and  remain  there  ;  it  may  pass  into  the  blad- 
der and  be  emitted  with  the  urine  or  rest  there  and  increase,  or  the  calculus  may  have 


sT(K\j-:  ly  Tin:  uladdj:!:,  a.mj  its  tili:atmi:m\  tioo 

its  (iri;.'!!!  ill  the  lilatKU-r.  i-itluT  fitun  tin-  jin-cipitutioii  of  tin-  cartliy  Cdiistitticnt*  of  the 
uriiu'  or  tVoin  tlu'  irritjition  of  :i  t'on*i;.'ii  ImkIv  introduced  from  with- 
out. A  st<iiie  having'  a  n-iial  origin  aii*l  nvtiiiir  in  thi*  hhuhhr 
seems  to  havf  the  power  ot"  extractiii":  from  the  uriiif  its  iiior^'atiic 
eleiiu'iits  and  thus  ra|>i<lly  iiu-rt'asiii<r,  oxalate  of  lime,  urate  of  am- 
monia, urie  aeid,  phospliate  of  lime,  or  trijde  jdiosphate  bein<:  firt'- 
cijiitated  hy  its  presence  and  a^irrejiatiiijr  or  crystallrzinjr  upon  it- 
surface.  It  acts,  too,  after  a  time,  as  a  foreifrn  bmly.  sets  up  Idad- 
der  irritation,  and,  a.s  a  con.seijuence,  the  phosphatic  salts  arc  de- 
posited, from  the  decomitositioii  of  the  urine.  Dr.  Owen  Kees  has 
shown  ill  his  Crnoniau  Lcrturcs  (185())  that  where  irritation  of  tlie 
bladder  exists,  from  either  a  calculus,  forei<rii  body,  or  other  cause, 
the  inucoiis  membrane  .secretes  an  alkaline  fluid  that  tends  to  cause 
a  precipitation  of  the  earthy  phosphates  and  the  formation  of  a  plios- 
phatic  deposit  upon  a  calculus. 

Renal  calculi  are  ■renerally  compo.sed  of  uric  acid,  urate  of  'nl!^p.  MuJ^"l"ep.  2077*'^>' 
amnmniii.  or  oxalate  of  lime,  and  Heale  states  that  microscopic  renal 

calculi  of  phosphate  of  lime  are  by  no  means  uncommon.  These  concretions  may  be 
either  impacted  in  the  uriniferous  ducts,  lodtred  in  pouches  connected  with  the  ducts, 
and  increase  in  the  structure  of  the  kidney,  or  pass  into  the  pelvis  of  the  kidney.  They 
may  be  siii<rle  or  multiple  and  the  size  of  a  hemp-seed,  nut,  or  walnut,  or  they  may  be 
so  moulded  to  the  divisions  of  the  pelvis  of  the  organ  as  to  assume  an  arborescent  shape 
such  as  that  figured  (Fijr.  378).  Dr.  Gee  has  lately  recorded  a  case  in  which  a  renal 
calculus  weighed  thirty-six  and  a  quarter  ounces  {Med.-Chir.  Trans.,  1874).  There  is 
rea.son  also  to  believe  that  a  renal,  like  a  vesical,  calculus  may  form  upon  a  nucleus  of 
blood  the  result  of  an  injury. 

When  the  stone  is  tixed  in  the  structure  of  the  kidney,  its  presence  may  be  indicated 
by  but  few  if  any  local  symptoms.  When  it  moves  about  in  the  pelvis  of  the  kidney,  it 
gives  rise  to  symptoms  known  as  tho-se  of  nephrkic  colic,  paroxysmal  lumbar  pain,  with 
nausea,  vomiting,  or  collapse,  irritabilitj-  of  bladder,  and  at  times  painful  micturition 
and  haMuaturia.  being  the  chief  symptoms. 

When  the  stone  passes  into  the  ureter,  all  these  are  aggravated,  pain  shooting  down 
the  groin,  thigh,  and  scrotum  of  the  affected  side,  with  retraction  of  the  testis;  and  these 
continue  till  the  stone  reaches  the  bladder,  when  a  sudden  relief  is  felt. 

When  calculi  accumulate  in  the  kidney  and  increase  in  size,  inflammation,  suppura- 
tion, and  even  the  entire  destruction,  of  the  kidney  may  ensue,  although  it  is  remarkable 
to  what  an  extent  one  kidney  may  be  destroyed  without  giving  rise  to  any  symptoms.  On 
the  other  hand,  severe  symptoms  may  appear  for  a  time  and  subside,  to  reappear  either 
months  or  years  later  or  not  at  all.  In  exceptionaJ  cases  a  renal  calculus  may  be  dis- 
charged externally  through  the  loin  with  suppuration  :  Dr.  Cayley  showed  such  a  speci- 
men at  the  Pathological  Society.  1874.  A  stone  may  V>e  impacted  in  the  ureter  and  not 
rarely  at  its  vesical  orifice,  when  it  will  give  rise  to  renal  symptoms  by  obstruction,  etc. 

After  a  stone  has  reached  the  bladder  it  may  be  discharged  with  the  urine  or  become 
fixed  in  the  urethra  and  cause  obstruction,  or  it  may  rest  in  the  bladder  and  increase  and 
reijuire  .surgical  treatment. 

It  is  probable  that  most  vesical  calculi  have  a  renal  origin,  and  that  some  small 
nucleus  of  either  uric  acic  or  oxalate  of  lime  forms  in  the  kidney  and  passes  downward 
into  the  bladder,  where  the  urine,  supersaturated  with  these  constituents,  deposits  them 
upon  the  renal  calculus  and  increases  its  size.  Stones  thus  formed  have  been  called 
priiiinri/  calcnloua  fornmtloua. 

When  a  foreign  body  has  been  introduced  into  the  bladder  or  a  stone  has  descended 
into  it  and  sets  up  much  bladder  irritation  or  cy.stitis.  the  phosphatic  salts  of  the  urine  are 
deposited  upon  its  surface  ;  and  stones  thus  formed  are,  therefore,  phosphatic.  When 
urine  is  retained  in  the  bladder  and  decomposes,  as  a  consequence  of  either  cystitis  fol- 
lowing paralysis,  diseased  prostate,  urethra,  or  a  new  growth,  its  earthy  constituents  are 
thrown  down  and  phosphatic  calculi  or  concretions  are  formed,  such  depo.sits  being  known 
as  secondary  calculous  forttiations.  How  far  these  latter  may  increase  so  as  to  form  stones 
is  yet  an  open  question. 

All  these  chemical  constituents,  however,  require  to  be  held  together  by  a  kind  of 
cement.  "  Marcet  referred  it  to  the  mucous  secretion  of  the  bladder ;  Fourcroy  and  A  au- 
quelin  to  albumen,  and  .sometimes  to  gelatine  with  an  admixture  of  urea:  Berzelius.  how- 
ever, could  not  determine  whether  it  was  composed  of  fibrin,  albumen,  gaseous  matter,  or 


65(3 


STONE  IN  THE  BLADDER,   AND   ITS   TREATMENT. 


mucus ;  Brande  considered  it  to  consist  of  a  mixture  of  gelatine  with  urea ;  Scharling 
holds  that  the  smaller  calculi  are  always  enveloped  by  a  layer  of  mucus,  albumen,  or  some 
other  organic  matter,  the  flocculi  of  which  entangle,  and  ultimately  determine  the  crys- 
tallization, of  the  more  insoluble  ingredients  of  the  urine  ;  and  Dr.  Hoskins,  as  quoted  by 
Gross,  extends  this  view  to  the  minutest  pai'ticle  of  the  concretion  "  (Coulson). 

Urinary  calculi,  says  Poland,  may  be  arranged,  like  the  deposits,  into  two  distinct 
classes.  The  Jirst  will  include  calculi  of  uric  acid  and  the  urates,  with  their  modifications 
the  oxalates,  xantJiic  and  cystic  oxide  (Dr.  U.  0.  Rees  regarding  the  oxalate  of  lime  as 
uric  acid  or  urates,  altered  after  secretion)  ;  the  second,  the  phosphatic  calculi.  A  third 
class  may  be  added,  consisting  of  the  rare  calculi  of  carbonate  of  lime,  the  fibrinous,  the 
uro-stealith,  and  the  siliceous  formations,  other  chemical  ingredients  being  present,  such 
as  organic  matters,  carbonate  of  magnesia,  silica,  oxide  of  iron,  benzoate  of  ammonia, 
oxalate  of  ammonia,  phosphate  of  iron,  urea,  etc.  The  oxalates  are  the  heaviest  stones, 
the  phosphates  the  lightest  and  largest ;  few  exceed  an  ounce  in  weight.  Coulson  records 
one,  however,  over  six  pounds.  Recent  calculi  contain  moisture,  and  consequently  are 
heavier  than  old.  Stones  vary  in,  shape  according  to  their  position.  Thus,  renal  calculi 
are  generally  irregular,  often  arborescent ;  those  in  the  ui'cfer,  elongated,  approaching  a 
cylindrical  form.  Bladder  calculi,  when  single,  are  more  ovoid  and  flattened  ;  when  mul- 
tiple, faceted.  The  mulberry  stone  or  oxalate  is  always  tuberculated,  mostly  globular, 
and  hard  ;  the  uric  acid  and  urate  calculi,  smooth  and  regular  ;  the  phosphatic,  irregular, 
of  odd  shapes,  and  soft.  The  dumb-bell  calculus  is  usually  prostato-vesical  or  encysted. 
The  color  of  the  layers  of  a  calculus  is  due  to  the  fact  that  the  uric  acid  or  urates  in 
their  deposition  take  with  them  the  coloring  matter  of  the  solution  from  which  they  are 
deposited.  All  calculi,  when  associated  with  bladder  irritation  and  ammoniacal  urine, 
become  covered  with  a  white  coating  of  phosphatic  deposit.  A  stone  of  uric  acid  is 
usually  fawn-  or  brown-colored ;  of  urate  of  ammonia,  cinder-gray  ;  of  oxalate  of  lime, 
brown  or  blackish-green  ;  of  xanthic  or  uric  oxide,  cinnamon-brown ;  of  cystic  oxide,  a 
gray-greenish  hue. 

Phosphatic  calculi,  as  are  other  forms  when  covered  with  a  like  deposit,  are  often 
horribly  fetid  and  ammoniacal.     They  are  too  commonly  soft  and  friable. 

The  section  of  a  calculus  reveals  its  structure,  and,  while  some  are  homogeneous,  the 
majority  display  concentric  layers  of  diff"erent  degrees  of  thickness,  exceptional  examples 
displaying  fine  lines  I'adiating  from  their  centre,  of  a  crystalline  form,  which  may  be  seen 
the  cystine  calculus  (Fig.  'S82). 

The  dift'erent  layers  of  a  calculus  may  have  the  same  composition  or  differ  widely. 
When  the  latter,  the  calculus  is  known  as  alternating ;  but  any  single  layer  is  generally 
composed  of  several  ingredients.  '•  It  is  probable,"  says  Odling,  "  that  if  a  very  exact 
analysis  were  made,  each  of  the  layers  of  nearly  every  calculus  would  be  found  to  contain 
uric  acid,  alkaline  urates,  phosphate  of  lime,  and  ammonio-phosphate  of  magnesia,  with 
or  without  the  other  constituents  of  calculi.  Moreover,  most  calculi  contain  traces  of  all 
the  salts  naturally  existing  in  the  urine,  as  well  as  coloring  matter,  mucus,  etc." 

Most  calculi  are  divisible  into  a  central  portion,  or  nvclens,  with  an  outer  portion,  or 
hodi/  ;  and  occasionally  there  is  an  outside  crvst  of  phosphate  (Fig.  B81). 

The  nucleus  may  be  of  the  same  nature  or  diftcr- 
ent  from  the  body. 

It  may  be  composed  of  some  organic  material, 
such  as  blood,  mucus,  etc.,  or  a  foreign  body  intro- 
duced from  without  (Fig.  080). 

1.  Uric  acid  calculus  is  by  far  the  most  fre- 
quent, forming,  according  to  Cadge,  nine-tenths  of  all 
primary  formations  {Address  on  Sirrgeri/,  1874).  It 
is  usually  derived  from  the  kidney,  and  when  re- 
tained in  the  bladder  becomes  a  flattened  oval  stone 
of  a  fawn  or  yellow  color,  with  a  compact  and  occa- 
sionally crystalline  laminated  structure  (Fig.  379). 
The  uric  acid  is  generally  mixed  with  the  alkaline 
urates  in  variable  proportions. 

This  form  of  stone  is  often  found  in  gouty  sub- 
Uric  Acid  Calculus,  with  Nucleus  uf  o.xahite  of    j^^ts,  and  2:enerallv  in  the  middle  period  of  life.     It 

Lime,     a  rep.  219.3.)  .J  '     ,,  •    ^' j       vi  •  l  •  1  1  " 

IS  usually  assocuited  with  acid  urine  and  such  as  is 
prone  to  deposit  the  urates.  The  nuclei  of  most  calculi  are  of  this  nature.  In  the  cata- 
logue of  calculi  of  the  Royal  College  of  Surgeons  of  England  (Plate  lY.  Fig.  G)  there 


Fig.  379. 


SToyj-:  L\  Tin:  uladdi.i:,  asi>  its  iiikatmicst.  057 

is  a   (Iruwiiit:  in  wliidi  ;i  uric  iicid  ralculiis    is   sliuwii    In    have    I'uniii'il    routiil    ii    jiiccc;   nf 

StOfl. 

'1.  The  urate  of  ammonia  calculus  is  not  rommon.  In  (iny's  .MuMMnn  tliLTi-  arc 
only  7  spt'cinicn^  <>r  it  out  nf  .I'.i  I  (alfiiri,  .Most  (•((ni|mnn(l  calculi  contain  this  sult.stancc  in 
aljuntlaiicc.  'I'licv  are  scliloni  lai-jre,  mostly  smooth,  ami  of  a  gray-fawn  c<)l(ir.  On  section 
thev  are  lionio^renciuis  or  iiidistiiictly  laminated  and  have  an  earthy  fracture.  They  are 
more  commonly  found  in  (diildren,  althout^li  they  have  ht.-en  removed  from  adults.  (luy'.s 
Museum  contains  a  hottle  (No.  'I'lXW)  in  whicdi  an;  ]\'l  calculi  of  this  luiture.  which  Sir 
A.  Cooper  removed  from  the  Madder  of  one  patient.  They  are  of  the  color  of  pipe-clay 
and  in  the  form  of  cubes  with  the  edges  and  angles  rounded  off. 

The  rarity  of  this  form  of  calculus  is  pr<d)al)Iy  due  to  the  solubility  of  the  salts. 

:{.   The  oxalate  of  lime,  or  mulberry,  calculus  stands  second  in  point  of  fre- 
quencv  to  the  uric  acitl  in  Kuropean  countries,  though  Dr.  II.  V.  Carter  tells   us  that  the 
oxalate  of  lime  ingredient  predominates  in  all  urin- 
ary calculi  in  Nortlu-rn  India  ( -SV.  (ivDn/ri^  Ifiiajntdl  Kio.  380. 
Reports,    1871-72).      These    calculi   vary   in    color             ''          7 
from  gray  to  a  rich   brown   or  black    and  have  an                             ^. 
e.Kteriial  form   of  a  tubercular,  angular,  or  spinous 
character,  being  rarely  perfectly  smooth  (Fig.  3S(I). 
In  some  the  surface  is  studded  with  spines  so  acute  (^^ 
and  slender  as  to  resemble  thorns,  while  in  others  v^--- 
there  is  a  coating  of  acute  octahedrons  of  transpar- 
ent oxalate  of  lime,  giving  an  extremely  beautiful 

appearance.    Occasionally  these  crystals  are  opa(|ue      Muiurry  (  aicuius.  its  Section. 

and  the  octahedron  is  flattened,  when  the  calculus 
appears  as  if  studded  with  pearl-spar  (Prep.  2139^  Guy's  Museum).  The  intervals 
between  the  spines  are  .sometimes  filled  with  urates  or  pho.sphates,  which  give  the  stone 
an  ovoid  form. 

The  section  of  a  mulberry  calculus  is  generally  that  of  an  imperfectly  lamellated 
structure,  the  consecutive  layers  forming  waving  lines  which  often  resemble  the  knotted 
heart  of  an  oak  (Fig.  38(1),  but  occasionally  a  layer  of  oxalate  of  lime  is  to  be  seen 
arranged  around  the  interior  one  with  great  regularity,  having  a  remarkably  radiated 
appearance,  like  a  series  of  infinitely  minute  needles  placed  side  by  side,  and  presenting  a 
perfectly  porcellaneous  structure.  In  compound  calculi  the  oxalate  of  lime  deposit  gives 
to  the  character  of  a  stone  a  remarkably  beautiful  appearance  resembling  that  of  fortifi- 
cation agate. 

The  oxalate  of  lime  calculi  that  have  their  origin  in  the  kidney  (and  pass  soon  after 
their  descent)  are  usually  small,  smooth,  hemp-seed  bodies. 

The  crystalline  mulberry  stone  is  of  a  pale-brown  color,  and,  according  -to  Dr.  Yelloly, 
composed  of  nearly  pure  oxalate  of  lime.  Poland  had  a  case  of  this  kind  in  which  the 
stone  on  extraction  crumbled  to  pieces  from  the  absence  of  any  binding  material  of  ani- 
mal matter.  He  gives  also,  on  the  authority  of  Mr.  C.  Williams  of  Norwich,  an  account 
of  a  pure  white  oxalate  of  lime  calculus.  ''  This,"  he  says,  "  is  of  a  milk-white  color,  po.s- 
sesses  a  highly-polished  surface,  is  of  extreme  rarity,  and  is  generally,  if  not  always,  found 
in  the  kidney  ;  its  external  surfiice  presents  no  crystals,  but  is  perfectly  smooth,  though 
it  may  be  spinous.      In  the  museum  of  the  Norwich  Hospital  are  three  specimens.'" 

The  nucleus  of  a  mulberry  stone  usually  contains  uric  acid  (Fig.  381),  while  the  body 
is  often  made  up  of  alternate  layers  of  uric  acid  and  oxalate  of  lime.  The  urine  is  gen- 
erally acid.  Singular  as  it  may  appear,  these  rough  mulberry  stones  rarely  give  rise  to 
so  much  bladder  irritation  as  the  smoother  forius  ;  possibly  they  roll  about  less. 

4.  Cystine  or  cystic  oxide  calculus  is  of  rare  occurrence  and  is  a  formation  of 
the  kidney.  Wollaston  discovered  it  in  1810,  and  the  second  calculus  which  he  analyzed 
is  in  Guys  Museum,  and  is  about  an  inch  in  diameter  (Fig.  382)  and  contains  sulphur  in 
large  proportions.  Poland  points  out  its  hereditary  nature,  since,  out  of  22  collected 
cases,  10  occurred  in  four  families,  and  in  these  the  subjects  of  the  complaint  were 
brothers.  The  calculi  are  generally  rounded  or  smooth,  but  may  be  slightly  tuberculated. 
They  have  a  waxlike  lustre  and  appear  semi-transparent  and  glistening.  When  recent, 
they  are  of  a  pale  yellowish-brown  color,  but  when  kept  long  assume  a  pea-green  appear- 
ance. Dr.  Bird  remarks  u]»on  this  point.  ''  It  has  been  suggested  to  me  by  Dr.  Prout  and 
Dr.  Willis  that  this  alteration  in  tint  may  in  some  way  depend  upon  changes  produced  ia 
the  sulphur." 

They  are  soft  in  consistence  and  on  section  present  a  very  imperfectly  radiated  strue- 
42 


658 


STOXE  IX  THE  BLADDER,  AXD  ITS  TREATMEXT. 


ture,  with  no  tendency  to  a  development  of  concentric  layers.  They  yield  easily  to  the 
knife  when  scraped  and  form  a  perfectly  white  powder,  whether  the  calculus  be  green  or 
brown.      The  fracture  is  crystalline. 

5.  Phosphate   of  Lime   Calculus. — There  are  two  varieties  of  this  form,  the 
one  as  described  by  Wollastnii.  nf  nual.  origin,  consisting  of  neutral  phosphate  of  lime. 


Fig.  381. 


Fig.  382. 


Mixed  Calculus. 


null  mze 
Cystic  Oxide  Calculus.    (Guy's  Mus.,  Xo.  2143.) 


The 


Fig.  383. 


These  usually  have  a  smooth  polished  surface  of  a  pale-brown  color  and  are  regularly 
laminated,  the  lamina?  being  so  slightly  adherent  as  to  be  easily  separable  into  concentric 
crusts ;  in  some,  lines  are  seen  radiating  in  a  direction  perpendicular  to  the  laminae. 
These  calculi  contain  a  considerable  proportion  of  animal  matter. 

The  other  form  is  of  vesical  origin  and  composed  of  phosphate  of  lime  similar  to  that 
of  bones,  and  hence  often  called  "  bone-earth"  calculi.  They  are  more  common  than  the 
former  and  constitute  irregular  masses  resembling  mortar  or  a  granular,  semi-crystalline 
powder  enveloped  in  a  tenacious  mucus,  these  latter  being  more  concretions  than  stones. 
There  ai*e  three  cases  on  record  in  which  the  phosphatic  calculus  has  been  followed  by 
other  forms.  Foreign  bodies,  as  a  rule  (and  vesical  calculi  of  long  standing  are  such), 
have  the  earthy  jdiosphates  deposited  upon  them. 

0.  Triple    phosphate,    or  ammoniaco-magnesian   phosphate,   calculus   is   rare. 
e  College  of  ^Surgeons  possesses  but  three  specimens,  and  Guy's  only  two.      No.  2154 

in  Guy's  3Iuseum  shows  one  which  has  no  nucleus,  but 
a  central  cavity  lined  with  delicate  crystals  of  triple 
phosphate,  resembling  the  crystals  of  quartz  in  the 
cavities  of  flints,  while  No.  2152  is  a  section  of  a  large 
calculus  of  the  kind  on  a  nucleus  of  a  tobacco-pipe. 
Fig.  383  represents  such  a  calculus  formed  round  a 
piece  of  broken  catheter,  and  occurred  in  the  practice 
of  my  friend  Dr.   Kitchener. 

7.  The  fusible  calculus,  or  the  phosphate  of  lime 
with  phosphate  of  magnesia,  and  ammonia  calculus,  is 
the  most  frequent  of  the  phosphatic  calculi.  It  is  gen- 
erally due  to  the  presence  of  ammoniacal  urine  from 
cystitis,  and  con.^titutes  the  crust  that  forms  on  other 
calculi  or  on  foreign  bodies  introduced  into  the  bladder.  These  calculi  increase  to  a  large 
size,  are  irregular,  and  mould  themselves  to  the  position  in  which  they  are  placed,  often 
filling  the  bladder.  Their  color  is  white,  gray,  or  dull  yellow,  their  consistence  friable 
and  more  earthy  than  any  other  variety,  sometimes  so  soft  as  to  resemble  moist  chalk. 

Their  appearance  on  section  is  thus  described  by  Mr.  Taylor  in  the  catalogue  of  the 
calculi  of  the  Hoyal  College  of  Surgeons  of  England  :  "  They  are  frequently  composed 
of  concentric  lamina?,  which  in  general  adhere  but  slightly  to  each  other  ;  between  the 
lamina?  shining  crystals  of  the  "triple  phosphate  are  often  observed  ;  or  some  of  the 
laminte  are  entirely  wanting,  and  these  form  a  white  friable  mass  like  chalk ;  in  others 
they  appear  semi-crystalline,  as  if  made  up  of  numerous  small  crystals  confusedly  aggre- 
gated together.  In  calculi  that  have  a  crystalline  and  glistening  texture  the  triple  phos- 
phate is  most  abundant,  while  the  calcareous  phosphate  is  in  excess  in  those  which  have 
an  amorphous  earthy  appearance." 

8.  The  carbonate  of  lime  calculus  is  a  very  rare  form.  Thudichum  says  that 
prostatic  calculi  sometimes  consist  almost  entirely  of  this  substance.     In  Guy's  Museum 


Tripi 


Phosi)hate  Calculus  with  Nucleus 
of  a  Piece  of  Catheter. 


STOSE  IS    Tin:   11  LAI)  It  nil,   AM)   ITS   THE  ATM  EST.  659 

(No.  21fS7^)  such  a  vesical  stimc  exists,  (if  a  siiow-wliile  culnr.  witli  a  nucleus  of  uric 
aeid.  Otlliuj^  says  tliat  calculi  which  have  uuder^rone  partial  (h-cunipositiou  in  tlie  Ijladiler 
ot'toii  etiiitaiu  tiiis  iii^^redieiit. 

It.  Tile  uric  (of  I.'ielii',')  or  xanthiC  oxide  calculus,  which  hears  a  dose  rela- 
tion to  uric  acid,  is  as  rare  as  the  last.  Dr.  Marcet  detected  tlu?  siihstancc  in  a  stone  ot" 
eif^ht  irrains'  weij;ht,  hut  no  remains  of  it  are  at  Guy  s.  Stronieyer  rediscovered  it  in  a 
stone  weiirhintr  tliree  hundred  and  thirty-five  grains,  removed  hy  Langenbeck,  which  was 
laminated  and  of  a  hriL'ht  hrown  color.  A  portion  of  this  calculus  is  in  <fuy's  Mu.seum 
(No.  lM  l.V"'). 

10.  The  fibrinous  calculus  of  Marcet  and  Prout  re<|uires  notice,  although, 
according  to  Bird,  it  must  lie  regarded  as  a  portion  of  dried  inspi.ssated  alhuminou.s 
matter  exuded  from  an  irritated  kidney.  Such  pseudo-calculi  present  considerable  lustre 
and  a  vitreous  fracture. 

11.  The  Uro-Stealith  calculus  seems  to  be  made  up  of  fatty  matter.  It  has 
been  described  in  llclK  r"s  Arc/iins  (  IS44 — 17))  and  by  Moore  in  the  Duhlln  Qn/trf.  Jonrn. 
for  ISol.      In  iluiitcr  s  collection  there  i.s  likewi.se  a  fine  sjtecimen  of  the  kind. 

1-.  Blood,  calculi  have  likewise  been  described  by  Marcet,  and  K(jberts  lias 
recorded  one  taken  from  a  sheep  by  Mr.  Lund  of  Manchester.  All  recorded  ca.ses 
have  been  connected  with  renal  lucmaturia.  Silica,  and  also  the  urates  of  soda  and  lime, 
are  occasional  ingredients  in  a  stone. 

With  this  brief  description  of  the  varieties  of  stones — for  much  of  which  I  am  indebted 
to  Poland's  article  in  Holmes's  tSi/s/em — it  may  be  well  to  consider  if  an}'  diagnosis  of  their 
nature  can  be  made  before  their  removal ;  and  for  this  purpose  the  character  of  the  urine 
is  of  great  value. 

If  it  be  acid,  the  stone  is  either  uric  acid,  oxalate  of  lime,  or  a  mixture  of  the  two; 
and.  as  the  uric  is  more  common  than  the  oxalate,  the  probabilities  point  to  the  former. 
When  the  urine  contains  either  ingredient,  the  nature  of  the  layer  that  is  being  depo.sited 
is  established. 

Gouty  people  are  more  prone  to  uric  acid  than  to  oxalate  calculi. 

If  the  urine  be  alkaline  from  /?.cet/  alkali,  as  indicated  by  the  permanent  change 
in  the  test  paper,  the  earthy  phosphates  or  the  carbonate  of  lime  calculi  are  indicated  ;  if 
from  the  carbonatr  of  ammonia  the  result  of  decomposition  of  the  urine,  the  mixed  phos- 
phates— that  is,  a  crust  of  these  is  being  deposited  upon  an  unknown  nucleus. 

When  a  small  stone  has  been  previously  passed  and  examined,  great  help  is  given 
towai'd  the  formation  of  an  opinion,  and  also  when  gravel  has  been  passed. 

In  England  one  person  in  one  hundred  thousand  dies  annually  from  stone,  in  Scotlanc) 
one  in  fifty  thousand,  and  in  Ireland  one  in  two  hundred  thousand.  The  proportion  of 
deaths  varies  greatly  in  diiferent  districts.  Cadge  informing  us  in  his  very  able  address 
given  before  the  British  Med.  Assoc,  for  1874  that  in  Norfolk  the  mortality  from  stone 
is  one  in  about  forty-two  thousand,  and  in  Cheshire  one  in  about  four  hundred  and  twenty- 
five  thousand. 

The  bills  of  mortality  indicate  that  ten  males  die  to  one  female  from  calculous  disea.se, 
and  stone  is  said  to  be  found  in  men  twenty  times  more  frequently  than  in  women.  It  \9 
probable,  however,  that  stones  form  as  readily  in  the  one  as  in  the  other,  but  that  in  women, 
owing  to  the  shortness  of  the  urethra  and  its  capability  of  dilatation,  they  are  more  readily 
discharged,  large  stones  being  not  rarely  discharged  in  the  female  sex  by  natural  efforts. 
(  Vide  '"  Stone  in  Female.'")  The  statistics  of  M.  Civiale,  Coulson.  and  Thompson  indicate 
that  about  sixty  per  cent,  of  the  cases  of  calculi  are  found  in  subjects  under  twenty  years 
of  age,  ten  or  twelve  per  cent,  in  those  between  twenty  and  forty,  twelve  to  fifteen  per 
cent,  in  those  between  forty  and  sixty,  and  about  ten  to  twelve  per  cent,  above  sixty. 
But  in  taking  these  absolute  numbers  and  comparing  them  with  the  relative  numbers  of 
persons  living  at  the  different  periods  of  life  named,  it  would  appear  that  children  and 
young  persons  are  less  liable  to  calculous  disorders  than  has  been  commonly  supposed, 
and  that  for  twenty  year.s  and  upward  the  tendency  goes  on  increasing  in  a  very  remark- 
able manner  to  the  end  of  life ;  or,  as  Sir  II.  Thompson  puts  it.  that  the  '•  proportion  of 
elderly  calculous  patients  to  the  existing  population  at  their  own  ages  is  larger  than  the 
proportion  of  children  afflicted  is  to  the  number  of  existing  children." 

Two-thirds  of  the  cases  of  stone  that  have  come  under  our  notice  in  hospital  practice 
are  in  children,  and  half  of  these  are  under  five  years  of  age.  These  young  ones  are, 
moreover,  generally  of  a  healthy  and  ruddy  a.spect  and  form  a  contrast  to  those  admitted 
for  other  diseases,  the  formation  and  presence  of  a  stone  in  young  life  being  apparently 
not  incompatible  with  good  health. 


660  STONE  IN  THE  BLADDER,   AND  ITS  TREATMENT. 

Causes  of  Stone. — With  respect  to  the  causes  of  stone,  I  concur  with  Cadge  that 
"  it  is  safer  to  attriVjute  lithuria  to  dyspepsia  and  malassirailation,  which  probably  concerns 
all  the  digestive  organs,  than  to  fix  the  fault  mainly  on  one,"'  and  that  this  condition  arises 
from  the  want  of  milk  as  an  ordinary  article  of  diet;  for  whilst,  in  tlie  children  of  the 
poor,  stone  in  the  bladder  is  so  common  as  to  constitute  half  the  whole  number  of  ca.ses 
met  with  in  jiractice,  it  is  seldom  seen  in  the  more  opulent  classes. 

STONE  IN  THE  BLADDER. 

When  a  stone  has  descended  from  the  kidney  into  the  bladder,  it  may  give  rise  to  no 
more  marked  symptom  than  a  slight  urinary  irritation  ;  and  when  it  passes  with  the  urin- 
ary stream,  this  symptom  will  disappear. 

When  the  calculus  rests  in  the  bladder  and  increases,  it  usually  gives  rise  to  more 
characteristic  symptoms,  which  differ  widely  in  different  subjects  and  apparently  have 
little  to  do  with  the  nature  of  the  stone. 

In  some — indeed,  in  the  majority — of  cases  the  symptoms  are  so  slight  as  to  be  disre- 
garded, whilst  in  the  larger  number  the  symptoms  have  frequently  existed  for  many 
months,  if  not  for  years,  before  advice  is  sought.  Indifference  or  carelessness  may  occa- 
sionally be  the  cause  of  this  delay,  but,  as  a  rule,  it  is  due  to  the  uncertainty  of  the  symp- 
toms and  the  comparatively  little  inconvenience  the  patient  suffers.  It  is  a  rare  thing, 
however,  for  a  parent  to  seek  professional  advice  for  a  child  suffering  with  stone  until 
Tistmaturia  has  been  observed,  some  prolapse  of  the  rectum  taken  place,  or  the  j)nin  which 
the  child  experiences  after  micturition  become  pronounced,  although  in  such  a  case  it  will 
generally,  upon  inquiry,  be  learnt  that  the  child  for  many  months  had  been  observed  to 
play  with  or  drag  the  penis  after  micturition,  that  the  stream  of  urine  had  occasionally 
been  interrupted  in  its  flow,  and  that  a  frequent  call  to  make  water  had  long  existed. 

These  symptoms,  therefore,  with  tolerable  accuracy  denote  the  presence  of  a  calculus, 
though  its  existence  can  be  positively'  affirmed  only  on  its  absolute  detection  by  a  sound. 
Yet  nearly  all  the  symptoms  which  have  been  enumerated  can  be  produced  by  other  and 
less  important  conditions,  and  more  particularly  by  an  elongated  and  adherent  prepuce. 

Retention  of  urine  in  an  otherwise  healthy  child  is  almost  always  cau.sed  by  the  impac- 
tion of  a  .stone ;  and  when  incontinence  exists,  it  frequently  indicates  the  presence  of  a 
calculus  which  has  been  forming  for  a  lengthened  period,  and  which  is  often  connected 
with  renal  as  well  as  vesical  changes  of  an  organic  character. 

In  adult  life  indifference  to  early  symptoms  is  not  common,  and  a  frequent  desire  to 
pass  water,  when  persistent,  will  soon  induce  a  man  to  seek  advice;  and.  as  this  may  be 
the  only  symptom  of  stone,  it  should  be  neither  disregarded  nor  lightly  treated.  Indeed, 
with  such  a  symptom  a  sound  .should  at  once  be  pa.ssed,  this  being  the  readie.'^t  and  best 
means  of  proving  w'hether  a  stone  be  the  cause  or  not.  The  symptoms  that  indicate  the 
presence  of  a  calculus  will  be  found  to  vary  from  the  slightest  irritation  of  the  bladder  to 
the  severest  agony,  and  those  which  have  been  described  will  be  present  in  different  degrees 
of  severity  or  in  different  combinations.  The  importance,  however,  of  an  early  detection 
of  a  calculus  is  so  great  that  in  every  case  of  persi.stently  irritable  bladder  which  is  not 
clearly  the  product  of  some  other  affection  it  is  better  to  suspect  the  existence  of  a  stone 
and  examine  with  a  sound  than  to  run  the  slightest  risk  of  overlooking  it,  and  conse- 
quently of  increa.sing  the  dangers  (which  are  alwa^'s  great)  of  exciting  or  keeping  up 
organic  disease  in  the  bladder  and  kidney.  It  is  to  be  remembered  that  the  presence  of  a 
calculus  is  dangerous  to  life  chiefly  from  the  organic  renal  changes  it  is  liable  to  excite, 
and  that  neither  the  operation  of  lithotrity  nor  that  of  lithotomy  is  commonly  fatal  if  such 
changes  have  not  taken  place.  The  early  detection  of  a  stone  becomes,  therefore,  neces- 
sarily a  point  of  the  highest  importance. 

The  confirmed  symptoms  of  vesical  calculus  in  the  adult  are  pain  of  different  degrees 
of  intensity  referred  to  the  bladder  and  aggravated  on  any  sudden  movement,  such  as  by 
riding,  jumping,  or  jolting  of  the  bod)\  pain  during,  and  particularly  after,  the  act  of 
micturition,  extending  along  the  urethra  to  the  penis,  exhausting  straining,  and  the  pas- 
sage of  blood.  During  the  flow  of  urine  a  sudden  arrest  of  the  stream  will  often  be 
observed,  this  arrest  being  followed  after  the  lapse  of  a  moment  of  time  by  the  return  of 
the  flow ;  and  this  interruption  maj-  be  repeated  more  than  once  in  each  act  of  micturi- 
tion. Retention  or  incontinence  of  urine  may  complicate  the  case.  Rectal  irritation  and 
tenesmus,  with  or  without  prolapse,  are  also  frequent  symptoms,  and  reflected  pains  along 
certain  nerves  are  very  constant.  Thus,  pain  in  the  glans  penis  is  most  common,  and 
pain  in  the  scrotum,  perinaeum,  and  down  the  thighs  is  pretty  constant.     John  Hunter 


STOSE  i.\  Tin:  ni.Ai)!)i:n. 


661 


relates  a.  Oiise  of  stoix-  in  wliitli  ])ain  in  tin.!  lel't  lun'-arin  was  the  only  indication  nf  a 
want  to  make  watt-r.  Sdint'tinies  tiic  Madder  syi'ip^'""'^  "'•'}  '"'  seven;  I'ur  a  time  and 
then  cease,  or  suddenly  appear  after  any  extra  exertion,  in  tlie  former  cu.se  the  .stone 
probably  becomes  fixed  in  a  .sacculus  and  cea.sos  to  irritate  ;  in  tiie  latter,  it  escapes  from 
a  sacculus  and  makes  its  presence  known.  As  lonjj;  as  the  bladder  remains  healthy  the 
chani^es  in  the  nrine  will  be  but  slight ;  but  when  the  stone,  actinj;  as  a  loreifjii  body, 
sets  up  cystitis,  all  the  symptoms  of  that  affection  will  appear,  with  the  muco-purulent 
discharire  and  ammoiiiacal  urine. 

When  the  symptoms  have  existetl  fur  :uiy  IciiirtluMied  jicriud.  the  jtroliabilities  of 
renal  eompiicatinns  are  threat,  as  indicated  by  albuminous  urine  witli  lunib.ir  p.iiii  and 
anasarca. 

In  rare  ca.ses  a  persistent  erection  (d'  the  ])enis  is  j)resent. 

Hut  these  symptoms  of  stone  are  merely  suhjictli-r :  they  are  those  ;^iven  l)y  the 
patient  ;  and,  however  suii<;estive  of  the  atfection  they  may  be.  they  are  not  conclusive, 
since  all  may  be  produced  by  other  bladder  affections.  The  oidy  conclusive  evidence  to 
be  obtained  is  by  the  physical  examination  of  the  bladder,  by  the  ''  .sounding  "  of  the 
patient  with  a  metallic  sound  or  catheter,  by  the  "  ringing  "  of  the  stone  against  its  end. 
To  sound  a  patient  su.spected  of  stone,  the  horizontal  position  should  be  .selected  and 
the  pelvis  raised  on  a  pillow.  The  bladder  should  contain  a  few  ounces  of  urine  if  possi- 
ble, three  or  four  being  enough  and  eight  being  ample,  and  the  rectum  should  be  empty. 
When  the  bladder  is  empty,  some  few  ounces  of  water  should  be  injected.  For  a  child 
a  small  metallic  bulbous  catheter  or  sound  with  a  short  sharp  curve  should  be  used  TFig. 

385),  the  bulbous  end  being 
one  size  larger  than  the  stem, 
and  for  the  adult  a  similar  in- 

=__^  ^  strument  suffices  (Fig.  oS4). 

'-*        -^  **^^.\^^  -^"  instrument  with  a  long 

curve  may  glide  over  the  stone, 
Catheter  Xo.  10.  "%,  %         and  will  certainly  fail  to  find 

T>      OD-  %     ^       one  lodued  behind  the  prostate; 

Fig.  38o.  \  _m      •,    •       V       ,  ,V        rp,  ' 

It    IS  also   less  movable.     Ihe 

shortei'-curved  catheter  can  be 
made  to  turn  downward  to  ex- 
plore the  base  of  the  bladder 
with  the  same  fticility  as  it  can 
to  explore  the  .sides.  A  hollow  sound  or  cath- 
eter is  better  than  a  solid,  as  a  stone  will  often  be 


Fig.  384. 


Child's  Catheter.    (Natural  size) 


detected  on  drawing  off  the  urine,  as  the  bladder,  in  the  act  of  contracting,  may  throw 
the  stone  upon  the  end  of  the  instalment  and  thus  make  its  presence  known.  The  cath- 
eter should  not  have  a  stylet. 

The  instrument  should  be  warmed,  freely  oiled,  and  passed  carefully  and  slowly  into 
the  bladder ;  nor  ought  its  introduction  to  give  pain.  It  should  be  at  first  pushed  well 
home  toward  the  posterior  part  of  the  organ  to  search  its  base,  and  then  turned  first  to 
one  side  and  then  to  the  other  to  search  its  sides,  the  sound  during  the  operation  being 
gradually  withdrawn  and  again  pushed  back.  When  an  enlarged  i)rostate  exists  and  a 
stone  is  expected  to  lie  in  a  pouch  behind  the  so-called  gland,  the  beak  of  the  instrument 
must  be  turned  backward ;  and  in  this  way  every  corner  of  the  bladder  can  be  examined. 
When  no  "ring"  of  the  calculus  is  first  obtained,  the  water  may  be  partially  drawn  off, 
and  by  this  mananivre  it  may  be  heard.  In  children  the  introduction  of  a  finger  into 
the  rectum  at  times  fticilitates  the  search,  and  the  pressure  of  the  hand  above  the  pubes 
often  facilitates  the  detection  of  the  stone. 

A  large  stone  is  generally  touched  on  the  sound  entering  the  neck  of  the  bladder,  and 
a  small  one  usually  lies  at  the  base  of  the  bladder,  to  either  the  right  or  the  left  of  the 
median  line.  An  encysted  stone  is  a  rarity.  A  stone  may  often  be  felt  at  one  time  and 
not  at  another  ;  consequently,  when  well-nuirked  symptoms  exist,  any  hasty  opinion  as 
to  its  absence  is  to  be  avoided.  Mr.  F.  L' Estrange  of  Dublin  has  invented  a  sounding- 
board  to  be  fastened  to  the  top  of  the  .sound  for  intensifying  the  noi.se  produced  by  the 
instrument  when  it  strikes  a  stone  in  the  bladder.     It  is  an  ingenious  instrument. 

The  late  Mr.  Napier  invented  a  pewter  sound,  the  surface  of  which,  being  oxidized 
by  nitric  acid,  is  easily  scratched  when  coming  in  contact  with  a  stone.  It  seems  to 
be  of  use  when  the  stone  is  otherwi.se  difficult  of  detection.  For  the  same  purpose  the 
microphone  may  possibly  prove  of  value. 


662  STONE  IN  THE  BLADDER,   AND  ITS  TREATMENT. 

The  operation  of  souiuling  ought  to  reveal  something  more,  however,  than  the  pres- 
ence of  the  stone,  such  as  its  size  and  nature  and  whether  more  than  one  is  present. 
The  size  is  indicated  by  the  extent  of  surface  passed  over  by  the  point  of  the  instru- 
ment;  and  the  nature,  by  the  noise  emitted  on  the  striking  of  the  stone,  such  hard  stones 
as  the  uric  acid  or  oxahite  of  lime  giving  a  sharp,  clear,  ringing  sound,  while  the  light 
and  soft  phosphatic  calculi  yield  a  dull  one.  The  roughness  of  the  oxalate  of  lime  cal- 
culus may  also  be  generally  felt.  In  children,  with  the  finger  in  the  rectum,  the  size 
of  the  calculus  can  often  be  readily  made  out.  The  character  of  the  urine,  as  already 
pointed  out,  throws  some  light  upon  that  of  the  calculus.  The  value  of  chloroform  in 
facilitating  the  search  for  a  stone,  more  particularly  in  children,  is  so  great  that  it  should 
almost  always  be  employed.  In  sounding,  the  surgeon  must  not  be  misled  by  the  sen- 
sation given  by  the  rugous  or  roughened  bladder,  the  viscus  feeling  hard  and  uneven  to 
the  end  of  the  sound,  and  the  examination  giving  pain.  When  this  condition  is  made 
out,  all  sounding  should  be  given  up ;  for  the  existence  of  such  with  a  stone  is  almost 
unknown. 

In  children  the  instrument  may  strike  against  the  sacrum  or  spine  of  i\\v  ischium  and 
mislead,  but  in  this  case  there  is  no  sound  emitted ;  indeed,  the  surgeon  must  be  careful 
to  hear  as  well  as  to  feel  the  stone  before  he  is  satisfied  as  to  its  presence,  as  there  are 
many  aifections  of  the  bladder  and  prostate  that  in  their  clinical  history  and  ph^'sical 
symptoms  simulate  those  of  stone,  but  in  none  is  any  perceptible  sound  given  when  using 
the  metallic  instrument,  as  in  stone.  The  only  unequivocal  sign  of  calculus  is  the  sound 
produced  on  sti'iking  the  stone. 

In  forming  a  diagnosis  the  surgeon  should  always  remember  that  when  irritation  at 
the  neck  of  the  bladder  arises  from  stone  it  is  referred  to  the  glans  penis;  when  from  dis- 
ease of  the  bladder,  to  the  organ  itself;  and  when  from  disease  of  the  prostate,  to  the 
perineum  or  rectum. 

When  a  calculus  is  suspected  in  the  female,  a  vaginal  examination  will  often  enable 
the  surgeon  to  feel  the  foreign  body.  It  will  also  remove  all  such  sources  of  fallacy  as 
are  prone  to  follow  from  uterine  affections.  In  female  children  a  rectal  examination  will 
do  as  well. 

Treatment. — A  calculus  having  been  detected  in  the  bladder,  there  is  only  one  form 
of  treatment  which  can  be  successful,  and  that  is  its  removal  ;  for,  with  rare  exceptions, 
a  stone,  if  allowed  to  remain,  will  set  up,  not  only  bladder  disease,  but  kidney  mischief, 
ending  in  death. 

A  stone  may  be  removed  by  a  cutting  operation — Jltltotomy ;  or  by  a  crushing  one — 
lithotrity  ;  the  treatment  by  UfhontripticA  and  electrolysis  has  hitherto  met  with  indifferent 
success. 

In  former  times  small  stones  were  removed  from  the  bladder  by  forceps.  Sir  B. 
Brodie,  Sir  AY.  Blizard,  Boyer,  George  Bell,  and  others,  have  recorded  many  such  cases. 
Sir  A.  Cooper's  celebrated  ca.se,  in  which  he  removed  eighty  small  stones  by  this  means, 
is  well  known  ;  but  the  practice  has  been  entirely  superseded  by  the  lithotrite. 

Lithontriptics,  or  stone  solvents,  were  used  long  before  the  composition  of  urinary 
calculi  had  been  made  known,  and  were  mostly  alkaline  remedies;  and  the  most  celebrated 
nostrum  of  Joanna  Stephens,  for  which  the  government  of  1739  gave  a  reward  of  five 
thou.sand  pounds,  was  composed  of  burnt  eggshells  and  snails,  with  Alicante  soap.  Prout 
showed  the  value  of  fluid  as  a  solvent  in  calculous  affections  ;  Chevallier,  of  alkalies ;  and 
Ch.  Petit,  more  particularly  of  the  Yichy  springs.  There  can  be  no  little  doubt,  too,  that 
in  the  lithic-acid  form  of  stone  alkalies  have  an  undeniable  influence  in  checking  their 
increase,  if  not  in  aiding  their  solution.     In  other  stones  they  have  no  such  influence. 

Dr.  Roberts,  who  has  in  recent  years  paid  much  attention  to  this  subject  (Med.-Clnr. 
Trans..  1865),  seems  to  think  that  "  the  results  obtained  by  his  experiments  demand  a 
considerable  modification  of  the  prevailing  opinion  regarding  the  inutility  of  the  .solvent 
treatment :  they  suggest  an  essential  improvement  in  the  treatment  of  renal  calculi ;  they 
indicate  that  uric  acid  and  cystine,  under  certain  circumstances,  are  capable  of  solution 
in  the  bladder,  by  means  of  alkaline  .salts  administered  by  the  mouth,  at  a  rate  which 
admits  of  practical  application,  and  that  in  picked  cases  a  solvent  treatment  deserves  to 
be  resolutely  tried."  He  adds,  however,  "  that  the  .solvent  treatment  is  only  applicable 
in  those  cases  of  vesical  calculi  in  which  the  urine  is  acid,  the  stone  not  large,  its  compo- 
sition known  to  be  uric  acid,  or  .strongly  su.spected  to  be  such."  The  best  solvents  are 
the  acetate  or  citrate  of  potash,  sufiicient  doses  being  given  to  make  the  urine  neutral, 
not  alkaline. 

Garrod  has  suggested,  as  the  results  of  experiment  and  experience,  that  as  in  herb- 


i.iTiioroMv  ni:  i.iriiorniTY  is  casks  or  stom:.  {](\:\ 

ivoroiis  animals  tlif  presence  (if  lii|i]Miric  acid  in  the  urine  linltls  uric  acid  in  Kuspcnsion, 
so  the  administrution  of  hi|i|iuric  or  benzoic  acid  nii^ht  \n'.  oi'  use.  lie  has  t'ounil  this  to 
be  tlie  case.  lie  jrives  lienzoate  of  .so(hi  in  twenty-grain  doses  three  times  a  dav,  and  con- 
tinues it  with  some  alkaline  citrate  if  the  urine  he  vt-ry  acid.  1  have  found  this  treatment 
very  efficacious  in  diminishinir  the  amount  of  uric  acid  in  the  urine. 

lirodie  -showed  that  the  injection  into  the  Madder  ol'  a  solution  oi'  nitric  acid  two  or 
three  minims  to  the  ounce  of  water  had  the  |M»wer  of  dissnlving  ]dios|ihatic  calculi,  and 
upon  this  su^Lrestinn  other  experimenters  hav(-  tried  dihi-r  fluids,  such  as  weak  alkaline 
stdutions,  fur  uric  acid  calculi,  carlxmate  of  lithia,  hurax.  and  acetate  of  lead,  etc.  ;  but 
there  is  this  «rreat  disadvantajre  in  the  jiractice — that  the  solutions  are  apt  to  irritate  the 
bladder  and  thus  do  more  harm  than  <rood.  In  the  uric  a<Md  and  o\alat(;  of  lime  calculi 
they  are  almost  useh-ss.  In  the  phosphatic  stones  most  surL'eons  admit  the  value  of  the 
practice,  a  solution  of  diluted  nitric  acid  ^ij  to  a  jiint  of  wat(;r.  injected  into  ji  bladder 
where  phosphates  are  being  deposited,  being  of  great  value  in  many  cases.  Such  a  prac- 
tice must,  however,  be  carried  out  with  great  caution. 

The  aid  of  the  galvanic  battery  ha.s  been  employed  to  break  up  stones  by  Dr.  Bence 
Jones,  8ir  W.  O  Shaughiiessy,  and  others ;  but  the  success  attending  the  experiments 
has  not  been  sufficient  to  warrant  the  recommendation   of  the  means. 

Small  stones  may  often  be  washed  out  of  the  bladder  by  means  of  the  urine,  and 
jiatients  who  are  prone  to  the  j)a.ssagc  of  renal  calculi  into  the  bladder  and  to  the  forma- 
tion of  lithic  acid  or  other  gravel  should  be  directed,  once  a  day.  when  the  full  bladder  is 
ab«nit  to  di-scharge  its  contents,  to  arrest  the  flow  of  urine  by  holding  the  penis,  and  then 
suddeidy  to  allow  the  stream  to  flow  ;  in  this  way  the  water,  passing  with  a  rush,  carries 
away  any  small  stone  or  sand  that  might  be  resting  in  the  bladder.  I  have  known  this 
practice  to  be  followed  by  good  success.  Old  men  should  do  this  on  their  hands  and 
knees.  When  a  stone  is  too  large  to  pa.ss  in  this  way,  it  must  be  removed,  which  is  to 
be  done  by  means  of  lithotomy  or  lithotrity. 

Lithotomy  or  Lithotrity  in  Cases  of  Stone. 
Stone  in  the  bladder  in  children  may  be  safely  treated  by  lithotomy, 

which  should  be  performed  as  soon  as  the  stone  has  been  detected  in  the  bladder ;  for 
the  dangers  of  any  individual  case  can  be  fairly  measured  by  the  size  of  the  stone  and 
the  duration  of  the  symptoms.  The  longer  a  calculus  has  existed,  the  greater  are  the 
probabilities  of  renal  disease  complicating  the  case  ;  and  the  dangers  of  lithotomy,  inde- 
pendently of  its  own  .special  risks,  are  mostly  due  to  the  kidney  affection.  When  the 
stone  is  large,  the  neck  of  the  bladder  may  be  so  injured  by  its  removal  as  to  set  up  a 
fatal  peritonitis,  and  hemorrhage  may  in  exceptional  cases  cause  death ;  but  in  skilful 
hands  the  operation  of  lithotomy  in  patients  under  puberty  is  most  successful. 

Sir  W.  Fergusson  informs  us  in  his  College  Lectures  that  out  of  fifty  cases  of  lithot- 
omy in  children,  he  lost  only  two.  In  my  own  practice,  out  of  the  .same  number  of  cases 
under  puberty,  I  have  lost  but  two.  In  one  the  stone  was  two  ounces  in  weight  and  two 
inches  in  diameter,  and  the  patient,  ten  years  old,  had  had  .symptoms  all  his  life,  and  incon- 
tinence of  urine  for  four  years.  He  died  from  peritonitis  and  extreme  di.sorganization  of 
the  kidney.  In  the  other  the  child  was  three  years  old.  The  stone  was  removed  without 
difficulty  and  without  bleeding,  and  convalescence  seemed  at  hand,  when  on  the  seventh 
day  secondary  hemorrhage  occurred,  and  death  took  place  from  convulsions. 

In  children,  therefore,  it  may  be  safely  asserted  that  success  may  with  .some  confidence 
be  looked  for  after  lithotomy  when  performed  with  care  and  .skill.  "  It  nuiy  reasonably  be 
doubted  if  better  can  be  done  before  fifteen  than  cutting  for  stone"  (Fergus.son). 

Lithotrity  in  a  child,  with  fine  instruments,  may  be  a  justifiable  operation  in  excep- 
tional cases  when  the  calculus  is  known  to  be  very  small,  but.  as  a  rule,  in  patients  under 
puberty  lithotomy  ought  to  be  selected.  In  Great  Britain  this  practice  is  generally  fol- 
lowed by  surgeons,  although  in  France  lithotrity  is  more  frequently  .selected. 

In  stone  in  the  bladder  in  adults  its  removal  by  lithotrity  ought  primarily 
to  be  entertained,  and  lithotomy  had  rectiurse  to  only  when  lithotrity  is  inapplicable. 
Lithotrity,  as  now  practised,  is,  thanks  to  Bigelow,  probably  applicable  to  at  least  four- 
fifths  of  all  cases  of  stone  in  adult  subjects.  The  danger  of  lithotomy  rapidly  increases 
with  age,  the  mortality  being  1  in  8  between  .seventeen  and  forty,  1  in  4  above  that  age. 
I  have  cut  24  adult  male  subjects  with  G  deaths,  or  1  in  4  :  and  Thompson,  out  of  78 
cases,  lost  29,  or  1  in  '2%. 

When  renal  disease  can  be  made  out  as  existing,  lithotrity  is  no  nn^re  favorable  an 


664  STONE  IN  THE  BLADDER,   AND   ITS  TREATMENT. 

operation  than  lithotomy  ;  when  with  it  there  are  bhidder  complications,  the  cutting 
operation  is  probably  the  right  one  to  adopt,  even  if  only  as  a  means  of  giving  relief, 
although,  when  the  stone  is  small  and  the  renal  symptoms  are  uncertain,  lithotrity  may 
be  undertaken  with  success. 

When  severe  bladder  mischief  complicates  the  case,  lithotrity  is  out  of  the  question 
and  lithotomy  should  be  selected,  although  experience  confirms  what  C.  Hawkins  has 
stated — that  lithotrity  may  be  performed  with  success  when  the  bladder  has  been  in  a 
very  considerable  state  of  irritation  and  secreting  much  ropy  mucus.  The  irritation  and 
the  secretion  of  mucus  cease  when  the  whole  of  the  calculus  has  been  removed. 

Paralysis  of  the  bladder  does  not  preclude  the  practice  of  lithotrity,  though  it  neces- 
sitates extra  care  and  gentleness  in  manipulation.  An  enlarged  prostate,  unless  mechan- 
ically interfering  with  the  introduction  of  the  instrument,  is  by  no  means  an  inseparable 
bar  to  the  operation. 

When  a  severe  organic  urethral  stricture  exists,  lithotrity  may  be  impossible  unless 
the  stricture  can  be  fully  dilated.  When  the  stone  is  very  large,  the  operation  of  crushing 
may  be  out  of  question.  I  have,  however,  crushed  a  lithic-acid  calculus  one  and  a  half 
inches  in  diameter  with  success. 

"  Formerly,"  wrote  Aston  Key  (1837,  Gki/'s  Reports),  "  patients  laboring  under  cal- 
culous disorders  entertained  a  feeling  of  dread  almost  amounting  to  horror  at  the  idea 
of  having  a  stone  in  the  bladder,  but  since  the  introduction  of  lithotrity  they  no  longer 
entertain  the  dread  of  their  symptoms  depending  on  the  presence  of  a  stone  ;  and  when 
the  stone  is  found,  they  cheerfully  make  up  their  minds  to  undergo  an  operation  which 
they  regard  as  free  from  danger,  and  nearly  so  from  pain.  I  have  known  a  patient,  and 
more  than  one,  to  be  pleased  with  the  discovery  of  a  stone  in  the  bladder,  convinced,  as  he 
expressed  it,  that  he  could  look  for  an  easy  cure  from  the  new  operation.  The  exagger- 
ated statements  of  the  advantages  of  lithotrity  have  thus  not  been  unattended  with  good ; 
they  have  been  the  means  of  inducing  persons  to  come  forward  to  obtain  relief  Avhen  the 
disease  was  incipient  and  the  stone  small.  Since  the  introduction  of  lithotrity  the  sur- 
geon examines  the  bladder  with  great  care,  knowing  the  importance  of  discovering  the 
calculus  at  the  earliest  period.  The  early  symptoms  of  stone  are  thus  watched  with  more 
jealousy  on  the  part  of  the  surgeon,  and  are  not  so  scrupulously  concealed  by  the  patient. 
The  advantages  of  an  early  knowledge  of  the  existence  of  a  stone  and  of  prompt  meas- 
ures for  its  removal  are  known  to  both.  The  result  of  this  is  that  patients  apply  for 
advice  when  the  stone  is  small,  the  bladder  uninjured  by  its  presence,  and  the  kidneys 
free  from  disease.  In  three  persons  out  of  four  who  apply  for  advice  for  symptoms  of 
calculus,  the  size  of  the  stone  and  the  conditions  of  the  viscus  render  lithotrity  an  easy 
and  a  safe  operation." 

These  extracts,  which  I  have  given  from  Aston  Key's  paper  written  nearly  fifty  years 
ago,  might  have  been  from  the  pen  of  a  more  recent  writer,  they  so  accurately  represent 
'the  advantages  of  what  was  then  called  "the  new  operation,"  and  prove  how  the  great 
surgeon  who  wrote  them  recognized  its  value.  What  Key  would  have  said  of  Bigelow's 
still  newer  method  can  easily  be  surmised. 

Summary. — It  would  thus  appear  that  in  children  lithotomy  ought  to  be  the  rule  and 
lithotrity  the  exception,  in  achilts  lithotrity  ought  to  be  the  rule  and  lithotomy  the  excep- 
tion, the  latter  operation  being  selected  only  when  the  former  is  impossible  from  some 
urethral  or  prostatic  irritability  or  mechanical  obstruction,  severe  bladder  disease,  or  a 
large  stone.  Renal  disease  in  all  cases  renders  doubtful  the  prognosis  of  any  operative 
procedure,  the  weight  of  evidence  tending  in  favor  of  a  cutting  rather  than  a  crushing 
operation  under  such  circumstances,  though,  when  the  stone  is  small,  lithotrity  is  not  pre- 
cluded. 

In  cases  in  which  neither  operation  can  be  recommended  or  when  both  are  rejected  it 
is  wonderful  how  long  patients  the  subjects  of  stone  and  organic  disease  by  care  and  good 
advice  will  live,  and  how  little  irritation  a  calculus  sometimes  causes ;  and,  though  the 
knowledge  of  this  fact  should  not  induce  a  surgeon  to  leave  alone  a  patient  who  has  a 
stone,  it  is  enough  to  enable  him  to  give  hope  and  encouragement  to  one  whose  life  would 
be  endangered  by  any  surgical  attempt  at  its  removal,  for  palliative  treatment  is,  doubt- 
less, a  source  of  great  comfort  and  a  valuable  means  of  prolonging  life. 

LITHOTRITY. 

"  In  the  whole  of  my  professional  experience,"  says  Fergusson  in  his  College  Lectures 
(1867),  "  I  know  not  of  a  useful  operation  which  has  been  so  shamefully  overpraised,  and 


THE  OPEIlATins.  6G5 

thcrchy  daiuairod  in  cliaractcr,  as  litliutrity.  I  know  not  any  process  in  sur<rery  requiring 
luori!  turotlioiijj;ht,  knuwk'djio,  manipulative  skill,  and  aftLT-judj^inL-nt."  ''  Nor  is  it  possi- 
ble, "  writes  Thompson,  "  to  t'ontluct  all  the  manipulations  with  too  much  car*;  ami  jrentle- 
ness."  These  o])inions,  emanating;  as  they  do  IVom  two  such  experienced  lithotritists, 
ouf;ht  always  to  be  remembered,  since  they  are  true  to  a  degree  that  oidy  surgeons  who 
have  had  s(»me  exj)erience  in  the  operation  can  appreciate.  To  Mr.  Klderton,  a  North- 
ampton surgi'on,  is  due  the  merit  ol"  hciMg  the  Hrst  to  construct  an  instrument  for  tiie 
purpose  ot"  crushing  a  calculus  and  enaltling  the  patient  to  pass  it  by  the  urethra  (Eiliii. 
Mill,  itnd  Sitiy.  Joiiniii/,  April,  ISl!)),  'out  lithotrity  was  first  realized  as  an  operation  and 
successfully  practised  bv  Civiale  in  1S24,  and  to  him  the  profession  is  chiefly  indebted  for 
the  operation,  though  Leroy  d'Ktiolles,  lleurteloup,  Amussat,  and  others  diil  much  towanl 
favoring  the  practice.  It  is  probably,  however,  to  Ileurtelou])  that  British  surgeons  are 
mostly  indebted,  as  he  came  over  to  Kngland  about  ISliU  and  fully  exj)lained  to  the  pro- 
fession the  mechanism  of  his  improved  instruments  and  the  steps  of  the  operation,  and 
on  the  invitation  of  Mr.  Aston  Key  this  instruction  was  given  in  the  theatre  of  Gruy's 
Hospital.  Weiss,  in  182!J,  had  previou.sly  devised  a  screw  lithotrite,  and  after  lleurte- 
loup's  visit,  and  probably  from  information  ac(|uired  through  him,  so  improved  it  that  all 
modern  instruments  are  based  upon  that  which  he  then  introduced.  A.ston  Key,  Brodie, 
(\)stello,  Hodgson,  Fergusson,  and  others  sub.sequently  practised  the  operation,  and 
through  the  result  of  their  experience,  with  that  of  Civiale,  the  operation  has  become  a 
recognized  one,  the  instruments  employed  having  been  vastly  improved  and  their  use 
better  understood. 

In  1829,  Aston  Key  read  a  paper  on  lithotrity  at  the  IFunterian  Society,  and  the 
report  of  a  successful  case,  and  in  Guy's  Riports  for  18)J7  will  be  found  a  masterly'  paper 
upon  the  subject  by  the  same  surgeon.  In  1834,  Fergusson  wrote  on  lithotrity  in  the 
Ellin.  Mill,  mill  Sitrq.  Jouriiuf,  in  which  he  introduced  his  rack  lithotrite,  and  to  him,  as 
well  as  to  Sir  B.  Brodie,  Sir  H.  Thompson,  and  Charles  Hawkins,  mo.st  of  our  modern 
improvements  are  due. 

The  greatest  improvement,  however,  was  left  for  H.  J.  Bigelow  of  Harvard,  United 
States,  who  in  1878  introduced  to  the  notice  of  surgeons  his  rapid  method  of  crushing 
stones  and  of  evacuating  their  (Uhris,  since  which  time,  it  may  be  said,  with  all  truth,  a 
new  starting-point  for  the  operation  has  been  supplied.  It  is  true  that  the  full  credit  of 
this  operation  must  not  be  given  entirely  to  Bigelow,  since  something  is  due  to  the  intro- 
duction of  anjusthetics,  something  to  the  principle  embodied  in  Crampton's  bladder  evacu- 
ator.  introduced  in  184G,  and  in  Clover's,  of  a  more  recent  period;  something  also  to  Otis, 
who  in  18T4  demonstrated  the  fact  that  the  normal  urethra  will  bear  fuller  dilatation 
than  it  had  hitherto  been  subjected  to ;  nevertheless,  it  was  left  to  Bigelow  to  see  fully 
the  bearing  of  all  these  points,  and  so  to  focus  them,  as  it  were,  upon  the  ojieration  of 
lithotrity  as  to  make  the  rapid  method  a  po.sitive  success,  the  method  depending  upon  the 
tolerance  of  the  bladder,  the  use  of  large  lithotrites,  and,  above  all,  the  employment  of 
large  cathetei's  and  of  a  more  powerful  evacuator  than  Clover's.  "  The  new  and  essential 
instrument  of  the  operation,"  writes  Bigelow,  "is  the  large  catheter,  25  to  31.  This  is 
indispen.sable.  The  small  size  of  the  previous  evacuating  catheter  delayed  surgical  prog- 
ress for  half  a  century." 

The  Operation. 

The  objects  of  lithotrity  may  now  be  defined  as,  fir.st,  to  reduce  a  stone  to  fragments 
sufficiently  small  to  pass  through  ushirqe  an  evacuating  catheter  as  can  be  introduced  into 
the  bladder  without  injury  to  the  bladder  and  passages;  and  secondly,  to  remove  the  frag- 
ments as  speedily  as  possible. 

Preliminary  Treatment. — Starting  with  the  assumption  that  our  patient  is  fairly 
healtliy,  the  stone  of  reasonalde  dimensions — that  is,  not  more  than  one  or  one  and  a  half 
indies  in  diameter — and  not  too  hard,  the  urethra  of  normal  size,  the  bladder  capable  of 
retaining  about  four  ounces  of  not  unhealthy  urine — conditions  under  which  operative 
interference  ought  to  be  most  favorable — it  is  always  well  to  keep  the  patient  quiet  for  a 
few  days,  and  to  test  the  urethra  and  bladder  as  to  their  capabilities  of  bearing  the  mechan- 
ical irritation  of  large  instruments  by  the  introduction  of  a  sound ;  attention  should  be 
paid  at  the  same  time  to  the  condition  of  the  secretions,  etc.  AVith  every  attention, 
however,  it  is  not  uncommon  to  meet  with  cases  in  which  the  mere  passage  of  a  sound  is 
followed  by  severe  local  and  constitutional  disturbance,  and  in  lithotrity  such  a  complica- 
tion is  most  detrimental.  On  the  other  hand,  where  irritability  exists  the  occasional  intro- 
duction of  an  instrument  is  often  followed  bv  relief. 


6Q6 


STONE  IN  THE  BLADDER,  AND  ITS  TREATMENT. 


When  the  bhxdder  is  inflamed  and  irritated  by  the  presence  of  a  stone,  rest  is  most 
essential,  with  the  use  of  alkalies  and  the  decoction  of  the  tritieum  repens  or  other  drugs 
suitable  for  cystitis.  When  the  urine  is  ammoniacal,  the  bladder  should  be  eni])tied  and 
washed  out. 

By  these  means  the  symptoms  may  subside  and  the  bladder  become  capable  of  retain- 
ing sufficient  urine — four  ounces — to  allow  of  the  operation  being  performed  where  i)re- 
viously  it  would  have  been  impossible. 

Preparation  for  Operation. — The  patient  having  been  prepared  for  operation 
by  the  treatment  just  laid  down,  the  bowels  cleared  by  a  mild  aperient  or  an  enema  the 
day  before,  and  the  bladder  sufficiently  distended  by  the  patient  retaining  his  urine  as 
long  as  he  conveniently  can  before  the  surgeon's  visit,  or  by  the  injection  into  it  of  a 
lotion  of  thymol  or  boracic  acid,  the  operation  may  be  proceeded  with. 

Position  of  Patient. — The  patient  should  be  placed  upon  a  firm  horsehair  mat- 
tress or  sofa,  with  his  right  side  near  its  edge ;  his  shoulders  should  be  low,  the  pelvis 
raised  by  means  of  a  firm  pillow,  and  the  knees  slightly  flexed  and  separated,  care  being 
taken  that  only  such  portions  of  the  pelvis  are  exposed  as  are  necessary  to  allow  of  the 
surgeon's  manipulation  ;  for  a  sudden  chill  often  acts  upon  the  bladder  and  induces  it  to 
contract  and  expel  its  contents. 

The  object  of  raising  the  pelvis  is  to  roll  the  stone  backward  from  the  neck  of  the 
bladder,  its  most  sensitive  point. 

An  instrument  with  large  teeth  and  a  fene.strated  female  blade  is  the  best  for  crush- 
ing large  stones  (Fig.  388,  A),  and  a  less  powerful  instrument  with  finer  teeth  for  small 
stones  or  fragments  (Fig.  388,  B). 

Introduction  of  Instrument. — The  instrument,  selected  by  the  surgeon  accord- 
ing to  the  size  of  the  stone  to  be  crushed,  having  been  previously  well  warmed  and  oiled, 
is  then  to  be  cai'efully  introduced,  no  force  being  employed  ;  indeed,  it  may  almost  be 
allowed  to  slide  into  the  bladder  by  its  own  weight,  the  surgeon  simply  guiding  it. 

When  the  instrument  has  reached  the  prostate,  and  not  before,  the  handle  of  the 
instrument  is  to  be  depressed  toward  the  patient's  thighs,  when  the  blades  rise  up  into 
the  bladder — "a  movement  which  is  rendered  more  easy,"  says  Thompson,  ''if  a  very 
slight  lateral  rotary  motion  is  given  to  the  instrument  at  this  part  of  its  progress." 

The  bladder  thus  reached  and  the  instrument  pressed  well  into  the  organ,  the  object 
is  to  seize  the  stone,  which  can  be  done  either  by  so  depressing  the  lithotrite  with  its 
open  blades  as  to  allow  of  the  stone  falling  between  them  or  by  turning  the  open  instru- 
ment to  the  stone  and  picking  it  up.  The  first  is  the  older  and  the  more  usual  method, 
and  the  one  I  have  commonly  adopted ;  the  second  is  useful  where  the  stone  is  not  readily 
found  by  the  first  method,  where  the  prostate  is  enlarged,  and  the  stone  rests  in  a  holloAV 
behind  it.     In  either  method  the  movements  of  the  instrument  are  to  be  gentle  and  quiet, 

and  care  is  to  be  observed  that  in  opening 
the  instrument  the  male  blade  does  not  in- 
jure the  neck  of  the  bladder. 

Finding  and  Seizing  the  Stone. 

"  Let  it  be  understood  that  the  blades  of  the 
lithotrite  have  entered  the  cavity  of  the  blad- 
der, and  that  the  instrument  slides  easily 
and  smoothly  down  the  trigone,  which  in 
the  living  and  healthy  organ  is  an  inclined 
plane,  although  (juite  otherwise  in  the 
atonied  and  in  the  dead  bladder.  In  many 
cases  the  instrument  in  thus  passing 
grazes  the  stone,  and  the  slightest  lateral 
movement  of  the  blades,  right  or  left,  will 
determine  on  which  side  it  lies.  Whether 
the  stone  is  felt  or  not,  when  the  blades 
have  passed  gently  down  in  the  middle 
line  until  a  very  slight  check  to  their 
movement  is  perceived,  the  lithotrite 
should  rest  there  for  three  or  four  seconds, 
and  then  the  male  blade  should  be  slowly 
withdrawn,  without  moving  any  other 
part  of  the  instrument,  toward  the  neck 
of  the  bladder,  until  a  very  slight  check  is  perceived  in  that  direction,  followed  by  another 


Fig.  386. 


Ujjeratiou  of  Lithotiity. 


'/'///•;  ()i'i:i:.\Tit)S. 


0(17 


Operation  of  Lithotrity. 


tliri'f  (ir  tour  scoonds'  rest  for  currt'iits  t(t  sultsidc.  Now  tlio  (iporiifor  slioiiM  r|uii'tly  jircsH 
Itack  tilt'  male  hlinie  without  eliaiij^inj;  the  position  of  tlu,'  lithotrite.  and  almost  eertainly 
the  stone  will  he  seized.      In  otiier  words,  open,  pause,  close;:   tliat  is  all. 

"  It'  no  stone  is  thus  found,  the  operator  aj^ain  withdraws  the  male  hlarlc  as  hcfore, 
but  inelininir  to  the  rijrht  side  ahout  forty-tive  def^rees,  and  (doses  without  disturhinj;  tlie 
central  position  of  the  instrument.  If  no  stone  is  felt,  he  then  turns  them,  opened,  t(i 
the  left  in  a  similar  manner,  and  tlien  closes  tln'in.  Thus,  in  almost  all  j)Ositions,  the 
stone  is  sci/cd  sideways  hy  the  hiades 
(if  the  lithotrite,  and  very  rarely  hy 
their  extremities.  Observe  thai  tin: 
hln'h\<  iir<'  iiiirai/s  to  he  opcnrd  before 
they  are  turneil^  for  thin  reason:  If  the 
turn  is  first  maile  and  the  blades  are  siifi- 
se(ji(nit/i/  opened,  the  ehanee  is  titat  the 
viah'  blade,  as  it  is  withdrawn^  wdl  more 
th''  stone  an-ai/  ;  n^hereas,  if  the  blaxbs 
are  inclined  ivhile  open,  the  stone,  if 
there,  is  almost  certaiidi/  seizid.  This  is 
one  of  the  many  apparently  minute  but 
extremely  important  points  of  which 
systematic  lithotrity  is  made  up.  To 
return  :  it  is  very  rare  that  the  stone 
will  elude  the  search  thus  far  ;  but  if  it 
does,  depress  the  handle  of  the  lithotrite 
half  an  inch  or  so,  which  raises  the 
blades  very  slightly  from  the  floor  of 
the  bladder,  and  turn  them  another 
forty-five  degrees  to  the  left,  bringinir,  in  f^iet,  the  blades  horizontally  to  the  left ;  close. 
If  unsuccessful,  turn  them  gently  to  horizontal  on  the  right,  and  close.  In  all  these 
movements,  if  properly  executed,  thei'e  has  been  barely  contact  of  the  lithotrite  with  the 
vesical  walls — at  all  events,  no  pressure,  nothing  to  provoke  undue  pain  or  cause  contrac- 
tions of  the  bladder.  If,  however,  there  is  an  enlarged  prostate,  causing  an  eminence  at 
the  neck  of  the  bladder  or  depression  behind  it,  or  the  stone  is  very  small,  or  we  are 
exploring  for  some  fragment  at  the  close  of  the  case  which  is  suspected  to  have  eluded 
previous  search,  the  blade  may  be  reversed  so  as  to  point  downward  to  the  floor,  and  the 
object  sought  may  then  often  be  secured  with  ease.  If  seeking  for  a  small  stone  or  for 
fragments,  we  may  employ  a  lithotrite  with  short  blades,  which  can  therefore  be  reversed 
with  much  greater  ease  than  one  with  long  blades. 

''  In  order  to  do  this  properly,  the  handle  of  the  lithotrite  is  depressed  another  inch  or 
so  between  the  patients  thighs,  so  that  the  shaft  of  the  instrument,  instead  of  being 
directed  a  little  upward,  is  level  with  or  points  below  the  horizon  ;  the  blades,  being  still 
closed,  are  cautiously  brought  round  to  the  reversed  position  and  the  floor  first  lightly 
swept  in  the  manner  of  a  sound  in  searching  for  stone.  Then  they  may  be  carefully 
opened  and  closed  two  or  three  times  in  slightly  varied  directions,  but  without  injuring 
the  floor  of  the  bladder.  When  the  prostate  is  considerably  enlarged  and  a  stone  or  frag- 
ments have  to  be  sought  behind  it,  the  lithotrite  is  reversed  without  depressing  the  handle. 

'•  All  these  movements  are  to  be  executed  at  or  beyond  the  centre  of  the  vesical  cavity, 
the  proper  area  for  operating,  without  hurry,  rapid  movement,  or  any  other  which  par- 
takes of  the  nature  of  a  jerk  or  concussion,  and,  if  in  a  fairly  healthy  bladder,  without 
causing  more  than  a  very  slight  degree  of  pain  to  the  patient.  The  operator's  eye  is  also 
to  be  so  familiar  with  the  scale  marked  on  the  sliding  rod  that  he  knows  at  a  glance  the 
exact  interval  which  it  indicates  as  existing  between  the  blades  in  the  bladder.  It  is 
essential  to  good  practice,  while  manipulating  the  lithotrite,  to  maintain  the  axis  of  the 
instrument  as  fiir  as  possible  always  in  the  same  direction.  The  blades  only  are  to  be 
moved;  the  shaft  should  occupy  the  same  inclination,  unless  when  this  is  intentionally 
altered.  In  screwing  home  the  small  blade  the  operator  is  very  apt  to  move  the  litho- 
trite also  at  each  turn  of  the  screw,  unless  he  is  conscious  of  the  care  necessary  to  avoid 
the  evil.  All  lateral  movements,  all  vibration  and  concussion,  necessaril//  fell  on  the  neck  of 
the  bladder  and  prostatic  urethra,  where  the  instrument  is  most  closely  embraced  and  its 
mobility  is  most  limited.  To  that  part  of  the  lithotrite  which  occupies  the  anterior  por- 
tion of  the  urethra  much  freedom  of  lateral  movement  is  permitted,  and  in  the  blaclder 
the  instrument  is  free,  although  in  a  less  degree ;  but  the  axis  or  fixed  point,  as  regards 


668  STONE  IN  THE  BLADDER,   AND  ITS  TREATMENT. 

lateral  movement,  is  at  the  part  indicated,  which  is  also  the  most  sensitive  spot  of  the 
entire  passage.  Hence  the  aim  of  the  operator  should  be  to  produce  in  this  situation  no 
motion  of  the  lithotrite  except  that  on  its  own  axis.  Few  of  the  details  of  the  operation 
require  more  practice  to  master  than  this. 

"  A  rule  has  been  laid  down  with  reference  to  the  situation  of  a  calculus  in  the  blad- 
der. It  is  said  that  the  larger  the  stone,  the  more  certain  is  it  to  be  found  lying  near  to 
the  neck  of  the  bladder  in  the  ordinary  recumbent  position,  while  a  small  one  is  usually 
detected  at  the  back  of  the  trigone.  Without  assenting  to  the  accuracy  of  this  reniark — 
at  all  events,  in  relation  to  the  small  stone,  which  is  often  close  to  the  vesical  orifice — it 
may  be  said  here  that  the  act  of  seizing  a  large  stone  in  this  position  requires  considera- 
tion ;  for  if  the  operator  commences  by  withdrawing  the  male  blade  according  to  the  ordi- 
nary custom,  this  blade  is  apt  to  be  drawn  against  a  large  stone,  which  it  therefore  fails  to 
catch,  and  presses  it  back  against  the  neck  of  the  bladder,  doing  mischief  and  not  succeed- 
ing. As  a  general  rule,  it  may  be  said  that  the  most  common  cause  of  failure  to  seize  a 
large  stone  arises  from  its  close  proximity  to  the  neck  of  the  bladder  (whatever  position 
is  given  to  the  patient)  and  from  the  male  blade  being  drawn  up  against  it  at  each  open- 
ing of  the  lithotrite  in  the  manner  just  described.  In  these  circumstances  the  operator 
feels  the  contact  of  the  stone  without  suspecting  its  precise  locality  each  time  he  with- 
draws the  blade,  and  is  apt  to  feel  embarrassed  on  failing  to  seize  it  when  he  closes  imme- 
diately after.  In  these  cases  it  is  essential  to  draw  the  male  blade  gently,  but  closely,  to 
the  neck  of  the  bladder,  and  to  slide  the  blade  between  the  neck  and  the  stone  which  lies 
in  contact  with  it." 

'•  The  rules  laid  down  for  finding  and  seizing  apply  more  or  less  to  lithotrites  of 
moderate  size,  but  this  general  rule  may  be  borne  in  mind :  viz.,  the  more  powerful  the 
lithotrite — that  is,  the  larger  and  longer  are  its  blades — the  less  readily  are  we  to  adopt 
the  reversed  positions  of  the  blades  and  the  more  fluid  is  it  desirable  to  have  in  the  blad- 
der. As  large  and  fenestrated  blades  are  used  chiefly  for  the  initial  act  of  breaking  up  a 
large  stone  into  fragments,  it  is  obvious,  also,  that  there  is  less  occasion  for  the  horizontal 
and  reversed  movements,  since  a  large  stone  may  almost  certainly  be  seized  by  the  right 
or  left  incline." 

Crushing  the  Stone. — "  Supposing  that  a  hard  stone  of  an  Inch  and  a  half  in 
diameter  has  fallen  into  the  grasp  of  a  powerful  lithotrite,  the  screw  is  to  be  gradually 
turned  at  first,  to  make  the  blades  bite,  since  a  sharp  turn  at  this  moment  may  drive  the 
stone  out  either  right  or  left.  As  the  power  is  increased  the  resistance  is  felt  to  relax, 
sometimes  by  degrees,  sometimes  suddenly  with  a  crack,  and  the  stone  is  broken  usually 
into  four  or  five  large  pieces,  besides  some  small  debris.  This  done,  the  male  blade  is 
again  drawn  out,  taking  care  not  to  shift  the  situation  or  alter  the  axis  of  the  lithotrite, 
and  almost  certainly  one  of  the  large  fragments  will  be  picked  up.  It  is  then  only  neces- 
sary to  screw  home,  release  the  screw,  and  open  as  before.  This  process  may  be  repeated 
several  times  at  the  same  spot,  for  tlie  area  within  which  the  larger  fragments  fall  is  very 
limited  and  is  unchanged  if  all  remains  quiet.  The  large  and  heavy  pieces  fall  invariably 
in  the  same  place,  and  may  be  picked  up  again  and  again  if  this  simple  rule  of  keeping  the 
blades  in  one  place  is  adhered  to.  Having  now  broken  up  the  stone  and  crushed  well  the 
largest  fragments,  and  thus  occupied  perhaps  from  ten  to  fifteen  minutes,  it  should  be 
time  to  employ  the  aspirator  and  remove  the  debris.  Accordingly,  the  screw  of  the  lith- 
otrite is  driven  well  home,  to  close  the  blades,  between  which  some  calculous  matter  prob- 
ably is  engaged,  and  the  lithotrite  is  withdrawn." 

Removal  of  Debris  of  Stone. — The  stone,  having  been  crushed,  has  to  be 
removed;  and  this  is  effected  by  means  of  a  large  catheter  and  powerful  evacuation. 

A  No.  15  or  16  evacuating  catheter  for  small,  and  a  No.  17  or  18  for  large,  stones 
should  be  selected  and  passed,  the  larger  instruments,  Nos.  25  to  30,  as  used  by  Bigelow, 
being  required  in  very  exceptional  instances,  the  size  being  determined  by  that  of  the 
urethra.  These  are  made  of  diiferent  curves  (Fig.  388,  C).  The  urine  should  then  be 
withdrawn. 

"An  aspirator  (Fig.  388,  D),  previously  filled  with  tepid  water,  is  then  attached,  the 
connection  tap  opened,  and  a  small  portion  of  its  contents  pressed  by  the  right  hand  into 
the  bladder,  the  left  hand  supporting  and  directing  the  evacuating  catheter." 

"  On  relaxing  the  pressure  an  immediate  current  outward  follows,  carrying  with  it, 
very  probably,  a  fair  quantity  of  debris.  Wait  some  three  or  four  seconds  after  expan- 
sion has  finished  and  the  current  apparently  ceased,  as  at  that  precise  time  it  is  quite 
common  for  one  or  two  of  the  larger  fragments  to  drop  into  the  receiver  which  would 
have  been  driven  back,  perhaps,  by  too  rapidly  resuming  the  pressure.     This  process  is 


Tiir:  (ii'iniATios. 


^Wj 


repeatiMl  sovorul  times,  iiccdnliii^  to  tin-  aiiiomit  ol'  ililirla  (ibscrved  to  enter  the  traji. 
After  a  larj^e  erusliiii;^  the  eiitl  <il"  the  evaeiiatiii^'^  eatheter  sliouM  nut  rest  (in  the  floor  of 
the  lilachler,  as  it  is  tlien  likely  to  })e  ehoked  witli  di'luis  ;  hut  after  most  of  tlie  fra^rments 
liave  heen  removed  it  is  ailvantaireoiis  to  htwer  the  end  of  the  eatheter,  in  onh-r  to  eateh 
tlie  hist  fra!j;meiits. 

'•  If  tile  outflow  of  the  (iiii'eiit  is  felt  to  he  suildenly  eheekcil  and  tlie  aspirator  eeases 
to  distend,  the  operator  may  he  almost  certain  that   a  fragment   ol'  a  roiunled  or  cuhieal 

Fjg.  388. 


Reeeiuer 


Lithotrites,  Catheters,  and  Evacuator  reciuireil  for  Bipelow's  Rapid  Lithotrity. 

form  or  a  small  calculus,  nearly  fitting  the  interior  of  the  catheter,  hlocks  the  pa.s.sage 
and  prevents  further  egress.  The  piece  must  be  expelled  by  making  smart  pressure 
on  the  india-rubber  bottle,  after  which  the  action  of  the  aspirator  will  probably  be 
resumed. 

"  If,  after  crushing  all  the  stone,  so  far  as  the  operator  is  able  to  judge,  and  removing 
the  debris  largely,  nothing  is  heard  or  felt  in  contact  with  the  end  of  the  evacuating 
catheters,  notwithstanding  that  three  or  four  successive  pressures  have  been  made,  there 
is  ground  for  believing  that  all  the  fragments  may  now  have  been  removed.  Perhaps 
there  can  be  no  better  proof  that  the  bladder  has  been  emptied  than  is  afforded  by  the 
fact  that  a  succession  of  outward  and  inward  currents  through  the  aspirator  shows  no 
sign  either  to  the  eye  or  to  the  ear  of  the  presence  of  another  fragment. 

"  If  all  has  not  been  removed,  the  sound  of  a  large  piece,  perhajis  making  itself  heard 
and  felt  at  each  outward  current  against  the  end  of  the  catheter,  indicates  that  this  must 
be  withdrawn  and  a  lithotrite  introduced.  If  the  fragments  are  not  of  considerable  size, 
a  lighter  and  handier  lithotrite  may  succeed  with  advantage  to  the  heavy  fenestrated  one 
originally  used,  and  the  crushing  continued.  Of  course,  if  more  stone  remains,  the  pro- 
cess is  repeated  once  or  more.  In  from  ten  to  forty  or  fifty  minutes,  however,  a  uric-acid 
calculus  of  very  considerable  size  may  be  thus  broken  up  and  removed.'" 

After-Treatment. — When  the  patient  has  fully  recovered  from  the  ana?.sthetic,  if 
suffering  severely  say  three  or  four  hours  after  the  operation — a  condition,  by  the  way, 
which  is  very  uncommon — a  hot  bath,  as  hot  as  he  can  have  it,  for  fifteen  minutes,  gives 
great  relief.  The  treatment  for  the  first  three  or  four  days  in  cases  of  large  calculus  is 
that  of  a  mild  acute  cystitis — recumbent  position,  external  warmth.  fre((uent  hip  baths, 
and  small  but  fre(|uent  doses  of  solution  of  potash,  just  to  neutralize  the  acidity  of  the 
urine.  If  the  urethra  is  overstretched  or  bruised,  an  india-rubber  catheter  may  be  tied 
in  for  twenty-four  hours  or  so,  but  this  is  not  frequently  necessary  ;  while  if  the  bladder 
had  previously  lost  the  power  of  emptying  itself,  such  an  inlying  catheter  for  a  day  or 
two  is  mostly  better  than  frequent  catheterism." 

"  As  a  general  rule,  we  fiiul.  during  the  three  or  four  days  immediately  following  the 
operation,  that  the  relief  is  considerable,  that  the  urine  is  clear,  that  the  bladder  tolerates 
a  large  quantity,  and  the  aspect  of  the  case  is  one  of  rapid  and  unchecked  convalescence. 
But  on  the  fourth  or  fifth  day  a  little  excitement  is  not  infrequently  observed ;  the  blad- 


670  STONE  IN  THE  BLADDER,   AND  ITS   TREATMENT. 

der  becomes  irritable,  the  urine  is  cloudy,  and  after  twenty-four  hours  or  so  subacute 
cystitis  is  established,  often  destined  to  be  troublesome  for  a  week  or  two.  This  liability 
indicates  that  it  is  mo.st  desirable  to  enforce  the  recumbent  position,  confinement  to  the 
room,  a  warm  temperature  (in  cold  weather),  and  care  in  every  particular  of  management 
for  at  least  some  days  after  crushing  a  calculus,  whatever  its  size." 

Complications. — When  a  fragment  becomes  impacted  in  the  urethra  and  produces 
retention,  it  should  either  be  gently  pushed  back  into  the  bladder  with  a  large  catheter  or 
removed  with  urethral  forceps.  These  fragments  not  only  produce  retention  at  times, 
but  epididymitis,  from  irritation  of  the  caput  gallinaginis. 

Should  fever  follow  the  operation,  ushered  in  with  a  rigor,  there  is  probably  some 
slight  lesion  of  the  urethra.  "  In  nine  cases  out  of  ten  it  is  not  of  serious  import,  and 
is  treated  by  keeping  the  patient  warm,  wrapping  him  up  well,  applying  hot  bottles,  and 
giving  some  warm  drink,  as  hot  tea  or  warm  wine  and  water."'  A  moderate  dose  of 
opium  is  perhaps  the  most  useful  prophylactic. 

Occasionally  the  attack  of  fever  announces  the  onset  of  a  cystitis,  testitis,  or  some 
renal  complication. 

Hemorrhage  is  a  rare  complication.  When  present,  by  rest  and  cold  it  usually 
subsides. 

Chronic  retention  of  urine  is  a  complication  which  is  to  be  carefully  looked  for,  since 
it  occurs  very  insiduously ;  it  is  to  be  relieved  by  careful  catheterism. 

Sir  H.  Thompson  reports  that  he  has  had  104  consecutive  cases  of  rapid  lithotrity  in 
men  averaging  sixty-two  years  of  age,  with  only  three  deaths.  This  mortality,  he  adds, 
"is  a  better  achievement  than  I  had  ever  ventured  to  hope  for"  (Holmes's  System,  3d 
edition,  vol.  iii.). 

LITHOTOMY. 

In  children  where  lithotrity  is  inapplicable,  and  in  adults  when  lithotrity,  for  reasons 
already  given,  ought  not  or  cannot  be  applied,  lithotomy  mnsf  be  employed;  and  lateral 
lithotomy  is  doubtless  the  best,  as  it  is  the  most  usual,  operation.  "  In  children  it  is 
difficult  to  mention  any  operation  in  surgery  so  uniformly  successful  as  lithotomy  is. 
The  incomplete  development,  and  the  consequently  little  susceptibility,  of  the  parts 
involved,  the  small  size  of  the  vessels  and  the  little  risk  of  hemorrhage,  the  yielding 
nature  of  the  textures,  rendering  force  unnecessary  in  the  extraction  of  the  stone,  are 
circumstances  that  combine  to  divest  the  operation  of  much  of  the  danger  that  surrounds 
it  when  performed  in  the  adult.  From  childhood  to  the  age  of  puberty  the  dangers  can 
hardly  be  said  to  increase.  Boys  of  thirteen  years  of  age  suffer  scarcely  more  from  the 
operation  than  children,  and  for  the  same  reason.  Seeing,  then,  that  so  little  risk  and 
suffering  attends  lithotomy  in  children,  it  is  difficult  for  us  to  find  an  equally  safe  and 
efficient  substitute  :  it  can  .scarcely,  indeed,  be  said  to  be  required  "  fAston  Key). 

In  the  adult  male  lithotomj'  is  rarely  resorted  to  until  the  surgeon  becomes  convinced 
that  the  removal  of  the  .stone  by  lithotrity  is  inapplicable  or  has  failed ;  at  least  such 
has  been  the  practice  at  Guy's  Hospital  for  many  years,  and,  taking  the  average  of  cases 
of  stone  in  the  adult  admitted,  half  only  have  been  subjected  to  lithotomy.  In  private 
practice  the  proportion  of  cases  of  lithotomy  to  lithotrity  is  much  smaller,  patients 
applying  for  advice  at  an  earlier  period.  From  this  fact  the  worst  cases  of  stone  are 
alone  submitted  to  the  cutting  operation,  and,  as  a  con.sequence,  the  mortality  is  high. 
At  Guy's  lithotrity  being  the  rule  in  adults  and  lithotomy  the  exception,  the  mortality 
of  the  latter  operation  in  adults  is  one  in  three,  whereas  in  places  where  lithotrity  is  little 
practised  it  is  one  in  five. 

•'It  is  probable."  writes  Birkett  (Gnys  Rep.,  1867),  "that  the  rate  of  mortality  after 
lithotomy  must  henceforth  always  appear  higher  than  formerly,  in  consequence  of  so 
many  of  the  patients  sufi"ering  with  stone  who  might  have  been  cut  successfully  being 
those  now  selected  for  the  performance  of  lithotrity.  In  point  of  fact,  the  very  cases 
which  swelled  the  li-st  of  succes.sful  results  no  longer  appear  in  the  category  of  those 
.submitted  to  the  cutting  operation  ;  but,  on  the  contrary,  those  patients  too  ill  to  recover 
from  lithotrity  frequently,  as  a  last  resource,  submit  to  lithotomy  and  perish." 

Lateral  lithotomy,  or  the  operation  of  Raw.  Jaques.  and  Cheselden.  is,  without 
doubt,  the  favorite  means  of  extracting  a  stone  from  the  bladder  among  modern  surgeons, 
assuming  that  lithotrity  is  inapplicable  or  inadvisable.  As  an  operation  it  has  been  nobly 
planned,  and  to  see  it  performed  with  skill  and  precision  is  still  a  sight  which  affords 
gratification  to  the  youngest  as  well  as  to  the  oldest  surgeon.  In  my  student  days  to  see 
Aston  Key  cut  for  stone  was  an  event  which  I  now  fondh'  think  over  with  pleasure  and 


LITHOTOMY. 


G71 


adininition,  and  tliti  niomory  of  t]»o  skill  uinl  preci.sirm  of  lii.s  acts  in  this  as  in  all  other 
operations  is  still  hcrnn-  nio  as  a  standard  of  perfection  at  which  all  shonld  aim. 

These  remarks  are  not  inapplicable  ;js  a  prel'ace  to  tlie  siiltjcet  of  lateral  lithotomy, 
for  Key  s  use  aiitl  advocacy  of  the  straight  staff  in  that  operation  have  s(»  influenced  all 
his  successors  that  up  to  the  present  day  "  Key's"  operation  is  the  one  usually  performed 
at  Guy's,  the  exceptions  to  this  rule  heinj^  so  rare  as  not  to  he  named.  'J'he  success  which 
lias  attended  this  practice  has  been  very  <^ooil  ;  when,  indeed,  compared  with  that  I'lir- 
nished  from  other  sources,  it  seems  so  remarkable  that  it  is  difficult  to  arrive  at  any 
other  conclusion  than  that  the  mode  of  oj)eration  has  something  to  do  with  it,  for,  taking 
the  most  reliable  statistics — the  Norwich  408  cases  in  sul^jects  under  puberty,  and 
Thompson's  '^^\f^,  eliminating  the  Guy's  cases — the  mortality  was  1  in  every  14 A  cases; 
whilst  of  Guy's  eases  and  Key's  operation  during  seventeen  years  it  was  1  in  57  cases,  3 
deaths  only  having  occurred  in  171  ca.scs,  the  success  of  Key's  operation  being  four  times 
greater  than  that  of  others. 

In  children  under  five  years  of  age  these  points  are  still  more  strongly  marked,  as, 
out  of  4U0  cases  tabulated  by  Thompson,  the  mortality  was  1  in  every  i:^i,  the  Norwich 
not  being  quite  so  good  ;  whilst  at  Guy's  after  Key's  operation,  in  my  old  table  it  was  1 
in  23 A  out  of  73  cases,  and  more  ncfntli/^  ditruKj  seventeen  i/ears^  enih'ng  In  187^,  100 
patients  hure  been  cut  consecutively  witliout  (t  denth. 

In  the  nine  years  ending  1882  the  results  were  not  (|uite  so  good,  as  one  child,  ajt.  3, 
died  on  the  fifth  day  from  convulsions  after  secondary  hemorrhage  when  he  was  thought 
to  have  been  convalescent,  out  of  15  cases  operated  upon. 

This  success  is  certainly  more  striking  than  I  anticipated  when  I  began  the  comparison, 
and  must  in  a  measure,  if  not  altogether,  be  ascribed  to  the  greater  safety  of  Key's 
operation. 

I  propose  now  to  describe  the  operation  of  lateral  lithotomy,  and  I  shall  do  .so  after 
what  I  believe  to  be  the  best  method — that  of  "  Key,"  giving  also  that  with  the  curved 
staff.     But  first  of  all  as  to  the  instruments  required. 

The  staff,  whether  .straight,  as  in  Key's  operation,  curved  (Fig.  389).  or  rectangular, 
as  in  others,  must  be  regarded  as  a  director.     It  is  a  means  the  surgeon  employs  to  guide 

Fig.  389. 


J'ertjfusson's  Ste^ 


his  knife  into  the  bladder,  and  I  may  say  with  Key  that  "the  advantage  of  a  straight 
over  a  curved  line  as  a  conductor  to  a  cutting  instrument  is  too  obvious  to  require  any 
comment.  Is  it  surprising  that  the. blind  should  err  in  a  crooked  path?"  Key's  staff  is 
blunt-pointed  as  a  sound  and  more  deeply 


grooved  than  the  common  staff,  to  prevent 
the  risk  of  the  knife  slipping  out ;  the 
groove  is  in  the  centre  of  the  staff,  not  at 
one  side,  as  in  the  ordinary  curved  one, 
and  it  runs  to  within  half  an  inch  of  the 
end.  "  Its  chief  superiority."  writes  Key, 
"consists  in  allowing  the  surgeon  to  turn 
the  groove  in  any  direction  he  may  wish." 
The  staff  must  vary  in  lensth  and  size. 


Fig.  390. 
yrvm  Fcrgussan 


/{ey's  Knife 


according  to  the  age  of  the  patient  and  size  of  the  urethra,  it  heing  well  to  use  as  large 
a  one  as  will  pass  readily  down  the  urethra. 


672 


STONE  IN  THE  BLADDER,   AND  ITS  TREATMENT. 


The  knife  varies  much  with  the  fancy  of  the  operator.  That  employed  by  Key 
(Fig.  390)  and  his  successors  resembles  in  form  a  common  scalpel,  but  is  longer  in  the 
blade  and  slightly  convex  in  the  back  near  the  point  to  enable  it  to  run  with  more 
facility  in  the  groove  of  the  director.  Different  sizes  are  required  for  a  child  and  an 
adult. 

The  knife  as  employed  by  Sir  W.  Fergusson  (Fig.  390)  is  given  as  a  type  of  that 
required  for  the  curved  staif. 

A  probe-pointed,  bistoury  or  blade  with  a  round  point  is  sometimes  of  use  to 
enlarge  the  vesical  opening  when  not  made  free  enough  or  to  give  vent  to  a  large  stone. 

Lithotomy  forceps  should  be  made  of  several   shapes  and  sizes,  and  a   scoop 

(Fig.  391)  ought  also  to  be  at  hand.     It  is  used  by  passing  it  behind  the  stone  and  fix- 

YiQ  391  iii,^  it  there  by   the  pressure  of  the 

left  index  finger,  the  instrument  with 
the  two  hands  being  withdrawn  with 
mSIoBP  II  »-A  w^    tbe  stone. 

When   the  perinaeum  is  very  deep 
Lithotomy  Scoop.  ^^^^   ^^^^^^  ^^^^.^  ^^^-^^  j^  required   by 

the  surgeon  for  the  introduction  of  his  forceps  into  the  bladder  and  the  extraction  of  the 

stone,  the  blunt  gOrget  (Fig.  392)  may  be  used,  the  instrument,  guided  by  its  beak. 

Fig.  392.  being   passed   into  the   bladder  upon 

the  staff,  and  upon   this  the  forceps 
can  readily  be  introduced. 

The  gorget  is  never  needed  in  chil- 
di'en,  but  in  adults  it  is  often  of  great 

The  Blunt  Gorget.  ^ 

Preparation  for  Operation. — The  bowels  should  be  well  cleared  out  by  a  dose 
of  castor  oil,  given  some  hours  previously,  and  the  rectum  emptied  by  means  of  an  ene- 
ma the  morning  of  the  operation,  care  being  taken  that  the  enema  has  returned.  The 
perinaeum  should  likewise  be  shaved. 


Fig.  393. 


The  Operation. 

The  surgeon,  having  decided  upon  his  operation,  selected  his  instruments,  and  seen 
that  he  has  at  hand  everything  he  may  require,  having  also  obtained  the  help  of  three, 
if  not  four,  assistants,  besides  the  aufiesthetist,  proceeds  to  place  his  patient. 

A  narrow  but  well-raised  table  should  be  employed,  so  that  the  patient's  perina;um 
and  the  surgeon's  face  should  be  nearly  on  the  same  level.     The  patient  should  be  placed 

on  his  back  with  his  thighs  flexed  upon  the  pelvis  and 
the  legs  upon  the  thighs,  the  hands  of  the  patient  being 
made  to  grasp  his  feet  and  fastened  in  such  a  position 
by  the  figure-of-8  bandage,  the  padded  bracelets  and 
anklets,  as  seen  in  Fig.  393,  or  Clover's  crutch.  Chil- 
dren need  not  be  fastened,  but  it  is  more  prudent  for 
adults,  although  some  surgeons,  since  the  introduction 
of  anaesthetics,  have  given  up  the  practice  under  all 
circumstances.  The  shoulders  should  be  well  raised, 
the  knees  separated,  and  the  pelvis  kept  well  down  upon 
the  table  by  two  assistants  ;  the  surgeon  should  also  see 
that  the  patient  is  quite  straight,  the  line  of  the  umbili- 
cus being  the  best  guide  to  this  position.  The  peii- 
npcum  should  he  perpendlcnlar.  The  surgeon  may  then 
pass  the  staff,  and,  having  introduced  it  well  into  the 
bladder  and  felt  as  iveJl  as  heard  the  stone,  he  is  to  entrust  it  to  the  hands  of  an  assistant 
— one  who  can  confidently  be  relied  upon  to  hold  it  in  the  position  in  which  the  surgeon 
has  placed  it  and  who  will  not  draw  it  forward  in  any  degree.  This  point  is  of  import- 
ance, for  there  is  good  reason  to  believe  that  many  of  the  mishaps  connected  with  the 
operation  are  due  to  the  staff  having  been  partially  withdrawn  from  the  bladder  by  an 
assistant,  who  perhaps  in  stooping  forward  tries  to  get  a  sight  of  the  operator's  movements. 
When  the  straight  staff  is  used,  it  is  to  be  held  well  up,  with  the  liandle  slightly  tilted 
toward  the  operator  ;  and  when  the  curved  staff  is  employed,  some  surgeons  like  it  to  be 
well  hooked  up  against  the  symphysis ;  but  under  all  circumstances  it  is  to  be  held 
steadily. 


Lithotomy  Bracelets. 


THE   OI'EllA  TIDS. 


G73 


First  Slip. — The  surgeon,  liaviiig  ascertained  the  sizft  of  the  prostate  through  an  anal 
examination,  may  tlieii  proceed  with  tlie  y'/>/  «/'/>  of"  the  operation — viz.,  to  hiy  l>are  the 
staff  <»r  direct(»r  that  is  to  guide  his  knife  into  th(!  bladder  ;  and  the  |)oint  at  wliich  this 
opening  is  (h'sired  is  nt  llir  iminhriiitoim  [xtrtion  hi  liiml  tlu;  hnlh  iiml  In  front  of  ihc  ni<>slntf. 
IJIi/.ard,  Martineau,  Stanley,  Key.  and  Kergiisson  all  lay  stress  upon  this  important  point. 
Willi  this  view  the  pi-rineal  incision  is  to  Ite  made,  and  in  lateral  lithotomy  the  line  of  inci.s- 
ion  lies  IVom  the  left  oi'  the  median  line  of  the  perinit'uni  downward,  hackwanl,  and  (jutward, 
midway  hetween  the  anus  and  the  left  tuher  ischii.  The  incision  is  usually  from  three  to 
three  and  a  half  inches  long.  Some  surgeons  commence  the  cut  an  inch  in  front  of  the 
anus,  others  tix  it  at  one  and  a  (juarter  to  one  and  three-((uarters  ;  hut  this  j)oint  is  not 
one  of  primary  importance.  The  object  of  the  incision  is  to  nuike  a  free  external  opening, 
to  enable  the  surgeon  to  reach  the  groove  of  the  staff  at  the  part  indicated  and  allow 
Hubse(|uently  <if  the  removal  of  the  stone  ;  a  point  midway  betw(!en  the  scrotum  and  anus 
is  probably  the  best  to  start  from,  the  length  of  the  perineal  region  varying  greatly  in 
difftrcMt  subjects. 

In  making  this  ])eriiieal  incision  the  left  thumb  of  the  operator  should  be  firmly  fixed 
above  the  point  at  which  the  knife  is  to  be  introduced,  and  it  is  well  for  the  surgeon  with 
the  left  fingers  to  hold  the  staff  firmly  at  the  root  of  the  penis  at  the  same  time.  The 
point  of  the  knife  may  be  well  introduced  into  the  soft  parts  in  the  line  of  the  director 
and  the  tissues  freely  divided  in  the  cut  downward,  a  second  or  third  touch  of  the  knife 
being  made  to  complete  the  section.  If  these  be  made  too  low,  the  rectum  is  liable  to  be 
wounded.  In  this  incision  the  perineal  triangle  and  ischio-rectal  space  are  laid  open,  and 
the  skin  and  fascia  with  the  transverse  perineal  muscle  and  its  artery  divided. 

Second  Step. — The  surgeon,  having  exposed  the  groove  of  the  director  (staff)  that  is 
to  guide  his  knife  into  the  bladder,  should  then  proceed  to  the  Rfcoud  strp  of  the  operation. 
For  this  purpose,  when  the  curved  staff  is  used,  he  should  introduce  the  forefinger  of  his 
left  hand  into  the  wound  and  feel  for  the  staff  Itehiad  and  to  the  left  of  the  bulb,  and,  liav- 
inrj  charlji  made  out  the  two  edt/es  of  tlie  groove  and  run  hia  nail  betzveen  them,  he  should 
introduce  the  point  of  his  knife  upon  the  nail  of  the  finger  into  the  groove,  and,  having 
clearly  divided  the  tissues  sufficiently  to  make  him  confident  that  the  point  of  the  knife 
is  well  into  the  groove  of  the  staff",  complete  his  deep  section  by  pushing  the  knife  along 
the  groove  of  the  .staff  into  the  bladder,  lateralizing  it  to  divide  the  left  lobe  of  the  pros- 
tate and  neck  of  the  bladder  sufficiently  (Fig.  394).     "  The  point  of  the  knife  in  Key's 

Fig.  394. 


Lateral  Lithotomy  with  a  Curved  Staflf. 


operation  being  kept  steadily  against  the  groove,  the  operator  with  his  left  hand  takes  the 
handle  of  the  director  and  lowers  it  till  he  brings  the  handle  to  the  elevation  described  in 
Fig.  8U5,  keeping  his  right  hand  fixed  ;  then  with  an  ea.sy,  simultaneous  movement  of 
both  hands  the  groove  of  the  director  and  the  edge  of  the  knife  are  to  be  turned  obliquely 
toward  the  patient's  left  side  ;  the  knife,  having  the  proper  bearing,  is  now  ready  for  the 
section  of  the  prostate  ;  at  this  time  the  operator  should  look  to  the  exact  line  the  director 
takes,  in  order  to  carry  the  knife  safely  and  slowly  along  the  groove,  which  may  now  be 
done  without  any  risk  of  the  point  slipping  out"  (Key). 

"  In   the  majority  of  cases  it  will  merely  be  necessary  to  pass  the  knife  along  the 
4^ 


674 


STONE  IN  THE  BLADDER,   AND  ITS  TREATMENT. 


director,  and,  having  cut  the  prostate,  to  withdraw  it,  without  carrying  it  out  of  the 
groove,  varying  the  angle  according  to  the  age  of  the  patient,  the  width  of  the  pelvis, 
and  size  of  the  stone.     As  the  direction  in  which  the  prostate  should  be  divided,  in  order 

Fig.  395. 


.^' 


Lateral  Lithotomy  with  Key's  Straight  Staff.     (Taken  froiii  Key's  works.) 

to  adhere  to  Cheselden's  operation,  is  obliquely  downward  and  outward,  increasing  the 
angle  at  which  the  knife  enters  the  bladder  will  incur  no  risk  of  wounding  the  pubic 
artery.  The  knife  may  be  conducted  with  deliberate  care  into  the  bladder  ;  the  resistance 
afforded  by  the  prostate  will  be  readily  felt,  and  the  hand  of  the  operator  should  be 
checked  as  soon  as  he  feels  the  prostate  has  given  way  "  (Key). 

The  surgeon  knows  when  he  has  entered  the  bladder  by  the  absence  of  resistance,  and 
occasionally  by  a  rush  of  urine.  He  should  remember,  however,  that  some  urine  will 
escape  so  soon  as  the  urethra  has  been  opened,  and  not  be  misled  by  the  fact.  The  angle 
which  the  knife  makes  with  the  staff  regulates  the  size  of  the  incision  into  the  neck  of 
the  bladder.  When  the  knife  is  in  a  line  with  the  staff,  the  incision  will  be  limited ;  the 
larger  the  angle  the  knife  makes  with  the  staff,  the  larger  will  be  the  wound. 

As  a  rule,  a  large  wound  can  be  of  no  advantage  unless  the  stone  is  vei'y  large.  A 
small  wound,  however,  is  a  disadvantage  when  the  stone  is  of  medium  size ;  for.  although 
the  neck  of  the  bladder  is  capable  of  a  good  deal  of  dilatation  under  moderate  force,  any 
severe  laceration  of  the  prostate  is  almost  certain  to  be  followed  by  bad  results.  Surgeons 
differ  much  upon  this  point,  some  recommending  dilatation  in  preference  to  free  incisions 
into  the  neck  of  the  bladder,  whilst  others  prefer  free  division  of  tissues  rather  than  run 
the  risk  of  lacerating  them. 

Moderate  dilatation  is  certainly  free  from  risk,  while  severe  dilatation  is  dangerous, 
inasmuch  as  it  necessitates  great  laceration.  As  a  rule,  the  incision  should  never  exceed 
the  limits  of  the  prostate. 

Third  Step. — The  bladder  having  been  opened,  the  third  step  of  the  operation  remains 
to  be  performed,  which  consists  in  the  removal  of  the  stone.  This  is  to  be  done  by  means 
of  forceps. 

The  knife  having  been  withdrawn  on  the  completion  of  the  second  step,  the  index 
finger  of  the  surgeon's  left  hand,  guided  by  the  staff,  should  be  introduced  through  the 
wound  into  the  bladder ;  and  the  operator  ought  always  to  remember  that  till  the  finger 
has  been  fairly  passed  into  the  Madder  vpon  the  staff,  this  insfnnnent  is  not  to  be  ivifhdraicn, 
although,  when  the  bladder  cannot  be  reached  by  the  finger,  the  blunt  gorget  may  be 
passed  along  the  staff,  to  act  as  a  guide  to  the  forceps.  The  forceps,  held  in  the  surgeon's 
right  hand,  is  then  passed  into  the  wound  upon  the  left  index  finger,  and,  guided  by  it, 
pushed  into  the  opening,  the  forceps  being  introduced  into  the  bladder  at  the  moment  the 
finger  is  withdrawn. 

"  Having  delivered  his  knife  to  the  assistant,  the  operator,  in  '  Key's  '  operation,  takes 
the  staff  in  his  right  hand,  and,  passing  the  forefinger  of  his  left  along  the  director  through 
the  opening  in  the  prostate,  withdraws  the  director,  and,  exchanging  it  for  the  forceps, 
passes  the  latter  upon  his  finger  into  the  cavity  of  the  bladder." 

"  In  extracting  the  calculus,  should  the  aperture  in  the  prostate  prove  too  small  and  a 
great  degree  of  violence  be  required  to  make  it  pass  through  the  opening,  it  is  advisable 
always  to  dilate  with  the  knife  rather  than  expose  the  patient  to  the  inevitable  danger 
consequent  on  laceration  "  (Key). 

The  forceps  should  be  full-sized  and  introduced  into  the  bladder  closed  fiat  npon  the 


SOi'n('J:s   OF  JUFFICULTY  jy   LITHOTOMY :    lloW   To   AVOID    THEM.      (>7o 

stone,  and  iinmediati'ly  ofuMU'tl,  the  stone  <renorally  Ix'irif^  at  once  cauj:lit  in  tlic  liladcs,  the 
rush  (tf  urine  carrvinj:;  it  toward  the  wound.  The  stone  sliouhl  he  ^rra.sjted  hiddly,  and 
when  seized  lie  sliiwly  and  deliherately  extracted,  the  extractinj^  force  beiiiir  niaile  in  tlie 
direction  of  the  axis  of  the  pelvis  ihiwiiwanl  an<l  backward  and  then  forward;  a  little 
rotatory  and  side-to-side  motion  ol'  the  instrument  at  times  facilitates  the  extraction  of  a 
calculus,  the  sur<;enn  at  thi'  same  time,  with  his  index  fin^^er,  pushini;  the  soft  parts  off 
the  stone.  Before  extracting;,  the  operator,  by  the  sensation  f;iven  to  the  forceps,  will 
assuH'  liiinsclf  tliat  the  bladder  is  not   caiif^ht. 

It  is  in  this  third  step  of  the  opcjration  that  the  surgeon  frequently  meets  with  his 
difficulties,  and  much  discretion  and  fertility  of  resource  is  often  needed  to  overcome  them, 
since  no  definite  rules  can  be  laid  down  as  a  guide.  The  stone  may  elude  the  grasp  oi' 
his  instrument :  sometimes  it  clings  to  the  bladder  above  the  wound  behind  the  .symj)hy- 
sis,  and  is  thus  without  the  reach  of  the  instrument;  at  others  it  is  caught  above,  under 
which  circumstances  the  pressure  of  the  hand  of  an  assistant  above  the  pubes  Ijecomes  of 
value,  or  the  injection  of  a  stream  of  water  is  advantageous.  Occasionally,  although 
rarely,  the  stone  may  be  encysted.  At  times,  when  the  stone  is  very  small,  it  may  be 
washed  out  with  the  fir.st  rush  of  urine,  and  consecjuently  not  felt.  I  have  seen  this  hap- 
pen in  a  child.  At  times  a  bladder  may  be  opened  and  no  stone  found  ;  '•  but  from  all 
my  experience,"  writes  8ir  W.  Fcrgusson,  "  I  feel  justified  in  stating  my  conviction  that 
most  of  the  cases  heretofore  related  as  instances  where  the  incisions  for  lithotomy  have 
been  made,  and  a  istone  has  not  been  present,  have  been  examples  where  the  surgeon  has 
failed  to  reach  the  bladder."  In  children  this  is  particularly  the  ca.se,  the  surgeon  push- 
ing the  bladder  inward  off  the  staff.  This  accident  is  liable  to  occur  when  the  neck  of 
the  bladder  is  not  sufficiently  opened. 

After  the  removal  of  the  stone  the  finger  or  sound  should  be  introduced  into  the 
bladder,  to  ascertain  the  existence  or  non-existence  of  a  second  stone. 

Aftek-Trk.\tme\t. — As  soon  as  the  operation  has  been  completed  the  patient  should 
be  unbound  and  any  bleeding  vessels  twisted.  In  children  the  introduction  into  the 
wound  of  a  piece  of  ice  or  the  application  to  the  wound  of  a  cold  sponge,  with  or  without 
ice,  is  usually  enough  to  arrest  any  hemorrhage,  and  in  the  adult  the  same  practice,  a.^.  a 
rule,  suffices.  When,  however,  the  hemorrhage  is  persistent,  a  piece  of  sponge  or  a 
sponge  tent  .should  be  introduced  into  the  wound  up  to  the  neck  of  the  bladder ;  such  a 
proceeding  arrests  bleeding,  though  not  the  flow  of  urine,  which  percolates  through  the 
sponge.     The  sponge  may  be  removed  at  the  end  of  twenty-four  hours. 

Liston  was  in  the  habit  of  introducing  a  gum-elastic  tube  six  inches  long  through  the 
wound  into  the  bladder,  to  carry  off  the  urine  for  the  first  two  days,  and  fastening  it  in 
with  tapes.  This  practice  is  still  followed  by  some.  It  is,  however,  quite  unnecessary ; 
and  at  Guy's  we  use  the  tube  only  in  exceptional  cases — that  is,  when  severe  hemorrhage 
ensues,  the  wound  being  plugged  around  it.  Dupuytren  employed  a  tube  to  which  was 
attached  a  circular  piece  of  oil  silk  at  its  centre,  like  an  unribbed  umbrella  ;  sponge  or 
charpie  was  introduced  between  the  tube  and  silk  when  bleeding  took  place,  after  the 
upper  end  of  the  tube  had  been  introduced  through  the  wound  into  the  bladder.  Mat- 
thews has  adapted  an  india-rubber  bag  around  the  tube,  which  can  be  introduced  into 
the  bladder  empty  and  then  expanded  with  air  and  water.  It  answers  the  same  purpose 
as  Dupuytren's  cannle  a  chtmise,  and  is  probably  more  efficient. 

In  exceptional  cases,  when  the  bulb  is  cut  into,  it  may  be  necessary  to  apply  pressure 
with  the  finger  on  the  pudic  artery  to  arrest  bleeding. 

•The  patient  having  been  placed  in  a  bed,  a  good  draw  sheet  should  be  placed  beneath 
his  hips  and  a  pillow  behind  his  knees,  to  keep  them  flexed,  while  the  knees  should  not  he 
tvd  together.  A  sedative  may  be  employed  to  give  rest,  but  beyond  this  little  or  no  med- 
ical treatment  is  required.  The  diet  should  be  nutritious,  but  unstimulating,  and  wine 
and  meat  given  as  soon  as  the  appetite  demands.  The  bowels,  if  not  acting  naturally  on 
the  fifth  or  sixth  day,  should  be  cleared  by  an  enema  or  mild  aperient  such  as  castor  oil, 
and  the  horizontal  position  should  be  maintained  till  the  wound  has  closed.  Key  has 
remarked  that  in  children  partial  incontinence  is  apt  to  follow  when  this  rule  has  not 
been  observed. 

Sources  of  Difficulty  in  Lithotomy,  and  how  to  Avoid  them. 

The  difficulties  connected  with  the  operation  are  too  often  due  to  carelessness  and 
too  great  speed  ;  consequently,  they  are  mostly  of  the  surgeon's  own  making. 

If.  however,  he  feels  the  stone  and  hears  its  ring  before  operating,  he  is  sure  of  its 


676  STONE  IN  THE  BLADDER,   AND  ITS  TREATMENT. 

presence,  and  knows  also  that  the  staft'  is  in  tlic  bladder,  and  that  it  has  not  passed 
through  any  false  passage  in  the  urethra  or  between  the  bladder  and  rectum.  If,  more- 
over, before,  cutting,  he  assures  himself  by  touching  the  staff  that  it  has  not  been  dis- 
placed, he  has  a  direct  guide  down  to  the  calculus. 

If  when  cutting  after  having  exposed  the  groove  of  the  staff,  and  then  proceeding  to 
the  second  step  of  the  operation,  he  feels  the  tico  borders  of  the  groove  with  the  nail  of 
his  left  index  finger,  and  with  certainty  cuts  between  them  into  the  groove,  he  will  be 
still  sure  of  his  guide  into  the  bladder,  and  not  likely  to  fall  into  the  not  uncommon  error 
of  mistaking  the  side  of  the  staff  for  the  groove,  and  thus  going  astray. 

If,  again,  when  running  his  knife  down  the  director  into  the  bladder,  he  pushes  it 
sufficiently  far  as  to  feel  all  resistance  cease  and  for  urine  to  flow,  he  may  be  certain  that 
the  bladder  has  been  opened.  And  if,  on  introducing  his  finger  into  the  bladder,  "  he 
never  pushes  the  point  of  his  forefinger  onward  unless  he  feels  certain  that  he  has  it 
between  the  stafi'  and  the  wound,"  he  is  not  likely  to  make  a  cavity  with  his  finger  in  the 
cellular  tissue  outside  the  bladder  or  to  push  the  l)ladder  off'  the  end  of  the  staff;  and  if 
he  never  removes  the  director  or  staff  till  his  finger  or  gorget  has  been  introduced  into 
the  bladder  as  a  guide  to  his  forceps,  he  is  still  free  from  error. 

In  the  last  step  he  has  only  to  handle  his  forceps  boldly  to  grasp  the  stone  fully,  and 
in  extracting  it  alicai/s  to  draw  doivnicard  and  backward,  with  some  rotation,  and  he  will 
complete  his  operation  without  a  mishap. 

The  external  wound  should  always  be  free,  the  internal  limited,  moderate  dilatation 
of  the  neck  of  the  bladder  being  free  from  harm. 

If  in  operating  the  sui'geon  lose  his  guide,  from  the  end  of  the  staff  slipping  out  of 
the  bladder,  and  he  be  unable  to  effect  its  reintroduction,  or  if  by  some  error  he  has 
missed  the  staff  and  allowed  his  knife  to  travel  by  its  side,  and  thus  failed  to  find  the 
bladder,  it  is  better  to  relinquish  the  operation,  let  the  W'Ound  heal,  and  operate  again  -. 
for  without  the  guide  of  the  director  the  operation  is  an  impossibility  and  all  manipu- 
lation hazardous.  But  so  long  as  the  staff  is  in  the  bladder  errors  may  be  corrected  and 
the  operation  completed,  for  by  the  reintroduction  of  the  knife  along  the  groove  an  open- 
ing into  the  neck  of  the  bladder  that  has  been  made  so  small  as  to  forbid  the  introduction 
of  the  finger  may  be  enlarged,  even  when  the  neck  of  the  bladder  has  been  pushed  back- 
ward and  the  finger  seems  about  to  travel  into  an  unknown  region. 

Should  the  rectum  receive  a  .wiall  wound  during  the  operation,  it  may  be  disregarded, 
as  it  is  rarely  followed  by  any  injurious  effect ;  and  even  when  the  wound  is  large,  it  is 
well,  perhaps,  to  leave  the  case  to  nature.  Should  it  not  heal,  the  case  may  have  to  be 
dealt  with  as  one  of  fistula  in  ano,  by  division  of  the  sphincter. 

At  times  the  walls  of  the  rectum,  after  the  operation,  may  slough  from  the  injury 
they  sustained  during  the  removal  of  the  .stone,  but  such  cases  usually  do  w^ell  when  left 
alone.  In  my  own  practice  this  sloughing  took  place  after  the  extraction  of  a  large  mul- 
berry calculus,  but  the  case  did  very  well,  nor  was  the  recovery  tedious. 

Prostatic  enkayement  may  be  a  cause  of  difficulty  in  the  operation  in  elderly  patients  ; 
and  when  with  this  enlargement  there  is  rigidity,  the  difficulties  are  increased,  for  the 
surgeon,  under  these  circumstances,  in  order  to  make  a  sufficient  opening  into  the  bladder, 
may  have  to  travel  far  into  the  pelvis  upon  the  staff;  and  when  the  bladder  is  opened,  he 
may  be  unable,  on  account  of  its  depth,  to  reach  it  with  his  finger.  Under  these  circum- 
stances the  blunt  gorget  becomes  of  great  value,  as  it  can  readily  be  run  along  the  straight 
or  curved  staff  into  the  bladder  and  form  a  certain  guide  to  the  introduction  of  the  for- 
ceps. Martineau  was  very  fond  of  the  blunt  gorget  in  most  cases,  and  I  am  tempted  to 
think  that  in  adult  subjects  it  might  now  be  used  more  frequently  with  advantage.  I 
have  found  the  greatest  benefit  from  its  use  in  several  cases. 

When  the  prostatic  enlargement  encroaches  on  the  bladder,  the  vesical  lobe  may 
be  lacerated  by  the  blades  of  the  forceps  and  torn  away,  and  prostatic  adenoid  tumors 
may  likewise  be  enucleated.  Key  noticed  this  in  1837  ;  Fergusson  brought  the  subject 
forward  at  the  Pathological  Society  in  1848;  Cadge  exhibited  two  specimens  in  1862; 
and  in  1878  I  reported  two  others.  I  removed  one  in  the  fork  of  my  forceps,  an  inch  in 
diameter,  on  January  19,  1875,  when  operating  for  stone  upon  a  man  ajt.  67,  with  a  mul- 
berry calculus  one  inch  and  a  half  in  diameter,  and  the  man  made  an  excellent  recovery. 
The  second  was  from  a  patient  vet.  70  who  was  operated  upon  in  February,  1876,  the 
prostatic  tumor  being  enucleated  during  the  extraction  of  a  large  stone  with  the  forceps, 
and  the  recovery  was  complete. 

When  the  stone  is  soft,  friable,  and  comes  away  piecemeal,  it  is  wise  to  wash  the  blad- 
der well  out  with  a  stream  of  tepid  water ;  and  at  times,  when  the  stone  is  apparently 


or  in:  II  (ipkiiatioss.  crn 

lifkl  liy  the  Idaddcr  in  such  a  posit iim  -aa  torliitls  its  hciii^j  caiij^ht  hy  the  forceps,  a  stn-ain 
ni"  water  thrmijih  the  bhulder  may  dixhidire  it  and  allow  (tf  its  removal. 

Vvii/  tiii'iji  stones  should  he  erushed  tiinuifjh  the  pi-ririeul  wound  before  their  removal, 
and  a  short  stront;  lithotrite  is  tlu'  best  instrument  for  that  purpose. 

In  moderately  larj^e  stones,  when  the  wound  in  the  neck  (»f  the  bladder  is  not  large 
cnouirh.  Liston's  advice  should  be  followed  and  an  itu'ision  made  r)n  the;  opp(»site  side  of 
the  neck  of  the  bladder  by  passing  a  blunt-pointed  bistoury  into  the;  wound,  guided  by 
the  linger,  and  turning  its  edge  toward  the  rii//if  tuber  isehii.  Martineau  savs  that  he  like- 
wise often  enhirgi'd  the  inner  wouml  two  or  three  times  to  facilitate  the  escape  of  the  stone. 

When  a  sicoiul  sfmir  I'orms  in  the  bladder  and  another  operation  is  demanded,  there  is 
no  reason  why  it  should  not  be  jierforuied  in  the  siiuw.  ])osition  and  manner  as  the  first, 
and  with  ecjual  success.  At  intervals  of  three  and  fifteen  months  I  have  had  to  cut  a 
patii'ut  ;ot.  (I<(  three  times  for  stone,  removing  nn  the  first  occasion  .seven  calculi,  on  the 
second  two.  aiul  on  the  third  two,  with  good  results.  The  stones  averaged  on  each  occa- 
sion more  than  an  inch  in  diameter.  The  patient  did  as  well  after  the  second  and  third 
operations  as  after  the  first,  and  is  now  quite  well.  The  Norwich  .statistics,  as  compiled 
by  Mr.  C.  Williams,  show  that  a  third  operation  uiay  be  performed  with  like  succes.s 
{Lancet,  May  18,  1878). 

Other  Operations. 

The  median  operation  i^  the  old  Italian  or  Marian  method.  ba.sed  upon  the  pre- 
cept "A  small  incision,  much  dilatation,"  and  has  been  revived  by  Allarton.  It  i.s  per- 
formed as  follows  :  The  operator  fir.st  introduces  an  ordinary  grooved  staft'  into  the  bladder 
and  gives  it  to  an  assistant.  He  then  passes  his  left  forefinger  into  the  rectum,  with  the 
]ialniar  surface  upward  as  fjir  as  the  apex  of  the  prostate,  and  holds  it  there  as  a  guide  to 
the  ne.xt  step  of  the  operation.  He  then  takes  a  long  .straight  bistoury,  and,  with  its 
edge  upward,  introduces  it  about  half  an  inch  in  front  of  the  anus  in  the  median  line, 
down  to  the  membranous  portion  of  the  urethra  or  apex  of  the  prostate,  into  the  groove 
of  the  staff,  and  presses  it  toward  the  bladder  for  about  half  an  inch.  He  then  cuts 
upward,  dividing  the  membranous  portion  of  the  urethra  freely  and  the  soft  parts  of  the 
perinjeum.  making  an  external  wound  about  an  inch  and  a  half  long.  Through  this 
wound  he  next  introduces  his  finger  into  the  bladder  with  a  rotatory  movement,  the  pros- 
tatic piu'tion  of  the  urethra  and  the  neck  of  the  bladder  being  dilated;  the  forceps  are 
then  inserted  into  the  bladder  and  the  stone  removed. 

Where  the  .stone  is  large  Allarton  employs  Weiss's  three-bladed  female  dilator  or 
Arnott's  hydraulic  dilator. 

This  operation  as  described  is  precisely  the  one  now  generally  performed  for  the  digi- 
tal exploration  of  the  bladder  and  the  removal  of  growths  from  the  bladder.  It  is  found 
to  give  abundance  of  room  for  these  purposes,  and  may  therefore  be  said  to  be  of  value 
for  the  removal  of  foreign  bodies  or  stones  of  moderate  size  from  the  bladder.  I  have 
employed  it  in  several  cases  of  stone  during  the  last  three  years  with  success,  and  in  one 
case  removed  five  calculi  over  half  an  inch  in  diameter  with  facility.  I  am  indeed  dis- 
posed to  think  that  this  operation  may  prove  to  be  better  than  the  lateral  in  old  subjects, 
for  it  is  certainly  attended  with  less  hemorrhage.  In  children  the  dilating  process  is  dan- 
gerous and  apt  to  be  attended  by  a  tearing  away  of  the  neck  of  the  bladder  from  its 
perineal  attachment.  The  experience  of  Norwich  surgeons,  however,  in  no  way  tends  to 
give  it  any  support,  the  mortality  of  the  median  being  nearly  twice  as  great  as  that  after 
the  lateral  operation. 

Dolbeau's  operation  must  be  mentioned  as  a  modification  of  the  median.  A  full 
description  ut'  it  can  be  fnunil  in  his  work  La  Lithotritie  Perineale  (1872).  In  its  first 
step,  where  the  membranous  portion  of  the  urethra  is  opened,  it  differs  in  no  important 
respect  from  Allartons.  but  in  the  second  the  neck  of  the  bladder  and  parts  external  to  it 
are  dilated,  while  in  the  third,  unless  the  stone  be  very  small,  it  is  broken  before  removal. 

The  dilating  process — an  essential  part  of  the  operation — is  effected  by  means  of  a 
very  ingenious  six-bladed  dilator,  the  blades  of  which  are  so  arranged  as  to  separate  with- 
out diverging  by  means  of  two  balls  which  move  upon  a  central  stem. 

The  external  parts  down  to  the  urethra  are  dilated  first,  then  the  membranous  portion 
of  the  urethra,  and  lastly  the  neck  of  the  bladder,  the  passage  into  the  bladder  by  these 
successive  dilatations  being  of  uniform  calibre  and  with  smooth  walls.  The  stone  is 
broken,  not  crushed,  by  the  "  cassepierre.  '  an  instrument  that  opens  in  the  bladder  with- 
out divergence  of  its  limbs.  The  fragments  should  then  be  removed  with  care  and  the 
bladder  washed  out. 


678  STONE  IN  THE  BLADDER,   AND  ITS   TREATMENT. 

Dolbcau  claiin.s  for  tliis  operation  great  advantages  which  are  not  yet  proved.  The 
instrunient.s,  liowever,  are  very  ingenious. 

Dupuytren's  bilateral  section  of  the  prostate  for  the  removal  of  hirge  stones, 
with  tlie  semilunar  transverse  perineal  incision  in  front  of  the  anus,  meets  with  few  sup- 
porters at  the  present  day.  He  made  his  first  incision  with  a  scalpel  down  to  the  mem- 
branous portion  of  the  urethra,  and  afterward  introduced  into  the  groove  of  the  staff  a 
double-bladed  curved  lithotome,  which  was  pushed,  closed,  down  to  the  stone  into  the 
bladder  along  the  staff.  The  blades  were  then  opened  transversely  and  the  instrument 
withdrawn.  13y  these  means  the  neck  of  the  bladder  and  the  prostate  were  freely  incLsed, 
the  prostatic  section  having  an  oblique  direction  downward. 

Oiviale's  Operation. — Civiale  in  1836  suggested  his  medio-bilateral  operation, 
"  being  dissatisfied  with  the  bilateral,  and  shunning  the  lateral  method  on  account  of  the 
anatomical  objections."  Having  introduced  a  staff  with  a  median  groove,  he  made  an 
incision  in  the  median  line  an  inch  and  a  half  long  in  front  of  the  anus  down  to  the 
membranous  portion  of  the  urethra.  He  made  also  a  free  opening  into  the  urethra,  and 
then  introduced  art  instrument  similar  to  Dupuytren's  lithotome,  but  straight,  along  the 
groove  of  the  staff  into  the  bladder,  opening  the  blades  when  the  bladder  had  been 
entered,  and  dividing  the  neck  of  the  bladder  on  its  withdrawal.  The  finger  was  then 
introduced,  the  staff"  removed,  and  the  forceps  inserted,  the  stone  being  removed  as  in 
other  operations.  It  differs  little  from  Dupuytren's  except  in  the  form  of  perineal  incis- 
ion. Sir  H.  Thompson,  who  first  described  this  operation  in  England,  and  Erichsen  have 
both  successfully  removed  calculi  by  this  operation. 

Buchanan's  Operation. — Dr.  Andrew  Buchanan's  operation  with  the  rectan- 
gular staff,  bent  three  inches  from  the  point  and  deeply  grooved  laterally  with  a  posterior 
opening,  is  essentially  a  central  operation.  He  suggested  it  in  1847.  The  staff  is  intro- 
duced into  the  bladder  and  guided  by  the  finger  in  the  rectum  ;  the  angle  of  the  staff  is 
made  to  correspond  to  the  apex  of  the  prostate.  The  operator,  still  retaining  his  finger 
in  the  rectum,  inserts  a  long  straight  bistoury  in  front  of  the  anus,  with  the  blade  hori- 
zontal and  the  edge  turning  to  the  left  down  to  the  groove  and  angle  of  the  staff,  and 
pushing  it  toward  the  bladder,  to  stop  at  the  end  of  the  staff.  He  then  withdraws  the 
knife,  and  as  he  does  so  makes  a  curved  incision  through  the  soft  parts  around  the  left 
side  of  the  rectum  toward  the  tuber  ischii,  the  wound  being  about  an  inch  and  a  half 
long.  Dr.  Buchanan  describes  his  operation  as  being  half  that  of  Dupuytren's.  When 
the  stone  is  large,  the  right  side  of  the  prostate  is  cut,  thus  approaching  it  more  nearly 
as  a  whole. 

The"  recto-vesical  operation  was  at  one  time  a  very  favorite  one.  The  late 
Mr.  Lloyd  of  St.  Bartholomew's  was  about  the  last  English  surgeon  who  freely  practised 
it,  whereas  now  it  has  been  almost  lost  sight  of.  The  operation  consists  in  the  introduc- 
tion of  the  knife  into  the  rectum,  with  the  blade  flat  upon  the  palmar  surface  of  the 
right  index  finger,  the  turning  of  the  edge  of  the  knife  upward,  and  the  perforation  of 
the  bowel  and  urethra  at  the  apex  of  the  prostate  down  to  the  groove  of  the  staff",  the 
sphincter  and  soft  parts  being  freely  divided  upward  in  the  median  line  of  the  perina?um 
for  about  one  inch  on  the  withdrawal  of  the  knife.  The  left  forefinger  is  next  inserted 
into  the  wound  down  to  the  groove  of  the  staff,  and  the  bistoury  again  introduced  with 
its  edge  downward  and  pushed  into  the  bladder  along  the  groove,  the  neck  of  the  bladder 
and  prostate  being  freely  divided  when  the  stone  is  large.  The  finger  is  then  jnxssed 
into  the  bladder  along  the  staff,  the  staff"  removed  and  forceps  passed,  the  calculus  being 
extracted  in  the  usual  way.  As  an  ordinary  operation  this  is  greatly  inferior  to  the  lateral. 
Kbnig's  statistics,  as  quoted  by  Poland,  show  it  to  be  very  unsuccessful.  When  the  stone 
is  very  large,  it  may,  however,  be  entertained. 

Supra-Pubic  Operation. — The  high  operation,  or  supra-pubic,  is  one  of  the 
oldest,  and  was  practised  by  Cheselden  and  Civiale.  It  was  at  one  time  supposed  to  be 
the  most  direct  and  least  dangerous  operation,  the  only  dangerous  part  involved  in  it 
being  the  peritoneum,  which  can  readily  be  avoided.  For  large  stones  it  may  be  enter- 
tained. 

The  operation  consists  of  three  stages  : 

The  Jxraf  consists  in  exposing  the  anterior  wall  of  the  bladder  by  a  vertical  incision 
made  in  the  median  line  above  the  pubes  through  the  parietes,  with  the  patient  on  his 
back,  his  pelvis  raised,  and  the  bladder  moderately  distended  with  a  one-per-cent.  solution 
of  carbolic  acid  or  thymol  of  the  temperatur-e  of  the  body,  and  well  raised  out  of  the  pelvis 
by  the  rubber  rectal  dilator  (Fig.  363). 

The  second  step  is  that  of  opening  the  bladder,  and  care  should  be  observed  that  this 


stom:  i.\  Tin:  ri:MM.i:  i:i.MH)i:n.  ()70 

opciiiiitr  is  made  in  the  iin'tliaii  liiu'  ami  r/osr  tn  tUr  syiiii>lii/sis.  Tliis  is  host  dono  by  traits- 
lixiiiir  the  MaddtT  wIhtc  it  is  fxpuscd  and  opcninjr  it  from  liclow  u|)\vard.  can;  heinj^  also 
ohsiTVi'd  that  tho  wound  in  tlic  alxhunimil  parictcs  is  cand'iilly  kci»t  open  witli  retractors. 

The  tltlnl  step  is  tlie  removal  of  the  stone  liy  means  of  ioreeps. 

After  the  operation  the  wound  in  the  Madder  should  be  brou^'ht  tofrether  carefully 
with  sutures  ami  the  external  wouml  (dosed  above,  a  space  beiiifr  left  below  for  drainage, 
and  the  ease  lit'l  to  nature.  Tlif  urine  should  8ubse(|uently  be  drawn  off"  at  short 
intervals. 

The  statistics  of  the  operation  are  not  (|uite  satisfactory.  (Jross  J2;ives  1  death  in  4 
cases;  Civiale,  1  in  2;  Humphry  of  Cambridge  and  Dulles,  1  in  :{.  The  latter  author 
speaks  hij^hly  (d'  it  (Aiiirn'rdii  ./oiinia/  of  Mail.  Srlmrr,  duly.  1S75;  April.  1S7S).  He 
believes  the  o])eration  to  be  (U'servinj,'  of  mr»re  attention  ami  should  receive  a  fairer  trial 
than  it  has  yet  had. 

All  theso  varieties  of  operations  have  been  detailed,  as  exceptional  cases  of  stone  may 
be  met  with  in  which  one  or  the  other  may  be  better  than  the  lateral  ;  but  as  a  general 
operation  lateral  and  median  lithotomy  are  the  best,  and,  of  the  modes  of  performing  the 
lateral  operation,  Key's  is  the  simplest  and  mo.st  successful. 

Causes  of  Death  after  Lithotomy. 

When  ])atientsdie  unrelieved  with  calculus,  they  generally  do  so  from  kidney  disease ; 
and  in  the  majority  of  fatal  cases  of  lithotomy  the  .same  cause  produces  a  like  result. 
When  kidney  disease  is  imt  present,  any  of  the  operations  described  for  the  removal  of 
the  stone,  wiien  performed  with  average  skill,  is  likely  to  be  successful.  When  kidney 
disease  exists,  any  operation  is  likely  to  prove  unsuccessful. 

These  facts  are  fully  illustrated  in  a  paper  I  read  in  1862  (Roy.  Med.  and  Chir. 
Society)  on  the  causes  of  death  after  lithotomy. 

Prognosis. — The  longer  a  stone  remains  in  the  bladder,  the  greater  are  the  probabili- 
ties of  renal  disease  ;  and,  consequently,  the  larger  the  stone,  the  greater  the  risk. 

The  duration  of  the  symptoms  and  the  size  of  the  stone  are,  consequently,  valuable 
aids  in  forming  a  prognosis. 

When  death  takes  place  from  so-called  shock,  it  is  probably  connected  with  organic 
renal  disease. 

In  a  small  proportion  of  cases  death  takes  place  from  hemorrhage,  such  a  result,  how- 
ever, when  uncomplicated,  being  very  exceptional.  It  does  not  probably  occur  once  in  a 
hundred  cases. 

Pelvic  cellulitis  and  peritonitis  have  usually  been  regarded  as  common  causes  of  death. 
Pelvic  cellulitis  is  very  insidious,  and  often  only  positively  made  known  when  some  peri- 
toneal complications  make  their  appearance.  Its  cause  has  generally  been  assigned  to  a 
too  extensive  incision  of  the  neck  of  the  bladder,  but  the  careful  investigation  of  a  large 
number  of  fatal  cases  suggests  the  probability  that,  although  a  fatal  complication,  it  is 
one  which  for  the  most  part  arises  without  urinary  infiltration  and  as  a  result  of  continu- 
ity with  structures  that  have  become  inflamed  from  injury  sustained  during  the  operation 
or  from  the  prolonged  presence  of  the  stone.  It  is  also  commonly  associated  with  renal  dis- 
ease, and  it  is  now  well  known  that  under  such  circum.stances  the  inflammation  of  serous 
membranes  is  very  common.  It  is,  consequently,  an  open  question  as  to  how  far  the 
renal  disease  or  the  operation  is  the  cause  of  the  pelvic  cellulitis  and  peritonitis. 

Death  from  acute  cystitis  may  occur,  as  it  may  from  the  hemorrhagic  diathesis, 
pyajmia.  chloroform,  or  any  accident. 

Ursemia  as  a  cause  of  death  is  classed  with  renal  disease. 

In  children  incontinence  of  urine  is  apt  to  follow  the  operation,  particularly  when  the 
horizontal  position  has  not  been  rigidly  enforced  during  the  healing  process.  It  is.  how- 
ever, a  rare  effect. 

Wasting  of  a  testis  may  likewise  take  place  from  some  disease  or  wound  of  the  vas 
deferens.  I  have,  however,  known  this  to  occur  but  once,  but  cases  of  it  have  been 
recorded  by  Teevan  and  others. 

STONE  IN  THE  FEMALE  BLADDER.  ' 

Calculi  are  doubtless  formed  as  frequently  in  the  kidney  of  the  female  as  in  that  of 
the  male,  and  pass  downward  into  the  bladder,  although,  from  the  absence  of  the  pros- 
tate, as  well  as  owing  to  the  shortness  and  dilatability  of  the  female  urethra,  they  rarely 
require  surgical  treatment. 


680  STONE  IN  THE  BLADDER,   AND  ITS  TREATMENT. 

The  records  of  surgery  contain  many  instances  in  which  hirge  calculi  have  been  passed 
by  natural  efforts  from  the  female  bladder  without  any  very  injurious  effect  resulting,  and 
Mr.  Clogg  of  Looe,  Cornwall,  has  recorded  a  case  in  which  a  stone  nearly  four  inches  round 
was  thus  passed  (Brit.  Med.  Journ..,  May  2,  1074).  But  the  experience  of  every  surgeon 
will  supply  him  with  instances  in  which  calculi  of  moderate  dimensions  have  been  readily 
passed,  and  I  have  a  specimen  of  mulberry  stone  nearly  an  inch  in  diameter  which  a  young 
woman  thus  got  rid  of. 

In  neglected  cases  of  vesical  calculi  in  women  the  stone  may,  however,  excite  ulcera- 
tion of  the  bladder  or  be  discharged  per  vaginam. 

Symptoms. — The  symptoms  of  stone  in  the  bladder  of  the  female  are  very  similar  to 
those  in  the  male,  such  as  irritability  of  bladder,  pain  during  and  after  the  act  of  mictu- 
rition, intermittent  flow  of  urine,  and  hsematuria,  a  bearing-down  pain  and  incontinence 
of  urine  being  common  accompaniments.  In  the  female  sex  uterine  and  vesical  symp- 
toms are  so  closely  associated  that  surgeons  cannot  be  too  much  aware  of  the  fact,  since 
cases  of  stone  in  the  bladder  are  frequently  passed  over  as  examples  of  uterine  disease, 
when  a  vaginal  examination  would  reveal  the  true  state  of  affairs ;  a  calculus  can  often 
be  felt  by  the  finger  through  the  vesico-vaginal  septum,  but  where  doubt  exists  the  sound 
will  settle  the  point. 

Treatment. — The  treatment  of  stone  in  women  is  far  less  complicated  than  in  men, 
on  account  of  the  anatomical  formation  of  the  parts  ;  and  the  majority  of  calculi  can  be 
readily  removed  either  by  urethral  dilatation  and  extraction  or  by  lithotrity. 

The  method  by  xirethral  dilatation  is  based  on  the  natural  one  of  expulsion,  and  is 
applicable  in  all  cases  of  small  calculi.  In  children  a  stone  three-quarters  of  an  inch  in 
diameter,  and  in  adults  of  one  inch  in  diameter,  with  the  patient  under  the  influence  of 
an  anaesthetic,  may  be  fearlessly  removed  from  the  bladder  by  rapid  urethral  dilatation 
and  extraction.  Indeed,  I  have  removed  calculi  two  inches  in  diameter  by  this  means 
without  any  injurious  after-effect;  but  it  is  probably  wise  not  to  make  the  attempt,  the 
surgeon  possessing  in  lithotrity  an  efficient  aid  or  substitute. 

Slow  dilatation  of  the  urethra  is  almost  certain  to  be  followed  by  incontinence,  while 
after  rapid  proceedings  it  is  rare  to  meet  with  this  result. 

The  operation  may  be  performed  as  follows:  With  the  patient  on  her  back,  under  the 
influence  of  an  anaesthetic,  the  urethra  should  be  dilated  by  my  urethral  dilator  (Fig. 
438)  sufficiently  far  to  allow  of  the  introduction  of  the  left  index-finger,  or  by  Weiss's 
three-pronged  dilator,  which  should  be  introduced  and  rapidly  expanded.  The  forceps 
should  then  be  introduced,  when  the  stone,  having  been  seized,  can  be  rapidly  removed. 
I  have  on  several  occasions  employed  the  lithotrite  for  this  purpose,  w^ith  the  view  of 
crushing  the  stone  should  any  difficulties  be  experienced  in  its  extraction,  and  therefore 
recommend  the  practice.  On  four  occasions  I  have  not  dilated  the  urethra  at  all,  but 
passed  the  lithotrite  or  forceps  and  extracted  at  once,  and  consider  this  plan  is  as  good  as 
any  other;  for  every  surgeon  must  be  struck  with  the  facility  with  which  a  finger  or  any 
moderate  instrument  can  be  introduced  into  the  female  bladder  when  the  subject  is  under 
the  influence  of  an  anaesthetic. 

If  any  difficulty  is  felt  in  the  extraction  of  the  stone  or  it  prove  larger  than  can  be  safely 
removed  as  a  whole,  it  may  be  broken  up  and  removed  piecemeal.  By  these  means  I  took 
away  at  one  operation  without  any  difficulty  or  bad  result,  from  a  child  only  four  years 
old,  a  calculus  an  inch  and  a  half  in  diameter,  and  in  the  year  18G9  I  successfully  removed 

with  facility  three   calculi   from   three   patients   by  these 
Fig.  396.  means.     In  female  subjects  there  can  be  no  such  hesita- 

tion as  to  the  wisdom   of   removing   fragments  after  the 
crushing  operation  as  there  is  in  males. 

When  the  stone  is  too  large  for  removal  by  rapid  dila- 
tation, or  the  bladder  too  contracted,  inflamed,  and  ulcerated 
to  allow  of    lithotrity,  the    stone   should  be  removed  per 
vaginam,  the  surgeon  in  this  operation  again  imitating  a 
method  sometimes   resorted  to   by  nature.      To   do   this  a 
Extracted  ihrou^Ji     *^'^^    /         clcan  incision  of  sufficient  length  to  admit  the  removal  of 
''^"^'"JLctr^  throucyh  L'reiAr/A      the  calculus  has  to  be  nnide  into  the  bladder  through  the 
Calculus   removed  ironi  the  Female  vaginal  Septum,  guided  by  a  director  introduced  through 
naturaf  size!*)"^       ^    agma.    (   a    ^jjj^  ^^j.g|^]^j.a.     The  wound  should  Subsequently  be  closed  by 

means  of  stitches,  as  in  vesico-vaginal  fistula. 
In  this  way  I  have  removed  with  good  success  a  stone  two  inches  long  that  formed  a  com- 
plete cast  of  the  contracted  bladder  (Fig.  396).     Dr.  Aveling  and  M.  Vidal  strongly  recom- 


FouKicy  iioDiEs  ix  Till-:  i:i..\i>i)i:u.  f;8l 

nu'iul  this  ofitTiitidii,  wliilc  the  lute  .Mariuii  Sims  tlnni<rlit  so  well  of  it  as  t<»  assert  '"that 
it  is  tin-  (iiily  jiistiHalilc  (i|t('rati(tn  fur  stdtic  in  tlic  t'ciiiak'  bladder;"  and  if  by  the  w<»rd 
'' o|)erati(tn"  he  means  a  eiittinjr  one.  he  is  eertaiidy  rif^ht.  {'or  where  the  urethra  lias  been 
divided  to  aHow  of  the  removal  of  stone  ineontineiice  is  u  eoinnioii  conse(juence. 

Urethral  lithotomy  is  here  mentioned  only  to  be  ef)ndeinned.  as  any  ineision  into 
the  neek  of  the  leniale  bladder  is  liable,  as  has  just  V>een  said,  to  fie  followed  by  incon- 
tinence of  urine,  half  the  eases,  as  a    rule,   beinj^  so  afleeted. 

Hv  way  of  summary,  therefore,  it  may  be  concluded  that  a  stone  of  m<iderat»!  size 
mav  readily  be  removed  from  tlii'  female  bladder  by  immediate  extraction.  an<l  one  of 
larjier  dimensions  by  lithotrity  and  extraction,  the  patient  beinjr  JnHij  under  the  influ- 
ence of  an  ana'sthetic  :  that  where.  I'roin  the  size  of  the  stmie.  immediate  extraction  i.s 
not  atlvisable.  or  from  the  condition  of  the  bladder  lithotrity  cannot  be  performed.  va;:inal 
lithotomy  is  the  best  operation,  while  all  slow  dilatati(»n  of  the  urethra  is  to  be  avoided 
and  all  urethral  lithotomy  condemned,  (»n  account  of  the  fre<|Ucn(y  of  incontinence  of 
urine  as  the  result   of  such   treatment. 

(For  further  information  and  statistics,  cldc  Dr.  Aveling,  Ohst.  Trnnx.^  18(J4  ;  and  paper 
by  author,  Mtd.-Chir.  Trans.,  18G4.) 

Foreign  Bodies  in  the  Bladder. 

These  are  occasionally  met  with  in  both  the  male  and  the  female  suVjject.  Broken 
catheters  and  bougies  are  probably  the  most  common,  but  a  tobacco-pipe,  pins,  French 
chalk,  slate-pencil,  straw,  a  silver  toothpick,  penholder,  etc.,  are  in  the  Guy  s  Museum 
recorded  as  foreign  bodies  that  have  been  removed  from  the  male  bladder,  and  a  bone 
bodkin-case,  a  cedar-pencil,  and  a  stiletto  from  the  female. 

Foreign  bodies  may,  however,  obtain  acce.ss  to  the  bladder  through  wounds,  gunshot 
or  otherwise,  or  through  abscesses  connected  with  bone.  Brodie  has  related  a  case  in 
which  he  removed  from  a  young  lady  a  calculus  which  contained  •'  a  small  portion  of 
bone  and  two  imperfectly  formed  human  teeth,"  doubtless  the  remains  of  a  blighted 
ovum  or  contents  of  some  dermoid  cy.st ;  and  a  second,  in  which  a  stone  from  the  female 
bladder  had  a  hazel-nut  as  a  nucleus. 

When  a  foreign  body  remains  long  in  the  bladder,  it  acts  as  an  irritant  and  usually 
becomes  rapidly  covered  with  phosphates  (Fig.  38;-)).  In  a  specimen  at  the  College  of 
Surgeons  a  foreign  body  is  the  nucleus  of  a  uric  acid  calculus. 

As  soon  as  a  foreign  body  is  known  to  exist  it  ought  to  be  removed.  Where  this  can 
be  effected  through  the  urethra,  so  much  the  better ;  and  as  long  as  the  substance  is  in 
the  pas.sage  and  not  impacted,  this  may  be  done  ;  but  when  this  cannot  be  effected  and 
the  urethra  is  the  seat  of  the  offending  body,  a  clean  ineision  should  be  made  and  the 
foreign  body  removed,  as  incised  wounds  into  the  urethra  usually  heal  well,  and  it  is 
better  to  make  them  than  to  lacerate  the  urethra  by  forcible  internal  manipulation. 

I  had  a  case  some  years  ago  in  which  a  long  hairpin  had  been  impacted  in  the  penis 
and  perinaeum  with  its  points  forward,  one  end  being  felt  at  the  base  of  the  penis  imbed- 
ded in  the  tissues  beneath  the  skin.  Under  chloroform,  I  pressed  the  point  through  the 
skin  and  gradually  withdrew  the  pin,  which  came  out  nearly  straight.  A  rapid  recovery 
followed,  without  a  bad  symptom. 

When  the  foreign  body  is  in  the  bladder  and  cannot  be  crushed  by  the  lithotrite  or 
drawn  out  by  the  scoop,  cystotomy  must  be  performed,  and  in  adults,  when  the  foreign 
body  is  not  large,  the  median  operation  should  be  chosen. 

The  portion  of  catheter  illustrated  below  (Fig.  397)  I  removed  from  the  l)ladder  of 

Mr.  B ,  ajt.  (II.  on   August  23,  1875,  by   means  of  a   .snjall   lithotrite.  thirteen   days 

after  it  had  been  broken  off  in  the  bladder. 
I  was  fortunate  enough  to  catch  it  at  its 
bulbous  end  and  to  withdraw  it  without 
much  difficulty,  a  rapid  recovery  following. 

In  icomeii  under  the  influence  of  an  ana>s-       ^c***^ j\\,tJ-  aize 

thetic  the  body  may  usually  be  readilv  ex-       r,  a   t  rv.  .  ^  <•       x,  i   t>i  i.        .», 

^1,  '         „•',  .*  ,         ,.  •  i-nd  of  Catheter  removed  from  Male  Bladder  with 

tractea  by  means  of  dressing  or  other  forceps.  .  Lithotrite. 

In   the  ca.se  in  which   a  lady's  stiletto  (Fig. 

398)  was  in  the  bladder  of  a  young  woman,  I  found  the  point  of  the  instrument  present- 
ing forward  and  upward  and  fixed  in  the  .symphysis.  With  my  left  finger  in  the  urethra, 
I  pressed  it  back,  and  after  some  little  manipulation  with  the  right  index  finger  through 
the  rectum — for  the  patient  was  a  virgin — I  so  placed  the  stiletto  as  to  fix  the  point 


682  SURGERY  OF  THE   URETHRA. 

against  the  pulp  of  my  left  index  finger,  and  with  a  pair  of  forceps  introduced  upon  niy 
finger  extracted  it.     The  patient  recovered  without  any  inconvenience. 

Most  cases  may,  indeed,  be  treated  with  a  pair  of  forceps  in  the  bladder  and  a  finger 

Fig.  398. 


.stiletto  leinoveil  from  Female  Bladder. 


in  the  vagina  or  rectum  to  mani])ulate  and  place  the  foreign  body  in  a  good  position  for 
removal,  the  surgeon  seizing  the  foreign  body  by  one  end.  For  the  removal  of  such  a 
thing  as  a  hairpin  a  blunt  hook  may  possibly  be  serviceable. 


CHAPTER    XXIII. 
SURGERY    OF    THE    URETHRA. 

A  DIMINUTION  in  the  calibre  of  the  urethra  the  result  of  organic  changes  within  its 
walls  gives  rise  to  sfncfure ;  any  encroachment  on  the  passage  from  without  or  within 
causes  obsfrvcfion. 

Obstruction  occurs  when  the  urethra  is  narrowed  from  inflammatory  engorgement 
of  its  mucous  and  submucous  tissue  (the  inflammatory  stricture  of  some  authors)  or 
from  spasm  of  the  urethral  muscles  (spasmodic  stricture)  ;  when  an  abscess  or  tumor 
outside  or  any  prostatic  enlargement  encroaches  on  the  urethra  or  when  any  fracture  of 
the  pelvis  presses  upon  it ;  and  lastly,  when  a  calculus  or  foreign  body  is  impacted  in  the 
passage  or  a  urethral  polypus  blocks  it  up. 

Organic  stricture  is  caused  by  the  contraction  of  inflammatory  deposit  situated 
upon,  within,  or  beneath  the  mucous  membrane  of  the  canal,  or  from  the  contraction  of 
the  cicatrix  of  a  ruptured  or  injured  urethra.  The  first  form  may  be  described  as  simple 
organic' stn'cfnre ;  the  second,  as  traumatic  or  cicatricial  stricture.  The  former  is  the  more 
common,  my  notes  showing  603  examples  of  the  former  to  43  of  the  latter  in  consecutive 
cases,  or  in  the  j)roportion  of  14  to  1. 

In  the  majority  of  cases  the  contraction  of  an  organic  stricture  is  of  a  chronic  nature, 
and  in  some  may  be  readily  traced  to  a  more  or  less  distinct  chronic  inflammation  of  the 
passage ;  but  years  will  frequently  pass  before  the  obstruction  to  the  flow  of  urine 
becomes  of  sufficient  importance  to  arrest  attention,  and  a  sudden  attack  of  retention  of 
urine,  induced  by  some  act  of  irregularity  or  exposure  to  cold,  will  probably  be  the  first 
symptom  to  draw  the  patients  attention  to  his  condition. 

The  stricture  may  consist  simply  of  a  perforated  membranous  diaphragm  stretched 
across  the  canal ;  of  a  narrow  band  of  inflammatory  product  surrounding  the  passage,  to 
which  the  terms  "  whip-cord,"  "ring,"  or  '-annular"  stricture  are  attached;  and  in  rarer 
cases  to  bands  of  lymph  stretching  across  the  passage  and  forming  what  are  known  as 
"  bridle"  strictures.  It  may  be  general  or  partial,  and  when  the  latter  may  have  been 
caused  by  some  adhesion  either  of  the  natural  rugae  of  the  urethra  or  of  some  folds  of 
its  mucous  lining.  When  the  stricture  is  more  extensive,  there  is  hardly  a  limit  to  the 
extent  of  inflammatory  deposit  which  nuiy  exist,  from  the  narrow  band  already  alluded 
to  as  forming  the  "  annular  "  stricture,  passing  onward  to  the  broader  band  which  answers 
to  Sir  A.  Cooper's  term  of  "  ribbon  "  stricture,  to  the  still  severer  cases  in  which  the 
urethra  is  f(juiid  more  or  less  contracted  throughout  its  entire  course.  Between  these 
extremes  numberless  varie.ties  and  degrees  of  mischief  may  be  observed,  the  urethra  pre- 
senting one  single  contraction  or  several  independent  ones.  John  Hunter  mentioned  a 
case  in  which   six  strictures  coexi.sted. 

Lastly,  the  urethra  may  unijuestionably  become  "  impermeable,"  the  pathological 
specimens  in  Guy's  Museum  being  sufficient  to  demonstrate  the  fact.  Such  a  condition, 
liowever.  cannot  exist  uncomplicated  with  other  .symptoms,  since  it  is  obvious   that  the 


CAi'sK  or  sriiKTrRE.  083 

urine  must  have  some  chiuinel  for  «>.scii|i»'.  In  iln;.st;  casert,  therefore,  urinary  fistula  will 
always  he  fnuiid.  An  nhUti  rnilim  of  tin-  urethra  the  result  of  injury  from  eieatrieial 
stricture  is  also  met    witli. 

Locality  of  Stricture. —  I'or  the  only  iletinite  facts  rclatin<^  to  this  suhject  1  must 
refer — ami  I  ilo  >"  with  idrasure — to  the  lahors  of  Sir  II.  Thompson;  for,  although 
other  writers  have  i^iven  their '"  im|iressioiis  "  u|ion  the  suhject  and  puhlisheiJ  isolated 
eases,  it   is  to    him    that    the    profi-ssion   is 

indehteil    for  the  analysis  of  two   hundred  I"i<i-  •'!'•'•'■ 

and  seventy   preparations  contained  in  the     ^i^'^^^^^K^SSjaffT'^^'^^^^imt'^-, -  — 
various  museums,  hy  which   in(|uiry   alone   L/-^^^^^^^^^^ 
this  iiuestiou  could  have  heen  satisfactorily   \  -.^^i^MBiBi^^Kv 
determined.       lie    has    most     satisfaetordy      ^*^^^^^^^^^5__^ 
proved  what   is  now   irenerally   received  as 
true — that  in   hy  far  the  majority  of  ca.ses 
of  stricture  the  juncture  of  the  spongy  and 
membranous  portions  of  the  urethra  is  its 
most  frequent  seat  (Fig.  39!h,  and  that  the 

1        -^^    ^     1    •       L'        J^    o    ^\-  A.    •      ^\        .Stricture  of  the  I'rethra,  with  iJilatatiini  ol' I  ruthia  iHihind 

inch    situated    m    front    ot     this    spot    is    the  .stricture  and  Hypertrophy  of  Hla.l.l.r 

ne.Kt   jiosition   in   point  of  fre(|uency,  while 

exceptional  cases  may  he  found  in  the  prostatic  end  of  the  membranous  portion,  at  the 
external  orifice,  or  at  the  terminal  two  inches  of  the  urethra  ;  but  no  specimen  exi.sted  in 
which  a  stricture  has  been  observed  in  the  pro.static  portion. 

Looking  over  my  own  cases  with  a  view  to  ir)(|uiring  into  the  aiuaf)^  of  i^fricfiire,  I 
find,  omitting  congenital  narrowing  of  the  urethra,  that  chronic  gonorrhteal  inflammation 
had  existed  in  27H  out  of  the  G4(i  instances,  and  that  in  78  of  these  injections  had  been 
employed  in  its  cure  ;  that  direct  injury  w^as  the  assigned  cause  of  43,  while  in  ?>?>i)  no 
definite  cause  could  be  obtained.  With  these  facts  it  seems,  therefore,  right  to  conclude 
"  that,  although  gonorrh(jea  often  precedes  a  stricture,  at  least  half  the  ca.ses  are  found  in 
subjects  who  have  not  suffered  from  such  a  disease,  and  that  when  gonorrhoea  might  be 
assigned  as  a  cause  the  use  of  injections  for  its  cure  does  not  appear  to  have  had  any 
positively  injurious  influence  in  producing  a  .stricture."  I  may  add  that  these  results  can 
be  strictly  relied  on.  as  when  noting  the  ca.ses  considerable  care  was  taken  to  .search  out 
this  fact.  It  may.  therefore,  unquestionably  be  asserted  that  injections  have  not  the 
injurious  influence  in  exciting  stricture  which  some  authors  have  ascribed  to  them. 

Among  the  330  eases  in  which  no  positive  cause  could  be  assigned  were  3  in  which 
"gout "'  existed,  and  several  in  which  the  contraction  of  chancres  might  fairly  be  ascribed 
as  the  cause  of  the  obstruction. 

I  have  been  unable  to  discover  that  the  so-called  phosphatic  diathesis  has  any  influ- 
ence in  exciting  the  formation  of  an  organic  stricture  or  any  other  urethral  disea.se, 
although  this  is  a  point  upon  which  Sir.  B.  Brodie  has  largely  dwelt ;  but  there  can  be 
no  doubt  that  any  morbid  condition  of  the  urine  has  considerable  power  in  exciting  a 
spasmodic  contraction  of  the  muscular  walls  of  the  urethra,  more  particularly  when  an 
organic  stricture  exists,  and  of  inducing  retention  of  the  urine. 

Sy.mptoms. — In  a  large  proportion  of  the  cases  of  simple  organic  stricture  an  attack 
of  retention  of  urine  is  the  first  thing  which  attracts  the  attention  of  the  patient,  which 
may  have  followed  some  indiscretion  in  diet,  excess  of  drinking,  or  exposure  to  cold.  It 
is  then,  perhaps  for  the  fir.st  time,  that  the  patient  can  bring  to  his  recollection  the  fact 
that  other  less  marked,  but  not  less  certain,  symptoms  had  previously  existed  for  some 
time.  It  may  be  that  a  chronic  glf-et  had  been  present  for  many  months  or  that  some 
urethral  pain  or  difficulty  had  attended  the  act  of  micturition,  that  the  stream  of  urine 
had  been  somewhat  narrowed,  divided,  twisted,  or  of  a  screw  shape,  or  that  micturition 
had  been  more  frequent  or  prolonged  ;  yet  these  symptoms  by  themselves  had  failed  to 
make  sufficient  impression  upon  the  mind  of  the  sufferer  as  to  lead  him  to  suspect  the 
i^xistence  of  a  stricture. 

It  mu.st  not  be  thought,  however,  that  the  retention  is  usually  caused  by  the  gradual 
contraction  of  the  stricture,  though  in  exceptional  cases  such  a  condition  may  exist ;  yet 
it  is  tolerably  certain  that  in  the  majority  the  retention  is  due  to  some  spasmodic  action 
of  the  urethral  muscles  at  the  seat  of  stricture,  for  very  slight  cau.ses  appear  capable  of 
exciting  .spasmodic  action  of  the  canal  in  a  disea.sed  urethra,  and  consequently  of  giving 
rise  to  retention,  s])asniodic  and  organic  stricture  being  generally  combined.  Indeed,  out 
of  483  cases  of  stricture  con.secutively  admitted  into  Guys.  120.  or  more  than  n  fourth. 
were  suffering  from  retention.     When  the  stricture  is  not  discovered  under  these  circum- 


684  SURGERY  OF  THE   URETHRA. 

stances,  it  will,  if  not  detected  early,  soon  give  rise  to  other  and  more  characteristic 
symptoms.  The  stream  of  urine  will  gradually  contract,  so  that  it  will  at  last  cease  to 
exist,  the  urine  passing  only  in  drops.  The  bladder  will  become  so  irritable  that  the 
patient  will  have  to  rise  frequently  in  the  night  to  micturate,  and  the  effort  will  be 
attended  with  pain  ;  a  small  quantity  of  urine,  moreover,  will  probably  also  be  ])assed ; 
symptoms  aft'ecting  the  rectum  will  soon  appear,  and  the  straining  during  the  act  of  mic- 
turition will  be  associated  with  tenesmus,  these  symptoms  at  times  being  so  severe  as  to 
necessitate,  whenever  natural  relief  is  sought,  the  use  of  the  stool  in.stead  of  the  chamber- 
vessel.  Prolapsus  recti  or  piles  also  frequently  complicate  the  case,  while  incontinence 
of  urine  may  follow. 

Under  these  ciix'umstances  it  is  clear  that  the  bladder  is  never  emptied,  although  some 
small  quantity  of  urine  may  be  passed  at  each  act  of  micturition.  The  retained  urine, 
undergoing  partial  decomposition,  acts  as  an  irritant  and  becomes  cloudy  and  ammoniacal, 
depositing  more  or  less  mucus  and  phosphates.  The  urine,  collecting,  gives  rise  to  dis- 
tension of  the  bladder,  which,  pressing  on  the  rectum,  excites  tenesmus  and  prolapsus, 
and,  interfering  with  the  retui'n  of  the  venous  blood,  to  piles.  As  the  distension  increases 
the  bladder  loses  its  power  of  contraction,  and  consequently  expands  till  it  overflows,  the 
ovirflow  of  urine  giving  rise  to  incontinence^  which  is  a  direct  result  of  chronic  retention. 
A  physical  examination  of  the  abdomen  of  a  patient  under  these  circumstances  will 
reveal  the  distended  viscus  as  a  central  globular  swelling  giving  a  dull  sound  on  per- 
cussion. 

During  these  changes  others  no  less  important  are  going  on  at  the  seat  of  stricture.: 
the  urethra  behind  the  stricture  dilates,  this  dilatation  being  mechanical  and  the  direct 
result  of  the  ineifectual  eiforts  of  the  bladder  to  overcome  the  obstruction  (Fig.  399). 
As  the  pressure  continues  inflammation  of  the  urethra  and  parts  around  appears  ;  the  tis- 
sues as  they  expand  become  indurated,  and  after  a  time  ulcerate.  A  few  drops  of  urine, 
as  a  result,  then  percolate  into  the  cellular  tissue  behind  the  stricture,  and,  setting  up 
suppuration,  form  a  urinary  abscess,  which  to  the  finger  will  appear  as  a  deep-seated  peri- 
neal swelling.  When  the  abscess  is  .slow  in  its  formation  it  will  be  indolent  and  painless, 
but  if  rapid  very  painful ;  when  opened  or  left  to  natural  processes,  it  will,  almost  to  a 
certainty,  be  followed  by  2i  perineal  urinary/  fis^tula. 

If,  however,  the  abscess  and  the  urethral  stricture  be  left  unrelieved  and  the  bladder 
with  the  abdominal  muscles  still  continues  to  act  ineffectually  to  overcome  the  urethral 
obstruction,  the  urine,  by  being  forced  into  the  dilated  urethra  behind  the  stricture  and 
into  the  perineal  abscess  communicating  with  it,  will  sooner  or  later  cause  rupture  of  the 
abscess  into  the  cellular  tissue  of  the  parts  around,  and  as  a  result  give  rise  to  extravasa- 
tion of  urine. 

When  the  parts  thus  gave  way  during  the  efforts  of  the  patient  to  overcome  the  stric- 
ture, or  some  uncontrollable  spasmodic  action  of  the  bladder  and  abdominal  muscles,  a 
sudden  relief  from  the  previous  agony  and  a  sensation  that  something  has  yielded  may 
for  a  time  lull  the  apprehensions  of  the  patient  and  mislead  him  into  the  idea  that  all  is 
well  ;  but  the  swelling  of  the  perinseum,  scrotum,  penis,  and  supra-pubic  region,  which 
must  soon  follow,  with  the  absence  of  any  flow  of  urine  through  the  natural  channel,  will 
reveal  to  the  professional  eye  the  true  nature  of  the  accident,  and  prove  that  the  urethra 
has  given  way  behind  the  stricture  and  that  exfravaxadon  of  urine  has  taken  place. 

Instruments  for  the  Detection  of  a  Stricture.— For  the  detection  of  a 

stricture,  as  well  as  for  its  dilatation,  metallic  catheters,  elastic  catheters,  or  Jiliform 
bougies  may  be  employed. 

The  metallic  catheter  I  prefer  is  that  shown  in  Figs.  384,  385.  The  curve  being 
short  and  the  end  bulbous  and  a  size  larger  than  the  shank,  this  form  of  catheter  is  very 
perfect  for  mere  examination  purposes.  The  elastic  instruments  are  upon  the  French 
model  and  are  made  of  the  same  material  throughout,  a  groove  in  the  top  answering  as  a 
substitute  for  the  ivory  head,  which  is  never  known  to  keep  its  place  ;  and  when  a  catheter 
has  to  be  fastened  into  the  bladder,  the  benefit  of  this  arrangement  is  at  once  proved. 
These  catheters  are  made  very  small  fFig.  400),  even  to.  the  half  size.  For  dilating  a 
stricture  they  should  always  be  pi'eferred. 

The  filiform  bougies  are  made  of  the  same  material  as  the  elastic  catheter  or  of  catgut 
or  whalebone.  I  prefer  the  first  and  last,  as  they  are  made  very  fine  and  smooth,  with  or 
without  olive  tips  ;  some  are  of  the  same  thickness  throughout,  whilst  others  have  finer 
points  than  shafts.  They  can  often  be  insinuated  through  a  narrow  stricture  when  a 
catheter  cannot  be  introduced,  and  are  consequently  of  great  value  for  dilating  purposes. 

As  guides  into  the  bladder  they  are  also  of  equal  use,  and  particularly  for  internal  or 


/•;.v. I  u/.v  I  y/o.v  inn  sriin ti 'rk. 


(J85 


external  urctlirotoiny.      When  these  .small   bougie.s  are  u.snJ.  tin-  un-thra  .should   he  jin-- 
vioii.sly  tilltMl  with  nil. 

I'ni'drliiiiatt'lv.  the  sizes  ol"  the  Kreneh  and  Kn;_dish  catheters  are  imt  alike,  the  former 
beiiij;  inueh  more  jrradual  in  their  increase.      1  a|t|ienil  a  table  of  the  two  scales: 

N".   1    Kn«lish  —  No.   7  French. 

..     o  ..  ..      g       .> 

••    :{       ••       .=    "    9     •• 

'•4  "  :    r        "      11  '• 

..     5         «         ^     ..    \.>       .. 

"  6  "  -     '•  l->  •' 

"  7  "  ••  Ki  " 

..  ^  <>  ..  j7  u 

..  „  ..  ,.  j^  >. 

General  Symptoms. — During  the  development  of  a  .stricture,  and  more  particu- 
larly wlitii  the  >trietiiie  has  become  a  real  cause  of  obstruction,  a  patient's  general  con- 
dition is  rarely  good,  and  what  are  generally  known  as  dyspeptic  symptoms  commonly 
exist ;  as  a  con.se(iuence,  from  the  digestive  organs  failing  to  do  their  duty  as  in  health, 

Kio.  400. 


N. 

.    10 

11 

1'2 
13 
14 

I'^nglisl 

= 

No. 

19 
20 
2-2 
Zi 
2o 

•reiieli. 

15 

= 

20 

•< 

16 

= 

27 

17 

rz: 

28 

« 

IH 

^ 

30 

'• 

the  patient  often  loses  flesh  and  looks  careworn  and  ill.  As  the  disease  progresses  a  con- 
stant feeling  of  chilliness  is  very  common,  and  rigors,  followed  by  fever,  are  not  unusual ; 
these  symptoms  are  at  times  intermittent,  and  are  often  regarded  as  being  due  to  "  ague." 
AVhen  a  perineal  abscess  is  forming,  they  are  commonly  present. 

When  the  rigors  are  uncomplicated  with  abscess  and  are  still  frequent,  there  is  good 
reason  to  believe  that  they  indicate  some  renal  complication  :  for  it  cannot  be  too  strongly 
impressed  upon  the  surgeon's  mind  that  no  stricture  can  long  exist  without  producing 
seciimlarilv  iiiipdrtaut  changes  in  the  bladder  and  kidneys. 

Results  of  Stricture. — When  a  stricture  is  neglected,  renal  di.sease  is  certain  to 
follow ;  and  when  death  takes  place  as  a  con.sequence  of  stricture,  it  will  be  from  kidney 
disease  if  it  has  not  been  suddenly  brought  about  by  one  of  the  complications  of  stric- 
ture, such  as  retention  or  extravasation  of  urine.  Thus,  out  of  100  deaths  from  stricture 
analyzed  by  Dr.  Goodhart,  the  kidneys  were  suppurating  in  41,  wasted  or  inflamed  in  18, 
diseased  in  a  less  degree  or  cystic  in  7,  and  liealthy  in  34,  or  about  one-third. 

Organic  strictures  are  not,  however,  all  of  the  same  character. 

The  simple  stricture  is  the  most  usual,  and  beyond  the  mechanical  eff'ects  of  its 
existence  has  no  special  feature.  The  irritable  stricture  is  comparatively  rare,  and 
is  characterized  by  excessive  .sensibility  on  being  touched  by  a  catheter,  with  a  disposition 
to  bleed.  It  is  also  prone  to  be  associated  with  chilliness,  and  even  rigors.  The  Con- 
tractile stricture  may  belong  to  either  of  the  former  two  groups,  its  peculiarity  cdiisist- 
ing  in  its  tendency  to  recnntract  after  it>>.  dihitation.  The  cicatricial  Or  traumatic 
stricture  has  characters  of  its  own,  and.  of  these,  its  obstinacy  is  the  most  marked. 

It  is  important  to  bear  these  divisions  of  organic  stricture  constantly  in  mind,  for  the 
successful  treatment  of  a  case  will  often  turn  upon  their  recognition. 

Examination  for  Stricture. — Before  a  surgeon  can  say  with  certainty  that  a 
stricture  exists  a  urethral  examination  is  often  a  necessity,  and  this  is  an  operation  in 
which  difficulties  are  met  w-ith  by  the  inexperienced ;  indeed,  without  some  skill  and  con- 
fidence the  attempt  to  pass  a  full-sized  catheter  down  even  a  healthy  urethra  constantly 
fails. 

To  pass  a  catheter  it  is  usually  wise  to  place  the  patient  in  the  recumbent  position, 
with  the  shoulders  slightly  raised  and  the  knees  separated  :  he  should,  too,  be  lying  quite 
straight,  with  the  abdomen  exposed  to  the  navel,  as  the  linea  alba  is  the  best  guide  as  to 
the  line  of  the  urethra.  A  large  metallic  instrument  (No.  7  or  8  being  the  best)  should  be 
selected  for  the  examination,  made  moderately  warm  by  being  dipped  in  warm  water  or 
rubbed  by  the  hand,  and  thoroughly  well  oiled.  The  operator  should  stand  on  the  hff 
side  of  the  patient,  and.  raising  the  penis  with  his  left  hand,  should  introduce  the  end  of 
the  catheter  into  its  urethral  orifice,  keeping  its  point  during  the  introduction  of  the  first 
three  or  four  inches  well  to  the  lou-er  surface  of  the  urethra,  in  order  to  avoid  the  lacunae 
that  exist  in  the  roof  of  the  passage.  The  handle  of  the  instrument  at  this  step  of  the 
operation  may  be  directed  over  the  left  thigh  of  the  patient,  or,  what  is  preferable,  main- 
tained over  the  median  line  of  the  body  in  the  direction  of  the  umbilicus.     With  the  left 


686  SURGERY  OF  THE   URETHRA. 

hand  he  may  then  gently  draw  the  penis  up  the  instrunient,  while  he  allows  the  catheter 
by  its  own  weight  to  slip  down  the  passage,  simply  directing  it  with  a  light  hand.  When 
its  end  has  reached  the  bulbous  portion  of  the  urethra,  the  handle  of  the  catheter  must 
then  be  gently  depressed  in  the  central  line  of  the  body  ;  and  if  no  obstruction  exists,  the 
bladder  will  be  entered,  the  point  of  the  instrument  during  this  movement  being  kept  well 
along  the  upper  surface  of  the  urethra.  In  a  healthy  urethra,  indeed,  the  surgeon  has 
little  more  than  to  guide  a  metallic  instrument  into  the  bladder,  the  weight  of  the  catheter 
being  alone  nearly  sufficient  to  allow  it  to  pass  down  the  passage.  Half  the  errors  com- 
mitted in  catheterism  arise  from  a  non-appreciation  of  this  fact,  the  desire  to  ^>a.ss  the 
catheter  originating  efforts  that  interfere  with  the  entry  of  the  instrument  into  the  blad- 
der under  proper  guidance. 

When  a  stricture  exists,  the  catheter  will  be  arrested  in  its  course;  and  under  these 
circumstances  it  should  be  withdrawn  an  inch  or  so  and  passed  on  again,  with  the  handle 
slightly  altered  in  direction.  If  the  resistance  is  still  felt,  the  instrument  should  be  with- 
drawn and  one  of  a  smaller  size  employed,  and  on  this  failing  to  glide  by  the  obstruction 
a  yet  smaller  one  should  be  tried  ;  and  so  on  till  the  stricture  is  entered. 

The  seat  of  stricture  or  strictures,  as  well  as  the  nature  of  the  contraction,  will  be 
made  out  by  this  process.  If  much  pain  attend  the  examination,  either  the  surgeon  has 
employed  too  much  force  or  an  irritable  stricture  exists ;  and  if  bleeding  follows,  this 
latter  probability  is  strengthened,  particularly  if  no  violence  has  been  employed.  Cathe- 
terism, indeed,  ought  never  to  be  attended  with  violence;  and  if  gentle  measures  do  not 
succeed,  no  other  should  be  attempted. 

In  passing  a  catheter  some  prefer  the  patient  to  be  in  the  erect  position,  but  I  cannot 
recommend  it;  there  is  more  chance  of  inflicting  injury  in  this  position  by  the  patient 
moving,  and  the  surgeon  has  not  so  complete  a  control  over  his  instrument  or  patient  as 
when  he  is  recumbent.  When  there  is  a  stricture,  the  erect  position  is  certainly  wrong. 
The  mode  known  as  the  tour  de  maitre  has  to  be  named  only  to  be  condemned,  though  in 
the  hands  of  a  skilled  surgeon  it  may  be  used  with  impunity.  The  plan  consists  in  intro- 
ducing the  catheter — the  patient  standing — with  the  handle  presenting  downward  and  the 
convexity  of  its  curve  upward,  passing  it  along  the  urethra  down  to  the  bulb,  and  then 
onward  into  the  bladder  by  describing  a  half  circle  toward  the  umbilicus,  the  handle  of 
the  instrument,  when  it  has  reached  the  median  line  of  the  body  above,  being  gradually 
depressed,  and  the  end  of  the  instrument  in  this  turn  made  to  enter  the  bladder. 

Treatment. — The  treatment  of  stricture  must  be  based  on  the  pathology  of  the  dis- 
ease, and  mild  means  should  always  be  preferred  to  forcible  or  cutting  measures. 

The  pathology  of  stricture  is  simple  and  consists  either  in  the  deposition  of  inflamma- 
tory products  in  the  mucous  and  submucous  tissue,  with  their  subsequent  contraction,  or 
in  the  contraction  of  a  cicatrix  the  result  of  an  injury. 

The  principle  of  treatment  is  also  simple,  for  it  is  primarily  to  dilate  the  contracted 
canal,  and  secondarily  to  obtain  the  absorption  or  breaking  up  of  the  effused  inflamma- 
tory products.  The  more  simple  the  means  by  which  these  ends  can  be  secured,  the 
better. 

Where  the  first  end  has  been  obtained  without  the  second,  temporary  benefit  may  have 
been  effected,  but  no  more.  Where  both  ends  can  be  gained  by  simple  means,  the  treat- 
ment must  be  pronounced  good.  In  ordinary  cases  of  organic  stricture  there  is  little  doubt 
that  these  ends  are  to  be  secured  by  dilatation  of  the  stricture,  and  that  by  such  local 
treatment  alone  the  majority  of  cases  of  organic  stricture  may  be  succes.sfully  overcome., 

Now,  this  treatment  by  dilatation  may  be  continuous  or  intermittent.  The  former  method 
is  to  be  preferred  and  should  be  carried  out ;  it  is  the  most  rapid  and  effectual  the  surgeon 
has  at  his  disposal,  although  it  necessitates  about  a  fortnight's  rest. 

The  Continuous  Method. — The  size  of  the  stricture  having  been  gauged,  an  elastic  con- 
ical catheter  with  a  bulbous  end  is  to  be  taken  and  well  oiled,  and  as  large  a  one  as  can  be 
passed  through  the  stricture  introduced.  Should  the  English  catheter  be  preferred,  it  ought 
to  be  made  soft  and  flexible  by  being  dipped  in  warm  water  or  by  friction  with  the  finger, 
and  used  without  the  stylet.  The  penis  of  the  recumbent  patient  must  then  be  raised  by 
the  left  hand  and  drawn  forward  as  well  as  slightly  downward,  so  as  to  make  the  urethra 
as  straight  as  possible.  The  catheter  should  then  be  introduced  and  passed  gently  down 
the  passage.  If  obstruction  be  felt,  the  catheter  may  be  slightly  withdrawn  and  then 
pressed  forward.  The  largest  instrument  the  .stricture  will  admit  without  force  should  be 
introduced,  and,  having  passed  the  stricture  and  entered  the  bladder,  it  is  to  be  fastened 
in  (Fig.  401).     The  end  of  the  catheter  up  to  its  eye  alone  should  rest  in  the  bladder. 

The  orifice  of  the  catheter  may  be  either  plugged   with   a  peg  of  wood   or  the   end 


TRKATMllST  ni'  STllK'TrnK.  <j«7 

capped  V»y  a  y'\vvv  of  iii<lia-riiltJ)«'r  tuliitijr.  the  fret-  cikI  nf  which  shDiild  he  dropju'd  into 
a  urinal  or  tied  in  a  kin»t  tn  prevent  escupt-  <»f'  urine. 

Alter  twfiif y-toiir  hniir.s.  il'  the  catheter  moves  freely  in  the  stricture,  it  may  he 
removed  and  a  lartrt-r  si/e  introduced,  the  sur^'con  hcinj:  careful  not  to  he  tempted  to 
introduce  one  that  fits  th«'  stricture  too  firndy.  On  the  third 
and  following'  days  the  same  practice  may  he  loilowed.  and 
in  ahout  ten  days  a  comjtlete  <lilatation  of  the  stricture  will 
prohahly  have  heen  perfected.  If  the  catheter  does  not  move 
freely  in  the  stricture,  it  must  he  left  a  few  hours  longer. 
When  the  presence  of  the  instrument  in  tlie  hladder  caus«'.s 
irritation  which  is  not  remedied  hy  such  alkalies  as  the  citrate 
or  tartrate  of  potash  with  huchu  and  hyoscyatnus.  it  is  wise  to 
have  tin-  catheter  removed  some  few  hours  hefore  a  lar{:er  size 
is  introduced,  therehv  <:ivinL'  the  hladder  rest.  When  it  is 
impossihle  for  the  patient  to"  maintain  rest,  a  catheter  may  he-^''^^'^''  l  ^-tenim.^ra.heter  in  the 
passed  in  the  evenint:.  retaine<l  all   niirht,  and  removed  in  the 

niorninir.  At  other  times,  where  the  symptoms  are  more  severe,  some  slight  intermi.ssion 
of  the  treatment  may  he  advi.sahle.  the  pas.sage  of  the  catheter  alone  heing  practised. 
After  the  stricture  has  heen  fully  dilated  tlie  daily  passage  of  an  instrument  for  a  few 
days  suli.sequently  is  all  that  is  re<juired,  the  intervals  hetween  the  introduction  of  the 
catheter  heing  gradually  lengthened. 

The  patient  need  not  always  V>e  confined  to  bed  during  this  treatment,  but  may  lie  on 
a  sofa  or  sit  <|uietlv  in  a  redining-chair.  When  movement,  however,  causes  irritation  of 
the  bladder,  it  must  be  forbidden. 

In  severe  and  neglected  strictures  this  plan  is  one  that  ought  always  to  Vje  followed 
when  po.ssible.  as  it  is  sound  in  its  princijde.  safe  in  its  practice,  and  as  expeditious  as  is 
consi.stent  with  the  oVjject  aimed  at. 

Iiiffrrniittaiit  Dihitiitioii. — The  intermittent  method  of  dilatation  is  required  in  less 
severe  cases  or  where  rest  cannot  be  obtained,  and  it  can  be  carried  out  by  the  introduc- 
tion of  an  instrument  on  one  day.  and  after  the  lapse  of  one  or  two  more  its  reintroduc- 
tion.  followed  immediately  by  the  employment  of  a  larger  size,  and  then  the  next,  and  the 
next  size  larger  still,  till  complete  dilatation  of  the  stricture  has  been  effected.  It  is  the 
second-best  plan  the  surgeon  lias  at  his  command,  and,  although  more  tedious  than  the 
former,  is  in  the  end  successful  :  patients  so  treated,  however,  require,  doubtless,  the  more 
frequent  introduction  of  a  catheter  to  maintain  the  urethra  in  its  dilated  condition  than 
others  treated  by  the  former  plan.  For  this  method  of  treatment  metallic  instruments 
are  better  than  ela.stic. 

When  a  stricture  is  so  contracted  that  a  catheter  cannot  be  passed  even  after  very 
careful  manipulation,  the  attempt  should  be  given  up  and  alkalies  prescribed.  AVhen  the 
urethra  is  irritable,  opium,  enforced  rest,  and  the  hip  Vxith  are  of  use.  and  after  the  lapse 
of  a  day  or  more  success  may  follow  another  attempt.  When  the  stricture  is  reached  by 
the  catheter,  gentle  pressure  upon  it  may  be  employed ;  indeed,  pressure  may  be  kept  up 
for  two  or  three  minutes,  the  parts  often  yielding  under  its  influence  and  allowing  the 
instrument  to  pass.  If  this  end  be  obtained,  let  the  surgeon  he  .satisfied  and  leave  the 
catheter  in.  whether  silver  or  elastic  ;  for  should  he  remove  it.  he  will  in  all  probahtility 
fail  to  pass  a  second.  If  the  instrument  be  silver,  an  elastic  one  should  be  substituted 
when  it  is  removed. 

When  a  catheter  is  grasped  and  '■  held  "  in  the  urethra,  the  operator  may  be  tolerably 
sure  that  he  has  entered  the  stricture ;  and  when  its  end  is  movable,  he  may  be  equally 
sure  that  he  is  in  a  false  passage.  When  the  catheter  has  been  held  and  passed  forward 
into  the  bladder,  all  is  well ;  when  it  .slips  suddenly  into  a  movable  space,  the  urethra  has 
probably  Vjeen  perforated.  Under  these  circumstances,  when  a  false  passage  probably 
exists,  it  is  wise  to  give  up  local  treatment  for  a  few  days,  to  allow  the  parts  to  heal. 

A  stricture  should  be  dilated  up  to  its  fullest  extent. 

It  i'.s  important  to  hear  in  mind  that  aftn-  the  full  (lilatation  of  a  stricture  contraction 
xciU  aijain  take  place  after  a  time  if  the  pasiiaije  he  not  kept  open,  but  the  introduction  of  a 
catheter  once  in  every  two.  three,  four,  or  more  months,  according  to  circumstances,  is 
generally  sufficient  to  prevent  such  a  result  taking  place. 

On  Splittin;j  Strictures. — What  in  modern  language  is  called  fh^  rapid  or  immediate 
treatmtnt  of  stricture  is  in  reality  its  rupture  or  splitting,  it  being  in  all  probability  a  rare 
thing  for  a  stricture  to  be  suddenly,  fully,  and  rapidly  dilated  without  being  lacerated. 
The  plan  known  by  this  name  has  certainly  a  taking  title,  and  in  practice  has  apparent 


688  SURGERY  IN  THE    URETHRA. 

advantages  which,  if  supported  by  experience,  would  establish  its  claims  on  the  attention 
of  surgeons.  In  our  day  it  is  known  as  that  of  Holt,  but  Holts  instruments  are  mere 
modifications  of  M.  Perreve's  made  in  1847,  and  the  same  sort  of  practice  has  been 
adopted  by  Mr.  T.  Wakley,  Dr.  Hutton  of  Dublin,  Maisonneuve,  Buchanan,  and  others. 

Holt  describes  his  instrument  "  as  consisting  of  two  grooved  blades  fixed  in  a  divided 
handle  and  containing  between  them  a  wire  welded  to  their  points,  and  on  this  wire  a  tube 
(which  when  introduced  between  the  blades  corresponds  to  the  natural  caliVjre  of  the 
urethra)  is  quickly  passed,  and  thus  ruptures  or  splits  the  obstruction.'" 

The  stricture  having  been  split,  the  dilator  should  be  rotated,  to  separate  further  the 
sides  of  the  rent,  and  then  withdrawn,  a  catheter  corresponding  to  the  number  of  the  tube 
being  substituted,  for  the  purpose  of  removing  the  urine.  This  method,  however,  no 
more  effects  a  permanent  cure  of  a  stricture  than  the  plan  of  dilatation,  already  referred 
to,  since  every  hospital  surgeon  has  been  called  upon  to  treat  cases  of  stricture  that  have 
been  subjected  to  this  plan  and  then  have  relapsed.  Indeed,  there  is  reason  to  believe 
that  after  tJie  rapid  metluxl  an  early  relapse  is  more  common  than  after  others,  and  that 
the  cicatrices  of  these  split  structures  contract  faster  than  the  original.  Bad.  and  even 
fatal,  effects,  moreover,  are  more  common  after  the  splitting  operation  than  after  gradual 
dilatation. 

The  plan  of  treatment  by  dilatation  I  have  laid  down  is  safe  and  rarely  followed  by  a 
fatal  result,  but  this  cannot  be  said  after  the  splitting  of  the  stricture,  although  facts  are 
wanted  to  establi-sh  the  proportion  of  fatal  to  successful  cases. 

To  narrow,  ring  or  annular,  subpubic,  or  penile  strictures  Holt's  method  is  probably 
well  adapted,  but  for  indurated,  ribbon,  tunnel,  or  complicated  strictures  it  is  dangerous 
and  unsuitable. 

When  a  stricture  is  associated  with  a  vesical  calculus  and  it  is  a  matter  of  necessity 
to  cure  the  one  before  lithotomy  is  employed,  the  immediate  method  may  be  used,  but  it 
ought  to  be  understood  that  a  greater  amount  of  danger  attends  its  practice  than  follows 
the  more  ordinary  method. 

The  best  instrument  for  this  plan  of  treatment  is  that  made  by  Weiss  for  3Ir.  B.  W. 
Richardson  of  Dublin  (Fig.  402). 

Fig.  402. 


Richardson's  liilator. 

Other  Forms  of  Treafnifut. — Yet  all  strictures  cannot  be  treated  by  dilatation,  for 
"  cases  occur  occasionally  which  are  so  exquisitely  sensitive  that  the  passage  of  a  catheter, 
however  skilfully  performed,  is  followed  by  such  severe  constitutional  and  local  disturb- 
ance as  to  produce  more  harm  than  good,  and  in  which  it  is  clear  some  other  method  of 
cure  must  be  employed ;  whilst  there  are  others  which  are  relieved  by  means  of  the 
catheter,  and  even  fully  dilated,  but  which  have  a  tendency  to  recontract  immediately 
upon  the  omission  of  the  treatment.  In  the  former  case  the  treatment  aggravates  instead 
of  relieves  the  symptoms  ;  in  the  latter  it  must  be  continued  for  life  to  preserve  an  open 
passage.  Under  such  circumstances  some  other  plan  of  treatment  must  be  adopted  ;" 
and  I  believe  now,  as  when  the  above  words  were  written.  ••  the  most  beneficial  to  be  the 
external  division  of  the  stricture  from  the  perinfeum.  and  it  is  to  the  late  Professor  Syme 
that  we  are  here  especially  indebted  for  having  so  ably  recalled  our  attention  to  the  treat- 
ment of  such  troublesome' and  painful  cases''  (^Guys  Reports,  1858). 

The  surgeon  must  not,  however,  in  all  cases  of  irritable  stricture  come  to  the  conclu- 
sion that  Syme's  operation  is  required,  as  it  is  only  in  exceptional  examples  that  it  is 
needed,  for  in  some  the  irritability  rapidly  disappears  under  the  use  of  the  catheter,  and 
in  others  rest,  alkalies,  and  opium  have  a  mo.st  beneficial  influence.  If  these  fail,  the  cut- 
ting operation  may  be  performed. 

Recently  the  laminaria  stalks  have  been  employed  for  dilating  stricture,  but  for  peri- 
neal strictm-es  they  are  dangerous  and  are  apt  to  break.  For  strictures  at  the  orifice  of 
the  urethra  from  the  contraction  of  cicatrices  they  are  most  valuable,  but  for  all  other 
forms  they  are  ill  adapted.  A  laminaria  tent  swells  to  at  least  twice  its  diameter  and 
may  be  introduced  into  the  urethra  dry  and  left  there,  a  small  shield  being  fixed  to  one 
end.  to  prevent  its  slipping  into  the  passage. 

Caustics  are  not  at  the  present  day  much  employed  in  the  treatment  of  stricture  ; 
indeed,  few  use  them.      The  practice  in  theory  is  neither  sound  nor  in  its  results  certain  ; 


URKTIIIIOTOMY. 


<j«9 


imlced,  it  is  probably  injurious,  siiicf  it  is  iuijxissibk'  to  iippiy  sucb  a  oaustic  as  tho  potassa 
fusa  to  tbc  si'at  oi"  stricture  aloiic  ;  and  when  tissues  an?  tlcstroyed  l)y  its  influiMice.  tlioy 
will  subsi'tpu'utly  i-icatrizK  and  coiitrat-t,  and  tliu>  add  In  llic  iiiisrliicl".  'I'bc  i)ractict!  is 
not  one  tliat  can  in  any  way  l>c  rcconmii'iidcd. 

Otis's  method  of  treating  stricture  may  Ik-  described  as  a  combination  of 
rupture  and  urelludloiny.  lie  a>serts  it  Id  \)v.  applicable  to  all  cases  of  stricture  situated 
anterior  to  ti»e  bulb,  and  that  it  is  a  radical  cure  in  nine  cases  out  ol"  ten. 

The  operation  is  performed  by  tirst  stretchinjj^  the  stricture  to  the  full ;  second,  slightly 
cuttinj^  it  by  an  instrument  with  a  concealed  blade  ;  and  third,  at  once  dilating  the  urethra 
to  a  little  more  than  its  normal  size. 

Alter  the  operation  the  urethra  is  to  be  niaint;iiii(<l  at  its  lull  size  by  the  daily  pa.s- 
sa;;c  dT  metal  sounds  until  the  incisions  have  healed. 


Fig.  403. 


Urethrotomy 

is  a  comprehensive  term,  and  includes  the  infmi'if  d'wiAon  of  a  stricture  from  the  urethra 
as  well  as  the  external  through  the  ))erin;oum. 

Internal  urethrotomy  has  now  many  advocates,  and  in  hard,  old  strictures  it  is 
preferable  to  their  rupture;  lur  strictures  also  at  the  orifice  of  the  urethra  and  within  the 
penis  it  is  a  safe  and  valuable  practice.  In  the  hands  of  some  surgeons  it  has  been  much 
practised  advantageously,  and  Mr.  Lund  of  Manchester  has  lately  advocated  it.  Many 
instruments  have  been  invented  for  the  purpo.se,  and  Stafford's  instrument,  made  in  1827, 
is  well  known.  Fergusson  employed  a  long  grooved  director,  which  he 
pas.sed  through  the  stricture,  and  a  very  narrow-bladed  knife,  which  can  be 
buried  in  the  groove.  Many  ingenious  instruments  have  been  invented,  but 
the  best  is  that  which  divides  the  strictures  from  behind  forward  on  its  with- 
drawal, such  as  that  represented  in  Fig.  403.  It  is  one  that  I  have  had 
made  on  Trelat's  principle,  perforated  at  its  end  for  a  guide  bougie.  In 
strictures  of  the  orifice  a  bistoury  may  be  used. 

After  the  division  of  the  stricture  it  was  a  common  custom  to  pass  a 
large  catheter  into  the  bladder  and  leave  it  in,  but  M.  Gouley  has  fairly 
shown  that  such  a  practice  is  not  required.  In  orificial  strictures  after  their 
division  the  laminaria  tent  is  the  best  to  use,  with  a  shield. 

Maisonneuve  employed  a  filiform  gum-elastic  bougie  as  a  guide  through 
the  stricture,  as  well  as  a  grooved  steel  director,  which  is  screwed  to  the 
bougie  and  pushed  into  the  bladder  when  the  stricture  has  been  divided. 

Subcitfinti'ons  perineal  urethrotomy  has  been  praetLsed,  but  my  own  expe- 
rience of  ir  has  not   been  favoraljle. 

External  urethrotomy  is  a  valuable  operation  in  .selected  cases  and 
includes  three  very  different  measures — o)ic,  in  which  the  stricture  is  divided 
through  the  periujeum  upon  a  grooved  director  passed  through  the  stricture 
(extermd  diri'sfoii  or  Syme's  operation),  the  acconJ.  in  which  the  urethra  is 
opened  in  front  of  the  stricture  and  a  grooved  probe  passed  through  it  into 
the  bladder  previous  to  its  division  (Wheelhouse's  operation )  ;  and  the  third^ 
in  which  the  perinjxjum  is  laid  open  witlioat  a  urethral  guide,  the  stricture 
being  impervious ;  and  to  this  the  term  piriiiecd  section  ought  to  be  confined 
(Cock's  operation). 

Syme's  operation,  as  already  stated,  is  valuable  in  the  highly  irrita- 
ble as  well  as  contractile  stricture,  in  cases  which  Syme  described  as  stric- 
tures that  "  continue  to  present  symptoms  after  being  dilated  "  and  that  ''  are 
indomitable  by  the  ordinary  means  of  treatment."  It  is,  moreover,  usually 
successful. 

The  operation  is  by  no  means  one  of  difficulty.  A  grooved  straight  staff 
as  large  as  can  be  passed  through  the  stricture  is  first  introduced,  the  patient 
having  been  placed  upon  his  back,  as  if  about  to  be  cut  for  stone.  The  sur- 
geon should  then  with  perfect  precision  introduce  his  knife  into  the  centre 
of  the  periufpum,  and  at  one  stroke  cut  down  upon  the  groove  situated  at 
the  lower  border  of  the  staff,  and,  using  this  as  his  guide,  divide  the  perineal 
portion  of  the  urethra  in  which  the  stricture  is  situated.  There  are  but  two 
important  points  to  be  observed  in  this  the  second  step  of  the  operation  :  the  ^^ethr 
first  is  to  be  certain  that  the  knife  occupies  the  groove  of  the  staff,  and  sec-  perforated  at 
ondly  that  the  whole  of  the  diseased  or  strictured  portion  of  the  urethra  is    Bougie. 

44 


690 


SURGERY  OF  THE   URETHRA. 


freely  divided.  Having  succeeded  in  this  the  essential  part  of  the  operation,  and  after  ;i 
grooved  probe  or  director  has  been  introduced  into  the  bladder  through  the  perineal 
wound,  the  sound  may  be  removed,  when  either  a  full-sized  elastic  catheter  can  be  readily 
introduced  through  the  penis  into  the  bladder  and  fixed  in,  or  Syme's  catheter  (Fig.  404) 
may  be  introduced  through  the  perineal  wound  for  twenty-four  hours. 


Fig.  404. 


Syme's  Perineal  Catheter. 

After-Treatment. — The  patient  should  then  be  sent  to  bed  and  a  mild  opiate  given, 
such  as  ten  grains  of  Dover's  powder,  if  much  general  or  local  vesical  irritability  exists. 
The  catheter  may  be  left  in  for  several  days  if  it  fiiil  to  cause  pain,  but  if  the  bladder 
resents  its  presence  it  may  be  removed ;  indeed,  more  extensive  experience  has  led  me  to 
think  that  the  presence  of  a  catheter  is  scarcely  required  for  three  or  four  days  after  the 
operation,  when  it  should  be  passed  and  left  in  during  the  healing  process. 

After  the  wound  has  closed  the  occasional  introduction  of  a  catheter  is  essential,  and 
I  cordially  agree  with  Professor  Syme  in  thinking  ''  prudence  requires  that  every  patient 
who  has  had  a  stricture  divided  should  learn  to  introduce  bougies,  since  by  doing  so  at 
intervals  of  a  week  or  a  fortnight  he  will  be  perfectly  secure  from  future  trouble."  The 
division  of  a  stricture  no  more  effects  a  permanent  cure  than  its  dilatation  or  rupture,  and 
occasional  dilatation  is  essential  to  maintain  its  patency. 

WheelhOUSe's  Operation. — Mr.  C.  G.  Wheelhouse  of  Leeds  has  introduced  an 
operation  for  impermeable  stricture  which  I  believe  deserves  attention.  He  states  that 
in  his  hands  and  in  those  of  his  colleagues  it  has  been  most  successful. 

The  instruments  required  for  its  performance  are  as  follows : 

"  Lithotomy  bandages ;  a  special  staff  fully  grooved  through  the  greater  part,  but  not 
through  the  whole,  of  its  extent,  the  last  half  inch  of  the  groove  being  '  stopped  '  and 

Fig.  40.5. 


Grooved  Staff,  with  Button-like  tnd. 

terminating  in  a  rounded  button-like  end  (Fig.  405)  ;  an  ordinary  scalpel ;  two  pairs  of 
straight-bladed  forceps,   nibbed  at  the  points;    ordinary  artery  forceps  and  ligatures; 

Fig.  406. 


Teale's  Probe-Gorget. 

sponge;  a  well-grooved  and  finely  probe-pointed  director;  Teale's  probe-gorget  (Fig. 
406);  a  straight  probe-pointed  bistoury;  a  short  silver  catheter  (No.  10  or  11  gauge) 
with  elastic  tube  attached. 

"  The  patient  is  placed  in  lithotomy  position,  with  the  pelvis  a  little  elevated,  so 
as  to  permit  the  light  to  fall  well  upon  it  and  into  the  wound  to  be  made.  The  staff 
is  to  be  introduced  with  the  groove  looking  toward  the  surface  and  brought  gently  into 
contact  with  the  stricture.  It  should  not  be  pressed  much  against  the  stricture, 
for  fear  of  tearing  the  tissues  of  the  urethra  and  causing  it  to  leave  the  canal, 
which  would  mar  the  whole  after-proceedings,  which  depend  upon  the  urethra  being 
opened  a  quarter  of  an  inch  in  front  of  tlie  stricture.     Whilst  an  assistant  holds    the 


ri:i:riii:()T(iMY 


091 


Whuellioiise's  Oiieration  of  Opeiiin);  frethra. 


etiiff  ill  tliis  |)ositiiiii  an  iiicisioii  is  iiiiidc  into  tlio  pciiiia'um,  cxtorulin;;  from  opposite  the 
point  of  rt'flci'tinii  ol"  the  siipcrliciiil  prrinoal 
fasciu  to  tlu'  anterior  nliri-  nl'  the  spliiiictcr  ani. 
The  tissues  (if  tlio  periiiiiMiin  arc  to  Itc  steadily 
divided  until  tlu'  urethra  is  reached.  This  is 
now  to  lie  opened  In  thf  ijriiinr  kA'  the  stall,  not 
vpnii  ifs  ftiii'iit,  so  as  eerrainly  to  seeiire  a  (|uart(!r 
of  an  iiieli  of  healthy  tiihe  iniinediately  in  fniiit 
of  the  strietiiri'.  As  soon  as  the  urethra  is  open- 
ed and  the  LM'oove  in  the  staH'  fully  exposed  the 
edgi's  of  the  healthy  urethra  are  to  he  si'ized  on 
each  side  hy  the  straiirht-hladed  iiihhed  lorceps 
and  held  apart.  Tiie  stall'  is  then  to  he  jreiitly 
withdrawn  until  the  hiitton-poiiit  appears  in  the 
wound.  It  is  then  to  he  turned  round,  so  that 
the  fjroove  may  look  to  the  pubes,  and  the  hut- 
ton  may  he  hooked  into  the  upper  angle  of  the 
opened  urethra,  whieh  is-  then  held  stretched 
open  at  three  points;  thus  ( Fig.  407),  and  the 
operator  looks  into  it  iniinediately  in  front  oi' 
the  stricture.  Whilst  thus  held  open  the  probe-pointed  director  is  inserted  into  the 
urethra,  and  the  operator,  if  he  cannot  see  the  opening  of  the  stricture — which  is  often 
po.ssible — generally  succeeds  in  very  quickly  finding  it,  and  passes  the  point  onward 
thnnKjIi  the  stricture  toward  the  Idadder.  The  stricture  is  sometimes  hidden  amongst  a 
crop  of  granulations  or  warty  growths,  in  the  midst  of  which  the  probe-point  easily  finds 
the  true  passage.  This  director  having  been  passed  on  into  the  bhuhler  (its  entrance  into 
which  is  clearly  denionstrated  by  the  freedom  of  its  movements),  its  groove  is  turned 
dowmcard,  the  whole  length  of  the  .stricture  is  carefully  and  deliberately  divided  on  its 
under  surface,  and  the  passage  is  thus  cleared.  The  director  is  still  held  in  the  same 
position  and  the  straight  probe-pointed  bistoury  is  run  along  the  groove,  to  ensure  com- 
plete division  of  all  bands  or  other  obstructions.  These  being  thoroughly  cleared,  the 
old  difficulty  of  directing  the  point  of  a  catheter  through  the  divided  stricture  and  onward 
into  the  bladder  is  to  be  overcome.  To  effect  this  the  point  of  the  probe-gorget  is  intro- 
duced into  the  groove  in  the  director,  and,  guided  by  it,  is  passed  onward  into  the  blad- 
der, dilating  the  divided  stricture  and  forming  a  metallic  floor,  along  which  the  point. of 
the  catheter  cannot  fail  to  pass  securely  into  the  bladder.  The  entry  of  the  gorget  into 
the  latter  viscus  is  signalized  by  an  immediate  gush  of  urine  along  it. 

"  The  short  catheter  is  now  passed  from  the  meatus  down  into  the  wound  ;  is  made  to 
pass  once  or  twice  through  the  divided  urethra,  where  it  can  be  seen  in  the  wound,  to 
render  certain  the  fact  that  no  obstructing  bands  have  been  left  undivided ;  and  is  then, 
guided  by  the  probe-dilator,  passed  easily  and  certainly  along  the  posterior  part  of  the 
urethra  into  the  bladder. 

''  The  gorget  is  now  withdrawn,  the  catheter  fastened  in  the  urethra  and  allowed  to 
remain  for  three  or  four  days,  the  elastic  tube  conveying  the  urine  away  to  a  vessel  under 
or  by  the  side  of  the  bed. 

'•After  three  or  four  days  the  catheter  is  removed,  and  is  then  passed  daily  or  every 
second  or  third  day,  according  to  circumstances,  until  the  wound  in  the  perinjijum  is 
healed  ;  and  after  the  parts  have  become  consolidated  it  recjuires,  of  course,  to  be  passed 
still  from  time  to  time,  to  prevent  recontractinn." 

Perineal  section,  or  Cock's  operation,  is  a  more  difficult  and  dangerous 

operation  than  Symes,  and  is  called  for  in  far  more  severe  cases — that  is,  when  the 
urethra  is  impervious  and  no  guide,  to  the  urethra  exists  beyond  that  which  the  surgeons 
knowledge  of  the  anatomy  of  the  parts  affords.  It  should  also  be  remembered  that,  as  a 
rule,  the  normal  anatomy  has  been  nearly  destroyed,  for  impervious  strictures  requiring 
urethrotomy  are  usually  chronic,  as  well  as  complicated  with  extravasation,  suppuration, 
or  urinary  fistulre. 

The  operation  I  shall  describe  is  that  one  suggested  by  Mr.  Cock  and  known  by  his 
name.  "  The  objects  aimed  at  in  the  operation  can  be  accomplished,  while  I  doubt  if  those 
of  any  other  have  ever  been  fulfilled.  However  complicated  may  be  the  derangement  of 
the  pcrinticum  and  however  extensive  the  obstruction  of  the  urethra,  one  portion  of  the 
canal  behind  the  stricture  is  alwa^'s  healthy  and  often  dilated,  and  is  accessible  to  the 
knife  of  the  surgeon.     I  mean  that  portion  of  the  urethra  whieh  emerges  from  the  apex 


692 


SURGERY  OF  THE    URETHRA. 


Mr.  Cock's  Operation  of  Tapping  the  Urethra  at  the  Apex  of 
the  Prostrate,  or  Perineal  Section. 


of  tlie  prostate — a  part  whicli  is  never  the  subject  of  stricture,  and  whose  exact  anatom- 
ical position  may  be  brought  under  the  recognition  of  the  linger  of  the  operator.  Thus, 
when  we  cannot  introduce  a  catheter  by  the  ordinary  method,  and  even  when  we  cannot  tap 
the  bladder  through  the  rectum,  it  still  remains  to  us  to  tap  the  unthraas  it  emerges  from 
the  prostate,  and  thus  to  effect  the  desired  communication." 

The  operation,  which  Mr.  Cock  has  described  as  '•  tapping  the  urethra  at  the  apex  of 
the  prostate,  unassisted  by  a  guide  staff','  is  illustrated  in   Fig.  408.     I  have  seen  Mr. 

Cock  frequently  perform  it,  have  done  it 
myself  on  many  occasions,  and  have  no 
hesitation  in  strongly  recommending  it 
as  the  operation  for  external  urethrotomy 
without  a  staff".  The  only  instruments 
retpiired  ar€  a  Lrood  double-edged  knife 
with  a  very  sharp  point,  a  large  silver 
probe-pointed  director  with  a  handle,  and 
a  catheter. 

"The  patient,"  writes  Cock/  "is  to 
be  placed  in  tfhe  usual  position  for  lithot- 
omy ;  and  it  is  of  the  utmost  importance 
that  the  body  and  pelvis  should  be 
straight,  so  that  the  median  line  may  be 
accurately  preserved.  The  left  forefin- 
ger of  the  operator  is  then  introduced 
into  the  rectum,  the  bearings  of  the 
prostate  are  carefully  examined  and 
ascertained,  and  the  tip  of  the  finger  is  lodged  on  the  apex  of  the  gland  ;  the  knife  is 
then  plunged  steadily  but  boldly  into  the  median  line  of  the  perinjeum  and  carried  on  in 
a  direction  toward  the  tip  of  the  left  forefinger,  which  lies  in  the  rectum  (Fig.  408).  At 
the  same  time,  by  an  upward-and-downward  movement,  the  vertical  incision  may  be  car- 
ried in  the  median  line  to  any  extent  that  is  considered  desirable.  The  lower  extremity 
of  the  wound  should  come  to  within  half  an  inch  of  the  anus. 

"  The  knife  should  never  be  withdrawn  in  its  progress  toward  the  apex  of  the  pros- 
tate, but  its  onward  course  must  be  steadily  maintained  until  its  point  can  be  felt  in  close 
proximity  to  the  tip  of  the  left  forefinger.  When  the  operator  has  fully  assured  himself 
as.  to  the  relative  position  of  his  finger,  the  apex  of  the  prostate,  and  the  point  of  his 
knife,  the  latter  is  to  be  advanced  with  a  motion  somewhat  obliquely  either  to  the  right 
or  the  left,  and  it  can  hardly  fail  to  pierce  the  urethra.  If  in  this  step  of  the  operation 
the  anterior  extremity  of  the  prostate  should  be  somewhat  incised,  it  is  a  matter  of  no 
consequence. 

"  In  this  operation  it  is  of  the  utmost  importance  that  the  knife  be  not  removed  from 
the  wound  and  that  no  deviation  be  made  from  its  original  direction  until  the  object  is 
accomplished.  If  the  knife  be  prematurely  removed,  it  will  probably,  when  reinserted, 
make  a  fresh  incision  and  complicate  the  desired  result.  It  will  be  seen  that  the  wound, 
when  complicated,  represents  a  triangle,  the  base  being  the  external  vertical  incision 
through  the  perin^eum,  while  the  apex,  and  consequently  the  point  of  the  knife,  impinges  on 
the  apex  of  the  prostate.  This  shape  of  the  wound  facilitates  the  next  step  of  the  operation. 
'*  The  knife  is  now  withdrawn,  but  the  left  forefinger  is  still  retained  in  the  rectum. 
The  probe-pointed  director  is  carried  through  the  wound,  and.  guided  by  the  left  fore- 
finger, enters  the  urethra  and  is  passed  into  the  bladder.  The  finger  is  now  withdrawn 
from  the  rectum,  the  left  hand  grasps  the  director,  and  along  the  groove  of  this  instru- 
ment the  catheter  is  slid  until  it  enters  the  bladder. 

"  The  operation  is  now  complete,  and  it  oidy  remains  to  secure  the  catheter  in  its 
place  with  four  pieces  of  tape,  which  are  fastened  to  a  girth  round  the  loins. 

"  A  direct  communication  with  the  bladder  has  now  been  obtained,  and  the  relief  to 
the  patient  will  be  immediate;  unless  the  kidneys  have  become  irremediably  disorganized, 
we  may  confidently  anticipate  a  favorable  result;  and  the  restoration  of  the  urinary  organs 
will  be  more  or  less  complete  in  proportion  as  the  obstructed  portion  of  the  urethra  is  more 
or  less  amenable  to  the  ordinary  judicious  treatment  of  stricture. 

"  The  catheter  ma}'  generally  be  retained  in  the  bladder  for  a  few  days  ;  and  if  the 
state  of  the  urine  renders  ablution  necessary,  the  viscus  may  be  fi'equently  washed  out. 
The  catheter  may  then  be  removed,  cleansed,  and  reintroduced. 

I  Guy\  Eosp.  Rep.,  1866. 


CdMi'LicATioss  OF  sTi'jcrriii:.  093 

■  It'  tlif  previous  dcstructidii  has  not  })C('m  very  ^reat.  and  if  tin;  ease  progresses  favor- 
ably, tlic  swellintr  ol"  the  |ieriii:eiiiii  and  scrotiun  frradiially  sul)sitles,  the  induration  dis- 
appears, and  the  urinary  sinuses  become  obliterated.  The  urethra  may  then  be  examined 
in  the  i)rdinary  way.  to  test  its  pernu'ability,  and  one  may  be  agreeably  surprised  t<»  find 
that  tlu'  sound  or  catheter  readily  passes  through  the  fnrnier  stricture  into  the  bla<Ider ; 
its  passage  mav.  il'  necessary,  be  facilitated  by  passing  a  director  through  the  periiueum 
into  tlie  bhidiler  and  guiding  tin-  catheter  along  its  groove.  The  urethra  once  restore<l  to 
its  normal  «'iiiidition  and  calibre,  the  artificial  opening  through  the  periujcum  soon  heals 
up,  and,  barring  the  liability  of  stricture  to  return  if  not  attt-ndcd  to.  the  cure  may  be 
said  to  be  complete. 

*'  We  must  not.  howcvt-r,  always  expect  so  favorable  a  result.  I  have  operated  in 
several  ca.ses  where  the  obstruction  of  the  canal  was  complete  and  impermeability  per- 
manent.' 

•*  In  such  cases  the  patient  is  condemned  to  pass  his  water  through  the  artificial  open- 
ing in  the  perinteum  unless  a  new  pas.sage  .should  be  bored  to  unite  the  upper  and  loM'er 
portions  of  the  patient's  ui-ethra — an  operation  which  I  have  seldom  or  never  known  to 
be  successful. 

•'  The  necessity  of  micturating  through  the  perinteum  may  seem  to  be  a  considerable 
hardshij).  but  with  a  little  arrangement  the  inconvenience  is  not  very  great;  and  be  it 
renu'nibered  that  the  man's  micturition  is  merely  assimilated  to  that  of  the  other  sex. 

"  To  keep  the  artificial  passage  in  a  permeable  state,  it  is  generally  necessary  to  pass 
a  flexible  bougie  through  the  opening  occasionally  and  to  retain  it  in  situ  for  a  few  hours. 
The  patient  ver}'  soon  learns  to  do  this  for  himself. 

"  I  have  now  under  my  frequent  observation  two  men,  on  one  of  whom  I  operated 
twenty-five  years  ago,  on  the  other  twenty,  and  both  are  thankful  for  their  condition. 

•'  I  have  not  found  this  operation,  with  its  result  in  a  permanent  factitious  urethra, 
at  all  interferes  with  the  sexual  function,  although  it  is,  of  course,  a  complete  bar  to 
procreation." 

I  have  described  fully  this  admirable  operation  in  the  words  of  its  originator,  and 
believe  it  to  be  the  only  form  of  perineal  section  that  ought  to  be  performed  in  an 
impervious  urethra.  It  is  not  sufficiently  known.  In  exceptional  cases  the  surgeon  may 
examine  the  urethra  itself  with  the  view  to  find  a  passage  through  it,  and  for  this  purpose 
use  as  a  guide  to  its  distal  end  a  grooved  staiF  introduced  through  the  penis  down  to  the 
obstruction,  the  two  sides  of  the  urethra  being  held  weW  apart  by  forceps,  or.  as  suggested 
by  Avery,  a  loop  of  silk  introduced  through  each  edge  of  the  divided  urethra.  If  the 
surgeon  be  fortunate  enough  to  slip  a  fine  grooved  director  through,  the  stricture  will  be 
readily  divided.  Under  these  circumstances  a  catheter  should  be  pas.sed  through  the 
penis  into  the  bladder  and  the  one  which  had  been  introduced  through  the  perinteum 
withdrawn.  I  need  hardly  say,  however,  that  it  is  very  rare  for  the  surgeon  to  be  able 
to  trace  the  urethral  passage  through  the  stricture. 

Complications  of  Stricture. 

I  have  thus  far  dwelt  upon  pi  rmeable  and  impermeable  organic  stricture  and  its  treat- 
ment, but  have  made  only  passing  reference  to  its  complications.  I  propo.se  now  to  con- 
sider these  points  more  fully,  including  perineal  abticeni^,  extravasation  of  urine,  and  peri- 
neal jistithi,  all  of  which  are  the  direct  results  of  stricture  and  of  local  or  diffused  urinary 
extravasation. 

Extravasation  of  urine  is  a  complication  which  will  almost  necessarily  follow  a  neg- 
lected stricture,  and  the  pathological  process  by  which  it  is  produced  has  been  already 
described.  It  is  one  of  the  means  which  nature  adopts  to  find  an  outlet  for  urine  when 
the  natural  passage  has  become  so  contracted  as  to  forbid  its  flow.  It  is  a  complication 
of  great  danger  and  requires  in  its  treatment  great  decision  on  the  part  of  the  surgeon, 
the  effect  of  retained,  and  often  putrid,  urine  upon  any  tissue  of  the  body  being  generally 
followed  by  sloughing.  The  early  detection,  therefore,  of  the  beginning  of  an  extrava- 
sation is  important  and  requires  a  few  remarks. 

Perineal  Abscess.  Sympto.ais. — If  a  patient  the  subject  of  a  stricture  appears 
before  a  surgeon  suflering  from  more  or  less  severe  febrile  symptoms,  a  parched  skin,  dry 
tongue,  and  a  rapid  irritable  pulse,  with  or  without  an  occasional  rigor,  a  careful  exam- 
ination should  be  made  of  the  perina?um  and  the  parts  around,  and.  whether  there  exist 
any  local  symptoms  sufficient  to  have  attracted  the  notice  of  the  patient  or  not.  a  circum- 
scribed and  almost  solid  mass  will  probably  be  discovered  in  the  region  of  the  bulb,  which 


694  SURGERY  OF  THE   URETHRA. 

on  firm  pressure  will  be  painful.  The  patient  will  frequently  state  that  this  has  existed 
for  some  weeks  and  cannot  be  the  cause  of  all  his  symptoms.  The  surgeon,  however, 
must  not  be  misled,  since  this  circumscribed  mass  is  in  effect  a  urinary  abscess  the  result 
of  a  local  and  limited  extravasation,  and  the  symptoms  will  disappear  only  when  its  con- 
tents have  been  evacuated. 

Treatment. — If  the  urethra  be  examined,  the  stricture  will  almost  to  a  certainty  be 
found  much  contracted  and  the  stream  of  urine  very  small.  Some  discharge  from  the 
urethra  may  perhaps  be  observed,  a  little  of  the  pus  contained  within  the  abscess  behind 
the  stricture  making  its  way  by  the  natural  passage.  If  an  instrument  be  made  to  pass 
the  stricture,  it  may  then  only  enter  the  dilated,  ulcerated,  and  suppurating  cavity  of  the 
abscess  situated  behind,  and  it  will  be  a  matter  of  difficulty  to  find  the  vesical  end  of  the 
urethra,  and,  as  a  consequence,  the  instrument  will  be  passed  onward  into  the  bladder  in 
only  exceptional  cases. 

The  abscess  itself  must  be  opened  and  its  contents  evacuated  ;  for  if  this  be  not  done, 
it  will  to  a  certainty  increase,  and,  being  bound  down  by  the  perineal  fascia,  pass  backward 
and  spread  mischief  around  the  neck  of  the  bladder  and  in  the  cellular  tissue  of  the  pelvis 
to  the  serious  injury  of  the  sufferer. 

At  the  same  time,  the  treatment  of  the  stricture  is  to  be  remembered,  as  no  treatment 
can  be  regarded  as  scientific  if  it  be  not  directed  to  remedy  the  stricture  which  is  the  cause 
of  the  abscess. 

I  am  well  aware  some  surgeons  are  satisfied  to  open  the  abscess  in  the  perinjeum  and 
leave  the  stricture  to  be  subsequently  treated  by  dilatation  or  other  means,  but  such  a 
measure  is  temporizing  ;  and  the  soundest  and  most  correct  practice  is  to  open  the  abscess 
and  at  the  same  time  to  divide  the  stricture.  This  is  readily  done  by  passing  a  grooved 
staff  through  the  urethra  into  the  abscess,  if  not  into  the  bladder,  and  freely  dividing  all 
the  tissues  by  a  scalpel  introduced  through  the  perinsBum.  If  the  orifice  of  the  vesical 
end  of  the  urethra  can  be  detected  with  a  probe,  a  large  catheter  may  be  passed  and  left 
in  ;  but  this  point  is  not  of  any  importance,  as  In'  the  operation  the  surgeon  is  certain  that 
the  stricture  has  been  divided,  all  pus  freely  evacuated,  the  possibility  of  further  extrava- 
sation taking  place  prevented,  and  a  free  outlet  for  the  urine  at  the  same  time  been  obtained. 

By  adopting  this  practice  much  time  is  saved,  the  stricture  being  treated,  and  proba- 
bly curedj  by  the  same  means  that  are  absolutely  essential  for  the  treatment  of  the  com- 
plication. 

When,  however,  perineal  abscesses  occur  unconnected  with  strictui'e.  they  should  be 
opened  early  to  prevent  their  breaking  into  the  urethra  and  degenerating  into  urinary 
fistula.     External  urethrotomy  under  these  circumstances  is  not  required. 

Extravasation  of  Urine. — The  complication  of  extravasation  of  urine  does  not 
always  appear  as  a  local  and  confined  extravasation  or  as  a  urinary  abscess.  It  not  rarely 
shows  itself  as  an  extravasation  of  a  severer  nature — as  one  more  sudden  and  marked  in 
its  symptoms  and  more  fatal  in  its  effects,  requiring  also  at  the  hands  of  the  surgeon  active 
and  energetic  treatment.  It  occurs  as  the  result  of  a  sudden  ruptiire  of  the  urethra  from 
internal  injury  or  giving  way  of  the  walls  of  an  abscess  communicating  with  it,  the  rup- 
ture taking  place  suddenly  during  some  effort  of  a  patient  the  subject  of  a  narrow  and 
contracted  stricture  to  relieve  his  distended  and  overcharged  Idadder. 

Symptoms. — The  symptoms  by  which  the  complication  is  manifested  are  very  marked. 
The  patient  will  probably  relate  that  during  some  sudden  expulsive  effort  to  pass  his  urine 
he  felt  something  give  way.  and  that  this  sensation  was  attended  with  relief  to  the  symp- 
toms caused  by  the  retention  of  urine.  He  will  soon  discover,  however,  that  the  relief 
which  he  experienced  was  not  the  result  of  a  flow  of  urine  from  the  natural  passage,  and 
from  the  rapid  enlargement  of  the  perinaeum,  scrotum,  and  penis  will  be  convinced  that 
something  wrong  has  taken  place.  This  swelling  will  be  attended  by  a  burning  pain  in 
the  parts  thus  gradually  enlarging,  and  will  be  increased  at  each  effort  made  to  relieve 
the  distended  bladder.  The  absence  of  pain  on  the  fir.st  onset  of  the  extravasation  may 
delude  the  patient  into  a  false  idea  of  relief  and  safety.  The  surgeon,  if  now  called  to 
see  the  patient,  will  find  him  laboring  under  retention  of  urine,  with  the  perinaeum,  penis, 
and  scrotum  more  or  less  swollen,  and  oedematous  from  tirinary  infiltration,  the  extrava- 
sated  fluid,  perhaps,  having  made  or  making  its  way  upward  over  the  abdominal  parietes 
even  to  the  thorax.  If  the  symptoms  have  existed  long,  a  peculiar  inflammation  and 
gangrene  of  the  integuments  will  make  its  appearance,  and  all  the  constitutional  symp- 
toms described  as  typhoid  will  certainly  be  present. 

Treatment. — Under  these  circumstances  the  surgeon  in  his  treatment  has  three 
objects  to  keep  in  mind: 


COMrLICATlOSS   OF  STJllCTL'Jth'. 


005 


First,  to  free  the  tissues  alrcaily  iiililtratccl  tif  tlicir  extravasatfd  uriru,',  and  thus  pre- 
vent  their  total   (K'struetion. 

S'VDiii/,  to  secure  a  tree  ami  ready  outUft  for  the  urine  from  tlie  )>lail<ler.  ami  thus 
relieve  the  reteutinii   aixl   prevent   an  extension  of  the   mischief. 

Thin! — which  is  no  h-ss  important — to  cure  the  stricture,  and  thi-rehy  n^move  the 
cause  on   whidi   tlic  complication  orijiinally   depended. 

The  first  ol)ject  is  to  he  secured  hy  free  incisions  made  throufrh  the  intejrumcnt  into 
the  inliltrated  cellular  tissue;  the  second  may  perhaj)s  l)e  f<»rtunately  .secured  hy  the  pas- 
sajre  ol"  a  catheter,  hut  this  success  is  exceptional  ;  and  in  the  majority  of  cases  the  second 
and  thinl  indications  are  carried  out.  either  hy  the  external  division  of  the  .stricture  or  hy 
the  perineal  section  as  just  descrihed.  A  small  grooved  staff"  may  be  pa.sscd  in  hy  far  the 
niajoritv  of  ca.ses,  tin-  emplovnieiit  of  some  force  heini:  perfectly  justitiahle  t<j  make  it 
pass  throuirh   the  strictured   portion. 

Urinary  Fistulee. — These  may  be  the  result  of  a  urinary  abscess  burstinjr  in  the 
poriiKcuMi  or  scrotum  or  the  conse<|uence  of  a  nujre  diffused  urinary  extravasation,  the 
fistuhe,  under  these  latter  circumstances,  appearinj;  in  the  perimeum.  .scrotum,  groin, 
thighs,  pubes,  or  nates  (Fig.  -lU'Jj.     They  are  lieiierally  the  direct  consequence  of  some 

Fig.  409. 


Urinary  Fistuke  the  Result  of  Stricture. 

urethral  obstruction.  Occasionally,  however,  they  follow  an  accidental  wound  in  the 
perin.Bum  or  urethra  or  some  such  operation  as  lithotomy. 

When  the  fistuhie  are  simple  tracts  communicating  with  a  urethra  behind  a  stricture 
and  the  tissues  through  which  they  pass  are  healthy,  they  need  not  be  regarded  with  any 
anxiety,  as  in  all  possibility  they  will  rapidly  heal  so  soon  as  the  urine  flows  readily  the 
natural  way  after  the  dilatation  of  the  stricture. 

When,  however,  the  tistuhi3  pass  through  indurated  and  diseased  tissues  and  are  asso- 
ciated with  a  contracted,  if  not  impermeable,  urethra,  or  are  the  result  of  some  urinary 
extravasation  and  sloughing  of  the  parts,  the  .same  success  is  not  always  secured. 

Treatment. — It  is  true  that  in  a  large  number  of  cases  when  the  stricture  is  dilated 
and  cured  the  fistulse  will  close,  but  in  exce])tional  cases  they  refu.se  to  heal  and  re<|uirc 
the  local  stimulation  of  some  such  escharotic  as  the  nitrate  of  silver,  liquor  ammonias, 
tincture  of  cantharides,  the  galvanic  or  actual  cautery,  to  stimulate  the  indolent  passage 
and  assi.st  its  contraction. 

It  should  be  remembered,  however,  that  in  all  these  cases  it  is  the  entrance  of  the 
urine  into  the  fistuhie  which  prevents  their  contraction  and  closure,  and  that  any  means 
by  which  such  an  occurrence  can  be  prevented  will  be  followed  by  recovery.  To  allow 
the  patient  to  pass  his  urine  is  most  injurious,  and  to  pass  a  plugged  catheter  into  the 
urethra  and  leave  it  in  will  not  suffice,  as  daily  experience  proves  that  urine  .soon  flows  by 
the  side  of  the  catheter  and  enters  the  fistula.  The  best  plan  is  to  have  a  catheter  passed 
whenever  the  bladder  requires  to  be  emptied:  and  if  the  surgeon  has  dilated  the  stricture 
to  its  full  size  and  in.structed  the  patient  to  pass  an  elastic  catheter  into  the  bladder, 
there  are  very  few  in.stances  of  urinary  fistulfc  that  require  further  treatment.  ^^  here 
this  practice  cannot  be  followed,  the  introduction  of  a  soft  catheter  into  the  bladder,  with 
its  end  open  to  allow  the  urine  to  flow  away  as  secreted,  is  to  be  advised. 

When  difficulty  is  experienced  in  dilating  the  stricture,  Syme's  operation  may  be  per- 
formed, the  surgeon,  when  he  can.  laying  open  the  fistula  at  the  same  time. 


69^  SURGERY  OF  THE   URETHRA. 

The  urinary  Ostala  following  litliotomy  is  best  dealt  with  V)y  the  galvanic  cautery  and 
catheterism.  In  these  cases,  however,  the  surgeon  should  always  investigate  the  case 
sufficiently  to  assure  himself  of  the  absence  of  a  second  stone  or  of  a  foreign  body  within 
the  wound,  for  I  have  known  one  case  of  a  sponge,  applied  to  arrest  bleeding,  being  left 
in  the  wound  and  preventing  repair.  In  another  a  second  calculus  was  overlooked  and 
prevented  recovery  ;  the  fistula  healed  when  the  stone  had  been  expelled  by  natural 
eiforts  through  the  fistulous  perineal  opening.  I  have  likewise  seen  two  cases  where  some 
calculous  formations  took  place  in  the  wound,  and  thus  kept  it  open. 

Urinary  fistula  the  result  of  an  abscess  communicating  with  the  rectum  will  generally 
heal  as  soon  as  the  urine  is  prevented  from  entering  the  passage.  The  use  of  the  catheter 
will  sometimes  efi"ect  this ;  at  others,  position  will  suffice.  8ir  H.  Thompson  gives  a  case 
in  which  recovei'y  followed  the  practice  of  micturating  in  the  prone  position  for  a  month. 
But  any  means  that  for  a  time  prevents  the  passage  of  urine  into  the  fistula  will  probably 
suffice  to  allow  of  its  contraction.  When  this  does  not  succeed,  the  passage  may  be  stim- 
ulated by  the  galvanic  or  other  cauter}-,  and  in  exceptional  cases  a  plastic  operation  may 
be  called  for. 

The  urinary  fistulae  associated  with  loss  of  tissue,  whether  in  penis,  scrotum,  or  peri- 
naeum,  require  the  greatest  amount  of  ingenuity  in  the  surgeon,  as,  besides  the  constric- 
tion of  the  normal  channel,  some  plastic  operation  is  often  necessary. 

Cicatricial  or  Traumatic  Stricture. 

The  difference  in  the  cause,  the  permanency  in  the  nature,  and  the  difficulties  in  the 
treatment  of  a  so-called  traumatic  stricture  have  led  me  to  separate  the  cases  thus 
denominated  from  that  larger  class  which  we  have  been  just  considering,  the  result  of 
local  inflammations  ;  and  from  my  notes  of  forty-three  consecutive  examples  of  this  kind, 
in  all  of  which  a  distinct  history  could  be  obtained  of  some  definite  accident  affecting  the 
perinjieum,  the  blow  or  fall  was  immediately  followed  by  hemorrhage  from  the  urethra, 
with  or  without  other  symptoms,  and  at  a  later  date  by  difficulty  in  micturition. 

As  a  rule,  these  accidents  take  place  in  boyhood  or  in  young  adult  life,  though  no  age 
is  free  from  the  dangers  of  such  an  injury ;  and  the  kick  of  a  man  or  a  horse  on  the 
perinfBum,  a  fall  upon  a  pointed  instrument  or  across  a  bar,  beam,  or  rail,  an  injui-y  from 
a  saddle  when  riding,  a  blow  from  a  rope,  and  sloughing  of  the  perineum  after  a  violent 
contusion,  are  the  principal  causes  to  which  the  stricture  has  been  assigned  in  the  cases 
before  me.  In  one  and  all  there  was  clear  evidence  at  the  time  of  the  injury  that  the 
urethra  was  more  or  less  involved,  as  hasmaturia  in  almost  every  case  immediately  fol- 
lowed, while  difficulty  in  micturition  apppeared  subsequently  at  variable  intervals.  In 
some  few  cases  several  years  had  passed  away  before  the  attention  of  the  patient  was 
called  to  the  smallness  of  his  stream  of  urine,  when  some  sudden  attack  of  retention  was 
the  first  symptom  which  attracted  notice  ;  but  in  the  majority  of  ca.ses  the  difficulty  of 
micturition  appeared  rapidly  after  the  receipt  of  the  primary  injury,  and  w^ent  on  slowly 
but  surely  to  increase. 

Pathology. — The  pathology  of  these  cases  is  not  difficult  to  understand.  The 
urethra  is  either  partially  or  wholly  ruptured  by  the  injury,  the  wound  being  irregularly 
transverse  ;  union  takes  place,  and  subsequent  contraction  of  the  cicatricial  tissue,  with  a 
narrowing  of  the  urethra  and  the  formation  of  traumatic  stricture  follow.  It  is  this  path- 
ological fact  which  enables  us  to  explain  the  obstinacy  of  the  symptoms  and  the  difficulty 
in  the  treatment. 

Complications. — Traumatic  stricture  is  as  liable  as  any  other  organic  stricture  to 
be  followed  by  complications,  these  complications  being  the  result  of  the  obstruction  to 
the  urethra,  in  whatever  way  that  obstruction  may  primarily  have  been  caused.  Among 
my  43  examples  of  traumatic  stricture,  27  were  admitted  simply  on  account  of  their  con- 
tracted stream  and  difficulty  in  micturition ;  in  8  retention  of  urine  was  the  immediate 
cause ;  in  3,  extravasation  of  urine ;  and  in  five  urinary  fistula  complicated  the  cases. 

Treatment. — There  are  no  cases  of  complicated  or  non-complicated  organic  stricture 
more  obstinate  in  their  treatment  than  the  traumatic,  and  the  nature  of  the  obstruction, 
being  cicatricial,  is  quite  sufficient  to  account  for  this  fact,  since  it  is  well  known  that  all 
cicatrices  have  a  constant  and  almost  perpetual  tendency  to  contract.  A  traumatic  stric- 
ture the  result  of  a  contracting  cicatrix  is  consequently  in  its  nature  essentially  a  con- 
tractile stricture,  and  its  treatment  is  therefore  very  troublesome.  When  treated  by  dila- 
tation, it  will  recontract,  and  even  if  treated  by  perineal  section  or  external  division,  it  is 
far  more  likely  to  return  than  any  form  of  inflammatory  stricture. 


CAFSrS   OF   DFA'lll    I'lloM    STIlK'Tilll-:.  697 

All  forms  of  trcatiiiciit  arc  t'»»iise<|iiciilly  iinccrtaiii  and  unsatisfactory.  If  <lilatation 
of  tlio  iiri'tlira  is  onci'  sccunMl,  tlic  introdiictitm  of  a  catluiti'r  at  short  intervals  is  iintst 
essential,  or  otherwise  the  canal  is  certain  to  reeontraet  ;  and  if  it  is  doiihtfiil  whether  any 
case  of  simple  inflammatory  stricture  is  ever  really  cured,  it  may  unr(uestional)ly  be 
usserted  that  a  traumatic  stricture  will  exist  for  life,  and  that  it  will  rccjuire  constant  and 
repeated  treatment  to  preserve  even  a  moderate  patency  of  the  narrowc^d  passage.  Tiie 
princijjles  of  treatment  in  both  varieties,  however,  are  the  same,  althou<rh  the  practice 
mav  not  he  so  successful. 

If  the  urethra  lie  ])crmcal)lc,  the  treatment  liy  dilatation  shouhl  tie  primarily  employed, 
and  jpcrsevered  in  for  some  time  if  success  is  to  be  secured.  If  the  stricture  is  so  narrow 
and  indurated  as  to  resist  dilatation  and  a  grooved  stafl"  can  be  passed  through,  the  ripe- 
ration  of  external  division  is  the  soundest  jiractice  and  gives  the  surest  hopes  (»f  imme- 
diate aud  future  benefit. 

If  the  stricture  be  impermeable  and  from  its  narrowness  require  imnx'fliate  treatment, 
or  should  its  complications,  either  of  extrava.sation  or  of  urinary  fistula,  demand  attention, 
the  perineal  section  must  be  carried  out  in  the  same  matinctr  as  in  the  cases  previously 
referred  to. 

If  extravasation  of  urine  be  present  as  a  secondary  result  of  this  traumatic  stricture, 
the  .same  principles  and  practice  which  have  been  advocated  in  the  treatment  of  simple 
organic  stricture  are  eciually  applicable,  as  are  also  the  recommendations  which  have  been 
made  for  the  treatment  of  perineal  fistula. 

In  cicatricial  stricture  where  the  urethra  has  so  contracted  as  to  render  the  passage  of 
a  catheter  impracticable,  the  establishment  of  a  permanent  perineal  fistula  is  sometimes 
demanded. 

The  permanent  success,  however,  of  the  practice  in  these  traumatic  cases  is  not  nearly 
so  great  as  in  the  inflammatory,  although  the  practice  in  both  is  really  the  same.  It  is 
hardly  necessary  to  illustrate  these  facts,  as  the  experience  of  all  surgeons  will  bear 
them  out. 

To  show  the  greater  severity  of  these  cases  and  the  difficulties  of  their  treatment  by 
dilatation,  it  may  be  stated  that  out  of  the  43  examples  of  traumatic  stricture  which  have 
been  tabulated,  in  G,  or  fourteen  per  cent,  of  the  whole  number,  the  operation  of  perineal 
section  or  of  external  division  was  absolutely  required  ;  whereas,  amongst  the  cases  of 
simple  organic  stricture,  only  six  per  cent,  required  such  operative  interference,  the  simple 
treatment  by  dilatation  answering  every  other  purpose. 

Causes  of  Death  from  Stricture. 

There  are  few  local  diseases  which,  if  neglected,  have  a  more  fatal  tendency  than 
urethral  stricture,  and  there  are  none  in  which  the  progress  toward  evil  can  be  so  accu- 
rately and  clearly  traced,  from  the  portion  of  the  urethra  situated  behind  the  stricture 
which  primarily  experiences  the  evil  influence  of  the  obstruction  to  the  bladder,  which 
becomes  secondarily  involved,  and  last,  but  not  least,  to  the  ureters  and  kidneys.  The 
importance  of  the  kidneys  in  the  animal  economy  as  excretory  organs  receives  thus  a  fresh 
demonstration  from  the  fatal  effects  of  disease  in  their  structure. 

To  assert  that  renal  disea.se  is  the  .sole  cause  of  death  from  stricture  would  not,  per- 
haps, be  strictly  true :  nevertheless,  it  is  the  principal  one  ;  and  if  these  glands  are  not 
involved,  .stricture  and  its  complications  are  not  fatal. 

Simple  uncomplicated  stricture  is  not  a  fatal  disease,  few  cases  terminating  in  death. 

Stricture  and  retention  of  urine  form  a  more  serious  combination,  and  stricture  with 
extravasation  of  urine  is  .still  more  fatal. 

It  Avould  thus  appear  that  only  when  stricture  has  existed  for  a  lengthened  period  and 
become  complicated  does  its  fatal  influence  become  apparent,  the  increase  in  the  mortality 
of  the  cases  increasing  with  the  severity  of  the  complication. 

The  duration  of  the  .stricture  has  necessarily  a  serious  influence  in  producing  a  fatal 
result :  the  longer  the  obstruction  exists,  the  greater  the  probability,  if  not  the  certainty, 
of  the  production  of  renal  affection. 

In  26  fatal  cases,  the  notes  of  which  are  before  me,  the  average  duration  of  the  stric- 
ture was  seventeen  years;  in  5  symptoms  had  existed  under  ten  years,  and  in  10  for 
upward  of  twenty  years. 

When  stricture,  therefore,  has  existed  for  a  long  period,  and  more  particularly  when 
it  has  been  neglected,  it  may  be  inferred  with  certainty  that  some  disease  of  the  kidneys 
has  been  produced  and  that  the  slightest  injury  or  accession  of  mischief  is  likely  to  ter- 


698  SURGERY  OF  THE   URETHRA. 

minate  in  death,  for  every  subject  of  renal  disease  stands,  as  it  were,  continually  on  the 
edge  of  a  precipice  over  which  the  slightest  adverse  wind  may  send  him  ;  and  the  fatal 
results  of  many  operation  cases,  whether  upon  the  urinary  organs  or  other  parts,  are  to  be 
thus  explained,  for  no  subject  of  renal  disease  is  able  to  resist  the  slightest  tax  upon  his 
powers,  and  his  vital  energy  sinks  irrecoverably  upon  the  receipt  of  the  most  trifling  injury. 
By  way  of  summary  of  the  treatment  of  stricture,  the  following  conclusions  may  be 
drawn  : 

1.  At  least  ninety-five  out  of  every  hundred  cases  of  stricture  are  readily  and  safely 
dilated  by  means  of  catheters,  and  every  stricture  might  be  so  treated  if  recognized 
before  any  complications   appeared. 

2.  Of  peinifable  strictures,  it  is  only  in  the  obstinately  irritable  and  contractile  forms 
that  any  other  treatment  is  called  for ;  and  in  these  external  division  by  the  plan  recom- 
mended by  Syme  is  probably  the  best  operation,  though  rapid  dilatation,  sjilitting,  or 
internal  division  of  the  stricture  may  be  justifiable  under  exceptional  conditions. 

o.  Strictures  complicated  with  urinary  abscess  or  extravasation  in  which  perineal  incis- 
ions are  called  for  should  be  treated  by  external  division  or  Syme's  operation  when  a  staflF 
can  be  passed  through  the  stricture,  and  by  perineal  section,  Wheelhouse's  or  Cock's  ope- 
ration, when  no  such  guide  can  be  employed. 

4.  In  strictures  complicated  with  nrinary  fistidse,  the  stricture  itself  should  be  treated, 
since  the  fistulje  usually  close  as  soon  as  the  urethra  has  been  fully  dilated.  When  this 
result  does  not  take  place,  it  is  essential  that  all  urine  be  prevented  passing  into  the  fis- 
tulcTJ ;  and  the  best  means  to  ensure  this  is  by  the  passage  of  the  catheter  whenever  relief 
is  required. 

5.  The  extermd  division  of  the  stricture  is  an  excellent  operation  in  obstinate  cases  of 
permeable,  contractile,  and  irritable  strictures,  in  all  cases  of  extravasation  of  urine  in 
which  perineal  incisions  are  called  for,  and  also  in  long  indurated  strictures  complicated 
with  urinary  fistulae. 

G.  Perineal  section,  Wheelhouse's  or  Cock's  operation,  is  good  in  all  cases  of  imperme- 
able stricture  or  obliterated  urethra,  complicated  or  not  with  urinary  abscess  or  fistula,  in 
which  a  free  outlet  for  the  escape  of  urine  is  essential. 

7.  Internal  urethrotomy,  except  in  penile  or  in  the  obstinately  irritable  or  contractile 
strictures,  is  not  often  required,  and  the  treatment  by  caustics  is  dangerous. 

8.  Ckatririal  strictures  should  be  treated  as  others,  but  they  are  far  more  obstinate  and 
require  more  frequently  external  urethrotomy. 

Ruptured  Urethra. 

The  secondary  eifects  of  an  injury  to  or  a  rupture  of  the  urethra  have  already  been 
considered  under  the  heading  '•  Traumatic  Stricture,"  and  it  has  been  .shown  that  in  at 
least  6.65  per  cent,  of  the  cases  of  organic  stricture  an  injury  was  the  assigned  cause. 
It  has  also  been  shown  that  the  worst  and  most  intractable  cases  of  stricture,  as  Avell  as 
the  majority  of  examples  of  obliterated  urethra,  are  of  this  kind. 

I  propose  now  to  consider  the  subject  of  ruptured  or  injured  urethra,  with  its  imme- 
diate effects  and  treatment.  In  the  majority  of  instances  the  injury  is  caused  by  some 
direct  violence  applied  to  the  perinaeum,  such  as  a  fall  against  a  post,  plank,  fence,  or 
chair,  a  blow  or  kick  on  the  perinteum.  In  not  a  few  instances  the  injury  has  been  pro- 
duced by  the  passage  of  a  cart-wheel  across  the  pelvis,  although  it  may  be  somewhat 
difiicult  "to  understan'd  how  such  a  result  can  be  produced  by  this  cause  unless  some  frac- 
ture of  the  pubic  portion  of  the  pelvis  coexists ;  but,  explain  it  how  we  may,  in  practice 
we  meet  with  cases  of  ruptured  urethra  following  the  passage  of  a  wheel  across  the  pelvis 
and  unconnected  with  any  other  distinct  evidence  of  fracture. 

Symptoms. — The  characteristic  symptom  of  a  rupture  or  laceration  of  the  urethra  is 
the  passage  of  blood  from  the  penis  unconnected  with  micturition.  The  blood  appears 
usually  as  an  immediate  result  of  the  injury  and  may  be  little  or  profuse  in  quantity  ;  it 
seldom  endangers  life,  and.  as  a  rule,  subsides  without  treatment.  If  the  injury  has  been 
but  a  superficial  tear  in  the  mucous  membrane,  it  is  just  possible  that  this  is  the  only 
symptom  by  which  the  laceration  can  be  recognized ;  and  if  some  time  has  elapsed 
between  its  receipt  and  the  calls  of  nature  to  relieve  the  bladder,  micturition  may  be 
completed  with  little  or  no  difficulty  and  convalescence  re-established. 

It  is  not  often,  however,  that  the  subject  of  a  lacerated  or  ruptured  urethra  escapes  so 
easilv,  for  in  the  majority  of  cases  retention  or  extravasation  of  urine  is  the  result;  and 
for  the  relief  of  this  the  advice  of  the  surgeon  is  generally  at  once  sought. 


RKTESTios  or  rnisi:.  OUG 

TkkaTMKNT. — Wlicii  c:i1I(m1  to  attond  a  itatii-iit  wIid  has  been  tlie  subject  of  an  injury 
to  the  urethra  sutterinf^  from  siniph'  retention,  the  first  objeet  of  the  surgeon  is  to  utteuipt 
tlie  ita.s.sajre  of  a  catheter;  anil  if  the  uretlira  be  ii<»t  eoniph-tely  torn  away  and  there  is 
not  much  bh>ud  h)cally  efl'u.sed,  there  is  a  stnjii;;  proljability  that  lie  will  succeed.  A  j.'uin 
elustic  instrunu'ut  with  a  stronj;  stylet  should  be  ein])loyed.  llaviiijr  accomplished  this, 
the  instrument  should  be  fastened  in  and  the  urine  allowed  to  flow  away  as  secreted, 
beini^  conducted  at  once  by  means  of  u  tube  into  a  vessel  placed  close  at  hand;  for  if  the 
catheter  Ite  |)lui:,ired.  uriiu!  is  sure  to  find  its  way  by  its  side  into  the  |»erina'um.  If  the 
attempt  at  catlifterism  fail,  some  other  means  must  be  employed  to  provide  an  outlet  for 
the  urine  ;  (ttherwise.  extravasation,  with  all  its  dan;.cer.  will  necessarily  f<»llow.  Under 
these  circumstances  an  incision  into  the  ])erinaMim  on  a  <;rooved  staff"  jtassed  down  to  the 
^eat  of  laceration  in  the  ))erinaMim  is  un<|Uestionably  the  soundest  practice  to  adopt,  as 
bv  this  means  the  extravasated  blooil  and  urine  Knd  a  ready  outlet,  and  the  bladder, 
when  it  contracts,  a  vent  fur  its  contents,  the  dauLcer  of  extravasation  of  urine  being 
thus   prevented. 

When  the  periiucuin  has  been  laid  open  and  the  two  ends  of  the  divided  urethra  can 
be  made  out,  tliey  may  be  brought  together  by  a  suture;  and  if  the  orifice  of  the  vesical 
end  of  the  ruptured  urethra  can  be  found  with  a  grooved  probe,  a  catheter  should  be 
passed,  the  instrument  having  been  first  introduced  through  the  penis,  and  sub.sequently 
guided  upon  the  grooved  probe  into  the  bladder.  If  difficulty  is  experienced  in  finding 
the  orifice,  there  need  be  no  alarm,  as  it  s  tjuite  clear  that  the  urine  will  readil}-  find  its 
way  externally  through  the  artificial  wound  ;  nevertheless,  an  early  attempt  to  pass  the 
catheter  should  certainly  be  made,  as  it  is  mo.st  important  that  the  c<jntinuity  of  the 
urethra  should  be  restored  as  early  as  possible. 

When  a  catheter  has  been  introduced,  it  must  be  left,  since  the  patency  of  the  canal 
should  1  i  maintained  iluriny  the  whole  period  of  its  repair  and  its  subse<juent  contraction 
in  a  measure  neutralized. 

The  frequent  passage  of  an  instrument  afttr  the  repair  has  taken  place  is  an  import- 
ant point  to  be  observed,  this  practice  being  the  best  guarantee  that  a  cicatricial  stricture 
cannot  ensue.  In  the  case  of  a  man  I  treated  seventeen  years  before  for  retention  fol- 
lowing a  ruptured  urethra  by  a  perineal  incision  there  has  not  since  been  any  difficulty  in 
micturition. 

RETENTION  OF  URINE. 

When  a  patient  is  unable  to  pass  his  urine,  he  is  said  to  be  the  subject  of  retention, 
which  may  be  due  to  the  presence  of  organic  or  cicatricial  stricture,  spasm  of  the  urethra, 
urethral  obstruction  from  inflammation  of  the  urethra  or  prostate,  urethral  calculus,  and 
many  other  local  and  general  causes.  Amongst  the  latter  must  be  placed  brain  disea.se, 
and  my  friend  Dr.  Hess  of  Fiu-sbury  Square  told  me  in  1879  of  the  case  of  a  gentleman 
who  had  a  bladder  so  dilated  that  it  reached  up  to  the  ensiform  cartilage  and  led  the 
medical  man  in  attendance  to  believe  that  ascites  existed.  There  was.  at  the  same  time, 
very  marked  anasarca  of  the  lower  extremities  up  to  the  groins.  All  these  symptoms, 
however,  disappeared  when  ten  pints  of  urine  were  drawn  off",- 

I  have  already  .stated  that  retention  existed  in  129  out  of  608  cases  of  organic  stric- 
ture admitted  into  Guy's  during  seven  years,  and  in  S  out  of  43  cases  of  traumatic  stric- 
ture. It  was  also  present  in  SO  other  cases,  the  result  of  varied  general  and  local  causes 
unassociated  with  stricture.  Spasmodic  stricture  was  the  assigned  cause  in  half — /.  e.,  it 
was  found  in  subjects  in  whom  no  permanent  narrowing  of  the  canal  existed.  In  almost 
all  excess  of  drinking,  with  or  without  exposure  to  wet  and  cold,  was  the  exciting  cause, 
and  no  complication  aggravated  the  cases.  One  was  in  a  bovfet.  10  who  paid  the  penalty 
of  a  drinking-bout  by  suffering  the  pain  of  a  retention.  Catheterism  relieved  him.  In 
all  these  40  cases  spasm  of  the  muscles  of  the  urethra  was  the  assigned  cause. 

Retention  in  a  child  is  generally  from  stone  impacted  in  the  urethra ;  in  an  adult, 
from  stricture  ;  and  in  an  old  man.  from  prostatic  disease. 

Spasmodic  Stricture  as  a  Cause  of  Retention. 

The  existence  of  a  trur  sp'isniodic  strictuiT  is  no  longer  a  subject  of  doubt.  That  the 
seat  of  the  stricture  is  the  membranous  portion  of  the  urethra,  which  is  encircled  by  mus- 
cles, is  also  now  generally  acknowledged,  and  that  the  usual  exciting  causes  are  exposure 
to  wet  or  cold  and  excess  in  drinking  many  cases  before  me  clearly  prove.  Anything, 
however,  which  can  induce  an  altered  or  acid  state  of  the  urine  is  likelv  to  be  followed 


700  SURGERY  OF  THE    URETHRA. 

"by  this  complication,  gouty  and  rheumatic  patients  being  particularly  liable  to  such 
attacks. 

Treatment. — The  treatment  of  such  cases  is  not  difficult,  the  simple  passage  of  a 
large  metallic  catheter  being  the  most  expeditious  and  certain  practice.  The  instrument 
should  be  well  warmed  and  freely  oiled,  and  then  passed  slowly,  so  as  not  to  excite  alarm 
or  increase  the  spasm  of  the  muscles.  In  skilful  hands  its  introduction  is  not  an  opera- 
tion of  difficulty.  If,  however,  the  operator  be  foiled  in  his  endeavors,  he  must  be 
cautious  not  to  employ  force,  which  is  never  required  and  never  justifiable.  An  anjes- 
thetic  should  then  be  administered,  and  with  a  patient  fully  under  its  influence  all  obstruc- 
tion ceases,  while  the  instrument  will  pass  into  the  bladder.  If  there  be  an  objection  to  the 
use  of  the  anresthetic,  the  old  remedy  of  a  hot  hath  cannot  be  too  highly  extolled,  few 
patients  suifering  from  simple  retention  failing  to  micturate  when  thus  immersed  ;  by  the 
bath  the  introduction  of  a  cathetre  is  likewise  much  facilitated.  .1  faU  oplnte  is  also  an 
invaluable  remedy,  relieving  the  involuntary  contraction  of  the  bladder  which  is  so  pain- 
ful in  cases  of  retention,  and  thus  removing  one  of  the  most  constant  causes  of  spasmodic 
stricture.  The  value  of  opium  in  these  cases,  according  to  .some,  cannot  be  upheld  too 
strongly;  indeed,  they  assert  that  there  is  no  case  of  retention  of  urine  which  will  not 
yield  to  its  benign  influence,  allowing  either  a  natural  relief  or  the  introduction  of  a 
catheter.  The  inhalation  of  an  anaesthetic  I  believe  to  be  a  preferable  remedy,  its  action 
being  more  rapid  and  certain.  If  failure  follow  the  application  of  these,  other  measures 
must  be  adopted ;  and  without  doubt  the  simplest,  safest,  and  most  expeditious  practice 
is  puncturing  the  bladder.  I  prefer  to  do  this  through  the  rectum  ;  others,  above  the 
pubes.     In  a  simple  spasmodic  stricture,  however,  such  a  necessity  can  scarcely  arise. 

Inflammatory  Stricture  as  a  Cause  of  Retention. 

It  has  been  already  shown  that  in  spasmodic  stricture  exposure  to  wet  or  cold  and  an 
altered  condition  of  the  urine,  produced  from  either  excess  of  drinking,  gout,  or  rheuma- 
tism, are  the  chief  exciting  causes  of  an  attack  of  retention  ;  and  if  this  be  true,  there 
can  be  no  difficulty  in  understanding  that  a  like  result  may  be  brought  about  and  is  m.ore 
liable  to  be  experienced  if  the  urethra  itself  should  be  the  seat  of  an  inflammatory  action. 
Retention  of  urine  occasionally  comes  before  our  notice  as  a  result  and  concomitant  of 
gonorrhoea.  The  causes  of  the  retention  are  evidently  compound — viz.,  spasmodic  stricture, 
and  the  mecbanical  obstruction  produced  by  the  oedema  of  an  acute  inflammation  combin- 
ing to  produce  the  result. 

Treatment. — The  treatment  required  to  aff'ord  relief  must  be  based  upon  the  appre- 
ciation of  these  two  conditions  which  have  combined  to  cause  the  eff"ect.  The  retention 
is  in  a  measure  mechanical,  and  must  be  met  by  mechanical  treatment,  but  it  is  also  func- 
tional, and,  as  a  consequence,  must  be  so  considered. 

The  symptoms  being  urgent,  time  is,  therefore,  a  great  object;  and  if  called  to  a  case 
there  are  few  surgeons  who  would  not  at  once  attempt  to  pass  a  catheter.  Let  the  sur- 
geon choose  an  instrument  of  medium  size.  No.  4  or  5,  being  the  best,  taking  care  that  it 
be  well  warmed  and  oiled,  and  then  with  gentleness,  and  yet  with  firmness,  the  obstruc- 
tion may  be  overcome ;  arte  non  vi  must  be  the  guide  to  action,  as  force  is  to  be  con- 
demned as  much  in  these  cases  as  it  was  in  the  preceding. 

If  these  means  fail,  a  hot  bath  and  a  full  opiate  are  the  soundest  remedies.  They 
relieve  the  local  turuescence  of  the  passage,  and  also  the  obstruction,  and  with  it  the 
associated  spasm,  in  some  instances  the  introduction  of  a  piece  of  ice  into  the  rectum 
serves  a  like  purpose.  The  use  of  an  anaesthetic  in  these  cases  cannot  be  recommended, 
as  it  merely  relieves  the  spasm,  but  does  not  alter  the  condition  upon  which  the  spasm 
depends — viz.,  the  inflammation.  When  these  means  fail — which  is  not  commonly  the 
case — some  operative  measure  may  be  required,  which  will  be  dwelt  upon  in  another 
page. 

Retention  of  Urine  following  a  Blow  in  the  Perinaeum. — Under  this 

heading  it  is  not  my  intention  to  allude  to  cases  of  ruptured  urethra,  as  this  condition  has 
already  been  con.sidered.  But  cases  of  retention  occasionally  come  under  notice  which 
follow  a  simple  contusion  in  the  perinaeum.  I  possess  three  such  records — two  in  chil- 
dren aged  three  and  seven  respectively,  and  one  in  an  adult  aged  twenty-nine.  In  none 
of  these  cases  could  hemorrhage  or  other  symptom  of  ruptured  urethra  be  made  out. 
The  retention  followed  the  contusion  and  was  caused  by  some  spasmodic  condition  of  the 
passage  excited  by  the  injury.  In  all  the  cases  the  simple  passage  of  a  catheter  was  the 
only  treatment,  and  with  the  relief  of  the  symptoms  convalescence  followed. 


niynisrios  or  riii.sK.  701 

Retention  of  urine  from  the  pressure  of  an  abscess  in  the  perinseum 

imist  lie  iiitiil  ioiicd,  :is  cax's  nl'  rrtnitioii  IVdim  siicli  ;i  caii.-'C  ipcc;i>i()iiall  v  i'miuc  uimIit 
iidtict',  wliiln  absci'ss  aliuut  tin-  rt'rtiim  is  nut  uiitVci|iU'iilly  associatt'd  with  >ii(li  a  ilitli- 
ciiltv.      It  slioiilil  1k'  tivatoil  hy  oitcniiitr  tlic  al),sc(.'ss. 

iParalysiS  of  the  bladder  IVmn  any  cause  situated  either  in  the  or^'an  itself  <ir 
assueiated  witli  spinal  disease  is  a  eitniniun  eause  ot"  n^tentiitn.  aiid  the  same  ecjnijdieation 
may  he  tV)und  in  lever  or  otiier  e(Uistitutiunal  eondition  in  wliieli  the  vital  jxtwers  of  the 
patient  luive  heen  niucli  reduced  and  the  nervous  system  has.  as  a  fonse<(uenee.  become 
unable  to  answer  to  its  accustomed  stimulus.  Iletention  of  urine  is  also  met  witli  as  a 
.svinptoni  of  peritonitis,  loe.il  or  general,  or  as  a  result  of  some  otlier  abdr)minal  disea.se. 
It  is  well  for  the  surj-eon  In  renieniber  that  this  complication  may  be  produced  by  the 
causes  enumerated. 

It  is  not  to  treat  retention  of  urine,  however,  that  the  surueon  is  usually  called  to 
such  cases,  but  for  the  incontinence  of  retention,  the  incontinence  beinjr  merely  the  over- 
flow of  an  already  overdistended  and  enfi-or<icd  bladder.  The  symptom  of  incontinence  i.s 
a  very  positive  one  and  should  never  mislead  any  practitioner.  It  is  almost  always  a 
concomitant  and  result  of  retention,  and  at  any  rate  should  be  so  regarded  until  the  sur- 
geon has  convinced  liimself  by  a  carel'ul  examinatifni  that  the  bladder  is  not  distended. 

Retention  of  Urine  as  a  Symptom  of  Enlarged  Prostate,  and  in  the 

Aged. 

It  has  been  a  coninion  opinion,  held  by  all  surgeons  for  many  generations,  that  an 
enlarged  prostate  is  a  very  general  condition  of  old  age,  and  retention  of  urine,  as  a  con- 
sequence and  symptom  of  this  affection,  is  of  frequent  occurrence.  The  investigations  of 
recent  pathologists  have  shown,  however,  that  such  an  opinion  is  b}^  no  means  correct ; 
for  although  an  eidargemeiit  of  the  prostate,  either  as  an  hypertrophy  or  from  the  devel- 
opment of  independent  prostatic  glandular  tumors,  may  take  ])lace — and  when  it  does,  it 
is  most  commonly  met  with  in  old  people — yet  such  a  condition  is  by  no  means  to  be  con- 
sidered as  a  necessary  senile  change. 

Treatment. — When  retention  of  urine  takes  place  in  old  people  in  whom  no  stricture 
exists,  it  is  too  frequently  ascribed  to  this  chronic  enlargement  of  the  prostate,  and,  as  it 
is  really  a  rare  thing  to  find  such  a  condition  in  the  bodies  of  tho.se  that  die,  it  is  fair  to 
believe  that  this  retention  is  due  to  other  causes,  such  as  atony  of  the  bladder,  which 
may  be  relieved  by  the  introduction  of  a  large  catheter.  This  operation  .should  always 
be  undertaken  with  great  care,  as  an  injury  to  the  prostate  or  bladder  in  old  people  is  of 
consitlerable  consequence.  An  elastic  instrument  with  a  full  curve,  in  the  bands  of  those 
who  are  not  in  the  constant  habit  of  using  instruments,  is  to  be  preferred,  and  this  may 
be  passed  slowly  down  to  the  neck  of  the  bladder.  It  is  at  this  point  that  the  difficulty 
in  its  introduction  is  always  experienced  ;  but  if  the  index  finger  of  the  left  hand  be  intro- 
duced into  the  rectum  and  the  end  of  the  instrument  tilted  upward  by  the  slightest  pres- 
sure with  the  right  hand,  the  catheter,  as  a  rule,  will  be  readily  passed  onward,  and  relief 
will  be  .secured.  The  patient's  pelvis  should  always  be  well  raised  before  the  catheter  is 
used. 

Retention  of  urine  may  also  be  produced  by  an  abscess  situated  in  the  prostate  gland, 
and  the  retention  is  relieved  only  when  the  abscess  is  opened.  This  treatment,  therefore, 
is  that  which  should  be  followed. 

Retention   of   Urine   as   a   Result   of  an  Elongated  and  Adherent 

Prepuce. 

It  is  a  somewhat  inexplicable  fact  that  surgical  writers  have,  with  rare  exceptions,  omit- 
ted to  notice  that  an  elongated  prepuce  and  adhesion  of  the  glans  penis  to  its  mucous 
membrane  covering  is  capable  of  producing  retention  of  urine  with  every  symptom  of 
vesical  irritation  ;  yet  few  surgeons  can  have  had  much  experience  at  any  ho.spital  or  dis- 
pensary, particularly  in  out-patient  practice,  without  seeing  many  such  examples.  I 
could  quote  cases  in  which  an  adherent  prepuce  had  been  the  cause  both  of  retention  and 
of  incontinence  of  urine,  and  in  which  it  had  produced  symptoms  of  irritable  bladder  and 
every  other  symptom  of  vesical  calculus,  even  haniiaturia.  prolapsus  recti,  or  constant 
priapism. 

All,  or  nearly  all,  these  cases  take  place  in  early  life,  and  I  never  see  a  case  of  vesical 
irritation  in  a  male  child  without  first  examining  the  condition  of  the  penis.     I  have  been 


702  SURGERY  OF  THE   URETHRA. 

in  the  habit  of  pointing  out  this  fact  to  students  for  some  years,  and  have  advised  them 
to  follow  the  practice  suggested,  under  the  conviction  that  in  at  least  two-thirds  of  the 
cases  suffering  from  urinary  irritation  which  pass  under  observation  an  adherent  and  elon- 
gated prepuce  is  the  sole  cause. 

Treatment. — Circumcision  and  the  careful  separation  of  the  prepuce  from  the  glans 
penis,  with  the  removal  of  the  confined  secretion  of  Tyson's  glands,  is  the  only  remedy, 
which  is  at  once  simple  and  complete. 

Retention  of  Urine  from  Organic  or  Cicatricial  Stricture. 

Among  the  many  contingencies  to  which  a  patient  suffering  from  organic  stricture  is 
continually  exposed,  none  cause  more  agony  and  alarm  or  demand  more  prompt  and  deci- 
sive action  on  the  part  of  the  surgeon  than  retention  of  urine. 

The  retention  may  be  the  result  of  a  slowly-contracting  organic  stricture,  but  it  will 
probably  be  produced  by  some  sudden  accession  of  spasm  of  the  muscles  of  the  passage^ 
and  thus  be  compound  in  its  nature,  a  spasmodic  being  grafted  upon  an  organic  stricture. 
The  symptoms,  however,  are  necessarily  urgent ;  and  it  becomes  an  important  question  as 
to  what  practice  should  be  pursued. 

Treatment. — With  this  object  it  will  be  of  interest  to  inquire,  first  of  all,  what  prac- 
tice has  been  proved  of  value,  and  as  a  means  to  the  solution  of  the  difficulty  I  can  show 
that  out  of  224  examples  of  retention  from  simple  oi'ganic  stricture,  184  were  successfully 
treated  by  means  of  catheterism,  warm  baths,  and  opium.  In  40  cases  only,  or  17.4  per 
cent.,  were  any  other  operative  measures  called  into  requisition,  and  in  all  of  these  40 
examples  the  bladder  was  punctured  per  rectum  with  complete  success  and  without  any 
of  the  theoretical  objections  which  have  been  adduced  against  the  operation. 

Out  of  14  cases  also  of  retention  of  urine  produced  by  the  gradual  contraction  of  a 
traumatic  stricture,  8  were  treated  by  means  of  catheterism  and  G  by  puncture  of  the 
bladder,  the  proportion  of  cases  requiring  such  an  operation  being  much  greater  in  trau- 
matic strictures  than  in  the  preceding  class  of  simple  organic  stricture,  the  cause  of  this 
difference  being  very  apparent. 

If  a  surgeon  is  called  to  a  patient  suffering  from  retention  of  urine  produced  by  either 
a  simple  spasmodic  or  an  inflammatory  stricture,  it  has  already  been  explained  that  relief 
can  be  obtained  by  the  cautious  introduction  of  a  catheter,  aided,  if  required,  by  the  use 
of  the  warm  bath  or  a  full  dose  of  opium,  and  in  certain  cases  by  the  inhalation  of  an 
anaesthetic.  If  these  means  fail,  as  experience  proves  may  be  the  case,  either  from  some 
peculiarity  of  the  stricture  or  from  the  manner  in  which  the  treatment  has  been  carried 
out,  other  measures  will  necessarily  be  called  into  requisition  ;  and  it  has  been  already 
stated  that  the  best  and  most  expeditious  practice  is  to  puncture  the  bladder  through  the 
rectum.  It  is  true  that  this  practice  is  rarely  needed  in  .simple  spasmodic  or  in  inflamma- 
tory, stricture,  for  in  the  majority  of  cases  the  means  already  suggested  are  amply 
sufficient  to  secure  relief;  nevertheless,  in  exceptional  instances  this  operation  is  of  great 
value.  It  must  be  remembered,  also,  that  the  practice  is  required  only  when  simpler 
means  have  failed. 

Since  the  introduction  of  the  "  aspirator  ""  many  surgeons  have  employed  it  with  success 
in  cases  of  retention,  but  relief  by  such  a  measure  does  not  commend  itself  to  my  mind- 
being  merely  a  temporizing  operation  and  requiring  frequent  repetition  in  the  .same  case  ; 
it  has  no  such  influence  for  good  upon  the  cause  of  the  retention  as  the  operation  of 
puncturing  the  bladder  through  the  rectum.  In  exceptional  cases  of  retention  of  urine 
it  may  be  a  justifiable  proceeding. 

In  the  treatment  of  retention  of  urine  with  simple  organic  or  traumatic  stricture  the 
same  principles  of  practice  .should  be  applied  as  have  been  recommended  in  the  former 
class  of  cases,  and  in  a  large  proportion  of  instances  it  has  been  already  shown  that  suc- 
cess by  such  treatment  may  be  secured,  since,  out  of  238  cases  of  retention  admitted  into 
Guy's,  operative  measures  were  ref(uired  in  only  46,  and  the  simple  introduction  of  a 
catheter,  with  the  aid  of  warm  baths  and  the  internal  administration  of  opium,  proved 
sufficient  to  carry  out  all  the  objects  required  in  192.  If  the  surgeon  is  called,  therefore, 
to  a  case  of  retention  of  urine  with  organic  stricture,  the  introduction  of  a  catheter  is 
the  primary  means  to  be  employed.  If  the  history  informs  him  that  the  retention  is  the 
result  of  a  gradually  contracting  passage,  a  medium-sized  instrument  should  be  selected, 
and  on  this  failing  a  second  attempt,  with  a  smaller  one,  may  be  followed  by  success. 
Force,  however,  must  not  be  employed,  and  too  much  time  should  not  be  expended  in 
making  the  attempt.     If  success  is  to  follow  the  operation,  it  will  readily  be  obtained; 


PuycTrni:  or  tin:  r.i.M>i>i:ii  r/.n  iiEcrrM.  70;} 

perseverance  and  repeati-d  endeavors  to  pass  an  instrnnient,  as  a  rule  do  harm.  It"  the 
symptoms  are  not  very  nr-reiit  aii<l  some  delay  may  he  aMowed,  the  warm  hath  and  a  full 
opiate,  siieh  as  two,  or  evt-n  three,  {grains  of  opium,  may  he  enqdoved,  and  under  their 
comhined  influence  it  will  he  oidy  in  exceptional  cases  that  reliei'  will  not  suhsequently 
be  secured. 

If  the  symptoms  id"  retention,  however,  are  very  urfrent  and  the  ajronies  of  the  suf- 
ferer demand  immediate  relief,  or  if  the  means  which  have  heen  just  described  have  been 
fouml  wantinjr  after  a  fair  trial,  there  is  little  doubt  that  the  mo.st  scientific  and  certain 
practice  is  the  puncturin<:  of  the  bladder  throu<rh  the  rectum  ;  for  all  experience  has 
correctly  endorsed  the  opinion  expressed  l»y  Mr.  Cock  wlien  he  recalled  the  attention  of 
the  prcdessiou  to  this  operation  in  his  valuable  paper  published  in  1S52  (vol.  xxxv.  of 
the  .I/t'/.-^VaV.  Trans.) — "that  the  bladder  nuiy  be  readied  with  tlie  smallest  amount  of 
pain,  with  the  least  risk  of  present  or  future  danger,  and  with  the  greatest  prospect  of 
ulterior  good,  by  puncture  through  the  rectum." 

The  records  I  possess  of  the  cases  of  this  operation  positively  prove  the  truth  of  this 
opinion,  and  it  is  gratifying  to  find  that  in  the.se  days  many  surgeons  recognize  the  value 
of  the  practice. 

The  operation  is  as  simple  as  it  is  safe,  and  as  efficient  as  it  is  scientific.  As  a  means 
of  relieving  a  patient  from  the  agony  of  retention  of  urine  which  has  been  proved  to  be 
irrenjediable  by  the  rational  use  of  catheters  it  .stands  unrivalled.  By  its  adoption  all 
forcible  catheterism,  with  its  dangers,  is  avoided.  Perineal  section  and  its  difficulties  as 
a  remedy  for  retention  are  done  away  with,  and  the  operation  for  puncturing  the  bladder 
above  the  pubes  may  nearly  be  forgotten.  Puncturing  the  bladder  through  the  rectum 
embodies  in  itself  all  the  advantages  of  these  means,  without  any  of  their  evils,  and  on 
practical  grounds  commends  itself  for  our  adoption. 

I  would  add.  therefore,  as  a  final  conclusion,  ••  that  in  all  cases  of  retention  of  urine 
from  stricture  in  which  relief  cannot  be  given  by  means  of  rational  and  not  forciVjle 
catheterism,  and  in  which  the  use  of  the  warm  bath  and  opium  have  failed,  the  operation 
of  puncturing  the  bladder  through  the  rectum  should  be  performed. 

Puncture  of  the  Bladder  per  Rectum. 

In  all  cases  of  retention  of  urine  in  which  relief  cannot  be  afforded  by  the  introduc- 
tion of  a  catheter,  and  the  nature  of  the  obstruction  is  not  such  as  to  require  the  opera- 
tion of  urethrotomy,  puncturing  the  bladder  through  the  rectum  is  the  right  operation  to 
perform,  as  by  it  relief  can  be  given  with  rapidity,  certainty,  and  safety. 

In  former  times  the  bladder  used  to  be  punctured  with  a  full-sized  trocar  and  canula 
from  the  perinaeum.  but  such  a  clumsy  operation  is  not  now  recognized  among  surgical 
proceedings,  though  with  the  aspirator  the  .same  proceeding  has  been  often  undertaken. 
At  the  present  day  some  surgeons  prefer  tapping  the  bladder  aVjove  the  pubes,  but  in 
safety  and  efficiency  the  operation  is  not  to  be  compared  with  that  which  I  now  recom- 
mend, for.  in  the  words  of  its  modern  advocate,  Mr.  Cock.  "  the  operation  is  safe,  easy  of 
accomplishment,  and  without  danger  as  to  its  consequences.  In  cases  of  retention  which 
resist  ordinary  treatment  it  is  greatly  to  be  preferred  to  the  long-continued  attempts 
at  catheterism,  which,  whether  successful  or  not,  must  be  infiniteh'  more  injurious  to  the 
urinary  organs  than  the  .simple  and  almo.st  painless  operation  of  tapping." 

''I  consider."  writes  Cock,  "that  the  benefit  of  the  operation  consists  not  merely  in 
the  immediate  relief  given  to  the  patient,  but  also  in  the  opportunity  which  it  affords,  by 
the  retention  of  the  canula  in  the  bladder  through  an  indefinite  period,  of  diverting  the 
flow  of  urine  from  its  ordinary  channel,  and  thus  giving  quiet,  freedom  from  pain,  and 
the  natural  means  of  restoration  to  the  maimed,  irritable,  or  diseased  urethra.  I  conceive 
also  that  the  bladder  might  be  tapped  with  advantage  in  cases  of  ob.stinate  stricture  in 
which  retention  of  urine  does  not  actually  exist." 

These  views,  published  by  Mr.  Cock  in  1852  {M/d.-Chir.  Tnms..  and  6-'«3/'.«  Reporfis, 
1866).  I  cordially  endorse.  The  practice  of  Guy's  Hospital,  to  my  knowledge,  has  only- 
confirmed  their  accuracy ;  and  the  more  I  .see  of  the  operation,  the  more  I  like  it.  The 
objections  rai.sed  against  it  are  theoretical,  and  not  practical ;  for  absces.ses  between  the 
bladder  and  rectum,  persistent  fistulous  openings,  injury  to  the  seminal  vesicles,  and 
wounds  of  the  peritoneum  do  not  commonh*  occur.  They  are  said  to  have  done  so  in 
exceptional  instances,  but  such  must  indeed  be  very  rare.  Mr.  Cock,  in  his  large  experi- 
ence, has  known  but  one  bad  result  to  follow  the  operation,  and  that  was  atrophy  of  the 
testicle,  from  which  he  infers  that  the  vas  deferens  was  wounded.     At  Guv's,  from  the 


704 


SURGERY  OF  THE   URETHRA. 


carelessness  of  a  house-surgeon,  a  fatal  peritonitis  from  the  perforation  of  a  coil  of  intes- 
tine once  followed  the  operation,  the  puncture  having  been  made  too  far  back  ;  but,  elim- 
inating carelessness — a  ca,use  of  half  the  errors  in  surgery — the  operation  is  very  safe. 

The  only  requisite  is  a  moderately  full  bladder — a  feature  always  present  under  the 
circumstances  which  call  for  the  operation.  An  enlarged  prostate  is  no  real  obstacle  to 
its  performance,  since  it  may  be  perforated  with  impunity. 

Operation. — The  best  instruments  are  those  suggested  by  Mr.  Cock.  The  long 
curved  trocar  and  canula,  as  originally  employed,  are  inefficient  instruments ;  indeed, 
many  of  the  objections  to  the  operation  are  probably  traceable  to  their  use.  Cock's  instru- 
ments consist  of  a  canula  six  and  a  half  inches  long,  a  blunt  pilot  trocar,  and  a  sharp 
trocar,  a  second  tube  Avith  an  expanding  end  to  keep  the  canula  in  position,  and  a  third 
to  maintain  the  second  in  position  (Fig.  410). 

The  patient  should  be  placed  and  held  in  the  position  for  lithotomy  and  brought  well 
to  the  edge  of  the  bed.  The  operator  must  then  introduce  the  index  finger  of  the  left 
hand  into  the  rectum  with  the  palm  upward  to  feel  for  the  prostate  (Fig.  410),  and,  if 


Fig.  410. 


UnihUlc 


Operation  of  Puncturing  the  Bladder  per  Rectum. 

possible,  for  the  bulging  base  of  the  tense  bladder  beyond.  Some  little  pressure  above 
the  pubes  may  help  in  this  attempt.  The  pulpy  point  of  the  index  finger  is  then  to  be 
held  in  the  median  line,  just  below  the  spot  at  which  the  puncture  is  to  be  made.  The 
surgeon  then  with  his  right  hand  is  to  take  from  his  assistant  the  canula,  well  oiled  and 
fitted  with  the  hhmt  pilot  trocar,  and  to  introduce  it  into  the  rectum  upon  his  left  index 
finger,  passing  it  well  up  to  the  point  .selected  for  puncture.  He  should  then  steady  the 
canula  and  hold  it  firmly  in  position  with  the  thumb  and  three  outer  fingers  of  his  left 
hand,  and  withdraw  the  blunt  trocar.  The  i^liarp  trocar  can  then  be  introduced  through 
the  canula,  and,  having  reached  its  end,  the  handle  with  the  canula  is  to  be  depressed  and 
driven  home,  in  a  direction  upward  and  forward,  in  a  line  toward  the  umhiUcm  (dotted 
line,  Fig.  410).  The  bladder  in  this  way  will  be  entered,  the  free  end  of  the  instrument 
moving  freely,  and  all  resistance  ceasing.  The  trocar  should  then  be  withdrawn  and  the 
canula  pressed  well  home.  Before  the  bladder  is  completely  emptied  it  is  well  to  insert 
the  two  inner  canulae  and  fasten  the  whole  in  by  means  of  tapes,  two  passed  in  front  and 
two  behind  the  thighs,  to  a  girth  round  the  waist.  The  canula  may  then  be  plugged  with 
a  peg,  to  retain  the  urine,  or  with  a  hollow  plug  inserted  into  a  piece  of  india-rubber  tub- 
ing, through  which  the  water  may  drain  away. 

As  soon  as  the  urethral  passage  has  become  pervious  to  the  catheter,  hut  not  before. 


sri'liA-rriiic  rrxcrrnh'  or  the  uladd/:!:.  705 

the  canula  should  \>r  witlMlrawn  ;  this  cfinditioii  usimlly  takes  |ilac(!  within  a  week  from 
the  iiitrodiictiou  of  the  eatlictiT.  In  a  casi-  ol'  iiiiiic  the  canula  was  h'ft  in  for  seven 
wt'(k>  lit'foro  a  catheter  eould  be  passed,  when  a  rajtid  cmr  ensued.  The  stricture  may 
then  he  treated  on  rational  prineiples  by  dilatation.  It  is  very  remarkable  hr)w  at  times 
a  stricture  which  has  thus  been  left  alone  and  unirritated  by  catheterism  or  ineffectual 
natural  i-fforts  at  micturition,  f.nves  way  under  such  treatment,  and  a  thoroughly  imper- 
vimis  indurated  urethra  becomes  pervious  and  aincnabh!  to  sim|)le  nteasures. 

The  wound  into  the  bladder  doses  rapidly  after  the  removal  of  the  canula,  even  after 
many  weeks,  and  in  a  case  of  my  own  no  urinary  fistula  followed  the  presence  of  the 
canula  for  seven  weeks. 

In  retention  of  urine  from  cidarjicd  jirostate  such  an  operation  as  this  is  rarely  called  i'ur, 
yet  at  times  it  is  necessary.  It  was  performed  at  (iuy'.s  in  two  out  of  twenty-four  cases  of 
retention  of  urine  from  this  cause,  an(i  with  complete  success.  I  have  had  recourse  to  it  on 
three  occasions  where  the  neck  of  the  bladder  and  prostate  gland  had  been  seriously  injured 
from  rough  catheterism,  and  with  such  good  success  that  I  shall  never  hesitate  to  repeat 
it  when  any  difficulty  exists  in  entering  the  bladder  or  in  subse(|uently  keeping  an  instru- 
ment in  the  bladder.  In  two  of  the  ca.ses  mentioned  the  irritability  of  the  bladder  was 
so  great  as  to  resent  the  presence  of  an  instrument,  and  the  pain  and  difficulty  in  its  pas- 
sage were  .';o  severe  as  to  be  nearly  unendurable.  In  both  the  operation  was  followed  by 
speedy  and  permanent  relief;  the  blad<ler  recovered  its  healthy  condition  after  the  parts 
had  had  rest  for  a  few  days,  the  urethra  allowed  of  catheterism  without  distress,  and  con- 
valescence was  soon  established. 

I  know  of  no  operation  attended  with  equal  good  that  is  so  safe,  satisfactory,  or  free 
from  danger.  The  surgeon  may  perform  it  without  fear  in  all  cases  of  retention  where 
any  difficulty  in  catheterism  exists. 

In  all  cases  of  supposed  retention  of  urine  the  surgeon  should  guard  himself  against 
falling  into  the  error  of  mistaking  suppression  for  retention,  as  in  all  ca.ses  of  supposed 
incontinence  he  should  i-enieniber  that  it  may  be  due  to  retention  and  overflow. 

SuPRA-PuBic  Puncture  of  the  Bladder. 

This  operation  has  been  growing  in  favor  and  claims  description.  Mr.  T.  Smirth^ 
asserts  ''  that,  while  it  is  as  safe  as  the  rectal  puncture,  it  is  easier  of  performance," 
and  that  "  it  is  applicable  to  all  cases  of  retention  in  which  the  bladder  rises  above  the 
pubes." 

In  corpulent  subjects,  and  in  such  alone,  the  skin  should  be  punctured  with  a  knife, 
to  facilitate  the  entrance  of  the  trocar. 

Whilst  the  urine  is  in  full  flow  it  is  wise  to  introduce  through  the  canula  a  gum- 
elastic  catheter  with  a  terminal  as  well  as  lateral  orifice,  the  former  allowing  the  passage 
of  a  stylet  into  the  bladder  to  serve  as  a  guide  for  the  introduction  of  a  fresh  instru- 
ment. The  catheter  should  be  firmly  secured  in  position  by  means  of  threads  attached 
to  a  belt  of  strapping  and  plugged,  and  for  permanent  wear  fitted  with  a  soft  rubber 
or  vulcanite  shield.  Were  I  to  perform  this  operation  T  should  probably  raise  the  blad- 
der out  of  the  pelvis  by  distending  the  rectum  with  the  dilator  as  described  at  pacie  640, 
Fig.  3G3. 

Extravasation  of  Urine  in  Children,  and  Retention  from  Impacted 

Urethral  Calculus. 

It  has  been  already  explained  how  retention  and  extravasation  of  urine  in  the  aduh 
may  be  produced  by  the  mechanical  obstruction  of  a  urethral  stricture.  It  remains  to 
show  how  in  children  the  same  effects  ensue  from  a  mechanical  obstruction  of  a  very  dif- 
ferent kind.     I  allude  to  the  obstruction  caused  by  a  urethral  calculus. 

A  vesical  calculus,  when  small  and  ejected  from  the  bladder,  may  become  lodged  or 
impacted  in  any  portion  of  the  urethra,  and  as  a  consequence  give  rise  to  every  degree 
of  difficulty  of  micturition,  even  to  a  retention  of  urine  and  extravasation.  In  adult  life 
I  have  seen  complete  retention,  but  I  have  never  seen  extravasation  occur  as  a  result  of 
impacted  urethral  calculus.  In  infancy  and  childhood,  however,  almost  all  the  examples 
of  extravasation  of  urine  that  have  passed  under  my  observation  have  been  the  pi'oduct 
of  such  a  cause ;  I  have  seen  it  in  an  infant  fourteen  months  old,  and  in  many  others 
older.     When  a  case  of  retention  in  a  child  comes  under  notice,  and  there  is  no  phimosis, 

'  St.  Earth.  Hosp.  Rep.,  1881,  p.  294. 
45 


706  SURGERY  OF  THE    URETHRA. 

paraphimosis,  or  adherent  prepuce  by  which  this  symptom  may  be  produced,  a  strong 
probability  exists  tliat  a  urethral  calculus  is  the  cause. 

Treatment. — If  the  calculus  can  be  removed  by  forceps  carefully  used,  this  practice 
is  the  right  one  to  adopt ;  it  is,  however,  rarely  successful,  and  Avhere  these  means  fail  the 
stone  must  be  excised.  When  extravasation  has  taken  place,  the  urethra  must  be  opened 
in  the  perinfcum  by  a  free  incision  upon  a  grooved  staff.  The  stone  is  sometimes  lost  in 
the  sloughing  tissues. 

Summary. — By  -svay  of  summary  of  the  causes  of  retention,  it  may  be  stated  that 
retention  in  a  male  child  is  usually  due  to  a  urethral  calculus,  phimosis,  paraphimosis, 
adherent  prepuce,  or  the  mechanical  obstruction  caused  by  a  piece  of  string,  etc. ;  in  a 
female,  to  ulceration  about  the  meatus  or  to  adherent  labia  ;  retention  in  the  young  adult., 
to  stricture,  obstruction  of  the  urethra  from  stone,  gonorrhtjea,  perineal,  anal,  prostatic 
abscess,  or  rectal  disease  ;  in  the  aged.,  from  enlarged  prostate  or  atony  of  the  bladder. 

Eetention  from  fever  or  general  nerve  shocks  may  occur  at  all  periods.  In  women 
hysterical  retention  may  also  occur,  as  well  as  retention  from  uterine  causes. 

Urethral  or  Urinary  "Shock"  and  "Fever." 

Surgeons  have  long  been  familiar  with  the  fact  that  after  the  ])assage  of  a  catheter 
certain  male  patients  experience  symptoms  which  seem  to  be  altogether  irreconcilable 
with  the  simplicity  of  the  operation  that  apparently  excites  them.  They  have  known  that 
immediately  or  soon  after  the  easy  passage  of  a  catheter  and  micturition  a  man  may 
shiver  and  turn  pale  and  cold,  or  perhaps  faint,  turn  sick,  or  vomit — that  he  may  even 
have  a  slight  epileptic  convulsion  and  soon  recover,  the  "  shock"'  either  passing  off  or  being 
followed  by  a  more  or  less  severe  febrile  condition. 

Mr.  Banks  and  others  have  also  pointed  out  how  after  the  same  simple  exciting  cause 
a  man  may  suffer  from  '•  shock"  of  so  severe  a  character  as  to  terminate  in  death  within 
twenty-four  hours,  or  become  the  subject  of  a  "continuous"  or  "intermittent"  attack  of 
fever  which  may  or  may  not  terminate  in  speedy  death,  the  symptoms  under  these  cir- 
cum.stances  assuming  a  shape  of  either  urtemic  or  septicajmic  poisoning ;  and  in  these 
cases,  when  suppiirative  urethral  or  kidney  disease  in  any  of  its  forms  is  made  out  to 
exist,  there  is  no  difficulty  in  finding  an  explanation  of  the  "  shock"  or  of  the  "  fever." 

Since  the  days  of  Richard  Bright,  and  more  particularly  the  publication  of  Dr.  N. 
Chever's  valuable  paper  on  the  causes  of  death  after  injui'ies  and  surgical  operations 
(^Guya  IIosp.  Reports.,  18-13),  surgeons  at  Guy's  have  accepted  as  truisms  "  that  an  opera- 
tion or  injury  in  itself  of  a  most  trivial  kind  is  liable  to  be  followed  by  fatal  results 
should  the  subject  of  it  be  suffering  at  the  time  from  either  acute  congestion  or  granular 
degeneration  of  the  kidneys  ;"  "that  it  is  impossible  to  urire  too  strongly  the  necessity  of 
testing  the  urine  for  the  presence  of  albumen  in  each  patient  before  deciding  upon  the 
performance  of  any  surgical  operation,"  however  trivial  it  may  appear;  and  that  an 
operation  upon  the  urinary  organs  of  the  simplest  character  must  always  be  regarded  as 
most  dangerous  when  kidney  trouble  complicates  the  case,  as  well  as  when  the  patient  has 
been  long  under  the  influence  of  tropical  malaria,  as  pointed  out  by  Sir  J.  Fayrer. 

But  this  explanation  of  the  symptoms  cannot  be  given  for  all  cases,  and  we  must 
accept  as  true  to  a  degree  Sir  A.  Clark's  recent  assertion  '•  that  in  persons  apparently 
healthy  catheterism  is  sonjetimes  followed  by  fever  neither  distinctly  uraemic  nor  dis- 
tinctly pyaemie,  that  this  fever  sometimes  ends  in  death,  and  that  in  such  cases  the 
autopsy  reveals  no  definite  visible  structural  lesion  adequate  to  account  for  death."  ^ 

Under  these  circumstances  we  of  necessity  go  to  the  nervous  system  as  the  one  at 
fault,  and  recall  the  anatomical  fact  which  "  Miiller  long  ago  demonstrated — that  the 
nervous  supply  of  the  penis,  prostate,  and  neck  of  the  bladder  is  almost  purely  sympa- 
thetic, the  nerves  being  traceable  to  the  pelvic  or  inferior  hypogastric  plexuses,"'^  and 
acknowledge  that  such  plexuses  are  as  susceptible  to  shock  as  are  the  abdominal. 

Other  points  also  in  urethral  or  bladder  troubles  favor  this  view;  for  instance,  medical 
men  must  often  have  observed  that  with  contraction  of  a  distended  bladder,  on  the  expul- 
sion of  the  last  drops  of  urine  a  shudder  constantly  passes  through  the  healthy  frame, 
and  I  well  remember  the  case  of  a  lady  about  thirty  years  of  age  who  had  the  severest 
rigor  I  ever  witnessed  as  the  direct  and  immediate  effect  of  the  bladder  emptying  itself 
after  a  long  enforced  retention. 

Again,  in  a  case  of  rapid  lithotrity  I  had  in  1883  in  a  man  aged  fifty-nine,  from  whom 
two  hundred  grains  of  uric  acid  calculus  were  removed  without  difficulty  or  the  slightest 
^  Edin.  Med.  Journ.,  April,  1884.  ^Mr.  Banks's  paper,  Edin.  Med.  Jmirn.,  1871. 


URETIIHM,    on    riUXAin'  ''SHOCK"   AM)  ''FEVKR."  707 

hitch  ill  forty-five  iniiiutt-s,  and  where  ii  jroml  result  waH  with  cijiifideiice  predicted,  the 
patit'iit  ill  forty  lioiirs  .sank  collapsed,  the  coHapst?  not  folhiwiiii;  the  operatittn,  hut  show- 
iiii;  itself  within  the  first  Iwciity-lour  hours.  After  death  perfectly  healthy  kidneys  were 
found  and  an  uiiiiijiircd  empty  lu  aitliy  liladdcr.  In  I'act,  no  j»atholoj;ical  cause  of  death 
was  detected. 

In  all  these  cases  ''shock"  was  manifested,  and  shock  without  fever,  the  "shock"  in 
its  mildest  form  showini;  it.self  in  the  shudder  of  normal  evacuation,  in  its  more  severe  in 
the  evacuation  <d' retention,  and  in  its  most  severe  and  fatal  funii  in  that  followiiif^  a  some- 
what proloniretl,  thoutrh  apparently  not  violent,  operation. 

I  hold,  therefore,  that  "  urethral  shock"  as  well  as  "  urethral  fever"  is  met  with  in  cer- 
tain patients  the  sutijects  of  urethral  and  hladder  aH"ecti(»ns,  and  that  probably  both  shock 
and  lever  are  broiiLjJit  about  throiij^h  the  influence  rjf  the  .sympathetic  .system  ;  that  the 
shock  may  be  only  a  passing  shudder  or  faintne.ss,  but  that  occasional  rare  cases  occur 
where  the  nervous  shock  is  so  profound,  even  after  the  simple  introduction  of  a  bougie  or 
catheter,  that  death  may  result  within  twenty-four  liours  ;  that  urethral  fever  may  a.ssumc 
any  degree  of  intensity,  from  a  slight  rigor,  and  subsequent  general  malaise,  to  such  seri- 
ous prostration  as  may  end  fatally  after  some  days;  that  a  careful  distinction  must  be 
made  between  true  urethral  fever  and  py;oinia  resulting  from  operative  interference  with 
the  urinary  passages;  that  renal  disease,  with  its  resulting  vitiated  condition  of  the  blood, 
pndjably  predisposes  to  death,  as  it  unquestionably  is  one  of  its  cau.ses  in  such  ca.ses. 

It  will  be  seen  that  these  conclusions  coincide  to  a  degree  with  those  given  bv  Mr. 
W.  M.  Banks  in  his  able  paper  already  referred  to. 

Trkatmkxt. — The  surgeon  should  ever  have  before  him  the  possibility  of  a  jiatient 
requiring  the  pas.sage  of  a  catheter  being  prone  to  suffer  from  urethral  "shock"  or  "fever." 
He  should,  therefore,  where  possible,  prepare  liiin  for  the  ordeal  by  clearing  out  the  bowels 
and  keeping  him  warm  and  cjuiet  for  twenty-four  hours,  and,  in  many  ca.ses,  in  bed.  Where 
any  malarious  fever  has  previously  existed  a  good  dose  of  quinine — say  five  grains — should 
be  given  a  few  hours  beforehand ;  and  even  when  no  such  history  can  be  obtained,  a  like 
practice  has  advantages.  Should  tlie  patient  have  any  external  appearances  of  renal  di.s- 
ease  and  albumen  be  found  in  his  urine,  the  surgeon  should  not  pass  a  catheter  without 
these  precautions  unless  under  the  pressure  of  urgency. 

Under  all  circumstances  the  catheter  must  be  clean,  warm,  and  well  anointed  with 
some  anti.septic  oil.  It  must  be  used  carefully  and  tenderly,  Should  the  bladder  be 
much  distended,  part  of  the  urine  should  be  drawn  off  at  the  time  and  the  remainder  at 
a  later  period ;  and  if  the  contents  of  the  bladder  are  fetid  and  the  organ  requires  to  be 
washed  out,  some  little  of  the  injected  antiseptic  fluid  should  be  left  behind  in  the  blad- 
der. When  a  soft  instrument  can  be  used,  it  should  be  preferred.  When  "  shock"  is 
caused  by  the  manipulation,  the  warmth  of  a  bed.  with  some  external  appliance  to  the 
extremities,  and  the  administration  of  a  wineglas.sful  of  hot  spirit  and  water,  often  acts 
well. 

When  slight  febrile  disturbance  takes  place,  a  dose  of  Dover's  powder  or  the  bromide 
of  potassium  is  very  useful. 

In  more  chronic  cases  quinine  and  iron,  combined  or  separately,  are  of  great  value,  as 
also  are  vapor  or  hot-air  baths.  When  the  symptoms  are  continuous  or  recurring,  renal 
disease  is  to  be  suspected,  and  the  treatment  must  be  conducted  under  such  a  Jight.  The 
prognosis  of  the.se  cases  always  turns  upon  the  persistency  or  frequent  recurrence  of  the 
symptoms  and  the  elevation  of  the  temperature,  together  with  the  indications  afforded  by 
the  dailv  careful  examination  of  the  urine. 


708  AFFECTIONS  OF  THE  GESITAL   ORGANS. 

CHAPTEE    XXIV. 

AFFECTIONS  OF  THE  GENITAL  ORGANS. 

There  is  probably  no  peri  oi  the  body  which  varies  more  in  its  conformation  than  the 
penis,  or  one  in  which  any  congenital  defect  is  more  likely  to  be  inherited.  The  elongated 
and  contracted  prepuce  is  particularly  hereditary,  and  all  the  male  branches  of  a  family 
may  be  the  subjects  of  it.  I  have  known  this  to  be  the  case  in  many  instances,  and  in 
one  family  five  sons  suffered  from  it,  as  well  as  their  father. 

Phimosis,  or  a  condition  of  prepuce  which,  either  from  narrowness  of  the  preputial 
orifice  or  from  adhesion,  cannot  be  retracted  behind  the  glans.  is  sometimes  a  congenital 
affection,  but  as  often  as  not  it  is  an  acquired  one,  the  result  of  inflammatory  thickening 
and  contraction  sub.sequent  to  a  preputial  chancre  or  other  trouble. 

So  long  as  the  prepuce  is  only  long  and  the  glans  can  be  uncovered  for  purposes  of 
cleanliness  and  during  erection  operative  interference  is  not  called  for,  though  it  is  well 
to  impress  upon  nurses  the  necessity  of  paying  attention  to  the  infant's  penis  and  of 
cleaning  it  daily,  since  a  want  of  such  attention  is  frequently  the  source  of  urinary  trou- 
ble and  penile  irritation.  From  neglect  the  secretion  of  Tyson's  glands  collects  behind 
the  corona  and  acts  as  an  irritant ;  the  prepuce  and  glans  penis  as  a  result  constantly 
become  adherent,  and,  as  a  consequence  of  the  irritation,  bladder  symptoms,  simulating 
those  of  stone,  appear.  (  Vide  page  632.)  In  some  neglected  cases  an  acute  inflamma- 
tion is  induced,  followed  by  oedema  of  the  prepuce  and  the  secretion  of  pus,  which  sus- 
picious minds  have  too  often  interpreted  as  gonorrhoea,  much  to  the  injury  of  nursemaids 
and  otliers  in  whose  charge  the  child  rested.  This  disease  is  essentially  a  balanitis  and  is 
easily  cured  by  cleanliness.  In  the  adult  a  long  and  narrow  prepuce  is  injurious,  as 
being  a  bar  to  proper  cleanliness  and  interfering  with  coitus  or  rendering  it  painful.  It 
is  also,  without  doubt,  an  exciting  cause  of  cancer  of  the  organ  where  a  disposition  to 
such  an  affection  exists.  In  boyhood  it  may,  by  exciting  an  irritation  in  the  parts, 
induce  a  habit  which  ends  in  masturbation.  It  often  gives  rise,  moreover,  to  inconti- 
nence, and  may  produce  retention  of  urine.  Dr.  Lewis  Sayre  of  New  York  has  also 
pointed  out  in  his  work  on  Orthopedic  Surgf-ry  (1876)  that  as  a  direct  result  of  this  con- 
dition of  the  prepuce  talipes,  paralysis,  and  other  nervous  affections  may  take  place,  the 
talipes  being  due  to  muscular  contraction  of  the  lower  extremities  owing  to  i-eflex  nerve 
irritation,  and  paralysis  as  a  consequence  of  nervous  exhaustion  caused  by  the  undue 
genital  excitement  which  is  often  associated  with  this  condition. 

Treatment. — When  the  narrowing  is  not  great,  the  daily  retraction  of  the  prepuce 
over  the  glans  for  purposes  of  cleanliness  is  generally  sufficient  to  dilate  the  orifice,  care 
being  taken  to  replace  it  subsequently.     Dr.  Cruise's  plan  of  dilating  the  orifice  mechani- 
cally is  not  satisfactory  ;  I  have  given  it  a  trial  and  rejected  it.     The 
Fig.  411.  suggestion,  also,  of  making  two  partial  lateral  sections  of  the  mucous 

membrane  has  in  my  hands  met  with  the  same  fate.     Neither  of  these 
methods  is  so  successful  as  to  warrant  its  being  recommended. 

When  phimosis  exists,  congenital  or  otherwise,  it  is,  as  a  rule,  best 
treated  by  circumcision.     In  exceptional  cases,  where  a  narrowing  of 
the  prepuce  is  more  marked  than  an  elongation,  the  prepuce  may  be 
slit  up  (Fig.  -411),  but  in  children  circumcision  is  the  better  operation. 
^-^         '      In  some  instances,  however,  where  the  penis  is  very  short,  the  fault 
//\^  resting  more  in  the  penis  itself  than  its  skin  covering,  circumcision 

'\  should  not  be  performed,  for  I  have  known,  under  these  circum- 
stances, the  operation  to  fail,  even  when  well  done ;  in  such  cases  the 
prepuce  should  rather  be  slit  up  to  the  corona,  and  its  mucous  cover- 
ing turned  well  back  and  fixed  to  the  skin. 

In  minor  cases  the  sh'ffi)i(/  plan  should  be  carried  out,  the  .'^kin  and 
its  mucous  lining  being  divided  in  the  middle  line  either  by  the  intro- 
duction of  a  bistoury  guided  by  a  director  beneath  the  prepuce  or  by 
inosis.  means  of  a  pair  of  .sharp  scissors.  The  surgeon  must  be  careful,  in 
doing  this,  to  divide  the  mucous  membrane  rif/ht  bade  to  the  corona. 
In  the  adult  he  should  then  turn  the  two  flaps  backward  and  ftisten  the  mucous  to  the 
skin  flap  by  means  of  some  fine  carbolized  catgut  sutures.     In  the  infant  there   is  no 


\ 


(  7/.V  7  ■}/(  /.s/O.V.     /'. I  l:.\riHMnsfS. 


709 


ri<i.  412. 


Operation  Tor  I'hiiiiosis.    fFirststep.) 


ncct'ssitv  to  stitch.     Wlicii  tlu' ])rt'])ii('t;  ri'i|iiirfs  divi.-inii    to  expose  a  sore  or  .sonio  warty 
growth,  the  iihovt'  phiii  shniihl  he  sclfctcd. 

Circurncision  i>^  an  operation  that  reijiiires  frreat  nicety,  for  it  fails  if  .sufficient 
skin  is  not  tnketi  away  and  the  mucous  covering;  of  tlie  jrhms  is  not  fully  dividcil  up  to 
the  cnrona,  and  it  does  not  turn  out  well  when  too  much  skin  is  removed.  It  is  by  no 
means  a  danj;erous  o|»eration,  althouL'h  in  '' hieeders "  it  may  he  so,  (iraiididier  (/Jie 
ILhnnphllr^  1S55)  rectirdinir  seven  cases  of  .Jewish  children  who  dieil  from  preputial 
hemiu"rha<jje  after  circumcision.  The  following  is  the  plan  I  have  lor  years  adopted  ami 
taujrhf.  and  have  never  known  to  lail  if  properly  carried  out  : 

The  first  point  is  to  decich;  how  much  skin  is  to  he  removed,  which  can  .satisfactorily  he 
dcterminetl  hv  applyinj^  a  pair  of  lont^  dressinj;  forceps  to  the  skin  (»f  the  penis  whilst  it 
rests  in  the  natural  ],ositioti.  on  a  level  with  the 
corona,  and  clnsiuix  them  as  .soon  as  the  glans  penis 
has  heen  allowed  to  slip  hackward.  The  inteirunient 
in  front  of  the  forceps  may  then  he  amputated  with 
a  scalpel  (  Ki-r.  412). 

The  force))s  should  now  be  taken  away  and  the 
mucous  covering  of  the  glans  he  divided  in  the  mid- 
dle line,  well  up  to  the  corona  (as  in  the  slitting  ope- 
ration), and  turned  backward,  the  two  flaps  being 
stitched  to  the  skin  by  fine  sutures.  In  adults  a  fine 
uninterrupted  suture  is  probably  the  best ;  in  infants 
a  strip  of  dry  lint  wrapped  round  the  parts  is  all  that 
is  necessary. 

The  glans  penis,  in  this  as  in  the  former  opera- 
tion, should  be  comjiletely  separated  from  its  mu- 
cous covering,  all  secretions  removed,  and  the  frajnum  divided  when  short. 

By  adopting  these  suggestions  the  student  has  a  definite  guide  to  aid  him  in  the 
removal  of  the  skin  ;  whereas,  if  the  end  of  the  foreskin  be  drawn  out,  as  usually  recom- 
mended, he  has  none. 

"  Circumcision  is  practised  amongst  the  Tongans  (Friendly  Islands),  not  as  a  religious 
rite,  but  principally  because  the  women  won't  have  the  men  who  are  ^/^circumcised,  and 
they  have  to  remain  unmarried  "  (J.  E.  Moulton,  Wiabijan  MlsAlotiKiy,  February  26, 188(J). 

Paraphimosis  is  said  to  exist  when  a  tight  prepuce  which  has  been  retracted 
behind  the  glans  cannot  be  replaced,  and  as  a  consequence  a  .strangulation  of  the  glans 
and  mucous  lining  of  the  prepuce  with  oedema  takes  place,  and  at  a  later  period  ulcera- 
tion in  the  line  of  strangulation,  and  even  sloughing. 

In  children  it  follows  the  accidental  retraction  of  a  narrow  prepuce,  and  in  adults  the 
mechanical  retraction  of  the  prepuce  during  coitus  and  the  neglect  to  reduce  it.  It  may 
be  associated  or  not  with  some  venereal  complication. 

Treatment. — The  object  of  the  surgeon  should  be  to  reduce  the  glans  behind  the 
narrow  prepuce  by  which  it  is  strangulated,  and,  failing  this  by  simple  means,  he  must 
divide  the  constricting  preputial  orifice,  so  as  to  effect  this  end. 

To  carry  out  the  first  object  an  india-rubber  band  applied  as  an  Esmarch's  bandage 
will  sometimes  answer,  but  if  it  does  not  an  anajsthetic  should  be  given  and  the  patient 
placed  on  his  back  ;  the  surgeon  should  take 
the  penis  between  the  index  and  middle 
fingers  of  his  two  interlocked  hands,  and 
while  thus  pulling  the  prepuce  forward  for- 
cibly press  the  glans  backward  with  his  two 
thumbs,  the  pressure  of  the  thumbs  and 
counter-pressure  with  traction  of  the  inter- 
locked fingers  so  displacing  the  fluid  from 
the  (edematous  tissues  as  to  allow  of  the  re- 
duction of  the  paraphimosis.  When  the 
oedema  is  very  great,  a  few  needle  or  lancet 
punctures  facilitate  the  operation.  When 
the  affection  has  been  of  .some  days'  standing 
and  ulceration   exists,  and  when   failure  has 

followed  all  attempts  at  reduction,  the    Stric-  .M„a>  .,l   Dividing  Prepuce  in  Paraphimosis. 

tured  preputial  orifice  must  be  divided  ;  but 

the  band  must  not  be  looked  for  directly  behind  the  glans,  but  behind  the  roll  of  cedema- 


FiG.  413. 


710  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

tous  prepuce  that  surrounds  it.  This  is  best  done  by  a  cut  half  an  inch  long,  made  with 
a  scalpel,  in  a  vertical  direction  over  the  con:«triction,  the  thumb  of  the  left  hand  forcibly 
depressing  the  glans  penis  (Fig.  413).  The  prepuce  at  times  yields  audibly  and  the 
wound  gapes ;  the  whole  constricting  medium  should  be  divided.  Some  antiseptic  lotion 
should  be  applied  to  the  parts  subsequently  to  assist  recovery.  After  the  paraphimosis 
has  been  reduced  and  the  oedema  subsided,  it  is  wise  in  the  case  of  children  to  circumcise, 
and  in  the  adult  the  same  practice  is  frequently  desirable.  In  all  cases  of  oedema  of  the 
pi'iih  in  children  the  surgeon  must  remember  that  it  may  be  due  to  mechanical  strangu- 
lation. 

Warty  growiihs  are  very  common  on  the  penis,  and  they  may  be  found  fringing 
the  oritice  of  the  prepuce  and  the  urethra  or  growing  from  any  part  of  the  mucous  mem- 
brane between  these  two  points ;  indeed,  they  may  grow  from  within  the  urethra  as  well 
as  from  the  outside  skin  of  the  prepuce.  In  the  bulk  of  cases  they  have  a  venereal 
origin — that  is,  they  have  been  caught  by  contagion,  for  warts  are  contagious — but  they 
at  times  occur  without  any  such  cause  in  men  who  have  long  prepuces  and  who  are  not 
sufficiently  careful  in  local  cleanliness. 

Treatment. — When  they  are  numerous,  their  excision  is  the  only  successful  treat- 
ment, nitrate  of  silver  being  applied  to  their  bases ;  but  in  less  severe  examples  the  dry 
oxide  of  zinc,  freshly  powdered  savine,  and  calomel  are  good  local  applications,  the  warts 
rapidly  withering  under  their  influenc. 

Cancer  of  the  Penis. — In  the  middle-aged  and  old  it  is  sometimes  difficult,  if  not 
impossible,  to  distinguish  simple  warty  from  cancerous  growths,  although  the  greater 
obstinacy  of  the  cancerous  and  their  disposition  to  bleed  are  probably  the  best  points  of 
distinction. 

When  there  is  ulceration,  the  disease  is  probably  cancer.  If  the  cancer  be  left  to  take 
its  course,  the  glans  penis  and  pi'epuce  become  infiltrated  and  the  ulcer  discharges  a  fetid 
ichorous  secretion,  breaks  down,  and  spreads ;  the  inguinal  glands  become  involved,  and 
death  takes  place  from  exhaustion.  At  times  the  whole  organ  is  destroyed  and  the  scro- 
tum involved. 

Cancer  of  the  penis  is  generally  of  the  epithelial  variety,  true  carcinoma  being  com- 
paratively rare. 

Treatment. — In  all  clear  cases  of  this  disease,  unless  the  inguinal  or  lumbar  glands 
are  extensively  involved,  amputation  is  the  only  sound  practice  to  follow,  and  in   the 
doubtful  it  is  the  wisest.    When  the  prepuce  alone  is  involved,  the  excision  of  the  growth 
may  be  sufficient ;   but  nothing  less  than  amputation  is  of  any  use  when  the  glans  is 
affected.     Under  all  circumstances  the  surgeon  should  cut  quite  free  of  the  disease,  for 
the  tissues  about  it  are  probably  more  or  less  infiltrated  with  cancerous  products.    I  have 
a  patient  alive  and  well  now  (1884)  who.se  penis  I  cut  off  for  cancer  seventeen  years  ago, 
and  a  second  from  whom  I  excised  a  cancerous  mass  from  the  prepuce  sixteen  years  ago. 
Amputation  of  the  Penis. — Since  the  galvanic  cautery  has  been  in  use  I  have 
employed  nothing  else  fur  amputation  of  the  penis.     A  gum-elastic  catheter  should  be 
introduced  into  the  urethra  and  the  platinum  wire  passed  with  a 
Fig.  414.  needle  between  the  spongy  and  cavernous  bodies,  and  then  round 

the  penis  and  made  tight  with  the  ecraseur  screw.  Connection  with 
the  battery  must  then  be  made  and  the  wire  screwed  i^loidy  home ; 
for  if  the  ti.ssues  are  divided  too  rapidly,  hemorrhage  will  take  place. 
The  heat  should  not  be  too  intense.  The  wire  should  then  be  made  to 
livide  in  the  same  way  the  spongy  body  and  the  urethra,  half  an  inch 
or  more  nearer  the  glans  penis.  Under  ordinary  circumstances  the 
operation  is  absolutely  bloodless  and  the  subsequent  pain  slight. 
After  the  penis  has  been  removed  it  is  wise  to  slit  the  urethra  open 
for  about  half  an  inch,  turn  its  two  edges  outward,  and  fasten  them 
to  the  skin  with  sutures.  This  step  is  good  to  prevent  the  contrac- 
tion of  the  urethral  orifice  that  may  otherwise  ensue.  When  the 
^^"'"o^ratVon.'^'^^^'^  Cautery  is  not  to  be  had.  the  knife  should  be  used.  The  old  opera- 
tion consisted  in  the  removal  of  the  organ  by  one  clean  sweep  of 
the  bistoury,  an  assistant  having  steadied  and  compressed  the  base  of  the  organ  by  a  band 
of  tape.  The  modern  improved  operation — which,  I  believe,  was  suggested  by  Hilton — 
consists  in  the  introduction  of  a  narrow  bistoury  between  the  spongy  and  cavernous  bodies, 
and  after  dividing  the  latter  the  spongy  body  with  the  urethra  must  be  cut  through  about 
half  an  inch  more  forward.  The  object  of  this  is  to  make  the  urethra  stand  out  from  the 
stunted  oruan.  and  thus  facilitate  micturition.     It  is.  without  doubt,  the  best  mode  of 


MALF()li)IATI()\    or   Tin:    II!I\0-(;/:MTAL    (fJ!(;AXS. 


711 


aniputatiii^  a  \)v\\'\s  witli  tlu-  kiiilV'.  'I'o  pri'vont  any  tencK'ncy  in  th(!  urethra  to  contract, 
it  may  lu-  slit  itjim  or  stitclieil  hark  to  the  preputial  .skin.  Kijr.  414  illustrate.s  tlie  stump 
after  sueh  an  amputatinn. 

To  arrest  liemorrhaL'e  ilnrini:  the  upcratinn  Chtver's  clamp  for  compresHing  the  penis 
is  verv  cxci'Ilciit.  ami  oui:lit  to  >iipcix(li'  the  tape. 

Other  Tumors  of  the  Prepuce. — The  prepuce  may  he  the  seat  of  f'lfh/, 
sf/iiKioiis,  or  even  jihioKs,  tumors,  though  these  are  rare.  It  is  not  uncciinmonly  the 
suhject  of  what  has  heen  tlescriheil  as  r/iii/uiufoisis,  althou<;h  when  the  penis  is  involved 
the  scr(»tuin  is  usually  similarly  attccted.  I  have,  however,  seen  one  case  in  a  man  ajred 
tiiirtv-five  where  the  penis  was  thus  alone  afleeted.  The  orjran  was  immense  and  fright- 
ful to  hiok  at.  When  in  rejio.se  it  measured  eij^ht  inches  round  and  si.x  long.  The  man 
came  to  me  with  a  gonorrlnea,  admitting,  however,  that  he  had  never  been  able  to  have 
true  coitus  since  the  disease  had  existed,  whicli  was  about  four  or  five  years. 

The  di.sease  is  a  chronic  hypertrophy  of  the  skin  and  cellular  ti.ssues.  Nothing  but 
the  excision  of  the  redundant  integument  is  beneficial. 


Fig.  415. 


Injuries  to  Penis. 

These  are  not  common,  excepting  such  minor  injuries  as  laceration  of  the  frsenum  or 
prepuce  produced  in  coitus.  Inci-sed  wounds,  however,  arc  occasionally  met  with,  the 
products  of  insanity,  jealousy,  or  malice ;  the  parts 
require  careful  adaptation  with  sutures.  Recently  I 
had  a  man  under  care  who  was  lifted  off  a  bench  b}-  a 
Woman  holding  his  penis.  The  accident  was  followed 
by  much  urethral  bleeding,  which  was  stopped  by  ice, 
and  a  good  recovery  took  place.  The  body  of  the 
penis  at  times,  however  becomes  the  seat  of  injury 
from  some  rough  bending  of  the  organ  during  con- 
nection or  otherwise,  and  as  a  consequence,  when  the 
immediate  effects  of  the  injury  have  passed  away, 
strange  symptoms  appear.  Thus,  some  years  ago  I 
was  consulted  by  a  gentleman  whose  penis,  when 
turgid,  arched  laterally,  the  cavernous  body  of  one  side 
having  atrophied  and  become  a  mere  gristly  mass.  This 
condition  had  followed  an  injury  received  in  coitus  many  years  before.  Some  great 
induration  had  existed  for  months  in  the  cavernous  body  that  had  sub.sequently  atrophied. 
More  recently  I  have  seen  a  married  man  about  (50  who  a  year  before  '•  missed  his  mark  "' 
in  coitus  and  hurt  his  penis  ;  an  induration  followed,  and  at  the  present  time,  where  this 
existed,  there  is  a  deficiency  of  tissue  and  when  the  penis  becomes  turgid  it  is  never 
straight,  but  bent  laterally. 

A  singular,  ca.se  of  injury  to  the  penis  was  seen  at  Guy's  in  1867,  in  the  practice  of 
Mr.  Hilton.  It  was  in  a  man  aet.  50  who  when  nineteen  had  had  his  penis  bitten  by  a 
stallion  ;  after  the  accident  some  little  bleeding  occurred  and  a  fleshy  cylindrical  body  an 
inch  and  a  quarter  long  and  one-third  of  an  inch  in  diameter  projected  from  the  urethral 
orifice.  It  was  evidently  the  corpus  spongiosum,  which  had  been  divided  by  the  horse 
behind  the  glans  penis  and  had  become  everted.  When  the  patient  was  admitted,  the 
corpus  spongiosum  urethn\i  terminated  abruptly  about  one  inch  behind  the  glans  penis 
and  the  urine  flowed  by  the  side  of  the  protrusion  (Fig   415). 


Corpus  s'pongiosMin  projecting  from  Urethra 
after  Injury. 


Malformation  of  the  Urino-Genital  Organs. 

Malformations  of  the  urino-genital  organs  are  more  common  in  the  male  than  in  the 
female  subject,  and  show  themselves  in  many  degrees  of  severity.  Thus  when  the  upper 
surface  of  the  urinary  passage,  from  the  orifice  of  the  urethra  to  the  fundus  of  the  blad- 
der, is  deficient,  a  case  of  rxfrovcrxion  of  the  Lhuhbr  or  ectopioii  rrsicpc  is  said  to  exist ;  when 
the  urethra  alone  is  deficient  at  its  upper  part,  epicpwlian  is  the  term  employed.  Some 
authors  apply  the  latter  also  to  the  more  complete  condition.  With  this  imperfect  con- 
dition a  separation  of  the  pubic  bones  frequently  exists,  as  well  as  some  malformation  of 
the  scrotum,  this  sac  being  often  bifid,  though  containing  the  testicles  in  proper  position. 
At  times  a  hernia  complicates  the  case.  When  no  testes  are  present  and  the  scrotum  is 
bifid,  the  question  as  to  sex  often  arises  ;  for  in  the  female  the  vagina  is  frequently 
absent  or  so  small  as  more  nearly  to  represent  a  urethra  than  a  vagina. 


712  AFFECTIONS  OF  THE  GESITAL   ORGANS. 

In  extroversion  of  the  bladder  tlie  posterior  wall  of  the  bladder  appears  as  a 
red  inucuus  mass  below  the  uiubilicus.  which  is  lost  in  the  upper  border  of  the  deformity 
At  the  lower  part  of  its  surface  the  orifice  of  the  ureters  may  be  often  seen  as  small  nip- 
ple-like projections,  and  in  some  instances  these  orifices  are  lost  in  the  pelvic  chink, 
although  they  may  be  brought  into  view  by  depressing  the  fissured  penis,  or  what  repre- 
sents the  penis ;  for  this  will  probably  appear  only  as  an  expanded  glans  penis  and  a 
pendulous  prepuce.  The  cleft  urethra,  as  it  becomes  lost  in  the  pelvic  fissure,  can  be 
made  visible  by  pulling  the  parts  down  (Fig.  416). 

In  the  female  subject  the  exposed  urethra  will  be  seen  between  the  two  labia.  When 
the  vagina  is  present,  it  will  open  at  its  upper  border  and  appear  continuous  with  the  lower 
labia  (Fig.  417).     At  times,  though  very  rarely,  the  epispadias  involves  only  the  urethra. 

Fig.  416.  Fig.  417. 


\ 

Ketopion  Vesicie  in  Male.  Ectopion  Vesicae  in  Female. 

I  have  seen  but  a  few  cases  of  this  peculiarity,  and  in  all  the  exposed  mucous  surface  of 
the  urethra  passed  backward  toward  the  pubes  into  a  fissure,  which  was  covered  in  by  a 
thin  transverse  fold  of  skin,  from  beneath  which  urine  flowed.  The  scrotum  was  large, 
but  bifid,  and  contained  the  testes  (Ouj/'s  Hosp.  R<?p.,  1868). 

Treat.mext. — The  chief  annoyance  connected  with  this  deformity  being  due  to  the 
constant  dribbling  of  the  urine,  Messrs.  Simon  and  Lloyd  were  induced  to  carry  out  an 
ingenious  operation  by  which  the  urine  might  be  carried  into  the  rectum  and  the  fissure 
subsequently  closed,  but  the  attempt  failed  and  has  not  been  repeated.  For  particulars 
the  reader  may  refer  to  the  Lancet  (1851  and  1852).  Holmes  has  suggested  a  modifica- 
tion of  Simon's  plan,  and  it  is  probably  in  this  direction  that  some  good  may  eventually 
be  found. 

In  a  case  of  epispadias  in  a  boy  recently  under  my  care  (September,  1875),  in  which 
the  whole  of  the  urethra  down  to  the  neck  of  the  bladder  was  fissured,  and  in  which, 
consequently,  there  was  incontinence  of  urine,  I  tapped  the  urethra  in  the  perinjeum  in 
front  of  the  prostate  and  established  an  artificial  urethral  opening.  By  these  means  the 
urine  passed  through  the  perinajum  instead  of  above  the  pubes.  and  consequently  could 
be  caught  and  retained  in  a  urinal,  greatly  to  the  patient's  comfort.  In  another  case — 
one  of  a  boy  ?et.  7 — I  in  May,  1880,  after  making  a  perineal  incision,  drew  down  the 
penis,  brought  it  out  of  the  perineal  wound,  and  fixed  it  there.  Subsequently  I  com- 
pletely closed  the  original  fissure  below  the  pubes.  The  case  did  well,  and  all  the  urine 
flowed  through  the  perinaeum  and  was  readily  caught  in  a  urinal. 

Other  surgeons,  however,  have  devised  means  by  which  the  exposed  mucous  covering 
of  the  bladder  may  be  covered  in,  thereby  adding  to  the  comfort  of  the  patient,  and  of 
these  Wood  of  King's  College  has  been  the  most  succes.sful.  He  has  operated  in  ten 
such  cases,  and  Holmes  in  five.  I  have  operated  only  in  two.  Four  of  Woods  succeeded 
completely,  three  of  Holmes's,  and  one  of  mine,  the  others  being  partially  succes.sful. 
The  operation  consists  in  bringing  up  flaps  of  skin  from  either  side  of  the  fissure  and 
covering  it  in,  fastening  them  together  by  sutures.  (For  full  details  viJf  M<d.-Chir. 
Trans.,  vol.  Hi.,  and  Holmes's  Suiy.  Bis.  of  Child.,  1868.)  In  one  case  I  destroyed  the 
mucous  membrane  with  the  cautery,  and  thus  turned  it  into  a  cicatrix,  avoiding  the  ureters. 

Hypospadias  is  a  term  applied  to  any  deficiency  of  the  under  surface  of  the 
urethra,  and  in  the  larger  number  of  cases  the  urethral  orifice  is  placed  below  the  glans 
at  a  spot  corresponding  to  the  preputial  frfenum.  In  some  a  depression  exists  in  the 
glans  penis  corresponding  to  the  natural   outlet,  with  several   small  depressions  between 


MALI- OHM  AT  loS   OF   Till:    llllS<J-(;ESITAI.    OIK  .ASS. 


13 


Vu;.  418. 


the  urethral  orifice  ami  the  cuiiliko  ilcpressiDii  at  the  extremity  of  the  frhins,  wliile  iti 
others  one  or  imtre  fnramiiia  arc  prt'seiit.  situated  hclow  the  true  opening  of  the  urethra, 
throii'^h  which  urine  eseape.s.  Thi-  urethral  opunin;:  in  the.se  euse.s  is  often  small  anil 
re((uires   eiilar^in^'. 

In  more  e.vtreuje  eases  the  urethral  oritic<-  appears  at  the  hase  of  the  jienis,  when  the 
ileformitv  is  eouunonly  associated  with  a  hifid  scrotum;  under  the.se  circumstances,  when 
the  testes  are  ahsent.  the  (juestion  of  sex  is  rai.sed.  In  a  ea.se  of  tlii.s  kind  which  I  saw 
in  l.S()7  tlic  sexual  passion  was  so  strong  that  a  man  eame  to  me  to  ask  for  <;astration,  as 
he  was  unable  to  copulate  on  account  of  the  stuntefl  condition  of  his  penis,  and  the  way 
in  which  it  was  held  dcnvn  by  a  band  winch  caused  it  to  arch  downward  under  excite- 
ment.    The  man  at  the  tinu*  had  testitis  from  uiifrratitied  passion. 

Tkk.vtmknt — 'i'he  operative  measures  that  have  been  employed  for  the  relief  of  this 
deformity  have   hitherto   not   been    very   successful,  althoufrh   recently  (M'</.   Tlnvx  (mil 

(^/<»;.,  Januarv  o*'.  IST.") )  Mr.  John  Wood  has  recorded  twrt  cases  of  the 
hahinir  or  prnllr  varieties  in  which  relief  was  f:iven.  and  M.  Duplay 
has  published  (Paris.  lS74j  full  details  of  his  method  of  dealin-r  with 
the  more  advanced  form  of  malformation,  called  the  perineo-.scrotal 
(Fiir.  41S,  A).  I  think  so  well  of  Duplay's  ojieration  that  I  will 
describe  it.  It  has  for  its  object.  ./?/>/.  to  separate  the  peni.s  from 
the  scrotum  and  destroy  its  arching,  in  order  to  allow  erection  and 
coition  ;  and.  seconiV;/.  to  con.struct  a  new  urethra  from  the  abnormal 
perineal  openiiiir  to  the  «rlans  penis. 

To  carry  out  the  first  indication,  a  free  division  of  the  fibrous 
bands  conneetintr  the  penis  with  the  .scrotum  has  to  be  made ;  and 
when   this  can   be  effected  by  a  subcutaneous  wound,  as  adopted  by 

Bouisson.  so  much  the  better.     Dujtlay.  however,  incises  transversely 

the  tissues  from  without  inward,  dividing,  if  necessary,  the  envelopes 

and  septum  of  the  corpora  cavernosa:  this  incision  leaves  a  lozenge-     ^'*^"°*^',^i'^s'  "-'P**** 

shaped  wound  TFig.  419,  B),  the  edges  of  which   may  be   brought 

together  by  sutures  (Fig.  419.  C;.    After  this  operation  the  penis  is  to  be  kept  constantly 

stretched,  to  guard  against  subsequent  retraction,  and  six   months  later  the  second  part 

of  the  operation  should  be  carred  out. 

The  construction  of  a  new  urethra  is  a  difiicult  matter,  and  must  be  carried  out  in  stages. 
Duplays  method  is   divided   into  three:   1st.  the  restoration  of  the  urinary  meatus ; 

2d.  the  creation  of  the  new  urethra  from  the  meatus  down   to  the  hypospadia  perineal 

opening ;  and  3d.  tlie  reunion  of  the  two  portions  of  the  urethra. 

The  first  stage  may  be  done  at  the  same  time  as  the  correction  of  the  arching  of  the 

penis,  and  consists  in   simply  paring  the  edges  of  the  glans  penis  and  bringing  them 

together  by  sutures  round  a  catheter  (Fig.  419,  C).    It  is 

almost  always  successful. 

The  s<rond  stnge   is   to    be    effected   in    the   following 

manner : 

The  penis  being  held  up.  two  longitudinal  incisions  are 

made  on  its  inferior  surface  parallel  to  the  median  line  and 

extending   from   the  glans  penis    to    the  perineal  urethral 

opening,  these  inci.sions  being  bounded  by  two  transverse 

ones  (Fig.  419.  D).    Two  quadrilateral  flaps  are  thus  formed 

(a  ?>,  a!  b'),  which  should    be  large  enough,  when   turned 

back,  to  cover  a  catheter  that   has  been  previously  intro- 
duced into  the  urethra. 

The  cutaneous  surface  of  these   flaps  .should   next    be 

turned  toward  the  catheter  and  the  raw  surface  exposed  to 

view. 

The  .skin  of  the  penis,  in  continuation  of  the  transverse 

incisions,  is  then  by  a  little  dissection  made  to  furnish  two 

new  flaps  (c  d.  c  <!' )  for  covering  the  raw  exposed  surface  of 

the  first  flaps. 

Lastly,  the  lower  edge  of  the  glans  penis  is  vivified  in 

the  part  which  corresponds  to  the  new  channel. 

The  flaps  mu.st  now  be  united,  their  sujierior  edges  being 

stitched  to  the  vivified  glans,  and  the  rwo  flaps  on  each  side  of  the  urethra,  the  superficial 

and  deep,  brought  together  with  metallic  or  other  sutures  (Fig.  419,  E). 


Fig.  419. 


Operations   for  Perineo-ScroUl 
Hypijspadias. 


714  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

The  thml  stage  of  the  operation  consists  in  the  reunion  of  the  two  portions  of 
urethra,  and  should  be  effected  by  paring  the  edges  of  the  hypospadic  orifice  and  bring- 
ing them  together  by  sutures,  deep  and  superficial. 

After  the  operation  the  urine  must  be  drawn  off  by  means  of  a  catheter,  and  the 
union  of  the  parts  is  usually  completed  after  three  or  four  days.  To  render  this  result 
more  certain  the  membranous  portion  of  the  urethra  might  be  opened  in  the  perinji^um, 
as  in  cystotomy  or  median  lithotomy,  and  a  catheter  introduced  into  the  bladder  to  divert 
the  urine  from  the  seat  of  operation  during  the  healing  process. 

Puberty  is  the  best  period,  pi'obably,  for  the  performance  of  this  operation. 

Occlusion  of  the  urethra  from  some  membrane  or  band  sometimes  exists,  which  if  not 
broken  down  in  intra-uterine  life  leads  to  dilatation  of  the  bladder,  sacculation  of  the 
ureters,  distension  of  the  pelvis  of  the  kidney,  and  destruction  of  its  secreting  structure. 
(Vide  cases  by  Morris,  Med.-Chir.  Trans.,  1876.) 

ON  LOCAL  VENEREAL   DISEASE. 

GONORRHCEA. 

Urethritis,  gonorrhoea,  and  clap  are  terms  applied  to  cases  of  inflammation  of 
the  urethra  of  every  degree  of  intensity  and  the  product  of  a  great  variety  of  causes. 
In  some  the  affection  is  the  consequence  of  the  direct  irritation  of  an  instrument  passed 
into  or  left  in  the  urethra,  while  in  others  it  follows  excessive  or  oi'dinary  sexual  inter- 
course with  unchaste  women  or  with  chaste  women  who  are  out  of  health  and  suffering  from 
acridity  of  the  vaginal  secretion.  "A  leucorrhcea,"  writes  Diday,  '•  which  would  have 
remained  inoffensive  after  a  single  coitus,  takes  on,  by  redoubled  excitement,  irritant  proper- 
ties, and  furnishes  then  a  contagious  fluid  "  (gonorrhoea).  It  is  the  direct  product,  most  com- 
monly, of  contagion  from  the  pus  of  an  inflamed  mucous  membrane,  Simon  {^Holmes  s  Si/stem ., 
vol.  i.)  having  shown  that  "  there  is  ample  room  to  question  the  popular  impression  that 
only  specific  inflammations  are  communicable ;  much  reason  for  suspecting  it,  on  the  con- 
.trary,  to  be  a  generic  and  essential  property  of  inflammation  that  its  actions  are  always 
in  their  kind,  to  some  extent,  contagious,  pus  from  an  acute  inflammation  producing  its 
kind  on  inoculation." 

Lee  states  {Holnuss  Si/sffm,  vol.  iii.  ed.  3)  the  causes  of  urethritis  to  be  the  applica- 
tion of  a  gonorrhoeal  discharge  to  the  sexual  organs,  and  also  certain  irritating  substances 
applied  to  the  mucous  membranes,  such  as  menstrual  fluid,  leucorrhoeal  discharges,  and 
the  injection  of  a  solution  of  ammonia  ;  he  does  not  exclude  constitutional  cause,  such  as 
gout  or  rheumatism. 

It  is  well  to  bear  in  mind  also  Ricord's  observation,  "  that  gonorrhoea  often  arises  from 
intercourse  with  women  who  themselves  have  not  the  disease  ;"  and  Diday's,  "  that  from 
the  very  fact  of  a  woman  having  a  discharge,  no  matter  what  its  origin,  she  is  liable  to 
give  a  discharge  to  a  man."  Complaints  closely  resembling  gonorrhoea  sometimes  appear 
in  persons  the  subjects  of  .stricture  after  sexual  intercourse,  a  debauch,  or  other  excite- 
ment. 

The  disease  may  be  acute  and  come  on  within  a  few  hours  of  connection,  or  it  may 
fail  to  show  itself  for  five  or  ten  days ;  and,  in  a  general  way,  the  sooner  the  symptoms 
appear  after  the  contagion,  the  acuter  the  disease.     It  may  be  subacute  or  chronic. 

Symptoms. — It  generally  commences  by  an  itching  about  the  orifice  of  the  urethra, 
the  mucous  membrane  of  which  will  probably  appear  swollen  and  injected  ;  there  will  be 
the  sensation  of  heat  on  micturition,  and  after  the  lapse  of  a  few  hours  some  muco- 
purulent fluid  will  be  squeezed  out  of  the  urethra.  In  acute  diseases  the  urethral 
discharge  will  soon  become  abundant,  and  yellow,  green,  or  blood-stained  pus  will  flow 
from  a  highly-injected  and  swollen  urethra  ;  the  whole  glans  and  peiiis  Avill  become  red, 
swollen,  and  painful ;  micturition  will  also  probably  be  difiicult,  painful,  and  scalding,  the 
passage  being  obstructed  by  the  swelling  of  the  mucous  membrane.  Chordee,  or  painful 
erections,  as  the  disease  advances,  will  appear,  and  later  on  perineal  pain,  if  not  suppura- 
tion. The  groins,  testicles,  and  perinaeum,  too,  become  the  seat  of  more  or  less  tender- 
ness, and  constitutional  symptoms  show  themselves,  varying  with  the  degree  of  the 
inflammatory  action  ;  in  some  subjects  the  febrile  condition  is  well  marked,  but  in  most 
it  is  absent.  After  the  lapse  of  ten  or  fourteen  days  these  acute  symjjtoms  partially  sub- 
side, the  discharge  becomes  thinner  and  more  muco-purulent,  the  external  signsof  inflam- 
mation less  marked,  the  pain  on  micturition  less  severe ;  the  perineal,  inguinal,  or  scrotal 
pain  probably  will  have  disappeared,  a  thin  muco-purulent  urethral  discharge,  with  a 
slight  sensation  of  heat  on  micturition,  alone  remaining. 


c;oy(>J:J:J/<i:.i.  Tlo 

When  these  symptoms  nre  alldwed  uneliecked  to  run  their  foiirse,  I  hoy  will  ^TiKlimlly 
pass  into  tlie  e()mliti(»ii  kimwu  as  that  tify/"7,  in  which  a  thin  imico-iiuriilenl  urclliral 
discharj^e  exists,  uinittenth-d  liy  any  litcal  (»r  f.M'ncral  source  ol"  pain.  G'/tr/,  however, 
luav   he  the   result  of  some   stricture  or  local    urethra!  disease,   such   as  an   ulcer. 

The  onlinarv  seat  of  the  afh^etion  is  the  mucous  memhrane  of  tin;  urethra,  the  ori- 
fices of  the  laeumi?  hi'in^'  chiefly  involved.  TIk;  fossa  riavicularis  and  parts  around  and 
the  mucous  memhrane  of  the  hull)  are  the  most  common  s»;ats,  the  dissections  of  Sir  A. 
('o<»per,  Kie(U-d,  Thomp.son,  and  others  havin<^  proved  this.  At  times,  howtjver,  ;.'oiior- 
rlweal  intlammatiou  may,  as  Wallace  pointed  ont  ( (Jii  Vcmnnl  Dijinist),  involve  at  the 
same  time  the  whole  of  the  urethra,  tlie  hiadder,  the  testicles,  the  f^lans,  and  the  prepuce 
in  the  male,  ami  in  the  female  the  nymphic,  clitoris,  vagina,  etc.,  the  disease,  as  it  creeps 
along  to  the  posterior  part  of  the  urinary  passage,  decreasing  in  intensity  in  the  anterior. 
In  severe  cases  the  inflammation  may  extend  to  the  submucous  tissue  and  run  on  to 
thickening,  and  even   to  suppuration. 

I'rethritis  the  result  of  some  mechanical  irritation  of  the  urethra  is  rarely  acute;  as 
a  rule  it  subsides  as  soon  as  the  cause  has  been  removed,  Urethritis  the  consef|uence  of 
some  gonorrha'al  contagion  is  almost  always  acute,  and,  having  once  been  started,  is  not 
readily  arrested. 

(Jleet,  whether  tlie  conse<(uence  of  an  acute  or  of  a  subacute  inflammation,  when  of 
some  standing,  is  almost  always  due  to  some  urethral  C(Uitraction  r)r  stricture. 

Gonorrhoea  in  the  Female. — Tn  the  female  gonorrha-a  is  to  be  recognized  as  a 
yellow  purulent  vaginal  discharge  accompanied  by  heat,  pain,  and  signs  of  acute  inflam- 
mation. The  less  purulent  it  is,  and  the  more  the  discharge  is  made  up  of  mucus  and 
epithelium  scales,  the  greater  is  the  probability  of  the  di.sease  being  due  to  vaginal 
irritation  other  than  gonorrhoeal — that  is,  to  leucorrhuja  ;  and  when  the  discharge  is  made 
up  of  masses  of  glutinous,  semi-transparent,  albuminoid  material  like  the  white  of  e^:^, 
the  more  certain  is  it  that  the  discharge  is  uterine  and  comes  from  the  glands  in  the  neck 
of  the  uterus. 

It  must  be  remembered,  however,  that  in  both  sexes,  as  long  as  any  purulent  or  semi- 
purulent  fluid  is  poured  out  by  the  mucous  membrane  of  the  genital  passage  (even  the 
slightest  gleet),  violent  urethritis  or  inflammation  of  the  vagina  may  arise  in  another 
subject  by  contagion,  and  there  is  good  reason  to  believe  that  sexual  excitement  is  an 
important  element  in  aiding  the  propagation  by  contagion.  Mr.  J.  Morgan  of  Dublin 
believes  that  the  vaginal  discharges  of  constitutionally  infected  women  are  the  cause  of 
the  majority  of  sores  in  men. 

TitEAT.MENT. — Gonorrhoea  or  urethritis  is  a  local  disease  and  may  be  treated  locally 
with  success.  When  it  is  the  result  of  local  irritation  from  the  passage  of  an  in.stru- 
ment,  no  treatment  is  called  for,  the  discharge  cea.sing  naturally  as  soon  as  its  cause  has 
been  removed;  but  when  from  gonorrhoeal  contagion,  such  a  result  is  not  met  with. 

In  a  very  acute  clap,  wdien  the  urethra  and  penis  are  swollen  from  vascular  turgescence, 
free  purgation  with  salines  is  the  best  practice,  and  in  plethoric  patients  the  addition  of 
antimony  in  quarter-grain  doses,  to  excite  nausea,  is  most  valuable. 

In  less  severe  cases  copaiba  may  be  given  in  doses  of  twenty  drops  or  half  a  drachm 
three  times  a  day  with  advantage,  iDut  this  drug  should  not  be  continued  for  more  than 
three  days.  If  it  is  to  do  good,  it  will  show  its  influence  within  that  time,  and  a  huiger 
continuance  of  the  drug  is  useless  and  deleterious.  The  yellow  oil  of  sandalwood  may 
also  be  employed  in  the  same  dose  and  under  like  circumstances,  and  at  times  it  acts  most 
beneficially  even  when  the  copaiba  has  failed,  but  it  is  in  no  w^ay  certain  in  its  action. 

For  cleansing  purposes  an  injection  containing  three  or  four  drops  of  Condy's  fluid 
to  the  ounce  of  water  is  to  be  advocated.  It  may  be  used  in  all  stages  of  the  disease. 
Astringent  injections  are  always  of  value  when  they  can  be  used  frequently  and  efllicient- 
ly,  but  strong  injections  are  to  be  condemned.  They  may  cure  the  disease  suddenly,  but 
more  commonly  they  fail  and  set  up  inflammation  of  the  bladder  and  other  mischief  by 
adding  to  the  irritation. 

The  best  injection  in  all  stages  of  the  disease  is  tannin  in  the  proportion  of  three  to 
six  grains  to  the  ounce,  and  next  to  this  is  alum  in  the  proportion  of  two  or  three  grains 
to  the  ounce,  or  the  chloride  of  zinc  one  grain  to  the  ounce.  A  solution  of  salicylic  acid 
is  also  good,  half  a  drachm  of  the  acid  being  dissolved  in  six  ounces  of  water  with  a 
scruple  of  borax.  The  perchloride  of  mercury,  one  grain  to  six  ounces  of  distilled  water, 
as  an  occasional  injection,  has  been  recently  advised.  To  be  of  use  injections  .should  be 
used  from  four  to  six  times  in  the  twenty-four  hours.  An  ordinary  glass  syringe  will  answer 
every  purpose  if  the  glans  penis  be  well  held,  but  there  are  special   syringes  which  are 


716  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

supposed  to  have  some  advantages.  During  this  treatment  the  use  of  such  alkalies  as 
the  citrate  or  tartrate  of  potash  in  twenty-grain  doses,  or  ten  grains  of  the  bicarbonate, 
may  be  given  and  good  food  allowed,  but  little  or  no  .stimulant. 

In  the  chronic  stage  I  have  found  great  benefit  from  the  introduction  into  the  urethra 
of  a  large  catheter  covered  with  the  glycerine  of  tannic  acid,  and  at  times  the  supposi- 
torium  acidi  tannici  rolled  into  sticks  and  passed  into  the  urethra  acts  most  beneficially. 

The  best  way  to  give  copaiba  is  as  a  bolus  mixed  with  calcined  magnesia  and  wrapped 
in  wafer  paper,  or  as  a  mixture  with  gum  and  peppermint  water.  The  capsules  are 
uncertain  in  their  action.  Copaiba  is  well  known  to  produce  in  some  patients  a  severe 
rose  urticarious  eruption.     Cubebs  are  less  to  be  relied  on  than  is  copaiba. 

In  using  injections  the  object  is  to  make  an  impression  upon  the  mucous  membrane 
by  their  astringent  effects,  and  to  keep  it  up.  Weak  astringents  frequently  employed  are 
far  more  valuable  than  strong  ones  used  at  longer  intervals.  When  so  used,  they  are  as 
beneficial  in  gonorrhoeal  inflammations  of  the  urethra  as  in  that  of  the  eye.  When  a 
man  can  devote  himself  to  the  cure  of  his  clap  and  throw  into  his  urethra  a  weak  astrin- 
gent every  hour,  he  will  often  check  it  within  two  or  three  days,  in  the  same  way  as  a 
gonorrhoeal  inflammation  of  the  eye  may  be  controlled  under  .similar  treatment.'  The 
nitrate  of  silver  injection  is  an  uncertain,  and  at  times  a  dangerous,  remedy,  often  adding 
to  the  disease  instead  of  diminishing  it.  In  all  cases  of  long-continued  clap  or  gleet  in 
the  male  the  presence  of  a  .stricture  .should  be  suspected.  It  may  often  be  made  out  by 
the  passage  of  a  full-sized  bougie  a  hoide  when  an  ordinary  catheter  fails  to  detect  it. 
The  gleet  should  only  be  satisfactorily  treated  by  the  cure  of  the  .stricture — that  is.  its 
full  dilatation. 

Tonics,  particularly  iron,  are  valuable  adjuncts  to  the  treatment. 

All  connection  must  be  forbidden  for  some  time  after  the  apparent  cure  of  a  clap,  for 
any  sexual  excitement  is  likely  to  be  followed  by  a  relapse.  Drinking  and  smoking  to 
excess  are  injurious. 

In  women  a  clap  is  readily  cured  by  the  frequent  use  of  astringent  injections  of  tan- 
nin, alum,  or  sulphate  of  zinc  ^ss  to  a  pint  ;  the  passage  into  the  upper  part  of  the  vagina 
of  the  tannic  acid  suppository  is  also  excellent  treatment.  In  the  use  of  both  these 
means  the  patient  should  lie  down  with  her  hips  raised,  and  the  astringent  should  be 
allowed  to  remain  in  the  passage.  To  inject  it  sitting  or  standing  is  a  useless,  although 
a  too  common,  practice. 

Complications. 

In  male  subjects  inflammation  of  the  epididymis  is  the  most  common  com- 
plication, the  disease  doubtless  spreading  in  a  direct  way  from  the  urethra  through  the 
vas  deferens  and  cord  to  the  epididymis.  In  .some  cases  it  stops  at  the  cord  ;  in  others, 
it  goes  on  to  affect  the  testicle  itself.  It  is  often  associated  with  hydrocele,  and  from 
this  fact  some  surgeons  have  been  led  to  bfelieve  that  inflammation  of  the  testicle  itself 
is  a  common  consequence  of  a  clap.  The  treatment  of  this  affection  will  be  con.sidered  in 
a  future  page. 

In  the  female  inflammation  of  the   ovary  is  said  to  occur,  and  even  pelvic 

peritonitis. 

Abscesses  in  the  cellular  tissue  external  to  the  urethra,  penile  or  perineal,  are 
often   met   with  in  acute  gonorrhoea,  and  should  be  opened  early. 

Ohordee,  or  painful  erection  caused  by  the  stretching  of  the  corpora  cavernosa, 
into  which  inflammatory  products  have  been  infiltrated,  is  a  common  consequence,  and  a 
vei-y  painful  one.  Full  doses  of  opium  (gr.  j)  or  ten  grains  of  henbane,  and  a  like  dose 
of  camphor,  are  reliable  remedies.  Ricord  used  a  suppository  of  ten  grains  of  camphor 
and  one  grain  of  the  extract  of  opium  ;  I  have  sometimes  thought  the  morphia  supposi- 
tory the  most  useful.     Belladonna  smeared  over  the  urethra  also  gives  relief  at  times. 

Retention  of  urine  may  likewise  occur  from  the  mechanical  closure  of  the  urethra 
through  its  swelling,  from  spasm  of  the  urethra,  or  from  both  causes.  The  warm  bath 
and  opium  are  the  best  remedies  for  the  complication,  a  catheter  being  passed  only  when 
an  absolute  neces.sity  exists. 

Inflammation  of  the  prostate  is  likewise  a  complication,  as  is  also  inflam- 
mation of  the  bladder.     (  Vi'ie  Chapter  XXI.) 

Inflammation  of  the  inguinal  glands,  or  sympathetic  bubo,  i?  often 

present,  the  glands  occupying  the  upper  part  of  the  groin  being  usually  involved,  but 
tho,se  below  Poupart's  ligament  are  not  seldom  affected.     In  neglected  cases  these  glands 


COMl'LIf'ATKfXS.  717 

may  suppurate.  Fomontations  and  t<iiiics  are  the  necessary  treatment.  The  aVisorltcnts 
of  the  penis  are  at  times  inHanied  and  suppurate. 

Balanitis.  —  Wlien  tlu-  jrhms  penis  and  jircpuee  are  involved  in  the  inflammation  and 
this  inllaniination  is  attended  with  protu.se  discharge,  hafdnifis  or  rxtenud  ijouonlian  is 
said  to  be  present.  This  att'eetion  may  be  due  to  want  (d  cleaidiness  a.s  much  as  to  gon- 
orrha'al  contact.  When  the  ]>repuce  becomes  a'dematous  and  is  long,  phhnonn  takes 
place;  when  narrow  and  retracted  behind  the  glands,  so  as  to  be  irreducible,  y>«r«yy/(/>/to«<» 
exists. 

Tkk.vt.mk.nt. — This  balanitis  should  be  treated  locally  by  astringents,  such  as  the 
acetate  of  lead  or  the  nitrate  of  silver  lotion  v-vj  grs.  to  the  ounce,  painted  on  the  inflamed 
part.      Phimosis  and  jiaraphiinosis  should  be  treated  on  principle's  already  stated. 

It  should  be  remembered,  too,  tliat  a  balanitis  associated  with  a  rawness  or  erosion  of 
the  gians  or  ju'epuce  may  be  due  to  a  syphilitic  inoculation. 

^T^artS. — As  a  con.><e((uence  of  balanitis  irarfs  are  very  common,  and  may  cover  the 
mucniis  membrane  of  the  glans  and  jtrepuce  or  invade  tlie  urethra  it.self.  They  may 
grow  to  a  great  size,  putting  on  much  the  appearance  of  a  cancerous  penis.  I  have  seen 
them  perforate  the  prepuce  of  a  penis  when  phimosis  was  present. 

Tkk.vt.me.nt. — They  can  be  treated  only  by  removal.  When  extensive,  their  excision 
is  the  best  plan,  the  operation  being  performed  with  the  patient  anaesthetized,  nitrate  of 
silver  or  perchloride  of  iron  or  the  galvanic  cautery  being  freely  applied  to  the  base  of 
the  warty  growths.  In  less  severe  cases  the  warts  will  often  wither  if  kept  dry  with  the 
oxide  of  zinc  or  the  fresh  powder  of  savin. 

All  warts  are  not,  however,  gonorrhijeal ;  some  may  arise  without  any  such  cause, 
even  in  clean  sulijects.  They  are  nevertheless  contagious.  In  women  they  are  often 
found  up  the  vauiiKi.  l)ut  more  fr('<|uently  at  its  orifice. 

Gonorrhoeal  Rheumatism. — An  attection  so  called  is  an  undoubted  complica- 
tion of  the  disease,  explain  it  as  we  may.  At  the  end  of  an  attack  of  clap,  patients,  with- 
out doubt,  are  often  attacked  with  severe  pain  and  tenderness  of  one  or  more  joints, 
attended  with  effusion  and  constitutional  disturbance.  It  uiay  occur  with  every  fresh 
attack  of  clap,  and  I  have  recorded  a  ca.se  in  my  book  on  the  joints  in  which  it  recurred 
sixteen  times  after  sixteen  diff'erent  attacks  of  gonorrhoea.  Some  authors  look  upon  this 
aff'ection  as  a  .species  of  pyaemia  due  to  the  absorption  of  some  morbid  matter  from  the 
inflamed  urethra,  but  evidence  is  still  wanting  to  prove  the  truth  of  the  theory.  It  rarely 
appears  during  the  acute  .stage  of  the  affection,  mostly  in  the  chronic,  but  arrest  of  the 
discharge  cannot  be  associated  with  its  appearance.  The  knees  and  ankles  are  the  joints 
mostly  involved,  yet  those  of  the  upper  extren)ities  are  so  at  times.  The  fair-haired  and 
what  are  called  strumous  subjects  are  said  to  be  more  prone  to  the  disease,  but  I  cannot 
say  I  have  observed  this.  At  times  the  rheumatic  pains  are  more  confined  to  the  tendons, 
fasciic.  and  muscles ;  the  heels  and  soles  of  the  feet  are  also  frequent  seats  ;  as  a  result 
of  this  inflainmaticm  the  parts  involved,  and  particularly  the  fascia,  may  soften  and  yield. 
The  late  Dr.  liabbington  used  to  say  that  this  form  of  fascial  rheumatism  was  found  only 
in  those  who  had  taken  copaiba. 

The  disease  may  be  nritte^  siihttcn'e,  or  chronic;  and  when  acute,  it  may  run  on  rapidly 
to  suppuration.  The  most  acute  example  of  suppuration  of  a  knee-joint  I  have  .seen  was 
of  this  nature  ;  it  occurred  in  a  man  aet.  35  during  the  acute  stage  of  gonorrhoea.  It  was 
treated  by  free  incisions  into  the  joint,  and  followed  by  a  good  recovery  with  a  stiff"  joint. 
This  may  well  be  called  .acute  f/onorr/taal  i^T/iioi-i'fit!,  to  distinguish  it  from  an  acute  gnnor- 
rhoeal  arthritis,  upon  which  ray  friend  and  colleague  Mr.  Davics-Colley  has  written  an  able 
paper  {Guys  IIosj).  R'p.,  vol.  xli.,  1883,  p.  187).  Gonorrhoeal  arthritis  "  is  as  often  found 
in  the  female  as  the  male — perhaps  more  often.  It  usually  begins  before  the  gonorrhoea 
or  discharge  has  existed  for  any  considerable  time,  and  the  subjects  are  generally  under 
the  middle  age.  The  onset  is  like  that  of  an  attack  of  acute  rheumatism.  The  patient 
is  feverish  and  has  pain,  tenderness,  and  swelling  of  several  joints.  These  symptoms  are 
often  so  severe  that  he  has  to  take  to  his  bed.  In  a  few  days  the  inflammation  leaves  all 
the  joints  save  one.  in  which  it  concentrates  itself  with  great  severity.  This  may  be  any 
one  of  the  larger  joints.  Most  frefjuently  I  have  seen  it  in  the  elbow.  The  appearance 
of  the  joint  is  not  at  all  like  that  which  is  seen  in  acute  synovitis.  There  may  be  eff"usion 
within  the  synovial  sac,  but  the  most  striking  characteristic  is  the  cedema  of  the  soft  parts 
round  the  joint,  accompanied,  as  a  rule,  during  the  height  of  the  attack,  by  redness  of  the 
skin.  The  swelling  is  in  some  cases  very  great  ;  and  when  the  elbow  has  been  aflfected.  I 
have  seen  the  redness  and  oedema  extending  from  the  shoulder  to  the  wrist-joint.  I  believe 
that  the  superficial   eff'usion  is  due  to  the  inflammation  having  attacked  especially  the 


718  AFFECTIOXS  OF  THE  GEyiTAL   ORGANS. 

fibrous  tissues  of  the  capsule  ratlier  than  the  synovial  membrane  by  which  it  is  lined. 
The  slight  amount  of  eft'usion  which  occurs  in  the  synovial  sac  is  probably  secondary  to 
the  affection  of  the  adjacent  fibrous  tissues,  just  as  we  sometimes  see  an  acute  periostitis 
near  the  end  of  the  diaphysis  of  a  long  bone  accompanied  by  some  effusion  into  the  neigh- 
borino'  articulation.  The  joint  is  very  tender,  hot,  and  full  of  pain,  and  any  attempt  to 
move  it  gives  rise  to  excruciating  pangs.  The  general  temperature  of  the  body  is  but 
little  elevated."  From  the  great  oedema  which  accompanies  this  aff"ection  it  may  be  mis- 
taken for  phlegmonous  erysipelas,  phlebitis,  or  lymphangitis,  but  a  little  care  should  pre- 
vent an  error  in  diagnosis  from  being  made.  Mr.  Davies-Colley  has  pointed  out  that  it 
may  be  associated  with  cardiac  complications. 

Treatment. — Medicines  seem  to  have  but  little  influence  on  this  disease.  Local 
treatment  is.  however,  very  necessary,  such  as  immobility  of  the  affected  joint,  with  warm 
fomentations,  with  or  without  the  decoction  of  poppy-heads.  The  extract  of  belladonna 
or  opium  diluted  with  vaseline  is  at  times  a  valuable  application.  Opiates  to  relieve  pain 
are  essential. 

Should  the  joint  suppurate,  it  must  be  dealt  with  by  free  incisions.  In  the  arthritic 
form  this  result  is  rare.  When  the  acute  symptoms  have  subsided,  pressure  is  of  great 
value. 

Under  all  circumstances  the  urethral  or  vaginal  discharge  must  be  cured.  Passive 
movement  of  the  joint  must  be  resorted  to  as  soon  as  swelling  and  heat  have  gone,  but 
many  joints  become  permanently  stiff"  after  this  aff"ection. 

5lessrs.  Duplay  and  Brun,  who  have  written  on  the  subject  (Archives  Generalcs  de 
Medecine,  1881),  advocate  the  use  of  plaster  of  Paris  splints. 

Herpes  Preputialis. — This  is  a  simple  affection  which  may  be  mistaken  for  chan- 
cre, and  i>  known  by  the  appearance  of  a  crop  of  vesicles  around  the  corona  of  the  glans 
or  upon  the  external  or  internal  surface  of  the  prepuce.  It  is  generally  attended  by  much 
local  irritation  and  local  evidence  of  inflammation,  the  vesicles  when  they  burst  often  dis- 
charging freely.  The  affection  runs  its  course  in  a  few  days,  and  then  the  parts  heal.  A 
zinc  lotion  of  three  or  four  grains  to  the  ounce,  or  a  solution  of  nitrate  of  silver  gr.  v  to 
the  ounce,  expedites  recovery. 

The  number  of  vesicles  and  their  grouping  is  generally  sufficient  to  enable  the  surgeon 
to  diagnose  this  aff"ection  from  a  venereal  disease. 

Chancre 

-may  be  defined  as  a  sore  the  result  of  venereal  contact,  and  in  a  general  way  it  is  found 
upon  the  penis  of  the  male  and  the  genitals  of  the  female,  but  it  may  be  seen  upon  other 
parts  of  the  body,  such  as  the  pubes,  thighs,  lips,  tongue,  nipples,  fingers,  etc. — in  fact, 
wherever  the  secretion  from  an  infected  subject  may  be  applied  to  a  raw  surface. 

In  by  far  the  larger  number  of  cases  this  disease  begins  and  ends  as  a  local  affection  ; 
in  a  smaller  number  it  is  a  local  inoculation  of  a  constitutional  disease  and  is  followed  by 
syphilis.  The  sore  is  not  syphilis,  although  it  is  the  direct  means  of  communicating  syph- 
ilis, any  more  than  the  inoculation  of  smallpox  is  smallpox,  although  the  inoculation  may 
be  the  means  of  giving  smallpox. 

So  long  as  the  chancre  is  a  local  affection  alone  it  is  comparatively  unimportant,  how- 
ever extensive  and  troublesome  it  may  be  in  healing;  but  whenever  it  is  the  local  inocu- 
lation of  a  constitutional  affection  such  as  syphilis,  it  is  of  grave  importance,  however 
apparently  trivial  may  be  the  local  sore. 

It  becomes,  therefore,  a  vital  question  to  make  out  from  the  appearances  and  conditions 
of  the  sore  whether  it  is  likely  to  prove  a  local  disease  only  or  to  be  followed  by  constitu- 
tional symptoms,  and  to  a  certain  extent  this  diagnosis  may  be  made — that  is,  a  surgeon 
may  from  the  external  appearance  of  a  chancre  go  so  far  as  to  say  that  in  all  probability 
this  one  will  not  be  followed  by  syphilis  and  that  one  will,  but  he  can  do  no  more;  to  dogma- 
tize upon  the  point  and  to  speak  with  certainty  are  beyond  his  power. 

The  chancre  which  will  not  in  all  probability  be  followed  by  syphilis  is  the  soft  siijjj^u- 
ratirig  sore  ;  the  chancre  that  will  in  all  probability  be  followed  by  syphilis  is  the  hard  nov- 
snpjvirntinff  sore. 

John  Hunter  thus  described  the  indurated  chancre :  '•  The  sore  is  somewhat  of  a  cir- 
cular form,  excavated,  without  granulations,  with  matter  adhering  to  the  surface,  and  with 
a  thickened  edge  and  base.  The  hardness  and  thickening  are  very  circumscribed,  not  dif- 
fusing themselves  gradually  and  imperceptibly  into  the  surrounding  parts,  but  terminating 
abruptly."    In  this  description  we  read  the  type  of  the  hard  infecting  chancre — the  chancre 


ciiAscni:.  719 

of  tilt'  iriitcul:iti(»ii  of  syjiliilis.  wherever  ffuuul.  Hunter  aiMs.  however,  that  "a  cliancre- 
has  ciiiiiiiHtiily  a  thiekeiiftl  base;  ami  althduirh  tht;  (•(iiiimnii  iiitlaiiiiiiatioii  spn-ads  iiiueh 
further,  vi't  the  sju-eilie  iiiflaniiiiatioii  is  ckiiHikmI  t(»  this  hase.  An  infeetitijr  <*liaii(ie  may, 
tno.  appear  only  as  a  erack,  i-xenriatifHi,  nr  iii(lurati'<l  tiihercle,  witlnmt  abrasion. 

This  form  of  ehanere  is  e(immr)nly  associate<l  with  some  induration,  not  suppuration, 
of  the  tirst  row  of  the  inguinal  glands — the  mnlliplr  imlobni  bnho.  It.s  secretion  consists 
of  epithelial  ifehris,  of  globules  of  lymj)!!  more  or  less  perfectly  formed  or  disintegrating, 
and  of  serum,  »'>^  ;>»s,  and  not  auto-inoculable.  In  debilitated  and  unliealthy  subjects, 
adds  Lee,  infecting  sores  will  suppurate  as  any  non-specific  lesion  would  do,  and  in  such 
cases  it  is  sometimes  very  difficult  to  distinguish  the  .secretion  produced  by  the  local  dis- 
ease from  that  which  de])cnds  upon  constitutional  peculiarity. 

The  soft  siipinintfiiii/  c/iaiicrc  is  often  multiple  and  has  an  excavated  surface  witli 
neatly  shaped  and  cut  edges,  as  if  the  wouiul  had  been  punched  out.  It  has  an  irregular 
and  worm-eaten  surface  secreting  abundance  of  pus.  It  is  ])r(jne  to  spread  rapidly  and  to 
liecome  phagedivnic.  It  has  usually  a  soft  base  ;  but  if  otherwise,  it  will  have  what 
Kicord  has  described  as  a  phlegmoinjus  hardness,  and  not  a  defined  one.  as  in  the  svphi- 
litic  chancre.  It  is  commonly  associated  with  a  suppurating  bubo,  and  secretes  pus  which 
'•  has  the  property  of  always  reproducing  its  specific  action  when  ajtplied  to  another  part 
of  the  same  body  or  when  inoculated  upon  another  person  "  (H.  Lee). 

The  experiments  of  Fournier  and  Kollet  and  Lee's  observations  led  the  latter  surgeon 
to  '■  conclude  that  if  a  venereal  sore  yields  a  .secretion  capable  of  being  inoculated  so  as 
to  produce  the  specific  pustule,  the  evidence,  so  far  as  it  goes,  is  in  favor  of  its  being  a 
local  disease  and  of  its  not  requiring  constitutional  treatment.  If,  on  the  contrary,  a  dis- 
ease which  we  believe  to  be  primary  syphilis  yields  a  secretion  which  is  not  auto-inocula- 
1)le.  then  the  evidence  is  against  the  local  character  of  the  affection  and  indicates  a  con- 
stitutional mode  of  treatment."  In  this  we  read  the  type  of  the  simple  local  venereal 
sore. 

In  a  clinical  point  of  view,  however,  this  great  distinction  between  the  two  forms  of  chan- 
cre is  not  always  definable  ;  and  consequently  an  intermediate  class  of  cases  in  which 
syphilis  occurs  has  to  be  recognized,  in  their  clinical  features  more  approaching  the  soft 
sore. 

There  are,  therefore,  three  forms  of  syphilitic  sore,  which  the  government  committee 
on  syphilis  has  thus  well  described  :  One  characterized  by  induration  throughout  its 
entire  course ;  one  soft  in  its  early  stage  and  becoming  subsequently  indurated  ;  and  one 
soft  throughout  the  whole  course,  but  which,  unlike  the  simple  local  sore,  is  followed  by 
constitutional  disease. 

Hard  sores  do  not  of  necessity  give  rise  to  syphilis,  whilst  soft  .sores  may.  And  it  is 
an  undoubted  fact  that  the  question  of  induration  or  non-induration  is  greatly  determined 
by  the  position  of  the  sore,  chancres  on  the  female  genitals  simple  or  syphilitic,  and  chan- 
cres on  the  glans  penis  being  rarely  hard. 

The  point,  therefore,  resolves  it.self  into  this — that  the  indurated  chancre  with  a  fair 
amount  of  probability,  although  not  certainty,  may  be  the  precursor  of  syphilis,  and  not 
a  merely  local  disease.  The  soft  or  non-indurated  sore,  in  exceptional  cases,  may  be  due 
to  a  syphilitic  inoculation,  although  in  the  majority  of  cases  it  is  a  purely  local  affec- 
tion. 

A  crop  of  soft  sores  fringing  the  prepuce  or  surrounding  the  corona  is,  in  all  proba- 
bility, a  simple  and  non-syphilitic  disease. 

A  spreading  chancre  with  a  suppurating  bubo  is  probably  a  local  affection. 
A  small  single  chancre  indurated  from  the  beginning  is  the  nio.st  suspicious  of  syphi- 
lii?,  although  even  in  this  there  is  no  certainty  of  its  being  so.  In  fact,  it  is  not  possible 
to  speak  with  any  certainty  as  to  a  chancre  being  syphilitic  or  otherwise.  Syphilis  is  a 
constitutional  disease  which  can  be  recognized  only  by  its  constitutional  symptoms,  and 
not  by  the  point  of  its  inoculation. 

With  respect  to  the  ])erio(/  of  incubation  of  a  simple  or  syphilitic  chancre  no  definite 
time  can  be  given,  since  it  varies  from  a  few  hours  to  a  week,  but  the  multiple  suppurat- 
ing simple  chancres,  as  a  rule,  appear  more  rapidly  after  infection  than  an}-  other  ;  the 
syphilitic  chancre  often  does  not  appear  for  a  week  at  least,  sometimes  two  or  three,  after 
infection.  Dr.  Bumstead  of  New  York  says  that  "  an  interval  of  at  least  ten  days  will 
be  found  to  have  existed  between  infection  and  the  appearance  of  the  sore  "  (edition  of 
Ciilleriers  Atlas  of   Venereal  Disease,  1868). 

A  chancre,  like  any  ordinary  sore,  may  present  different  appearances  at  different 
times.     It  may  be  at  its  origin  vesicular,  papular,  pustular,  or  an  excoriation,  and  pass 


720  AFFECTIOXS   OF  THE  GENITAL    ORG  ASS. 

througli  the  ulceratlni/.  fjranulatlug,  and  cicatrizing  stages  ;  in  one  case  the  ulcerating  stage 
will  be  a  long  one.  while  in  another  it  may  be  so  brief  as  hardly  to  be  recognized. 

The  action  of  the  sore  may  vary  with  the  condition  of  the  patient,  as  well  as  with  the 
condition  of  the  part  upon  which  it  is  placed  ;  and  it  will  probably  be  influenced  by  the 
nature  or  the  stage  of  the  infecting  sore  from  which  the  disease  has  been  communicated. 

A  chancre,  like  an  ordinary  sore,  when  there  is  much  local  action  and  little  con.stitu- 
tional  power,  may  become  irritable,  inflamed,  or  phagedaenic.  more  particularly  when 
drink,  irregular  living,  and  debauchery  have  so  enervated  the  .system  as  to  render  the 
patient  unable  to  withstand  the  eifects  of  any  local  irritation.  These  various  actions  may 
attack  the  chancre  at  any  period  of  its  progress. 

When  a  chancre  is  sloughing  or  phagedaenic  from  the  first  and  has  originated  from  an 
inoculation  of  syphilitic  matter,  there  is  every  reason  to  believe  that  the  sloughing  pro- 
cess may  have  a  beneficial  tendency,  since  the  very  intensity  of  the  local  eff"ects  of  the 
poison  may  be  the  means  of  preventing  its  absorption,  and  thus,  also,  the  outbreak  of 
syphilis.  ^Yhen.  however,  the  sloughing  action  appears  during  the  ulcerating  or  later 
period  of  the  chancre's  progress,  it  will  have  no  such  useful  influence  ;  for  when  syphilis 
is  inoculated  through  a  chancre,  it  is  during  its  vesicular,  papular,  or  pu.stular  condition, 
prior  to  its  ulcerative  stage,  and  no  action  of  the  sore  that  appears  after  this  period  can 
have  any  eff"ect  in  checking  the  diff'usion  of  the  poison.  '•  If  the  inflammation  spreads 
fast,''  writes  Hunter,  ••  it  shows  a  constitution  more  than  naturally  disposed  to  inflamma- 
tion ;  if  the  pain  is  great,  it  .shows  a  great  disposition  to  irritation  ;  it  also  sometimes  hap- 
pens that  they  very  early  begin  to  form  sloughs.  When  this  is  the  case,  they  have  a 
strong  tendency  to  mortification."'  '•  These  three  conditions  of  a  sore,'"  adds  Aston  Key, 
commenting  upon  the  above,  ••  distinct  in  their  cause  and  in  their  operation  from  the 
.syphilitic  action,  are  adverted  to  as  pointing  out  the  distinction  that  is  to  be  drawn 
between  the  irritable,  inflamed,  and  the  sloughing  chancre,  and  afl'ord  a  guide  to  the 
pathological  surgeon  as  safe  and  as  intelligible  as  the  more  elaborate  descriptions  of  mod- 
ern writers"  (6^»^'.s  Hoi^p.  Rep..  1840). 

Treatment. — The  uncertainty  that  most  surgeons  entertain  as  to  the  nature  of  a 
chancre,  from  the  knowledge  that  any  sore  upon  the  penis,  ranging  from  a  simple  excori- 
ation to  an  indurated  chancre,  may  be  the  inoculation  of  syphilis,  renders  it  desirable  and 
expedient  that  all  sores  should  be  destroyed  at  the  very  earliest  period ;  and  when  this  is 
eff'ectually  done  before  the  ulcerative  stage  has  set  in,  or  during  the  vesicular,  papular, 
or  pustular  stages,  there  is  good  reason  to  believe  that  constitutional  syphilis  may  often 
be  prevented. 

When,  however,  the  sore  exists  as  an  ulcer,  this  abortive  practice  is  useless ;  indeed, 
in  the  majority  of  cases  it  makes  a  .small  sore  large,  retards  recovery,  and  in  no  way  pre- 
vents syphilitic  symptoms  appearing  if  the  chancre  had  had  a  syphilitic  origin.  But, 
taking  all  together,  not  one  chancre  out  of  four  has  a  syphilitic  origin. 

For  the  destruction  of  a  chancre  on  its  first  appearance,  nitrate  of  silver,  nitric  acid, 
potassa  fusa,  or  chloride  of  zinc  may  be  applied,  so  that  the  base  of  the  sore  is  well 
destroyed. 

When  this  is  not  done,  the  chancre  should  be  treated  on  ordinary  principles  :  to  the 
inflamed  sore,  lead  lotion,  with  or  without  opium,  may  be  applied  ;  to  the  sloughing  sore, 
opium  with  tonics,  internally,  is  indicated ;  to  the  indolent  sore,  nitric  acid  lotion  or  black 
wash  is  the  best  stimulant :  while  to  ordinary  sores,  iodoform  should  be  used. 

A  chancre  requires  no  special  treatment  beyond  its  primary  destruction  from  motives 
of  expediency  or  with  the  hope  of  preventing  constitutional  infection.  The  common  prac- 
tice of  applying  black  wa.sh  to  all  sores  on  the  penis  is  not  needed,  and  to  cauterize  all 
chancres  at  everj'  stage  of  their  existence  as  soon  as  they  come  under  notice  is  unneces- 
sary. When  the  powers  of  the  patient  are  feeble,  tonics  are  called  for.  and  any  special 
conditions  are  to  be  treated  on  common  principles. 

Medicines  useful  for  syphilis  should  be  given  only  when  other  evidence  of  syphilis 
exists  beyond  that  afforded  by  the  local  inoculation.  To  treat  all  chancres  alike,  as  if 
due  to  syphilis,  is  uncalled  for  and  un.scientific ;  by  doing  so  many  patients  are  materially 
injured. 

Complications. 

Ptdmosis  is  one  of  the  most  common  complications,  and  is  found  in  at  least  a  fourth 
of  all  forms  of  chancre  and  at  all  stages  of  their  progress.  It  is  probably  most  frequent 
with  the  sloughing  sore.  In  the  fringing  preputial  chancres,  however,  it  is  a  common 
complication.     It  is  an  accidental  accompaniment  of  a  chancre,  and  is  due  to  the  inflam- 


COM  in.  TC.  I  TToys.  72 1 

luatnry  infiltration  of  tin;  propucf.  WIh-ii  imt  severe,  it  is  not  a  condition  of  much 
inijiortance  if  local  cleanliness  he  attended  to.  lor  as  the  chancres  heal  the  iiiHaniniatory 
a-dftna  will  suhside  and  the  parts  will  assume  their  natural  condition. 

When,  however,  aitinin  is  presrnf  and  a  hlood-staitied  discharge  mi.\ed  with  the  dthrix 
of  hroken-up  tissues  escapes  from  beneath  the  prepuce,  and  doubt,  conse(juently,  is  felt 
as  to  the  nature,  position,  and  character  of  the  chancre;  when  evidence  exists  that  the 
parts  beneath  are  undergoing  a  destructive  process  which  demands  direct  local  treat- 
ment.— the  prepuce  must  be  slit  up,  the  surgeon  taking  care  to  do  this  efl'ectually,  since 
through  a  want  of  due  attention  to  this  point  the  glans  [»enis  may  be  destroyed  or  the 
prepuce  pcrfurated.  When  the  sore  has  been  exposed,  it  ought  to  be  treated  on  onlinary 
principles.  When  a  simple  purulent  discharge  comes  from  the  orifice  of  the  pre|»U(;e.  the 
constant  use  of  water  and  simple  lead  or  other  injeetioii  will  jtrobably  siifiice.  IMiimosis 
witlmut  iiifianimatory  (cdema  rarely  calls  for  treatment. 

PhagedSBna. — Venereal  like  other  sores  may  slough,  the  suppurating  chancre  being 
mure  ])roiie  to  take  on  this  action  than  the  non-suppurating  and  indurated.  When  a  .sore 
sloughs  from  the  first,  it  will  probably  prove  to  be  non-infecting ;  and  even  if  .syphilitic 
in  its  origin,  it  may  lose  its  syphilitic  nature,  the  sore,  when  the  sloughing  action  has 
cea.sed.  becoming  a  simple  one.  This  action  is  at  times  so  intense  that  the  penis  rapidly 
swells,  inflames,  and  becomes  gangrenous  after  infectifjn,  the  whole  organ  at  times  slough- 
ing oft",  while  at  others  the  action  will  be  more  partial. 

In  exceptional  instances  the  mortification  is  of  the  dry  kind.  In  the  Peninsular  war, 
when  the  British  troops  were  in  Portugal,  this  sloughing  of  the  penis  from  inflammation 
was  so  severe  that  Inspector  Fergus.son  [  Mi'il.-Chir.  Trans.,  vol.  iv.)  wrote:  '•  It  is  prob- 
able more  men  have  sustained  the  most  melancholy  of  all  mutilations  during  the  four 
years  at  war  in  Portugal  through  this  disease — which  was  called  the  '  black  lion  — than 
the  registers  of  all  the  hospitals  in  England  could  produce  in  the  last  century."  He 
attributed  the  severity  of  tliis  afi'ection  to  the  free  sexual  intercourse  of  per.sons  of  dif- 
ferent nations. 

How  far  this  phagednena  depends  upon  some  peculiar  power  of  the  infecting  poison  or 
upon  the  constitution  of  the  individual  patient  is  difiicult  to  determine,  although  the  latter 
probably  has  the  greater  influence,  aince,  when  any  such  depressing  agency  as  that  cau.sed 
by  drink,  excess  of  venery,  or  illness  is  present,  phagedaena  is  more  likely  to  occur  than 
under  other  circumstances. 

Treatment. — In  the  treatment,  of  all  ca.ses  of  phagediena,  opium,  tonics,  and  good 
living  are  the  three  essentials,  while  mercury  and  the  iodide  of  potassium  are  inad- 
missible. 

Locally,  the  part  must  be  kept  clean  by  frerjueut  ablution,  and  to  this  end  the  pre- 
puce often  requires  to  be  .slit  up.  Lotions  of  nitric  acid  one  drachm  to  five  ounces  of 
water,  of  carbolic  acid  one  part  to  thirty,  of  sulphate  of  copper  five  or  ten  grains  to  the 
ounce,  of  potassio-tartrate  of  iron  from  ton  to  tw^enty  grains  to  the  ounce,  are  also  useful, 
and  opium  in  solution  is  often  a  good  addition.  When  the  di.sease  spreads,  local  mer- 
curial fumigation  is  said  to  be  of  value,  but  change  of  air  is  mo.st  beneficial. 

Adenopathy,  or  bubo,  is  a  common  complication  of  the  simple  as  well  as  of  the 
infecting  chancre — that  is,  it  is  found  in  the  local  venereal  sore  as  well  as  in  the  inocula- 
tion of  true  syphilis,  but  in  the  former  the  gland,  as  a  rule,  suppurates,  while  in  the  latter 
it  rarely  does  so — at  any  rate,  as  a  consequence  of  the  local  .sore. 

''  Lymphatic  absorption,"  writes  Lee.  '•  from  a  suppurating  syphilitic  .sore  (simple) 
necessarily  produces  a  suppurating  bubo  ;  any  attempt  to  jtrevent  such  an  afi'ection  from 
suppurating  is  entirely  futile.  The  disea.se  within  the  lymphatic  system  is  the  same  and 
runs  a  similar  course  as  that  upon  the  surface  of  the  body." 

The  bubo  associated  with  -the  simple  non-infecting  sore  is  the  direct  result  of  the 
absorption  of  the  specific  pus,  the  matter  in  the  interior  of  the  gland  retaining  its  specific 
characters,  whilst  that  outside  the  gland  is  ordinary  non-specific  pus.  As  the  di.sease 
advances,  however,  the  two  fluids  mix,  and  the  wdiole  acquires  the  characters  of  the  spe- 
cific fluid,  the  surface  of  the  sore  about  the  glands  becoming  in  this  way  inoculated. 

In  the  infecting  and  syphilitic  chancre  the  enlargement  of  the  glands  is  usually  indo- 
lent and  unconnected  with  suppuration.  It  appears  within  the  first  or  second  week  of  the 
inoculation,  and  many  glands  are  usually  involved,  forming  hard,  ind<dent,  painless  swell- 
ings. In  exceptional  cases,  however,  where  the  sore  is  a  source  of  local  irritation,  sup- 
puration of  the  glands  may  take  place,  the  suppurating  bubo  in  the  course  of  the  consti- 
tutional symptoms  being  no  rare  event.  The  presence  or  absence  of  suppuration  in  the 
inguinal  glands  is  not.  therefore,  evidence  of  any  positive  value  as  to  the  existence  or 
46 


722  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

non-existence  of  a  syphilitic  affection.  It  may,  however,  be  .stated  that  a  local  sore  on 
the  penis  associated  with  an  adenopathy  which  passes  rapidly  on  to  suppuration  is  in  all 
probability  a  local,  and  not  a  syphilitic,  affection,  while  a  local  sore  with  a  simple  indura- 
tion of  the  glands  is  in  all  probability  a  syphilitic  inoculation. 

In  every  form,  therefore,  of  chancre,  though  more  frequently  in  the  local  sore,  simple 
adenitis  or  sympathetic  bubo  may  be  met  with  as  a  result  of  local  irritation  which  diflers 
in  no  respect  from  the  adenitis  of  any  other  local  organ.  One  or  more  glands  may  be 
involved  in  the  action,  and  suppuration  may  be  acute,  subacute,  or  chronic.  In  the  simple 
local  sore  it  is  usually  acute.  As  a  rule,  too.  the  sore  formed  by  the  venereal  bubo,  unlike 
that  resulting  from  simple  adenitis,  instead  of  healing  kindly,  often  takes  on  very  much 
the  appearance  of  the  local  disease  :  the  edges  ulcerate,  the  opening  enlarges,  and  a  large 
sore  is  formed;  indeed,  from  this  action  the  sei-jn^iiK/vsi  sore,  to  which  allusion  will  be  made, 
often  takes  its  origin.  At  times  the  bubo  puts  on  a  phagedasnic  action  and  spreads  fear- 
fully. 

In  rare  cases  the  glands  are  said  to  enlarge  without  any  local  lesion,  this  chronic 
enlargement  being  followed  by  syphilis.  I  have,  however,  never  seen  a  marked  instance 
of  this,  and  in  reputed  cases  have  suspected  the  former  existence  of  some  overlooked 
local  sore  or  fissure.     Mr.  Cock  does  not  recognize  the  affection. 

Treatment. — There  is  nothing  to  be  gained  by  suppuration  of  the  inguinal  glands, 
for,  even  when  associated  with  syphilis,  the  poison  is  not  eliminated  by  such  means,  and 
when  due  to  some  simple  local  source  of  irritation  is  only  an  additional  cause  of  annoyance. 

To  endeavor  to  prevent  suppuration  is,  consequently,  a  wise  course  ;  this  can  best  be 
done  by  rest  and  the  local  application  of  cold  in  the  form  of  ice  or  lotions  of  lead,  muri- 
ate of  ammonia,  or  spirit.  When  suppuration  is  threatening  or  cannot  be  retarded,  warm 
fomentations  are  the  best;  and  as  soon  as  pus  has  formed  a  free  incisio-n  should  be  made, 
followed  by  warm-water  dressing  or  a  p(uiltice.  A  vertical  incision,  as  a  rule,  is  the  best; 
but  when  the  abscess  is  large,  the  opening  should  be  made  in  the  long  axis.  The  appli- 
cation of  leeches  or  iodine  to  a  bubo  that  threatens  to  suppurate  seems  a  useless  practice. 

In  the  indolent  bubo,  or  rather  where  indurated  glands  exist,  local  treatment  it  useless, 
though  care  should  be  observed  that  no  local  source  of  irritation  is  added  to  that  of  the 
sore  and  no  excess  of  exercise  taken  by  which  the  inflammation  may  be  increased. 

When  the  cellular  tissue  around  the  glands  is  infiltrated  with  inflammatory  products, 
as  indicated  by  its  brawniness,  etc.,  the  value  of  local  pressure  by  means  of  a  pad  and  the 
spica  bandage  (Fig.  311,  p.  5-42)  is  unquestioned,  while  tonics,  rest,  and  other  constitu- 
tional treatment  are  beneficial.  The  local  application  of  some  mercurial  ointment  at  times 
appears  to  be  of  use,  and  a  small  blister  or  a  strong  solution  of  iodine  or  of  nitrate  of 
silver  is  of  value  in  hastening  either  the  absorption  of  the  inflammatory  products  or  their 
suppuration.  As  soon  as  suppuration  appears  the  abscess  should  be  opened.  When  a 
hard  gland  is  left  at  the  bottom  of  a  suppurating  wound,  the  American  practice  of  apply- 
ing such  a  caustic  as  the  potassa  fusa  to  its  centre,  to  cause  its  death  and  subsequent 
sloughing,  or  Golding-Bird's  electrolytic  caustic,  occasionally  is  of  great  use,  this  practice 
being  as  useful  in  syphilitic  glandular  enlargements  as  in  others.  In  some  instances  the 
removal  of  the  gland  by  the  scalpel  may  be  expedient.  Sinuses  must,  if  possible,  always 
be  laid  open. 

If  phagedaena  attacks  a  bubo,  the  local  application  of  nitric  acid  or  the  actual  or  gal- 
vanic cautery  is  sometimes  called  for,  more  particularly  when,  in  spite  of  general  or  other 
local  treatment,  it  spreads.  Opium,  tonics,  and  other  internal  remedies  must  not  be 
omitted. 

HYDROCELE  OF  THE  CORD  AND  OF  THE  TESTICLE. 

Hydrocele,  or  a  collection  of  serous  fluid  in  close  connection  with  the  testicle  or  sper- 
matic cord,  is  a  term  which  has  been  applied  to  two  classes  of  cases  which  differ  in  their 
progress  as  well  as  in  their  pathology  and  agree  only  in  the  one  marked  and  prominent 
symptom,  to  which  the  term  "  hydrocele  "  is  applicable.  For  clinical  purposes,  however, 
the  word  has  certain  advantages,  and  with  this  view  may  still  be  employed. 

Accepting  the  term,  therefore,  as  signifying  a  collection  of  fluid  in  close  contact  with 
the  testicle  or  spermatic  cord,  two  great  divisions  of  the  subject  at  once  suggest  them- 
selves— namely,  the  vaginal  1ij/<lr(iceh  or  the  collection  of  fluid  into  some  portion  of  the 
tunica  vaginalis  of  either  the  cord  or  the  testicle,  and  the  encysted  hydrocele,  or  spermato- 
cele, which  is  an  expanded  and  newly-formed  cyst,  as  a  rule,  in  connection  with  the  epi- 
didymis, and  but  rarely  with  the  body  of  the  testis. 


riiE  iwTiKn.oi.Y  or  TrvDnnchL/:.  723 

On  the  Formation  of  the  Serous  Sac. — Ii  is  well  kti<»\vii  t<i  all  wli..  havo 

stiidirtl  pliysidliiuv  llial  in  its  dcsri'iit  IVoiu  tin-  loin  duriii^r  fa'tal  liiV'  the  tt-sticle  draws 
with  it  into  tlio  scrotum  two  layers  of  poritoiR-uin  with  its  attciidaii't  nerves  and  vessels, 
and  that  all  pass  tludui;h  the  internal  and  external  alxloininal  rin<^s  in  front  of  tlic!  cord 
into  the  serotuni,  the  posterior  layer  of  peritoneum  hein^  in  close  connection  with  the 
tiiirous  capsule  of  the  body  of  the  testicle — the  tunica  all)u;:inea — and  the  anterior  in 
coiMU'ction  with  the  purse,  or  scrotum.  In  a  perl'ectly  normal  conditiou  it  is  jrenerally 
suppitsi'il  that  at  l)irth,  or  shortly  alter,  tlie  two  surfaces  of  this  serous  memhrane  close 
and  l)ec(une  a<lherent,  the  canal  which  was  at  one  time  present  ceasing  to  exist  fntm  the 
internal  alidominal  rinti'  to  the  upper  p(»rtion  (d"  tin;  testicle,  while  in  the  scrotum  the  two 
serous  surfaci's  remain  permanently  free,  i'or  the  purpcse  (d'  allowing  easy  and  ready  middl- 
ity  of  the  testicle  in  its  scrotal  covering.  It  is  now,  however,  well  kn»nvn  that  the  pro- 
louiration  of  the  serous  membrane  down  the  inguinal  canal  i/ito  the  srrotdl  skc  oi'ten 
remains  patent  for  a  longer  period  than  has  generally  been  supposed,  and  that  in  .some 
cases  it  continues  as  a  pervious  canal  during  the  whole  of  life.  It  is  likewise  known  that 
the  rdt/iiial  fnucrss  of  the  peritoneum  may  be  closed  at  the  upper  part  of  the  testicle,  but 
remain  open  above,  during  childhood,  and  even  up  to  old  age ;  also  that  this  naturally- 
formed  peritoneal  tube  and  .sac  may  be  closed  at  the  internal  or  external  abdominal  rings, 
or  at  any  intermediate  spot  between  these  points,  or  at  its  junction  with  the  te.stis. 

As  a  conse((uence  of  these  facts,  it  is  tolerably  clear  that  a  collection  of  .serous  fluid 
may  take  place  in  any  part  of  this  prolonged  .serous  channel,  and  that  a  hydrocele  of  the 
coi'd  or  testis  of  different  kinds  may  be  produced. 

We  thus  find  during  infant  and  early  life,  from  a  want  of  closure  of  this  tube  at  the 
internal  ring,  that  a  serous  exudation  may  take  place  either  into  the  cord  alone  or  through 
the  cord  into  the  scrotal  portion  of  this  peritoneal  .sac.  Under  the  former  circumstances 
a  vonr/enitaJ  }ti/<Jrocde  of  the  cord,  and  under  the  latter  a  congenital  hydrocele  of  (he  tistirle, 
are  said  to  exist.  When  the  tubular  portion  of  the  canal  is  closed  at  the  junction  of  the 
cord  and  testicle  and  the  testicular  part  is  open,  a  simple  vaginal  hydrocele  exists  ;  and 
when  the  tubular  portion  of  the  canal  is  closed  only  at  the  internal  ring,  the  hydrocele 
may  extend  more  or  less  up  the  canal,  even  as  far  as  the  internal  ring. 

In  another  class  of  cases  the  serous  fluid  may  be  confined  between  the  internal  and 
external  rings,  giving  rise  to  the  so-caWed  diffused  hydrocele  of  the  cord ;  and  when  it  occu- 
pies a  still  more  restricted  space,  it  is  usually  described  as  an  encysted  hydrocele  of  the 
same  part. 

The  pathology  of  all  these  different  conditions  remains,  however,  the  same,  the  differ- 
ent position  of  the  fluid  being  accidentally  determined  by  the  extent  and  lines  of  adhesion 
or  the  closure  of  the  peritoneal  testicular  prolongations.  A  congenital  hydrocele  may  be 
complicated  with  a  hernia.  A  reference  to  Figs.  292,  293,  294  (p.  524),  given  to  illus- 
trate the  subject  of  hernia,  will  assist  the  student  in  understanding  these  points. 

The  Pathology  of  Hydrocele. 

Acquired  Hydrocele. — It  may  with  considerable  confidence  be  asserted  that,  as 
a  general  rule,  the  secretion  of  the  .serous  fluid  which  gives  rise  to  the  ordinary  vaginal 
hydrocele  is  due  to  an  inflammatory  affection  of  the  tunica  vaginalis,  because  in  certain 
cases  flocculi  of  pure  lymph  may  be  .seen  floating  in  the  secretion,  while  in  others  spon- 
taneous coagulation  of  the  same  may  be  observed.  The  thickening  of  the  tunica  vagi- 
nalis, moreover,  which  .so  fi'equently  takes  place  in  chronic  cases,  the  presence  of  mem- 
branous bands  and  septa  in  the  cavity  of  the  serous  sac.  and  the  fact  that  this  f  )rm  of 
hydrocele  may  W  produced  by  extension  of  the  inflammatory  action  from  the  epididymis 
or  the  body  of  the  testicle,  jioint  likewise  to  the  same  conclusion. 

Congenital  Hydrocele. — It  is  not,  however,  so  clear  that  an  inflammatory  action 
has  any  influence  in  the  production  of  the  serous  effusion  in  the  congenital  form  of  hydro- 
cele, in  which  a  communication  still  exists  between  the  abdominal  peritoneal  cavity  and 
the  scrotal  serous  sac  ;  indeed,  it  would  rather  appear  as  if  the  exudation  was  of  a  passive 
nature  and  merely  an  excess  of  the  natural  secretion  of  the  serous  membrane,  since  in 
many  of  these  cases  the  fluid  rapidly  disappears  under  tonic  treatment,  being  reabsorbed 
as  the  powers  of  the  patient  improve,  and  vice  versa. 

The  fluid  of  a  vaginal  hydrocele  is  invariably  albuminous,  and  under  the  influence 
of  an  inflammatory  action  this  is  markedly  increased ;  hence,  the  amount  of  albumen  in 
the  fluid  of  a  hydrocele  is  determined  by  the  nature  and  violence  of  the  inflammatory 
action.     In  the  congenital  variety  it  is  a  thin,  serous,  and  saline  fluid  of  a  clear  color, 


724  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

sliglitly  tenacious  and  albuminous,  the  fluid  differing  in  no  single  point  liom  the  natural 
serous  fluid  of  the  peritoneal  cavity.  In  the  acquired  form  it  may  present  the  sama  cha- 
racters, but  it  is  usually  more  tenacious  and  varies  from  a  pale  amber  to  a  deep  straw 
color.  In  some  examples  the  fluid  will  be  stained  with  blood,  in  others  it  will  hold  choles- 
terin  in  suspension,  at  times  being  perfectly  opaque  and  syrupy  from  the  presence  of 
such  matters.  It  is,  however,  in  the  old  and  chronic  cases  alone  that  these  last  conditions 
are  to  be  observed. 

In  the  acute  vaginal  hydrocele  more  or  less  fibrin  will  be  found,  either  in  solu- 
tion or  in  the  form  of  false  membrane  or  adhesions  between  the  two  surfaces  of  the  serous 
membrane  ;  in  the  chronic  the  walls  of  the  cyst  will  be  found  to  have  undergone  great 
changes,  the  thin  clear  membrane  having  become  thick  and  opaque,  owing  to  the  organi- 
zation of  the  inflammatory  product  which  had  been  poured  out  into  its  tissue,  and  in  cer- 
tain cases  containing  cartilaginous  or  ossific  deposits,  while  on  its  surface  it  will  present  a 
firm  fibrous  appearance.  In  rare  cases  suppuration  may  occur  in  the  tunica  vaginalis, 
and  even  prove  fatal.  Thus,  in  1883  a  male  child  a?t.  8  days  was  brought  to  Guy's  with 
a  red,  swollen,  glistening  scrotum  and  the  report  that  it  had  not  passed  urine  for  hours. 
The  penis  and  the  perineeum  were  healthy.  A  catheter  was  passed  without  diftieulty  and 
a  few  drachms  of  urine  drawn  oiF,  but  the  child  died  next  day.  After  death  the  ui'inary 
organs  were  found  to  be  healthy,  but  the  tunica  vaginalis  on  both  sides  was  full  of  pus, 
and,  as  the  vaginal  process  of  the  peritoneum  on  both  sides  was  open  and  communicated 
with  the  peritoneal  cavity,  there  was  evidence  of  peritonitis  by  extension. 

Uncomplicated  hydrocele,  or  a  simple  eff"usion  into  the  tunica  vaginalis,  unas- 
sociated  with  any  disease  of  the  testis  or  epididymis,  is  generally  a  painless  and  insidious 
afiection  •,  it  attracts  attention  mainly  by  its  size,  and  demands  treatment  chiefly  from  the 
mechanical  inconvenience  it  causes.  It  is  generally  of  slow  progress,  and.  as  a  rule,  will 
be  found  to  have  existed  for  many  months  before  being  seen  by  the  surgeon,  the  patient 
seeking  advice  only  when  the  organ  has  become  cumbersome  and  from  its  weight  has 
excited  some  pain  and  dragging  in  the  lumbar  region. 

The  Clinical  Examination  of  a  Hydrocele  of  Testicle. 

On  examining  a  testicle  the  seat  of  this  disease  the  enlargement  will  be  found  free 
and  readily  movable  and  to  occupy  the  positioli  of  that  organ  which  it  includes.  On 
inquiring  into  the  history  of  the  case  it  will  be  ascertained  that  the  swelling  appeared 
primarily  in  connection  with  the  testis  and  gradually  enci'oached  upon  the  upper  portion 
of  the  scrotum  towai'd  the  external  ring.  On  the  surgeon  grasping  the  neck  of  the 
tumor  below  the  external  ring  he  will  at  once  feel  the  cord  clear  and  distinct  above  the 
tumor.  In  exceptional  cases,  however,  the  fluid  will  be  found  to  pass  upward  through 
the  external  as  far  as  the  internal  ring,  and  in  such  examples  the  peritoneal  testicular  pro- 
cess has  closed  only  at  one  point,  and  that  is  at  its  internal  abdominal  opening  (Fig.  292). 
On  taking  the  tumor  in  the  hand  it  will  be  found  to  be  light,  and  on  passing  the  fingers 
over  its  surface  it  will  be  felt  smooth  and  uniform.  Fluctuation  will  also  readily  be 
detected  on  the  slightest  and  most  delicate  palpation.  The  position  of  the  testicle  should 
then  be  looked  for  and  made  out,  its  natural  site  being  somewhat  posterior,  and  in  large 
tumors  toward  the  upper  part.  But  it  must  be  borne  in  mine  that  in  certain  examples — 
that  is,  in  cases  in  which  the  organ  is  misplaced — the  testicle  may  be  in  front  of  or  below 
the  tumor.  The  best  test  of  its  presence  is  aff"orded  by  manipulation,  the  peculiar  testic- 
ular pain  felt  on  the  application  of  pressure  affording  a  certain  indication.  The  question 
of  translucency  should  next  demand  attention  ;  for  when  present,  it  is  of  peculiar  import- 
ance and  indicative  of  the  vaginal  hydrocele.  It  must  be  remembered,  however,  that 
such  a  symptom  is  not  constant,  since  it  is  present  neither  in  cases  of  hydrocele  in  which 
the  fluid  is  thick,  bloody,  or  opaque,  nor  when  the  walls  of  the  vaginal  tumor  have  become 
thickened  by  fibrinous  deposit. 

It  should  be  added  that  for  this  translucency  to  be  well  observed  the  integuments  of 
the  scrotum  should  be  firmly  stretched  over  the  scrotal  enlargement. 

The  tumor  is  generalh'  described  as  being  of  a  regular  and  pyriform  shape,  but  this 
condition  is  very  variable,  since  the  shape  of  the  swelling  depends  upon  the  openness  of 
the  tubular  peritoneal  membrane  of  the  cord  and  the  connection  which  exists  between 
the  surfaces  of  the  tunica  vaginalis  testis  and  tunica  vaginalis  scroti.  When  the  canal 
has  closed  and  withered  down  to  the  body  of  the  testis,  the  swelling  will  be  more  or  less 
globular ;  and  the  higher  the  point  of  closure  of  the  vaginal  peritoneal  sac  toward  the 
internal  ring,  the  more  pyramidal  will  the  watery  swelling  necessarily  become.     If  adhe- 


ifVDiiocinj-:  or  Tiff:  conn.  725 

sions  exist  between  the  two  layers  (if  serous  incmliraiie  at  the  lower  portion  of  the  testis, 
the  hydrocele  will  appear  to  he  at  tiie  upper  part;  and  when  the  natural  contraction 
between  tlie  tunica  vaginalis  of  the  cord  and  of  the  testicle  is  not  completed  (Fifr.  2'J4), 
an  irregular/or  even  an  hour-glass,  contraction  may  make  its  appearance.  l\w  outline  of  a 
hydrocele  dependinj:  much  upon  the  anatomical  comlitions  of  tlu;  part  in  which  it  is  situ- 
ated and  the  pathological  changes  which  may  have  resulted  from  the  aflection.  The  true 
pyriform  swelling  is  best  seen  in  children,  in  whom  the  fluid  will  fre«|uently  be  found  to 
pass  well  up  the  cord  ;  in  adults  it  is  not,  how(!Ver,  unc<)mmon. 

Hydrocele  <»ccurs  at  all  ages,  but  it  is  .somewhat  common  at  birth  and  niid<lle  age.  and 
in  a  large  prnpnrtiiui  of  cas(>s  ajtpears  as  a  one-sided  aflection  and  seems  to  aff'ect  the  right 
or  left  testis  indiscriminately,  ('urling  informs  us  that  (»f  115  ca.ses,  <J5  <»ccurred  on  the 
right  side,  44  on  the  left,  ami  (!  were  double;  while  out  of  117,  my  own  ca.ses.  consecu- 
tively ob.served.  in  which  these  facts  were  noted.  41  occurred  on  the  right  side.  <i2  on  the 
left,  and  14  were  double — results  coinciding  with  the  opinions  of  Velpeau,  Gerdy,  and 
others. 

General  Si'm.mary. — By  way  of  summary,  it  may  be  said  a  chronic  vaginal  hydro- 
cele appears  as  a  painless  enlargement  of  the  testicle,  of  slow  and  unequal  growth,  and 
tif  variable  size,  with  a  .>«mooth  and  uniform  surface  and  more  or  less  ten.se  ami  fluctuat- 
ing feel.  It  is  invariably  movalde  within  the  scrotum,  and,  as  a  rule,  appears  to  be  dis- 
tinct from  any  abdominal  connections.  The  presence  of  the  testis  within  the  swelling 
can  generally  be  made  out  by  the  testicular  pain  which  is  produced  by  pressure  at  its 
posterior  and  upper  jiortion  if  the  tumor  be  large,  and  at  its  lower  if  small,  or  by  the 
ab.senee  of  translucency  at  one  spot,  the  tumor,  as  a  rule,  transmitting  light  when  its 
scrotal  coverings  have  been  well  stretched.  It  has  a  tendency  to  remain  tranquil  for 
many  years,  and  by  age  simply  increases  in  size.  It  occasiooilly  grows  to  enormous 
dimensions,  when  the  penis  may  become  buried  within  the  swelling,  but  never  proves 
dangerous  to  life.     It  causes  pain  and  requires  treatment  mainly  from  mechanical  causes. 

Hydrocele  of  the  Cord. 

Sv.MPTOM.-i  .\xi»  Diagnosis. — It  has  been  already  briefly  explained  how  a  hydrocele 
of  the  cord  may  be  produced,  and  under  what  circumstances  it  may  appear  as  a  diffused 
or  a  .so-called  ancysful  tumor.  It  has  likewi.se  been  shown  how  these  two  conditions  are 
but  modifications  of  the  .same  disease,  the  diff"u.seness  or  isolation  of  the  affections  being 
determined  by  the  adhesion  or  more  or  less  complete  closure  of  the  vaginal  process  of 
peritoneum  as  it  passes  downward  into  the  .•^crotum.  Thus,  a  conjenit<d  hyilroct^le  of  the 
cord  will  be  present  when,  from  a  want  of  closure  at  the  abdominal  orifice  of  the  vaginal 
peritoneal  process,  serous  fluid  can  gravitate  downward  toward  the  testis.  A  diffused 
hydrocelf  of  the  cord  will  be  .said  to  e.xist  when,  either  at  an  early  or  a  late  period  of  life, 
serous  fluid  collects  in  the  vaginal  peritoneal  process,  which  is  closed  above  at  the  inter- 
nal ring  and  below  at  any  point  above  the  upper  portion  of  the  testis,  while  in  a  third 
class  of  cases  an  eno/sted  hydrocele  of  the  cord  may  appear  as  a  small  isolated  bag  of 
serous  fluid  movable  with  the  cord  and  connected  with  it. 

situated  V»etween  any  of  these  points  (Fig.  42<l).  its  cir-  Fig.  420. 

cumscribed  nature  having  been  determined  by  a  more    /^^^  _—  -^_"~^-^"  ""~^    Ij/ 

complete  closure  of  the  vaginal  jieritoneal  process  and     %'  '^^; 
the  limited  space  into  which  the  effusion  has  taken  place.       T  "^ 

PATHfiLftOY. — Under  all  these  conditions,  however, 
the  pathology  of  the  affection  is  the  .same,  and  the  symp- 
toms indicating  its  presence  vary  only  according  to  the 
size  and  tension  of  the  .«ac  which  contains  the  fluid.  In 
the  congenital  form,  in  which  a  communication  exi.sts 
with  the  peritoneal  cavity,  the  hydrocele  will  fluctuate 
and  have  a  smooth  and  uniform  outline,  but  it  can  never 
be  tense.     It  will  also  disappear  more  or  less  readily 

by  pressure  or  by  elevating  the  testicle  on  the  patient  Encrsted  Hy.in.ceie  of  the  rord. 

assuming  the  recumbent  position,  when   the  fluid  will 
gravitate  into  the  abdominal  cavity  with  a  rapidity  which  varies  according  to  the  size  of 
the  peritoneal  communication. 

In  the  diffused  hydrocele  of  the  cord  this  disappearance  of  the  swelling  by  rest  or 
pressure  will  not  take  place,  for  in  such  the  opening  of  the  vaginal  process  will  have 
closed  naturally.     The  tumor  will  thus  appear  as  a  baggy  or  tense  elastic  swelling  in 


;/ 


726 


AFFECTIONS  OF  THE  GESITAL   ORGANS. 


tlie  inguinal  canal,  which  it  will  more  or  less  fill.  It  will  give  to  the  hand  a  sensation 
of"  fluctuation,  and  in  certain  instances  may  appear  translucent.  It  will,  moreover,  on 
any  traction  of  the  testicle,  be  found  movable  and  painful  in  proporrtion  to  the  amount 
of  tension  of  the  cyst  or  of  the  inflamniatory  action. 

In  the  more  localized  or  apparently  cystic  hydrocele  of  the  cord  the  same  symptoms 
will  present  themselves.  The  tumor  will  be  more  isolated,  probably  more  movable  and 
more  tense,  and  it  will  be  readily  acted  on  also  by  any  traction  on  the  testis.  It  may 
occur  as  a  single  cyst  or  as  many  cysts,  but  each  will  present  the  same  symptoms.  When 
a  single,  tense,  movable  cyst  exists,  it  may  be  mistaken  for  a  distinct  morbid  growth ; 
but  the  diagnosis  of  the  case  ought  not  to  be  diflBcult  when  care  is  observed.  Fig.  420 
well  illustrates  the  ordinary  appearance  of  the  affection. 

Treatment  of  Vaginal  Hydrocele  of  the  Testis. 

In  the  conyenltul  hijdrucelt  of  young  life  surgical  treatment  should  be  very  sim- 
ple, for  the  disease,  as  a  rule,  readily  disappears  with  age  and  increasing  strength.  A 
little  cold  lotion  applied  to  the  part,  such  as  a  solution  of  the  hydrochlorate  of  ammonia, 
and  tonic  medicine,  is  frequently  sufficient  to  effect  a  cure  ;  for,  as  I  have  already  stated, 
the  effusion  into  the  vaginal  sac  in  these  instances  seems  to  be  often  of  a  passive  nature. 
The  hydrocele  found  in  infancy  is  not,  however,  always  of  the  congenital  form.  A  hydro- 
cele may  exist  in  an  infant  in  which  there  is  no  communication  with  the  peritoneal 
abdominal  cavity  through  the  neck  of  the  vaginal  process,  and  under  the.se  circum- 
stances a  different  treatment  may  be  required.  Cold  lotions  and  tonics  may  be  of  use, 
and  certainly  should  be  primarily  employed ;  yet  in  many  instances  the  treatment  will 
fail  to  cure  the  case.  Acupuncture  may  be  then  employed  and  the  fluid  allowed  to  escape 
into  the  cellular  tissue  around  the  sac,  when  it  may  be  altogether  removed  by  al)Sorption  ; 
but  this  treatment  is  not,  as  a  rule,  satisfactory,  it  being  exceptional  for  a  permanent 
recover}'  to  be  secured  by  such  means,  and  I  am  disposed  to  think  it  better  practice  to 
draw  off  the  fluid  by  means  of  a  fine  trocar  and  canula.  and  to  excite  some  fresh  action 
in  the  membrane  lining  the  tunica  vaginalis  by  stirring  it  up  with  the  end  of  the  canula. 
This  practice  has  been  very  successful  in  my  experience. 

In  early  examples^,  when  the  hydrocele  is  still  small  and  consequently  of  little  incon- 
venience, it  is  well,  perhaps,  to  leave  it  alone ;  for  unless  it  causes  anxiety  to  the  patient 
or  proves  troublesome  or  inconvenient  from  its  size,  there  is  no  necessity  for  interference. 
In  vfTji  old  ]>f<ip1e  it  is  as  well  not  to  interfere  unless  a  strong  necessity  exists,  as  slough- 
ing of  the  scrotum,  suppuration  of  the  sac,  and  other  bad  results  occa.sionally  occur  in 
these  cases  from  slight  causes.  It  must  be  added  that  the  feelings  of  the  patient  as  to 
the  amount  of  pain  and  inconvenience  are  the  best  guide  to  interference,  verj-  slight 
enlargement  causing  as  much  pain  in  some  patients  as  a  greater  increase  in  others.  If, 
then,  some  treatment  be  demanded,  simple  tapping  should  be  performed  as  a  primary 
measure,  the  fluid  being  drawn  off  by  means  of  a  moderate-.sized  trocar  and  canula.  In 
doing  this  some  care  is  necessary,  although  the  operation  is  really  simple,  as  difficulties 
are  often  made  by  the  operator,  while  dangers  result  from  want  of  caution. 


The  Tapping  of  a  Hydrocele. 

As  a  point  of  primary  importance,  the  true  position  of  the  testicle  should  be  defined. 

In  the  majority  of  cases  it  will  be  found  at  the  posterior  part  of  the  tumor  and  toward 

its  lower  part,  unless  the  hydro- 
FiG.  421.  0g]g    )}g   very   large.     At    times, 

however,  as  has  been  ob.'jerved, 
it  will  be  found  in  front,  from  a 
congenital  malpo.sition.  as  well 
as  in  certain  other  cases  which 
are  difficult  to  explain.  The 
true  position  of  the  gland  can 
generally  be  made  out  by  manip- 
ulation, and  further  by  the  want 
of  transluceney  in  the  tumor  at 
the  part  it  occupies.  Having 
made  out  to  a  fair  certainty  the 

position  of  the  testis,  the  tumor  .should  be  taken  in  the  left  hand  and  grasped  firmly  at 


Tapping  a  Hydrocele. 


TREATMEST  OF  IIYDROCEIJ-:   OF   TlfE  CORD.  727 

its  nock,  tlic  siir<ri'nii  (iikiii>;  care,  at  tlic  saiiic  time,  tn  stretcli  tlic  iMtc<;iiiiictit  well  over 
the  cvst  uikI  to  niiilcr  its  wall  teiist;  and  uiiyicMiii;;  (  FifT.  421).  Tlie  trocar,  with  weli- 
fittiiiLT  eaimla  (haviiiir  hei'ii  previoirsly  well  oileil ;.  .should  tlieri  )»(!  taken  in  the  ri;;lit 
lianil,  with  the  index  linger  placed  ahout  three-((iiartcrs  ol"  an  inch  IVoni  the  extremity  of 
till'  caniila,  while  the  front  ol"  the  tliumh  rests  on  its  flan<.'e.  The  oliject  of  this  position 
of  the  tin<;er  is  to  prevent  the  instrument  ^oinjr  in  t(jo  far  with  a  rush  and  therel)^' 
endaiiirt'i'ini;  the  testicle;  the  ol)ject  of  that  of  tlnr  thumh  is  to  press  home  the  caniila 
as  the  trocar  is  l»ein<;  withdrawn.  The  tumor  should  he  punc-tured  at  its  lower  jtart.eare 
l)eini;  taken  to  avoid  any  larjjje  vein.  an<l  the  fluid  allowed  to  run  out.  IIavin<r  completely 
emptied  the  cyst,  the  punctured  intejiument  should  he  firmly  held  and  nipped  up  with 
the  thumh  and  finder  of  the  left  hand,  and  tlie  cunulu  should  be  withdrawn.  A  little 
cold  air  or  the  irritation  of  the  finjrer  <;enerally  cau.ses  sufficient  contraction  of  the  darto.s 
to  close  the  wouiul  and  prevent  hemorrhaire  or  any  further  escape  of  the  remainintr  fluid. 
A  jtiece  of  lint,  however,  may  he  ai»plied  over  the  jMuicture  for  jmrposes  of  cleanliness 
and  to  prevent  friction. 

In  certain  examples  of  this  di.sea.se  in  the  adult  I  have  been  induced  to  stir  up  the 
cy.st  as  I  have  descrilted  in  the  hydrocele  of  the  young,  and  have  met  with  some  succe.s.s. 
In  no  instance  has  any  evil  c()nse(|uenee  resulted  from  the  practice,  and  in  several  a  cure 
has  taken  place,  evidently  from  inflammation.  I  would  advise  thi.s  practice  to  be  con- 
fined, however,  to  young  adults.  As  a  palliative  practice  it  is  scarcely  necessary  to  rec- 
ommend any  other  than  that  described,  as  it  is  siinf)le.  more  efficacious  than  any  other, 
and  not  more  dangerous.  Acupuncture  has  been  advised,  but  it  has  no  practical  advantage 
over  the  simple  tapping,  and  it  is  certainly  less  .successful  in  its  result.  In  exceptional 
cases  it  may  be  good,  particularly  in  such  a  case  as  Mr.  Curling  has  described,  on  the 
authority  of  Mr.  Luke,  of  a  gentleman  who  was  about  to  proceed  to  a  part  of  the  world 
where  surgical  advice  could  not  be  secured,  and  where  the  patient  could  then  perform 
this  simple  operation  on  himself.  I  have  more  than  once  known  a  patient  to  tap 
himself. 

The  period  of  relief  which  a  patient  experiences  from  a  siiuple  tapping  varies  exceed- 
ingly from  a  few  weeks  to  many  years,  and  even  in  the  same  patient  the  interval  will  be 
found  to  vary  from  time  to  time.  In  the  young  and  middle-aged  adult,  when  the  general 
health  is  sound  and  a  return  of  the  eftusion  has  taken  place,  unless  any  personal  objection 
should  be  made,  it  is  generally  advisable  to  adopt  some  plan  for  a  more  permanent  cure. 
In  old  men  it  is  the  soundest  practice  to  rest  .satisfied  with  the  palliative  treatment,  and 
in  such  the  radical  cure  should  Vje  proposed  only  in  exceptional  cases. 

Treatment  of  Hydrocele  of  the  Cord. 

The  principles  of  treatment  which  have  been  laid  down  in  ca.ses  of  hydrocele  of  the 
testis  are  likewise  applicable  to  those  of  hydrocele  of  the  cord,  their  application  requiring 
only  such  modifications  as  may  be  demanded  by  the  altered  position  of  the  affection.  In 
tlie  c(>ii(fi)i!t<il  hydrocele  no  special  treatment  is  required,  becau.se  as  .strength  comes  to 
the  child  the  fluid  probably  will  be  reabsorbed ;  failing  this  result,  tonics  .should  be  given 
to  expedite  the  cure,  and  some  cold  lotion,  such  as  the  chloride  of  ammonium  with  vin- 
egar 3J  to  Oj,  should  be  applied. 

In  the  diffused  or  enajstad  hydrocele  of  the  child  or  adult  more  active  treatment  is 
frequently,  though  not  in  all  cases,  demanded ;  the  fluid  will  at  times  disappear  without 
treatment,  though  it  may  recur  at  a  later  date ;  still,  the  aflfection  cea.ses  to  trouble,  and 
unless  some  real  inconvenience  is  produced  by  its  presence  it  is  as  well  to  leave  things 
alone.  When,  however,  pain  or  inconvenience  is  experienced,  something  must  be  done; 
and  no  doubt  the  best  practice  is  to  evacuate  the  fluid.  In  small,  tense,  encysted  hydro- 
celes the  practice  of  evacuating  the  fluid  by  acupuncture  is  certainly  sound,  since  tapping 
by  the  trocar  and  canula  is  an  operation  of  some  difficulty  where  the  cyst  is  small.  It 
may  be  done  with  any  needle,  but  those  employed  for  cataract  are  probably  the  best,  and 
several  openings  .should  be  made.  Tapping  may  be  employed  as  in  any  other  case  of 
ordinary  hydrocele.  I  have  on  several  occasions  efl^ected  the  radical  cure  by  injection, 
and  have  not  met  with  any  bad  results.  "When  this  treatment  fails  and  further  ujcasures 
are  demanded,  as  a  last  resource  an  incision  into  the  cyst  may  be  made. 

Radical  Cure  of  Hydrocele. 

It  is  not  necessary  to  review  all  the  various  plans  which  have  been,  and  are  now, 
employed  for  the  permanent  cure  of  a  hydrocele  of  the  tunica   vaginalis.     It   will   be 


728  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

more  to  the  purpose  to  give  the  line  of  practice  which  is  most  successful,  and  which  at 
the  same  time  is  very  simple — viz.,  the  injection  of  the  cyst  with  a  solution  of  iodine. 
It  is  not,  perhaps,  a  question  of  much  importance  whether  the  fluid  should  be  concen- 
trated or  diluted,  or  whether  it  should  be  permanently  left  in  the  cyst  or  withdrawn  after 
a  few  minutes  have  been  allowed  for  it  to  act  upon  the  secreting  surface  ;  such  minor 
difl"erences  may  be  left  to  the  fancy  of  the  operator.  My  own  judgment  leans  toward 
the  practice  of  injecting  from  two  to  four  drachms  of  a  mixture  of  equal  parts  of  the 
tincture  of  iodine  and  water  and  allowing  it  to  remain,  care  being  taken  that  tlie  canula 
is  previously  well  pushed  home  into  the  cyst,  and  that  no  iodine  solution  is  allowed  to 
escape  into  the  cellular  tissue  outside  the  sac.  By  this  practice  a  radical  cure  is  almost 
certain  to  be  secured,  and  only  exceptionally  does  any  failure  or  evil  result  follow.  The 
American  surgeons  are  fond  of  injecting  from  half  a  drachm  to  a  drachm  of  pure  carbolic 
acid  liquefied  with  water  or  glycerin  into  the  sac,  and.  Dr.  Levis  reports,  with  success. 
In  obstinate  cases  a  free  incision  into  the  tunica  vaginalis  and  the  filling  of  the  cavity  with 
carbolic  or  iodoform  gauze,  to  make  it  fill  up  by  granulation,  is  also  to  be  recommended. 
When  a  cure  does  not  occur,  it  is  generally  due  to  the  fact  that  a  hydrocele  has  been 
injected  when  some  inflammation  of  the  testicle  coexists,  and  from  which  it  has  been 
produced.  In  all  examples  of  hydro-testitis  the  practice  of  injection  must  be  looked 
upon  as  injurious  and  as  treating  the  result  of  a  disease,  and  not  the  disease  itself — the 
effect,  and  not  the  cause.  Within  the  last  few  years,  where  the  iodine  has  failed,  I  have 
often  used  warm  water  as  an  injection.  It  answered  well,  but  set  up  more  inflammatory 
action  than  the  iodine ;  indeed,  in  several  cases  it  excited  suppuration.  Some  of  the  Dub- 
lin surgeons  speak  highly  of  the  practice  of  introducing  into  the  sac  of  the  tunica  vag- 
inalis a  grain  or  more  of  the  biniodide  of  mercury  made  into  a  paste  with  some  grease, 
and  I  have  followed  this  practice  in  some  cases  with  advantage.  I  prefer,  however, 
the  iodine  treatment. 

Encysted  Hydrocele  of  the  Testis. 

On  examining  the  testis  of  the  adult  after  death  it  is  by  no  means  an  uncommon 
occurrence  to  meet  with  small  cysts  connected  with  the  epididymis.  These  may  be  sin- 
gle or  multiple,  and  in  many  instances  are  very  numerous.  These  cysts  are  generally 
more  or  less  pedunculated,  and,  as  a  rule,  are  connected  with  the  upper  portion  of  the 
epididymis.  They  are  filled  with  a  clear,  watery  fluid  which  contains,  in  certain  cases, 
some  granules. 

Pathology. — The  pathology  of  the  formation  of  these  cysts  is  somewhat  difficult  to 
understand,  and  surgically  is  of  small  importance,  since  they  seldom,  if  ever,  become  of 
sufficient  size  to  cause  inconvenience  or  to  require  any  operative  interference ;  indeed, 
they  are  rarely  diagnosed  during  life,  and  are  discovered  oidy  on  post-mortem  dissection. 

Another  kind  of  cyst  is  occasionally  met  with  connected  with  the  testis,  and  in  close 
contact,  if  not  associated,  with  the  epididymis.  It  has  been  described  as  the  encysted 
hydrocele.  It  springs  from  the  same  part  as  the  smaller  cyst,  but  grows  to  much  larger 
dimensions  and  generally  contains  a  very  different  kind  of  fluid.  Its  origin  is  as  obscure 
as  the  former  kind  of  cyst.  It  enlarges  very  slowly,  does  not  give  rise  to  any  pain,  nor 
does  it  produce  any  inconvenience  other  than  that  caused  by  its  size.  It  seldom  requires 
treatment  in  its  early  stage,  and,  as  a  rule,  many  years  are  allowed  to  pass  before  inter- 
ference is  demanded,  the  tumors  frequently  developing  for  twenty  years  or  more  before 
advice  is  sought.  These  cases  are  by  no  means  so  common  as  the  ordinary  vaginal 
hydrocele,  not  more  than  five  per  cent,  of  the  cases  of  hydrocele  being  of  this  kind. 

A  cyst  is  occasionally  developed  between  the  tunica  albuginea  of  the  testis  and  the 
tunica  vaginalis  testis,  the  pathology  of  which  is  very  obscure.  Mr.  S.  Osborne  suggests 
— and  I  think  with  good  reason — that  this  is  merely  an  enlargement  of  the  corpus  or 
hydatid  of  Morgagni,  a  constant  structure,  existing  as  a  pedunculated  vesicle  situated 
between  the  summit  of  the  globus  major  and  the  body  of  the  testicle,  between  the  visce- 
ral layer  of  the  tunica  vaginalis  and  the  tunica  albuginea  (>SV.  Thomas  s  Ho^.'pital  Report, 
1874).  Cases  of  this  kind  are  described  by  Curling  and  Hutchinson.  Guy's  Museum 
contains  a  specimen.  I  know  of  no  means  of  diagnosing  their  existence.  Their  treat- 
ment would  be  similar  to  that  of  other  cysts. 

Symptoms  and  Diagnosis. — In  an  early  stage  of  encysted  hydrocele  the  diagnosis 
is  not  dfiicult,  as  the  cyst  usually  appears  as  a  kind  of  budding  of  the  testis,  or  rather 
of  the  upper  portion  of  the  epididymis ;  as  a  tense,  hard,  globular,  and  in  some  cases 
pendent,  tumor  more  or  less   intimately  connected  with   some  portion  of  the  spermatic 


ENCYSTKD   IIYDIWVKLE   OF  THE   TESTIS.  729 

duct.  It.  is  «;cii('rally  disci ivi-red  on  tlic  i»iirt  of  tlic  patient  \\y  accident,  and  wlicii  as 
large  as   the   natural   testicle   has   Iteen   (iccasimially   set    down   as  an   extra   nrj^an. 

The  surj^eon  is  not  often  c<insulted  in  such  a  case  in  its  curly  sta<re,  the  tumor  usually 
havin<:  ln-eii  allowed  to  j^row  to  an  inconvenient  size  before  advice  is  soufiht.  in  f'orniing 
a  diagnosis  the  history  of  the  ease  will  ol'ten  at  (dice  throw  some  light  upon  its  nature, 
and  ill  all  prohahility  it  will  he  lound  that  the  increase  has  heen  extri.'mely  slow,  twenty 
years  or  miu-e  (d"ten  intervening  hel'ore  the  cyst  attains  anything  like  a  large  size.  The.se 
encysted  hydroceles  probahly  never  grow  so  fast  nor  accpiire  such  dimensions  as  the  more 
cummon  vaginal  species. 

The  next  feature  demanding  attention  in  the  development  of  these  cysts  is  their  shape 
and  outline,  which  are  often  rather  striking.  They  never  in  their  early  stage,  and  rarely 
at  any  time,  assume  the  appearance  (»f  ordinary  vaginal  hydrocele,  ami  almost  always 
maintain   a   gloliular  outline. 

The  position  of  the  testis  in  its  relation  to  the  cyst  next  claims  attention,  and  a  marked 
diftereiiee  exists  between  the  encysted  and  the  vaginal  hydrocele.  In  the  vaginal,  as  a 
rule,  it  is  to  be  found  at  the  }»osterior  part  of  the  sac  when  the  tumor  is  small  toward  its 
lower,  when  large  toward  its  upper,  part.  In  the  eiicjsted  it  is  to  be  found  in  front,  to 
one  side,  or  below,  and  rarely  at  the  posterior  part.  The  reason  for  this  is  easily 
exjilained.  The  cyst  is  usually  connected  with  the  epididymis,  which  normally  lies  at  tlie 
[•osterior  part  of  the  gland. 

The  nature  of  the  cystic  contents  differs  also  in  many  points  from  the  fluid  of  a  vagi- 
nal hydrocele,  and  is  very  characteristic.  In  the  raginal  hydrocele  the  fluid  has  been 
described  as  being  generally  clear,  like  the  serum  of  the  blood,  more  or  less  albuminous, 
of  a  straw  color,  and  at  times  spontaneously  coagulable,  blood  and  cholesterin  also  being 
occasional  elements.  In  the  fluid  of  an  encysted  hydrocele  none  of  the.se  elements  are 
generally  present,  but,  as  a  rule,  it  is  a  limpid,  feebly  saline,  watery  liquid  :  at  times  it  is 
slightly  opalescent,  as  if  mixed  with  milk,  and  then  it  will  be  found  to  contain  some 
granules  in  suspe»ision.  and  fre({uently  spermatozoa.  Cystic  hydrocele  differs  from  the 
vaginal  in  the  slowness  of  its  growth,  its  globular  outline,  the  anterior  position  of  the 
testicle,  and  the  nature  of  its  cystic  contents. 

The  origin  of  the  spermatozoa  in  these  cysts  is  a  point  of  peculiar  interest,  and  has 
been  a  disputed  point  with  pathologists  for  many  years.  Mr.  Curlings  investigations  on 
this  subject  have  proved  that  in  some  instances  their  presence  is  certainly  due  to  the 
rupture  of  one  of  the  spermatic  tubes  which  pass  over  and  are  in  close  connection  with 
the  walls  of  the  cyst,  this  rupture  generally  taking  place  from  an  injury  and  being  indi- 
cated by  some  rapid  increase  in  the  .size  of  the  cyst.  Mr.  Curling  has  shown  that  this 
history  was  given  in  several  of  the  cases  in  which  spermatozoa  were  found,  and  in  some 
he  was  even   able  to  demonstrate  a  distinct  communication    between   the  cyst  and  the 

spermatic  tube.     The  following  case  tends  to  support  his  views.     Robert  P ,  ast.  tlO, 

came  under  my  care  at  Guy's  Ho.spital  on  December  28,  I860,  with  an  encysted  hydro- 
cele of  the  left  testicle  of  twenty  years'  growth.  The  increase  had  been  very  .slow  until 
the  la.st  month,  when  the  tumor  had  doubled  its  normal  size,  this  rapid  growth  having 
followed  an  injury  produced  by  a  fall.  When  first  under  my  observation,  the  scrotum 
contained  an  irregular  cystic  tumor  on  its  left  side,  evidently  made  up  of  several  cysts, 
of  which  three  of  large  size  could  readily  be  distinguished,  two  being  very  tense,  while 
the  third  was  baggy.  The  testis  was  found  on  the  inner  side  of  the  tumor.  Tapping 
was  at  once  resorted  to  and  the  lai'gest  cyst  emptied,  many  ounce.?  of  a  milky  fluid  being 
drawn  off.  The  second  tense  cyst  was  then  tapped  through  the  same  opening,  with  a 
similar  result,  and  the  fluid  collected  in  a  distinct  glass.  The  third  cyst  was  also  tapped, 
but  in  this  the  fluid  was  quite  watery.  The  fir.st  two  contained  abundance  of  sperma- 
tozoa, while  the  third  did  not  contain  any.     A  good  recovery  took  place. 

Trkat.mext  of  Encysted  IIyi»rocele. — However  interesting  the  two  forms  of 
hydrocele  which  we  have  just  been  considering  may  be,  both  in  their  pathology  and  in 
their  points  of  difference,  the  treatment  in  the  two  cases  is  practically  alike.  When  any- 
thing is  required  to  be  done,  simple  tapping  may  suffice,  and  as  a  primary  measure  it 
should  always  be  preferred ;  but,  should  the  radical  cure  be  required,  the  injection  of 
iodine  may  be  carried  out.  The  slow  growth  of  these  cysts,  however,  and  the  equally 
slow  reaccumulation  of  their  contents  after  tapping,  are  points  which  indicate  the  pro- 
priety of  adopting  the  palliative  treatment  in  the  majority  of.  cases. 


730  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

Ruptured  Hydroceles 

It  is  well  known  that  in  children  hydroceles,  as  a  rule,  disappear  spontaneously  with 
little  or  no  treatment,  but  in  adults  such  a  result  is  must  uncommon.  Messrs.  Pott, 
Cui'ling,  and  Sir  B.  Brodie  relate  cases  of  this  kind,  and  attempt  to  explain  the  process 
by  which  such  a  recovery  takes  place  with  more  or  less  success.  A  single  instance  of  the 
kind  has  passed  under  my  hands  for  treatment. 

Charles  C .  aet.  04,  came   to  Guys  Hospital   on  January  29.  1863.  with  a  hydro- 

•cele  of  the  left  testis  the  size  of  a  cocoanut.  It  was  of  two  years"  standing,  and  had  been 
tapped  six  times,  under  my  care  each  time.  He  came  under  my  notice,  at  length,  when 
I  was  about  to  leave  the  hospital,  and  I  did  no  more  than  examine  the  parts,  which  were 
tense  and  painful,  telling  the  patient  to  return  to  me  in  the  course  of  a  few  days  to  be 
relieved.  When  he  came  the  following  week,  all  indication  of  swelling  had  completely 
■disappeared,  the  man  assuring  me  that  he  had  gone  to  bed  the  night  of  the  second  day 
before  his  visit  with  a  large  tumor,  and  that  when  he  awoke  it  had  disappeared.  He 
added  also  that  on  the  following  morning  he  had  passed  a  large  quantity  of  thin  urine. 
The  patient  was  a  steady  man  and  a  widower,  and  told  his  tale  with  all  the  appearance 
of  truth  and  with  some  astonishment.  In  three  months  the  fluid  had  again  collected,  and 
he  was  tapped.  This  case  was  doubtless  an  example  of  subcutaneous  rupture  of  the 
tunica  vaginalis. 

In  the  following  cases  the  rupture  took  place  without  hemorrhage.     Rob.  M ,  set. 

^Q^  came  under  my  care  in  1879  for  a  hydrocele  of  the  right  testis.  It  commenced  six 
years  before  and  steadily  increased  up  to  one  year  and  a  half  ago.  when  he  accidentally 
struck  it,  and  in  four  or  five  hours  the  whole  swelling  had  disappeared.  He  remained 
well  for  three  months,  when  it  began  to  increase,  and  on  admission  the  tumor  was  the 
size  of  a  fist.     It  was  tapped  and  injected  with  iodine  with  success.    ' 

At  times  rupture  of  the  tunica  vaginalis  is  followed  by  a  blood  tumor,  and  this  occurs 
■when  any  large  vessel  is  ruptured.     It  took  place  in  the  following  case. 

R.  B-^ ,?ei.  50,  came  under  my  care  in  July,  1879,  with  a  large  scrotal  tumor.     He 

said  that  his  right  testicle  had  been  large  for  years,  but  that  he  had  never  been  tapped. 
Four  days  before  his  admission,  when  sitting  at  his  desk,  he  felt  a  pain  in  his  scrotum, 
and  on  putting  his  hand  to  it  he  found  it  enlarging,  whilst  the  swelling  of  the  testicle  was 
rapidly  diminishing.  The  scrotum  continued  to  increase  for  three  days,  when  it  ceased 
to  do  so,  and  he  came  to  Guy's.  When  admitted,  the  scrotum  was  very  large  and  in  cir- 
cumference measured  twenty-three  by  sixteen  inches.  It  was  uniformly  smooth  and  but 
slightly  painful.  The  groin  had  an  ecchymosed  appearance  and  was  brawny.  Ice  was 
applied.  On  the  fifth  day  I  cut  into  the  tumor  and  evacuated  from  the  scrotal  integu- 
ments a  mass  of  blood.  Having  done  this,  a  rent  about  two  inches  long  was  clearly  visi- 
ble in  the  tunica  vaginalis,  and  within  this  cavity  was  blood-stained  serum  and  clot.  On 
turning  this  out  the  testicle  was  visible.  The  cavity  was  cleared  out,  washed  with  iodine 
water.and  drained ;  and  in  the  course  of  two  weeks  the  patient  was  well,  the  cavity  hav- 
ing granulated. 

The  nature  of  these  cases  is  not  generally  recognized. 

HEMATOCELE. 

As  the  term  "hydrocele  "  is  applied  to  the  efi'usion  of  serous  fluid  into  the  sac  of  the 
tunica  vaginalis  and  of  its  tubular  prolongation  upward  to  the  internal  ring,  as  well  as 
into  the  c^'sts  which  have  been  already  described  as  being  connected  with  the  testis,  so 
the  term  ""  hfematocele  "  is  employed  to  designate  an  effusion  of  blood  into  the  same 
parts.     We  thus  have — 

A  vaginal  and  an  encysted  hematocele  of  the  testis. 

A  diffused  and  an  encysted  hfematocele  of  the  cord. 

Haematocele  may  occur  in  an  organ  which  had  not  previously  shown  any  symptom  of 
disease,  or  it  may  be  associated  with  a  hydrocele.  It  may  appear  spontaneously  without 
an  injury  or  as  the  result  of  a  blow,  strain,  or  the  tapping  of  a  hydrocele.  It  may  attack 
patients^  at  any  period  of  life,  and  in  certain  rare  cases  at  a  very  early  age.  even  in 
infancy.  I  have  the  records  of  a  case  in  which  it  was  said  to  have  made  its  appearance 
at  two  years  of  age. 

In  the  notes  of  my  cases  various  cau.ses  have  been  assigned  for  its  production.  In 
more  than  one  instance  "  it  appeared  gradually  without  any  known  cause."  In  another 
"  it  occurred  when  hard  at  work  pushing  a  wheelbarrow,  something  giving  way  with  a 


ii.kmatockij:.  7:U 

snap."  In  the  majority  it  ''anK'  on  us  an  iniineiJiatc  conseipu'rice  of  a  hlow,  and  in 
several  as  the  result  of  tlie  ta|>|iin;:  of  a  liytlrorele.  In  all.  however,  the  result  was  the 
.sanie — a  nmre  or  less  rapid  furniatioii  of  a  tuiiiur  in  tin-  po>itii»n  or  iici;.'Jil(()rhood  of  the 
testiele. 

Sy.mI'To.m.s  ani>  iM.viiNusi.s. — The  symptoms  of  a  lutMnatocele  wiiieh  lias  made  it.s 
apjiearanee  witiioiit  any  injury  or  assiirned  cause  are  very  ohseure.  and  are  jiretty  weli 
summed  up  in  the  jtromiiient  one  of  a  LMailual  and  uniform  eidar^rement  of  the  orr;an.  The 
sweliinj;  will  vary  in  shape,  as  in  a  hydroeele.  hut.  like  it  also,  may  pre.sent  a  more  or  les.s 
pyriform  outline.  The  testiele  will  always,  in  the  vaf^inal  lufuiatoeele  (on  careful  manipu- 
lation hein<:  matle),  he  detected  somewhere  in  the  sac.  and  usually  at  its  jiosterior  and 
lower  part,  the  peculiar  testicular  sensation  heinj;  jiroduced  hy  sliirht  pressure. 

When  caused  hy  a  sudden  strain  or  injury,  the  enlar<:ement  will  he  more  .sudden  as 
well  as  rapid,  and  ho  found  to  follow  dose  upon  the  receipt  of  the  accident,  while  the  rup- 
ture fA'  the  hlood  vessel  may  he  announced  liy  the  sensation  of  a  >udden  snap  or  jriving 
way. 

The  local  symptoms  are  similar  to  those  already  described. 

The  tumor,  on  its  tirst  appearance,  may  l»e  somewhat  soft  and  fihscure  or  clear  fluctua- 
tion may  he  detected  in  it  ;  hut  if  much  time  he  allowed  to  pass  before  coming  under 
observation,  this  fluctuation  will  not,  in  all  probability,  be  made  out.  for  the  eflfu.sed  blood 
rapidly  coagulates  and  irive.s  rise  to  the  .sensation  of  a  solid  growth.  The  sac  of  the 
haematocele,  whether  tunica  vaginalis  or  cyst,  rapidly  alters  in  character  and  becomes 
thick,  and  in  certain  eases  fibrinous,  or  even  cartilaginou^5.  at  first  from  the  coagulation 
of  the  fibrin  of  the  blood  u])on  its  inner  surface  and  in  ca.ses  of  longer  standing  from  di.s- 
tinct  inflammatory  changes  brought  about  by  the  presence  of  the  blood  acting  as  foreign 
matter.  In  some  instances  this  thickening  of  the  cyst  is  very  great,  even  to  the  extent 
of  half  an  inch. 

When  a  hiematocele  has  followed  tipon  a  hydrocele,  there  will  usually  be  a  sudden 
enlargement  of  the  part  after  the  strain  or  injury,  accompanied  with  more  or  less  pain, 
this  pain  apparently  depending  upon  the  amount  of  distension  to  which  the  cyst  ha.s  been 
subjected.  If  it  follows  the  operation  of  tapping,  it  will,  as  a  rule,  be  recognized  by  the 
escape  of  more  or  less  blood  or  bloody  fluid  at  the  time  of  operation  and  the  rapid  refill- 
ing of  the  hydrocele  sac  or  cyst  with  a  more  solid  and  opaque  material. 

To  form  a  correct  diagnosis  of  hj^matocele  the  history  of  the  case  is  most  important — 
indeed,  more  so  than  the  local  symptoms  ;  for  it  is  certainly  true  that  by  the  latter  alone, 
in  some  instances,  it  is  almost  impossible  to  make  out  the  true  nature  of  the  affection. 

Sr.MMAKV. — By  way  of  summary,  it  may  be  stated  that  a  haematocele  is  usually  a 
uniformly  smooth,  tense,  and  HO?i-transparent  tumor  with  an  liuUstinct  sen.sation  of  fluctu- 
ation, but  with  iJUtinct  evidence  of  testicular  pain  on  pressure.  It  may  be  accompanied 
with  pain  during  the  early  period  of  the  afl^'ection.  from  the  distension  of  the  cyst,  but  not 
at  a  later  date  or  during  its  chronic  stage,  unless  softening  down.  As  time  passes,  it  will 
become  harder  if  no  .symptoms  of  inflammation  show  them.selves,  but  on  their  manifesta- 
tion evidence  of  suppuration  will  soon  appear:  for  h:ematoceles  have  not,  as  a  rule,  a  dis- 
position to  remain  quiet,  like  hydroceles,  but  tend  to  open  outward  by  the  breaking  up  of 
the  coagulated  blood  which  has  been  effused,  and  the  inflammatory  process. 

The  symptoms  which  indicate  the  presence  of  a  Jtfnmotocrle  of  the  spermatic  cord  a^re 
somewhat  similar  to  those  already  described  for  vaginal  hfematocele,  the  difference  in 
locality  being  remembered.  It  is  generally  produced  by  a  blow  or  strain,  as  in  the  ordi- 
nary vaginal  hiismatocele.  It  can  be  diagno.sed  by  the  suddenness  of  its  appearance  or  the 
suddenness  of  the  enlarged  hydrocele  sac.  by  the  opacity  of  the  swelling  and  tendency  to 
consolidation  which  it  pos.ses.ses,  also  by  the  accompanying  ecchymosis  of  the  parts. 
Cases  are  recorded  by  Bowman.  Curling,  and  others  in  wliich  this  di-sease  obtained  enor- 
mous dimensions,  but  such  examples  are  very  rare,  the  affection  being  very  uncommon. 

Source  of  the  Blood. — A  very  common  question  with  students  is  as  to  the  origin 
of  the  blood  in  these  cases  of  lu^matocele.  and  in  the  spontaneous  cases  and  those  follow- 
ing a  strain  or  injury  with  an  apparently  sound  testis  this  question  is  diflieult  to  answer 
with  certainty  of  accuracy.  There  can  be  little  doubt,  however,  that  a  distinct  rupture 
of  some  of  the  vessels — probably  veins — which  ramify  upon  the  body  of  the  testis  or  on 
the  tunica  vaginalis  mu.st  have  taken  place. 

When  occurring  upon  a  hydrocele  or  after  the  operation  of  tapping,  it  is  probably  due 
to  the  distinct  rupture  or  perforation  of  one  of  the  large  veins  which  ramify  outside  the 
tunica  vaginalis,  into  its  interior,  or  of  one  belonging  to  the  body  of  the  testis. 

Scarpa  relates  a  case  of  hjematocele  in  which  the  spermatic  artery  was  wounded,  find 


732  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

Sir  A.  Cooper  another,  in  which  a  distinct  rent  in  the  tunica  vaginalis  was  found  on  dis- 
section.    This  latter  condition  is  probably  the  most  common. 

Treatment. — The  treatment  of  hemorrhage  into  the  tunica  vaginalis  testis,  or  cord, 
differs  in  no  respect  from  the  treatment  of  hemorrhage  into  any  other  part  of  the  body. 
In  the  very  earliest*  period  of  its  occurrence  rest  in  the  horizontal  posture  with  the  testi- 
cles well  raised  and  the  application  of  cold,  either  as  ice  in  a  bag  or  by  means  of  the 
metallic  tube,  are  the  most  efficient  means  to  arrest  the  flow  of  blood  and  relieve  pain. 
By  such  means  the  blood  may  also  be  reabsorbed  and  all  future  mischief  prevented. 
Should  the  blood,  however,  remain  fluid  for  a  long  time  and  no  symptoms  of  reabsorp- 
tion  or  of  inflammatory  action  manifest  themselves,  it  is  a  sound  practice  to  draw  off'  the 
fluid  contents  with  a  trocar  and  canula.  I  have  had  a  case  in  which  this  course  was 
adopted  with  good  effect. 

If  signs  of  inflammation  appear  soon  after  its  occurrence,  cold  lotions  and  leeches, 
with  the  aid  of  saline  purgatives,  may  occasionally  be  found  efficient  in  arresting  its  prog- 
ress and  to  allow  of  the  subsequent  reabsorption  of  the  effused  blood.  But  should  symp- 
toms of  suppuration  show  themselves,  or  of  the  softening  down  of  the  coagula,  a  free 
incision  into  the  cyst  or  tunica  vaginalis  is  the  only  sound  practice,  the  whole  semi-solid 
contents  being  thoroughly  turned  out  and  the  interior  of  the  sac  allowed  to  granulate.  In 
old  and  chronic  cases  with  thickened  sac  walls  the  same  treatment  is  also  effectual.  I 
possess  the  records  of  many  cases  in  which  this  plan  was  carried  out  with  marked  benefit 
— in  one  case  of  only  four  months'  duration,  and  in  another  of  twenty-nine  years',  in  which 
the  tunica  vaginalis  was  at  least  half  an  inch  thick,  and  in  both  a  good  recovery  followed. 
I  need  hardly  add  that  excision  is  rarely  called  for  in  the  treatment  of  these  cases, 
although,  owing  to  difficulties  in  the  diagnosis,  recourse  may  occasionally  have  been 
had  to  it.  I  have  seen  several  such  instances,  but  beyond  the  loss  of  the  organ  no  evil 
resulted.  In  old  cases  of  haamatocele  in  aged  subjects  the  practice  of  excision  is  probably 
the  best,  but  in  the  young  and  middle-aged  it  cannot  be  advised.  The  treatment  of 
haematocele  of  the  cord  is  to  be  conducted  on  similar  principles. 

ON  DISEASES  OF  THE  TESTICLE. 

Inflammation  of  the  Testicle. 

Under  the  term  orchitis  most  authors  have  been  in  the  habit  of  including  the  inflam- 
mation of  two  distinct  portions  of  the  testicle  and  of  mixing  up  the  symptoms  of  two 
affections,  to  the  prevention  of  a  sound  and  clear  understanding  of  the  subject.  In  this 
chapter  I  shall  separate  the  two  and  describe  inflammation  of  the  epididymis  as  one  affec- 
tion and  inflammation  of  the  true  secreting  gland  as  another,  calling  the  former  epiduly- 
mitii>  and  the  latter  orchitis.  In  certain  cases,  it  is  true,  both,  structures  are  involved  in 
the  inflammatory  action,  and  to  this  state  I  shall  apply  the  term  tesfitis,  the  three  words 
accurately  indicating  the  true  seat  of  the  malady,  their  use  consequently  tending  to 
facilitate  its  better  study. 

All  surgeons  will  be  ready  to  admit  the  distinctness  of  these  two  parts  anatomically 
and  physiologically — viz.,  the  epididymis  and  the  gland.  It  is  as  well  also  to  acknowledge 
that  pathologically  they  are  constantly  divided,  and  I  am  certain  that  to  the  student  of 
the  affections  of  this  organ  such  a  division  tends  to  a  more  ready  discrimination  and 
appreciation  of  the  several  diseases  of  the  testicle. 

As  a  preliminary  to  the  more  special  clinical  and  pathological  consideration  of  these 
diseases,  the  following  observations  of  Sir*  J.  Paget,  as  given  by  Curling,  upon  the  devel- 
opment of  the  epididymis  and  testis  may  be  read  with  interest  and  advantage. 

Sir  J.  Paget  observes  ''  that  in  the  normal  course  of  human  development  the  proper 
genital  organs  are  in  either  sex  developed  in  two  distinct  pieces — namely,  the  part  for  the 
formation  of  the  generative  substance,  the  testicle  or  ovary  ;  and  the  part  for  the  convey- 
ance of  that  substance  out  of  the  body,  the  seminal  duct  or  ovi-duct.  The  testicle  or 
ovary,  as  the  case  may  be  (and  in  their  earliest  periods  they  cannot  be  distinguished)  is 
formed  on  the  inner  concave  side  of  the  corpus  Wolffianum,  and  the  seminal  or  ovi-duct, 
which  is  originally  an  isolated  tube  closed  at  both  extremities,  passes  along  the  outer 
border  of  that  body  from  the  level  of  the  formative  organ  above  to  the  cloaca  or  common 
sinus  of  the  urinary,  genital,  and  digestive  systems  below.  The  perfection  of  develop- 
ment is  attained  only  by  the  conducting  tube  acquiring  its  just  connections  at  once  with 
the  formative  organ,  and  through  the  medium  of  the  cloaca  with  the  exterior  of  the  body. 
The  sexual  character  is  first  established  when  in  the  male  the  formative  and  conducting 


EI'IDIDYMITIS,    on    IM'LAMMATloy    OF   THE  SEMIS  A  L    DUCT.  T-'i.'i 

orj^ans  bocoine  coiiiu'ctcil  hy  tlic  tlcvolopiiH'iit  of  iiiteniKMliatL-  tubes  wliidi  con.stitute  the 
epiditlyiiiis,  or  wlioii  in  I  ho  I'euiah'  a  siiiiph;  apcrtun-  is  fDinu'd  at  tin;  upp»!r  extreiiiities 
of  tlic  i-iiii(Iiirtiiii;  tube  ami  is  placed  elosely  adjacent  to  the  I'orinative  urfraii.  in  both 
sexes  alike  the  lower  extremities  of  the  eonduetint^  tub(!S  first  open  into  the  common 
cloaca,  and  subseijuently,  when  that  cavity  is  jiartitioned  into  the  blailder  and  re(;tuni.  or 
bladder,  vay;ina,  and  rectum,  they  ac(|uire  in  eacdi  their  just  cf)nnections,  and  b(;conie  in 
the  male  the  perfect  vasa  deferentia,  and  in  the  female  Kallo|)ian  tubes  and  uterus." 

T  will  remind  the  student  tliat  the  epididymis  naturally  forms  the  pijsterior  and  outer 
]).irt  of  the  testicle,  ami  the  secretins?  portion  or  true  f^land  the  anterior;  that  the  ffjriner 
in  a  j)erfectly  healthy  state  is  only  indistinctly  felt,  the  vas  deferens,  on  being  traced 
downwanl  from  the  cord,  losiiiir  itself,  as  it  were,  in  this  part.  The  body  of  the  gland 
can  always  be  made  out  by  its  smooth  ami  elastic  globular  form. 

Epididymitis,  or  Inflammation  of  the  Seminal  Duct. 

Inflammation  of  the  epididymis  may  be  caused  by  some  local  inguinal  injury  or  the 
pressure  of  a  truss,  but,  as  a  rule,  it  is  a  consecutive  afiection  and  occurs  in  a.s.sociation 
with  a  urethritis,  gonorrhueal  or  otherwise,  or  as  the  result  of  some  irritation  of  the  pros- 
tatic urethra,  such  as  the  presence  of  a  calculus  or  the  passage  of  a  sound  or  lithotrite. 
It  is  caused  by  an  extension  of  inflaunnation  from  the  urethra  down  the  vas  deferens  to 
the  epididymis,  and  is  an  inflammation  of  the  seminal  (hirf,  and  not  of  the  seminal  gland. 
It  generally  comes  on  suddenly  and  is  attended  with  considerable  pain,  a  marked  enlarge- 
ment of  the  epididjMuis  or  posterior  part  of  the  testicle  forming  its  chief  local  .symptom. 
It  is  constantly  i)receded  by  severe  pain  in  the  anal  and  iliac  fossjx;  and  accompanied  by 
special  tenderness  of  the  part,  this  tenderness  being  readily  traceable  up  the  cord,  which 
is  occasionally  swollen  and  (edematous.  It  is  usually  attended  with  uedenia  and  redness 
of  the  scrotum  over  the  inflamed  tu])e. 

The  eidargement  of  the  e])ididymis  is  very  rapid,  and  in  some  instances  very  great. 
It  invariably  assumes  a  special  outline  when  uncomplicated — that  is,  when  confined  to 
this  special  part — the  epididymis  appearing  of  a  boat  or  truncated  half-moon  shape,  hold- 
ing the  body  of  the  testicle  in  its  concavity.  The  lower  portion  of  this  body  is  usually 
the  most  enlarged,  being  composed  of  the  greater  number  of  the  convolutions  of  the 
tubes,  and  consequently  containing  more  connective  tissue,  since  it  is  from  the  infiltration 
with  inflammatory  eff'usion  of  this  connective  tissue  around  the  inflamed  seminal  duct 
that  this  enlargement  is  produced. 

The  affection  generally  is  acute,  comes  on  suddenly,  runs  a  rapid  cour.se,  and  is  accom- 
panied in  most  patients  by  some  constitutional  disturbance.  In  some  subjects  this  is  very 
severe,  while  in  others  it  is  of  a  milder  description,  the  sharpne.ss  of  the  inflammation  and 
the  peculiarity  of  the  patients  influencing  the  severity. 

It  is  at  times,  however,  complicated  with  other  conditions,  such  as  an  inflammation  of 
the  true  secreting  poj-tion  of  the  testicle  ;  but  this  complication  invariably  occurs  as  a 
secondary  symptom,  and  is  produced  by  the  direct  extension  of  the  disease  from  the  sem- 
inal duct  to  the  gland.  I  have  never  seen  a  genuine  orchitis  or  inflammation  of  the  sem- 
inal gland  as  a  result  of  gonorrhoea,  except  as  an  extension  of  the  inflammation  from  the 
epididymis,  and  it  is  in  quite  exceptional  examples  of  this  affection  that  the  body  of  the 
testicle  is  ever  involved. 

AVhen  the  inflammation  has  extended  to  the  gland  itself,  the  diagnosis  is  readily  made, 
the  enlargement  and  great  tenderness  of  the  part  clearly  indicating  what  is  the  matter. 
The  whole  organ  presents  an  expanded  biit  flattened  aspect,  the  swelling  of  the  epididy- 
mis posteriorly  and  of  the  body  of  the  testis  anteriorly  producing  this  peculiar  laterally 
flattened  outline.  The  two  inflamed  parts  will,  however,  be  always  felt  distinct  from  each 
other  and  can  be  readily  distinguished.  There  is,  however,  a  second  complication  of 
epididymitis  more  common  than  that  just  described,  which  is  the  effusion  of  fluid  into  the 
tunica  vaginalis,  or  the  production  of  an  acute  hydrocele  ;  and  I  am  disposed  to  think 
that  it  is  this  apparent  swelling  of  the  organ  which  has  given  rise  to  the  mistaken  idea 
that  orchitis  is  a  common  affection  after  gonorrhoea.  The  enlargement  of  the  organ  from 
such  a  condition  is,  however,  very  different  from  that  already  described  as  due  to  an 
inflamed  gland.  It  is  more  globular,  tense,  and  ela.stic ;  it  is  certainly  equally  painful 
with  that  affection,  but  its  true  nature  can  be  readily  made  out  by  its  translucency  and  the 
presence  of  fluctuation  on  palpation.  It  is  the  result  of  a  direct  extension  of  the  inflam- 
mation from  the  epididymis  to  the  tunica  vaginalis,  and  the  following  explanation  of  its 
occurrence  by  Gendrin.  as  given  by  Curling,  who  assents  to  its  soundness,  seems  most 


734  AFFECTIONS  OF  THE  GENITAL   OEGANS. 

satisfactory,  since  it  is  certainly  borne  out  by  clinical  observation.  He  says,  '•  When  the 
subserous  cellular  tissue,  which  always  participates  in  the  inflammation  of  a  serous  mem- 
brane, penetrates  into  the  interior  of  an  organ,  it  becomes  a  ready  means  of  communicat- 
ing the  inflammatory  action  ;  but  when  the  contiguous  organ  in  subjacent  parts  is  of  a 
different  structure  from  that  of  the  cellular  tissue,  the  extension  of  inflammation  inward 
is  checked.  Thus,  in  the  case  of  the  inflamed  tunica  vaginalis  the  cellular  tissue  readily 
transmitted  the  morbid  action  to  the  epididymis,  but  the  tunica  albuginea  arrested  its 
progress  to  the  body  of  the  testicle ;  and  this  explains  the  fact  that  after  inflammation 
of  the  tunica  vaginalis  excited  by  injection  the  body  of  the  gland  is  rarely  found  to  suffer. 
On  the  other  hand,  the  epididymis  is  seldom  attacked  with  inflammation  without  the  dis- 
ease being  quickly  propagated  to  the  tunica  vaginalis.  The  hydrocele,  as  a  rule,  however, 
disappears  as  the  disease  subsides  in  the  epididymis,  it  being  exceptional  for  the  former 
condition  to  remain  when  its  cause  has  been  removed. 

As  a  consequence  of  this  epididymitis,  it  is  by  no  means  uncommon  for  a  considerable 
thickening  of  the  seminal  ducts  and  of  their  surrounding  cellular  tissue  to  remain  for 
many  weeks,  or  even  months.  In  the  majority  of  cases,  however,  this  result  does  not 
take  place;  for  in  the  healthy  subject  there  is  every  reason  to  believe  that  with  the 
inflammation  all  effusion  disappears  and  the  organ  is  left  as  sound  as  it  was  before.  In 
the  cachectic  patient  this  happy  event  does  not,  however,  always  take  place,  and  more  or 
less  thickening  of  the  inflamed  part  will  generally  be  observed,  the  epididymis  feeling 
indurated  and  enlarged  and  in  parts  nodulated  and  cordy.  It  has  been  a  disputed  point 
by  pathologists  whether  this  condition  ever  leads  to  an  atrophy  or  destruction  of  the  tes- 
ticles or  whether  it  has  any  influence  upon  the  true  function  of  the  organ  in  causing  ster- 
ility, and  upon  this  point  I  have  no  positive  facts  to  adduce,  though  I  have  certainly  seen 
a  wasting  of  the  glandular  structure  of  the  testicles  after  inflammation  the  result  of  an 
epididymitis.  In  one  instance  I  witnessed  inflammation  of  the  body  of  the  testis  in  a 
young  man  who  married  at  a  time  when  he  had  a  marked  induration  of  the  epididymis 
the  result  of  an  attack  of  inflammation  some  months  previously.  I  entirely  attributed 
the  inflammation  in  his  case  to  the  retention  of  seminal  secretion  from  the  obstruction  to 
the  seminal  duct  the  result  of  the  old  epididymitis,  since  we  know  that  all  ducts  or  canals, 
when  surrounded  by  organized  inflammatory  products,  are  liable  to  obstruction  or  stric- 
ture, and  it  is  only  right  to  believe  that  the  spermatic  ducts  are  obedient  to  the  same  law, 
although  this  result  may  not  be  very  common. 

On  the  dictum  of  Sir  A.  Cooper  it  has  generally  been  asserted  that  the  left  testis  is 
more  often  attacked  in  cases  of  epididymitis  than  the  right,  but  Curling's  figures  and  my 
own  disprove  the  truth  of  this  assertion,  and  show  that  in  202  cases  of  this  affection  the 
right  testis  was  the  seat  of  the  disease  in  113  examples,  the  left  in  74.  and  both  glands  in 
15.  The  right  organ  is,  therefore,  more  often  affected  than,  the  left,  while  in  hydrocele  the 
left  side  is  the  most  frequent  seat  of  disease. 

With  respect  to  the  cause  of  the  disease,  I  took  some  pains  during  the  eight  years  I 
was  registrar  at  Gruy's  to  find  out  the  correctness  of  the  general  opinion  that  the  epididy- 
mitis usually  supervened  on  the  disappearance  of  the  urethral  discharge  and  was  relieved 
on  its  reappearance,  or  if  it  could  be  traced  to  any  peculiarity  in  the  treatment  of  the  gon-. 
orrhcea,  to  any  neglect,  or  other  cause.  I  have  to  confess  that  I  was  not  able  to  connect 
these  phenomena  in  any  way,  as  the  epididymitis  made  its  appearance  during  all  stages 
of  the  complaint  and  under  every  kind  of  condition — when  injections  were  employed,  and 
when  they  were  not;  when  copaiba  and  cubebs  had  been  taken,  and  when  they  had  not — 
although  in  some  cases  the  diminution  of  the  discharge  and  appearance  of  the  epididymitis 
were  coincident;  but  such  a  result  is  only  consistent  with  the  general  rule  that  an  inflam- 
mation set  up  in  one  part  tends  to  relieve  an  inflammation  existing  in  another,  and  more 
particularly  in  a  neighboring  tissue.  The  disease,  however,  appeared  in  the  majority  of 
cases  of  neglected  gonorrhoea,  and  in  others  in  which  strong  injections  had  been  recklessly 
employed,  but  more  particularly  in  the  cachectic  and  irregularly  living  patients  who  had 
been  utterly  regardless  of  their  affection  and  taken  no  means  to  keep  the  testes  well  sus- 
pended. 

Treatment. — The  treatment  of  this  affection  must  depend  upon  the  intensity  of  the 
inflammation  and  the  severity  of  the  local  and  constitutional  symptoms  which  it  produces. 
Eest  in  the  horizontal  posture,  with  elevation  of  the  testes,  or  even  of  the  pelvis,  active 
purgatives,  with  saline  medicines,  combined  in  acute  cases  with  tartar  emetic  or  colchicum 
wine,  are  advantageous  ;  the  local  application  of  ice,  hot  poppy  fomentations,  or  swathing 
the  parts  in  cotton-wool  are  often  sufficient  to  check  the  disease  at  its  onset  and  prevent 
its  passing  into  a  chronic  stage.    It  is  also  a  wise  measure  to  administer  an  opiate  at  night. 


Acrri:  oiicurns,  on  isfi.ammatios  or  the  skmisal  oi.amis.    7;55 


Wlu'ii  till'  liical  sviii|>ii>iiis  ami  |tiiiii  an-  very  si'Vciv,  Iccclics  may  Jh'  applitMl  to  tlu'  ricrk 
oftlu'  tiiiijur,  iir  one  nftlic  tiirjri"!  veins  in  tlic  scrotnni  (i|i('ni'»l.  Tlic  use  of  ini-rciiry  ilucs 
not  a|t]t('ar  tn  lie  til'  much  value  except  as  a  puTL^e. 

If  the  patient.  Imwever,  I'nmi  social  reasons,  olijeets  or  is  unalile  to  keep  at  rest,  tiie 
parts  must  he  well  supported  hy  a  suspenst»ry  bandage;  and  a  very 
efficient  suspeiisor  is  l'(inne<l  hv  a  handkerehiel"  folded  crossways  in 
a  triani:le.  the  apex  of  which  is  well  hraeed  up  posteriorly  hy  a  piece 
of  tape  or  handa^e  and  the  haso  attaclu'd  firmly  to  a  hand  hroujrht 
round  the  waist  (  Kiir-  \--).  The  same  treatment  must  then  lie  jiur- 
sued  as  we  have  already  indicated.  A  hetter  mode  of  sujiportinj;  the 
testicles  is  by  attaehinu;  two  loops  of  tape  three  or  four  inches  ajiart 
to  the  central  jiortion  of  the  jiosterior  fla|i  of  the  shirt,  and  tw<»  lon<^ 
tapes  to  the  bottom  of  the  shirt  front.  On  drawinj:'  the  jiosterior  flap  y* 
between  the  leiis  atid  loopintr  the  front  tapes  throuiih  the  jiosterior 
loops  a  most  comfiu'table  and  efficient  support  is  obtained. 

Tlu'  treatment  by  compression  by  means  of  strappinjr  or  an  india- 
rubber  bail  has  also  been  strongly  advocated.  1  have  used  it  but 
little  ill  the  acute  affection,  although  in  the  more  chronic  or  sub- 
acute, when  the  disease  has  passed  into  an  inactive  stage  and  little  remains  behind  but 
the  product  of  the  inflammatory  process,  the  treatment  by  j)ressure  appears  very  valu- 
able— indeed,  more  so  than  any  with  which  I  am  acquainted,  nothing  tending  more  to 
hasten   the  absorjition  of  the  iiiflatiimatory  product   (Fig.  420). 

Vidal's  plan  of  puncturing  the  tunica  vaginalis,  or  even  the  testis  itself,  has  been 
freely  practised  by  some  Knglish  surgeons,  and  Mr.  II.  Smith  speaks  highly  of  its  value. 
I  have,  however,  never  seen  a  case  calling  for  so  severe  a  measure.  When  tension  exists, 
an  incision  into  the  tunica  vaginalis  may  be  made  with  impunity;  but  I  should  hesitate 
to  puncture  the  testicle  unless  suppuration  were  present. 

If  mercui'y  is  ever  needed  in  this  affection,  it  is  at  the  chronic  stage  ;  as  its  power 
doubtless  lies  in  its  tendency  to  produce  disintegration  of  inflammatory  products,  so  it 
prevents  the  organization  and  subsequent  contraction  of  such  in  and  around  the  spermatic 
ducts,  and  thus  guards  against  the  special  evil  effects  of  epididymitis.  When  I  have  had 
occasion  to  use  it,  I  have  done  so  as  an  ointment  applied  wuth  pressure  to  the  part ;  but 
how  far  the  good  results  which  I  have  had  from  the  practice  have  been  due  to  the  pres- 
sure alone  T  am  unable  to  say.  Of  late  I  have  been  accustomed  to  employ  simple 
pressure  in  these  cases,  an.d  have  no  reason  to  believe  my  success  has  been  le.ss  fiivorable 
than  previously. 

If  suppuration  takes  place  as  a  consequence  of  epididymitis — a  result  which  occasion- 
ally happens — it  is  well  to  open  the  abscess  early  and  freely  ;  by  such  a  practice  the 
discharge  finds  easy  vent  and  the  formation  of  sinuses  is  prevented.  Simple  dressing  to 
the  part  and  the  use  of  the  suspen.sory  bandage  are  the  best  subsequent  local  means, 
while  tonics  and  good  living  are  generally  required. 


Acute  Orchitis,  or  Inflammation  of  the  Seminal  Gland. 

Orchitis  or  inflammation  of  the  seminal  gland  as  an  acuh;  affection,  for  the  most  part, 
occurs  as  the  result  of  an  injury,  but  it  appears  at  times  .spontaneously  without  any  such 
cause,  and  more  particularly  in  connection  with  parotiditis  or  mumps.  It  may.  too,  be 
due  to  an  extension  of  inflammation  from  the  epididymis  or  spermatic  duct,  but  it  rarely 
if  ever  takes  place  as  a  primary  affection  in  connection  with  urethritis  or  gonorrhcea. 

Acute  orchitis  may  also  attack  the  gland  in  its  descent  into  the  scrotum.  The  follow- 
ing case  illustrates  this  fact  :  Robert  H ,  aet.  12,  was  brought  to  me  at  Guy's  Hos- 
pital on  June  20,  1859,  and  as  he  walked  into  the  room  it  w\is  at  once  observed  that  his 
body  was  bent  unusually  forward  and  his  movement  much  restrained.  The  ricjlit  testicle, 
not  having  descended  from  the  abdomen,  could  not  be  felt,  and  the  left  had  first  shown 
itself  at  the  external  ring  three  days  before  the  boy's  application.  Pain  in  the  groin, 
extended  upward  toward  the  loin,  had  been  experienced  for  two  weeks  previously.  The 
testicle,  which  had  pas.sed  down  the  canal  and  partially  through  the  external  ring,  was 
about  as  big  as  an  e^^  and  remarkably  tender.  The  horizontal  posture  was  ordered  to  be 
maintained,  with  the  thigh  flexed  and  cold  lotion  or  ice  applied.  In  three  days  the 
symptoms  had  somewhat  abated,  and  at  the  end  of  the  week  the  swelling  was  much  less. 
On  July  11,  or  the  twenty-first  dav  after  coming  under  observation,  the  testicle  had 
passed  the  external  ring,  although  resting  close  to  it  in  the  scrotum.     In  another  week 


736  AFFECTIOXS   OF  THE  GEMTAL    ORG  ASS. 

all  pain  had  subsided  :  the  testis  was  free,  and  the  patient  disappeared  from  observation, 
being  quite  well. 

On  August  16.  1S71.  I  saw  with  Mr.  Forman  of  Stoke  Newington  a  boy  aet.  14  with 
acute  inflaoimation  of  the  left  testis,  which  was  at  the  internal  ring.  It  was  accompanied 
with  such  severe  local  and  abdominal  pain,  con.stipation.  and  vomiting  as  to  lead  Mr. 
Forman  to  suspect  the  presence  of  a  hernia.  I  saw  the  patient  with  these  symptoms, 
and.  finding  an  inflamed  painful  inguinal  swelling  the  size  of  an  e^o^.  I  explored  it  with  a 
scalpel  and  discovered  a  tunica  vaginalis  filled  with  pus  and  a  small  undeveloped  testis. 
All  the  symptoms  .speedily  subsided  after  the  operation,  and  a  good  recoverv  en.sued. 

Symptoms. — The  symptoms  of  acute  orchitis  are  very  marked  and  its  diagnosis  is 
ea.sy,  for  the  rapid  enlargement  of  the  body  of  the  gland,  its  flattened  oval  form  and 
extreme  tenderness,  are  very  characteristic.  The  patient  will  complain  of  its  weight, 
and.  if  standing,  will  probably  as.sume  a  bent  posture.  The  disease  will  be  accompanied 
by  extreme  local  tenderness  and  pain  of  a  dull  aching  character,  which  p»asses  up  the 
loins,  round  the  hips,  and  often  down  the  thighs.  The  scrotum  will  probablv  manife.st 
some  .symptoms  of  inflammation,  such  as  swelling,  redness,  heat,  and  increased  vascular- 
ity. In  exceptional  examples  there  will  be  eff"usion  of  fluid  into  the  tunica  vaginalis,  but 
this  complication  is  not  so  common  after  acute  orchitis  as  after  epididvmitis.  for  reasons 
which  have  been  already  given. 

The  con.stitutional  symptoms  will  be  those  of  general  irritative  fever,  and  will  vary 
according  to  the  .susceptibility  of  the  subject  of  the  disease ;  in  some  cases  they  will  be 
very  severe,  and  in  others  less  so. 

As  a  rule,  it  may  also  be  asserted  that  acute  orchitis  tends  toward  recovery  and  seldom 
terminates  in  suppuration,  unless  it  be  of  the  tubercular  form  or  aflfecting  very  cachectic 
patients.  In  one  known  example  it  ended  in  gangrene  of  the  part.  This  case  was 
recorded  by  the  late  Mr.  Harvey  Ludlow  in  his  unpublished  Jacksonian  prize  es.say.  It 
was  under  the  care  of  Mr.  Stanley,  who  was  induced  to  cut  into  the  gland  from  the 
.severity  and  obstinate  character  of  the  pain,  and  a  black  gangrenous  cavity  was  exposed, 
which  was  seen  after  death  to  have  occupied  half  the  organ.  I  have  the  records  of  a 
case  in  which  the  patient  stated  that  one  testicle  sloughed  out  after  inflammation  six 
months  previou.sly  ;  the  man  came  under  treatment  for  inflammation  of  the  other.  The 
termination  by  suppuration,  however.  occa.sionally  takes  place,  and  numerous  are  the 
examples  of  this  condition  which  I  possess.  These  cases  may  also  at  times  end  favorably, 
the  abscess  healing  without  any  evil  result.  }>ut  too  frequently  the  di.scharge  of  the 
ab.s»ess  ends  in  what  has  been  variously  described  as  benign  fungus  of  the  testis,  granular 
swelling,  or  hernia  testis.  The  latter  is  the  most  correct  and  intelligible  name,  the  affec- 
tion being  the  result  of  rupture  or  ulceration  of  the  tunica  albuginea  and  the  gradual 
extrusion  or  hernia  of  the  tubuli  of  the  gland,  the  extruded  gland  being  covered  with 
granulations.  The  true  nature  of  this  affection  was  first  described  by  Sir  W.  Lawrence 
in  1808  ( Edinhiirffh  Med.  and  Surg.  Joinnal.  vol.  iv.  p.  257). 

Acute  orchitis  as  a  consequence  of  parotiditis,  or  mumps,  is  a  well- 
recognized  affection,  althougli  it  may  be  difficult  to  explain  the  connection  between  the 
two.  It  is  described  by  some  as  a  kind  of  meta.stasis.  but  there  are  no  published  facts 
tending  to  support  this  view ;  no  one.  however,  is  disposed  to  deny  that  the  one  affection 
occurs  in  connection  with  the  other.  The  disea.se  is  not  usually  very  .severe :  it  com- 
monly p»asses  away  with  little  treatment  and  leaves  the  testicle  sound,  few  cases  being  on 
record  of  atrophy  of  the  glands  attributable  to  this  disease.  The  symptoms  are  precisely 
similar  to  those  already  described,  and  need  no  further  illustration. 

Treatment. — The  ordinary  principles  of  treatment  applicable  to  local  inflammation 
in  general  are  to  be  acted  on  in  the  treatment  of  this  aff"ection.  Rest  in  the  horizontal 
posture,  with  elevation  of  the  parts,  and  cold  or  warm  fomentations  according  to  the 
relief  they  afford,  are  points  to  be  attended  to  :  leeching  the  groin  or  local  venesection  and 
saline  pnirgatives  with  sedatives  are  the  chief  remedies.  The  disea.se  has  a  tendency  to 
get  well  by  itself,  and  unless  badly  treated  or  neglected  or  attacking  very  cachectic  sub- 
jects this  will  generally  be  attained.  In  extremely  severe  examples,  when  the  inflamma- 
tion runs  high,  tartar  emetic  in  full  doses  is  a  mo.st  valuable  drug,  while  colchicum  in 
half-drachm  doses  of  the  wine,  with  saline  purgatives,  often  acts  like  a  charm.  Opium 
in  full  doses  may  also  be  given  where  pain  is  severe  and  con.stitutional  disturbance  great. 
A.n  acute  attack,  however,  generally  runs  its  course  in  about  ten  days,  and  seldom  ends 
otherwise  than  well. 


cininsic  (HK'iuTis.  7:57 

Chronic  Orchitis. 

Clirutiii'  iriflaniiiiatioii  is  the  must  comiiioii  nl'  the  true  diseases  of  tlie  seminal  ^'laiid, 
and  niav  t'ulliiw  the  acute  ancctinti  or  an  injury,  hut  most  t're((uetitly  it  is  indueed  hy 
some  special  constitutional  condition,  such  as  ^'out.  tuhi-rculosis,  and  more  jiarticularly 
syphilis. 

Sympto.ms. — The  jxeneral  symptoms  of  chronic  orchitis,  from  whatever  cau.se.  are 
much  alike,  although  they  differ  in  some  minor  hut  important  jxdnts.  In  tlic  sypiiilitic 
affection  the  symptoms  are  somewhat  peculiar,  and,  as  its  diajrnosis  is  important,  it  will 
receive  special  consideration.  The  subject  will  conse(|uently  l)e  divided  for  consideration 
into  the  ordinary  fttrms  of  chronic  orchitis  and  syphilitic  orchitis.  Chronic  inflammation 
of  the  testicle  comes  on  most  insidiously,  and  unless  it  follows  an  acute  attack  is  so 
unmarked  hy  any  special  symptom  and  unaccompanied  hy  pain  that  it  is  often  oidy  by 
the  increased  size  of  the  <rland  that  the  jiatient  is  induced  t«j  seek  advice.  In  .some  ca.ses, 
however,  this  swellinjr  is  acccunpanied  by  pain  of  a  dull  and  achinjr  character.  In  the 
early  stage  of  tlie  disease  the  gland  may  be  more  or  less  painful  on  manipulation,  but  in 
a  more  advanced  condition  or  in  a  very  chronic  case  no  local  pain  will  be  experienced 
even  on  somewhat  rough  manipulation  ;  and  in  these  examples,  on  firm  pressure,  the 
ordinary  testicular  sensation  will  fail  to  be  excited.  The  general  appearance  also  of  the 
testicle  the  subject  of  this  affection  is  somewhat  peculiar.  It  is  not  pyriform  or  globular, 
as  in  hydrocele  and  many  other  affections  of  the  gland,  but  has  a  peculiar  flattened  out- 
line from  side  to  .side,  and  a  smooth,  even  surface. 'unless  the  disea.se  be  a.s.sociated  with 
some  eff"usion  into  the  tunica  vaginalis,  when  the  tumor  will  naturally  assume  more  the 
shape  of  a  vaginal  hydrocele.  But  the  simple  affection  is  rarely  associated  with  such  a 
complicati(»n  ;  and  when  it  is,  the  fluid,  as  a  rule,  is  secreted  in  ver}'  small  quantities. 
The  epididymis,  in  exceptional  examples,  from  the  extension  of  the  inflammation  to  its 
tissue,  may  be  slightly  enlarged  and  thickened  ;  but  this  never  occurs  to  any  great  extent. 

There  are  also  seldom  any  constitutional  symptoms  worthy  of  remark,  except  in 
cachectic  and  irritable  patients,  when  the  dull  aching  pain  of  the  part  may  give  rise  to 
some  general  irritability  of  the  patient's  condition  and  an  anxious  expression  of  coun- 
tenance. 

Pathology. — The  pathology  of  this  affection  is  that  of  chronic  inflammation  of  any 
other  part,  and  consists  in  a  more  or  less  general  infiltration  of  the  gland  with  an  organ- 
izable  or  organized  material,  the  inflammatory  effusion  separating  the  secreting  tubuli 
and  affecting  them  in  ways  determined  by  the  amount  of  fibrin  poured  out  between  them 
and  the  amount  of  pressure  to  which  they  are  subjected,  the  inflammatory  product  in 
some  cases  being  very  generally  diffused  between  the  tubuli,  while  in  others  it  is  deposited 
in  irregular  masses.  When  the  material  poured  out  is  very  great  and  equally  diffused 
between  the  meshes  of  the  testis — /.  e..  when  the  disease  is  extensive  or  of  long  standing 
— that  condition  of  the  gland  is  probably  produced  which  is  indicated  by  an  utter  absence 
of  the  natural  sensation  of  the  organ  on  handling  or  on  firm  pressure,  and  under  such 
circumstances  there  is  the  greatest  anxiety  for  the  subse(|uent  maintenance  of  the  integ- 
rity of  the  organ,  tliough,  .should  the  disease  make  a  favorable  progress  toward  recovery 
and  the  inflammatory  product  be  reabsorbed,  the  pressure  will  be  proportionately  removed 
from  the  delicate  tubuli  of  the  organ  and  the  natural  testicular  sensation  be  restored. 

If  the  inflammatory  product  soften  down,  as  it  will  in  the  delicate  and  cachectic  sub- 
ject, suppuration  will  take  place ;  and  in  proportion  to  its  extent  will  be  the  liability  to 
a  hernia  testis. 

Again,  should  this  inflammatory  product  proceed  to  a  more  permanent  organization 
and  contract,  the  delicate  tubuli  of  the  testicle  will  suffer  in  proportion  to  the  extent  of 
the  part  involved,  and  an  atrophy  of  the  organ  be  the  result  as  a  consequence. 

All  these  complications  are  met  with  in  various  degrees  in  practice,  and  with  greater 
or  less  frequency,  the  general  condition  of  the  patient  having  a  more  important  influence 
in  determining  the  result  even  than  the  treatment  ;  but  I  nuiy  add  that  there  are  few 
affections  which  are  more  amenable  to  good  treatment  than  that  now  under  consideration. 

When  the  disease  is  remarkably  insidious  in  its  advance,  slow  in  its  progress,  and 
painless  in  its  character;  when  the  patient  is  cachectic  and  irritable,  with  an  anxious 
countenance,  a  disposition  to  a  hot  skin,  and  to  other  symptoms  of  con.stitutional  irri- 
tation;  and,  more  particularly,  when  the  disease  ends  in  suppuration,  as  in  all  probability 
it  may  when  coming  on  and  progressing  in  the  manner  just  indicated. — it  is  reasonable 
to  believe  that  the  organ  is  the  seat  of  tubercular  muchief,  and  that  it  disorganizes  as  a 
result.     It  must  be  added,  too,  that  in  these  cases  the  tubercular  affection  is  probably  of 


738  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

the  infiltrating  or  miliary  tubercular  form,  and  not  of  that  crude  nature  which  runs  a  dif- 
ferent course,  and  to  which  attention  will  subsequently  be  directed. 

In  gouty  inflammation  of  the  organ  the  symptoms,  as  a  rule,  are  not  so 
chronic  as  in  the  class  of  cases  to  which  we  have  just  alluded.  Indeed,  they  may  more 
rationally  be  described  as  being  of  a  subacute  nature ;  for,  though  generally  coming  on 
slowly,  they  are  manifested  by  gi'eater  local  tendei'ness  and  pain,  the  pain  being  consider- 
ably aggravated  at  certain  periods,  and  most  probably  at  night.  The  disease  has,  more- 
over, a  strong  tendency  toward  recovery,  and  not  toward  disorganization  of  the  testis. 
Besides  these  symptoms,  others  indicating  a  gouty  disposition  will  probably  be  present, 
such  as  acidity  of  stomach,  a  loaded  condition  of  the  urine,  and  a  more  or  less  distinct 
history  of  gout.  There  will  also  be  frequent  nocturnal  pains  of  a  darting  character  in 
the  opposite  testicle,  leading  the  patient  to  fear — what  is  by  no  means  rare — a  double 
attack  ;  and  when  these  pains  occur,  they  are  valuable  in  connection  with  others  as  diag- 
nostic symptoms. 

Symptoms  and  Diagnosis  of  Syphilitic  Orchitis. 

That  syphilitic  inflammatory  disease  may  attack  the  testicle  as  any  other  gland  or  tex- 
ture within  or  without  the  body  is  at  the  present  day  a  well-recognized  pathological  fact, 
and  the  credit  of  establishing  this  position  is  largely  due  to  my  colleague.  Dr.  Wilks.  In 
what  way  the  syphilitic  diifers  from  other  forms  of  inflammation  is  a  point  worthy  of 
consideration,  and,  fortunately,  the  points  of  diff"erence  are  neither  numerous  nor  deeply 
seated.  The  main  one  is  palpable  and  apparent,  foe  even  by  the  most  casual  observer  it 
is  readily  seen  that  in  syphilitic  inflammations  there  is  not  only  an  infiltration  of  the  part 
aflfected  with  an  organizable  or  organized  material  of  a  dense,  firm,  and  fibrous  structure, 
but  a  mai'ked  tendency  of  the  deposit  to  undergo  fibrous  changes.  We  see  this  in  every 
tissue  and  in  every  stage  of  the  disease.  We  see  it  primarily  in  the  almost  cartilaginous 
hardness  of  the  base  of  the  true  infecting  chancre ;  we  see  it  in  the  early  constitutional 
symptoms  of  syphilis  and  in  the  greater  permanency  of  skin-staining  in  the  diff'erent 
eruptions;  in  the  diff'erent  affections  of  the  mucous  membranes  in  all  their  parts;  in  the 
inflammation  of  the  eye,  cellular  tissue,  periosteum,  and  bone.  The  pathologist  sees  it, 
moreover,  in  the  varied  changes  found  after  death  in  the  internal  organs  of  the  syphilitic 
subject,  and  the  surgeon  sees  it,  likewise,  in  the  inflammation  of  the  testes  ;  for  in  the 
subject  of  hereditary  or  acquired  syphilis  the  testicle  may  at  some  period  of  the  disease — 
and  generally  at  a  late  one — become  the  seat  of  a  syphilitic  inflammation  which  manifests 
all  the  peculiarities  of  this  pathological  condition.  The  aff"ection  is  essentially  chronic — 
as  much  so  as  the  other  forms  of  chronic  orchitis — but  is  almost  invariably  confined  to 
the  body  of  the  gland,  and  rarely  affects  the  spermatic  duct.  It  is  quite  painless  in  its 
nature,  local  and  general,  the  patient  bearing  free  manipulation  without  flinching  and 
often  thinking  little  about  his  disease  except  from  the  increased  size  of  the  organ.  The 
special  sensation  of  the  gland  usually  disappears  at  a  very  early  stage  of  the  disease,  and 
there  is  rarely  any  constitutional  disturbance  accompanying  its  progress.  It  may  or  may 
not  be  associated  with  other  symptoms  of  constitutional  syphilis,  but  usually  appears 
alone. 

The  disease  manifests  itself  locally  in  a  special  manner  which  claims  attention.  It 
usually  affects  the  body  of  the  testis  and  both  testes  at  diflferent  periods  of  its  progress, 
though  rarely  at  the  same  time.  It  is  almost  always  complicated  by  the  presence  of  a 
vaginal  hydrocele,  which  at  times  increases  to  a  considerable  size,  and  much  more  so  than 
in  other  forms  of  chronic  orchitis.  The  most  characteristic  point  of  all.  however,  is  the 
remarkable  stony  induration  of  the  gland  and  its  peculiar,  irregular,  nodular  outline,  small 
fibrous  projections  from  the  body  of  the  gland  being  distinctly  visible  in  some  cases,  while 
in  others  loose  bodies  are  felt  in  the  tunica  vaginalis. 

Prognosis. — In  the  majority  of  cases  this  disease  terminates  by  resolution  and  appar- 
ently leaves  the  gland  intact,  although  in  many  a  gradual  wasting  of  the  testicle  is  the 
result,  which  ends  in  atrophy,  and,  as  a  consequence,  in  sterility.  In  exceptional  cases 
suppuration  with  or  without  hernia  testis  may  take  place.  The  disease,  too,  when  appar- 
ently cured,  has  a  remarkable  disposition  to  return  on  the  slightest  provocation. 

Treatment. — There  are  few  affections  more  amenable  to  treatment  than  chronic 
orchitis,  especially  when  taken  early,  and  there  are  none  which  better  prove  the  value  of 
pressure  and  mercurials  in  procuring  the  absorption  and  disintegration  of  inflammatory 
products.  In  the  common  as  well  as  in  the  syphilitic  orchitis  this  statement  holds  good. 
In  a  healthy  subject  with  good  powers  and  an  unbroken  constitution   any  form  of  mer- 


sv}rPTn}rs  axd  Di.i(;\ns/s  of  syriiii.rnc  oik  ii ins.  739 

curial  may  In-  adiiiiiiistcri-d,  such  as  liliu'  pill  in  fV)iir-<:ruiii  doses  or  th(!  [lorcliloridc,  or 
iiitTfurial  iiiiinctioii  with  tlic  nlcati-  oi'  incifiiry  is  likewise  hc^iieficial.  The  object  of  the 
sui'ijeon  is  neither  to  salivate  iior  to  hriii<;  the  patient  rapidly  under  the  influence  of  the 
remedy,  but  rather  t(»  ]troeure  a  leiij^thened  and  eijual  action  oi"  the  druj;  ujton  the  local 
disi'ase  ;  the  close,  therefore,  should  he  carefully  re;:uluted.  In  my  hands  the  iodide  of 
mercury  t:;iven  in  one-j;rain  doses,  with  live  L^rains  ol"  Dover's  powder  twici;  a  day.  or  tlie 
uu'rcurial  suppository,  has  proved  eminently  beneficial,  the  testicle  b(Mn<r  well  strapped  up 
by  common  soap  plaster.  (See  V'v^.  4liG.)  Iri  a  more  cachectic;  patiiMit  in  whom  mercury 
may  still  be  tolerated  the  same  treatment  may  be  employed,  thoujrli  in  smaller  doses; 
and  in  others  the  mercurial  may  l)e  locally  ap]»lied  iti  tlie  form  of  an  ointment,  or  as 
an  oleate  dissolved  in  oleic  acid  in  the  proportion  of  Kve  per  cent.  I)urinfr  this  time 
tonics  such  as  (|uiMinc  and  iron  may  be  administered  an<l  j^ood  livin;^  and  fresh  air 
enjoined. 

In  certain  examples,  however,  occurring  in  cachectic  patients  it  may  not  be  desirable 
to  administer  mercurials  in  any  shape  ;  under  such  circumstances  iodine  may  be  substi- 
tuted in  the  form  of  the  iodide  of  potassium  in  three-  or  four-grain  doses,  gradually 
increased  to  ten  or  twelve,  combined  with  half-drachm  doses  of  the  syrup  of  the  iodide 
of  iron  in  infusion  of  quassia,  three  times  a  day.  Locally,  strapping — or,  rather,  pres- 
sure— should  still  be  enforced.  In  hospital  practice  this  treatment  has  been  of  great 
value ;  by  it,  steadily  persevered  in  for  six  or  eight  weeks,  even  the  worst  of  cases  may 
be  expected  to  yield,  the  organ  gradually  becoming  softer  and  more  natural  in  sensation 
and  shape,  and  at  last  resuming  its  normal  condition. 

In  the  //""('/  form  of  orchitis,  which  can  be  recognized  or  suspected  by  the  symptoms 
already  quoted,  the  administration  of  colchicum  is  very  beneficial.  It  should  be  given 
in  small  doses  and  continued  for  several  weeks.  The  acetic  extract  in  half-grain  do.ses, 
with  Dover's  powder,  is  tho  best  form  ;  and  with  it  a  cure  may  generally  be  guaranteed. 
This  form  of  disease  is  easily  reduced  when  early  recognized.  It  is  more  liable,  however, 
than  other  forms  to  relapses,  but  less  so  to  disorganization  and  subsequent  atrophy. 

If  there  be  sudden  accessions  of  pain  in  the  part,  with  other  evidences  of  some  fresh 
inflammatory  attack,  the  application  of  a  few  leeches  with  hot  fomentations  is  very  ser- 
viceable ;  but  these  conditions  are  uncommon. 

When  vaginal  hydrocele  coexists  with  the  inflamed  gland — a  frequent  complication 
of  the  syphilitic  variety — it  is  a  good  practice  to  draw  off  the  fluid,  to  enable  the  surgeon 
to  apply  his  j»ressuve  with  more  certainty  and  better  effect.  It  is  of  no  use  to  attempt  to 
cure  the  hydrocele  itself,  as  it  must  be  remembered  that  the  hydrocele  is  the  direct  con- 
5e(|uence  of  the  diseased  testis,  and  that  it  is  of  little  use  to  treat  the  effect  of  a  diseased 
condition  and  not  its  cause.  Remove  the  latter,  and  the  former  will  probably  disappear; 
cure  the  orchitis,  and  the  hydrocele  will  generall}'  depart. 

I  have  the  records  of  a  case  which  passed  under  my  care  for  treatment  where  by 
some  oversight  this  attempt  had  been  made,  and  the  hydrocele  was  tapped  and  injected 
with  iodine  on  three  different  occasions  without  success.  Under  the  subsequent  treatment 
the  chronic  orchitis  disappeared,  and  with  it  the  hydrocele. 

It  is  not  always  desirable,  nor  is  it  possible  in  a  large  proportion  of  cases,  to  keep  the 
patient  absolutely  at  rest  during  the  process  of  treatment.  In  some  it  is  advisable  to  do 
so  as  much  as  possible,  particularly  when  the  patient  experiences  more  pain  and  inconve- 
nience when  walking  or  moving  about,  but  in  the  majority  of  cases  it  is  suflScient  to  keep 
the  parts  well  supported. 

In  the  consideration  of  the  treatment  of  chronic  orchitis  it  has  been  stated  that  a 
good  recovery  may  generally  be  secured  by  the  means  which  have  been  suggested  when 
the  disease  has  been  taken  in  hand  at  an  early  period  of  its  existence — that  is,  when  not 
niore  than  five  or  six  weeks  have  been  allowed  to  elapse.  But  in  cases  of  longer  standing 
the  prognosis  is  not  so  ftivorable,  as  regards  either  the  removal  of  the  disease  or  the  sub- 
se((uent  integrity  of  the  part  as  a  seminal  gland.  These  remarks  apply  more  particularly 
to  the  syphilitic  form  of  the  affection,  for  if  of  long  standing  the  fibrinous  matter  has 
generally  become  too  well  organized  for  future  ab.sorption ;  and  when  this  is  the  case  the 
subsequent  contraction  of  the  organized  product  will  almost  to  a  certainty  go  on  to  the 
destruction  of  the  seminiferous  tubuli  and  an  atrophy  of  the  gland.  In  Guy's  Hospital 
Museum  are  several  admirable  specimens  exhibiting  this  result. 

Again,  in  certain  examples  of  chronic  orchitis,  whether  syphilitic  or  otherwise,  sup- 
puration and  disintegration  of  the  gland  structure  will  take  place.  This'termination  may 
be  suspected  when  the  disease  is  of  a  very  torpid  character,  the  pain  of  a  constant  aching 
kind,  and  when  all  treatment  fails  to  influence  its  course. 


740  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

When  pus  has  formed,  its  early  evacuation  is  the  best  practice,  as  a  clean  incision  or 
puncture  into  the  part  often  prevents  that  destruction  of  the  glandular  structure  and  its 
fibrous  covering  which  usually  precedes  that  troublesome  affection,  hernia  testis. 

Tubercular  Disease  of  the  Testicle. 

Tubercular  disease  of  the  testicle  may  attack  any  part  of  the  organ — that  is,  either 
the  seminal  gland  or  its  duct,  or  it  may  affect  these  parts  separately  or  together.  It  may 
show  itself  either  in  the  form  of  an  infiltration  of  the  so-called  miliary  tubercles  or  in 
the  more  distinct  and  usual  condition  of  the  yellow,  cheesy,  unorganizable  material 
described  as  crude  tubercle.  When  it  appears  in  the  form  of  miliary  tubercle,  it  is  not 
characterized  by  any  very  definite  symptoms;  indeed,  the  infiltration  of  a  gland  with 
those  small  gray  miliary  bodies  seldom  makes  itself  known  by  any  outward  visible 
signs,  and  their  presence  should  be  suspected  only  when  a  rapid  disorganization  of  the 
part  takes  place  after  an  attack  of  acute  or  chronic  inflammation.  Organs  thus  infil- 
trated have  no  power  of  resisting  the  inflammatory  process,  and,  whether  it  be  a  lung  or 
a  testicle  which  is  the  seat  of  this  affection,  active  breaking  up  of  tissue  with  suppuration 
generally  ensues.  I  shall  exclude  from  present  consideration  those  interesting  cases, 
remembering  that,  while  pathologically  they  are  cleai'ly  to  be  recognized,  practically 
their  presence  can  be  suspected  only  when  the  riesult  to  which  I  have  already  alluded 
takes  place. 

Symptoms. — The  other  form  of  tubercular  testis  is  characterized  by  more  special 
symptoms  and  local  conditions.  It  may  involve,  as  already  stated,  either  the  body  of 
the  gland  or  the  epididymis,  but  doubtless  the  latter  is  the  more  frequently  diseased.  It  is 
generally  discovered  accidentally  by  the  patient,  and  frequently  not  until  some  secondary 
change  in  the  structure  is  about  to  show  itself.  It  appears  primarily  as  an  indolent,  pain- 
less enlargement  of  the  epididymis  and  is  usually  described  by  the  patient  as  a  lump  in 
the  testicle,  this  lump  appearing  generally  at  the  upper  part.  This  symptom,  in  all  prob- 
ability, is  the  only  one  to  which  attention  can  be  drawn  ;  and  the  surgeon  will  recognize 
it  at  once  on  manipulation,  for  the  tubercular  matter  will  feel  as  if  some  foreign  body,  as 
a  pea,  bean,  or  nut,  had  been  placed  between  the  convolutions  of  the  epididymis  or  in  the 
substance  of  the  gland.  The  gland  is  not  painful  on  pressure,  nor  in  its  inactive  stage 
does  the  disease  seem  to  cause  any  injurious  influence  on  the  organ,  which  is  otherwise 
natural  in  its  sensation  and  function. 

In  other  cases  the  disease  will  appear  as  a  general  infiltration  of  the  part  involved ; 
and  should  this  be  the  epididymis,  it  will  be  enlarged,  indurated,  and  nodular — painless, 
perhaps,  and  inactive,  the  body  of  the  testis,  apparently  sound,  resting  on  the  concavity 
of  the  affected  portion.  If  the  body  of  the  gland  be  the  part  affected,  like  symptoms 
will  be  present,  although  the  enlargement  will  show  itself  as  a  uniform  or  nodulated 
expansion  of  the  secreting  structure,  the  epididymis  or  seminal  duct  being  quite  dis- 
tinct. 

This  inactivity  of  the  disease,  however,  does  not  always  remain,  though  it  may  last 
months,  or  even  years ;  but  the  time  will  come  when  the  tubercular  matter,  in  all  prob- 
ability, will  soften  down,  and  thus  excite  some  increased  action  in  the  parts  around.  It 
may  be  that  this  increased  action  in  the  part  will  first  draw  the  patient's  attention  to  his 
affection,  when  the  history  of  some  previous  thickening  of  the  organ  will  for  the  first 
time  be  obtained.  When  inflammatory  symptoms  are  once  developed,  the  di.sease  will 
certainly  make  rapid  progress,  and  disintegration  of  this  unorganizable  tubercular  matter 
accompanied  by  suppuration  will  speedily  follow. 

In  tubei'cular  epididymitis — for  such  this  disease  may  be  named — local  suppuration 
will  soon  appear,  with  the  discharge  of  ill-formed  pus  and  dehria  as  a  curdy,  friable,  and 
granular  material,  and  after  this  sinuses  are  apt  to  form,  which  may  go  on  discharging 
for  a  period  depending  on  the  extent  of  the  disease  and  the  amount  of  foreign  material 
existing  to  disintegrate  and  soften. 

If  the  body  of  the  testicle  be  the  part  implicated,  the  same  gradual  softening  and 
suppuration  will  take  place  ;  but  too  often  it  will  be  followed  by  the  formation  of  the 
hernia  testis,  to  which  allusion  has  been  already  made.  It  is  not,  moreover,  in  every 
case  of  this  disease  of  the  testis  that  disintegration  of  the  tubercular  material  is  to  be 
expected,  with  its  accompanying  suppuration  and  abscess  ;  for  in  many  examples  no  such 
result  can  be  found,  this  tubercular  matter  undergoing  a  gradual  change  and  showing 
itself  after  death  as  an  earthy  concretion.  The  same  changes  take  place  in  the  testicle 
as  is  seen  in  the  absoi'bent  glands,  the  lungs,  and  other  parts. 


HKIIMA    TESTIS.  741 

TiiliiTciilar  disease  of  the  testis  may  neeur  at  any  ajre,  but  is  more  commdii  in  ;'<lult 
life.  The  hest  eXiinipK-  that  I  liave  seen  was  in  a  cliiM  ai^cl  two  years  whdse  tcstiele  I 
excised  fur  ilisease  of  six   nnuiths"  standing,  which 

had   |»ni};ressed   very   sh»wly   and  ac(|uired  a   hirjre  Kio.  423. 

size   hcinre   su|)i)urati»in   occurred.      Convah'sceiice 
f«)nowcd    the    operation    (  Fij:.    A'lW).      The    wh<dc         ^ 
oriran,  with   the  epididymis,  was  nearly  filled  with  ^<L 

scrol'ulous  deposit.  It  is  in  the  testicle  that  we 
have  the  hest  opportunity  of  examining  the  true 
tubercular  disease  in   its   diflerent   stages,  and  oi"  V 

watching   the  various   form    of  its   deposition,   its  \ 

clKniL,^es.  ami  decay.  k 

Tke.vt.mk.nt. — Wlu'u  tultercular  material  has 
been  once  deposited  in  the  testicle,  as  in  any  other 
tissue,  there  are  no  recognized  means  by  which  the  /^ 

absorption  of  this  material  can  be  procured.      It  is      ,^^ 
true  that  it    may   remain  in  an   inactive  or  passive 

!•   .  ,.  '     •      1    12    •.  •     1  1    c       11        1.        Hernia  of  the  Testicle  followiii;;  Tubercular  I'is- 

condition  tor  an  indebnite  period,  and  tinally,  by  ease.   (Removed  from  iiiiant  at.  2.) 

undergoing  an  earthy  degeneration,  cease  to  trou- 
ble ;  nevertheless,  it  will  still  exist,  ready,  as  it  were,  on  the  least  disturbance  to  light  up 
some  inflammatory  action  in  the  tissues   around  and  to  give  ri.se  to  any  or  all  of  the 
various  conditions  just  described. 

Looking  also  upon  the  deposition  of  turbecle  in  a  te.sticle  as  only  one  of  the  local 
manifestations  of  that  general  condition  described  as  tuberculo.sis,  it  is  dear  that  the 
principles  of  treatment  should  be  of  a  general  character  to  improve  the  health  and  revive 
the  powers  of  the  patient  by  tonics,  good  living,  good  air.  regular  habits,  and — what  is 
of  great  importance — total  abstinence  from  sexual  excitement  or  gratification.  Indeed, 
the  parts  should  be  maintained  as  much  as  possible  in  a  quiet  condition,  and  for  this  pur- 
pose cold  sponging  night  and  morning  is  of  some  service. 

When  inflammatory  symptoms  make  their  appearance,  they  will  generally  run  their 
cou-rse.  in  spite  of  treatment,  for,  as  already  shown,  they  are  usually  caused  by  the  break- 
ing down  of  the  tubercular  deposit,  which  may  be  looked  upon  as  one  of  nature's  means 
for  its  elimination  ;  indeed,  until  this  material  has  been  discharged  the  sub.sidence  of 
inflammatory  symptoms  is  not  usually  to  be  expected  ;  fomentations  in  this  stage  and  the 
application  of  water  dressing  to  the  part  are,  therefore,  suitable,  and  the  testes  should  be 
supported  in  a  suspensory  bandage.  When  suppuration  is  nigh  at  hand  or  has  mani- 
fested itself,  it  is  good  practice  to  open  the  abscess  freely  with  a  lancet,  as  it  saves  time 
and  pain  to  the  patient  and  often  prevents  the  formation  of  the  sinuses  which  prove  so 
troublesome.  During  all  this  time  the  health  of  the  patient  must  be  attended  to  by 
ordinary  measures. 

When  the  gland  has  attained  a  large  size  and  is  evidently  destroyed  by  abscesses  and 
disintegration  of  the  infiltrating  material,  it  may  be  excised,  and  more  particularly  if 
hernia  testis  has  appeared  and  the  disorganized  testis  is  a  source  of  trouble  and  weak- 
ness to  an  enfeebled  patient. 

Hernia  Testis. 

This  affection,  which  has  been  variously  described  as  '•  granular  swelling "'  and 
''  benign  fungus  of  the  testis,"  has  also  more  correctly  been  called  "  hernia  testis,"  for  it 
is  essentially  a  gradual  protru-sion  of  the  substance  of  the  gland  through  a  rupture  or 
ulceration  of  its  fibrous  envelope,  the  tunica  albuginea.  It  may  follow  upon  suppuration 
of  the  body  of  the  gland  the  result  of  an  injury  or  of  an  acute  or  chronic  orchitis,  or 
from  the  softening  down  of  tubercular  deposit.  It  seems  to  be  the  result  of  pressure 
produced  by  the  natural  elasticity  of  the  fibrous  tunica  albuginea,  the  testicle,  as  it  were, 
being  gradually  squeezed  out  of  its  capsule  and  everted,  the  mass  being  eventually 
increased  by  the  free  granulations  which  spring  up  on  its  surface.  The  whole  organ  or 
only  a  portion  of  it  may  thus  be  extruded  from  its  natural  position,  the  extent  varying 
according  to  the  amount  of  disease  and  the  size  of  the  opening  in  the  tunica  albuginea 
and  integuments.  It  must  not  be  suppo.sed.  however,  that  this  hernia  testis  is  the  neces- 
sary conseijuence  of  suppuration  or  of  di.^organization  of  any  portion  of  the  gland,  for 
such  is  not  the  case ;  indeed,  in  the  majority  of  instances  of  suppuration  it  does  not 
occur. 

Diagnosis. — The  diagnosis  is  not  difficult,  and  the  disease,  havicg  been  once  seen, 


742  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

can  be  subsequently  readily  recognized.  It  is  a  peculiar  fungating-looking  growth  with 
everted  edges  and  a  sinus  in  its  centre,  generally  secreting  pus.  It  is  of  variable  extent 
and  presents  a  more  or  less  irregular  surface  and  a  pedunculated  base,  the  pedicle  pass- 
ing through  an  opening  in  the  scrotum  to  the  remains  of  the  testicle.  The  margin  of 
the  opening  in  the  scrotum  is  generally  free,  although  in  some  cases  adherent  to  the 
growth.  It  may  be  slightly  indurated,  from  inflammatory  thickening,  but  will  never  pre- 
sent the  same  aspect  as  a  cancerous  growth,  for  which,  however,  this  affection  may  be 
mistaken,  the  term  "fungous  testis"  having  doubtless  been  the  means  of  encouraging 
the  great,  error  of  regarding  this  simple  disease  as  malignant.  The  natural  sensation  of 
the  gland  remains,  however,  in  these  cases,  and  will  be  readily  excited  by  manipulation, 
whereas  in  cancerous  disease  no  such  natural  sensation  exists ;  in  doubtful  cases  this 
point  is  one  of  primary  importance. 

Treatment. — It  may  safely  be  stated  that  the  majority  of  cases  of  hernia  testis  can 
be  successfully  treated  by  other  less  severe  measures  than  castration,  although  this  ope- 
ration has  been  very  generally  performed  for  this  affection.  In  exceptional  instances  it 
may  be  demanded,  and  I  have  the  records  of  many  in  which  it  has  been  successfully  per- 
formed. The  surgeon's  object,  it  may  be  briefly  stated,  is  to  restore  the  extruded  testicle 
to  its  natural  place,  which  may  frequently  be  done  by  simple  pressure  applied  by  fixing 
a  good  firm  pad  over  the  surface  of  the  growth  and  drawing  the  margin  of  the  ulcerated 
scrotum  well  forward,  fixing  the  whole  in  position  by  strapping.  In  other  cases,  where 
the  granulations  are  very  exuberant,  caustics  may  be  used  to  hasten  their  destruction  ; 
among  the  best  is  the  red  oxide  of  mercury  ;  pressure  should  be  well  maintained  during 
its  use.  All  minor  cases,  and  many  of  the  severe,  may  certainly  be  cured  by  these 
means  if  steadily  pursued  and  well  applied.  In  the  more  obstinate  and  severe  examples 
other  measures  must  be  adopted.  The  excision  of  the  surface  of  the  growth  was  for- 
Dierly  employed,  and  is  occasionally  resorted  to  in  the  present  day,  but  at  best  the  prac- 
tice is  a  very  doubtful  one,  for  in  the  majority  of  cases  to  which  it  is  applicable  it  would 
be  tantamount  to  castration,  as  the  fungating  mass  is,  as  a  rule,  composed  of  the  everted 
tubules  of  the  testis,  covered  with  granulations,  and  consequently  by  this  measure  the 
tubules  would  be  cut  off  and  the  gland  destroyed. 

Mr.  Syme  described  in  the  London  and  Edinhurgh  Monthly  Journal  for  January, 
1845,  a  plan  of  treatment  which  in  these  cases  is  very  serviceable.  The  operation  con- 
sists in  the  elevation  of  the  margin  of  the  scrotum  from  the  protruding  mass,  the  reduc- 
tion of  the  hernia  testis  within  the  scrotum,  and  the  retention  of  the  part  in  its  natural 
position  by  stitching  together  the  margins  of  the  wound,  careful  bandaging  and  strapping 
being  also  required  in  the  treatment  of  these  cases.  The  granulating  organ  becomes 
attached  to  the  inner  surface  of  the  scrotum,  and  a  healthy  action  is  subsequently 
restored.  It  is  almost  needless  to  add  that  a  local  and  constitutional  treatment  for  the 
original  affection  of  the  testis  should  at  the  same  time  be  maintained. 

Cystic  Disease  of  the  Testicle. 

There  is  no  affection  of  the  testicle  on  the  nature  of  which  there  has  been  a  greater 
diffei'ence  of  opinion  than  cystic  disease,  and,  although  modern  pathologists  have  devoted 
considerable  attention  to  its  investigation,  the  subject  has  not  yet  been  brought  out  of  its 
obscurity  and  made  plain  to  the  profession. 

Sir  A.  Cooper,  one  of  its  original  inquirers,  looked  upon  it  as  a  distinct  disease  of  the 
secreting  tid>nU  of  the  organ,  and  upon  his  authority  this  view  was  for  a  time  generally 
received.  More  recently  Mr.  Curling's  researches  have  tended  to  prove  it  to  be  an  affec- 
tion of  the  ducts  of  the  testicle,  and  not  of  its  secreting  tubuli.  "  Why  they  alone,"  says 
Mr.  Curling,  "are  subject  to  the  -morbid  change  I  admit  my  inability  to  explain." 
Whether  this  opinion  be  correct  or  not  will  be  one  of  the  subjects  for  present  considera- 
tion, since  I  am  disposed  to  think  that  it  is  not  quite  consistent  Avith  observed  facts, 
although  there  can  be  no  doubt  that  the  rete  testis  appears  to  be  the  seat  of  the  disease 
in  certain  cases,  while  in  exceptional  examples  cystic  disease  is  undoubtedly  formed  inde- 
pendent of  this  structure. 

It  has  been  my  privilege  to  examine  many  examples  of  this  rare  affection  with  some 
care,  and  I  entirely  concur  in  the  main  with  Mr.  Curling's  conclusions,  although  I  am 
not  so  sure  of  the  special  seat  of  the  disease  as  he  appears  to  be.  It  is  doubtless  made 
up  of  cysts,  which  are  multilocular  and  of  sizes  varying  from  that  of  a  mustard-seed  to  a 
moderate-sized  nut  (Fig.  424).  These  cysts  are  filled  with  a  thin,  serous,  blood-stained, 
or  glairy  fluid,  and  at  times  with  more  or  less  pedunculated  intracystic  growths  made  up 


CYSTIC   niSh'AS/':   OF   TllH    TKSTK'LK. 


743 


.^ 


L'j-itiC  I)lJLU2C  ul    lllf  ll 


of  :i  (li'licate  cclluliir  struct  mo  or  ol"  u  distiiict  cl-W  tissue.      Tlioso  cysts  appear   imbedded 
■^iii  a  fibrous  strnuiu  iA'  dillcrciit  deirrees  of  coiisisteucv  and  density-    Tlie  fibrous  eleiueuts  ia 
some  ari'  much  more  iiumcnius  than  th«'y  arc  in 

otliers,.\vliilst  in  some,  apiiii.  it  will  \w  of  a  moie  I'lo.  424. 

delicate  initure  and  more  allied  to  the  fibre  struc- 
ture found  in  the  softer  sarcounituus  growth.s 
of  other  ))arts.  In  certain  examples  the  cysts 
are  clearly  made  up  of  dilated  tubes  with 
pouches  at  their  e.xtremities  or  as  lateral  dila- 
tations, these  tubes  containinjr  uranular  matter 
being  occasionally  lini'd,  as  .Mr.  Curlini;-  was  the 
first  to  observe,  with  tessellated  epithelium.  I 
have  failed,  however,  to  find  this  in  all  the  cases 
1  have  e.Kamined.  and  am  disposi-d  to  look  upon 
the  ])resenee  of  this  tessellated  epithelium  as 
specially  eharacterizintr  a  certain  growth.    Sjier- 

matozoa  are  invariably  ab.sent  in  the  cysts  or  .  v 

tubes  of  this  affection,  while  cartilage  or  bone  \^  i'  / 

elements  will  almost  always  be  found  to  exist, 
either  as  small  isolated  patches  or  as  filling  the 
cyst,  in  which  case  the  growth  might  be  de- 
scribed as  an  enchondromatous  tumor  ;  the  car- 
tilage is  deposited  in  separate  mas.ses,  and  these  ma.s.ses  are  divided  by  a  fibrous  stroma. 
The  true  secreting  ])ortion  of  the  testicle  will  often  be  found  pushed  up  into  some  corner 
of  the  tumor,  spread  out  over  the  cystic  mass,  or  distributed  between  the  cysts  them- 
selves, the  tumor  being  invariably  encysted  in  its  own  capsule;  in  rare  cases  tumors  of 
this  nature  will  l)e  found  iipon  the  cord  and  body  of  the  testicle.  The  above  facts  lead 
me  to  conclude  that  the  majority  of  these  are  new  growths  following  the  great  law  which 
governs  the  development  of  all  tumors  by  taking  on  the  likeness  of  the  part  in  which 
they  are  developed,  and  that  they  are  more  or  less  built  up  as  is  the  stricture  of  the 
normal  gland.  The  testis  being  essentially  a  tubular  organ,  all  morbid  growths  developed 
in  or  near  it  have  a  tendency  to  assume  a  tubular  or  cystic  character,  this  character  vary- 
ing in  extent  in  different  cases,  the  cystic  or  tubular  and  fibrous  or  sarcomatous  structure 
being  found  in  different  degrees  of  perfection  and  quantity  in  different  cases. 

We  may  thus  find  in  the  testicle  a  tumor  presenting  all  the  elements  of  the  fibrous  oi 
sarcomatous  tumor  without  cysts,  whilst  in  another,  in  which  the  cystic  formation  more 
or  less  predominates,  the  same  elements  will  exi.st  in  smaller  proportions ;  and  in  the 
majority  of  these  examples  the  true  structure  of  the  testicle  will  be  found  spread  out  in 
a  variable  extent  oyer  the  special  capsule  of  the  new  growth.  In  other  cases  the  new 
growth  will  be  altogether  free  from  any  connection  w-itli  the  testis  itself  and  be  found 
growing  from  the  cord.  All  the.se  .separate  kinds  of  tumors,  examples  of  which  may  be 
seen  in  G-u.y's  Mu.seum,  appear  to  me  merely  modifications  of  one  kind  of  growth,  the 
simple — or,  perhaps  more  correctly,  adenoid — growth  of  the  testis. 

We  thus  see  a  close  analogy  between  these  tumors  of  the  testis  and  those  of  the  mam- 
mary gland,  as  well  as  of  the  ovary,  and  find  in  all  the  simple  adenoid  tumor  partaking 
more  or  less  of  the  nature  of  the  gland  in  which  it  is  developed,  and  a  true  cystic  disease 
of  the  gland  it.self,  the  latter  being  evidently  a  special  affection  of  the  tubes  and  ducts  of 
the  mammary  gland  or  testis,  and  not  of  the  secreting  structure.  In  both  organs  they 
are  new  growths  simulating  more  or  less  correctly  the  anatomical  structure  of  the  true 
gland. 

Symptoms  and  Diagnosis. — Having  described  the  special  pathology  of  this  disease, 
I  pass  on  to  consider  its  clinical  aspect,  as  well  as  to  point  out  the  symptoms  which  indi- 
cate its  presence  and  help  the  formation  of  a  correct  diagnosis.  In  doing  so  I  must  pre- 
mise that  the  several  forms  of  this  cystic  disease  are  to  be  recognized  more  by  negative 
than  by  positive  signs,  since  they  appear  usually  as  painless  enlargements  of  the  organ, 
are  of  slow  growth,  and  are  unaccompanied  by  any  such  symptoms  as  attract  attention, 
the  patient,  indeed,  seldom  seeking  advice  until  the  organ  has  become  troublesome  from 
its  size,  or  the  dragging  pain  in  the  loin,  which  always  exists  when  the  testicle  has  become 
large  and  heavy  from  any  cause,  excites  anxiety.  The  testis  soon  loses  its  natural  shape 
and  assumes  more  the  oval  or  pyriform  outline  of  a  vaginal  hydrocele  or  hfematocele.  It 
will  probably  have  a  smooth  and  equal  surface  and  be  indistinctly  fluctuating:,  though  not 
translucent,  while  its   natural  sensation,  experienced  on  manipulation,  will   most   likely 


744 


AFFECTIONS  OF  THE  GENITAL    ORGANS. 


have  disappeared  at  a  very  early  stage  of  the  disease.  The  general  health  of  the  patient 
may  probably  be  good,  and  there  will  be  no  evidence  of  any  secondary  glandular  affection. 

From  hydrocele  and  haimatocele  the  disease  may  generally  be  recognized  by  the  his- 
tory of  the  case,  the  opacity  of  the  tumor,  and  the  loss  of  the  natural  testicular  s£«isation. 
When  doubt  exists,  an  exploratory  puncture  by  the  trocar  and  canula  will  decide  the 
point ;  for  in  cystic  disease  a  little  bloody  and  glairy  fluid  will  alone  escape. 

From  the  inflammatory  aflections  it  may  be  diagnosed  by  the  difterence  in  the  shape 
and  feel  of  the  tumor,  the  flattened  compressed  form  of  the  organ,  with  its  hard  and 
nodulated  feel,  as  met  with  in  the  diflerent  forms  of  orchitis,  contrasting  with  the  more 
or  less  globular  or  pyriform  shape,  smooth  outline,  and  elastic  feel,  without  the  peculiar 
testicular  sensation  present  in  cystic  disease.  The  inflammatory  affections  are  also  often 
associated  with  a  hydrocele  ;  the  cystic,  rarely.  In  the  former,  also,  both  organs  are  gen- 
erally affected  sooner  or  later,  while  in  the  latter  the  disease  attacks  only  one.  IMedical 
treatment  does  not  appear  to  have  any  influence  in  arresting  the  development  of  the 
cystic,  whilst  in  the  inflammatory  disease  a  good  recovery  may  generally  he  secured  by 
the  use  of  proper  remedies. 

Treatment. — There  is  but  one  remedy,  which  is  the  removal  of  the  diseased  organ. 
No  drugs  seem  to  have  the  slightest  effect  in  diminishing  its  size  or  arresting  its  growth. 
Excision,  therefore,  should  be  performed,  the  operation  being,  as  a  rule,  most  successful. 


Cancer  of  the  Testicle. 

The  testicle,  like  all  glands,  may  become  the  seat  of  cancerous  disease,  both  of  the 
carcinoma  fibrosum,  or  hard  cancer,  and  of  the  carcinoma  medullare,  or  soft  cancer.  It 
is  rare,  however,  for  the  hard  cancer  to  attack  the  testis,  the  majority  of  examples  being 
of  the  soft  or  encephaloid  form.  For  one  example  of  the  hard  cancer  it  is  probable  that 
at  least  twenty  of  the  soft  are  met  with  in  practice.  In  the  different  museums  specimens 
of  the  former  kind  may  be  seen,  and  at  Guy's  several  exist. 

Cancer  may  also  attack  this  organ  in  one  of  two  forms,  either  as  the  tuberous  or  as 
the  infiltrating  cancer.  In  the  former  the  disease  appears  either  as  an  isolated  growth  or 
as  several  distinct  tumors  separating  the  parts  and  then  eventually  coalescing  into  one 
mass ;  in  the  latter  it  appears  from  the  beginning  as  the  infiltrating  kind,  the  cancerous 
elements  being  more  equally  distributed  between  the  tubes  and  ducts  of  the  true  secret- 
ing gland  tissue. 

The  malignant  affections  of  the  organ,  as  the  simple,  are  accompanied  by  the  develop- 
ment of  cysts,  and  these,  in  the  malignant  cases,  ai'e  filled  with  cancerous  matter  in  lieu 

of  the  glairy  mucous  or  fibro-cellular  intra- 
FiG  425.  cystic  growths  which  are  found  in  the  sar- 

comatous, adenoid,  or  cystic  diseases.  In 
rare  examples  both  conditions  seem  to  co- 
exist in  the  same  organ,  simple  cysts,  with 
the  clear  or  blood-stained  glairy  fluid,  being 
found  in  one  portion,  whilst  in  others  these 
cysts  are  filled  with  cancerous  material,  and 
in  a  third  enchondromatous  masses  may  at 
times  be  present  (Fig.  425). 

The  part  of  the  organ  generally  attacked 
is  the  body  of  the  gland,  although  the  epi- 
didymis may  be  the  seat  of  the  disease  ;  but 
when  the  latter  is  involved,  as  a  rule  it  is  an 
extension  of  the  disease  from  the  body  of 
the  tumor.  Rare  examples,  however,  exist 
which  illustrate  a  primary  affection  of  the 
epididymis. 

Cancer  may  attack  the  testis  of  the  old 
as  well  as  of  the  young,  and  I  have  the 
records  of  cases  occurring  in  men  aged  fifty-six  and  sixty-two  respectively.  Instances 
of  this  disease  attacking  infants  even  so  young  as  seven  months  have  likewise  been 
recorded  by  different  aiithors,  and  I  have  excised  a  cancerous  testicle  from  a  boy  only 
two  years  old.  The  majority  of  cases  occur,  however,  in  young  adult  life,  from  twenty- 
five  to  forty  years  of  age,  as  is  indicated  by  the  following  facts. 

I  possess  the  records  of  twenty-five  cases,  which  I  have  added  below  to  the  fifty-one 


(  ancer  of  the  Testicle 


CAycr.R  OF  Tin:  T/.srirrE.  7lo 

examples  orijxiiially  talmlatcd  Ky  Mr.  Harvey  liiidlnw  in  liis  Jacksonian  prize  essav.    The 
results  are  as  follows  ; 

Before  the  ajre  of  5  .                                                                                         .6  ea^cs. 

From  1")  to  "Jd  vears .  .                                        .             2  " 

••      1!-Jto30'"  .                                        .             .                                        .     17  " 

"      ;n  to  4(1     "       .  .             .             .             .                                                    .'U  " 

"      41  to  .',()"  .              .             .             .             .                           .     11  " 

"      ■■)1  to  70     "       .  .              .              .              .              .              .                           9  " 

T.-tal    ..........     7(; 

Out  of  my  25  ea.ses  the  disease  in  2<l  had  been  frrowin<r  for  one  year  or  less,  and  in  the 
remaininir  5  eases  2  were  of  three  years'.  2  (d'  four  years',  and  1  of  five  years'  standing. 

It  is  rare,  if  not  unknown,  for  both  testieles  to  be  the  seat  of  caneer  at  the  same  time. 
I  am  not  aware  of  any  such  example  being  on  record.  In  IC  out  of  the  25  ea.ses  before 
me  the  right  organ  was  attacked,  and  in  9  the  left.  Malplaced  testicles  appear  to  be  par- 
ticularly prone  to  this  di.sease. 

Cancer  of  the  testicle  may  come  on  as  insidiously  as  the  simple  cystic  di.sease.  but  in 
general  its  growth  is  more  rapid.  It  makes  its  appearance  as  a  gradual  enlargement  of 
the  body  of  the  organ,  seldom  attended  by  pain.  There  is  also  an  early  loss  on  pressure 
or  manipulation  of  the  special  testicular  sensation.  The  outline  of  the  tumor  is  smooth, 
semi-elastic,  and  fluctuating,  but  as  the  disease  progresses  its  surface  may  become  some- 
what uneven  or  irregularly  bossy,  thq  tumor  being  harder  in  some  parts  than  in  others, 
the  softer  parts  projecting.  In  the  carcinoma  fibrosum,  however,  the  whole  tumor  is  hard 
and  at  times  nodular.  The  tumor  is  opaque  from  the  beginning,  and  rarely,  if  ever,  asso- 
ciated with  hydrocele  ;  and  when  it  is  so,  it  is  by  chance,  the  one  affection  having  no  direct 
relation  to  the  other.  In  this  respect  cancer  differs  from  inflammation  of  the  organ,  which 
is  very  frequently  complicated  by  the  presence  of  hydrocele. 

The  disease  rarely  extends  beyond  its  fibrous  covering  or  involves  the  scrotum,  and 
for  a  bleeding  fungus  to  form  the  tumor  must  be  very  large.  As  the  disease  progresses 
the  health  of  the  patient  may  suffer  and  a  general  aspect  indicative  of  exhaustion  and 
Bome  wasting  disease  appear,  although  it  is  not  till  a  late  period  of  this  affection  that  any 
such  .symptoms  are  to  be  expected.  When  lumbar  pain  or  a  constant  aching  exists,  a 
suspicion  of  enlarged  lumbar  glands  should  be  excited,  and  in  certain  examples  a  chain 
of  enlarged  glands  may  be  felt  extending  upward  along  the  psoas  muscle. 

The  inguinal  glands  are  occasionally  enlarged  from  infiltration,  though  it  is  believed 
by  some  that  this  complication  does  not  appear  till  the  scrotum  is  involved  in  the  disea.se. 
This,  however,  is  certainly  not  the  ca.se,  for  large  inguinal  glands  may  appear  at  an  early 
stage  of  the  affection. 

Diagnosis. — The  diagnosis  of  this  di.sease  is  by  no  means  easy,  particularly  in  its 
early  stage ;  indeed,  in  many  instances  it  is  almost  impossible  to  be  certain  of  its  nature. 
It  is  the  size  of  the  organ  which  generally  first  draws  the  attention  of  the  patient  to  the 
part,  and  the  pain  and  inconvenience  caused  by  its  weight  which  prompt  him  to  seek  advice. 

The  hi.story  of  the  case  and  the  absence  of  translucency  will  prevent  its  being  mis- 
taken for  a  hydrocele,  Haematocele,  as  a  rule,  has  a  distinct  and  special  history  of  its 
own.  and  the  fact  that  the  testis  may  be  made  out  to  exist  in  some  portion  of  the  tumor 
is  a  material  aid  to  the  surgeon  in  forming  a  correct  opinion  as  to  the  nature  of  the  case. 

The  tenderness  of  the  organ,  the  nature  of  the  pain,  and  the  shape  of  the  swelling  are 
sufficient  to  indicate  the  inflammatory  affection ;  and  when  fluid  exists  the  diagno.sis  is 
rendered  more  plain,  since  a  vaginal  hydrocele  rarely  coexists  with  any  other  disease  than 
the  inflammatory,  except  to  a  very  slight  extent. 

The  simple  cystic  disease  is  of  slower  growth  than  the  cancerous,  and  generally  firmer 
to  the  feel ;  when  punctured,  it  yields  also  a  glairy  fluid  unlike  the  creamy  material  which 
comes  away  from  the  cancerous  disease.  The  subject  of  diagnosis  of  all  these  growths 
will,  however,  be  discussed  hereafter. 

Treatme.nt. — The  only  treatment  which  gives  any  comfort  to  the  patient  is  excision 
of  the  organ,  and  this  .should  be  done  as  early  as  the  diagn<»sis  can  be  made,  for  there  is 
then  less  chance  of  the  glands  in  the  loin  becoming  involved.  The  general  health  must 
also  be  attended  to  with  great  care  at  the  .same  time. 

Diagnosis  of  Scrotal  Tumors. 

I  propose  now  to  consider  the  subject  of  the  diagnosis  of  scrotal  tumors  as  a  whole,  to 
de.scribe  the  train  of  thought  which  passes  through  the  surgeons  mind  when  examining 


746 


CHRONIC  DISEASE  OF  THE  TESTICLES. 

Table  of  Diagnosis  of  Chronic 


Symptoms. 

Hydrocele. 

Hsematocele. 

Chronic  orchitis. 

Condition   of    tu- 
mor. 

Tense,  usually   transparent, 
fluctuating. 

Tense  and  elastic ;  not 
ti'ansparent ;  obscure 
fluctuation. 

Firm,  and  not  elastic ;  not 
transparent ;  not  fluc- 
tuating unless  comjili- 
cated  with  hydrocele. 

Outline. 

Smooth  and  uniform. 

Smooth  and  uniform. 

Smootli  and  compressed 
laterally. 

Position  of  testis. 

Posteriorly  in  vaginal;  an- 
teriorly at  side  or  below 
in  encysted. 

Posteriorly. 

Evidently    an    enlarged 
testis. 

Testicular    sensa- 
tion. 

Present  on  manipulation. 

Present  on  manipula- 
tion. 

Present   at   first;   absent 
after  long  existence  of 
disease. 

Rapidity  of  growth. 
Size. 

Gradual ;    most    so    in   en- 
cyaled. 

To  great  dimensions  in  vagi- 
nal; moderate  in  encysted. 

As  a  rule  sudden,  and 
after     accident    at 
times   spontaneous 
and  gradual. 

Moderate. 

Slow. 

Rarely  more  than  three 
or  four  times   natural 

Form. 

Pyriform  or  oval  in  vaginal; 
globular  in  encysted. 

Pyriform  or  oval. 

size. 
Oval,  with  flattened  sides. 

Pain. 

Manipular  indica- 
tions. 

Very  slight,  if  any,  except 
when  complicated  with  in- 
flamed testis,  and  in  acute 
hydrocele.    Not  increased 
on  pressure. 

Like  fluid,  vibration  on  pal- 
pation. 

Painful  at  first  and  at 
a   later  stage ;    not 
so  during  the  inter- 
mediate. 

Firm  and  solid. 

Dull  pain,  increased  on 
pressure,     except     in 
very  chronic  disease. 

Firm  and  solid  unless  as- 
sociated  with    hydro- 
cele. 

Seat   of    its  com- 
mencement. 

Cause. 

In  vaginal,  at  the  lower  part 
of  the  tumor  ;  in  encysted, 
at  the  upper. 

No  recognized  cause. 

Evidently    in    body    of 
gland. 

Injury,  or  idiopathic. 

An  injury  or  strain  ; 
rarely  spontaneous. 

Progress. 

Has  a  tendency  to  remain 
tranquil,   and   not   to  in- 
flame unless  injured. 

Has   tendency  to  in- 
flame   and    suppu- 
rate, and  not  to  re- 
main  tranquil   for 

Slow  growth ;  rarely,  but 
at  times,  ends  in  sup- 
puration. 

Condition  of  cord. 

Results  of  tapping, 
exploratory    or 
otherwise. 

Free  and  healthy. 

Straw-colored,   serous   fluid 
in  vaginal;  limpid,  opal- 
escent in  encysted. 

long. 
Healthy. 

Blood  fresh  or  broken 
up  with  pus. 

Often  full  and  tender  on 
manipulation. 

Condition   of    in- 
guinal  and  ab- 
dominal glands. 
Complications. 

Organs  involved. 

Free  and  healthy. 
Inflamed  testicle. 
Occasionally  double. 

Healthy. 

None,  unless  hydro- 
cele or  injured  tes- 
ticle. 

Never  double. 

Healthy. 

Occasionally  with  hydro- 
cele. 

Generally   both    organs, 
either    separately    or 
together. 

CllJlOMC  DISEASE   OF   THE   TESTICLES. 
Disease  of  the  Testicles. 


747 


Sypliilitlc  orchitis. 

Tubercular  ilUease. 

Cystic  or  adenoid  diHcase. 

Carcinomatous  disease. 

Very    snliil,     Imt     iidt 

Indolfiu  indurations  in 

Firm    and   elastic;    in- 

\  tense  and    firm  en- 

elastic   or   tiaiispai- 

body  of  gland  or  epi- 

sidious   enlargement 

largement    of    body 

eiit     mili'ss     roiiipli- 

didymis,  like  foreign 

of  gland;    not  trans- 

of testis ;   not  trans- 

I'ati'd    willi      liydro- 

bodies.     Toward  the 

lucent  ;         indistinct 

lucent.        Indistinct 

cvk',  wliicli    is    very 

end  these  bodies  .soft- 

fluctuation. 

fluctuation      toward 

general. 

en    and    excite    sup- 

later    stage ;     bossy 

puration. 

outline;  parts  softer 
than  others. 

Irregularly        nodular 

The     epididymis     the 

Generally          regular, 

and   very  hard. 

most   frequently   in- . 

smooth,  and  elastic; 

volved. 

rarely  bossy. 

In  tunu)r. 

In  natural  jiosition,  of- 
ten  half  surrounded 
by  epididymis   as   a 
half  crescent. 

In  tumor. 

In  tumor. 

Absent  altogether,  ex- 

Present. 

Present  at  first,  but  soon 

Soon  disapjiears. 

cept     in     the     very 

lost. 

early  stage;  returns 

also    toward     conva- 

lescence. 

Slow   in   the  extreme, 

Slow    at     first;    rapid 

Unequal;  slow  at  first. 

Rapid,  as  a  rule ;  .slow 

often  hardly  noticed. 

afterward,  when  soft- 

more rapid  afterward. 

only  in  the  carcino- 

ening and  inflamed. 

ma  fibrosum,  which 
is  very  rare. 

Moderate. 

Moderate. 

Rarely,  but  sometimes, 
very  large. 

Sometimes  very  rare. 

Irregularly    oval    and 

Lumpy  ;  imeven  in  all 

Oval,     with     flattened 

Glol)ular  or  pyriform. 

lumpy. 

its  stages. 

sides.  Smooth  at  first. 

Smooth  at  first,subse- 

subsequently  bossy. 

(piently  lumpy,  .soft- 
est at  these  points. 

Very     slight  ;     allows 

Very  slight  pain  or  ten- 

Slight  when    present ; 

Very  slight,  even   on 

rough  handling.  To- 

derness, except  when 

generally      painless, 

free  manipulation. 

ward  end  of  disease, 

pressed  hard  or  in- 

even   on    manipula- 

on recovery,  pain  on 

flamed. 

tion. 

pressure  returns. 

\'ery  hard   and   irreg- 

At  first   as   if   foreign 

Firm  and  elastic,  more 

Firm,  but  ela.stic ;  softer 

ular  outline.     Often 

bodies  existed  in  the 

so  in  one  spot  than 

on  the  bosses,  when 

hydrocele,  with  small 

parts,  lumpy  ;  at  laal 

another. 

present. 

fibrous  bodies  in  tu- 

soft before  suppura- 

nica albuginea. 

tion. 

Always     in     body    of 

Generally  in    epididy- 

In body  of  gland. 

Body  of  gland. 

gland. 

mis;  occasionally  in 
body  of  gland. 

Constitutional      syplii- 

Tuberculosis. 

Unknown. 

Unknown ;      occasion- 

lis, hereditary  or  ac- 

ally from  injury. 

quired. 

Essentially       chronic ; 

Very  indolent  and   in- 

Unequal;     never     in- 

Rapid as  a  rule  ;  rare- 

rarely terminates  by 

sidious  ;  tends  to  in- 

flamed. 

ly  slow. 

suppuration. 

flame  and  suppurate 
after     an    uncertain 
period. 

Free. 

Healthy. 

Healthy. 

Full ;  veins  enlarged. 

Mucoid  fiiiidy  more  or 
less  blood-stained. 

Blood  or  creamy  fluid, 
with      characteristic 

cell-growth  on  micro- 

scopical examination. 

Generally  indurated. 

Generally  indurated. 

Rarely  involved. 

Generally  involved. 

Hydrocele,   almost   al- 

Rarely with  hydrocele. 

Rarely  with  hydrocele. 

Cancer  in  other  parts  ; 

ways.     Other  syphi- 

Tubercidar disease  in 

rarely   with    hydro- 

litic affections. 

other  parts  of  body. 

cele. 

Often  both  organs. 

Both  organs,  as  a  rule, 

Always  single. 

Single  as  a  rule. 

involved. 

748  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

such  a  case  with  diagnostic  intentions,  and  to  point  out  the  special  symptoms  or  their 
combination  as  they  tend  to  indicate  the  presence  of  any  special  affection.  In  doing  this 
I  believe  that  a  near  approximation  to  truth  may  generally  be  made  when  the  history  of 
the  case  and  its  special  symptoms  are  carefully  weighed.  Great  difficulty  may  occasion- 
ally be  experienced  in  any  given  case,  or  it  may  be  beyond  our  power  to  form  anv  posi- 
tive opinion  upon  its  jiature ;  but  I  am  not  disposed  on  that  account  to  place  among 
impossibilities  the  diagnosis  of  a  scrotal  tumor.  There  are  gradations  of  probabilitv  in 
all  our  conclusions  as  to  the  diagnosis  of  an}'  disease,  and  a  certainty  untainted  by  fal- 
lacy or  doubt  is  rarely  obtained,  but  I  take  it  we  are  as  often  correct  in  our  judgment  of 
a  scrotal  tumor  as  of  any  other  affection.  To  aid  the  student  in  this  task  the  table  on 
pages  7-46,  747  has  been  drawn  up. 

The  first  point  the  surgeon  has  to  decide  on  being  consulted  as  to  the  nature  of  a 
scrotal  tumor  has  reference  to  the  question  of  hernia.  Is  the  tumor  connected  with  the 
testicle,  or  has  it  passed  down  the  direction  of  the  cord  from  the  abdominal  cavity  ?  If 
the  surgeon  is  able  to  isolate  the  growth  at  its  neck  from  the  abdominal  cavity  by  the 
thumb  and  finger,  the  question  is  at  once  decided  ;  for  almost  all  scrotal  tumors  can  be 
so  isolated,  it  being  quite  exceptional  for  any  to  pass  up  the  cord  so  far  as  the  internal 
ring.  Rare  cases  of  vaginal  hydrocele  or  haematoeele,  however,  in  which  the  tunica 
vaginalis  is  open  up  to  the  internal  ring,  form  an  exception. 

It  being  determined  that  the  swelling  is  not  a  hernia,  the  nature  of  the  tumor  next 
claims  attention. 

Is  it  a  hydrocele  or  ha?matocele  ?  Is  it  the  product  of  inflammation  or  of  tubercular 
disease  ?    Is  it  a  new  growth  altogether  ?  and  if  so.  is  it  innocent  or  malignant  in  its  nature  ? 

If  the  tumor  prove  translucent  by  tran.smitted  light,  the  existence  of  a  hydrocele  is 
fairly  decided  ;  but,  then,  is  it  an  ordinary  vaginal  hydrocele  or  encysted  ?  Should  the 
tumor  be  large,  even,  and  pyriform,  and  the  testis  be  found  at  the  posterior  part  of  the 
tumor,  either  by  means  of  manipulation  or  by  the  opacity  displayed  at  one  spot  on  trans- 
mitting light,  vaginal  hydrocele  may  be  suspected  ;  but  should  the  testis  exist  in  front  or 
at  one  side  and  tlie  tumor  have  been  of  very  slow  growth,  small,  and  more  or  less  globu- 
lar or  evidently  multilocular,  a  cystic  hydrocele  may  probably  be  diagnosed.  The  tapping 
of  the  tumor  will,  however,  settle  the  diagnosis ;  for  in  vaginal  hydrocele  the  fluid  will 
be  more  or  less  straw-colored  and  albuminous,  while  in  the  encysted  it  will  be  watery,  non- 
albuminous,  and  occasionally,  but  not  always,  opalescent,  and  when  opalescent  containing, 
on  microscopical  examination,  granules  and  spermatozoa. 

In  examples  of  old  hydrocele,  however,  the  tumor  may'  be  opaque,  and  under  such 
circumstances  difficulties  may  be  experienced,  yet  the  history  of  these  cases  will  tend  to 
throw  much  light  upon  the  point,  for  to  a  certainty  it  will  reveal  a  disease  of  very  long 
standing ;  the  tumor  will  be  probably  painless  and  fluctuating  and  the  testis  made  out  to 
be  in  its  usual  position,  at  tbe  posterior  part  of  the  sac.  When  a  doubt  exists,  a  punc- 
ture with  an  exploring  trocar  and  canula  will  decide  the  question,  as  in  these  cases  fluid 
of  a  dark  color  will  be  drawn  off,  loaded  with  chole.sterin. 

"We  will  now  pass  on  to  the  consideration  of  tumors  which  are  not  translucent  and 
not  hydrocele  :  and  it  is  here  that  the  surgeon  experiences  true  difficulty  in  his  diagnosis, 
as  almost  all  the  diseases  of  the  testis  are  insidious  in  their  growth  and  chiefly  painless 
in  their  development.  The  haematoeele,  except  in  rare  examples,  usually  follows  upon 
some  strain  or  injury,  increasing  with  tolerable  rapidity  up  to  a  certain  point  and  accom- 
panied by  pain,  which  soon  subsides.  It  then  becomes  stationary  as  to  size  and  remains 
torpid  for  a  variable  period,  when  pain  reappears,  with  other  signs  of  inflammation.  The 
presence  of  the  testis  is  also  to  be  made  out  by  manipulation  toward  the  posterior  part 
of  the  organ.  The  surface  of  the  tumor  is  always  smooth,  more  or  less  oval  or  pyriform, 
and  semi-elastic  or  fluctuating. 

The  inflammator}'  affections  of  the  testis  have  a  peculiar  shape,  being  laterally  flat- 
tened, and  are  usualh-  accompanied  at  some  period  of  their  course  with  tenderness  and 
pain,  as  well  as  often  associated  with  fluid  in  the  tunica  vaginalis.  In  the  syphilitic 
inflammation  this  fluid  is  often  copious.  Both  organs  are  also  generally  involved,  either 
together  or  at  different  times.  The  tumor  is  usually  somewhat  tender  to  the  touch,  and 
has  a  firm  fibrous  feel  unlike  the  semi-ela.stic  and  half-fluctuating  sensations  afforded  by 
cystic  or  carcinomatous  disease.  In  very  chronic  cases  the  testis  may.  however,  be  per- 
fectly painless  and  allow  of  any  amount  of  manipulation  without  distress,  the  natural 
testicular  sensation,  in  fact,  having  disappeared.  In  syphilitic  disease  the  surface  of  the 
tumor  will  probably  be  irregular,  with  firm  fibrous  outgrowths  in  different  parts  and  in 
the  tunica  albuginea. 


CASTRATIOS.  719 

In  tilt'  tiiUiTciilur  afft'ctioii  of  the  e|ii(li(lyiiiis  or  testis  there  should  not  he  any  (Jitti- 
cillty  ill  the  tliaj^iiosis,  lor  the  tuhereular  deposit,  us  u  rule,  takes  place  uiiaeeoinpaiiied  Ijy 
pain  or  any  symptom  lu-yoiid  that  produee<l  hy  its  deposition.  When  dep(jsited  in  masses — 
i.s  usual  form — it  ieels  like  some  foreitru  hody  introduced  into  the  suhstanee  of  the  frland 
or  id"  the  epididymis,  and  is  at  first  (|uite  painless  and  unprorluctive  of  any  symptrjms  ; 
tlie>;e  symptoms  only  appear  when  the  material  he^nns  to  soften  down  and  excite  some 
infhimmat(»ry  action  in  the  parts  around.  The  tuhereular  material  may  he  deposited  in 
one  or  nnu'e  masses,  these  suhsecjuently,  perhaps,  coalescing  into  an  irregular  induration. 
When  suppuration  takes  place,  the  diagnosis  is  complete. 

The  cystic  or  simple  tumors  of  the  testis  are  painless  throughout  the  whole  course  of 
their  growth  and  can  he  recognized  by  purely  negative  symptcjms.  They  attract  the 
patient's  observation  only  from  their  size,  can  be  handled  withtuit  exciting  pain,  and  do 
not  usually  give  even  the  natural  sensation  of  the  organ  upon  pressure.  They  are  sh>w 
in  their  }»rogre.ss,  uniform  in  their  outline,  and  more  or  less  globular,  are  always  c(jnfini;d 
to  one  gland,  are  rarely  accompanietl  with  fluid  in  the  tunica  vaginalis,  and  on  being 
punctured  emit  only  a  more  or  less  blood-stained  glairy  mucus. 

The  cancerous  tumors  of  the  organ  are  more  rapid  in  their  development  than  the  cys- 
tic, a  year's  growth,  as  a  rule,  giving  a  large  tumor.  They  are  likewise  painless,  and 
readily  allow  of  free  manipulation.  The  natural  sen.sation  of  the  organ  also  .soon  di.s- 
appears.  They  are  unaccomjjanied  with  a  hydrocele,  and  also  involve  only  one  organ. 
They  have  a  more  elastic  and  fluctuating  feel  than  the  cystic  or  inflammatory  enlarge- 
ments ;  and  when  their  outline  is  unequal  or  bos.sy,  the  projection  is  generally  softer 
than  the  other  portion  of  the  tumor.  An  exploring  needle  or  trocar  and  canula  rarely, 
if  ever,  reveals  the  mucoid  fluid  so  characteristic  of  the  cystic  or  simple  affection.s,  but 
usually  lets  out  blood  or  the  thin  creamy  fluid  so  characteristic  of  a  cancer.  In  the  pre- 
ceding table  the  chief  points  of  difference  in  the  several  chronic  affections  of  the  tes- 
ticles are  clearly  sh(»wn.    (See  Table,  pp.  740,  747.) 

Castration. 

The  scrotum  having  been  shaven  and  the  skin  over  the  testicle  made  tense,  a  free 
incision  is  to  be  made  through  the  scrotum  and  tunica  vaginalis  down  to  the  tunica 
vaginalis  testis,  and  the  body  of  the  organ  with  the  cord  exposed.  When  any  doubt  as 
to  diagnosis  exists,  an  incision  should  be  made  into  the  growth  before  its  removal.  A 
strong  double  carbolized  silk  or  catgut  ligature  should  then  be  passed  between  the  struc- 
tures of  the  cord  and  firmly  tied  in  halves ;  the  cord  should  be  divided  below  the  liga- 
tures and  the  tumor  turned  out  of  its  scrotal  covering.  There  is  no  necessity  to  take 
away  any  of  the  scrotum,  however  stretched,  unless  disea.sed,  since  it  is  sure  to  contract. 
All  vessels  should  be  twisted,  the  wound  washed  out  with  some  hot  iodine  water  and 
dried,  and  a  few  sutures  put  in  at  the  upper  part  of  the  wound  ;  a  drainage  tube  should 
be  intn^duced  at  the  lower  part  of  the  WMjund  and  the  patient  put  to  bed  with  the  pur.se 
raised  by  a  small  pillow.  No  pain  is  caused  when  the  ligature  of  the  cord  has  been 
tightly  tied.     Recovery  is,  as  a  rule,  rapid  after  this  operation. 

To  take  the  ves.sels  of  the  cord  up  singly  is  a  troublesome  operation  and  has  no 
advantages.  No  assistant  can  hold  the  cord  with  his  fingers  after  its  division,  as  it  is 
sure  to  slip  from  his  grasp. 

To  strap  a  testicle  re(|uires  some  skill.  The  patient  should  be  made  to  stand 
against  the  edge  of  a  table  and  separate  his  legs.  The  surgeon  should  then  with  his  left 
hand  grasp  the  organ  from  behind  and  press  it  down 

to  the  bottom  of  the  scrotal  sac,  making  the  scrotum  Fig.  426. 

tense  over  its  surface,  the  thumb  and  index  finger  ,  a^    ^ 

of  his  left  hand  holding  its  neck.  A  piece  of  strap-  v  i^^*^' 
ping  spread  on  leather  half  an  inch  or  more  wide  is  /■  '  ' 
next  to  be  wound  round  the  neck  of  the  tumor 
once,  twioe,  or  even  thrice,  to  hold  it  in  positiim ; 
for  if  this  point  be  not  attended  to.  all  the  subse- 
quent steps  will  be  useless  (Fig.  426).  Having 
done  this,  pieces  of  stranpinir  three-quarters  of  an  c.       •     t   .-  i 

•      11  i.     v.  1-     1  .•      11      x-  -1  strapping  Testicle. 

mcti  fong  are  to  be  applied  vertically  irom  one  side 

of  the  circular  strip  to  the  other,  sufficient  force  being  employed  to  compress  the  organ. 
When  the  testis  is  completely  covered  in  and  compressed,  another  circular  piece  or  so 
should  be  applied,  to  keep  the  whole  in  position  and  to  bind  down  the  ends  of  the  vertical 


750 


AFFECTIONS  OF  THE  GENITAL   ORGANS. 


Fig.  427 


pieces.  The  strapping  will  probably  require  reapplication  every  second  day,  as  the  parts 
soon  yield  and  the  strapping  then  forms  a  loose  bag.  The  student  must  remember  that 
the  object  of  the  strapping  is  to  compress  the  organ,  and  not  to  cover  it. 

For  the  purpose  of  compression  a  narrow  rubber  bandage  nuiy  be  employed  with 
advantage. 

Imperfect  transition  and  malposition  of  the  testicle  are  occasionally  met 
with,  the  organ  being  either  arrested  in  some  part  of  its  course  into  its  scrotal  pouch  or 
misplaced.  At  times  one  testicle  is  found  in  the  canal  or  it  has  failed  to  put  in  an  appear- 
ance, at  all,  while  at  others  both  are  found  to  be  out  of  place.  Not  uncommonly  this 
arrested  descent  of  the  testicle  is  complicated  with  a  congenital  hernia,  the  vaginal  pro- 
cess of  peritoneum  being  still  open,  and  in  all  cases  of  scrotal  swelling  in  infants  the 
surgeon  should  examine  the  parts  with  care  to  discover  whether  the  testicle  is  or  is  not 
involved  in  the  tumor.  When  the  testes  are  thus  placed,  they  are  very  commonly  ill 
developed.  At  times  during  their  descent  through  the  rings  they  are  nipped  by  the 
muscular  structures  and  become  inflamed.  I  have  recorded  such  instances  in  a  former 
page. 

Treatment. — Nothing  can  be  done  by  way  of  treatment  to  expedite  the  descent  of 
the  organ.  When  within  the  internal  ring  and  complicated  with  hernia,  it  is  well  to 
recommend  a  truss ;  but  when  the  testis  is  in  the  canal,  such  an  instrument  cannot  be 
worn,  an  extra  element  of  danger,  under  these  circumstances,  being  added  to  the  case. 

Testes  so  situated  seem  to  be  very  prone  to  become  the  seat  of  cancerous  disease. 
Many  such  cases  have  been  recorded. 

In  a  case  under  my  care,  of  a  gentleman  over  fifty,  an  encysted  hydrocele  was  found 
with  a  small  testicle  situated  in  the  centre  of  a  congen- 
ital hernia,  the  cyst  on  the  reduction  of  the  hernia  appear- 
ing as  a  tumor  the  size  of  a  small  orange,  below .  the 
external  ring  and  behind  the  hernia.  I  tapped  it  from 
behind  and  drew  off  about  two  ounces  of  a  milky  fluid 
containing  many  spermatoza,  and  injected  it  with  iodine. 
A  good  result  followed.  This  gentleman  was  married  and 
had  a  fimily. 

Malplaced  testicles  are  less  common  than  those 
just  described.  I  have,  however,  seen  at  least  ten  cases; 
in  five,  one  of  which  I  have  reported  {Gui/s  Hasp.  Reports, 
18G7),  the  right  testicle  was  placed  in  the  perinaBum  in  its 
own  separate  scrotal  pouch  (Fig.  427),  whilst  in  the  other 
five  the  right  testicle  was  in  the  perinjcum,  but  outside  the 
scrotal  sac,  which  was  otherwise  natural.  There  was  in  one 
a  hernia  associated  with  the  malplaced  testicle,  the  bowel 
clearly  descending  into  the  tunica  vaginalis  down  to  the 
testicle.  It  would  seem  that  the  right  testis  is  more  prone  to  malposition  than  the 
left. 

Varicocele. 

This  signifies  a  varicose  condition  of  the  spermatic  veins ;  and  when  the  disease  is 
well  marked,  their  tortuosity  and  dilatations  present  the  appearance  (Fig.  428)  and 
impart  the  feeling  of  a  "  bag  of  worms"  within  the  scrotum.  It 
is  more  common  on  the  left  than  on  the  right  side,  the  assigned 
causes  of  this  preponderance  being  the  more  dependent  position 
of  the  left  organ  and  the  liability  of  the  vein  to  be  pressed  upon 
by  a  loaded  sigmoid  flexure  of  the  colon.  It  is  a  disease  of 
young  adult  life,  and  is  the  cause  of  the  rejection  in  the  British 
army  of  about  fifteen  recruits  in  the  thousand.  It  is  doubtless 
often,  although  not  always,  the  product  of  masturbation  or  excess 
of  venery  ;  but  anything  that  retards  the  return  of  the  venous 
blood  from  the  organ  aggravates,  if  it  does  not  really  cause  it. 

Symptoms. — The  affection  is  generall}^  accompanied  by  a 
dull  aching  pain  in  the  part,  as  well  as  a  sensation  of  weight 
or  fulness,  but  these  symptoms  are  rarely  complained  of  at  an 
early  period  of  the  affection.  The  pain  often  passes  up  the 
groin,  even  to  the  loins,  and  is  relieved  if  the  patient  assume  the 

Varicocele.    (Taken  from  case  i.      ^  -i-  t_        i         x-        xi  i. 

of  Mr.  jacobson.)  recumbent  position,  or  even  by  elevating  the  scrotum. 


Right  Testicle  in  the  Perinoeum. 


Fig.  428. 


AFFKCTIOSS  Ob'   TUE  SLllOTI'M. 


7.",! 


Tkkatmknt. — If  coiistijtatinn  tix'iHts,  tlio  luiwcls  must  he  n'jrulatcd.  If  tlio  sornturii 
.be  lu'iidiilniis,  cdld  iKitliiiii.'  ()iij.'lit  to  l»c  rocoiniiiciiilcil  and  iIk-  orf.'aii  supportt-d  hy  woiiic 
Buspciisory  lianda;:f.  Tonics  are  often  of  use.  When  this  palliative  treatment  ^ive.s 
relief  and  retanis  the  pro^'ress  of  the  disease,  nothing'  more  is  needed  ;  hut  when  the  dis- 
ease is  severe  and  these  means  are  inefl'eetuiil.  a  more  radieal  treatment  is  ealled  for.  which 
consists  in  the  exeision,  destruetion.  or  division  of  the  veins. 

Kirisinii  is  a  practice  which  has  heen  reintroduced  since  antiseptic  surj^ery  has  become 
a  fashion,  and  consists  of  the  removal  ol'  ahout  an  inch  of  the  diseased  vein  below  the 
external  in<;uinal  rinj^  after  the  application  of  a  li^^ature  of  carbolized  eatfrut  above  and 
l)elow  the  part  to  Ite  removed,  (iood  results,  as  a  rule,  follow  this  practice,  hut  I  have 
known  of  bad,  and  rejjard  the  operation  as  more  dangerous  than  tliat  now  to  be  de.scril)ed. 

Opnuition  of  Lii/dtinr. — This  is  a  subcutaneous  operation,  and  is  most  successful. 
Some  surgeons  employ  metallic  wire  for  the  purpose,  others  carbolized  silk,  catgut,  or 
kangaroo-tendon  ligatures.  Mr.  Lee  uses  two  pins  to  arrest  the  flow  of  blood  through 
the  veins  and  performs  subcutaneous  division  of  the  vessels  between  them  ;  I  prefer,  how- 
ever, the  ligature.  Sir  H.  Hrodie  u.sed  to  divide  the  veins  subcutaneously  and  a|ij»ly_ 
pressure.  Mr.  J.  Wood  of  Kings  subcutaneously  surrounds  the  veins  with  a  double 
wire  noose  and  keeps  up  pressure  upon  the  wire  by  means  of  a  metallic  spring  till  the 
division  of  the  veins  occurs.  The  operation  I  prefer  is  perffirmed  as  f(dlows  :  I'nder  an 
anivsthetie  or  not.  the  scrotum  on  the  side  of  the  varicocele  is  to  be  taken  between  the 
fingers  and  thumb  and  the  vas  deferens  (which  may  always  be  known  by  its  cordy  hard- 
ness) allowed  to  escape ;  so  soon  as  this  is  done  a  needle  armed  with  the  ligature  should 
be  passed  through  the  scrotum  beurath  the  bundle  of  spermatic  veins  and  drawn  through. 
A  Liston's  needle  on  a  handle  should  then  be  introduced  through  the  same  skin-opening 
as  was  made  by  the  first  needle  and.  passed  in  front  of  the  veins,  and  its  point  brought 
out  at  the  point  of  exit  of  the  first  needle.  The  ligature  first  passed  is  then  to  be  threaded 
through  the  eye  of  the  needle,  which  should  be  drawn  back.  When  this  step  has  been 
taken,  the  bundle  of  veins  have  been  surrounded  and  may  be  occluded  by  firmly  tying 
the  ends  of  the  ligature.  It  is  a  good  plan,  before  tying  the  ligature,  to  divide  the  skin 
at  its  point  of  exit  and  entrance  with  a  tenotomy  knife,  the  loop  of  the  ligature  by  this 
Step  being  lost  in  the  tissues  and  made  subcutaneous.  A  second  ligature  is  to  be  applied 
in  like  manner,  half  an  inch  or  more  lower  down  or  higher  up,  as  the  case  may  be  ;  and 
after  this  the  veins  may  or  may  not  be  divided  subcutaneously  between  the  two  needles 
by  a  tenotomy  knife.  Of  late  years  I  have  left  out  this  part  of  the  operation  with  no 
detriment.  As  a  general  rule,  this  operation  is  most  successful,  and  not  dangerous.  It 
is  only  to  be  done,  however,  when  palliative  treatment  fails. 

Mr.  Morgan  of  DuVjlin  has  recently  suggested  an  admirable  suspender  for  varicocele 
and  other  affections  of  the  testis,  which  is  illustrated  in  Fig.  429.  It  consists  of  a  piece 
of  webbing  four  and  a  half  inches  long,  three  and  a  half 
inches  wide  at  one  end,  four  inches  at  the  other,  and 
gradually  tapering  to  the  narrower  end.  A  piece  of 
thick  lead  wire  is  stitched  in  the  rim  of  the  smaller  end, 
two  tapes  sewn  along  the  entire  length  of  the  webbing, 
and  the  sides  furnished  with  neat  hooks,  a  lace,  and  a 
good  tongue  of  chamois  leather.  When  the  suspender 
has  been  applied  to  the  testicle,  the  tapes  are  to  be 
attached  to  an  abdominal  Vxdt.  The  size  may  vary  more 
or  less.  The  lead  wire  encircling  the  lower  end  gives  a 
foundation  to  the  general  means  of  support  and  keeps 
the  testis  within  the  bag ;  the  patient  can  mould  it  more 
or  less  to  his  convenience,  and  it  need  not  be  worn  at 
night. 

Fatty   tumors   are   occasionally  met  with   in   the 
cord — I    have   removed   one   the   size   of  a  walnut — and 
fibrous  or  sarcomatous  tumors  have  been  met  with  on  the  testicle.     I  have  seen  one  of 
the  latter,  the  size  of  an  orange,  excised  by  Mr.  Hilton  from  the  testicle  with  success. 


Fig.  429. 


Affections  of  the  Scrotum. 

The  scrotal  pouch  is  very  frequently  the  seat  of  injury,  while  the  testicle,  from  its 
mobility,  escapes.  When  the  parts  are  bruised,  the  effusion  of  blood  is  at  times  very 
great,  the  blood  forming  a  large  diffused  scrotal  haematocele,  while  at  others  it  forms  a 


752 


AFFECTIONS  OF  THE  GENITAL   ORGANS. 


Fig.  430. 


distinct  tumor.     On  January  29,  1871,  I  was  consulted  by  T.  B ,  3et.  40,  who  sat 

down  on  the  broken  arm  of  a  chair,  the  stump  of  the  arm  brui.sing  the  perineal  border 
of  the  scrotum.  A  swelling  at  once  appeared  ;  and  when  I  saw  him,  twenty-six  hours 
after  the  accident,  a  well-defined  blood  tumor  the  size  of  a  cocoanut  existed  in  the  median 
line  of  the  scrotum,  the  two  testicles  maintaining  their  position  on  either  side.  By  rest, 
cold  lotion,  and  tonics  the  blood  was  absorbed  in  three  months. 

Lacerated  wounds  of  the  scrotum  are  also  attended  with  blood  extravasation,  but  they 
usually  heal  readily,  on  account  of  the  vascularity  of  the  parts. 

CEdema  of  the  scrotum  takes  place  when  inflammation  attacks  neighboring 
structures.  It  is  seen  in  the  inflammation  of  the  epididymis  associated  with  gonorrhcjea 
and  in  acute  orchitis  ;  in  extravasation  of  urine  and  urinary  perineal  abscess  ;  in  the  reten- 
tion of  urine  in  childhood  due  to  the  obstruction  of  a  calculus ;  in  phimosis  or  paraphi- 
mosis ;  in  erysipelas.  In  all  these  cases  it  is  present  with  more  or  less  redness  and  exter- 
nal signs  of  inflammation. 

Simple  cedema  is  one  of  the  first  indications  of  renal  or  cardiac  dropsy. 
Elephantiasis  of  Scrotum. — Not  rarely  the  scrotum  is  the  seat  of  elephantiasis 
anibuin — solid  cedema  of  the  scrotum — and  the  disease  generally  attacks  the  penis  as  well. 
In  tropical  countries,  where  this  affection  is  common,  the  tumors  attain  an  enormous  size. 
It  is  the  same  disease  which  attacks  the  female  genitals  and  other  parts  of  the  body  and 
extremities,  and  in  the  West  Indies  is  known  as  the  "  Barbadoes  leg.  '  By  Mr.  Dalton 
of  Guiana  and  other  observers  it  is  regarded  as  a  constitutional  disease.     For  its  true 

pathology  refer  to  p.  178.  It  is  occasionally  associated  with 
ichthyosis  of  the  tongue  and  is  often  attended  with  fever 
and  local  erythema  with  oedema,  which  never  subsides. 
AVhen  attacking  the  scrotum,  nothing  but  its  excision  is  of 
any  use.  The  historical  case  in  which  Mr.  Key  removed 
from  a  Chinaman  fet.  32  a  tumor  weighing  fifty-six  pounds 
(Prep.  1620'''*,  Guy's  Museum),  of  ten  years"  growth  (Fig. 
430).  is  a  good  case  in  point  ;  but  the  growths  attain  a  larger 
size  than  this.  Mr.  "Wiblin  in  1862  excised  a  growth  equally 
large,  and  in  the  Med.-Chir.  Trans,  for  1863  the  report  of  hi.* 
case  will  be  found,  with  a  reference  to  others.  Such 
growths  are  made  up  of  the  elements  of  ordinary  connective 
tissue. 

Sir.  J.  Fayrer.  who  has  operated  on  many  cases,  writes : 
'•  The  operation  for  removal  of  a  scrotal  tumor  is  simple 
enough,  but  it  requires  determination  and  expedition.  It 
also  needs  the  aid  of  intelligent  assistants.  Before  commen- 
cing it  is  well  to  have  the  tumor  raised  and  supported  in  a 
vertical  position  for  half  an  hour,  to  drain  it  of  blood  as 
much  as  possible ;  then,  the  patient  having  been  placed  in  a  recumbent  position  on  an 
ordinary  table,  with  the  nates  brought  near  the  end  of  it,  he  is  to  be  put  under  the  influ- 
ence of  an  anfesthetic  and  the  incisions  are  to  be  commenced.  Several  assistants  are 
re(|uired.  to  hold  back  the  legs,  raise  the  penis  and  testes,  support  the  tumor,  and  rapidly 
secure  the  bleeding  points.  These  being  provided,  the  operation  nuiy  be  begun.  The 
director  is  to  be  introduced  into  the  passage  at  the  bottom  of  which  lies  the  glans  penis, 
and  that  organ  exposed  by  laying  open,  with  either  the  long  catlin  or  the  sharp-pointed 
bistoury,  the  dense  tissue  covering  it.  If  the  prepuce  is  healthy,  it  is  well  to  reflect  a 
portion  of  it  as  a  future  covering  to  the  penis.  If  the  prepuce  is  involved,  or  even  sus- 
pected of  being  involved,  it  should  be  carefully  dissected  away,  like  the  rest  of  the  thick- 
ened tissue.  Having  exposed  the  penis,  it  is  to  be  raised  and  carefully  dissected  out, 
with  or  without  the  prepuce,  as  the  case  may  be.  This  is  to  be  raised  and  held  aside  by 
an  assistant,  care  being  taken  in  clearing  it  out  of  the  morbid  tissue  not  to  divide  the  sus- 
pensory ligament. 

'"  The  next  step  is  to  make  a  deep  and  bold  incision  down  to  the  tunica  vaginalis  on  one 
side.  In  a  large  tumor  several  incisions  will  be  needed  before  the  tunica  vaginalis  is  exposed, 
■which  probably  will  be  found  much  thickened  and  distended  with  fluid,  forming  large 
hydroceles.  These  should  be  laid  open,  and  if  the  tunica  vaginalis  be  much  thickened  it 
shtjuld  be  removed  ;  if  not  so  aff"ected  and  the  testicle  not  enlarged,  it  need  not  be  inter- 
fered with.  The  testicle  is  then  to  be  dissected  out,  reflected,  and  held  upward  with  the 
penis.  A  similar  proceeding  is  to  be  carried  out  on  the  opposite  side.  The  tumor  is  then 
to  be  removed  by  connecting  transversely  the  three  vertical  incisions  already  made,  and 


Elephantiasis      <if      the 
(Key's  case.) 


STi:iiii.iTY.~M.\Li:  iMrnTi.sci-:  AM)  si'i:i:mai(iI'j:ii<i:a.  753 

then,  witli  citluT  tin-  scalinl  (ir  tlic  aiii|iiit:itiri;;  kiiitV.  the  n'liiainin;.'  porlion  nf  the  neck 
ol"  thi"  tuiiiur  is  to  hi'  cut  thniti<:h.  It  is  wi-ll  licfoic  scpariitiii^'  it  to  mark  out  on  the 
perineal  aspect  hy  an  incision  the  line  at  wliich  tlie  removal  is  to  he  cimipleteil.  During 
the  operation  vessels  are  to  he  comniaiiile<l  hy  the  fin^'ers  of  assistants  and  lar^re  viins 
contmllcd  hy  forceps.  It  is  well  that  even  the  most  ininutt;  hleediii'.'  point  should  he 
lij:aturi'd  (or  twisted);  otherwise,  when  reaction  occurs,  there  may  he  hemorrha;:e.  The 
hleedini:  haviiiu'  heeii  controlled,  the  testes  with  their  elonj^ated  cords  are  to  he  aj)plied  to 
the  surface  of  the  wound;  the  penis  is  to  he  enveloped  in  a  fold  of  oiled  lint  and  thus 
kept  apart  from  the  tc-tes.  which  are  also  covered  and  supported  in  position  hy  oiled 
cloths.  " 

The  larL'cst  tumor  df  this  kind  on  record  writrhcd  two  luindnd  |i(iunds. 

Dr.  Turner  of  Samoa  (^ii/asi/oir  Mdl.  .Jokih..  January,  l.S.SiJj  uses  a  clamp  with  a  notch 
in  its  centre  for  the  urethra,  to  compress  the  hase  of  the  scrotum  after  it  has  heen  drained 
of  its  hlood  by  elevation,  lie  likewi.se  lays  <rreat  stress  upon  the  propriety  of  dissecting 
out  the  penis  and  the  testicles  hefore  any  attempt  is  made  to  remove  the  tumor.  Other 
surgeons  have  used  a  rulihcr  tuhe  to  compress  the  hase  of  the  tumor. 

Cancer  of  the  Scrotum. 

This  is  a  rare  affection  compared  with  what  it  was  some  years  ago  when  .sweeps 
ascended  flues.  It  is  still,  however,  met  with  in  this  country  as  a  chunitn/siceep's  cancer. 
On  the  Continent  it  is  well  known  in  the  tar  and  paraflline  manufactories,  the  products  of 
distillation  of  coal,  according  to  Volkmann,  being  more  irritating  to  the  human  skin  than 
soot.  The  disease  is  in  reality  an  epithelial  cancer  similar  to  that  found  in  other  parts  of 
the  body  ;  at  times  it  is  very  extensive  and  involves  the  whole  scrotum. 

Tkkat.ment. — Nothing  but  its  removal  can  be  recommended.  Small  tumors  mav  be 
cauterized  down  or  destroyed  by  caustics,  but  the  larger  should  be  excised.  When  the 
growth  can  be  isolated  by  pins  passed  through  its  base,  the  platinum  wire  ecraseur  heated 
by  the  galvanic  battery  is  probably  the  best  instrument  to  use  ;  otherwi.se,  the  knife  is  to 
be  employed.  AVhen  the  whole  scrotum  is  removed  and  the  testes  are  left  exposed,  hang- 
ing from  their  external  rings,  the  surgeon  need  be  under  no  alarm,  for  the  parts  will 
granulate  up  in  the  course  of  time,  and,  what  is  more,  the  testicles  may  become  movable. 
I  have  seen  this  take  place  more  than  once.  The  earlier  the  disease  is  removed,  the  bet- 
ter ;  for  by  delay  the  glands  of  the  groin  may  become  involved. 

Other  Diseases  of  Scrotum. 

The  scrotum  is  occasionally,  though  rarely,  the  seat  of  tumors,  sebaceous,  fatty,  fibrous, 
or  sarcomatous.  It  is  likewise  the  seat  of  varicose  veins,  the  small  venous  radicles  appear- 
ing as  beaded  dilatations  of  a  peculiar  aspect;  the  disease  is,  however,  of  little  importance. 

Tumors  or  swellings  that  encroach  upon  the  scrotum  from  the  perinivjum  are  j>robably 
inflammatory,  and  are  most  frequently  urinary  ab.scesses  a.ssociated  with  and  dependent 
upon  some  stricture;  but  occasionally  an  anal  abscess  may  press  forward,  and  I  have  seen 
one  occupying  the  whole  perinajum  up  to  the  scrotum.  These  are  to  be  treated  by  free 
incisions. 

STERILITY.— MALE  IMPOTENCE  AND  SPERMATORRHCEA. 

The  influence  of  the  sexual  functions  is  so  great  in  the  economy  (jf  human  life  that 
any  impairment  of  the  organs  concerned  is  a  matter  of  importance,  not  only  in  its  effects 
on  the  bodily  health,  but  even  more  on  the  mental  state  of  the  person  affected. 

The  sexual  act  is  a  compound  one.  physical  and  mental.  The  jdiysical  organs  maybe 
perfect  and  capable  in  their  way  ;  but  if  the  mental  are  deficient  in  energy  or  weakened 
by  doubt  of  competency,  or  under  the  influence  of  some  emotion  such  as  shame  or  fear, 
the  sexual  act  will  be  spoilt,  and  failure  to  complete  it  must  ensue. 

It  is,  therefore,  clear  that  impotence,  real  or  imaginary,  may  be  due  to  either  physical 
or  mental  causes. 

Taylor  defines  tmpofcncy  to  be  "  an  incapacity  for  sexual  intercourse."  This  incapacity 
may  ensue  from  physical  causes,  remediable  or  irremediable.  The  latter  includes  loss  of 
penis  and  testicles,  deformity  of  penis,  including  excess  of  and  arrest  of  development, 
maldevelopment  in  such  cases  as  ectopia  vesicae,  etc.  The  remediable  causes  may  be 
some  local  afl!"ection  of  the  penis  or  testes. 
48 


754  AFFECTIONS  OF  THE  GENITAL   ORGANS. 

Any  condition  that  prevents  the  introduction  of  the  organ  into  the  female  passage  is 
enough  to  cause  impotence,  whether  such  condition  be  connected  with  the  penis  or  with 
the  testes.  The  same  effect  is  produced  by  any  disease  or  congenital  malposition  or  devel- 
opment of  the  testes  attended  with  loss  of  sexual  desire,  as  by  old  age.  A  man  may,  there- 
fore, be  impotent  and  virile  or  impotent  and  sterile. 

A  man  may  be  capable  of  sexual  intercourse  and  yet  be  sterile,  sterility  in  the  male 
depending  much  upon  the  secretion  of  the  testes,  as  well  as  upon  the  formation  of  the 
penis ;  for  semen  without  spermatozoa  is  destitute  of  procreative  power.  A  man  may 
have  a  penis  the  subject  of  epispadias  or  hypospadias;  he  may  have  sexual  desire,  and 
even  power,  but  if  the  urethral  orifice  be  so  low  down  as  to  prevent  the  semen  from 
being  conveyed  into  the  vagina  he  will  be  sterile,  though  all  patients  with  hypospadias 
are  not  so.  I  have  known  two  men  who  had  hypospadias — the  orifice  of  the  urethra  in 
each  opening  one  inch  behind  the  normal  urethral  opening — to  be  the  fathers  of  three 
and  four  children  respectively,  and  a  third,  in  whom  the  urethral  orifice  was  one  inch 
behind  the  glans,  whose   wife  died  in  childbirth. 

When  the  urethral  orifice  is  at  the  base  of  the  penis,  sterility  must,  however,  exist. 
When  partial  epispadias  exists,  there  is  no  reason  to  believe  that  a  man  must  be  sterile. 

When  both  testes  are  misplaced — that  is,  when  they  have  not  descended  into  the 
scrotum — there  is  a  strong  probability  that  the  organs  are  badly  developed,  that  they  do 
not  secrete  healthy  spermatic  fluid,  and  that  sterility  is  the  result.  Curling  asserts  this 
very  positively  to  be  the  fact,  but  he  at  the  same  time  brings  forward  evidence  from 
Messrs.  Cock's  and  Poland's  practice  that  such  is  not  always  the  case.  In  a  general  way 
Mr.  Curling  may  be  right,  but  there  are  many  exceptions  to  such  a  rule.  When  one  testis 
is  in  the  scrotum  and  healthy,  there  is  no  reason  to  suspect  sterility. 

Sterility  sometimes  follows  disease  of  the  testes,  inflammatory  or  otherwise ;  for  epi- 
didymitis or  inflammation  of  the  duct  of  the  testicle,  as  well  as  testitis  or  inflammation 
of  the  gland,  may  be  followed  by  atrophy  of  the  organ.  Gosselin,  Godart,  and  Liegeois 
have  laid  great  stress  upon  this,  and  Curling  ascribes  these  as  common  causes  of  sterility. 
Sterility  may  also  be  produced  by  involuntai*y  seminal  emissions  the  result  of  excess  of 
venery  or  masturbation  by  producing  either  loss  of  sexual  power  or  deterioration  of 
semen.  Stricture  or  any  impediment  to  the  seminal  discharge  is  also  another  cause.  The 
student  must  remember,  too,  that  a  man  may  be  capable  of  sexual  intercourse  and  be 
sterile  from  other  causes.  He  may  even  have  emissions  in  connection  without  seminal 
secretion,  for  the  emissions  may  consist  only  of  secretion  from  the  seminal  vesicles.  I 
have  known  this  fact  illustrated  in  a  man  who  had  lost  both  his  testicles  from  a  surgical 
operation  and  yet  had  sexual  power  as  strong  as  ever,  attended  with  emission.  The 
removal  of  one  testicle  seems  to  interfere  but  little,  if  at  all,  with  sexual  power.  Some 
years  ago  I  removed  a  testicle  for  cystic  disease  from  a  gentleman  who  had  been  married 
many  years  and  had  no  child.  After  the  operation  his  wife  soon  conceived  and  gave  birth 
to  a  boy. 

In  the  female  subject  impotency  may  be  said  to  exist  when  the  vagina  is  absent  or 
obliterated.  It  is  for  a  time  present  when  the  orifice  is  occluded  by  some  dense  mem- 
brane, or  when  the  introduction  of  the  male  organ  is  prevented  on  account  of  the  small- 
ness  of  the  orifice,  by  vaginismus,  or  from  the  presence  of  a  bifid  vagina. 

Sterility  is  due  to  many  causes,  the  occlusion  of  the  os  uteri  being  one,  but  morbid 
conditions  of  the  uterus  and  ovaries  are  probably  the  more  frequent. 

The  student  should  remember  that  "Ithe  functions  of  the  testicle,  like  those  of  the 
mammary  gland  and  uterus,  may  be  suspended  for  a  long  period — possibly  for  life — and 
yet  its  structure  may  be  sound  and  capable  of  being  roused  into  activity"  on  any  healthy 
stimulus.  Unlike  other  glands,  it  does  not  waste  or  atrophy  for  want  of  use,  the  physical 
parts  of  man's  nature  being  accurately  adapted  to  the  necessities  of  his  position  and  to 
his  moral  being. 

Spermatorbhcea. 

This  doubtless  exists  as  a  disease,  although  rare.  It  consists  in  the  discharge  of  sper- 
matic fluid  containing  spermatozoa  with  the  urine,  without  sexual  desire  or  sexual  excite- 
ment. It  is  commonly  associated  with  some  derangement  of  the  digestive  organs,  consti- 
pation, and  rectal  irritation,  spasmodic  action  of  the  levator  ani  acting  on  the  vesiculae 
seminales  and  prostate  gland.  In  its  most  complete  form  it  is  associated  with  an  absolute 
loss  of  sensation  about  the  veru  montanum  on  the  passage  of  a  sound,  a  patient  thus 
affected  allowing  the  introduction  of  an  instrument  without  flinching,  whilst  the  worst 
cases  are  associated  with  wasting  of  the  testicles  and  varicocele.     It  is  at  times,  without 


SI'hn.MAToHL'IKKA.  Too 

(l()ul)t,  (liic  to  excess  of  veiiory,  l)ut  inniv  foimeioiily  to  nia.stiirl)ation.  It  coiimiii'im-cs 
iiliiiitst  alwiiys  with  iinctunial  ciiiissioiis,  whicli  ^Tadiially  l)i'c<mic  iiioi-t'  f"re<|Ut'rit.  'J'lie.se 
are  at  tirst  atti'iidcil  with  fiDtic  .sensation,  althoii^^li  not  mo  suh.st;<|ui;ntly,  and  at  hist  occur 
without  erection.  If  cnpuhition  he  attenipteil,  tlie  ejacuhition  takes  place  at  once,  often 
before  the  intnxhiction  of  the  orj^an.  It  (-ikIs  in  the  total  loss  of  ,s(!xual  inclination  and 
power.  Lalleniand  says  that  ''seminal  emissions  supctrvening  durinj.'  micturition  are  the 
njoat  serious." 

He  holds  that  "  spermatorrha'a  is  nearly  always  deptMident  upon  irritation  olthe  pro.s- 
tate  iiland  and  its  ejaculatory  ducts,"  and  believes  that  "  in  most  eases  this  irritation, 
which  also  exists  in  the  neck  of  the  hhuhJer,  is  the  result  of  chronic;  inflammation  of  the 
urethra  in  the  prostatic  portion  of  the  verii  montanum.  An  ohl  attack  (»f  urethritis  is 
the  most  frecjuent  cause  of  the  seminal  emissions,  and  tlie.se  emissions  are  often  related 
to  stricture  of  the  un-thra.  ' 

Trousseau,  however,  whih;  admittinj^  the  force  of  these  observations,  believes  that  sper- 
matorrh(oa  or  incontinence  of  semen  is  due  to  som(>  inipcM-fection  in  the  nervous  system 
of  oriianic  life,  since  it  is  so  commonly  found  in  men  who  have  had  incontinence  of  urine 
in  childhood.  He  looks  upon  the  masturbation  as  an  indirect  proof  that  there  is  a  h»ad 
state  of  the  nervous  systen),  and  the  subsequent  impotence,  insanity,  or  paralysis  as  an 
aggravation  of  a  nervous  condition  of  which  masturbation  was  oidy  the  first  morbid 
manifestation  (Trous.seau,  Clin.  Med.,  vol.  iii.).  This  latter  view  is  supported  by  the  fact 
that  in  some  cases  of  injury  to  or  disease  of  the  spinal  column  sjjermatorrlnea  is  a  com- 
mon associate. 

False  spermatorrhcsa  is,  however,  a  more  common  complaint.  It  is  suppo.sed 
to  be  present  when  nocturnal  emissions  are  fre((uent,  when  diurnal  emi.ssions  take  place 
on  any  sexual  thought  and  urethral  discharge  of  a  glairy  fluid  attends  defecation,  when 
erections  with  discharge  follow  the  slightest  irritation,  such  as  that  produced  by  riding  or 
walking,  from  the  friction  of  trousers,  etc.  Such  cases  are  far  from  rare  and  are  com- 
monly due  to  masturliation,  but  are  not  cases  of  true  spermatorrlnjea,  although  the)'  often 
precede  it.  Nocturnal  emissions  may  be  tot)  frequent;  but  if  associated  with  sexual  feel- 
ing, they  are  natural.  They  should,  however,  be  checked,  as  they  lead  on  to  the  true  dis- 
ease. The  glairy  fluid  pressed  out  in  defecation  is  rarely  seminal,  but  is  prostatic,  of  a 
transparent,  tenacious  character,  and  not  milky.  The  whole  genital  tract  in  this  aflFection 
is  in  a  state  of  morbid  sensibility,  of  hyperjvsthesia,  and  requires  treatment,  since  the 
false  spermatorrhoea  is  often   only  the  prelude  to  the  true. 

Treatment. — Trousseau,  regarding  masturbation  as  a  manifestation  of  some  disease 
of  the  nervous  centres,  speaks  strongly  in  favor  of  belladonna,  and.  so  far  as  ni\-  experi- 
ence has  gone,  I  am  disposed  to  think  it  a  valuable  drug  given  in  half-grain  doses  of  the 
extract  twice  a  day,  with  some  tonic  such  as  iron,  zinc,  strychnine,  or  quinine.  It  seems 
to  act  most  beneficially,  and  in  a  marked  manner  to  check  the  disposition  to  masturbate. 
Of  course  this  good  can  be  met  with  only  when  there  is  in  tlie  patients  mind  a  strong 
wi.sh  to  overcome  a  repugnant  habit.  To  aid  this  the  application  of  a  ring  of  blistering 
fluid  around  the  penis  or  painting  the  prepuce  with  iodine  is  n  valuable  adjunct.  The 
bowels,  more  particularly  the  rectum,  under  all  circumstance,  should  be  kept  empty,  and 
the  nightly  injection  of  cold  water  into  the  bowel  is  a  useful  custom.  The  patient  should 
sleep  upon  a  hard  bed  and  be  lightly  covered.  He  should  not  rest  on  his  back,  and  a 
solid  substance  fastened  in  a  handkerchief  over  the  sacrum  is  a  good  mode  of  securing 
this  end. 

AVhen  evidence  exists  that  the  mucous  membrane  of  the  prostatic  urethra  is  affected 
near  the  orifices  of  the  spermatic  ducts,  Lallemand's  advice  of  applying  a  solution  of  • 
nitrate  of  silver  (gr.  v  to  gr.  x  to  the  ounce)  every  other  day  should  l)e  followed.  Some 
surgeons  use  a  stronger  solution  ;  and  when  an  absolute  loss  of  .sensibility  of  these  parts 
is  present,  galvanism  has  been  highly  spoken  of.  For  the  application  of  the  solution 
Erichsen's  syringe  catheter  is  the  best.  Every  means  .should  be  employed  to  divert  the 
patient's  mind  from  the  seat  of  his  affection  by  encouraging  mental  as  well  as  physical 
labor.     Simple  nutritious  food  should  be  allowed  and  cold  bathing  adopted. 

In  the  cases  of  imaginary  impotence  of  young  married  men  all  that  the  surgeon  has 
to  do  is  to  give  confidence,  for  the  failure  is  jirobably  in  the  mind  rather  than  in  the  body 
of  his  patient.  The  best  advice  is  to  recommend  abstention  from  coitus,  when  Nature  in 
her  own  time  will  have  her  way  and  assert  her  power. 


756  SURGICAL  AFFECTIONS  OF  FEMALE  GENITALS. 


CHAPTER    XXV. 
SURGICAL  AFFECTONS  OF  FEMALE  GENITALS. 

Wounds. 

Wounds  of  the  external  genitals  are  met  with  in  practice  as  the  result  of  violence 
intentionally  committed  or  happening  accidentally  from  falling  or  sitting  on  pointed  or 
cutting  bodies.  They  are  always  serious,  on  account  of  the  bleeding  that  attends  them, 
and  wounds  of  the  vagina  are  particularly  so.  However  severe  they  are,  they  should  be 
carefully  cleansed,  adjusted,  and  stitched  together ;  for  these  tissues  are  very  vascular 
and  heal  well. 

Severe  lacerations  at  times  takes  place  in  the  attempt  at  coitus.  Some  years  ago  I 
was  called  to  a  young  married  woman  for  severe  hemorrhage  from  these  parts  following 
marital  intercourse  the  night  after  marriage,  and  found  two  severe  lacerations  of  the  ori- 
fice of  the  vagina  and  the  hymen  unruptured ;  the  membrane  had  been  practically  driven 
in.     Pressure  arrested  the  bleeding. 

Wounds  of  the  vagina  are  apt  to  be  followed  by  inconvenient  cicatrices. 

Foreign  bodies  are  also  at  times  introduced  into  the  vagina  for  criminal  or  erotic  pur- 
poses. Mr.  Hilton  removed  at  Guy's  a  flat  bone-netting  me.sh  ten  inches  long  which  had 
pas.sed  through  the  vaginal  walls  into  the  pelvis.  Bottles  and  other  foreign  matters  have 
also  been  introduced.  Sponges  are  not  uncommonly  found  in  the  passage,  and  in  a  case 
I  knew  of  such  a  foreign  body  gave  rise  to  the  suspicions  of  cancerous  disease. 

Adherent  Labia. 

The  labia  during  childhood  are  apt  to  adhere  together  from  some  local  inflammatory 
action,  and  so  to  close  the  labial  orifice  as  to  interfere  with  the  act  of  micturition.  The 
urine  in  children  thus  afl'ected  often  squirts  in  a  backward  or  forward  direction,  and  for 
this  surgical  attention  is  sought.  In  these  cases  the  true  condition  of  affairs  will  at  once 
be  recognized  on  separating  the  genitals,  for  the  labia  will  be  found  connected  together 
by  a  membranous  adhesion  which  passes  forward  in  some  cases  to  the  urethral  orifice, 
thereby  affecting  the  urinary  stream.  This  membrane  is  readily  broken  down  by  sepa- 
rating the  labia  with  the  fingers  or  thumbs,  or  by  means  of  a  probe  introduced  behind  it 
from  above.  The  application  of  a  little  cold  cream  will  complete  the  cure  if  care  be 
taken  to  keep  the  parts  clean. 

Vulvitis. 

This  is  a  common  complaint  in  children,  and  is  almost  always  due  to  some  rectal  irri- 
tation such  as  that  caused  by  worms,  scybala,  etc.,  in  the  feeble  and  badly  fed.  It  is 
rarely  the  result  of  a  gonorrhoeal  aff"ection,  as  is  too  often  suspected ;  and  it  is  well  to  be 
aware  of  this  fact,  as  it  is  not  uncommon  for  a  surgeon  to  be  consulted  about  a  child  with 
vulvitis  under  the  suspicion  that  the  aff"ection  is  the  result  of  an  impure  criminal  contact, 
when  it  is  due  to  some  simple  non-venereal  cause. 

Treatment. — It  should  be  treated  by  local  cleanliness  and  mild  astringent  lotions 
such  as  lead,  alum,  etc. ;  when  worms  are  suspected,  by  the  administration  of  a  good 
mercurial  or  jalap  purge  and  attention  to  the  digestive  organs  and  general  health;  a 
mixture  of  rhubarb  and  .soda  for  a  few  days,  and  subsequently  a  tonic,  generally  efl'ect  a 
cure. 

Noma,  or  phagedaenic  ulceration  of  the  labia  similar  to  the  cancrum  oris  after  the 
exanthemata,  is  met  with  in  cachectic  children  and  is  a  disease  of  debility.  It  com- 
mences as  an  inflammatory  swelling  of  the  parts  similar  to  erysipelas,  passing  on  to  gan- 
grene and  ulceration,  and  is  always  attended  with  great  prostration. 

Treatment. — For  its  treatment  such  tonics  as  can  be  borne  should  be  given,  and 
particularly  iron,  quinine,  or  bark.  Wine  and  abundance  of  good  liquid  nouri.shment 
should  be  given  by  the  mouth,  or  by  the  rectum  when  the  stomach  rejects  it,  and  milk 
with  chlorate  of  potash  is  a  good  drink.  Locally,  opium  lotion  with  carbolic  acid,  nitric 
acid,  or  nitrate  of  silver  .should  be  used  ;  and  when  the  ulceration  spreads  nitric  acid  in 
its  concentrated  form  may  be  applied,  or  the  actual  or  galvanic  cautery. 


iii:i:ma,  etc.  7o7 

Nsevi,  wlu'ii  foiinil   involving  tliof  iiarts,  are  to  be  tri'utt'fl  liko  otiiors. 

Hernia. — In  wnmcii  tlu-  laliium  may  '>»'  tin-  seat  of  an  iii;.'iiiiial  /n  ruin  or  of  a  ran'- 
coct/i.  Till"  toniu-r  is  kiinwn  l>v  it>  own  syni|itoiiis.  the  latltT  \)\  its  wormy  fV'«;l.  It  may 
also  l»r(Miiiu'  tlu'  scat  of  thrombuS,  or  Itlooil  tumor  on  tlif  receipt  of  an  injury,  wliit-li 
is  to  l»e  made  out  liy  tlie  history  of  the  case,  the  smiih-n  a|i|>earanee  of  the  swcllin;^  al'ter 
an  injury,  its  external  aspect  an*l  Huetuatinj;  feel.  Such  hhnxl  swellin;rs  are  to  he  treated 
at  first  l»v  the  h>cal  ap|)lication  of  cold,  to  arrest  the  flow  of  l>lood,  and  suh.stM|ueritly  hy 
lead  lotions.  If  they  tend  to  hreak  up  and  form  an  altsccss,  a  free  incision  into  the  swell- 
inj^  is  the  ritrht  treatment  to  adopt. 

Labial  abscesses  lorm  at  times  as  a  result  of  a  softened  throm)»us,  hut  »n»re  fre- 
quently tVuni  fulliciilar  inflammation.  They  are  very  painful  and  ought  to  he  opened 
earlv.      ( )(i  a>iiiii;illv   tiiey   are   the   conse(|Uence   of  an   inflamed   cyst. 

Labial  cysts  :ii-e  very  common,  and  are  usually  met  with  on  the  inner  side  of  the 
lahia.  They  are  similar  in  their  nature  to  the  mucous  cysts  lound  in  the  mouth  or  ahout 
the  tonj;ue  and  are  lormeil  in  the  same  way.  hy  the  obstruction  of  the  <lucts  of  the  mucous 
L'lands  of  the  jiarts.  They  ajipear  as  chronic  painless  swellinirs.  jiroducinjL:  ordy  mechan- 
ical inconvenience;  but  if  ncirlectcd.  they  may  inflame  and  su]tpurate.  On  manipulation 
thev  feel  tense,  globular,  and  semifluctuatinir.  and  contain  a  ulairy  brown  or  blood-.stained 
fluid,  at  times  with  eholesterin. 

TuE.\T.MKNT. — They  are  to  be  treated  by  excision  or  the  removal  of  the  presenting; 
surface  of  the  cyst  by  a  pair  of  forceps  and  .scissors,  the  removal  of  one  wall  exposing 
the  other,  which  contracts.  Excision,  however,  is  the  .safe.st  practice.  When  an  opening 
into  the  cyst  is  made,  the  cavity  .should  be  plugged  with  lint  or  with  lint  .soaked  in  tinc- 
ture of  iodine,  this  fluid  exciting  adhesive  action  or  suppuration  in  the  cyst  wall.  When 
the  cyst  suppurates,  it  is  to  be  laid  freely  open  and  dealt  with  as  an  abscess. 

Mucous  cysts  like  the.se  are  also  found  in  the  vagina. 

Sebaceous  Tumors. — The  internal  labia  may  also  be  the  seat  of  .sebaceous  tumors 
and  of  a  solid  (cdenia  or  liy]iertrophy  similar  to  that  .seen  in  the  male  scrotum,  not  unlike 
clej>/i((iifi\tsisj  and  grow  to  a  large  size.  Nothing  but  their  removal  can  be  entertained. 
Some  time  since  I  removed  with  the  galvanic  ecraseur  from  a  middle-aged  woman  both 
labia,  whicb  had  attained  the  size  of  a  cocoanut,  without  tbe  loss  of  a  drop  of  blood,  after 
having  isolated  the  growths  by  long  pins  inserted  through  their  bases  and  passed  the  wire 
round  the  pins.  When  this  instrument  cannot  be  obtained,  the  knife  must  be  employed. 
Such  tumors  are  bighly  vascular,  and  the  surgeon  requires  good  assistants  in  their  removal. 

Cancerous  tumors,  both  epithelial  and  otherwise,  of  these  parts  are  also  met 
with,  and  are  known  by  their  ordinary  features;  they  should  be  treated  by  removal.  It 
seems  that  cancer  is  prone  to  appear  in  these  regions  at  an  earlier  period  of  life  than  in 
others.  In  1809  I  removed  a  well-marked  cancerous  tumor  from  the  labium  of  a  woman 
only  thirty-two  years  of  age. 

Epithelial  disease  of  the  clitoris  occurs  at  times,  and  I  have  seen  several 
well-niark(<l  ea.-es  ;  but  more  commonly  it  attacks  the  inner  labia  and  orifice  of  the 
vagina.  In  such  ca.ses  the  benefit  of  the  galvanic  cautery  is  well  ilhustrated.  for  the 
removal  of  these  growths  by  excision  is  very  diflicult  and  always  attended  with  copious 
bleeding.  When  the  whole  growth  cannot  be  isolated,  as  much  as  possible  should  be 
excised  or  scraped  off"  and  the  cautery  freely  applied  to  the  surface  and  base  of  what 
remains.  Where  the  growth  can  be  isolated  by  the  introduction  of  long  pins  beneath  its 
h»ase  and  a  wire  adjusted  beneath  the  pins,  the  galvanic  ecraseur.  not  made  too  hot  and 
slowly  worked,  is  an  admirable  instrument  to  employ.  By  its  means  I  have  on  several 
occasions  successfully  removed,  without  the  loss  of  a  drop  of  blood,  an  epithelial  cancer 
occupying  the  fourchette  of  the  vagina,  encroaching  on  the  passage  and  the  perin.-euni. 
The  patients  were  under  chloroform  during  the  operation  and  felt  no  pain,  the  after-pain 
in  these  cases  being  always  slight,  the  cautery  entirely  destroying  the  sensibility  of  the 
divided  parts.      Wounds  so  made  heal  kindly. 

Lupus  also  attacks  these  parts  like  others,  while  ivarff/  i/roirfh<i  are  common. 

Syphilis  has  received  attention  in  another  page. 

Imperforate  hymen  is  a  condition  to  be  recognized  and  not  confused  with  the 
adherent  labia,  already  referred  to.  The  hymen  is  more  deeply  placed,  nearer  the  orifice 
of  the  vagina.  When  imperforate,  it  causes  retention  of  the  menses,  the  accumulation 
of  the  .secretions,  and  a  pelvic  tumor  usually  accompanied  by  periodic  pain  and  constitu- 
tional disturbance. 

Tre.vtment. — The  proper  treatment  of  these  cases  is  the  division  of  the  imperforate 
membrane  or  its  complete  excision,  the  object  being  to  allow  of  the  free  escape  of  the 


758  SURGICAL  AFFECTIOyS  OF  FEMALE  GENITALS. 

retained  secretion,  which  is  usually  black  and  treacle-like.  Success  usually  attends  this 
practice,  though  a  fatal  peritonitis  at  times  ensues. 

A  rigid  hymen  is  occasionally  an  impediment  to  coitus  in  women  who  marry  late 
in  life,  and  I  have  known  one  in  which  for  two  years  after  marriage  the  husband  had 
never  had  perfect  connection  on  this  account ;  indeed,  it  was  not  till  after  his  wife  had 
become  pregnant  and  the  vaginal  membrane  had  been  ruptured  during  the  birth  of  the 
child  that  a  satisfactory  coitus  was  effected. 

I  have  also  been  called  upon  on  one  occasion  to  divide  the  hymen  of  a  lady  about 
thirty  who  had  been  married  for  some  months  and  had  never  had  complete  connection, 
the  husband's  penis  having  been  very  large. 

There  are  cases  on  record  showing  that  when  a  vagina  is  occluded  and  the  patient, 
has  been  married,  the  urethra  has  been  so  enlarged  as  to  admit  the  finger,  and  in  all 
probability  the  male  organ. 

A  double  vagina  is  another  cause  of  difficult  coitus.  I  was  consulted  in  such  a 
case  by  a  patient  who  had  been  married  for  several  years  and  never  had  connection.  The 
woman  came  to  me,  as  a  divorce  was  under  consideration.  She  complained  of  extreme 
pain  whenever  an  attempt  at  coitus  was  made,  and  the  husband  of  inability  to  penetrate. 
On  making  a  careful  examination  a  double  vagina  and  uterus  were  discovered.  I  advised 
the  division  of  the  septum  with  the  galvanic  wire  by  perforating  the  septum  near  the 
uterus  and  gradually  dividing  it  by  means  of  steady  traction  upon  the  wire ;  but  whilst 
the  question  was  under  the  consideration  of  both  parties  the  suspicion  of  pregnancy 
occurred,  and  time  proved  its  truth.  A  child  was  born  prematurely  after  a  tedious  labor, 
and  I  heard  no  more  of  the  difficulties  of  the  case.     She  became  pregnant  a  second  time. 

Besides  these  deformities,  others  may  occur,  such  as  occlusion  of  the  vagina  or  absence 
of  the  uterus,  or  the  opening  of  the  rectum  into  the  vagina,  etc. 

Enlarged  Clitoris. — The  clitoris  is  occasionally  enlarged  at  birth,  appearing  as  a 
small  jienis.  I  have  seen  an  example  of  this,  and  at  the  end  of  the  clitoris  a  depression 
existed  corresponding  to  the  male  urethra.  The  child  in  other  respects  was  natural. 
This  organ,  however,  may  in  after-life  become  the  subject  of  hypertrophy — indeed,  of  a 
kind  of  elephas.  as  of  the  male  penis — and  require  removal. 

Clitoridectomy  for  epithelial  cancer  has  already  been  alluded  to.  This  operation 
has  been  practised  for  epilepsy  and  supposed  erotic  complaints,  but  evidence  is  wanting  to 
justify  this  step.     The  operation  for  such  purposes  appears  at  present  to  be  unjustifiable. 

Vaginal  tumors,  besides  the  cystic  and  epithelial,  are  occasionally  met  with,  and 
vaginal  polypi  are  found.  I  removed  one  the  size  of  a  nut  from  a  child  three  years  old, 
and  similar  cases  are  on  record.     They  should  always  be  ligatured  and  excised. 

Rupture  of  the  Perineum. 

This  accident  is  not  rare  as  a  result  of  a  rapid  delivery,  and  to  a  small  extent  it  is 

somewhat  common  in  first  labors.     When  limited,  it  is  not  of  much  importance  ;  but  when 

p      ^oi  extensive  the  pelvic  organs  lose  their  natural  support  and  are 

liable  to  fall,  giving  rise  to  rectocelr.,  or  prolapse  of  the  pos- 

.  _  terior  wall  of  the  vagina,  or  cystocele,  or  prolapse  of  the  an- 

^.  ''^^^"         ^      y^    terior  wall  of  the  vagina. 

^    ^'  ^.  When  the  sphincter  ani  or  the  rectum  is  implicated,  the 

accident  becomes  of  grave  importance. 

At  times  the  rupture  is  central,  and  in  the  ease  from  which 
Fig.  4.31  was  taken  the  child  was  born  through  the  rupture  B. 
The  incident  took  place  in  the  practice  of  a  medical  friend, 
who  .sent  the  case  to  me.  Dr.  Wilson  witnessed  a  like  process 
in  a  similar  case  (Udi'n.  Med.  Jonrn.,  April,  1875). 

There  is  no  rea-son  to  believe  that  rupture  of  the  peri- 
naeum  is  in  all  cases  the  fault  of  the  accoucheur,  although, 
doubtless,  it  is  so  in  some ;  yet  with  a  large  child  and  rapid 
labor  it  is  often  difficult  to  prevent.  I  have  known  it  occur 
in  the  practice  of  very  good  men. 

Treatment. — Slight  ruptures  of  the  perinaeum  need  not 
be  regarded,  but  when  a  rupture  into  the  body  of  the  peri- 
Central  Rupture  of  the  Perinfeum,  naeum  takes  place  during  labor  and  the    accident  is  recog- 
through  which  Child  was  born.      ^:^^^^     ^^^  y^^^^  practice  IS   to  put  in    one   or  more  sutures 

at  once.      This  practice  is  so  sound  that  it  cannot  be  too  confidently  recommended. 


liiTTiTj-:  OF  Till'.  rrjiis.Ki:M. 


759 


Fig.  432. 


When  tho  (t|»«'rati(iii  is  not  |M'rfiirine(l  at  (tiicL',  hut  ]M).stp(»ri<'(l  to  tin-  future,  it  iiiu.st  Ijc 
left  (ill  tlif  jioritid  nl'  siickliii;.:  lias  passi-d  and  the  ^.'cricral  ln'altli  of  tin-  patient  been 
restort'd  ;  the  (i|)eratiuii,  hein<:  a  plastie  one,  rei|uires  j^ood  power  on  the  part  of  the 
patient,  and  immediate  union  of  the  wound  is  wanted  for  siieeess.  it  is  very  sueeessful 
when  properly  performed  ;   imleed,  it  rarely  fails. 

Ol'KKATKiN. — The  huwels  should  he  well  cleared  out  hy  an  aperient  ;:iv<ti  two  days 
before  and  an  entMua  on  the  day  <d'  operation.  An  an;esthetie  should  he  ^iven,  the 
patient  placed  in  the  position  for  lithotomy,  with  the  buttocks  brou^rht  to  the  edfre  of  the 
table,  ami  Clovers  crutch  applied,  to  keep  the  knees  apart.  The  vagina  should  be  well 
wasluMl  out  with  a  carbolic  acid  or  iodine  lotion.  An  assistant  should  then  well  .separate 
the  labia,  while  the  surtreon  with  his  scalpel  maps  out  the  j»(»rtion  of  the  intej^unient  that 
he  proposes  to  raise  (A,  V,  D,  H,  Kifr.  -il>2),  remembering  that  it  is  neces.sary  to  have  a 
broad  surface  to  bring  together  as  well  as  a  cleanly  cut  one,  since  a  thin  membranous 
union  is  u.sele.ss  and  a  jagged  surface  will  not  unite. 

At  least  an  inch  of  raw  surface  should  be  provided  on  either  side  of  the  jierinjeuni  for 
union,  the  width  of  the  bared  surface  diminishing  slightly  toward  the  anterior  portion  of 
the  labia  and  widening  toward  the  anal  end.  No  /i'sskc 
IS  to  If  s<icr!fi<-<(l . 

The  incisions  should  be  carried  along  the  outer  bor- 
der of  the  cicatricial  tissue,  and  extend  froni  A  to  C  and 
from  B  to  D,  with  a  transverse  cut  from  C  to  D,  and  thi.s 
broad  flap  is  to  be  raised  toward  the  vagina  and  held  up 
by  an  assistant,  two  sutures  inserted  into  the  angles  of 
the  flap  helping  this  act  (Fig.  -iWl). 

If  bleeding  follows,  the  larger  arteries  may  be  twisted, 
while  a  little  pressure  .soon  controls  the  smaller. 

The  Kccoud  step  of  the  operation,  or  the  introduction 
of  the  sutures,  ren)ains  to  be  performed  ;  and  it  is  of  no 
less  importance  than  the  first.  Four  or  five  sutures  are 
required,  and  they  should  be  of  silkworm  gut ;  they 
.sbould  be  introduced  from  a  fjuarter  to  half  an  inch 
from  the  margin  of  the  wound,  the  one  nearest  the 
rectum  being  first  inserted.  The  introduction  of  the 
first  suture  is  of  primary  importance.  It  should  be 
passed  deeply  through  the  left  side  of  the  wound,  rather 
behind  the  level  of  the  recto-vaginal  septum,  through  the 
tissues  and  the  septum,  and  out  at  a  corresponding  point 
on  the  right  side;  it  should  be  completely  buried  in  its       ^         .     , 

II  °  -^1      ^i  I  •      ^       £•     ^         '•  .1  Operation  for  Ruptured  Perinfeura. 

whole    course,   with   the    obiect    ot    drawing  the  recto-      .   r-  «  i.  —   .    .   .i         <•      <■   ~ 

1    /  TT.  ,      T1-  '     '    '  ^'  represents  the  surface  from 

vaginal    septum   well    forward  (  1  <ae    tig.    4!:>2).       A    sec-   which  the  flap  is  raised,  with  the  sutures 

ond.  third,  and  fourth  may  then  be  introduced,  as  indi-  JheTwo'ider"'' '"'*'"  approximation  of 
cated  in  the  drawing. 

A  needle  such  as  that  seen  in  Fig.  432  is  the  one  I  employ.  It  is  curved  on  the  flat, 
so  as  not  to  cut  the  recto-vaginal  septum  in  its  passage,  and  has  an  eye  in  its  point  to 
admit  the  suture.  The  parts  should  be  brought  together  carefully  and  pressed  together 
firmly  after  their  apposition  ;  .several  su])erficial  sutures  of  fine  carbolized  gut  may  be 
introduced  should  they  be  required.  If  thei'e  be  much  spasm  of  the  sphincter,  the 
muscle  may  be  well  stretched. 

After-Treat.ment. — After  the  operation  is  completed  the  surgeon  should  satisfy 
himself  that  the  parts  are  in  appo.sition,  and  the  vagina  should  be  well  syringed.  Some 
iodoform  gauze  should  be  applied  to  the  wound  with  some  iodoform  powder,  and  a 
morphia  suppository  placed  in  the  rectum  to  relieve  pain  and  spasm. 

The  patient  ought  then  to  be  removed  to  bed  and  her  legs  tied  together  and  flexed 
upon  the  abdomen.  The  urine  should  be  drawn  oft'  every  six  hours  for  the  first  three  or 
four  days  and  the  parts  kept  clean.  Iced  milk  and  beef  tea  should  be  given  for  the  first 
day,  but  meat  and  wine  subse({uently  if  the  appetite  allow.  The  patient  may  lie  on  her 
side  should  .she  wish.  The  sutures  need  not  be  removed  till  the  fifth  or  sixth  day.  but 
after  the  fourth  day  they  should  be  taken  away  if  suppuration  appears  in  their  track. 

On  withdrawing  the  sutures  great  care  should  be  observed  not  to  separate  the  thighs 
or  parts ;  indeed,  for  quite  ten  days  or  more  after  the  operation  this  point  should  be 
observed. 

After  the  first  week  the  use  of  the  catheter  may  be  dispensed  with,  the  patient  mak- 


760  SURGICAL  AFFECTIONS  OF  FEMALE  GENITALS. 

ing  water  on  her  hands  and  knees,  the  parts  subsequently  being  carefully  sponged.  When 
any  oflensive  vagina  discharge  appears,  the  passage  may  be  syringed  with  an  antiseptic 
lotion.  The  bowels  should  be  locked  up  for  at  least  a  week  by  small  doses  of  opium  twice 
a  day,  and  then  relieved  by  a  dose  of  castor  oil  after  some  warm  oil  has  been  injected  into 
the  bowel ;  but  in  some  cases,  where  union  is  thought  to  be  feeble,  it  is  well  to  keep  them 
from  acting  for  a  longer  period,  care  being  always  observed  that  no  large  indurated  motion 
be  allowed  to  pass,  warm  water  and  oily  enemata  being  used. 

With  this  attention  good  success  generally  follows,  and  women  may  have  subsequent 
labors  without  any  giving  way  of  the  parts. 

AVhere  much  prolapse  of  the  posterior  wall  of  the  vagina  coexists,  a  strip  of  mucous 
membrane  running  up  the  vagina  from  the  anal  end  of  the  recto-vaginal  septum  may  be 
cut  oif  and  the  edges  of  the  wound  brought  together.  I  have  done  this  in  many  cases 
with  an  excellent  result ;  indeed,  in  many  cases  of  prolapse  of  the  uterus  following  some 
slight  rupture  Qf  the  perina3um,  or  even  without,  this  operation  is  of  great  value. 

In  vaginal  cystocele  a  like  opei'ation  is  of  benefit,  the  removal  of  a  piece  of  vaginal 
mucous  membrane  at  its  labial  border  being  often  followed  by  a  good  result. 

Dr.  Kaspozilo  in  this  operation  catches  the  fold  of  mucous  membrane  to  be  removed, 
when  drawn  down,  between  the  blades  of  a  pair  of  long  forceps,  passes  the  sutures  below 
the  forceps,  and  finally  cuts  the  mucous  membrane  away,  and  then  ties  the  sutures. 

Operations  for  Prolapse  of  the  Uterus 

are  of  great  value,  and  consist,  with  certain  modifications,  of  the  removal  of  vertical  por- 
tions of  the  posterior  vaginal  wall,  though  Marion  Sims  prefers  the  excision  of  an  oval 
portion  of  the  anterior. 

To  do  Sims's  operation  the  patient  should  be  placed  in  the  position  for  lithotomy,  and 
the  uterus  or  anterior  vaginal  wall  near  the  uterus  .should  be  seized  with  a  vulsellum  or 
bullet  forceps  and  drawn  well  downward.  The  surface  of  mucous  membrane  to  be 
removed  should  then  be  marked  out  with  a  scalpel,  and  a  piece  from  the  neck  of  the 
uterus  to  the  urethra,  about  three  and  a  half  inches  long  to  two  and  a  half  wide,  removed. 
All  bleeding  vessels  should  be  twisted  or  tied  with  catgut  and  the  edges  of  this  gaping 
surface  brought  together  by  alternate  deep  and  superficial  sutures,  these  sutures  being 
introduced  about  a  third  of  an  inch  apart.  The  wound  should  then  be  well  washed  with 
an  antiseptic  lotion  and  the  parts  returned  into  the  pelvis. 

The  stitches  need  not  be  removed  for  two  or  three  weeks ;  and  when  carbolized  gut  is 
used,  they  may  be  left  alone  to  come  away. 

When  a  portion  of  mucous  membrane  is  removed  from  the  posterior  vaginal  wall, 
there  is  no  necessity  to  draw  the  uterus  or  vagina  down  ;  but  a  triangular  (Hegar),  five- 
sided  (Simon's),  perpendicular,  or  other  shaped  portion  of  mucous  membrane  should  be 
removed  and  the  cut  edges  brought  together,  as  in  Sims's  operation,  the  lower  border  of 
the  flap  under  all  circumstances  corresponding  to  the  junction  of  the  vaginal  mucous 
membrane  with  the  skin. 

In  all  these  operations  it  is  of  importance  that  the  bared  surfaces  should  be  clean  and 
smooth  and  that  there  should  be  no  blood  beneath  the  flaps. 

Vesico-  and  Recto- Vaginal  Fistula. 

Abnormal  communications  between  the  bladder  or  rectum  and  the  vagina  are  usually 
the  result  of  long  and  tedious  labor  from  sloughing  of  the  tissues  after  too  much  pres- 
sure, although  at  times  they  may  be  caused  by  the  rough  use  of  instruments,  the  reten- 
tion of  a  pessary,  or  the  presence  of  a  stone.  They  are  usually  discovered  a  few  days 
after  the  delivery  by  urine,  wind,  or  feces  passing  through  the  vaginal  passage,  these 
symptoms  appearing  on  the  separation  of  the  slough. 

The  surgeon  is  usually  called  upon  to  treat  the  case  when  the  puerperal  month  has 
passed  and  the  patient's  powers  been  restored ;  till  then  it  would  be  rash  to  think  of 
interference. 

The  operation  for  the  cure  of  these  aff"ections  is  a  very  good  one  and  generally  suc- 
cessful, failure  following  only  in  exceptional  instances — that  is,  when  the  subjects  are 
feeble,  with  small  reparative  power,  or  when  the  loss  of  tissues  is  too  great  to  be 
made  up. 

Recto-vaginal  fistulas  are  more  readily  cured  than  vesico-vaginal,  but  both  operations 
are  alike  in  principle. 


VKSICO.    AM)    lllUTD-VAdlSAL    FlSTrL.K. 


701 


Ol'KllATloN. — Without  yiin\\)i  into  its  history,  full  dctiiils  of  which  can  \hi  louml  in 
the  s|)C<'ial  works  on  tiic  surLncul  diseases  of  women,  it  may  l»e  saiil  that  it  is  l>v  Sims  ami 
Hu/eman  in  America,  and  liy  Simpson  and  Mrown  in  this  count ry.  that  the  modern  opera- 
tion has  heen  hrouji^ht  to  its  present  statt;  of  perfeclion,  althouf.'h  it  is  prohattly  to  tlitj 
introduction  of  an.i'sthetics  that  its  jijreat  success  is  to  he  attrihuted. 

\'cry  small  tistuhu  may  prohahly  be  cured  by  the  actual  or  pilvanie  cautery,  but 
every   opening;  aboye  the  size  of  a  cruwcjuill  demands  some  plastic  operation. 

In  the  operation  the  surjjeon  has  three  main  points  to  (d)serye :  Ist.  To  brinj^  the 
listuhi  well  into  view  and  under  control  ;  2d,  to  jtare  with  nicety  and  accuracy  its  wlude 
inaririn  ;  and  .'Id,  to  brinLC  into  and  maintain  in  apposition  the  raw  and  inci.sed  surfaces. 

For  the  first  (tbject  the  duckbill  speculum  is  uMd(»iibte<lly  the;  best;  by  some  authors 
it  is  sjxiken  of  as  Hozemans,  by  others  as  Sims's.  It  is  both  a  dilator  of  the  vajrina  and 
a  retractor.  Some  surj^eons.  Jobert  beinj^  amongst  them,  talk  of  e.\]»osin<^  the  fistula  by 
dramrinj;  the  uterus  externally  and  thus  evertinj;  tin;  vajrina.  I  have  never  had  the 
bohlness  to  use  sufficient  force  to  do  this,  and  cannot  advise  it.  Such  a  measure  would, 
however,  greatly  facilitate  the  different  steps  of  the  operation. 

Weiss  has  recently  so  arranned  the  duckbill  speculum  a.s  to  be  seIf-suj»porting  (Fig. 
4i}4).      1  have  used  the  instrument,  and  have  been  much  struck  Avith  its  value. 


Fig.  434. 


Fig.  435. 


Position  of  Patient  for  Vesico-Vaginal  Fistula.  Self-Retaining  Vaginal  Speculum. 

For  recto-vaginal  fistula  the  patient  should  be  placed  on  her  back,  a.s  in  lithotomy, 
and  for  ve.sico-vaginal  fistula  this  position  is  at  times  the  most  convenient,  though  I 
usually  prefer  the  semi-prone  position,  the  knees  and  thighs  falling  over  the  end  of  the 
table,  the  surgeon  looking  down  upon  the  fistula  (Fig.  433). 
When  the  uterus  is  dragged  down  sufficiently  far  to  evert  the 
fistula,  the  lithotomy  position  is  doubtless  to  be  preferred. 

The  fistula  having  been  brought  well  into  view,  the  next  step 
is  to  pare  its  edges;  and  in  doing  this  the  operator  must  not  be 
too  sparing  of  tissue,  his  aim  being  to  obtain  as  broad  and  as 
clean  a  surface  as  he  can.     AVhen  this  can  be  secured  by  means 
of  a  knife  and  forceps,  no  better  instruments  are  required,  the 
best  knife  being  one  that  can  be  adjusted  to  any 
angle  with  rapidity  and  ease.     When  the  fistula 
is  high  up  in  the  vagina  or  large,  the  pronged 
guide  (a  modification  of  that  of  Hilliard  of  Glas- 
gow) made  for  me  many  years  ago  is  an  excel- 
lent instrument  (Fig.  435).     It  is  readily  applied 
and  ensures  a  clean-cut  surface.     Some  surgeons 
prefer  the  scissors  (Fig.  436). 

When  this  step  of  the  operation  has  been 
completed,  the  edges  of  the  fistula  must  be 
brought  together ;  and  for  this  purpose  numer- 
ous devices  have  been  employed.  Splints  of  all 
kinds  have  been  suggested,  but  with  experience 
they  have  all  been  discarded,  simple  wire,  silk- 
worm-gut, or  silk  sutures,  fastened  with  shot  or 
otherwise,  being  preferred.  I  have  tried  every  form  of  splint,  and  have  at  last  come  to 
gul  sutures  with  or  without  shot  fastenings,  using  occasionally  a  plaited  fishing  silk. 


Paring  Edgos  of  Vaginal  Fistula. 


762 


SURGICAL  AFFECTIONS  OF  FEMALE  GENVrALS. 


Fig.  437 


The  sutures  should  be  introduced  tolerably  close  together  and  at  a  good  distance — 
say  a  third  of  an  inch — from  the  margin  of  the  wound,  and  should  not  be  drawn  too 
tight.  They  should  be  fastened  by  running  a  perforated  shot  down  over  them,  taking  the 
precaution  subsequently  to  tie  the  gut  over  the  shot  to  prevent  its  giving  away.  In  this 
step  the  operation  is  similar  to  that  for  fissured  palate.  In  Fig.  437  may  be  seen  the 
needles  employed,  with  the  mode  of  introducing  and  securing  the 
sutures. 

A  good  strong  pair  of  forceps  is  required  to  nip  the  .shot  after 
they  have  been  slipped  into  position. 

When  wire  or  gut  is  employed,  Startin's  hollow  needles  may  be 
used,  but  the  ordinary  curved  needles  with  good  eyes  at  their  ends 
are  the  best  for  silk.  With  wire,  gut,  or  silk,  the  shot  fastenings  are 
the  best. 

After-Treatment. — After  the  operation  the  vagina  should  be 
well  cleansed  of  blood  and  the  bladder  emptied.  Ice  or  iced  water 
will  generally  arrest  any  bleeding  that  may  ensue.  An  opiate  sup- 
positor}'  should  be  administered  after  the  operation,  to  give  ease,  and 
the  same  practice  should  be  followed  with  respect  to  the  bladder  and 
diet  as  has  been  recommended  after  the  operation  for  ruptured  peri- 
na?um. 

To  leave  a  catheter  in  the  bladder  after  the  operation  for  vesico- 
vaginal fistula  often  adds  to  the  irritation,  its  careful  introduction  at 
stated  periods  being  preferable.  When  from  circumstances  this  can- 
not be  attended  to,  the  introduction  of  a  short  catheter  with  an  open 
end,  to  allow  of  the  urine  passing  as  it  is  secreted,  should  be  employed. 
Dr.  Meadows  allows  his  patients  to  pass  their  urine  in  the  natural 
way  after  the  operation,  and  I  have  dispensed  with  the  catheter  in 
some  cases  without  any  bad  result. 

On  the  sixth  or  seventh  day  the  sutures  may  be  removed  ;  but  if 
good  union  has  not  taken  place  and  they  are  not  causing  irritation, 
they  may  be  left  in  position  for  a  longer  period. 

During  convalescence  the  vagina  should  be  kept  well  cleansed  by 
the  daily  use  of  some  antiseptic  lotion. 

In  recto-vaginal  fistula  the  bowels  should  be  kept  locked  up  for 
ten  days  or  a  fortnight,  till  the  wound  has  firmly  united,  and  then  the 
feces  should  be  rendered  .soft  by  enemata  of  oil  and  gruel. 

When  the  tissues  around  the  edges  of  the  fistula  are  too  thin  to 
allow  of  their  being  pared— and,  indeed,  under  some  other  circum- 
stances— they  may  be  split ;  that  is.  the  vaginal  mucous  membrane 
may  be  raised  from  its  submucous  bed  for  half  or  three-quarters  of 
an  inch  round  the  fistula  and  the  under-surfaces  of  the  raised  mem- 
brane brought  together  and  held  there  by  a  quill  suture.  I  have 
adopted  this  method  on  many  occasions  and  been  most  favorably 
impressed  with  its  advantages.  I  was  led  to  do  so  some  years  ago  in 
a  case  of  vesico-vaginal  fistula  where  there  was  no  tissue  to  spare, 
and  was  pleased  subsequently  to  see  so  good  a  surgeon  as  the  late 
Mr.  CoUis  of  Dublin  make  the  same  siiggestion.  When  this  plan  is 
adopted,  the  sutures  mu.st  be  removed  on  the  fourth  day,  otherwise, 
the  pressure  of  the  bougie  may  cause  ulceration.  At  times  it  is  best 
only  to  cut  the  sutures  and  leave  the  quills  in  position  for  a  day  or 
so  longer,  the  amount  of  irritation  they  cause  being  the  surgeon's 
guide.  Dr.  Kidd  and  Mr.  Mapother  of  Dublin  have  adopted,  how- 
ever, what  appears  to  be  a  better  practice.  They  make  a  U-shaped  cut  round  the  fistula 
through  the  mucous  membrane  of  the  vagina,  raise  the  flap  thus  formed,  and  cut  off"  its 
lower  half,  including  the  opening  of  the  fistula  into  the  vaginal  mucous  membrane.  They 
then  draw  down  the  shortened  flap  over  the  fistulous  opening  into  the  bladder  and  unite 
it  by  sutures  to  the  crescentic  border  of  the  mucous  membrane  forming  the  bed  from 
which  the  flap  had  been  raised.  The  fistulous  opening  into  the  bladder  is  thus  covered 
over  with  a  flap  of  sound  mucous  membrane  (Brit.  Med.  Journ.,  June,  1872). 

When  the  neck  of  the  uterus  is  involved  in  the  fi.stula.  it  may  be  necessary  to  lay  it 
open  ;  but  when  the  uterus  is  involved,  it  is  more  frequently  necessary  to  turn  the  neck 
of  the  uterus  into  the  bladder  and  close  the  vagina  high  up.     In  very  extensive  lacera- 


Introduction  of  Sutures 
in  Vaginal  Fistula. 


DISEASL'S  AM>    TCM'iUS   OF   Till:-   lillEAST.  763 

tions  of  the  vosico-vajriiiiil  septiini  tlie  surj^cdii  may  Ih-  falli-cl  iipdii  tf)  clone  the  vu^'ina 
nearer  its  orifice.  I  have  dom'  so  on  several  occasifuis  with  <ron(l  succesH,  two  or  more 
operations  liciiiLT  refjiiired. 

Wlieii  tlie  fistula  is  surroiimlcd  hy  cicatricial  tissm-,  and  alter  tlic;  coaptation  of  its 
ed^es  there  is  found  to  he  much  tension,  lateral  incisions  throu^di  the  tense  mucous  mcm- 
brunc  are  of  great  use  in  allowinji  the  ed<res  to  fall  rather  than  to  \h:  held  tojrether. 

In  recto-vaf^inal  fistula  unconne<'ted  with  parturition,  before  an  operation  is  attempted 
the  sur<;etm  should  satisfy  himself  by  a  digital  examination  of  the  rectum  that  no  stric- 
ture or  disease  (d"  the  rectum  coexists  to  which  the  fistula  is  secon(hiry. 

Vascular  excrescences  arc  very  common  in  the  female  urethra,  and  from  their 
great  scii^iliilit  v  cause  severe  pain.  They  at  times  project  from  the  meatus  as  a  florid 
outirrowtli  and  are  often  attended  with  a  discharge  of  mucus,  and  at  times  of  bl<»od.  also 
with  irritability  of  the  bladder.  Their  removal  is  the  oidy  sound  treatment,  and  this  can 
be  eftected  l)y  iiirce]is  and  scissors  or  by  nn-ans  of  the  galvanic  cautery.  Wlicn  tlie  former 
practice  is  lollowed,  the  growth  should  be  well  drawn  downward  and  excised,  a  stick  of 
nitrate  of  silver  being  ap[)lied  to  the  base  of  the  tumor,  to  prevent  bleeding.  When  any 
doubt  exists  as  to  its  complete  removal,  chloride  of  zinc  may  be  used. 

When  the  urethra  i.s  the  seat  of  more  than  one  such  growth,  the  introduction  of  a 
stick  of  sul{»hate  of  zinc  at  intervals  of  two  or  three  days  may  be  followed  by  the  wither- 
ing of  the  growths;  but  when  this  result  does  not  ensue,  the  pas.sage  must  be  dilated  and 
the  growths  removed.  Nitric  acid  in  some  cases  is  a  good  caustic  to  ensure  their  destruc- 
tion when  excision  or  the  galvanic  cautery  cannot  be  employed,  and  Dr.  A.  Edis  recom- 
mends {Brif.  M(d.  Joitrii.,  April  4,  1874)  the  saturated  solution  of  chromic  acid,  to  be 
applied  by  means  of  cotton-wool  rolled  round  a  stick  to  the  growth  until  the  surface 
becomes  shrivelled. 

To  facilitate  the  use  of  any  of  these  means,  but  more  particularly  the  destruction  of 
the  growth  with  the  galvanic  cautery,  I  have  found  the  use  of  the  boxwood  or  ivory 
speculum  and  dilator  (depicted  in   Fig.  438)  of  great 

iise.      By  it  the   urethra   can    be   readily  dilated,   the  Fig.  4:38. 

urethral  growth  made  to  project  through  the  aperture  ^_„_— _;^_,_^.^^^^^ ^^_ ^^^ 
left  in  its  side,  and  the  whole  tumor  destroyed  without  ^^^^^^j^^^^WBI^FI 
doing  any  injury  to  the  healthy  tissues.  ^^^^**^BMi|[|U|^^^^^ 

Polypi  of  the  female  bladder  may  protrude  ^ 

through  the   urethra  and  put  on  the  appearances  of  a      speculum  Dilator  for  Female  Urethra. 

urethral   growth,  but   a   complete  examination   of  the 

urinary  organs  will  prevent  the  surgeon  falling  into  any  error  of  treatment. 

Fibro-Cellular  tumors  at  times  grow  in  the  urethra  and  cause  much  local  dis- 
tress. Some  years  ago  I  removed  one  which  occupied  the  whole  floor  of  the  urethra  to 
the  neck  of  the  bladder  from  a  lady  with  a  good  result. 

Irritable  bladder  in  women  is  a  very  common  effect  of  uterine  disturbance  or  dis- 
placement, as  well  as  of  rectal  disease.  Such  a  symptom  demands  the  closest  investi- 
gation to  ascertain  its  cause.  It  is  mostly  .secondary  to  disease  of  the  uterus,  etc.,  and 
not  often  dependent  on  bladder  affections.  When  difficulty  in  diagnosis  is  experienced, 
the  surgeon  should  without  hesitation  make  a  digital  exploration  of  the  bladder. 


CHAPTER    XXYI. 

DISEASES   AND   TUMORS   OF   THE   BREAST. 

Sore  nipples  are  .sources  of  great  distress  and  too  often  the  precursors  of  mam- 
mary abscess.  They  are  doubtless  often  caused  by  some  aphthous  condition  of  the 
childs  mouth,  but  they  as  frequently  result  from  some  unusual  .sensibility  of  the  skin 
of  the  part,  and  at  times  from  want  of  care.  In  first  pregnancies  mothers  should  always 
harden  their  nipples  by  the  daily  u.se  of  some  spirit  lotion  or  eau  de  cologne  and  water, 
and  where  they  are  not  sufficiently  prominent  a  breast  gla.ss  or  gutta-percha  shield  should 
be  worn,  as  nothing  tends  more  than  these  means  to  prevent  this  troublesome  affection. 

Treatment. — When  sore  nipples  occur  at  the  time  of  suckling,  the  same  shields 


764  DISEASES  AND  TUMORS  OF  THE  BREAST. 

should  be  worn,  great  care  being  observed  to  dry  the  nipples  after  use  and  never  to  leave 
them  in  the  child's  mouth  after  the  process  has  been  completed.  The  application  of  the 
glycerine  of  tannic  acid,  Richardson's  styptic  colloid,  tincture  of  catechu,  a  solution  of 
nitrate  of  silver  gr.  v  to  the  ounce  of  water,  and  an  ointment  of  extract  of  rhatany  gr. 
viiij  mixed  with  ^ij  of  the  oil  of  theobroma,  are  good  applications.  Castor  oil  as  an 
external  application,  or  collodion,  is  sometimes  useful.  When  cracks  exist,  it  is  a  good 
plan  for  the  mother  to  draw  out  the  nipple  by  means  of  the  old-fashioned  feeding-bottle 
before  giving  it  to  the  infant,  the  mother's  nipple  being  put  into  the  central  opening  and 
her  mouth  drawing  the  artificial  one.  Another  ready  method  is  the  application  to  the 
nipple  of  the  mouth  of  a  wide-necked  empty  bottle  that  has  been  heated  by  hot  water, 
the  nipple,  as  the  bottle  cools,  being  pressed  into  the  bottle  and  rendered  prominent  in  a 
painless  way. 

Engorgement  of  the  breast  takes  place  when  from  any  cause  a  woman  is 
unable  to  give  suck,  either  from  defect  or  disease  of  the  nipple  or  from  the  death  of  the 
child.  Under  these  circumstances  the  gland  may  become  tense  and  distended,  and  if  left 
unrelieved  for  twenty-four  or  thirty-six  hours  will  probably  inflame.  When  the  gland, 
however,  can  be  relieved  by  the  application  of  an  infant  to  the  nipple,  or,  next  best,  by  a 
bottle  in  which  a  partial  vacuum  has  been  made  by  means  of  hot  water,  the  mother's 
mouth,  or  a  very  carefulli/  applied  breast  pump,  the  engorgement  may  subside  and  no 
harm  accrue. 

Pressure  should  then  be  employed  by  means  of  strapping,  which  must  be  applied  over 
the  gland,  previously  smeared  with  the  extract  of  belladonna  rendered  liquid  with  an 
equal  part  of  glycerine.  A  saline  or  other  purge  is  often  of  value,  with  some  tonic  medi- 
cine as  quinine,  a  mixture  of  two  or  three  drachms  of  the  sulphate  of  magnesia  and  one 
or  two  grains  of  quinine  two  or  three  times  a  day  being  as  good  as  any. 

In  lobular  engorgement  of  the  breast  gentle  friction  is  of  great  value,  with  or  without 
oil,  and  warm  and  moist  applications  are  also  most  useful. 

INFLAMMATION  OF  THE  BREAST. 

This  may  appear  as  either  a  subcutaneous  more  or  less  extensive  periglandular  abscess, 
a  local  phlegmonous  lobular  inflammation,  or  a  diffused  abscess  throughout  the  whole 
gland.  It  may  primarily  involve  the  connective  tissue  which  exists  between  the  lobules, 
as  well  as  the  true  secreting  structure  of  the  gland ;  it  may  likewise  occur  behind  the 
gland. 

It  may  be  acute  or  chronic  in  its  nature  ;  it  may  run  its  course  without  any  breaking 
up  of  tissue  or  suppuration  or  be  attended  with  most  destructive  local  results,  the  extent 
of  destruction  of  tissue  depending  upon  the  severity  of  the  inflammatory  process  and  the 
amount  of  constitutional  power  of  the  subject  of  the  disease.  As  a  rule,  however,  suppu- 
ration takes  place. 

"  When  the  mamma,  in  its  state  of  full  expansion  and  perfect  functional  activity, 
becomes  the  subject  of  an  interference,  the  result  is  very  commonly  a  diff"use  or  nodular 
inflammation  and  the  formation  of  an  abscess.  A  sudden  stoppage  of  the  milk  soon  after 
the  lactation  has  been  established  is  apt  to  produce  inflammation,  and  the  same  result,  or 
a  degree  of  it,  sometimes  follows  the  weaning  of  the  child  after  a  long  course  of  suckling. 
The  disturbing  cause,  whatever  it  may  be,  acts  upon  the  mamma  when  its  function 
is  at  its  greatest  intensity,  and  the  characteristic  effect  is  inflammation  and  abscess " 
(Creighton). 

In  a  general  way,  inflammation  attacks  the  breast  gland  when  in  a  state  of  activity, 
and  it  is  exceptional  for  the  passive  organ  to  be  the  subject  of  this  process.  Out  of  102 
consecutive  cases  under  my  observation,  79  occurred  during  lactation,  2  during  preg- 
nancy, and  21  in  patients  who  were  neither  suckling  nor  pregnant.  Three-fourths  of  the 
cases  that  occurred  during  lactation  attacked  patients  during  the  first  two  months,  and  in 
many  of  these  a  cracked  nipple  was  the  assigned  cause;  but  I  am  disposed  to  think,  with 
Mr.  Ballard,  that  abscess  in  the  early  months  is  due  to  the  searching  of  the  child  after 
milk  before  the  gland  is  filled  in  patients  who  have  not  sufiicient  power  either  to  secrete 
milk  or  to  resist  the  inflammatory  process  when  once  originated.  The  aff"ection  is  more 
common  in  primiparae,  and  the  right  breast  is  more  frequently  afl"ected  than  the  left  in 
the  proportion  of  5  to  3.  In  some  cases  the  rapidity  of  the  process  is  very  marked,  an 
abscess  forming  within  a  few  days,  while  in  others  it  is  most  insidious ;  chronic  abscesses 
have  been  often  mistaken  for  new  growths,  and  amputation  of  the  gland  performed  under 
this  false  diagnosis. 


IyFLAM^fATl(^y   OF   Till:   l: II EAST.  TOo 

Aliscossos  occur  in  inhiitts  iinasts,  and  tlicy  arc  t<i<i  cniiunniily  the  conscijucticc  of  an 
i{::ni)raiit  nurse  ajtplviiiLr  prcssiirc  to  the  jrlands  in  wliicli  milk  is  fniiiul  or  friction  to  '•  rnli 
away  the  milk."  'I'lie  milk  appears  to  lie  mure  aluimlant  in  the  male  than  in  the  tcjnalc 
infant. 

Tlu'v  arc  also  met  with  in  the  male  subject  from  injury  or  otlier  causes. 

Chronic  mammitis  in  the  boy  or  j^irl  is  hy  no  means  a  rare  uflectioii,  the  umle- 
vt'lojied  Lrlaii'l  heeominu  indurated  and  very  painl'ul  ;  such  cases  rarely  suppurate. 

TitK.VTMK.NT. — The  activity  of  the  treatment  of  the  affection  we  are  now  considering 
must  he  regulated  by  the  acuteness  or  severity  of  the  inflammatory  process  and  the 
nature  of  the  constitutional  and  local  symptoms  to  whidi  it  may  give  ri.se.  As  u  broad 
truth  it  may  be  contidently  asserted  that  the  inflammatory  process  is  of  a  low  type  and 
of  a  destructive  nature,  and  that,  as  the  constitutional  powers  are  generally  feeble, 
nothing  like  lowering  measures  should  be  adopted,  but.  on  the  contrary,  soothing  local 
applications  and  constitutional  tonics  with  .sedatives  are  absolutely  demanded. 

In  cases  occurring  during  lactation  no  other  principles  of  treatUKMit  than  those  I  have 
just  laid  down  should  be  entertained.  Under  such  conditions  soothing  fomentations  to 
the  breast,  either  of  warm  water  or  of  some  medicated  solution  such  as  the  decoction  of 
poppies,  give  most  relief,  although  a  light  linseed  p(»ultice  or  some  spongiopiline  may  be 
well  employed.  In  young,  robust  women,  where  suckling  is  impossiblcj  the  application 
of  laxatives  and  powerful  purgatives  may  be  called  for. 

Rest  in  the  horizontal  position  affVirds  striking  comfort,  and  when  it  can  be  carried 
out  is  of  great  practical  advantage  ;  but  if  this  desideratum  cannot  be  secured,  the  whole 
breast  must  be  supported  by  a  band  or  linen  sling.  During  this  time  tonics  in  such  a 
form  as  can  be  borne  and  may  be  indicated  should  freely  be  given,  quinine  probably  being 
the  best.  Such  stimulants  as  wine  and  beer  must  be  cautiously  administered,  though  the 
cases  are  few  which  do  not  require  such  an  addition  to  their  diet,  while  plenty  of  nutri- 
tious food  should  be  allowed.  A  sedative  at  night  is  also  very  generally  required,  and 
Dover's  powder  in  ten-grain  doses  is  the  best  f(trm  ;  for  want  of  sleep  from  pain  is  a  com- 
mon accompaniment.  A  mild  purgative  in  the  early  stages  of  the  di.sease  may  be  neces- 
sary, but  excessive  purgation  .should  be  avoided,  since  the  object  of  the  surgeon  is  to  sup- 
]ily  |)ower.  and  not   to  remove  it — to  soothe,  and  not  to  irritate. 

Opening  a  Mammary  Abscess. — There  is  a  great  difference  of  opinion  among 
surgeons  about  the  propriety  of  opening  a  mammary  abscess.  Some  think  the  best  prac- 
tice is  to  let  the  breast  alone  and  leave  the  operation  to  nature,  while  others  advocate  an 
early  opening.  But  in  neither  am  I  disposed  to  coincide,  for,  while  I  regard  it  as  a  right 
practice  to  postpone  puncturing  the  organ  as  long  as  pos.sible  and  not  to  show  any  over- 
anxiety  in  evacuating  the  pus,  on  the  other  hand  I  know  that  when  the  abscess  is  left  to 
itself  much  unnecessary  suffering  is  endured  and  a  considerable  sacrifice  of  skin  often  fol- 
lows, entailing  a  long  convalescence  and  an  ugly  cicatrix.  The  practice  I  consequently 
generally  adopt  is  to  leave  the  parts  alone  till  pointing  has  taken  ])lace  and  then  to  punc- 
ture, making  uiy  incision  in  a  line  radiating  from  the  nipple  of  the  patient.  By  adopting 
this  practice  any  unnecessary  pain  is  saved,  for  the  appearance  of  jiointing  is  directly 
under  the  observation  of  the  surgeon,  and  it  is  not  necessary  to  make  frequent  and  care- 
ful physical  examinations.  Of  course  some  gentle  manipulation  is  ab.solutely  called  for 
to  enable  the  surgeon  to  form  an  opinion,  but  the  eye,  not  the  finger,  is  the  chief  guide. 
Much  manipulation  of  the  gland  is  both  painful  and  injurious,  and  an  absolute  abandon- 
ment of  all  local  surgical  treatment  can  only  be  condemned. 

Warm  fomentations  in  all  stages  of  the  disease  are  very  grateful  to  the  patient  and 
may  be  freely  used  ;  and  when  early  suppuration  threatens,  a  light  linseed  poultice  is 
probably  the  best  application.  When  the  abscess  has  discharged,  the  poultice  ma}-  be 
hiid  aside  and  some  antiseptic  application  employed,  as  constant  poulticing  soddens  the 
integument  and  retards  the  process  of  convalescence. 

Treatment  of  Chronic  Abscess. — The  existence  of  a  chronic  abscess  having 
been  made  out — a  point.  Iiy  the  by,  which  will  be  returned  to  when  the  subject  of  the 
diagnosis  of  a  mammary  tumor  is  discussed — it  becomes  an  important  question  what 
treatment  should  be  pursued. 

When  the  abscess  is  small,  causing  little  or  no  annoyance,  it  may  be  left  alone,  and 
under  the  influence  of  tonics  and  local  pressure  by  means  of  strapping  the  fluid  may  be 
absorbed,  and  such  a  result  is  occasionally  brought  about.  In  the  majority  of  examples, 
however,  some  more  active  treatment  is  neces.sary,  and  of  these  the  evacuation  of  the  pus 
is  the  chief  point.  If  the  abscess  is  large  and  deeply  seated — a  common  condition — the 
drawing  off  of  its  contents  by  means  of  a  trocar  and  canula  is  the  usual  practice  and  i.« 


766  DISEASES  AND  TUMORS  OF  THE  BREAST. 

generally  believed  to  be  the  best ;  but  it  has  this  disadvantage — that  the  wound  gener- 
ally soon  closes  and  a  second  operation  is  required.  The  same  treatment  may  be  again 
resorted  to,  with  the  same  results,  and  this  drawing  off  of  the  pus  and  the  subsequent 
closure  of  the  wound  may  go  on  for  many  times.  At  last,  however,  the  opening  remains 
patent  and  the  ab.scess  contracts,  leaving  a  sinus  in  the  majority  of  cases.  Under  these 
circumstances  a  bolder  plan  of  treatment  seems  absolutely  demanded,  as  time  is  an 
important  element  in  the  consideration  of  any  plan  of  treatment.  The  best  method 
appears  to  be  a  free  opening  at  the  first  operation,  the  surgeon  subsequently  inserting  a 
strip  of  oiled  lint  into  the  cavity  of  the  abscess  for  a  few  hours,  to  prevent  the  wound  closing. 
Submaminary  Abscess. — Abscesses  occasionally  form  beliind  the  breast  gland 
over  the  pectoral  muscle  ;  and  when  they  do,  the  gland  is  pushed  forward  in  a  way  that  is 

characteristic.    The  abscess  (Fig.  439),  as  a  rule,  points 

Fig.  439.  below  the  breast.     Such  abscesses  should  be  opened 

•    -s^  in  the  most  dependent  position  as  soon  as  any  indica- 

^--,.^,^^  tion  of  fluctuation  can  be  made  out.     This  disease  is 

X  very  slow  in  its  progress. 

\  Treatment  of  Sinuses.— The  treatment  of 

sinuses  in  the  breast,  as  elsewhere,  is  always  a  task  of 
difficulty,  and  in  certain  cases  all  plans  will  fail.  The 
one  principle  of  practice  which  seems  to  be  the  most 
valuable  is  the  establishment  of  a  dependent  outlet, 
and  for  this  purpose  the  introduction  of  a  drainage 
tube  is  a  simple  and  successful  practice.  If  there  are 
many  sinuses,  some  pressure  may  be  employed  by 
means  of  strapping,  care  being  taken  that  the  open- 
ings are  left  uncovered,  to  ensure  a  free  passage  for 
the  discharge.  Superficial  sinuses  may  be  slit  up 
(D.a\vin-40i''iTc"uy'sMifs'^B^^^^  wlien  Other  means  fail,  and  in  very  chronic  cases  some 

irritant  such  as  iodine  may  be  injected,  to  excite  a 
fresh  action.  The  great  principle  of  practice  in  these  cases,  however,  appeal's  to  be  that 
to  which  I  have  already  alluded,  although  other  means  may  at  times  be  demanded. 

Chronic  Induration  of  the  Gland. 

This  affection  occurs  when,  from  some  cause  or  other,  the  gland  is  morbidly  excited. 
It  is  chiefly  found  in  unmarried  women  between  the  ages  of  thirty-eight  and  forty,  though 
it  occurs  in  the  married,  and  then,  as  a  rule,  in  the  sterile.  It  is  usually  associated  with 
some  catamenial  irregularity  or  some  general  disturbance,  more  particularly  of  the  nerv- 
ous system. 

Symptoms. — The  affection  is  known  by  the  excessive  sensibility  of  the  indurated 
gland  on  manipulation,  the  nervous  excitement  the  examination  causes,  the  total  absence 
of  any  local  indications  of  a  titmor  when  the  fingers  are  placed  fiat  iqwn  the  part.,  and  the 
induration  of  the  gland  or  lobe  of  the  gland  when  the  organ  is  raised  from  the  pectoral 
muscle  and  pinched. 

Treatment. — The  treatment  consists  in  correcting  what  is  wrong  in  the  general  con- 
dition of  the  patient  by  means  of  iron,  tonics,  and  alteratives,  and  soothing  the  affected 
part.  Cold  lotions  are  at  times  grateful,  while  at  others  a  belladonna  plaster  affords  relief, 
with  or  without  pressure.  Large  breasts  should  be  suspended,  and  all  should  be  protected 
by  cotton-wool  from  the  risks  of  injury. 

The  irritable  marama  of  young  girls  is  closely  allied  to  the  affection  just  described, 
and  is  associated  with  a  morbidly  sensitive  condition  of  the  mammary  gland  and  parts 
around,  and  often  with  some  induration.  It  is  an  affection  closely  connected  with  the 
pelvic  generative  organs,  which  are  mostly  found  to  be  not  acting  fairly,  as  indicated  by 
catamenial  irregularity,  etc.  This  condition  is  doubtless  at  times  excited  by  depraved 
habits.     It  should  be  treated  on  the  same  principle  as  the  last  affection. 

TUMORS  OF  THE  BREAST. 

Tumors  of  the  breast  may  rationally  be  accounted  for  by  following  out  the  functional 
aberrations  of  the   organ,  and  in  proof  of  this  the   student   should  study  carefully  the 
highly  suggestive  and  valuable  work  of  Dr.  Charles  Creighton.'  who  has  shown  that  "the 
^  Contributions  to  the  Physiology  and  Pathology  of  the  Breast  (1878). 


Ti'Moiis  OF  Tin:  ni:i:.\sT.  707 

lnvt'stiir:iti(iii  nf  Im'ast  tunior.s  ri'vcals  iiicn-ly  tin-  woikinjr  <if"  the  pliysiulijiricnl  law  of 
lu'altliv  iiiaiiiiiiarv  artivity  umlcr  altcivd  rirciiiiistaiiccs.  tliat  various  ilf;_'ri'i'>  of  ilisordered 
function  niav  result  in  various  kinds  oi'  tumors.'  and  tiiat  tumor  fliscasu  of  tlic  l»rea.st  is 
"  I'ssi'iitiullv  a  disordi-r  id'  i'unctinii." 

Tlio  hrcast.  in  ))assin^  from  its '•  resting;  "  or  inactive  Htate  to  that  of  full  activity, 
iindcrj^ocs  durini;  the  entire  period  of  prej^nancy  a  process  of  "evolution,  '  which  is  cha- 
racterized in  its  dirt'ereiit  stages  hy  certain  cell  chanj,'es  within  its  acini  and  transport  of 
cells  without,  and  in  the  return  of  the  gland  to  its  (|uiescent  condition,  on  the  subsidence 
of  lactation,  a  process  of  '•  involution,"  in  which  a  parallel  series  of  changes  acting  in  an 
iiiversi'  order  is  to  1)C  ol)served,  the  fuiK-tioiial  sul)sidence  of  the  gland  being  s[)read  over 
a  shiirter  period  of  time  than  its  gradual  awakening  duriiig  pregnancy. 

When  the  functional  stimulus  of  the  mamma  is  acting  at  its  hunst  point  at  the  begin- 
ning of  "  evolution  "  or  the  ending  of  '•involution,"  the  secretory  products  arc  large 
granular  yelhtw  pigmented  cells,  which  are  found  within  the  secreting  acini,  in  the  con- 
nective-tissu(!  s])aces  outside  the  secreting  structure,  and  likewise  in  the  lymph  sinuses  of 
the  subjacent  lymphatic  glands,  these  cells  being  the  waste  products  of  a  feeble  degree 
of  secretory  activity  ;  and  if  tiie  mammary  e.vcitation  were  always  to  act  at  that  degree 
of  intensity,  the  secretion,  it  may  be  said,  would  always  be  in  the  lorm  of  large  granular 
pigmented  cells. 

At  the  m-xt  apprednhle  advunce  in  the  intensity  of  the  stimulu.s  the  product  formed 
in  the  gland  may  be  described  somewhat  generally  as  a  large  granular  nuclear  cell,  which 
is  nothing  else  than  the  crude  epithelium  of  the  middle  period  of  the  breast's  unfolding, 
in  which  an  imperfect  secretory  force  resides. 

Coming  sfi/l  nearfr  to  the.  full  excitation,  tlie  cellular  ingredients  are  fewer  and  the 
mucous  production  much  more  abundant,  and  finally,  when  the  stimulus  is  at  its  lieigld.  the 
mucous  fluid  has  given  place  to  a  fatty  fluid,  and  whatever  cellular  elements  the  secretion 
contains  are  the  woll-knowii  colostrum  cells,  which  approach  most  nearly  the  perfect  secret- 
ing cell.  The  periodical  unfolding  of  the  breasts,  which  is  an  obvious  accompaniment  of 
each  pregnancy,  is  thus  characterized  by  a  progressive  series  of  immature  secretory  prod- 
ucts, which  necessarily  run  to  waste.  The  epithelial  cells  are  not  transformed  into  milk 
till  the  time  of  delivery  and  during  the  period  of  suckling  following,  but  the  functional 
action  of  the  breast  has  been  at  W'Ork  all  through  the  pregnancy,  and  has  advanced  in 
intensity  just  as  the  secreting  structure  has  advanced  in  its  unfolding.  The  various 
stages  of  unfolding  have  corresponding  secretary  products,  becoming  less  and  less  crude, 
and,  as  there  is  a  similar  series  of  more  rapid  but  exactly  parallel  waste  products  in  the 
upfolding,  it  is  a  legitimate  inference  to  ascribe  "  a  special  kind  of  secretorj-  product  to  a 
certain  degree  of  intensity  of  the  glandular  force." 

When  the  breast  gland  is  disturbed  from  its  resting  state  by  a  cause  other  than  preg- 
nancy, and  in  consequence  of  some  morbid  excitation  is  urged  into  a  kind  of  evolution 
process,  the  steps  of  its  unfolding  are  less  orderly  than  in  the  normal  evolution,  and  the 
'■spurious  excitation"  never  carries  the  gland  to  the  end  of  its  unfolding  or  to  the  perfect 
degree  of  its  function.  And.  although  the  morbid  excitation  maybe  said  to  correspond  in 
its  intensity  to  a  stage  of  the  nornuil  evolution,  there  is  this  fundamental  difi'erence — that 
the  corresponding  stage  of  the  normal  ])rocess  is  transient,  giving  place  to  a  stronger  force, 
while  the  morbid  process  continues  indefinitely  at  the  same  enfeebled  level.  As  a  conse- 
quence the  cell  that  should  have  been  thrown  ofi"  from  the  acinus  as  waste  almo.st  as  soon 
as  it  was  formed,  remains  in  the  place  of  its  origin  to  multiply  and  with  its  progeny  to 
infest  the  glandular  structure  of  the  breast  as  either  intra-  or  extra-acinous  accumula- 
tions. Indeed,  according  to  Dr.  Creighton,  it  is  upon  deviations  from  the  physiological 
track  such  as  these  that  the  existence  of  a  tumor  depends. 

Thus,  ''  a  circumscribed  tumor  arises  at  a  particular  part  of  the  gland  where  the  spu- 
rious excitation  has  advanced  to  a  certain  stage  of  evolution  or  unfolding;  in  that  partic- 
ular region,  probably  a  territory  defined  by  the  blood  vessels,  the  functional  force  has 
acted  at  a  uniform  imperfect  level  for  a  length  of  time,  the  inevitable  cellular  waste  of 
the  crude  secretion  has  accumulated  within  the  acini  or  around  them,  and  the  foundation 
of  a  tumor  has  been  laid. 

In  the  healthy  action  of  the  organ  there  is  a  provision  for  the  disposal  of  the  very 
considerable  amount  of  cellular  waste  material  by  means  of  the  neighboring  lymphatic 
glands.  In  passing  from  the  secreting  acini  and  in  traversing  the  .stroma  of  the  gland 
the  waste  cells  often  acquire  a  spindle  form.  and.  although  these  cells  are  not  always 
distinguishable  from  the  connective-tissue  cells  of  the  part,  there  is.  especially  in  the 
bitch,  a  class  of  pigmented  epithelial  cells  in  which  such  changes  of  form  and  position 


768  DISEASES  AND   TUMORS  OF  THE  BREAST. 

can  be  clearly  traced.  The  spindle-shaped  waste  products  are  the  type  of  the  peri-aci' 
nous  cell  collections  in  cystic  or  adeno-sarcoma. 

So  far  as  relates  to  the  large  nuclear  cells,  the  wi^ra-acinous  collections  of  them  corre- 
spond to  the  structure  of  medullary  cancer,  and  the  eW/-a-acinous  infiltrations  of  the 
same  cells  are  a  distinguishing  feature  of  scirrhus.  "  The  distinguishing  feature  of  the 
less  malignant  form  of  tumor  is  that  the  spurious  functional  activity  comes  nearer  in  the 
degree  of  its  intensity  to  that  of  the  perfect  secretory  force^  the  transformation  of  the 
epithelium  is  a  more  real  transformation,  and  the  cellular  waste  is  reduced — in  part,  at 
least — to  the  class  of  fibre-like  or  crescentic  elements  that  characterize  the  myxomatous 
and  more  benign  issues  of  the  tumor  process." 

"  The  circumstance  that  the  unknown  diseased  excitation  most  commonly  befalls  the 
gland  when  it  is  in  the  state  of  rest  is  of  the  first  importance  in  accounting  for  the  for- 
mation of  a  tumor.  Whether  the  distubance  be  a  mechanical  injury  or  a  sympathy  with 
excitement  in  the  ovaries,  or  of  a  more  general  emotional  nature,  it  comes  upon  the  breast 
in  its  re.sting  state.  The  breast  can  react  in  no  other  way  than  by  following  the  somewhat 
slow  process  of  its  normal  evolution  ;  without  the  intermediate  stages  of  unfolding,  it 
cannot  reach  the  perfect  degree  of  its  functions  in  which  there  would  be  immunity  from 
danger.  The  intermediate  stages  are  necessarily  associated  with  the  formation  of  crude 
cellular  products ;  it  is  at  one  or  other  of  the  intermediate  stages  that  the  morbid  force 
delays,  and  the  corresponding  cellular  secretion  of  the  gland  thereupon  assumes  the  cha- 
racter of  a  formative  or  tumor  process." 

•'  The  circumstances  of  the  functional  disturbance  are  never  exactly  the  same  in  any 
two  cases ;  consequently,  the  respective  modifications  of  structure — or,  in  other  words, 
the  structure  of  the  respective  tumors — are  never  exactly  the  same." 

When  a  tumor  forms  in  the  breast  within  the  period  when  the  function  may  still  be 
awakened  to  its  full  and  healthy  vigor — that  is,  during  the  period  of  its  structural  and 
functional  maturity — a  resolution  of  the  disease  or  a  dispersion  of  the  diseased  products 
may  be  looked  for ;  but  when  it  appears  at  or  near  the  climacteric  years,  when  the  gland 
is  suffering  an  effacement  of  its  secreting  mechani.sm  and  a  withdrawal  of  its  secretory 
force,  no  such  a  result  can  be  expected,  and  it  is  at  this  period  that  the  greater  number 
of  intractable  tumors  occur. 

"  It  is  the  climacteric  effacement  of  the  bi'east  that  gives  a  peculiar  character  to  the 
disease  in  women,  and  there  are  well-marked  structural  differences  in  the  tumors  accord- 
ing as  they  appear  before  or  after  that  period.  Those  that  develop  after  the  climacteric 
years  are  perhaps  the  most  common,  as  they  are  certainly  the  most  intractable,  and  they 
have  been  the  real  source  of  ambiguity  in  the  pathology  of  the  organ.  That  ambiguity 
depends  upon  the  circumstance  that  they  occur  in  an  organ  which  is  gradually  losing  or 
has  lost  its  characteristic  structure."  Where  the  normal  it.self  is  vanishing,  the  departures 
from  the  normal  are  elusive. 

It  seems  probable,  therefore,  from  Dr.  Creighton's  investigation,  that  the  adenomata, 
sarcomata,  myxomata,  and  carcinomata  have  their  type  in  a  series  of  progressive  changes 
which  the  gland  undergoes  in  its  physiological  evolution.  The  feebler  the  intensity  of 
the  function,  the  more  cancerous  the  disease  ;  the  higher  or  more  advanced  the  evolutiorx 
from  the  re.sting  state,  the  more  benign  the  tumor. 

Clinical  Examination  and  Diagnosis  of  a  Breast  Tumor. 

From  a  practical  point  of  view,  tumors  of  the  breast  may  be  divided  into  inflamma- 
tory.! adenoid.,  or  innocent,  cystic.,  sarcomatous,  and  cancerous.  Simple  hypertrophy  or 
excess  of  growth  of  the  gland  can  hardly  be  classed  among  the  tumors. 

The  first  point  a  surgeon  has  to  determine  when  consulted  by  a  patient  who  has  "  some- 
thing the  matter  with  her  breast"  is  practically  the  exi.stence  or  non-existence  of  a  tumor 
— /.  €.,  is  there  a  new  growth  developed  behind  and  in  connection  with  the  mammary  gland 
or  is  the  di-sease  from  which  the  patient  is  suffering  situated  in  the  substance  of  the 
glandular  structure  itself?  This  first  and  most  important  question  ought  to  be  solved 
before  a  further  step  can  with  safety  be  taken,  before  the  formation  of  a  correct  diagnosis 
of  the  case  can  be  made  ;  and  it  is  quite  impossible  to  magnify  its  importance.  To  do  this, 
however,  considerable  care  is  necessary,  and  some  manipulative  skill  must  be  called  into 
requisition,  as  a  careless  examination  will  surely  end  in  an  uncertain  diagnosis,  and  with 
this  a  failure  in  treatment.  In  examining  a  breast,  therefore,  with  diagnostic  intentions 
the  surgeon,  with  the  whole  gland  well  in  view,  should  place  the  palmar  surfaces  of  his 
fingers  over  the  suspected  .spot,  and,  taking  the  gland  in  his  hand,  manipulate  it  gently 


Tl'MOllS    OF   THE    nUh'Asr. 


7(11) 


ami  ill  I'Vi-ry  part  with  his  Hiiirt'rs  ami  thuiiih.  wlit-ii,  if  an  isolated  tumor  ran  Ik;  foiinii, 
lu:  will  in  all  prohahility  di-trct  its  presence.  If,  however,  he  is  uneertain  upon  this 
point,  he  should  make  the  j)atient  lie  down  :  lor  •  if  a  patient  he  sittiiifz;  or  stamlinj;  and 
the  hreast  is  f^rasped  l)y  the  finger  and  thumh,  when  induration  of  the  jrland  itself  exists 
a  sensation  is  felt  as  if  a  tumor  were  present.  If  now  the  palmar  surface  of  the  linjrers 
be  pressed  flatly  a<;ainst  the  ehest  in  the  same  part,  nothini;  remarkahle  will  he  distinguish- 
able. If  11  tutnor  or  new  growth  exists,  however,  it  is  immediately  jtereeptihle.  lint  if  a 
doubt  arise  in  the  matter,  the  patient  should  reeline  when  under  exan)itiation,  and  then, 
if  there  be  a  tumor,  it  is  immediately  manifest  to  the  touch,  and  often  to  the  eye  (liir- 
krtt).  Having,  then,  detected  the  presence  of  a  tumor — that  is,  an  independent  growth 
developed  in  the  neighborhood  of  the  breast  gland,  and  jirobably  in  connection  with  it — 
the  (|uestion  arises  as  to  its  nature.  Is  it  a  simple  or  a  malignant  tumor?  If  the  tumor 
be  movable  ami  bard,  if  (|uite  free,  or  if  it  has  liut  a  very  uncertain  connection  with  the 
gland  structure,  there  is  a  strong  probal)ility  that  the  tumor  is  of  a  simple  nature;  and 
if  it  has  existed  for  several  months,  this  jtmliability  becomes  stronger,  for  the  anwrnm 
tumor  has  a  tendency,  even  when  primarily  developed  as  a  tuber  or  as  an  independent 
structure,  to  as.sociate  itself  and  become  connected  with  the  neighboring  tissues  by  an 
intiltrating  process  ;  and  if  this  has  not  taken  place,  the  absence  of  these  conditions 
enhances  the  probability  of  the  simple  nature  of  the  growth  under  examination.  If  the 
patient  is  also  young  and  healthy  and  no  other  abnormal  conditions  of  either  the  brea.st 
or  the  neighboring  structures  are  to  be  detected,  the  probability  becomes  a  certainty,  and 
the  presence  of  an  ••  adenocele  "  may  be  determined  on,  this  tumor  being  synonymous 
with  the  chronic  mammary  tumor  of  Sir  A.  Cooper,  the  mammary  glandular  tumor  of 
Paget,  the  sero-cystic  sarcoma  of  Brodie.  the  adenoma  of  Birkett.  or  the  fibroma  of 
Gross. 

These  adenoceJe.'^  are  found  as  a  rule  in  the  young  and  unmarried  and  in  the  apparently 
healthy  and  robust,  although  occasionally  they  occur  in  the  aged.  They  appear  during 
the  period  when  the  procreative  organs, 
and  among  them  the  mammary  glands, 
are  in  a  state  of  "  developmental  per- 
fection ;"  and  when  they  occur  in  mar- 
ried women  are  most  frequently  de- 
veloped during  pregnancy  or  suck- 
ling. They  are  never  associated  with 
any  other  symptoms  than  such  as  can 
be  produced  mechanically  by  their 
presence,  and  never  involve  the  integu- 
ment except  by  distension,  nor  is  the 
skin  ever  infiltrated  by  any  new  ma- 
terial. They  are  never  accompanied 
by  any  secondary  enlargement  of  the  

absorbent    glands    or    associated    with  a  .Succulent  and  Fibrous  Mammary  (ilaudular  Tumor  and  Cysta 

1  1  "f         +1  n      aa     of  ^ix  Ycars'  (irowth.    (Taken  from  .S.  A.  P ,  a  single  woman 

any  SeCOnaary  deposits;  tney  cause  jgt  26.  The  drawing  exhibits  a  section  of  the  "new  growth  and  a 
no  cachexia  and  do  not  undermine  the  pleceof  mammary  gland.  The  growth  is  enveloped  by  a  fibrous 
,       ,  ,       ,  ~  ,  .  ,1         capsule  continuous  with  the  suspensory  ligaments  ol  the  breast, 

health,    but     aiiect    the    patient    .solely      Prep.  22925,  Drawing  41U60,  Guy's  Museum.    J.  Birkett.) 

through  local  influences,  and    demand 

treatment  chiefly  from  local  considerations.  They  may  be  found  in  either  breast,  occa- 
sionally in  both,^  and  are  constantly  multiple,  two  or  more  tumors  being  often  found  in 
the  same  gland.  In  Fig.  440  the  way  the  growth  attacks  the  gland  as  an  encapsuled 
tumor  is  well  illustrated. 

From  my  notes  of  81  cases  consecutively  observed — 


Fig.  440. 


iiya/iicnts 
of  6t-ect.tt. 


'I'l  appeared  under  the  age  of  20. 
28  between  21  and  30  years  of  age. 
18        "        31     "    40" 
11        "        41     "    50  " 


2  above  the  age  of  50. 
37  were  in  suigle  women. 
31  in  the  married  and  prolific. 
12     "  "  "    sterile. 


As  long  as  these  tumors  remain  small  and  quiescent  they  are  of  little  importance,  and, 
being  movable,  are  readily  diagnosed  ;  but  when  j'ears  have  been  allowed  to  elapse  and 
their  growth  has  increased,  and  from  their  greater  size  they  have  become  burdensome 
and  press  on  neighboring  structures,  they  are  neither  of  small  importance  nor  readily 
to  be  distinguished.  But  yet,  if  careful  observations  are  taken,  an  error  in  diagnosis 
should  not  be  made  :  for.  althouirh  the  breast  itself  may  be  much  pressed  on,  or  even 

49 


770 


DISEASES  AND   TUMORS   OF  THE  BREAST. 


expanded  over,  the  tumor,  it  will  still  exist,  and  on  careful  examination  its  presence,  as 
a  rule,  will  be  made  out.  The  nipple,  although  flattened  from  the  extreme  glandular 
expansion-can  still  be  seen  (Fig.  442)  and  is  rarely  retracted.  The  integuments  may  be 
stretched  to  an   extreme  point,  yet  they  will  still  be   movable  and  sound  (Fig.  441), 


Fig.  441. 


Fig.  442. 


ni^Jde 


Cystic  .Adenocele. 


Solid  very  Lobulated  Adenocele  of  Six  Years'  Growth. 
-Taken  from  .\.  S ,  set.  35.) 


although  some  inflammation  from  overdistension  may  have  made  its  appearance,  and 
large  veins  are  always  to  be  observed  meandering  in  the  healthy  tissue.  The  tumor,  if 
solid,  may  appear  lobulated  (Fig.  442) ;  and  if  containing  cysts,  fluctuation  may  be 
detected.  Still  the  disease  is  essentially  a  local  one  and  aff"ects  the  patient  through 
purely  local  conditions.  It  is  to  be  treated  only  by  excision,  and  the  gland,  as  a  rule, 
should  be  left  unharmed,  the  tumor  being  turned  out  of  its  capsule.  In  extreme  exam- 
ples, however,  the  breast  is  so  stretched  out  as  to  be  useless,  and  then  must  be  removed. 
In  the  patient  from  which  Fig.  442  was  taken  this  was  the  case.  She  was  a  woman  aet. 
35,  and  the  tumor  was  of  six  years'  growth. 

Diagnosis  of  a  Tumor  evidently  caused  by  some  Partial   or  Gen- 
eral Enlargement  or  Infiltration  of  the  Mammary  Gland. 

Let  us  suppose  that  the  surgeon  has  a  case  of  disease  of  the  breast  before  him  in 
which  the  structure  of  the  gland  is  itself  involved,  and  there  is  no  independent  movable 

tumor  such  as  we  have  been  considering,  but  in  which  on 
manipulation  it  is  evident  the  growth,  whatever  it  may  be, 
is  intimately  connected  with  the  gland  structure. 

What  is  the  case?  Have  we  an  inflammatory  affection 
only  of  the  organ,  or  some  hypertrophy  or  innocent  enlarge- 
ment? Is  it  a  simple  or  a  malignant  disease?  When  the 
manipular  indications  of  the  mammary  gland  are  tho.se  only 
of  enlargement,  is  such  a  condition  due  to  pregnancy  or  the 
product  of  a  simple  hypertrophy,  confining  the  meaning  of 
that  term  to  an  excess  of  growth  ? 

If  the  increase  he  (hie  to  hypertrophy — which  is  a  some- 
what rare  condition — it  will  have  been  to  a  certainty  of  a 
chronic  nature,  its  increase  slow  and  growth  painless.  The 
gland  will  appear  simply  enlarged,  with  no  increase  in  action 
beyond  that  which  growth  demands,  although  this  increase 
in  growth  may  be  very  great.  It  is  found  mostly  in  young 
women,  but  I  have  seen  it  in  the  male  ;  at  times  it  afi'ects 
only  one  gland.  In  the  case  from  which  Fig.  443  was  taken 
each  gland  on  removal  weighed  about  fourteen  pounds.  I 
saw  the  case  some  years  ago  with  my  friend  Mr.  Shipman 
of  Grantham.     The  breasts  were  subsequently  removed  by  Sir  W.   Fergusson. 


Hyperli 


CAL'ri.yn.MA  nr  Tin:  j!i:i:.\s'i:  on  casceii.  771 

That  tlie  a  fleet  ii  111  is  suiiielliiii;;  iimre  tliaii  a  mere  iiiereuse  iit  the  irrowth  of  the  plaiid 
is  priiveil  hy  the  t'ael  thai  in  a  reiiiah'  patient  ol'  mine  ;ut.  l.">  whd  had  this  disease,  (d" 
thirtecMi  years'  jrrowth.  in  her  rij:;ht  hreast,  and  imi  in  hn-  hit.  and  had  a  eliihl,  no 
milk  was  seereted  in  tlie  diseased  j^laiid,  while   in   the  sctiind  one   there   was  uhiinduiice. 

//'  thr  enhinjiiiii  lit  In  dnv  to  prvijiuiiu-jf,  there  can  he  little  ditlieulty  in  the  diaj^noKis  ; 
for  it  is  attended  with  an  aetivity  'd'  the  ioeal  eireuhitioii,  a  fjeneral  f'nhiess  of"  the  •rhuid, 
an  enlartremeiit  <d'  its  veins,  ami  a  darkenin;,'  of  the  areola  whieh  will  not  fail  to  excite 
suspicion.  Besides  this,  hotli  ijlniuh  will  he  similarly  affected — a  crdncidence  which  is 
rarelv  sei'n  in  any  morhid  condition.  The  very  suspicion  of  preirnancy,  however,  will  he 
eiioui^h  to  call  attention  toother  points  hy  which  a  s(»lution  of  tlie  difficulty  can  he  ohtaiiurd. 

U  tin:  I  iiliiriiciiniit  to  hr  r.ifilniiiril  htj  <ini/  iiifhniuniitori/  i-oiulitioii  ?  I  do  not  mean  an 
acute  inflammatory  conditioji — for  such  an  aflecti<tn  has  featun^s  which  are  tot)  character- 
istic to  allow  any  mistake  in  tliatrnosis  lieintr  made — hut  is  the  infiltration  of  the  f^land  to 
be  explained  hy  some  chronic  inflamujatory  chanj^e  such  as  is  so  fre<(uently  found  in  the 
female  hreast.  or  is  it  the  early  stauc  of  an  infiltrating;  cancer?  The  answer  to  this  (|uery 
is  not  always  easy.  In  middle-atred  patients,  when  cancerous  affections  may  he  looked 
for,  the  presence  of  an  indurated  mammary  gland,  wholly  or  in  part,  must  always  be 
regarded  with  suspicion  ;  and  if  the  case  be  recent,  I  believe  it  to  be  an  impossibility  to 
form  any  certain  opinion  as  to  its  true  nature.  If  the  induration  of  the  gland  be  the 
only  symptom  and  is  associated  with  a  sharp,  or  even  a  dull,  pain,  either  a  simple  chronic 
inflammation  of  the  gland  may  be  indicated  or  the  early  condition  of  a  cancer.  If,  how- 
ever, much  time  has  already  passed — say  many  months — and  no  other  symptoms  have 
made  their  ai)]tearance.  there  is  .some  ground  for  tho  hope  that  the  enlargement  may  be 
due  to  inflammation,  since  infiltrating  cancers  are  not  generally  inactive — are  not  station- 
ary, as  a  rule — and  soon  give  rise  to  other  symptoms,  such  as  some,  though  it  may  be 
slight,  enlargement  of  the  absorbent  glands,  some  slight  dimpling  or  puckering  of  the 
skin — an  important  sign — or  some  more  marked  symptom,  such  as  infiltration  of  the 
intei:;ument  or  a  retracted  nipple.  It  should  be  remembered,  however,  that  a  retracted 
nipple  is  only  an  accidental  symptom  such  as  may  be  caused  by  several  co/iditions,  and 
is  not  by  any  means  of  itself  characteristic  of  cancer.  But  if  any  or  all  of  the.se  symp- 
toms show  themselves  soon  after  the  first  appearance  of  the  lobular  enlargement  of  the 
mammary  gland,  an  opinion  as  to  the  cancerous  nature  of  the  growth  may  be  confidently 
expres.sed.  If,  on  the  other  hand,  none  of  these  symptoms  make  their  appearance  and 
the  induration  or  infiltration  of  the  lobes  of  the  gland  remains  stationary  or  shows  some 
tendency  toward  improvement,  the  probability  of  the  .simple  character  of  the  disease 
gains  ground.  When  this  induration  of  the  mammary  gland  appears  in  2l  young  siihject, 
there  will  be  no  reason  to  suspect  a  cancer,  and  it  should  rather  be  regarded  as  the  result 
of  some  slight  inflammatory  effusirm.  Under  such  circumstances  there  will  generally  be 
some  increase  of  pain  after  examination,  but  an  absence  of  any  other  local  .symptom. 
There  will  probably  be  some  irregularity  of  the  catamenia  and  some  signs  of  general 
excitability  of  the  patient.  But,  as  a  local  affection,  there  will  be  only  the  one  .symptom 
of  .induration  of  one  or  more  lobes  of  the  mammary  gland,  which,  in  the  absence  of  nil 
o'her  Ki'ffns.  may  with  safety  be  regarded  as  inflammatory.  The  same  argument  holds 
good  when  the  di.sease  appears  at  a  later  period  of  life,  although  su.spicions  of  a  cancer 
should  rightly  be  excited  ;  still,  the  positive  diagnosis  must  be  postponed  till  by  the  lapse 
of  time  some  other  .symptoms,  such  as  those  already  mentioned,  make  their  appearance 
to  clear  up  all  doubt,  or  by  their  absence  prove  the  innocent  nature  of  the  affection. 

Carcinoma  of  the  Breast,  or  Cancer. 

This  affection  is  found  either  as  an  hijiltrttfion  of  the  gland,  wholly  or  in  part  (Fig. 
444),  or  as  an  independent  tumor  or  tuber  within  the  meshes  of  the  gland — tuberous 
cancer  (Fig.  445).  It  may  likewise  be  met  with  associated  with  cysts — ci/stic  cancer — 
this  being  only  a  variety  of  the  other  forms. 

In  the  infiltrating  form  the  gland  appears  hard,  inelastic,  and  incompressible ;  as  the 
disease  progresses  it  seems  to  contract  and  to  draw  all  the  parts  around  together,  and 
gradually  to  infiltrate  them.  In  this  way  the  nipple  often  becomes  drawn  in  or  to  one 
side.  At  times,  after  having  been  drawn  in,  it  becomes  infiltrated  with  the  di.sease  and 
becomes  again  prominent ;  at  others,  by  the  contraction  of  the  gland,  it  may  be  strangu- 
lated, become  oedematous,  and  then  slough  ofl'.  The  skin  is  at  first  dimpled,  then  puck- 
ered, and  at  last  infiltrated.  The  breast  also,  from  being  a  movable  organ,  becomes  fixed 
— so  fixed,  indeed,  that  it  cannot  be  separated  from  the  pectoral  muscle. 


772 


DISEASES  AND   TUMORS  OF  THE  BREAST. 


This  form  of  cancer  is  the  more  common.     The  disease  may  appear  in  one  lobe  or  in 
all  and  be  slow  in  its  progress  or  rapid,  but  in  all  cases  its  progress  is  much  alike. 


Fig.  444. 


Fig.  445. 


Infiltrating  Cancer  of  the  Breast. 
(Drawing  409i*,  'luy's  Mus.,  Birkett's  case.) 

Tuberous  cancer  commences  as  a  circumscribed  independent  growth  within  the 
gland  structure,  with  a  well-defined  capsule  separating  but  not  infiltrating  the  tissues 
(Fig.  445).  Sometimes  two  or  more  tubers  appear  together,  and  these  may  at  la.st  coalesce. 
This  form,  unlike  the  infiltrating,  does  not  contract,  but  grows  in  all  directions,  involving 
all  the  parts  which  it  touches,  pushing  the  brea.st  to  one  side,  or  drawing  it  to  itself.  It 
often  attains  a  large  size,  giving  rise  to  an  irregular  lobulated  tumor.  It  is  at  times 
soft  in  consi.stence,  when  it  is  called  medtdhiry  cancer  ;  when  firm,  it  is  known  ^%  fihrous  ; 
when  jelly-like,  rjdatlnlform  ;  and  more  rarely  it  is  black,  or  mehinotic.  As  it  grows  for- 
ward it  may  involve  the  skin,  break,  and  ulcerate,  giving  rise  to  the  appearances  formerly 
called /ioir/«s  hsematoiles,  this  form  Vjeing  always  accompanied  with  hemorrhage. 

In  both  forms  the  lymphatic  glands  in  the  axilla,  above  the  clavicle,  or  on  the  side  of 
the  neck  will  .sooner  or  later  become  involved  :  and  when  the  skin  is  implicated,  this 
symptom  soon  appears.  As  the  glands  enlarge  nerve  pains  down  the  arm  appear  and 
oedema  of  the  arm  commences,  from  the  mechanical  obstruction  to  the  venous  circulation  of 
the  extremity  caused  by  the  enlarged  glands.  At  times  a  serous  effusion  takes  place  into 
the  pleural  cavity  of  the  affected  side  suflficient  to  destroy  life. 

In  some  rare  cases  of  cancer  the  disease  appears  as  a  hrawvy  infiltration  of  the  breast 
and  integument  over  it,  some  erythematous  redness  and  cedema  being  mixed  with  it  at  its 
onset.     The.se  cancers  are  of  the  wor.st  kind  and  speedily  destroy  life. 

In  other  cases,  mostly  chronic,  the  disease  is  more  cutaneous  and  shows  itself  as  a 
tubercular  affection  of  the  skin,  which  gradually  spreads  till  at  last  the  part  affected 
seems  skin-bound.  This  condition  ma}-  be  limited  or  extensive  and  occasionally  involves 
the  whole  of  one  side.  I  have  recently  had  a  case  under  observation  in  which  both 
brea.sts,  the  sternum,  sides,  and  half  the  dorsal  region  of  the  back  were  thus  involved. 
At  times  this  tubercular  development  is  associated  with  acute  or  recurrent  disease.  ■  In 
rare  examples  it  occurs  as  a  primary  affection  and  is  very  chronic,  the  tubercles  even  dis- 
appearing by  atrophy. 

A  cancerovs  tumor  of  the  breast  most  frecjuently  appears  in  middle  life — that  is,  when 
the  procreative  organs  are  verging  toward  their  natural  period  of  functional  decline,  such 
a  period  taking  place  at  an  earlier  date  in  the  .single  than  in  the  fruitful  woman.  It 
attacks  married  women  more  frequently  than  the  unmarried,  and  when  infiltrating  or 
involving  the  breast  gland  is  seldom  stationary. 

As  the  disea.se  progresses  unchecked  ulceration  of  the  integument,  preceded  by  a 
softening  down  or  breaking  up  of  the  tumor  itself,  will  soon  appear,  and  with  this  the 
characteristic  infiltration  of  the  margin  of  the  wound  will  occur  and  give  rise  to  indura- 
ted, everted  edges  (Fig.  449).  A  general  cachexia,  from  the  pain  and  wasting  discharges, 
will  soon  .show  itself,  and  more  or  less  distinct  evidences  of  the  complication  of  other 
organs,  become  apparent.  Under  such  circumstances  the  end  is  not  far  off.  for  the  dis- 
ease has  run  its  course,  and  with  it  the  powers  of  its  victim  have  become  undermined  ; 
for  the  victory  remains  with  the  strongest.  In  a  general  way,  a  cancer  runs  its  course  in 
two  or  three  years,  though  sometimes  it  is  most  chronic  in  its  action. 

To  illustrate  some  of  the  points  connected  with  this  subject,  the  following  analysis  of 
400  cases  may  be  of  value.  The  cases  are  taken  from  my  own  notes:  180  occurred  in 
Guy's  during  the  period  of  ixiy  registrarship,  many  years  ago,  and  220  are  from  my  own 
case-book  .since. 


CYSTIC  rcMoii  OF  Tin:  i:i:i:.\ST.  773 

The  (/ist'dsc  iiindi    ifs  /irsf  iijiiirdinin  i- — 

111     17  liLsi's,  or    A  pLT  ((.'Mt.,      undtT  .U)  yciirs  of  iif^e. 
"    lOS     "  27        "  lii'lwft'ii  ;{1  iiiid   10  vi'iirs  of  miv. 

"   H4    "  ;i(i      '•  "       -n    "   r,()  ■ 

'•  KH    "  'jf)      "  "       r,i    "   IK) 

"     -J'J     "  7        "  "         (il     "    70 

"        1  over  70  vrars  of  a;;o. 

1  havi',  however,  seen  a  case  ol'  eaiiciT  of  the  hreast  in  a  patient  Ufred  2H.  and  one  of 
i\  year's  standintr  in  tlie  hreast  of  an  tthl  hnly  ;i't.  !Mi. 

C)f  these  K)()  eases,  Sl.'J  were  married,  77  single,  and  1(»  were  widows. 

Of  till'  !>1.">  married,  2!5")  wurv  prolific  and  7'S  sterile.  A  hir<:(!  proportion  of  the  pro- 
lific women  were  so  to  an  extreme  deirree.  ten  and  more  chihlren  heiiij^  a  common  note  to 
find  recorded.  Married  women  and  those  in  whom  the  ghiiid  has  been  the  most  active 
are  apparently  more  liable  to  cancer  of  the  breast  when  the  jieriod  of  trhiml  activity  has 
passed  than  the  single. 

(.)f  these  oxami>les,  ]!t4  were  in  the  ri<rht  breast,  1(S7  in  the  left,  and  lit  in  botli.  In 
140  the  di.sease  had  e.xisted  a  year  or  less; 

111  \>[)  lielween  1  and  2  years.        I        In  13  between  4  and  5  vears. 
"  2;J         "        2   "     3      "  "9         "       o   "     7  ■  " 

"  15         "       3   "     4      "  I         "     6         "       8   "     9      " 

In  4  cases  the  disease  had  existed  ten,  twelve,  fourteen,  and  twenty  years  respectively, 
and  the  form  of  cancer  in  these  of  long  standing  was  the  atrophic. 

With  respect  to  any  hcnditary  hisforj/  of  cancer  in  the  400  cases,  although  carefully 
inquired  into,  I  found  it  to  exist  in  only  47,  or  nearly  twelve  i)er  cent.  In  35  of  these 
cancer  was  reported  to  have  occurred  in  one  member,  in  11  in  two  members,  and  in  1  in 
three,  of  the  patient's  family. 

In  7  of  the  47  cases  the  relative  was  on  the  father's  side,  in  23  on  the  mother's,  and 
in  7  it  was  found  among  the  brothers  or  sisters.  In  5  it  had  attacked  the  aunts,  in  3 
cousins,  and  in  1  a  grandmother,  although  in  these  the  point  was  not  stated  respecting 
the  paternal  or  maternal  relation.  These  facts  are  enough  to  indicate  that  where  an 
hereditary  tendency  exists  it  is  more  powerful  on  the  mother's  than  the  father's  side. 

In  a  large  proportion  of  the  cases  in  which  an  hereditary  history  of  cancer  was  traced 
the  cancer  was  of  the  breast. 

A  section  of  an  infiltrating  cancer  is  well  slmwn  in  Fig.  444;  a  section  of  the  tuberous 
form  in  Fiu.  44."i.      For  the  microscopical  appearances  of  cancer,  vide  Fig.  45. 

Colloid  or  alveolar  cancer  is  occasionally  seen  in  the  mamma,  although  in  a 
clinical  point  of  view  the  growth  presents  no  such  features  as  to  enable  the  surireon  to 
recognize  its  presence.  In  Fig.  86,  page  138,  a  cancer  of  the  kind  is  illustnated.  In  it 
the  clinical  features  of  the  affection  were  those  of  the  cystic  disease.  It  is  found  in  the 
gland  as  an  infiltrating  and  tuberous  growth. 

To  the  eye  the  colloid  disease  has  a  peculiar  aspect,  its  jelly-like,  semi-transparent 
material,  of  all  tints  of  pink  and  red,  from  degrees  of  blood-.staining,  being  divided  by 
thin  meshes  of  fibre  tissue  into  cells  of  different  sizes.  The  way  the  jelly-like  structure 
oozes  from  its  cells  and  the  slight  changes  that  take  place  in  it  after  immersion  in  spirit 
are  its  chief  characteristics. 

It  ought  to  be  treated  by  excision  of  the  whole  gland. 

Cystic  Tumor  of  the  Breast. 

The  simple  Sero-Cyst  is  usually  found  single  in  the  mammary  gland,  and  appears 
as  a  small  hard  lump  in  one  spot,  which  is  at  times,  but  not  often,  ]iainful.  As  it  increases 
it  becomes  more  globular  and  dense,  sometimes  being  of  a  stony  hardness,  wdiile  at  a  still 
later  date  it  may  afford  the  sensation  of  fluctuation.  If  left  alone,  it  may  so  enlarge  as 
to  come  forward,  and  even  burst,  discharging  a  thin  watery  Ho»-albuminous  fluid  and  then 
collapsing.  In  rare  cases  the  di.sease  is  thus  cured,  but  more  commonly  the  fluid 
reaccumulatcs. 

"  The  cyst  wall  of  this  tumor,"  writes  Birkett,  ••  is  very  thin,  composed  of  fibre  tissue 
firmly  attached  to  the  surrounding  parts  and  lined  with  squamous  epithelium.  It  is 
always  perfectly  closed,  and  never  communicates  with  a  duct." 

Trf.at.ment. — Such  cysts  should  be  punctured  with  a  trocar  and  canula  and  some 
cold  lotion   applied,  for  by  this  means  many  are  permanently  cured.     Brodie   employed 


774 


DISEASES  AND    TUMORS   OF   THE  BREAST. 


Fig.  446. 


alone,  without  puncture,  a  lotion  made  up  of  an  ounce  of  the  solution  of  the  subacetate 
of  lead  and  thi'ee  ounces  and  a  half  of  both  spirits  of  wine  and  camphor,  which  was  to 
be  applied  on  a  piece  of  folded  flannel  and  renewed  every  three  or  four  hours  until  the 
skin  over  the  tumor  had  become  inflamed,  the  application  to  be  reapplied  after  the  lapse 
of  two  or  three  days. 

Spurious  Cyst. — Besides  the  simple  serous  cyst,  many  examples  of  tumors  of  the 
breast  come  under  the  observation  of  the  surgeon  the  diagnosis  of  which  is  much  obscured 
by  the  presence  of  cysts — or,  rather,  of  what  Mr.  Birkett  describes  as  capsules — contain- 
ing fluid  of  divers  characters ;  for  the  development  of  a  cyst  in  the  n)ajority  of  tumors 
is  a  mere  accident  due  to  the  eff'usion  of  fluid,  probably  serum,  more  or  less  blood-stained, 
into  the  connective  tissue  of  the  part,  the  fluid  separating  the  solid  growth,  and  so  forin- 
ing  an  apparent  cyst.  Such  a  cyst,  however,  is'  not  a  new  development,  like  the  more 
solid  portion  of  a  tumor,  nor  is  it  in  any  way  to  be  compared  with  the  simple  cystic  for- 
mations which  are  found  in  the  neck  or  other  portions  of  the  body.  The  existence  of  the 
false  cysts,  therefore,  such  as  I  have  briefly  sketched,  in  any  of  the  breast  tumors, 
whether  adenoid  or  malignant,  is  to  be  regarded  as  a  mere  accident,  and  ought  to  have  no 
weight  in  determining  either  the  innocency  or  the  malignancy  of  the  growth  under  exam- 
ination ;  they  are  the  product  of  a  mechanical  cause,  may  occur  in  either  form,  and  are 
not  special  growths  or  of  any  intrinsic  importance.  The  diagnosis  of  the  tumor  contain- 
ing such  cysts  rests,  consequently,  on  other  points,  and  more  particularly  on  such  as  have 
been  already  indicated.     As  a  rule,  these  so-called  cysts  are  found  in  the  less  firm  and 

solid  forms  of  tumor,  in  such  as  contain  less  cellular  or 
connective  tissue,  and  in  the  more  rapidly  developed 
rather  than  in   the  slowly  formed.      We  thus  find  in 
one  form  of  cystic  adenoma  a  more  or  less  solid  tu- 
mor, the  growth  being  more  lobulated  and  loosely  con- 
nected where  the  false  cysts  or  capsules  exist.     In  a 
second  class  of  cases  loose  pedunculated  growths  will 
,    r-..^j^'  ■^^:i=^Jim»  yw  H  M       ^^  >^een  lying  within  these  capsules,  with  their  float- 
i  lliflR      ^"^"^    '^^1       f  '\      ^"S  extremities  bathed  with  the  so-called  cyst  contents 
llll"il!'"^"  ^   ffl    _,        i     (Fig.   44(j),   the    different    forms    assumed    by    these 

tumors  depending  upon  the  amount  of  connective 
tis.sue  which  binds  together  the  several  lobes  and 
lobules,  and  the  dimensions  of  the  interspaces  which 
go  to  form  the  false  cysts.  In  a  third  class,  however, 
the  true  cystic  ndenoc.ele  of  the  breast,  the  adenoid 
Cystic  Tuinoi  ii.  i,i,..M,  uiih  r.duiiciiiatea  solid  elements  are  developed  within   cysts  composed 

Adeuomatous  (irowth  ot  One  Yeai'.s  Exi.s-       p     i.i    .     i      i       ,  t>    ^    •  ii  i     ^i.         vi  •„     r  i    „ 

tence.    (Removed  bv  T.  Bryant  from  s.  of   dilated   ducts.     But  in   all,  whether  Within   false 
W-— ,  set.  43,  in  1876    Three  years  later  ^  .g^    ^j.  j„  dilated  ducts.  the  elementary  structure  of 

patient  was  quite  well.)  ,•'  ,       .        -  i  i  i  i  j 

the  growths  is  either  dense  and  compact  or  loose  and 

pedunculated ;  in  all  they  simulate  the   structure  of  normal   gland  tis.sue.     In  some  the 

caecal  terminations  of  the  ducts  are  the  most  prominent,  and  in  others  the   ducts  and 

sinuses,  while  in  a  few  true  milk  or  cream   secretion   exists,  precisely  similar  to  that 

secreted  by  the  breast.     In  all-  probability,  all  adenomata  are  developed  in  cysts  as  intra- 

cystic  growths.      Dr.   Goodhart  has  supported  this  view  in  an  able  paper  (Edin.   Med. 

Joiirn.^  1872). 

DiA(JNOSls  OF  True  Cystic  Adenocele. — This  true  cystic  adenocele.  however,  is  of 
an  innocent  nature  and  pathologically  allied  to  the  genuine  adenocele.  It  is  the  tumor 
originally  described  by  Sir  B.  Brodie  as  "  arising  by  a  dilatation  of  portions  of  some  of 
the  lactiferous  tubes,"  and  by  Mr.  Birkett  as  duct  cysts,  distinctly  referable  to  the  dila- 
tation of  a  duct  or  to  a  connection  with  one,  and  containing  growths  which  appear  to 
spring  from  their  walls ;  and  these  two  forms  of  cystic  adenocele  are  strictly  analogous 
in  their  nature.  In  both  the  pedunculated  or  floating  bodies  possess  a  structure  allied  to 
the  breast  gland,  and  are  composed  of  more  or  less  distinct  caecal  terminations  of  newly- 
developed  ducts,  with  variable  quantities  of  true  connective  tissue.  This  affection  is 
more  common  in  middle  than  in  young  life.  Out  of  12  ca.ses,  G  occurred  in  women  under 
thirty,  17  in  women  over  forty,  while  1  was  as  old  as  seventy-one  (Path.  Trans.,  vol.  xvii. 
p.  283). 

Diagnosis  of  Cystic  Adenoma. — How,  then,  is  such  a  tumor  to  be  made  out?  and 
what  are  the  special  symptoms  which  characterize  it  from  the  other  forms  of  mammary 
tumor  ? 

First  of  all,  being  an  innocent  tumor,  it  will  be  found  to  aff"cct  the  patient  in  a  purely 


s.mrnMATurs  Ti'Muns  or  Tin-:  i-.ueast. 


i  (O 


Idoal  niamicr.  as  do  all  otlii-r  aik-ridul  tiiiiinr.s.  It  is  a  local  disease  which  at  no  period  of 
its  growth  and  in  no  way  will  afl'cct  the  patient  otherwise  than  throu^'h  local  causes.  It 
is  never  associatetl  with  secondary  ^'laiidiilar  etdarfreinents  or  with  deposits  in  other  tis- 
sues, as  the  cancerous  tumor,  and  it  can,  therefore,  he  by  local  syniptouis  only  that  a  cor- 
rect diagnosis  is  to  he  luaile. 

Tiu'  tumor,  heinjr  a  ijinit'inr  tj/slic  t/isxtsf,  is  always  made  uj)  of  cysts  filled  with  intra 
cystic  growths  in  different  degrees,  and  if  us  also  u  i/israse  of  /fit-  (jlnnd  ifs>//\  the  cysts 
having  a  distinct  relation  with  the  gland  ducts.  The  cysts,  having,  therefore,  in  the 
majority  of  cases,  if  not  in  all.  some  connuunication  through  the  nipple  with  the  external 
surface'  can  he  partially  emptied  of  their  contents  by  pressure  through  the  nipple  of  the 
affected  organ.  As  a  result,  this  discharge  from  the  nipple  must  always  materially  tend 
to  confirm  the  impressions  which  may  have  been  formed  hy  the  careful  ob.servation 
of  the  case,  and  hy  the  presence  of  tho.se  conditions  to  which  attention  has  ju.st  been 
drawn. 

Sr.MM.VKY. — Consequently,  a  n/sfir  f>inii>r  of  the  viitninKtri/  ijhinil  in  a  healthy  woman, 
unattended  by  any  other  than  local  symptoms  and  as.sociated  with  the  di.scharge  of  a  clear 
or  coK>red  viscid  secretion  from  the  nipi»le.  which  can  be  induced  or  materially  increa.sed 
by  pressure,  may  with  considerable  confitlence  be  set  down  as  the  trui-  ri/stlr  mhuocde  of 
the  breast.  The  I'alse  adenoceles  or  other  tumors,  which  have  but  little  if  any  connection 
with  the  true  gland  tissue,  are  new  growths  jjartaking  of  the  nature  of  the  breast  gland, 
according  to  the  universal  pathological  law  that  all- new  growths  partake  of  the  nature 
and  peculiarities  of  the  structure  in  which  they  are  developed.  In  Fig.  441  the  external 
appearances  of  one  of  the.se  cystic  adenoceles  are  well  seen. 


Fig.  447. 


Galactocele. 

This  is  a  milk  tumor  found  in  the  breast  during  lactation,  the  result  of  some  retention 
of  milk  in  an  obstructed  or  ruptured  duct,  the  secretion  being  either  fluid  milk-like  or 

more  solid  and  creamy,  owing  to  the  absorption  of 
the  more  fluid  elements.  Preps.  2290^,  2290^,  and 
2299*",  Guy's  Museum,  illustrate  these  points.  It 
usually  occurs  somewhat  suddenly  during  suckling, 
and  is  indicated  by  a  painless  fluctuating  swelling, 
unaccompanied  by  any  constitutional  disturbance. 
These  cysts  at  times  attain  a  large  size.  Scarpa  has 
recorded  a  case  in  which  two  pints  of  milk  were  re- 
moved from  the  tumor.  It  .should  be  treated  by  an 
incision  into  the  cyst,  leaving  the  walls  of  the  cavity 
to  granulate. 


X 


■  Cystic  Cancer. 

The  pathology  of  cystic  cancer  is  identical  with 

that  of  cv.stic  adenoma,  while  the  cysts  in  the  one 

instance  contain  the  more  or  less  solid  characteristic 

Cystic  Carcinoma  of  Breast  of  Nine  Months'  lobules  of  the  adenoid  growth,  and  in  the  other  are 

oyThre.Jt^SvS  axil-  AHed  with  the  less  developed  and  more  irregular,  but 

lary  glands  eniargfd.    Three  months  after  eouallv  characteristic,  material  which  goes  to   build 

operation  there  was  a  large  axillarv  growth        •  »  ,„.  .         >p,,         ,. 

and    <rdema    of  arm.     Mr.    Birketts   case.    Up  the    CancerOUS   tumor  (rig.  44i).       Ihe   diagnosis 

Drawing  40S12.)  of  these  caucers  rests,  therefore,  upon  .such  points  as 

have  been  alreadv  described  under  a  former  headintr. 


Sarcomatous  Tumors  of  the  Breast. 

Sarcomatous  tumors  of  the  breast  are  met  with  in  women  of  middle  age.  and  they  are 
generally  more  succulent  and  less  solid  than  the  adenomata  and  more  rapid  in  their 
growth,  while  they  have  also  a  greater  tendency  to  return  after  removal.  They  are 
more  closely  connected  with  the  breast  than  the  adenomata,  and  are  always  encapsuled 
(Fig.  448)  ;  they  do  not  infiltrate  the  breast  like  the  cancers.  They  run  their  course, 
moreover,  more  rapidly  than  the  former,  and  have  a  tendency  to  break  down  and  give 
rise  to  a  bleeding  mass  of  tissue  which  may  be  mistaken  for  a  cancer.  They  are  also 
local,  and  are  rarely  associated  with  any  secondary  glandular  enlargement.     They  should 


776 


DISEASES  AND    TUMORS  OF  THE  BREAST. 


Fig.  448. 


be  dealt  with  as  adenomata  and  removed,  and  the  brea.st,  as  a  rule,  .should  be  removed 
with  them.  I  have  the  records  of  many  interesting  examples  of  this  form  of  tumor, 
and  in  the  Fatli.  Trans,  for  1868,  vol.  xix.,  I  recorded  the  case  of  a  woman  aet.  35  from 

whom  I  removed  a  tumor  weighing  nearly  five 
pounds.  The  patient  from  whom  Fig.  448  was 
taken  was  thirty-three  years  of  age,  and  in 
her  no  return  took  place  after  operation — a 
result  which  is  not  constant,  since  in  a  large 
number  of  these  cases  the  disease  returns  lo- 
cally and  acts  in  that  point  as  badly  as  any 
cancer.  I  have  a  patient  now  under  care 
from  whose  breast  I  have  removed  five  tu- 
mors at  different  intervals.  When  a  return 
takes  place,  the  tumor  should  be  excised  at 
once  if  the  measure  be  practicable. 

Hydatid  cysts  are  found  in  the  breasts, 
but  are  not  common.  Only  one  example  has 
fallen  into  my  hands,  although   I  have   seen 

Sarcomatous  Tumor  of  Nine  Months' (Growth.    (Removed    fivp  nthprs    in    thp    Tirnr>(-ipp  nf  niv  r-nllpflo-iips; 

from  M.  T ,  at.  33,  by  T.  Bryant  in  1877.   Good  ^J*^  otners  111  ine  practice  01  my  coiicagues. 

recovery.)  My  own  patient  was  a  woman  aet.  30  who  for 

five  years  had  had  a  jvnnless  glohular  swell- 
ing in  her  left  breast ;  and  when  I  saw  her,  it  was  as  large  as  a  cocoanut.  I  tapped  the 
cyst  and  evacuated  sixteen  ounces  of  a  clear  non-albuminous  fluid,  and,  as  it  was  evidently 
the  fluid  of  a  hydatid,  I  made  a  free  incision  into  the  tumor  and  turned  out  a  large  acepha- 
locyst.     The  patient  made  a  good  recovery. 

NSBVUS,  involving  the  whole  mammary  gland,  may  be  met  with.  I  have  had  under 
my  care  a  splendid  example  in  a  girl  six  years  old  in  which  the  whole  organ  was  like  a 
sponge  and  as  large  as  half  an  orange. 

Open,  Ulcerating,  and  Discharging  Tumor  of  the  Breast. — In  the 

growth  of  any  tumor  situated  in  the  mammary  gland  or  its  neighborhood  there  must  be 
a  period  when  the  integuments  will  become  so  involved  as  to  ulcerate  or  give  way,  and 
under  these  circumstances  a  discharging  surface  or  cavity  will  present  itself  varying  in 
its  aspect  according  to  the  innocency  or  malignancy  of  the  growth  with  which  it  is  asso- 
ciated. If  the  tumor  is  cancerous,  the  open  surface  or  discharging  orifice  will  suggest  its 
nature,  and  the  integument  itself  or  the  margins  of  the  wound  will  be  infiltrated  with 
cancerous  material,  the  latter  presenting  the  thickened,  indurated,  and  everted  margin  so 
characteristic  of  the  cancerous  ulcer,  and  which,  when  once  seen  and  appreciated,  can 
hardly  be  mistaken  (Fig.  449).     But  if  the  tumor  be  innocent,  a  very  diff'erent  condition 

will  present  itself,  for  a  clear  understanding  of  which 
it  is  essential  to  recall  one  or  two  points  of  difference 
between  the  innocent  and  malignant  tumors,  although 
attention  may  previousl}^  have  been  drawn  to  them  in 
former  pages.  It  is  the  peculiar  nature  of  the  innocent 
tumor  to  aff"ect  the  part  in  which  it  is  developed  simply 
in  a  mechanical  way  ;  it  may  separate  or  displace,  but 
never  infiltrates,  tissues.  On  the  other  hand,  it  is  the 
peculiar  nature  of  the  cancerous  or  malignant  to  infil- 
trate and  involve  every  tissue  with  which  it  comes  in 
contact.  Applying,  therefore,  these  two  opposite  fea- 
tures of  the  innocent  and  malignant  tumors  to  the  class 
of  cases  now  under  consideration,  we  shall  readily  un- 
derstand how  two  very  different  local  appearances  may 
be  produced,  and  how  in  the  cystic  cancerous  disease 
the  wound  or  surface  will  be  characterized  by  all  the 
Open  Caucer^of  Breast ^w.u^^  peculiarities  of  the  cancerous  ulcer,  and  in  the  cystic 

innocent  tumor  which  may  have  ruptured  from  over- 
distension the  margin  of  the  wound  or  discharging  cavity  will  look  healthy,  free  from  all 
appearance  of  infiltration,  and  as  if  mechanically  cut  or  punched  out  rather  than  ulcer- 
ated. In  the  ci/stic  mhnoceles,  in  which  it  is  not  uncommon  to  find  a  sprouting  and  dis- 
charging intracystic  growth  protruding  from  a  wound  through  the  ruptured  integument, 
and  presenting  a  very  doubtful,  and  sometimes  cancerous,  aspect,  the  importance  of  this 
fcsymptom  cannot  be  overrated;  for  if  found  projecting  through  an  orifice  of  the  integu- 


Fig.  449. 


CJinosii  DisicAsE  or  Tin:  mammmly  mieola.  777 

liUMit  wliifh  is  iitiinfiltratcd  uimI  ii|i|»an'iitly  lu-altliy.  such  as  wc  liave  alri-;i(ly  (lescriljed,  the 
iniKici'iit  iiatiiro  ni"  the  tuiiior  may  with  smiic  iMiiitidnice  hi'  (h-rlariMl. 

Value  of  the  Retracted  Nipple  as  a  Symptom  in  Tumors  of  the 

Breast. 

There  ran  he  litth-  ihmlit  that  as  a  positive  iiidieatitdi  of  cancenHis  disease  the  iiiiport- 
anee  of  a  retracted  iiipph'  has  heeii  coiisiderahly  overrated.  Tlie  syiu{»toin  may  be  com- 
mon ill  intiltratiiijr  cancer  (d"  the  breast,  but  such  a  disease  may  exist  without  it;  it  may 
be  present,  moreover,  in  simple  non-cancerous  afl'eetions.  A  retracted  nipple  may  be 
rep;arded  as  an  accidental  sYn)|)tom  in  the  development  of  a  tumor,  as  well  as  the  product 
of  mechanical  causes,  its  presence  beiiifj;  determined  rather  by  the  manner  in  wliich  the 
gland  is  involved  than  by  the  nature  of  the  disease.  If  any  tumor,  simple  or  malignant 
— any  abscess,  chronic  or  acuti — attack  the  centre  of  the  mammary  gland,  a  retracted 
nipple  will  in  all  proliability  be  produced;  for  a  di.sease  so  place<l  necessarily  cau.se.s  sepa- 
ration of  the  gland  ducts,  and,  as  a  consei|uence,  their  extremities,  terminating  in  the 
nipple,  will  be  drawn  upon,  and  a  retracted  nipple  must  f(dlow.  We  thus  tind  this  symp- 
t<»m  of  freijucnt  occurrence  in  the  early  stage  of  an  iiitiltrating  cancer  of  the  organ,  the 
nipjde  being  always  drawn  toward  the  side  of  the  gland  wliich  may  be  involved,  while  at 
a  later  stage,  when  the  infiltration  is  more  complete,  the  nipple  may  again  project.  In  a 
central  chronic  abscess  of  the  breast  the  retracted  nipple  is  e<|ually  common,  and  in  the 
true  cystic  adenocele  it  may  be  also  present.  In  the  ordinary  adenocele,  whether  cystic 
or  otherwise,  it  is  rarely  met  with,  for  the  reason  that  this  disease  is  not  of  the  breast 
gland  itself,  but  only  situated  in  its  neighborhood.  In  rare  ca.ses,  however,  such  an  asso- 
ciation may  coexist,  and  in  one  case  in  which  I  observed  it  some  blow  or  injury  had  pre- 
ceded the  development  of  the  adenoid  tumor,  and  it  was  open  to  a  doubt  whether  the 
retracted  nipple  had  not  been  brought  about  by  a  chronic  inflammatory  condition.  It 
should  always  be  remembered,  moreover,  that  a  contracted  nipple  may  be  a  natural  con- 
dition. 

Value  of  a  Discharge  from  the  Nipple  for  Diaonostic  Purposes. 

When  the  discharge  is  slight  or  of  a  bloody  nature,  it  does  not  indicate  an}'  special 
affection,  though  it  is  well  known  that  in  cancerous  affections  a  discharge  from  the  nipple 
is  not  unfrequent,  the  fluid  having  the  appearance  of  blood-colored  serum  which  is  never 
profuse  and  rarely  amounts  to  more  than  a  few  drops.  In  the  true  cystic  adenoceles  this 
symptom  is  of  considerable  value,  for  in  all  the  eases  which  have  passed  under  my  obser- 
vation, as  well  as  in  the  majority  of  rec(jrded  examples,  this  discharge  from  the  nipple 
was  a  prominent  symptom,  the  fluid  being  generally  of  a  mucoid  nature  and  more  or  less 
blood-stained  ;  and.  although  at  times  it  occurred  spontaneously  and  with  relief  to  the 
patient,  at  others  it  could  readily  be  induced  by  some  slight  pressure  upon  the  parts.  In 
the  ontinnry  adeaocde^  this  symptom  is  seldom  present.  It  exists,  therefore,  as  a  symp- 
tom in  the  true  disease  of  the  breast  structure,  whether  cancerous  or  adenoid,  and.  while 
slight  and  uncertain  in  the  former,  it  is  more  general  and  copious  in  the  latter ;  conse- 
quently, as  a  means  of  diagnosis  it  is  of  some  value. 

Chronic  Disease  of  the  Mammary  Areola  preceding  Cancer 

(Paget's  Disease). 

Sir  J.  Paget  has  pointed  out  (.SV.  Bo rtholomeic  s  Hasp.  Rep.,  vol.  x..  1874)  what  my 
own  experience  confirms — that  cancer  of  the  breast  is  sometimes  preceded  by  a  chronic 
skin  disease  of  the  nipple  and  areola,  the  disease  in  the  majority  of  the  fifteen  cases  in  which 
he  had  observed  it  having  ••  the  appearance  of  a  florid,  intensely  red.  raw  surface,  very 
finely  granular,  as  if  nearly  the  whole  thickness  of  the  epidermis  were  removed,  like  the 
surface  of  very  acute  diffused  eczema  or  like  that  of  an  acute  balanitis.  From  such  a 
surface  there  was  always  copious,  clear,  yellowish,  viscid  exudation."'  In  some  cases  the 
eruption  has  presented  the  characters  of  an  ordinary  chronic  eczema  or  psoriasis,  the 
eruption  spreading  beyond  the  areola  in  widening  circles  or  with  scattered  blotches  of 
redness  covering  nearly  the  whole  breast. 

"  The  eruption  has  resisted  all  treatment,  both  local  and  general,  and  has  continued 
even  after  the  affected  part  of  the  skin  has  been  involved  in  the  cancerous  disease." 

Mr.  Henry  Butlin  has  shown  that  these  changes  are  due  to  an  extension  of  the  disease 
from  the  surface  of  the  nipple  to  the  smaller  ducts  and  acini  of  the  gland,  these  parts 


778  DISEASES  AND   TUMORS  OF  THE  BREAST. 

being  found,  on  microscopical  examination,  filled  with  proliferating  epithelium,  which  at 
times  escapes  from  the  ducts  by  rupture  or  growth  into  the  surrounding  tissues,  thereby 
producing  the  full  formation  of  carcinoma  (Med.-Chir.  Trans.,  January,  1877),  the 
mechanical  retention  of  the  epithelial  element  within  the  gland  and  ducts  evidently  play- 
in,o-  an  important  part  in  the  progress  of  this  disease.  Whether  the  disease  be  a  true 
eczema  or  a  specific  dermatitis — a  question  which  has  to  be  determined — the  conclusion 
is  clear  that  the  local  disease  is  not  to  be  disregarded.  When  much  epidermis  collects 
upon  the  nipples,  "  Busch's  practice  in  cases  of  epithelioma  ought  to  be  followed,  and 
such  should  be  removed  by  the  application  of  a  lotion  of  soda  from  three  to  six  grains  to 
an  ounce ;"  and  if  any  suspicious  hardness  of  the  base  of  the  sore  exists,  it  should  be 
removed. 

Importance  of  Enlargement  of  the  Absorbent  Glands  as  a  Diag- 
nostic Symptom. 

When  some  enlargement  of  the  axillary  or  clavicular  glands  exists  with  a  chronic 
tumor  of  the  breast,  the  malignant  nature  of  the  disease  is  rendered  probable ;  for  the 
simple  adenomata  are  generally  unattended  by  such  a  complication,  and  with  the  cystic 
affections  it  is  also  rare.  Many  months,  however,  may  elapse  in  cases  of  cancer  of  the 
breast  before  the  appearance  of  this  symptom,  because  enlargement  of  the  absorbent 
glands  and  infiltration  of  the  skin  have  some  connection. 

In  cancerous  affections  the  enlargement  of  the  glands  is  indolent  and  very  painless. 
In  the  inflammatory  affections  of  the  organ  glandular  enlargement  and  tenderness  are 
commonly  present. 

Value  of  the  Tubercular  and  General  Infiltration  of  the  Integu- 
ment over  the  Breast. 

When  the  integument  of  a  breast  is  sparsely  or  thickly  studded  with  shot  or  pea-like 
tubercular  infiltrations,  or  is  so  infiltrated  with  new  material  as  to  present  a  brawn-like 
feel  and  aspect,  there  can  be  no  question  as  to  the  cancerous  nature  of  the  disease,  since 
such  a  symptom  is  never  present  in  any  inflammatory  or  simple  disease  of  the  mariimary 
gland.  The  infiltration  may  be  slight,  from  the  mere  shot-  or  pea-like  affection  of  the 
skin,  to  its  more  brawny  infiltration,  but  in  all  stages  it  is  equally  characteristic  and  speaks 
in  positive  language  of  the  cancerous  nature  of  the  mammary  growth,  one  tubercle  tell- 
ing as  plain  a  tale  as  if  many  tubercles  existed. 

Cachexia. 

I  have  no  belief  in  the  existence  of  a  special  cancerous  cachexia.  A  cachexia  may 
be  present  in  cancer  as  in  any  exhausting  or  .wasting  disease,  but  that  of  cancer  differs  in 
no  single  point  from  that  of  any  other  aftection.  When  a  cachexia  exists,  it  indicates 
the  presence  of  some  affection  which  is  undermining  the  patient's  strength,  which  may  be 
cancer,  but  it  may  be  any  other  form  of  disease. 

Excision  of  the  Breast. 

There  is  no  great  danger  attending  excision  of  the  breast  beyond  that  which  accom- 
panies any  operation,  even  the  smallest.  It  is  true  that  patients  occasionally  sink  after 
the  operation,  from  pyaemia,  erysipelas,  or  visceral  diseases,  but  these  contingencies  attend 
any  operation  or  wound.  From  my  notes  of  133  cases  of  cancer  in  which  excision  was 
carried  out  I  find  that  9  died,  or  about  6.7  per  cent.,  while  in  4  only,  or  3  per  cent.,  could 
the  death  be  ascribed  to  the  operation.  One  died  from  pyasmia,  on  the  thirty-fifth  day ; 
1  from  erysipelas,  contracted  several  months  after  the  operation,  when  the  wound  had 
healed  ;  2 "from  acute  bronchitis,  three  weeks  and  a  month  respectively  after  the  excision  ; 
l.from  profuse  diarrhoea,  on  the  eighth  day,  probably  pyasmic  ;  1  from  haemoptysis,  in  the 
third  week  ;  2  from  exhaustion  after  a  return  of  the  growth,  in  three  and  six  months  ;  and 
1  from  actual  sinking  after  the  operation,  on  the  third  day.  The  3  cases  which  died  from 
pyaemia  and  diarrhoea  which  was  also  probably  pyaemic,  and  the  1  which  sank  on  the 
third  day  may.  perhaps  with  justice,  be  directly  assigned  to  the  operation,  but  the  fatal 
termination  in  the  remaining  5  examples  had  no  reference  whatever  to  the  excision.  In 
the  operations  for  innocent  tumors  of  the  breast  no  fatal  instance  occurred. 


/•;A'r/.s7o.v  or  rnr.  i:iii:.\sr. 


Ill  iiporatitit;  for  cancer  it  is  niit|iicsti()iial)ly  tlic  wisest  course  to  excise  the  whole 
gland.  It  is  well  not  to  he  oier-aiixions  ahoiit  prt'servinjr  too  niueh  integiinient  ;  and  if" 
anv  douht  exists  as  to  its  iterl'eet  healthiness,  the  suspected  jiortion  had  hetter  he  excised. 
When  enlarireil  Lrhmds  exist,  they  should  he  taken  away  ;  and  in  any  d<»ul)tl'ul  case  the 
axilla  should  he  ••xploreil.  It  is  always  important,  when  dissectiiifr  out  the  tumor,  to 
keep  dear  of  all  diseased  tissues,  and  in  i'at  suhjects  to  leave  a  fair  covering;  between  the 
incision  and  the  tumor  itself,  as  there  is  <;ood  reason  to  believe  that  an  early  return  of 
the  aHeetion  is  too  often  to  he  explained  by  want  f)f  attention  to  these  jioints.  In  several 
instant-es  1  have  found  small  cancerous  noduU's  in  the  fascia  over  the  pectoral  muscle 
which  if  left  would  have  been  the  centre  of  ntnv  jirowths.  In  the  oj)eration  for  (tiinioceh- 
it  is  (|uite  exceptional  for  the  removal  of  tin;  breast  to  l)e  necessary.  In  the  majority  of 
instances  such  a  practice  would  be  clearly  unjustifiabh!.  As  a  rule,  the  tumor  is  readily 
removed  by  makinti'  a  clean  section  throutrh  its  cyst  wall  and  enuclcatin<;  the  frrowth  ; 
the  breast  is  rarely  injured,  even  by  the  operati(»n.  In  exceptional  examples  of  this 
afi'ection,  however — that  is,  where  a  lar<;e  tumor  is  closely  connected  with  the  mammary 
«?land — as  well  as  in  \\\v  irenuine  or  true  cystic  adenocele,  it  is  absolutcdy  necessary  tliat 
the  breast  <;land  should  be  excised.  In  the  removal  of  a  .small  tumor  not  involving  the 
breast  the  best  practice  is  to  make  the  incision  in  a  liiie  radiating  from  the  nipple  and  to 
manipulate  the  parts  as  little  as  possible,  the  surest  plan  being  to  cut  well  into  the  tumor 
after  having  raised  and  made  it  prominent  by  gra.sping  its  base  with  the  thumb  and  finger 
of  the  opposite  hand. 

Ol'KH.VTioN. — In  the  removal  of  a  breast  the  patient  should  be  placed  on  her  back 
with  the  shoulder  of  the  affected  side  raised  by  :v  pillow  and  tlie  arm  drawn  out  at  a  right 
angle  to  the  })ody  (  Fig.  450). 

The  incision  should  be  elliptical   and   made  in  a  line   parallel  with   the   fibres  of  the 

pectoral  muscle  ;  and  when  the  skin  is 
Fig.  450.  diseased,    it   should    be   removed.      The 

inner  or  sternal  incision  should  first  be 
made,  and  bleeding  is  to  be  controlled 
by  the  pressure  of  the  fingers  of  an 
assistant.  The  second  or  pectoral  incis- 
ion may  then  follow,  and  should  be 
made  down  to  the  free  border  of  the 
])cctoral  muscle,  the  definite  form  of 
which  is  the  best  and  surest  guide  to 
the  base  of  the  gland.  The  whole  tumor 
by  these  means  is  thus  readily  excised, 
a  few  touches  of  the  scalpel  dissecting 
it  off  the  pectoral  muscle.  The  axillary 
angle  of  the  tumor  should  be  divided 
last,  as  it  usually  contains  the  chief 
vessels  that  supply  the  gland.  The 
incision  can  be  extended  upward  into 
the  axilla,  to  explore  or  remove  the 
glands.  When  this  is  done,  an  incision 
at  right  angles  to  the  wound  backward 
is  good  for  drainage  purposes.  All  bleeding  vessels  should  be  twisted,  the  surface  of  the 
wound  cleaned  with  iodine  water,  its  edges  well  adju.sted,  a  drainage  tube  introduced  at 
the  most  dependent  part,  and  steady  pressure  applied  by  means  of  pads  of  lint,  gauze,  or 
cotton-wool.  Adenoid  or  innocent  tumors  should  be  excised  only  if  they  are  steadily 
increasing  and  are  sources  of  trouble.  Conceravs  tumors  should  be  removed  as  soon  as 
the  diagnosis  of  their  existence  is  clear ;  for  accumulated  evidence  tends  to  .>^how  that  the 
earlier  a  cancer  is  removed,  the  better  are  the  prospects  of  a  complete  or  lengthened 
immunity  from  the  disease,  and  that,  whether  the  disease  returns  soon  or  late,  the  best 
chance  is  thus  afforded  to  the  patient. 


Excision  of  the  Breast,  with  Incision  Backward  for  Drainage: 


780  ON  OVARIAN  DISEASE  AND   OVARIOTOMY. 

CHAPTEK     XXVII. 
ON   OVARIAN   DISEASE   AND   OVARIOTOMY. 

The  ovaries  are  glands  and  are  developed  as  other  glands,  being  composed  of  like 
elements.  In  them,  during  infancy  and  childhood,  although  cell  growth,  and  even  cell 
shedding,  may  go  on,  such  processes  take  place  silently,  unattended  by  any  external 
manifestations  of  their  action.  At  puberty,  however,  when  the  ovum  has  matured  and 
impregnation  becomes  possible,  external  signs  of  these  changes  appear  with  menstruation, 
and  with  these  changes  functional  disturbances  of  the  ovaries  and  parts  connected  with 
them  occur  and  may  require  the  attention  of  the  physician.  The  surgeon's  aid  is  called 
for  only  when  organic  ovarian  disease  exists,  and  the  nature  of  this  aid  varies  with  the 
nature  of  the  case. 

Ovarian  Disease. — Ovarian  disease  is  a  somewhat  common  affection,  and,  although 
mostly  met  with  during  the  active  period  of  ovarian  life,  it  occurs  in  childhood  and  mature 
age.  Two  specimens  now  in  the  College  of  Surgeons  were  taken  from  twin  children  five 
and  eight  weeks  respectively  by  Dr.  Leared,  and  a  rare  preparation  at  Prague  shows  a 
cyst  in  the  ovary  of  a  child  a  year  old.  Roemer  of  Berlin  in  1884  records  a  case  in 
which  he  successfully  removed  a  dermoid  ovarian  tumor  from  an  infant  twenty  months 
old  {Brit.  Med.  Jonrn.,  April  12,  1884).  Kidd  of  Dublin  has  operated  on  a  child  aged 
three.  Spencer  Wells  has  recorded  a  succes.sful  case  of  ovariotomy  in  a  child  aged  eight. 
Dr.  Barker  of  Philadelphia  had  another  in  one  aged  six  years  and  eight  months.  I  have 
recorded  two  cases  in  which  girls  aged  respectively  fifteen  and  sixteen  sank  after  tapping 
from  suppuration  of  the  cyst;  and  in  18G9  I  published  in  the  Guys  Hospital  Reports  a 
case  in  which  I  successfully  removed  a  polycystic  ovarian  tumor  from  a  child  aged  four- 
teen in  whom  no  signs  of  puberty  existed.  But  these  instances  are  exceptional,  and 
ovarian  disease  is  essentially  an  affection  of  mature  adult  life.  In  Spencer  Wells's  thou- 
sand cases  the  age  averaged  thirty-nine. 

Ovarian  tumors  may  be  ciinicall}'  divided  into  four  classes :  Monocy&tic^  or  unilocular 
tumors  ;  poJi/(i/sf!(\  or  multilocular  tumors ;  dermoid  cysts ;  fibrons  and  cancerous  tumors. 
The  relative  frequency  of  these  difterent  forms  of  tumors  is  well  seen  in  the  following 
conclusions,  which  were  di'awn  up  after  a  careful  examination  of  the  records  of  88  fatal 
cases  of  ovarian  disease  extracted  for  me  by  the  late  Dr.  Phillips  from  the  Guy's  records, 
and  copied  from  my  work  On  Ovariotomy  published  in  18G7. 

Conclusions  (h-awn  from  an  analysis  of  88  fatal  cases  of  ovarian  disease: 

1.  That  1)  per  cent,  of  the  ovarian  tumors  are  apparently  monocystic,  9  per  cent,  der- 
moid, 18  per  cent,  cancerous,  and  the  remaining  64 -per  cent,  polycystic  or  more  or  less 
solid. 

2.  That  53  per  cent,  of  the  cases  are  on  the  left  side,  20  per  cent,  on  the  right,  and 
17  per  cent,  double. 

3.  That  simple  cystic  disea.se  of  the  ovary  is  rarely  double,  and  that  when  double 
ovarian  disease  exists  the  majority  of  the  cases  are  cancerous,  colloid,  or  of  the  solid 
kind. 

4.  That  about  70  per  cent,  of  the  cases  are  in  married  women,  and  that  the  disease  is 
most  frequent  between  the  age  of  twenty  and  forty,  or  during  the  vigor  of  sexual  life. 

5.  That  the  disease  runs  its  course  in  at  least  75  per  cent,  of  all  cases  within  two 
years,  30  per  cent,  dying  from  exhaustion,  20  per  cent,  from  peritonitis,  17  per  cent,  from 
suppuration  of  the  cyst  chiefly  following  tapping,  9  per  cent,  from  the  last  two  causes 
combined,  10  per  cent,  from  peritonitis  caused  by  rupture  of  the  cyst,  10  per  cent,  from 
the  cyst  ulcerating  into  some  viscus  such  as  the  intestine  or  bladder.  Hemorrhage  into 
the  abdomen  and  strangulation  of  the  bowels  by  the  pedicle  caused  death  in  one  case. 

6.  That  in  the  monocystic  tumors  there  is  a  greater  dispo.sition  for  the  cyst  to  ulcerate 
into  the  bowels  than  in  other  cases,  and  to  suppurate  after  tapping. 

7.  That  in  50  per  cent,  of  the  cases  of  cancerous  di.sease  both  organs  are  involved. 

8.  That  in  the  dermoid  tumors  there  is  a  greater  disposition  for  the  cyst  to  rupture 
than  in  all  other  forms  of  disease,  death  being  directly  due  to  this  cause  in  37  per  cent. 

9.  That  acute  peritonitis  and  suppuration  of  the  cy.st  as  a  direct  result  of  the  opera- 
tion of  tapping  are  by  no  means  unfrequent. 

Cases  of  spontaneous  recovery  occur,  but  they  are  so  rare  that  they  must  not  be  looked 


ni.Hi.snsi.s  OF  A.\  owiniAx  ri'Mnn.  781 

fbr.  Wlit'ii  they  opi'ur,  tlu'V  takt;  place  by  ni|>ture  of  the  cyst  :  ami  this  ni|itiire  i.s  {gen- 
erally the  result  of  aeeideiit  or  violent  lun.seiilar  action.  As  a  rule,  however,  when  a  cyst 
ru|ttiires,  death  takes  place  from  shock,  jieritoiiitis,  or  hlood  poisoninj^  {n'l/f  Corieliisittn  5). 
In  exceptional  eases,  when  the  cy'^t  has  dischar^rcd  itself  into  the  lar^M!  intestine,  the 
event  may  he  sijrnified  hy  a  copions  discharge  of  the  eyst's  contents  hy  the  reetuiu  ;  hut 
when  into  the  small  howel,  no  such  event  may  occur,  the  fluid  heinj^  reahsorheil.  Under 
both  eireumstances  there  is  alway.s  great  danger  to  life  from  the  entrance  into  the  cyst 
itself  of  fecal  matter  or  fetid  air. 

Diagnosis  of  an  Ovarian  Tumor. 

When  an  ovarian  tutnitr  has  attained  a  considerahle  size,  ha.s  risen  well  out  of  the 
pelvis,  and  is  unassoeiated  with  any  complications,  its  diagnosis,  as  a  rule,  is  not  difficult, 
more  particularly  if  it  can  he  made  out  to  be  comjto.scd  (jf  many  eyst.s — /.  t'.,  multilocular. 
Hut  when  the  tumor  is  small  or  very  large,  unilocular  or  very  solid,  central  or  of  rapid 
growth,  difficulties  of  diagnosis  are  met  with,  and  it  may  be  ailmitted  at  once  that  under 
any  of  these  circumstances  there  are  few  surgical  ca.ses  that  demand  more  care  on  the 
part  of  the  surgeon  before  he  gives  an  opinion,  and  still  more  caution  before  he  acts  upon 
it.  In  some  few  instances,  indeed,  a  positive  diagnosis  cannot  be  made  without  the  help 
of  some  exploratory  operative  proceeding.  Under  all  circumstances,  however,  "  in  the 
diagnosis  of  a  suspected  ovarian  case,  every  possibility  of  its  nature  .should  be  enter- 
tained and  a  conclusion  arrived  at  by  a  process  of  exclusion  ;  each  possibility  should  be 
separately  considered  and  weighed  and  the  most  probable  finally  acee])ted." 

The  possibility  of  a  solid  or  semi-solid  tumor  l)eing  due  to  pregnancy  and  the  proba- 
bility of  a  cy.stic  tumor  being  complicated  with  pregnancy  or  hydramnion  ought  always 
to  be  before  the  mind  of  the  surgeon,  while  the  complete  cessation  of  the  menses  for  a 
few  months  in  connection  with  tlu;  existence  of  an  abdominal  tumor  ought  also  to  suggest 
in  diagnosis  caution  and  delay  when  for  diagnostic  or  curative  ends  operative  measures 
are  being  considered,  since,  though  catamenial  irregularity  is  common  in  ovarian  disease, 
total  arrest  for  any  time  is  rare. 

The  early  history  of  an  ovarian  case  is  always  obscure,  and  the  statements  of  patients 
concerning  its  early  growth  must  be  accepted  with  caution.  In  a  general  way  the  tumor 
is  discovered  by  accident,  or  attention  is  first  drawn  to  its  presence  by  abdominal  enlarge- 
ment. 

Pain  is  rarely  present  in  the  early  stage  of  the  disease,  and  when  it  exists  is  usually 
the  result  of  mechanical  causes — that  is,  it  is  due  to  the  impaction  of  a  small  ovarian 
tumor  in  the  pelvis  or  to  the  pressure  of  a  larger  one  upon  the  viscera,  vessels,  or  nerves. 

When  the  tumor  presses  upon  the  bladder,  incontinence  of  urine  or  dysuria  will  occur  ; 
but  when  it  irritates  the  bowels,  diarrlnea  will  l)e  caused.  When  it  drags  upon  the  omen- 
tum or  pres.ses  upon  the  stomach,  nausea  and  vomiting  may  be  jiresent ;  and  where  it 
encroaches  upon  the  thorax,  dyspnijea.  Nerve  pains  will  be  produced  according  to  the 
nerves  that  are  pressed  upon,  and  wdema  of  the  genitals,  legs,  or  abdomen  according  to 
the  amount  of  interference  to  the  return  of  venous  blood  is  commonly  caused  by  the 
tumor.  Oedema  of  the  abdominal  walls  is  said  to  be  typical  of  cancerous  di.sease  of  the 
ovaries,  but  this  is  not  the  case,  since  I  have  seen  this  symptom  ver}'  frequently  in 
undoubted  examples  of  simple  ovarian  disease. 

Local  pain,  pyrexia,  with  a  high  temperature  and  ab<lominaI  tenderness,  associated 
with  a  cystic  abdominal  tumor,  generally  indicate  inflannnatory  changes  within  an  ova- 
rian cyst. 

Dermoid  tumors  are  said  to  be  more  comnionly,  and  unilocular  cysts  least  frequently, 
attended  with  pain  than  any  other. 

In  well-marked  examples  of  ovarian  disease  the  face  becomes  pinched  and  the  peculiar 
"  ovarian  exjiression  "'  manifests  it.self,  but  after  the  removal  of  the  tumor  by  ovariotomy 
it  is  remarkal)le  how  soon  this  expression  disappears. 

The  DIFFERENTIAI.  DIAGNOSIS  of  an  ovarian  tumor  will  now  occupy  our  attention, 
and  its  physical  signs  will  be  first  considered  as  made  out  by  percussion  and  palpation, 
.since  it  is  by  these  more  than  any  others  that  the  surgeon  is  generally  led  to  an  approximate 
opinion  of  the  nature  of  the  case.  Too  much  confidence,  however,  must  not  be  placed  on 
them,  since  they  are  of  value  only  when  taken  in  connection  with  other  symptoms. 

In  all  cases  of  suspected  ovarian  disease  the  patient  to  be  examined  .should  be  undressed 
and  then  placed  on  her  back  with  her  shoulders  and  knees  raised.  The  surgeim  should 
afterward  so  expose  the  abdomen  as  to  be  able  to  have  a  good  look   at  it  and  ob.serve 


782  ON  OVARJAN  DISEASE  AND   OVARIOTOMY. 

whether  the  abdominal  enlarfrenient  is  central  or  lateral,  smooth,  irreirular,  or  nodular  in 
outline.  Should  the  tumor  move  upward  and  downward  during  the  respiratory  act,  the 
tumor  is  probably  free  and  non-adherent.  The  surgeon  should  then  place  his  hand  flat 
upon  the  abdomen,  and.  having  rested  it  there  for  a  minute  or  so  to  test  the  points  just 
alluded  to,  should  move  it  steadily  over  the  whole  surface  of  the  tumor  in  all  directions, 
and  at  the  same  time,  by  palpation,  ascertain  something  of  the  condition  of  the  deeper  parts. 

By  these  means  much  will  have  been  ascertained  as  to  the  nature  of  the  case.  It 
will  have  been  made  out  whether  a  tumor  exists  or  not ;  something  will  have  been  learnt, 
too,  concerning  its  size  and  mobility  and  whether  it  is  solid,  fluid,  or  the  two  combined. 
Possibly  by  some  sudden  movement  of  the  contents  the  question  of  pregnancy  may  be 
raised  or  settled. 

The  surgeon  should  then  proceed  to  percuss  the  parts,  doing  this  at  first  superficially 
and  then  deeply.  He  should  also  examine  for  fluctuation,  asking  himself  during  the 
whole  examination  the  following  questions  :  Is  this  abdominal  enlargement  due  to  tym- 
panitis, or  is  it  some  phantom — that  is.  muscular — tumor?  Is  it  due  to  or  complicated 
with  pregnane}',  or  is  it  uterine  or  ovarian  disease  ?  Can  it  Ije  a  hydatid,  pancreatic 
(Lancet,  February  11,  1882),  or  renal  cyst,  or  an  enlarged  viscus,  such  as  spleen  or 
kidney  ?     Is  it  a  cancerous  tumor  ? 

A  fluctuating  tumor  rising  from  the  pelvis  in  a  central  position,  yielding  a  dull  note 
on  superficial  as  well  as  on  deep  percussion,  with  epigastric  and  lumbar  resonance,  is 
probably  a  cystic  ovarian  growth  ;  and  when  the  tumor  fluctuates  in  all  directions,  as  is 
proved  by  the  peculiar  thrill  of  the  wave  elicited  on  percussion,  the  growth  is  probably 
unilocular  or  monocystic.  When  the  tumor  has  an  irregular  or  botryoidal  outline  and 
fluctuation  is  confined  to  parts,  it  is  certainly  compound,  the  degrees  of  solidity  in  a  com- 
pound or  multilocular  tumor  varying  greatly.  If  the  tumor  seem  to  be  a  unilocular  or 
monocystic  growth,  the  surgeon  must  remember  that  ovarian  tumors  of  this  kind  are 
comparatively  rare,  and  that  those  which  appear  to  be  such  often  contain  some  intracystic 
growths.  He  should  also  know  that  purely  unilocular  cysts  are  probably  broad  ligament 
or  parovarian  cysts — that  is,  a  cystic  degeneration  of  the  tubules  of  the  Wolffian  body — 
although  multilocular  parovarian  tumors  have  been  recorded. 

If  the  tumor  be  clearly  cystic  and  multilrjcular.  the  probabilities  are  that  it  is  ovarian  ; 
and  if  more  solid  than  cystic,  it  will  probably  be  dermoid  or  uterine. 

Uterine  and  ovarian  tumors  yield  a  dull  note  on  deep  percussion,  and  as.  in  these  cases, 
the  intestines  are  pushed  upward  and  toward  the  loins,  these  regions  are  consequently 
resonant,  and  no  alteration  in  the  position  of  the  patient  will  alter  this  fact.  In  ascites, 
with  the  shoulders  of  the  patient  raised,  the  lower  portion  of  the  abdomen  may  likewise 
yield  a  dull  sound,  but  with  the  shoulders  depressed  and  the  hips  raised  resonance  will 
be  made  out,  the  bowels  naturally  floating  on  the  surface  of  the  ascitic  liquid.  In  ascites 
the  central  portion  of  the  abdomen  is  resonant  and  the  sides  are  dull,  whereas  in  ovarian 
drops}-  it  is  the  reverse.  "  In  ascites  the  greatest  circular  measurement  is  at  the  level 
of  the  umbilicus;  in  ovarian  dropsy  it  is  often  some  inches  lower  down"  (Wells).  When 
the  intestines  are  matted  together  from  cancerous  or  old  peritoneal  disease,  diflSculties 
occur,  and  errors  in  diagnosis  can  be  avoided  only  by  going  carefully  into  the  clinical  his- 
tory of  the  case  and  by  a  pelvic  examination.  In  ovarian  disease  a  friction  sound  may 
be  detected  at  times  on  auscultation  or  on  the  application  of  the  hand,  while  in  ascites  no 
such  symptom  will  be  present. 

Diagnostic  Value  of  a  Pelvic  Examination  in  Ovarian  Disease. 

The  diagnosis  of  an  ovarian  tumor  can  hardly  ever  be  said  to  be  complete  until  a  pel- 
vic examination  by  means  of  the  finger  and  uterine  sound  and  the  combined  examination 
between  the  abdominal  wall  and  rectum  have  been  made,  for  which  purpose  the  patient 
had  better  be  placed  on  her  side. 

When  the  uterus  is  found  to  be  in  front  of  and  distinct  from  the  abdominal  tumor 
and  movable  without  it,  the  growth  is  probably  ovarian.  When  the  tumor  and  uterus 
move  together,  or  if  the  uterus  be  drawn  up  out  of  the  pelvis,  difficulties  in  diagnosis 
may  be  experienced.  If  the  tumor  be  cystic,  it  may  be  ovarian  with  a  short  pedicle,  a 
broad  ligament  or  parovarian  cy.st,  or  a  cystic  disease  of  the  uterus.  W^hen  it  is  solid, 
it  may  still  be  ovarian,  dermoid,  fibrous,  or  cancerous,  or  it  may  be  a  fibrous  tumor  of 
the  uterus. 

A  fixed  pelvic  tumor  is  probably  neither  ovarian  nor  uterine ;  but  if  either,  it  is  can 
cerous. 


VALl'L'   OF   TArriMl    Foil   lHA(JSOSTir  riUFosFS.  783 

III  ail  (tvariiiii  tuiiiur  tlic  uti-riiic  .s(»uik1  will  ran-ly  f^o  bey<nid  twi»  inches,  urik-ss  coni- 
pliratcd  with  |irt'^'iiaiicy  or  some  uteriiK-  discasi-.  In  cystic  disease  of  the  uterus  it  may 
enter  for  six  or  more. 

The  uterine  scuiiid  should  not  he  used  tun  hastily  lor  diagnostic  purposes,  because 
wlieii  prt'^naney  and  ovarian  disease  are  eomljined  evil  may  follow  its  use,  althou<;h  it 
ought  always  to  be  employed  before  0{»erative  measures  are  resorted  to. 

\Vl»en  ascites  is  present,  a  pelvic  e.vainination  will  generally  detect  a  vaginal  rectocele 
— that  is,  a  bulging  into  the  vagina  of  the  posterior  wall  of  the  vaginal  passage  from  tlie 
pressure  of  the  ascitic  fluid  into  Douglas's  poucli ;  and  this  bulging  is  not  met  with  in 
uncomplicated  ovarian  di.sease,  though  it  may  occur  when  ovarian  di.sea.se  and  ascites 
coexist.  I  have  found  this  point  of  great  diagno.stic  value  for  many  years,  and  was 
pleased  to  read  that   Dr.   Peaslee  had  mentioned  it   as  one  of  valua. 

''Solid  uterine  tumors,"  writes  Tait,  "  besides  the  absence  of  fluctuation,  have  in 
addition  two  vascular  signs  which  I  have  never  met  with  in  ovarian  tumor.s — viz.,  an 
aortic  impulse  which  may  be  seen  and  felt,  and  an  enlargement  of  the  uterine  arteries  to 
be  felt  in  the  vagina." 

[n  pregnancy  there  is  also  to  be  seen  the  peculiar  pur]ile  livid  condition  of  vagina 
which  does  not  exist  in  other  pelvic  tumors,  the  changed  a]>[)earance  of  the  nij»ple, 
enlargement  of  the  brea.sts,  etc. 

I  have  often  found  the  value  of  rectal  digital  examination  for  diagnostic  purposes  to 
be  great,  and  particularly  in  young  or  old  virgins,  but  I  cannot  speak  from  personal 
experience  of  the  value  of  the  introduction  of  the  hand.  Professor  Simon  of  Heidelberg, 
however,  speaks  highl}'  of  it. 

Value  of  Tapping  for  Diagnostic  Purposes. 

When  there  is  any  doubt  as  to  the  true  nature  of  a  cystic  abdominal  tumor,  a  pre- 
liminary tapping  ought  to  be  performed  and  the  physical  nature  of  the  fluid  examined, 
although  in  our  present  state  of  knowledge  an  ovarian  fluid  is  not  to  be  recognized  by 
any  definite  physical  or  chemical  characters.  Drs.  Washington  Atlee  and  Peaslee,  how- 
ever, inform  us  that  the  fluid  of  an  ovarian  cyst  may  be  distingui.shed  from  all  fluids  by 
the  presence  of  a  peculiar  cell — which  they  call  the  ovarian  granule  cell — which  is  about 
the  size  of  a  pus  cell,  round  and  full  of  granules,  and  Mr.  Thornton  has  recently  con- 
firmed these  ob.servations  {Path.  Soc,  March  IG,  1875;.  adding,  moreover,  that  large  pear- 
shaped,  round,  or  oval  cells  containing  a  granular  material  with  one  or  several  large  clear 
nuclei,  with  nucleoli  and  a  number  of  transparent  globules  or  vacuoles,  are  characteristic 
of  malignant  tumors. 

When,  from  what  appears  to  be  a  monocyst,  the  fluid  drawn  is  clear,  slightly  opales- 
cent, and  limpid,  of  a  low  specific  gravity,  about  lOOo,  and  non-eoagulable  by  heat  or 
nitric  acid,  or  if  coagulable  by  heat  the  coagulum  is  redissolved  upon  the  addition  of 
boiling  acetic  acid,  there  is  a  strong  reason  to  suspect  that  the  tumor  is  a  broad  ligament 
or  parovarian  cyst,  and  under  such  circumstances  there  is  good  reason  to  hope  that  a  cure 
may  follow  the  operation  of  paracentesis,  or.  if  not  a  cure,  the  lapse  of  a  long  interval  of 
time  beiore  the  repetition  of  the  operation  is  called  for.  This  fact  was  pointed  out  bv  the 
late  Dr.  F.  Bird  (M'.l.  TUnrn.  July  19.  1851). 

When  the  fluid  drawn  off  is  clearly  albuminous,  tenacious,  dark,  or  light  colored, 
when  it  is  even  watery  and  like  that  contained  in  the  cysts  last  described,  and  is  found 
microscopically  to  contain  the  compound  cells  or  epithelial  elements  already  referred  to, 
the  tumor  is  probably  ovarian  and  ought  to  be  removed. 

When  the  fluid  drawn  off"  is  highh'  albuminous  and  coagulates  spontaneously,  the  sus- 
picion of  the  tumor  being  a  fibro-cj'stic  uterine  one  ought  to  be  raised,  though  there  is 
little  doubt  that  the  true  diagnosis  of  a  fibro-cystic  uterine  tumor  from  a  polycy.stic 
ovarian  can  only  be  made  out  in  the  majority  of  ca.ses  by  an  exploratory  incision, 
when  the  absence  of  the  pearly  appearance  of  the  ovarian  and  the  presence  of  the  pink- 
ish, vascular,  and  fleshy  aspect  of  the  fibro-cystic  are  enough  to  excite  the  surgeon's  sus- 
picion of  the  uterine  nature  of  the  growth. 

When  pregnancy  and  well-developed  ovarian  disease  coexist,  tapping  ought  to  be 
performed,  though  in  eases  where  the  operation  is  inadmissible,  from  the  nature  of  the 
tumor,  ovariotomy  is  a  justifiable  proceeding,  Spencer  Wells  and  other  surgeons  having 
performed  the  operation  in  many  cases  during  pregnancy,  and  with  success ;  it  should, 
however,  be  undertaken  before  the  fourth  month.  When  the  tumor  is  small,  it  should  be 
left  alone. 


784  ON  OVARIAN  DISEASE  AND   OVARIOTOMY. 

The  Treatment  of  Ovarian  Disease. 

In  the  treatment  of  ovarian  disease  medicine  is  of  little  value  and  has  no  direct  influ- 
ence in  arresting  its  progress.  It  does  good  only  by  improving  the  general  condition  of 
the  patient.  The  operation  of  tapping  in  unilocular  cysts  is,  however,  often  of  great 
value,  and  at  times  essential.  Injection  of  the  cyst  is  applicable  only  to  a  small  class  of 
cases.     Ovariotomy,  in  a  general  way,  is  the  only  radical  cure. 

John  Hunter  clearly  realized  the  truth  of  this  in  1787,  when  he  said,  "  In  the  early 
stage  of  ovarian  dropsy  I  would  almost  advise  that  they  should  be  removed  entirely  if  the 
complaint  can  clearly  be  ascertained,  as  they  otherwise  will  certainly  kill  the  patient." 
He  adds,  however,  that  "  electricity  has  been  serviceable  lately  in  diminishing  the  progress 
of  the  formation  of  the  fluid  in  a  patient  I  am  acquainted  with.  How  far  it  will  be  of 
further  service  I  cannot  say"  (MS.  lectui'es). 

At  the  present  day  the  operation  of  ovariotomy  is  an  accepted  one  by  the  profession, 
and  is  as  recognized  and  justifiable  as  any  other  grave  operation.  Surgeons  and  phy- 
sicians diff"er  only  as  to  the  class  of  cases  in  which  it  is  applicable  and  the  period  at 
which  it  should  be  performed. 

British  surgeons  may  probably  claim  the  credit  of  having  established  this  operation 
in  spite  of  early  difficulties  and  blind  opposition,  and  the  names  of  Lizars  of  Edinburgh, 
MacDowell  of  Kentucky,  Jeaff'reson  of  Framlingham,  Walne,  Fred.  Bird,  Lane,  Morgan, 
Aston  Key,  Cooper,  and  Cajsar  Hawkins  of  London,  must  ever  be  remembered  as 
amongst  its  earliest  practical  promoters.  Charles  Clay  of  Manchester,  however,  the  first 
great  ovariotomist  in  this  country.  Brown,  and  particularly  Spencer  Wells,  of  London, 
Keith  of  Edinburgh,  Koeberle  of  Strasburg,  Skbldberg  of  Stockholm,  and  Atlee  of  Amer- 
ica, with  Hutchinson,  and  possibly  the  present  writer,  have  by  their  successes  fairly 
overcome  all  prejudices  and  rendered  the  operation  an  established  and  accepted  one. 
Without  going  into  the  details  of  statistics,  which  are  now  no  more  needed  in  this  than 
in  other  large  operations,  it  may  be  confidently  asserted  that  the  operation  is  not  placed 
in  too  favorable  a  light  when  it  is  said  to  be  successful  in  three  out  of  every  four  cases, 
good,  bad,  and  indiff"erent,  and  in  at  least  nine  out  of  ten  selected  cases.  Sir  Spencer 
Wells  informs  us,  as  the  result  of  his  unrivalled  experience,  that  out  of  his  1000  cases, 
"232,  or  23.2  per  cent.,  died,  Avhilst  T.  Keith  lost  only  41  out  of  381  cases,  or  10.7  per 
cent.  Lawson  Tait  tells  me  that  with  the  year  ending  1883  he  had  209  cases  of  removal 
of  one  or  both  ovaries  for  cystic  disease  with  but  7  deaths,  or  a  mortality  of  3.3  per 
cent.,  and  that  of  36  cases  of  operation  for  cystic  disease  of  the  Fallopian  tubes  he  had 
no  death.  "  If  ovarian  tumors,"  he  adds,  "  are  operated  upon  as  soon  as  they  are  discov- 
ered, and  never  tapped,  there  would  be  a  mortality  hardly  perceptible." 

"  I  have  become,"  writes  Spencer  Wells,  "  more  and  more  disposed  to  advise  the 
removal  of  an  ovai-ian  tumor  as  soon  as  its  nature  and  connections  can  be  clearly  ascer- 
tained and  it  is  beginning  in  any  way,  physically  or  mentally,  to  do  harm,  since  the  risk 
of  the  operation  under  such  circumstances  is  certainly  less,  and  the  possible  evils  of 
delay  are  eluded." 

When  delay  must  ensue,  one  of  the  minor  methods  of  palliative  surgical  treatment 
may  be  required,  such  as  tapping,  tapping  and  draining,  incision,  or  tapping  and  iodine 
injection. 

Tapping. — This  operation  may  be  required  for  diagnostic  purposes,  and  for  relief 
when  other  operative  measures  are  necessarily  or  wisely  po.stponed  or  have  been  rejected. 
It  should  always  be  practised  once  in  monocystic  tumors,  .since  in  such  it  may  possibly 
prove  curative  and  probably  postpone  operative  interference  for  years.  It  is  not  to  be 
recommended  in  compound  or  semi-solid  tumors.  Spencer  Wells,  however,  maintains  that 
one  or  more  tappings  do  not  increase  cousichrnhly  the  mortality  of  ovariotomy. 

Injection  of  Iodine. — In  the  simple  or  monocystic  ovarian  tumors,  when  the  diag- 
no.sis  is  clear,  the  treatment  by  injection  of  iodine  may  be  employed.  M.  Boinet  says  that 
out  of  45  patients  suff"ering  from  this  disease,  31  were  cured,  5  had  relapses,  and  9  died. 
Sir  J.  Simpson  performed  it  in  about  20  cases  with  good  success,  only  1  case  dying,  while 
Dr.  Tyler  Smith  found  that  out  of  10  cases  in  which  this  practice  was  followed,  2  only 
were  satisfactory  and  2  died.      Dr.  West  in  8  cases  had  1  cured. 

The  method  at  the  best  is  uncertain.  Spencer  Wells  does  not  advocate  it.  In  the 
majority  of  cases  it  does  no  good,  and  may  even  be  followed  by  a  fatal  result.  It  is 
applicable  only  to  simple  cases  of  ovarian  or  extra-ovarian  cysts. 

Incision. — This  method  is  applicable  only  when  the  operation  of  ovariotomy  is  found 
impossible  from  the  adhesions  or  attachments  of  the  tumor.      Under  these  circumstances, 


THE  <)J'i:j:.\ti().\  or  ovmhotomy.  7h5 

in  certain  oases,  it  is  of  iiiiiiu'iiso  valiu'.      In  1S77,  I  liatl  tliis  truth  illustratcrl  in  the  {icr- 

8on  ot    Anii'lia  It ,  ;i't.  20.  whn  liad   recoLMiizfil  the  jirt'scMn'c  <»f"  an  ahduniinal  tumor 

some  months  hetore  slio  bocanic  i)rt.'_Lrnant.  Al'tur  the  confinement,  which  was  normal 
and  the  child  alive,  the  tumor  grew  rajtidly  ;  and  when  she  eame  under  my  care  her 
abdomen  measured  fifty-six  inehos  in  circumference. 

1  operated  upon  her.  but.  having  found  a  moiiocyst  universally  adherent,  I  emjitied  it 
and  evacuated  manv  ({uarts  of  a  viscid  fluid,  washed  the  cyst  well  out  witl>  iodine  water, 
dried  its  cavity,  and  then  drained  it.  For  about  a  week  there  was  some  draining  of  serous 
fluid,  but  there  were  no  constitutional  synijittuns.  The  cyst  was  irrigated  daily  with  iodine 
water.  Uv  the  eleventh  day  the  cavity  had  considerably  shrunk.  On  the  twenty-fifth  it 
would  not  hold  an  ounce  of  fluid.  By  two  months  it  hail  <|uite  healed,  and  the  woman 
returned  home. 

I  have  jierformed  a  like  operation  to  the  above  in  three  or  lour  other  cases  where 
suppuration  existed,  and  with  success. 

When  Operation  is  Required. 

Cases  of  the  polycystic  or  dermoid  kinds  .should,  as  a  rule,  be  operated  upon  a.s  soon 
as  they  become  sources  of  local  or  constitutional  distress.  "Justice,"  says  Wells,  "in 
these  cases  demands  a  most  positive  recommendation  of  excision,  with  a  warning  against 
delay."  "  Every  ovarian  tumor."  writes  Schroder  of  Berlin,  -'ought  to  be  removed  as 
soon  as  it  has  been  discovered.  ' 

It  should  not  be  entertainetl,  however,  when  other  organic  disease  is  present  or  when 
the  local  disease  is  clearly  cancerous.  The  operation  is  a  formidable  one  ;  but  if  the  gen- 
eral condition  of  the  patient  be  good,  the  prognosis  is  fiivorable  even  when  the  tuuKjr  is 
large  and  looking  unfavorable  for  removal. 

The  size  of  a  tumor  has  not  appeared  to  have  had  much  influence  on  the  result, 
although  when  it  is  solid  and  requires  a  large  incision  for  its  removal  the  dangers  are 
increased,  small  incisions,  without  doubt,  being  better  than  large. 

Adhesions  to  the  abdominal  walls,  parietes,  or  omentum  have  but  little  influence 
upon  the  mortality,  but  pelvic  adhesions  are  always  grave  and  visceral  dangerous. 

The  length,  of  the  pedicle,  when  the  clamp  was  used,  was  a  matter  of  import- 
ance, short  pedicles  adding  to  the  danger  of  the  case  by  necessitating  dragging  of  the 
uterus  upward.  At  the  present  time,  when  clamps  are  abandoned  and  the  intraperitoneal 
method  of  ligating  the  pedicle  and  dropping  it  in  is  the  common  custom,  the  length  or  the 
shortness  of  the  pedicle  is  of  small  importance. 

The  breadth  <ir  thickness  of  the  pedicle  i^,  however,  a  question  of  considera- 
tion, since  a  broad  pedicle  of  necessity  requires  many  ligatures,  and  a  thick  one  is  diflScult 
to  ligate  with  safety. 

The  Operation'  of  Ovariotomy. 

The  preliminary  treatment  of  a  patient  about  to  undergo  the  operation  of  ovariotomy 
need  not  differ  in  any  way  from  that  which  experience  has  taught  us  to  be  called  for 
previous  to  any  other  capital  operation.  AVe  should  do  our  best  to  raise  the  standard  of 
health  by  all  those  general  hygienic  and  other  influences  which  are  well  known  to  act 
benefieially.  such  as  good  air,  simple  nutritious  diet,  a  fair  amount  of  .stimulants,  and  the 
administration  of  some  tonic.  Let  the  patient  take  exercise,  when  she  can  without  pain, 
and  be  careful  that  it  is  kept  within  the  limits  of  fatigue,  that  it  be  taken  on  level  ground, 
and  that  no  shaking  or  straining  be  on  any  account  allowed ;  and  when  she  is  at  rest,  the 
half-reclining  position  ought  to  be  usually  assumed.  For  a  day  or  two  before  the  opera- 
tion, however,  exercise,  even  when  possible,  is  not  to  be  advised,  as  quiet  and  repose  are 
then  of  some  essential  service.  The  urine  should  be  carefully  examined  :  and  if  .scanty 
and  concentrated,  the  operation  must  be  delayed.  Lithia  water  and  alkalies  are  always 
useful  in  exciting  a  free  secretion  of  urine  and  in  making  it  clearer. 

As  a  tonic  medicine  iron  appears  to  be  of  real  and  important  value ;  it  has  apparently 
an  influence  for  good  which  other  tonics  do  not  possess.  It  is  no  more  useful,  however, 
before  the  operation  of  ovariotomy  than  before  any  other  capital  operation,  though  it  is 
as  good,  and  I  have  often  thought  that  in  hospital  practice  wounds  are  less  prone  to 
inflame  and  erysipelatous  affections  are  less  common  under  the  influence  of  this  medicine 
than  when  no  such  preliminary  treatment  has  been  adopted.  In  peritoneal  operations 
this  point  is  of  primary  importance,  and,  as  a  consequence,  the  adoption  of  this  practice 

50 


786  ON  OVARIAN  DISEASE  AND    OVARIOTOMY. 

should  be  recommended.  Tlie  fonu  of  iron  I  prefer  is  the  tincture  of  the  perchloriue, 
twenty  drops  combined  with  a  like  quantity  of  spirits  of  chlorofdrm  or  of  syrup  of  lemons 
or  tola  and  a  drachm  of  glycerine  in  water  forming  a  pleasant  draught. 

The  bowels  of  the  patient  should  be  gently  opened  two  days  previously  by  such  a 
mild  aperient  as  castor  oil  or  a  draught  composed  of  ten  grains  of  rhubarb  and  twenty  of 
sulphate  of  potash  in  some  aromatic  water,  and  on  the  morning  of  operation  the  large 
intestine  should  be  washed  out  with  a  warm-water  enema ;  but  nothing  like  powerful  pur- 
gation should  be  allowed  under  any  consideration.  Care  should  also  be  observed  that  the 
catamenial  period  has  passed  for  at  least  a  week  previous  to  the  operation,  as  all  ovarian 
excitement  is  necessarily  injurious  at  such  a  time  and  should  be  avoided.  I  have  known 
cases  of  ovariotomy,  however,  undertaken  without  any  consideration  of  this  point,  and 
believe  that  under  such  circumstances  an  untoward  result  is  to  be  expected. 

In  hospital  practice  the  patient  should  as  much  as  possible  be  isolated  from  all  others 
and  kept  in  a  private  room  in  which  good  ventilation  exists ;  a  special  nurse  should  also 
be  secured,  who  is  not  only  entirely  trustworthy,  but  understands  how  to  use  a  female 
catheter.  Country  patients  should  not  be  brought  into  town  unless  an  urgent  necessity 
exists,  as  there  is  little  doubt  that  the  atmosphere  of  a  large  city  is  not  so  conducive  to 
the  rapid  reparation  of  a  wound  as  fresh  country  air.  In  abdominal  surgery  this  influ- 
ence for  good  is  of  great  value,  and  should  not  be  thrown  away  unless  from  necessity. 

The  surgeon  who  is  to  operate,  as  well  as  his  assistant,  should  not  allow  himself,  for  a 
few  days  before  the  operation,  to  visit  the  post-mortem  or  dissecting  room,  nor  should  he 
handle  any  morbid  preparations.  Erysipelatous  affections  and  all  contagious  diseases 
should  also  be  shunned  as  much  as  possible ;  indeed,  the  same  rules  which  are  observed 
by  the  careful  obstetric  practitioner  are  necessary  to  the  surgeon  who  undertakes  the  ope- 
ration of  ovariotomy,  .since  the  same  subtle  poisons  which  are  recognized  by  all  to  be 
hurtful  to  the  puerperal  woman  act  with  equal  force  upon  the  subject  of  ovarian  as  of 
other  diseases  when  submitted  to  operation,  and,  as  a  consequence,  should  be  studiously 
avoided.  It  follows,  therefore,  as  regards  the  lookers-on  at  an  operation  and  all  who  may 
come  in  contact  with  the  patient,  that  none  who  may  bring  infectious  or  contagious  dis- 
ease should  on  any  account  be  admitted.  The  physician  who  is  attending  a  case  of  puer- 
peral fever  is  looked  upon  as  a  possible  poisoner  as  far  as  concerns  the  puerperal  woman. 
The  medical  attendant  of  a  scarlet-fever  case,  of  erysipelas,  or  other  contagious  disease 
should  be  regarded  in  the  same  light  in  the  presence  of  an  ovariotomy  operation,  and 
should  be  excluded.  Hence,  in  hospital  practice,  great  care  is  needed  to  exclude  all  such 
possible  means  of  injury  as  have  been  briefly  enumerated. 

I  need  hardly  allude  to  the  necessity  of  all  bed  and  bedding,  blankets,  sheets,  and 
hangings  being  perfectly  fresh  ;  all  sponges  being  iie>c,  soft,  well  cleansed,  scalded,  and 
free  from  soap  and  grit;  and  every  instrument  to  be  employed  being  scrupulously  clean. 
The  hands  of  the  operator  should  likewise  be  thoroughly  cleansed  from  soap  just  previous 
to  the  operation  and  be  well  warmed,  for  manipulation  with  a  cold  hand  cannot  but  prove 
injurious  to  an  exposed  peritoneum. 

Temperature  of  the  Room  in  which  the  Operation  is  Performed. — 

There  is  still  some  difference  of  opinion  on  this  point  among  operating  surgeons,  Dr.  Clay 
of  Manchester,  Peaslee  of  America,  and  others,  advising  that  the  operating  room  be  heated 
to  75°  or  80°  F.  and  a  good  supply  of  moisture  engendered  by  the  diffusion  of  steam, 
while  Wells  and  others  make  no  such  rule.  Speaking  from  my  own  experience,  I  have 
no  faith  in  the  adoption  of  such  a  practice.  I  would  have  the  room  heated  to  a  comforta- 
ble temperature,  65°  being  amply  sufficient,  since  a  greater  heat  acts  as  a  powerful  depres- 
sant upon  the  patient  and  can  do  no  good.  A  warm  room  with  good  ventilation  is  what 
I  always  seek  in  preference  to  a  hot  one  with  closeness.  A  cold  damp  room  is  to  be  con- 
demned under  all  circumstances. 

Position  of  the  Patient. — The  horizontal  position  is  that  which  patients  suffer- 
ing from  ovarian  disease  can  rarely  assume  ;  and  when  the  tumor  is  so  large  as  to  require 
ovariotomy,  this  position  becomes  almost  impossible.  As  a  consequence,  the  half-reclin- 
ing position  is  the  most  comfortable  for  the  patient  and  convenient  for  the  operating  sur- 
geon. It  is  the  posture  I  have  invariably  adopted  in  the  cases  Avhich  have  fallen  into  my 
hands,  and  I  know  of  no  good  reason  why  it  should  be  changed. 

The  semi-recumbent  position  affords  all  the  advantages  which  have  been  claimed  for 
other  postures  without  their  evils;  in  it  the  tumor  can  readily  be  removed  from  the  abdom- 
inal cavity,  and  with  care  its  fluid  contents  can  without  difficulty  be  prevented  from 
passing  into  the  peritoneal  cavity.  There  is  also  abundant  room  for  every  manipulative 
act  that  can  be  required. 


Till:    Ol'llllATIoS    or   oVMiloroMY.  7K7 

Administration  of  Anaesthetics  in  the  Operation. — Ammi;:  ihc  many 

iiicitlcnl.il  a(l\  aiitaizcs  wliicli  tlic  iiil  rnilncl  iuii  nl'  aii;c>t  licl  ir.s  |i.i>  allurilcti  licvoiitl  iliat  nl' 
rclicviiiu  pain,  few  arc  j^rcatcr  tliaii  that  <il"  ohviatiii;.'  Iiiirry — a  poitit  of  critical  iiiiport- 
aiicc  ill  ovariotinnv  ;  ami  tliciv  can  l»c  little  dmilit  lliat  the  success  of  the  <i|ierati<in  has 
thus  hcen  i:n'atly  infiiicnce(l  |>y  their  use. 

It  is  true  that  (iterations  for  the  removal  of  an  ovarian  tumor  were  iiinlertaken  In-fore 
the  introduction  of  anv  amost hetic.  I)iit  we  all  know  how  fatal  were;  their  results  and  how 
oxce|itional  was  n-coverv.  Those  who  had  an  ojiport unity  id'  witnessiii}.'  the  j)erformance 
of  iin  operation  under  sii<di  unfavorahle  eircuuistance.s  can  hardly  wonder  that  so  many 
patients  succunilu'd  to  the  |)raetice,  althoufrh  they  might  he  surprised  that  any  were  found 
to  convah'sce.  To  see  a  patient  writhinj;  under  the  agonies  of  an  ahdominal  section  was 
enough  to  make  the  hardest  heart  turn  with  horror,  and  to  witness  tlie  surgeons  hanrls 
within  the  ahdonicn  of  a  struggling  woman  in  his  endeavor  to  remove  an  adherent  growth 
was  almost  sufficient  to  make  any  professional  spectator  deciile  that  siudi  an  operation 
was  really  uiijustitiahlc. 

How.  ill  such  a  case,  was  it  possilile  for  a  surgeon  to  he  (jiiiet  in  all  his  movements, 
gentle  in  his  mani])ulations.  and  thoughtful  over  the  difficulties  which  of  necessity  pre- 
sent themselves  in  an  ovarian  operation,  when  the  cries  of  the  patient's  agony  stimulated 
him  to  expedition  and  her  struggles  forhade  gentleness':'  All  surgeons  who  have  ope- 
rated ujton  these  ca.ses  will  agree  that  success,  even  under  favorahle  circumstances,  is 
only  to  be  ae(|uired  by  attention  to  these  points  ;  that  hurry  in  any  ojieration  is  always 
bad  and  unjustifiable,  while  in  ovariotomy  it  is  destructive  ;  that  force  is  never  to  be 
employed  in  any  case  where  art  will  answer ;  that  in  ovariotomy  all  blind  force  and  drag- 
ging is  to  be  strongly  condemned ;  and  that  in  a  proceeding  in  which  steadiness  in  ope- 
rating. gentlene.s3  in  manipulating,  and  thoughtful  attention  to  every  detail  are  ab.soluteIy 
essential  to  success  the  safety  of  the  patient  must  depend  upon  her  quietness  and  passive- 
ness  under  the  surgeons  treatment. 

Under  these  circumstances  the  value  of  some  aiuesthetic  cannot  be  too  highly  jiraised, 
for  by  it  the  patient  is  not  only  rendered  insensible  to  pain,  but  her  perfect  (Hiieseence 
is  guaranteed  and  her  passiveness  under  the  hands  of  the  operating  surgeon  completely 
ensured. 

The  vomiting  that  occasionally  follows  is  the  only  argument  against  the  inhalation 
of  an  ana3sthetic,  but  this  is  an  evil  which  must  be  endured  for  the  .sake  of  the  positive 
good  it  affords.  By  the  use  of  the  nitrous-oxide  gas  followed  up  by  ether,  or  of  the 
chloroform  mixture,  of  alcohol  one  part,  chloroform  two.  and  ether  three  parts,  as  recom- 
mended by  the  chloroform  committee  of  the  Royal  Med.  and  Chir.  Societ}',  vomiting  is 
certainly  less  common  than  after  the  use  of  chloroform  alone,  and  as  a  general  anfesthetic 
it  should  be  employed.  When  chloroform  or  bichloride  of  methylene  is  used,  it  should 
be  given  by  '-Junker's"  spray  apparatus. 

Extent  of  the  Incision  into  the  Abdominal  Parietes. — The  temjierature 

of  the  room,  the  jmsition  of  the  patient,  and  the  propriety  of  tlie  administration  of  anaes- 
thetics having  received  our  attention,  the  operation  itself  next  claims  consideration  ;  and 
the  first  thought  naturally  is  as  to  the  extent  of  abdominal  inci.sion  re«|uired,  as  there  is 
still  a  want  of  uiianimitv  in  the  practice  of  different  surgeons  upon  this  jioint. 

Care  to  have  the  Bladder  Empty. — Before  commencing,  the  careful  surgeon, 
standing  on  the  right  hand  of  the  patient,  will  .see  that  the  bladder  has  been  emptied  by 
means  of  a  catheter,  the  linen  of  the  patient  well  drawn  up  out  of  harm's  way  and  freed 
from  the  chance  of  becoming  soiled  by  the  use  of  waterproofing,  the  limbs  of  the  patient 
well  protected  and  kept  warm  by  a  pair  of  drawers  and  covered  by  a  clean  sheet,  either 
with  or  witliout  a  blanket,  the  abdomen  covered  by  a  long  piece  of  waterproofing  with  an 
opening  in  the  middle  eight  inches  long  by  six  wide,  with  its  inner  surface  rendered  adhe- 
sive by  a  coating  of  plaster.  He  should  also  see  that  all  his  assistants  are  carefully 
arranged  and  special  duties  assigned  to  each,  and  that  every  instrument  that  may  be 
re(|uired  is  clean  and  nigh  at  hand.  He  .should  proceed  to  make  his  incision  as  soon  as 
tlie  patient  has  been  brought  completely  under  the  influence  of  an  anaesthetic,  though 
previously  he  should  determine  as  to  its  length.  From  Mr.  Walne's.  Sir  J.  Simpson's,  and 
Dr.  Clay's  practice  it  might  be  argued  that  the  long  incision  should  always  be  adopted, 
since  their  success  has  been  great  and  in  their  practice  the  long  incision  has  been  invari- 
ably employed.  From  the  practice  of  Dr.  Keith.  Sir  Spencer  Wells.  Lawson  Tait.  and 
others,  the  short  incision  would  appear  to  be  the  better,  for  their  success  has  at  least 
been  as  good  as  that  of  Dr.  Clay  and  others,  and  as  a  rule  the  short  incision  has  been  the 
one  selected.     I  regard  the  truth  as  between  the  two  extremes.     When  the  tumor  can 


788 


ON  OVARIAN  DISEASE  AND   OVARIOTOMY. 


be  removed  with  facility  by  means  of  a  short  incision,  a  long  one  is  clearly  not  required-, 
and  when  the  tumor  is  monocystic,  or  nearly  so,  and  free  from  abdominal  adhesions,  it 
may  be  so  removed.  But  when  the  tumor  is  large  and  semi-solid,  or  when  adhesions 
exist  which  cannot  be  readily  broken  down  by  the  employment  of  gentle  traction  upon 
the  growth,  it  is  the  best  practice,  doubtless,  to  make  a  long  incision,  as  by  so  doing  the 
removal  of  the  growth  is  much  facilitated  and  the  causes  of  its  abdominal  retention  and 
the  connection  of  the  adhesions  are  satisfactorily  ascertained,  and,  as  a  consequence,  can 
be  dealt  with  with  greater  safety. 

My  own  practice  has  hitherto  been  influenced  by  such  a  conviction,  and  I  have  in  all 
cases  commenced  the  operation  by  making  a  short  abdominal  incision,  and  in  many  have 
been  enabled  to  remove  the  tumor  without  further  trouble.  But  in  certain  examples  in 
which  difficulties  appeared,  and  in  which  it  was  clear  that  adhesions  existed  for  the  break- 
ing down  of  which  some  force  would  have  been  required  and  some  working  in  the  dark 
called  for,  I  have  been  induced  to  increase  the  length  of  the  wound  upward,  even  for  an 
inch  or  two  beyond  the  umbilicus,  regarding  such  an  increase  of  the  incision  as  unimport- 
ant in  comparison  with  the  evil  effects  of  violence  and  dragging  upon  the  tumor  for  the 
purpose  of  its  removal,  or  the  blind  tearing  down  of  the  abdominal  or  visceral  adhesions 
which  detain  the  growth. 

I  have  never  seen  any  evil  effects  from  the  long  incision  when  ma  Je  under  the  cir- 
cumstances I  have  just  indicated,  but  have,  beyond  doubt,  seen  the  bad  results  of  an 
opposite  practice,  of  violence  which  has  been  employed  in  an  attempt  to  remove  a  large 
growth  through  a  small  opening,  or  to  tear  an  adherent  one  from  its  abdominal  or  visceral 
connections. 

The  incision  should  also  always  be  made  sufficiently  low.  If  too  high,  considerable 
traction  upon  the  pedicle  of  the  tumor  must  be  made  to  bring  it  into  sight,  and  with  the 
tumor  the  uterus  will  also  be  drawn  out.  This  traction  is  always  injurious,  and  should 
be  avoided.  When  the  lower  end  of  the  wound  is  too  high  up,  this  traction  of  the  parts 
becomes  unavoidable ;  by  extending  the  incision  downward  toward  the  pubes  to  a  point 
corresponding  to  the  upper  part  of  the  healthy  uterus,  or  about  one  inch  above  the  pubes, 
this  evil  can  be  prevented,  and,  consequently,  the  practice  I  have  just  advised  should 
invariably  be  adopted. 

Tapping  the  Cyst. — The  cyst,  having  been  exposed,  ought  to  be  tapped,  and  for 
this  purpose  the  instrument  represented  in   Fig.  451,  as  made  for  me  by  Mr.  JMillikin  in 

1864,    is   the    one   I  prefer.      It 
Fig.  451.  includes    not    only   a   trocar    and 

canula,  but  a  vulselluin  forceps, 
which  slides  upon  the  latter,  and 
by  being  made  to  grasp  the  cyst 
walls  holds  the  instrument  firmly 
in  its  position,  thus  enabling  the 
surgeon  to  make  traction  upon 
the  tumor  for  the  purposes  of  its 
removal. 

Removal  of  Cyst. — When  the  cyst  has  been  emptied  and  is  of  a  simple  nature, 
its  removal,  unless  adhesions  exist,  is  readily  effected;  but  when  it  is  solid  or  very  com- 
pound, it  may  be  necessary,  to  allow  of  its  extraction,  to  lessen  its  size  by  breaking  down 
its  contents,  and  for  this  purpose  the  surgeon  must  make  a  free  opening  into  the  cyst  and 
introduce  his  hand  into  its  interior,  the  orifice  of  the  opening  into  the  cyst  at  the  same 
time  being  held  well  open  and  forward  by  forceps  (Fig.  452)  adapted  for  the  purpose. 

Fig.  452. 


Trocar  and  Canula  for  Tapping,  with  Movable  Forceps. 


Nelaton's  Cyst  Forceps. 


By  these  means  the  most  compound  cyst  may  be  broken  down  and  removed.     When  the 
cyst  is  so  adherent  to  the  abdominal  parietes  as  to  render  it  difficult  for  the  surgeon  to 


Tin:  <ti'i:i:.\ii().\  of  niAn/oroMV. 


789 


distiiiLTuisli  the  cvst  wall  itM'li"  lioiii  llir  |»:iri(lal  layrr  nf  pcrildiK'imi,  the  plan  a<l>i|iI<Ml 
by  Sir  Spt'iifiT  Wt-ils.  ol"  i-iiiptyiiij;  tlii-  i-yst  ami  seizing  its  posterior  or  u|)ptr  wall  from 
within  liv  forceps  ami  inverting  it,  is  a  good  one,  the  eyst  then  peeling  oH  on  good  trac- 
tion lieing  made. 

Adhesions  and  their  Treatment.— Winn  the  imisimi  through  the  ahdominal 
walls  has  heeii  inatle  and  the  smooth  glistening  surface  of  the  visceral  peritoneal  covering 
of  the  tninor  recogni/ed.  the  surgeon  may  he  satisfied  that  the  uhdominul  cavity  lias  heeii 
fairly  opened  ami  the  tumor  exposed;  and  when  the  ovarian  eyst  on  ea(di  respiratory  act 
is  seen  to  move  freelv  within  the  ahdomeii,  there  is  a  strong  prohahility,  if  not  certainty, 
that  tlir  tumor  is  free  and  the  tomplieatioii  of  adhesions  is  not  likely  to  be  severe;  for 
wlien  tlie  tumor  is  fixed  to  the  ahdominal  walls,  this  mobility  of  the  cyst  is  not  present. 
Fibrous  or  lil)ro-cvstic  tumors  of  the  ovary  or  uterus  usually  luive  a  fleshy  or  muscular 
appearance.  Adhesions  may  present  themselves  on  the  eomid(;tion  of  the  abdominal 
incision  in  three  f(M'ms — Jirsf,  as  forming  a  complete  and  compact  union  between  the  peri- 
toneal covering  of  the  cyst  and  the  abdominal  peritoiieuni :  .«'Y-o//f/,  as  loose  and  fibrous 
connective  bands;  and  /////•</.  as  visceral  adhesions.  When  a  firm  atid  compact  union 
exists  between  the  cyst  and  tlie  abdominal  ))eritoiieal  membrane,  the  surgeon  will  have 
lost  his  chief  guide  as  to  the  depth  of  his  abdominal  section,  and  under  these  circum- 
stances he  may  experience  .some  difiiculty  in  deciding  whether  the  abdominal  cavity  lias 
been  opened  or  not ;  he  must  consequently  be  careful  in  his  procedure,  for  he  is  not  far 
from  the  pos.sibility  of  perpetrating  a  fatal  error — the  separation  of  the  parietal  perito- 
neum from  its  muscular  connections;  but  this  error,  however,  can  be  avoided  by  merely 
extending  the  abdominal  incision  upward  until  the  distinct  line  of  separation  between  the 
cyst  wall  and  the  abdominal  peritoneal  membrane  is  clearly  seen.  The  next  step  of  the 
operation  consists  in  tlie  breaking  down  of  adhesions,  which  may  be  done  by  the  careful 
introduction  of  the  finger  between  the  cyst  walls  and  the  parietal  layer  of  peritoneum. 
And  here  some  force  is  perfectly  justifiable;  for  if  the  adhesions  are  confined  to  the 
abdominal  parietes  and  can  be  torn  through,  there  is  rarely  much  subsequent  danger  to 
be  apprehended.  Extreme  care,  however,  is  required  at  this  stage  of  the  operation.  The 
surgeon,  by  the  introduction  of  his  finger,  should  make  out  the  extent  of  the  adhesions 
and  test  their  strength.  If  they  should  be  found  numerous  and  too  firm  for  separation, 
the  operation  at  this  stage  had  better  be  abandoned  and  the  wound  closed;  or  should 
many  visceral  adhesions  of  a  firm  character  be  present,  it  would  be  well  to  follow  the 
same  practice,  as  the  latter  are  much  more  dangerous  than  those  merely  attached  to  the 
abdominal  walls.  It  is,  indeed,  difficult,  if  not  impossible,  to  describe  with  anything  like 
accuracy  what  extent  or  character  of  adhesions  would  justify  the  surgeon  in  abandoning 
an  operation  once  begun  and  then  closing  the  wound.  The  careful  study  of  reported 
cases  and  experience  alone  will  enable  him  to  decide  with  certainty  upon  these  points. 
Yet.  as  a  broad  rule,  it  may  be  asserted  that,  while  parietal  adhesions  may  be  fearlessly 
treated  when  they  can  be  divided,  those  connecting  the  cyst  with  the  viscera  and  the 
pelvis  should  always  be  regarded  with  alarm,  and  that  the  amount  of  force  permissible  in 
the  treatment  of  the  former  class  of  cases  would  be  quite  inexcusable  when  the  viscera 
are  concerned.  AVells's  method  of  emptying  the  parent  cyst,  passing  one  hand  into  its 
interior,  grasping  its  back,  and  inverting  it.  the  back  part  of  the  cy.st  being  withdrawn 
through  the  opening  made  in  its  front,  is  an  excellent  one. 

The  fear  of  hemorrhage  from  the  lacerated  adhesions  should  always  be  present  to  the 
surgeon,  and  the  torn  surface  should  be  carefully  examined  with  a  view  to  the  arrest  of 
any  bleeding. 

Omental  adhesions  should  be  particularly  examined  with  care  and  torn  through  with 
caution,  for  they  are  very  vascular  and  cannot  be  treated  with  too  much  consideration. 
As  a  rule,  they  should  be  divided  and 

secured  with  a  fine  ligature  of  silk  or  Fig.  453. 

carbolized  catgut.  Their  forcible  sep- 
aration is  always  bad.  Spencer  Wells's 
forceps  for  holding  the  omentum  (  Fig. 
453)  whilst  the  surgeon   secures  the   ^; 

vessels  is  invaluable.     Firm  band-like    e    i^- 

adhesions  may  be  similarly  treated. 
The  ends  of  each  ligature  may'  be  cut 

off  and    the    knot   left    in.  Omental  Clamp  Forceps. 

When  the  incision  has  been  made 
and  no  adhesions  exist  between  the  cyst  and  the  internal  abdominal  walls,  it  appears  to  be 


790  ox  oy'ARLiy  disease  axb  ovariotomy. 

an  unnecessary  practice  for  the  operator  to  introduce  his  hand  into  the  abdominal  cavity 
with  the  view  of  learning  whether,  they  exist  or  not.  Adliesions  in  front  must  neces- 
sarily be  broken  down,  and  this  can  generally  be  eifected  hy  the  finger  of  the  operator 
introduced  at  th-e  margin  of  the  wound.  As  the  cyst  empties  these  adhesions  are  neces- 
sarily brought  forward  ;  but  when  they  do  n(jt  exist,  the  peritoneum  escapes  even  the 
touch  of  the  hand  of  the  operator.  In  complicated  and  exceptional  examples  of  this 
operation  it  is  clear  that  this  practice  cannot  be  followed,  but  in  the  more  ordinary  and 
simple  cases  it  is  most  applicable.  In  many  examples  Avhich  have  come  into  my  hands 
the  value  of  this  advice  has  been  well  proved,  for  in  them  the  peritoneum  was  touched 
only  by  the  knife  and  needle. 

As  the  tumor  is  being  extracted  care  should  be  observed  to  guard  against  the  pro- 
trusion and  exposure  of  the  intestines  and  omentum,  and  this  is  best  done  by  the  intro- 
duction of  flat  sponges,  a  sponge  being  tucked  in  and  spread  out  beneath  the  parietes  as 
the  process  of  extraction  of  the  cyst  and  exposure  of  the  pedicle  is  going  on. 

Treatment  of  the  Pedicle. — At  the  present  day  the  pedicle  is,  as  a  rule,  tied  in 
two  or  more  segments,  according  to  its  size,  with  carbolized  silk,  the  ends  of  the  ligatures 
are  cut  ofi"  close  to  the  loop,  and  the  pedicle  with  the  ligatures  is  dropped  back  into  the 
pelvis.  This  method  is  doubtless  a  great  improvement  upon  the  clamp  and  dthcr  fnrms 
of  practice. 

In  France,  Maisonneuve  twisted  oft'  the  cyst  by  continued  torsion,  leaving  the  pedicle 
to  fall  back  into  the  abdomen,  w^hilst  Nelaton  preferred  to  fix  the  pedicle  externally 
and  secure  it  by  means  of  a  common  clamp.  In  Germany,  Martin  and  Langenbeck  cut 
through  the  peritoneal  covering  of  the  pedicle  by  a  circular  inci.sion,  cut  oft'  the  tumor, 
tied  each  vessel  separately,  and  fixed  the  pedicle  to  the  walls  of  the  abdomen  by  means 
of  a  double  ligature.  Dr.  C.  Clay  fastened  the  pedicle  by  a  double  ligature,  cut  oft'  the 
tumor,  and,  having  allowed  the  pedicle  to  drop  backward  into  the  pelvis,  brought  the  ends 
of  his  ligatures  out  through  the  lower  ends  of  the  incision.  Dr.  Tyler  Smith  followed 
the  same  treatment,  but  dropped  both  pedicle  and  ligatures,  which  are  cut  off'  close,  into 
the  pelvis,  and  then  closed  the  wound.  S.  "Wells  and  T.  Keith  for  years  fixed  the  ped- 
icle externally  by  means  of  a  clamp,  but  Wells.  Thornton,  and  most  operators  now  use 
the  ligature,  and  Keith  the  cautery,  as  first  employed  by  Mr.  B.  Brown  and  SkiJlberg, 
dropping  the  cauterized  end  of  the  pedicle  back  into  the  pelvis.  Atlee  of  America 
employs  the  ecraseur.     In  my  own  practice  I  now  always  employ  the  ligature. 

The  plan  of  treatment  now  principally  adopted,  of  drtipping  in  the  pedicle  with  the 
divided  ligature,  was  first  practised  in  1829  by  David  Eodgers  of  New  York.  His  patient 
made  a  good  recovery.  The  practice  did  not.  however,  meet  with  general  approval.  It 
was  too  bold  and  inconsistent  with  all  past  experience  and  professional  prejudices,  and 
fell  to  the  ground.  It  was  repeated  at  intervals  bj'  other  surgeons  with  tolerable  success ; 
it  has  now  gained  a  strong  hold  on  the  professional  mind  and  become  a  general  practice. 
J  may  mention  here  that  Sir  B.  Brodie  had  some  confidence  in  this  practice,  for  in  1843, 
when  discussing  the  case  upon  which  Mr.  Aston  Key  had  operated  without  success  at 
Guy's  Hospital,  he  expressed  his  belief  that  the  right  treatment  of  the  pedicle  was  to 
drop  it  in  and  close  the  wound,  and  that  if  success  could  be  secured  it  would  be  by  such 
means.  I  make  this  statement  on  the  authority  of  Dr.  H.  Oldham,  who  hoard  the 
remark. 

What  becomes  of  the  ligated  pedicle  Avith  the  ligature  or  of  the  cauterized  extremitj' 
is  a  point  of  interest,  and  it  may  with  some  confidence  be  said  that  the  ligated  or  cauter- 
ized end  does  not  slough,  nor  does  the  ligature  act  as  a  foreign  body.  In  a  case  of  my 
own  in  which  the  pedicle  was  secured  with  carbolized  catgut  and  dropped  in  with  a  good 
result  no  traces  of  the  ligature  were  visible  a  year  later,  when  the  patient  died  from 
some  cause  other  than  the  disease;  indeed,  there  was  not  even  an  adhesion,  for  the  fim- 
briated end  of  the  divided  pedicle  was  free. 

Dr.  Doran'  has  also  found,  from  a  careful  examination  often  cases  at  variable  periods 
after  ovariotomy,  that  ''  a  communication  between  the  distal  and  proximal  parts  of  the 
stump  is  established  by  inflammatory  plastic  eft'usion,  and  the  ligature  is  unravelled  by 
granulation  cells  insinuating  them.selves  between  its  fibres.'" 

Toilet  of  the  Peritoneum. — When  the  pedicle  has  been  secured,  all  bleeding 
points  should  be  carefully  looked  to.  particularly  at  the  seat  of  adhesions,  and  all  vessels 
should  be  twisted  or  ligatui-ed  with  fine  carbolized  .silk  or  catgut. 

The  second  ovary,  with  the  uterus,  should  then  be  examined,  and  the  pelvis  thor- 
oughly cleaned  with  soft  sponges.  Indeed,  the  greatest  care  should  be  observed  in  what 
'  St.  Barlh.    Hosp.  Repa.,  vols.  xiii.  and  xiv. 


Tin:  ui'/:i:.\Ti').\  or  ovmuoto.my.  7«jl 

is  culled  the  '•  toilet  til'  llie  iieritoiieiiiu,  "  so  that  Idotid  cIhIh  and  fluid  sliDuld  be  curerully 
removed.  In  iiiy  earlv  days  I.  in  cniimioii  willi  others,  did  not  see  the  neeesxity  of  this 
care.  When  this  iniportant  measure  has  heen  completed,  a  flat  spon;.'*-  should  he  intro- 
duced within  the  wound  and  left  (ill  the  sutures  have  lieeu  introduced. 

Treatment  of  the  Wound.— 'i'he  operation  completed,  the  ahdondnal  cavity 
cleansi'd,  the  opposite  ovary  examined,  and  all  siyn.s  of  hcnnu'rha^M-  ahscnt.  the  surjieon 
may  then  ju'oeecd  to  the  closure  of  the  wound.  He  should  do  this  l»y  nicuris  of  deep 
and  superficial  sutures;  tho.se  of  silk  plat,  as  sold  hy  fishiij'r-taekle  makers,  an.-  the  best. 
These  sutures  should  hi'  inserted  at  intervals  (jf  an  inch  and  maile  to  include  tlu;  museleit 
and  peritoneum,  intermediate  superficial  sutures  heinj.^  inserteil  throujrh  the  skin.  When 
union  has  taken  place — /. '.,  any  time  hetweeii  three  and  si.x  days — the  sutures  should  he 
reniovi'd.  no  nliject  lieini;  <rained  hy  leavinjj;  them  lon;;er  in  sifii. 

Drainage  Tubes. — In  :ill  complicated  cases  wliere  tlie  peritoneum  has  heen  much 
involved  and  there  is  a  pndtahility  of  luunorrhatre  or  sennas  exudation,  a  drainaj^e  tube 
should  he  introduced  at  the  lower  an^le  of  the  wound.  One  made  of  <rlass  is  better  than 
the   india-rul>l)er. 

Aftkk-Tukat.MK.NT. — Whenever  a  iiatient  has  taken  an  an;e.->tlietic,  it  is  wise  to 
keep  the  stomach  as  quiet  as  possible,  and,  as  the  benefit  of  an  opiate  after  the  ope- 
ratittn  is  always  frreat,  it  is  wise  to  administer  it  by  the  rectum.  In  abdominal  opera- 
tions this  practice  is  of  great  value,  and  for  some  years  1  have  been  accustomed  to 
•rive  a  half  grain  of  morphia  sup]iositorv  after  every  ovarian  operation,  as  well  as 
after  others  of  hernia,  ru])tured  ])erin;vum.  etc.  The  suppository  should  be  adminis- 
tered before  the  patient  lias  recovered  from  the  efilects  of  the  aiuosthetic,  and  care 
should  be  taken  that  it  be  passed  well  into  the  rectum.  If  pain  is  felt,  the  supposi- 
tory may  be  repeated;  but  it  is  rarely  necessary  to  administer  it  more  than  once  a  day — 
namely,  at  bedtime.  The  patient's  room  should  be  kept  cool  and  airy,  as  in  otiier  cases 
of  operation.  For  the  first  two  days  milk  or  barley  water  forms  generally  tlie  chief  diet ; 
but  should  sickness  sujiervene  as  a  result  of  the  an:esthetic,  ice  and  milk  or  ice  and  soda 
water  should  be  administered,  and  everything  should  be  cold.  If  sickness  continues,  food 
ought  to  be  given  two  or  three  times  a  day  by  the  rectum.  As  soon  as  the  stomach  will 
admit,  fresh  meat,  brandy,  and  wine  ought  carefully  to  be  given,  the  object  being  in  these 
cases,  as  in  all  others  of  general  surgery  after  the  fir.st  three  days,  to  keep  up  the  powers 
of  the  patient,  and  so  enable  nature  to  complete  the  cure.  The  ai)plication  of  a  Leiter's 
coil  to  the  abdomen  I  have  found  of  great  advantage,  and  an  ice  caj)  to  the  head  is  bene- 
ficial when  the  temperature  rises  above  102°.  The  urine  ought  to  be  drawn  ofi"  periodi- 
cally ;  and  when  the  bowels  rerjuire  relief,  their  action  should  be  rendered  easy  by  the 
use  of  enemata.  The  bladder  should  never  be  allowed  to  become  distended  or  the  bowels 
be  left  loaded  too  long. 

On  the  use  of  opium  a  few  remarks  remain  to  be  made,  for  u])on  this  point  the  prac- 
tice of  surgeons  appears  to  be  uixlergoing  a  change.  In  the  early  operations  of  ovari- 
otomy it  was  extensively  employed,  and  at  the  present  time  some  are  still  free  with  its 
use  ;  but  there  is  good  rea.son  to  believe  that  in  this  operation,  as  in  others,  a  very  free 
administration  of  the  drug  in  every  ca.se  is  not  attended  by  such  good  results  as  could  be 
wished,  and  that  in  a  ])atient  under  its  full  influence  a  wound  does  not  repair  .so  rapidly 
and  favorably  as  in  another  where  natural  processes  are  allowed  to  progress  without  inter- 
ference. Opium  carefully  given  to  allay  pain  and  cause  sleep  is  a  drug  concerning  the 
value  of  which  there  cannot  be  a  doubt,  but  o])ium  administered  with  sufficient  freedom 
to  bring,  and  repeated  often  enough  to  maintain,  a  patient  under  its  influence  is  a  drug 
against  the  use  of  which  a  surgeon  should  be  on  his  guard.  In  ovarian  cases  it  ought 
not  to  be  given  in  larger  quantities  than  sufficient  to  allay  pain  and  secure  sleep.  A 
patient  should  not  be  kept  under  its  full  influence  unless  there  are  specific  reasons  for  it. 
It  is  best  admini-stered  by  the  bowel,  being  less  liable  to  cause  injurious  effects  and  more 
likely  to  produce  good,  since  it  is  ab.sorbed  as  rapidly  by  the  rectum  as  by  the  stomach  ; 
and  in  aV)doniinal  operations  it  tends  much  to  maintain  that  quietude  of  the  bowels  which 
in  all  such  cases  is  so  desirable.  In  my  own  practice  I  have  been  accustomed  for  some 
years  to  administer  opium  by  the  bowel  in  preference  to  the  stomach  in  all  cases  of 
abdominal  surgery. 

After  the  operation  of  ovariotomy  jtatients  may  become  jiregnant.  Many  of  mine 
have  done  .so,  and  in  one  case,  recorded  in  the  Gaz.  Med.  de  Paris  (1873),  a  patient  had 
twins — one  male,  and  the  other  female. 


792  ON  OVARIAN  DISEASE  AND    ()\  ARIOTOMY. 

Ovariotomy  in  Pregnancy. 

Ovariotomy  may  even  succeed  when  performed  upon  a  pregnant  woman.  Sir  Spencer 
Wells  has  reported  9  such  operations,  with  8  recoveries.  In  5  of  the  0  cases  pregnancy 
proceeded,  and  living  children  were  born  after  natural  labor  ;  and  in  all  these  the  opera- 
tion was  performed  within  the  fourth  month.  In  the  other  cases  a  miscarriage  occurred. 
He  lays  it  down  as  a  rule  that  in  cases  of  multilocular  or  solid  tumor  the  tumor  should  be 
removed  in  an  early  period  of  pregnancy  ;  and  if  an  ovarian  cyst  should  burst  during 
pregnancy,  removal  of  the  cyst  and  complete  cleansing  of  the  peritoneal  cavity  may  save 
the  life  of  the  mother,  and  pregnancy  may  go  on  to  the  full  term. 

Treatment  of  Slppurating  Ovarian  Cysts. 

When  an  ovarian  tumor  is  breaking  down  and  undergoing  disorganizing  or  suppura- 
tive changes,  whether  spontaneously  or  after  tapping,  it  has  been  already  stated  that  it  is 
the  surgeons  duty  to  interfere  and  to  remove  what  is  a  serious  source  of  constitutional 
irritation,  and  one  which,  if  left  to  itself,  must  to  an  almost  certainty  destroy  life.  This 
should  be  done  by  means  of  an  exploratory  operation.  When  the  tumor  can  be  removed 
as  a  whole,  so  much  the  better ;  but  when  it  has  contracted  such  adhesions  with  the  parts 
around  as  to  be  practically  immovable,  as  much  of  the  tumor  should  be  turned  out  of  the 
parent  cyst  as  possible  and  the  cyst  it,self  stitched  to  the  margins  of  the  wound,  the  sup- 
purating cavity  being  well  washed  out  once  or  twice  daily  and  a  drainage  tube  left  in.  I 
have  recorded  an  excellent  example  of  this  practice  in  Gny'ii  Ilu^p.  Rep.  for  1868,  where 
a  woman  a?t.  34  was  successfully  ti'eated  by  these  means,  and  more  recently,  in  1874.  I 
removed  a  suppurating  ovarian  cy.st  associated  with  acute  peritonitis  with  a  successful 
result. 

The  strangulation  of  ovarian  tumors  by  rotation  is  not  rare.    Rokitan- 

sky  in  18G5  published  a  paper  upon  it.  It  means  that  under  certain  circumstances  the 
movable  ovarian  tumor  may  rotate  more  or  less  upon  its  axis,  and  so  twi.st  the  pedicle. 
If  the  twist  happens  to  be  slight,  no  important  interference  with  the  circulation  of  the 
vessels  through  it  may  be  brought  about ;  but  if  it  should  be  enough  to  prevent  the 
rettii'n  of  the  venous  blood  from  the  ovary,  congestion  of  the  part  strangulated,  followed 
by  exudations  of  .serum,  and  possibl}'  of  blood,  will  follow,  which  give  rise  to  symptoms 
not  unlike  those  of  strangulated  bowel.     Indeed,  cases  of  this  kind  have  been  regarded 

as  such.     In  Ann  R ,  ^et.  28,  under  my  care  in  February.  1884,  the  difficulties  of 

diagnosis  were  great,  the  onset  of  the  symptoms  having  been  sudden,  the  local  pain  severe, 
and  vomiting  persistent.  The  symptoms  had  appeared  after  a  railway  journey.  I  ope- 
rated at  once,  and  removed  a  large  polycystic  tumor  which  was  black  from  congestion  and 
with  a  Fallopian  tube  rigid  with  blood  ;  also  some  blood  from  the  peritoneal  cavity.  The 
pedicle  was  bloodless  where  twisted.  Had  relief  not  been  given,  the  whole  tumor  would 
have  become  gangrenous.     As  it  was,  the  patient  made  a  rapid  recovery. 

Wells  reports  two  cases  of  sudden  death  from  hemorrhage  into  the  peritoneal  cavity 
from  this  cause. 

Hysterectomy. 

Operations  upon  the  uterus  have  been  gradually  growing  in  favor,  and  the  fact  is 
probably  due  to  the  experience  which  ovariotomists  have  accidentally  acquired  in  the 
removal  of  uterine  tumors  which  have  been  mistaken  for  ovarian.  They  are  now  fre- 
quently undertaken  for  cystic  disease  of  the  uterus  and  fibroid  tumor,  whether  growing 
as  pedunculated,  subperitoneal,  or  intramural  growths,  and  much  success  has  attended 
the  practice. 

The  operation  has  likewise  been  undertaken  for  cancer,  but  experience  has  not  given 
much  support  to  the  measure. 

For  fibro-cystic  tumors  the  operation  is  a  good  one,  for  these  growths  steadily  increase, 
and  do  not,  as  the  fibroids,  cease  to  grow  when  menstruation  has  pas.sed  away. 

Fibro-cystic  uterine  tumors  present  all  the  external  features  of  the  more  solid  ovarian 
and  cannot  be  diagnosed,  more  particularly  when  a  pelvic  examination  reveals  but  little. 
When  the  uterus  can  be  made  out  to  form  part  of  the  tumor  and  to  move  with  it,  when 
the  uterine  sound  can  be  passed  freely  into  the  cavity  of  the  uterus  and  be  made  to 
extend  far  beyond  its  normal  distance,  when  at  each  monthly  period  the  flow  is  profuse, 
when  the  tumor  is  fixed  well  in  the  pelvis  and  the  abdominal  veins,  etc..  are  turgid  from 
its  mechanical  pelvic  pressure, — something  more  than  a  suspicion  of  its  fibro-cystic  nature 


iiYsTi'.in'.croMY. 


7f».'J 


may  be   foniKMl  ;    Imt   when  nm i    tlnsc  ^viiiiiliprii>.  arr  |irrsiiit,  the  ilia^'tuisis  cariiKit    he 

inadi"  with  cfiMaiiit v. 

Tilt'  t)|»<'ratinii  111'  cxtirii.-iliiiii  of  tin-  nlrnis  h:i>  hccn  ]mi  riprmcd  with  HUcceHS  hy  Chiy 
of  MaiirhcsttT,  Sturcr  of  |{(».stnii,  KikIici  li-  ol"  Stra.shiir;.',  SchnnMh-r  (jf  Berlin,  Keith  of" 
Ecliiihur^^h,  Wells,  'riionitoii,  Tait,  Davies-Colley.  ami   iiiy.self.      My  own  ca.se  waH   in   the 

person  of  Miss  M ,  :ut.  lid.      Tlu-  tumor  ha<l   ht-eri   ".'rowiii;:   for  three  years,  aii<l   for 

this  she  had  heeii  mider  the  eare  of  l>r.  Oldham,  who  helieved  the  ease  to  he  om-  of 
ovarian  disease.  He  .sent  her  to  me  for  operation.  On  .Mav  !!•,  I'^Tl.  I  operated,  and, 
finding  the  uterus  and  hoth  ovaries  diseased,  I  removed  the  whole,  ti.xinjr  its  hase  with  a 
hirj;e  elanip.  An  uninterrupted  reeovery  tnok  |ilacc.  l-'uli  particulars  will  he  Inund  in 
the    Trxna.  nf  Obstif.  Sar.  (  1S7I5). 

I  have  operated  on  three  other  cases,  hut  not  sueeessfullv.  one  patient  dyin<r  from 
hemorrhage  eau.sed  hy  the  rupture  ol'  a  pelvic  vein  and  the  others  from  the  shock  and 
peritonitis.  In  two  I  removed  the  uterus  and  its  tumors  hy  means  of  tlie  chain  ecra.seur 
made  by  Meyer  of  (ireat  Portland  street.  The  chain  should  be  passed  well  round  the 
base  of  the  <;rowtli  and  >crewcd  up  .-Idwly.  I  wnuld,  however,  ti(»w  use  Lawson  Tait'.s 
clatnp  (Fijr.  454). 

Kk;.  4r,4. 


"TT^    I^mT^JaSJSvjSSSS^^^^ 


Tail's  (lanip. 


Operations  for  uterine  fibroids  liave  been  more  frequent  than  for  cy.stic  uterine  disea.se, 
and  likewise  more  successful.  They  should  not,  however,  be  undertaken  unless  the 
tumors  form  decided  obstacles  to  the  patient'.s  progress  through  life,  or  give  rise  to  trouble- 
some hemorrhage.  Many  of  these  tumors  cease  to  grow  or  to  be  a  source  of  trouble  after 
the  menopause,  and  many  never  interfere  even  with  a  woman's  comfort. 

In  1873  I  removed  a  sessile  fibrous  tumor  the  size  of  a  large  cocoanut  from  the  right 
cornu  of  the  uterus  at  the  same  time  that  I  removed  a  large  ovarian  tumor  from  the  left 
ovary.     The  lady.  set.  51,  was  a  patient  of  Mr.  Collambell  of  Lambeth,  and  recovered. 

Mr.  Thornton,  who  has  had  good  experience  of  this  operation,  states  "  that  large 
pedunculated  subperitoneal  fibroids,  when  diagnosed,  ishould  be  removed,  even  though 
they  may  oidy  cause  inconvenience  at  the  time.'  He  adds,  however,  that  "  operations 
for  intramural  fibro-myomata  are  specially  dangerous,  since  they  naturally  involve  the 
opening  of  the  uterine  cavity."  The  operations  are  far  more  formidable  than  ovarioto- 
mies. "  If  you  have  to  think  twice,"  writes  Keith,  "  before  advising  a  woman  to  have 
ovariotomy  done,  you  must  think  fifty  times  ere  you  recommend  her  to  have  a  uterine 
tumor  removed."'  Neither  Wells  nor  Thornton  advocates  their  removal  indiscriminately, 
but  rather  the  adoption  of  Batteys  operation  or  the  removal  of  the  uterine  appendages 
to  check  the  growth  of  the  tumor  when  it  gives  rise  to  troublesome  hemorrhage. 

Thornton  has  performed  Batteys  operation  fifteen  times,  and  with  success,  ten  of  the 
patients  having  lost  their  tumors ;  in  two  the  tumors  are  lessening,  and  the  remaining 
three  are  recent  cases. 

Lawson  Tait  has  ably  advocated  this  same  measure,  and  has  had  much  success.  He 
writes  that  the  operation  for  the  removal  of  the  uterine  appendages  for  uterine  hemor- 
rhage, when  associated  with  uterine  tumors,  has  been  accepted. 

Operation. — In  a  general  sense  the  i«ame  principles  of  practice  are  apjilical)le  to 
these  cases  as  to  those  of  ovarian  disea.se.  The  one  difficulty  is  the  treatment  of  the 
pedicle  where  such  exists,  or  of  the  divided  uterus. 


794  '  OX  OVABIAX  DISEASE  AXB   OVARIOTOMY. 

When  a  fibroid  tumor  is  pedunculated,  there  is  no  difficulty,  as  .the  pedicle  may  be 
tied  in  halves  and  dropped  back,  as  in  an  ovarian  tumor.  When  it  is  large  and,  thick, 
possibly  Thorntons  method  is  very  applicable,  as  described  b}'  him  (Brit.  Mtd.  Journ., 
October  13,  I880)  : 

••  If  the  pedicle  be  transfixed,  hemoiThage  from  the  puncture  is  liable  to  occur  and 
very  difficult  to  control.  I  therefore  first  secure  the  pedicle  by  a  ligature  tied  firmly 
round  the  whole  of  it.  then,  threading  an  end  of  this  ligature  through  the  needle  again, 
transfix  the  pedicle  on  the  distal  side  of  the  first  tie  and  proceed  to  ligature  in  halves  or 
smaller  pieces  if  necessary.     This  method  renders  slipping  of  the  ligature  impossible.' 

Under  the  above  circumstances  the  pedicle  may  be  dropped  back  and  the  abdominal 
wound  closed. 

This  practice  must  not.  however,  he  adopted  when  the  uterine  cavity  is  exposed. 
Under  such  circumstances  the  pedicle  should  be  kept  outside  the  abdominal  walls.  Sir 
Spencer  Wells  uses  for  this  purpose  a  stout  pin  about  the  size  of  a  penholder,  around 
which  he  twists  a  figure-of-8  ligature,  the  two  acting  together  as  a  clamp.  Koeberle 
employes  his  serre-noeud.  and  it  is  useful ;  but  Lawson  Tait's  clamp  is  probably  better, 
as  it  can  secure  a  pedicle  of  any  size  and  hold  it  securely.  Indeed,  when  a  clamp  is 
wanted  for  any  operation,  no  better  can  be  used  (Fig.  454).  Should  there  be  any  fear 
of  the  clamp  slipping,  one  or  two  pins  may  be  passed  through  the  distal  side  of  the 
pedicle  to  make  it  secure. 

Hegar  of  Freiburg  (Berlin  l-Iiu.  Woch..  No.  12,  1882)  recommends  the  u.se  of  the 
elastic  ligature  in  the  removal  of  abdominal  tumors  and  organs.  He  has  removed  uter- 
ine fibroids  by  this  method  without  hemorrhage.  From  man}-  experiments  he  thinks  it 
is  evident  that  uterine  pedicles  can  be  treated  without  danger  by  the  ela.stic  ligature. 

Carl  Schroeder  of  Berlin,  when  removing  his  intramural  fibroids,  uses  an  india-rubber 
ligature  as  a  temporary  clamp,  enucleates  the  growth,  and  stitches  together  the  capsule 
of  the  growth  with  different  layers  of  sutures,  one  suturing  the  mucous  membrane  of  the 
uterine  cavity  and  the  other  the  peritoneal  layer,  subsequently  draining  the  cavity 
through  the  vagina. 

Out  of  66  patients  operated  on  by  him.  20  died,  or  30  per  cent.  Of  his  last  40, 
he.  however,  lost  but  9,  or  22.5  per  cent. 

L.  Tait  has  had  28  cases,  with  6  deaths,  or  21  per  cent.  Spencer  Wells  has  had  39 
cases,  with  21  deaths,  or  53  per  cent.     Keith  has  had  17  cases,  with  1  death. 

This  operation  of  hy.sterectomy  is  the  gravest  the  surgeon  can  undertake  ;  when  com- 
plicated, it  tries  him  to  the  utmost.  Let  it  not  be  undertaken  rashly  or  without  the 
fullest  consideration. 


THE  SURGERY  OF  THE  MUSCULAR  AND 
OSSEOUS  SYSTEMS. 


CHAPTEK    XXXIII. 

AFFECTIONS   OF   TIIK    MUSCLES   AND  TENDONS. 

Contusions. 

Contusions  of  muscleis,  as  of  other  parts,  may  occur,  and  when  severe  may  be  fol- 
lowad  not  only  by  want  of  power,  but  by  absolute  wasting.  Thus,  in  ISti!^  I  saw  a  man 
.•vt.  44  who  five  months  before  received  a  severe  contusion  of  the  left  deltoid  mu^jcle  from 
a  fall  upon  the  shoulder,  and  as  a  consequence  the  muscle  liad  completely  atrophied, 
although  there  was  no  loss  of  sensation  over  the  muscle  and  in  all  other  respects  the  limb 
was  normal. 

When  wasting  takes  place,  the  muscle  should  be  stimulated  by  galvanism  before 
degeneration  has  proceeded  too  far.  When  due  to  the  want  of  nerve  force,  there  is  little 
hope  (if  auv  good  rt'sult  being  ulitaiiicrl  iin<ler  any  treatment. 

Subcutaneous  rupture  of  rauSCle  to  a  slight  degree  is  far  from  being  uncom- 
mon, particularly  of  the  deltoid:  but  its  complete  rupture  is  very  rare.  In  most  ca.ses 
of  strains  some  rupture  of  a  muscle  takes  place,  which  often  shows  itself  by  the  effusion 
of  blood  into  the  part. 

At  times  a  muscle  is  torn  across  by  overaction,  as  in  tetanus,  the  rectus  abdominis 
being  that  mo.st  frequently  affected  ;  but  the  psoas  has  been  said  by  Mr.  Earle  to  be  .so 
injured.  Sedilhjt  reports  that  out  of  28  cases  of  ruptured  muscle,  13  occurred  at  its  point  of 
juncture  with  the  tendon.  He  says,  also,  that  rupture  occurs  only  in  some  involuntary 
action  of  the  muscle  or  when  it  is  taken  unawares.  In  1859  I  attended  a  man  aet.  21  who 
ruptured  the  left  rectus  abdominis  above  the  umbilicus  when  jumping  with  some  bricks  in  his 
hand.  He  was  collapsed  after  the  accident ;  and  when  I  saw  him,  the  next  day,  the  two  ends 
of  the  muscles  were  so  far  asunder  as  to  allow  the  fingers  to  })e  placed  between  them.  In 
1808  I  also  attended    a  man   xt.   05 

who,    when    lifting    a    cask    with    his  Fig.  45.^. 

body  bent,  felt  an  acute  pain  in  the 
posterior  ])art  of  one  thigh,  "  as  if  he 
had  been  .struck  with  a  potato ;"  he 
fell  forward  and  was  unable  to  walk. 
When  I  saw  him.  two  days  after  the 
accident,  the  semi-membranosus  mus- 
cle had  clearly  been  divided  at  its 
origin  from  the  tuber  ischii ;  the  body 
of  the  muscle  could  be  felt  as  a  loose, 
fleshy  mass,  and  below  the  tuberosity 
of  the  ischium  a  marked  deficiency  was  present.  I  have  also  the  notes  of  a  case  of  com- 
plete laceration  of  the  extensor  triceps  muscle  of  the  thigh  above  the  patella  in  a  railway 
inspector,  who  said  that  it  gave  way  with  a  report  on  his  attempting  to  start  off  suddenly 
for  a  run.  In  this  case  there  was  great  effusion  of  blood  into  the  part  within  a  few 
hours,  which  had  sub.sided  after  the  application  of  ice.  tlie  separation  of  the  muscle  from 
the  patella  being  very  distinct.  In  the  drawing  (Fig.  455\  rupture  of  the  rectus  femoris 
is  illustrated,  and  was  taken  from  a  male  patient  a^t.  42. 

Minor  degrees  of  laceration  of  muscles  are  of  common  occurrence,  often  followed  for 

795 


Rupture  of  Rectus  Femoris  just  above  Patella  in  a  Man  set.  42. 


796  AFFECTIONS  OF  THE  MUSCLES  AND   TENDONS. 

many  months  by  pain,  stiffness,  and  want  of  power  in  the  part,  the  pain  disappearing  for 
a  time  to  reappear  on  any  overaction  of  the  weakened  muscle.  These  pains  are  often 
called  ''  rheumatic." 

In  his  Fothergillian  prize  essay  Mr.  Poland  records  two  cases  of  complete  rupture  of 
the  rectus  abdominis  muscle  in  the  hypogastric  region,  so  that  the  finger  could  be  laid  in 
the  dents  between  the  retracted  ends.  Both  occurred  in  the  wards  of  Gruy's  Hospital  and 
in  men  of  advanced  years  suffering  under  organic  disease  ;  the  one  had  an  advanced  stage 
of  bladder  and  kidney  mischief  the  sequels  of  old  stricture,  the  other  was  suffering  from 
a  relapse  after  continued  fever.  In  both  the  accident  had  been  caused  by  a  fall  across 
the  iron  rods  of  the  bedstead  in  a  vain  attempt  to  rise  and  walk.  Both  died  a  few  days 
after  the  accident,  when  complete  rupture  of  the  rectus  was  found  in  the  middle  of  the 
hypogastric  region,  and  coagulated  blood  existed  between  the  divided  ends,  as  if  only  just 
poured  out.     No  signs  of  repair  were  present. 

Treatment. — In  all  cases  of  completely  ruptured  muscle  the  parts  must  be  relaxed, 
in  order  that  the  divided  ends  may  be  made  to  approximate  as  much  as  possible  and 
be  fixed  at  rest,  so  that  repair  may  not  be  interrupted.  AVhen  much  effusion  of  blood  or 
serum  follows,  ice  may  be  applied  in  a  bag;  and  when  absorption  has  somewhat  advanced, 
a  stimulating  liniment  ha.stens  recovery  and  gives  comfort.  When  these  are  not  attended 
to.  repair  cannot  go  on ;  indeed,  as  a  consequence  of  neglect,  suppuration  is  by  no  means 
a  rare  result,  as  is  seen  in  psoas  abscess.  When  the  laceration  has  been  complete,  perma- 
nent weakness  will  remain  ;  and  when  the  abdominal  muscles  are  at  fault,  some  hernial 
protrusion  of  the  abdominal  contents  will  take  place.  In  a  man  who  fell  from  a  ship's 
ladder  upon  a  blunt-pointed  iron  bar.  and  had  severe  rupture  of  the  abdominal  muscles 
attached  to  the  anterior  half  of  the  crest  of  the  ilium,  a  large  hernial  protrusion  existed 
and  I  could  press  my  fi.st  into  the  opening  through  the  muscles.  In  such  cases  some 
artificial  support  is  permanently  needed. 

Compound  Laceration  of  Muscle. 

When  muscles  are  lacerated  in  connection  with  wounds  of  the  soft  parts  covering 
them,  the  injury  is  grave,  and  the  primary  danger  of  the  case,  as  well  as  the  prognosis  as 
to  the  future  use  of  the  part,  turns  upon  the  amount  of  laceration.  In  compound  frac- 
tures, etc..  this  fact  is  well  known. 

But  at  times  muscles  are  torn  out  through  skin  wounds  or  are  ruptured  at  the  time 
of  the  accident,  and  may  even  hang  out  of  the  wound.  When  this  is  the  case,  the  mus- 
cle, unless  much  crushed  or  injured,  must  not  be  cut  away,  but  replaced  in  position  as 
well  as  possible ;  and  to  further  this  end  the  wound  in  the  soft  parts  may  be  enlarged. 
One  of  the  worst  cases  of  this  kind  I  have  ever  seen  I  attended  with  Dr.  Mason  of  the 
Barbican.  It  was  that  of  a  gentleman  fet.  22  who  when  sleep-walking  fell  a  height  of 
forty  feet  out  of  a  window  on  a  glass  skylight.  Among  other  injuries,  he  sustained  a 
lacerated  wound  of  his  right  thigh  and  complete  division  of  the  body  of  the  inner  ham- 
string muscles.  When  I  saw  him  a  large  mass  of  well-developed  muscle  protruded  from 
the  skin  wound.  I  enlarged  the  opening  in  the  integument  and  carefully  replaced  the 
muscle,  keeping  the  limb  on  a  splint.  In  five  weeks  he  was  convalescent.  A  year  later 
he  had  complete  movement  of  his  limb.  Entire  tendons  are  sometimes  torn  out  of  a 
limb,  and  in  Guy's  Hospital  Museum  there  is  a  preparation  (1367)  which  includes  the 
last  joint  of  the  middle  finger  with  its  tendon  of  the  flexor  profundus  attached.  It  was 
torn  by  a  threshing-machine,  the  accident  being  followed  by  tetanus ;  yet  the  patient 
recovered.     In  another  preparation  (1119^),  figured  below  (Fig.  456),  there  is  a  portion 

Fig.  456. 

Sllorl 


ThumVi.  with  Tendons,  etc  .  Torn  Out  bv  Machinerv. 


of  thumb  with  the  long  flexor  and  extensor  and  short  exten.^or  tendons,  together  with 
the  nerves,  torn  out  by  machinery.  It  was  taken  from  a  man  aet.  17  who  made  a  good 
recovery. 


Ri'i'ir/U:'  OF  rhWDoys. 


797 


Dislocation  of  Muscles  and  Tendons. 

TluTc  is  j^odd  reason  tti  l)clievo  tliiit  iiiiisclcs.  like  tciitloris,  iiiav  he  dislocate*!,  altlnMij^h, 
from  the  way  the  t'oniier  are  proteett'*!  hy  laseia  ami  the  latter  hy  tihnms  sheaths  ami  bony 
•grooves,  siieh  aeeideiits  are  rare.  When  they  occur,  they  are  the  result  of  some  sudden  and 
une.xpeeted  strain,  rick,  or  twist.  In  the  upper  extremity  the  accid(Mit  may  occur  to  the 
biceps  tendon  and  thosi;  al)out  the  wrist.  1  hav(;  never  seen  a  dislocated  biceps  tendon, 
but  must  refer  to  an  able  article  on  the  subject  l)y  Mr.  J.  W.  White  of  Philadelphia, 
published  in  the  Aincr.  Jiturti.  <>/'  Mnl.  Sci.,  .January.  11S84.  In  the  lower  limli  it  may 
occur  to  the  peronei  tendons  and  tendon  <d'  the  posterior  tibialis,  a.s  well  as  to  the  eon- 
joined  tendon  <d'  the  extensors  of  the  leg  attached  to  tlie  patella,  and  to  that  of  the  sar- 
torius  muscle.      Other  tendons  may  also,  doubtless,  be  dislocated. 

Whenever  dislocation  takes  place,  it  can  be  recofrnizcd  by  the  starting  of  the  tendon 
from  its  anatomical  jtosition,  as  well  as  by  the  pain  suffered  on  putting  the  muscle  into 
action,  the  muscle  necessarily  acting  at  a  disadvantage.  The  temlon  in  most  ca.ses  may 
be  readily  reduced,  but  the  greatest  difficulty  will  be  ex[)erieneed  in  keeping  it  in  ])osi- 
tion  ;  indeed,  it  is  a  question  whether  the  sheath  of  a  tendon,  when  fairly  ruptured,  will 
ever  unite  or  repair  ;  yet  the  attempt  to  obtain  it  should  be  made.  In  a  case  of  disloca- 
tion of  the  peroneus  longus  tendon  the  only  treatment  that  gave  permanent  relief  was 
its  division,  and,  what  is  more,  the  foot  was  not  visibly  weakened  by  the  operation.  In 
18t)!>  I  had  under  my  care  a  woman  ;et.  2!l  with  a  well-marked  example  of  dislocation  of 
the  peroneus  longus  tendon.  Some  ten  days  before  I  saw  her,  when  walking,  she  felt  a 
sudden  pain  behind  the  external  malleolus  which  led  her  to  think  she  had  been  struck 
with  a  stone.  She  was  at  once  disabled  and  experienced  severe  pain  in  the  part,  and  on 
rubbing  her  ankle  at  the  time  she  felt  a  cord  in  front  of  the  bone,  which  slipped  in  on 
moving  the  foot.  Since  that  time  any  movement  of  the  ankle  caused  the  same  cord  to 
appear.  When  I  saw  her,  by  giving  the  foot  the  slightest  twist  the  tendon  of  the  pero- 
neus longus  muscle  could  be  readily  displaced  from  its  groove  behind  the  external  mal- 
leolus and  made  to  appear  upon  the  bone,  where  it  could  be  rolled  under  the  finger.  Its 
reduction  was  eff"ected  by  abducting  the  foot,  but  it  was  kept  in  its  position  with  great 
difficulty.  For  this  purpose  the  best  means  were  a  good  pad  of  lint  fixed  over  and  behind 
the  ankle  by  means  of  strapping.  I  saw  her  a  month  after  the  accident,  when  she  could 
walk  witliout  pain  or  stiffness;  the  tendon  seemed  fixed  in  its  place,  but  the  bandage 
and  pad  were  reap]ilied  and  directions  given  to  retain  them  for  a  month.  I  have  like- 
wise seen  the  tendon  of  the  tibialis  posticus  displaced  from  behind  the  inner  malleolus. 

Dislocations  of  muscles  are  probably  more  rare  than  those  of  tendons,  and,  if  not,  are 
less  recognized.  They  may  be  suspected  to  have  taken  place  where,  after  a  rick  or  strain, 
pain  is  produced  when  the  muscle  is  put  into  action  and  the  pain  is  fixed  to  a  spot,  when 
this  pain  is  relieved  by  relaxing  the  affected  muscles  and  kneading  the  part  with  the  hand 
when  so  relaxed,  and  when,  moreover,  there  is  no  external  evidence  of  a  bruise  to  suggest 
rupture  of  muscle.  These  cases  should  be  treated  by  manipulation  after  relaxing  the 
muscles,  the  surgeon  with  a  strong  and  firm  pressure  manipulating  the  part  at  the  seat  of 
pain  ;  subsequently,  pressure  should  be  applied  and  the  muscle  kept  at  rest  for  a  sufficient 
time  to  allow  the  injured  part  to  heal. 


Fig.  457, 


Rupture  of  Tendons. 

This  accident  is  more  common  than  rupture  of  the  body  of  a  muscle,  and  a  tendon 
usually  gives  way  at  its  muscular  or  bony  origin.  It  occurs  chiefly  in  subjects  past  mid- 
dle life.  The  long  biceps  tendon  not  rarely  gives 
at  its  upper  end ;  and  when  it  does,  it  imparts  to 
the  biceps  muscle,  on  contraction,  a  peculiar  ap- 
pearance, its  inner  or  coracoid  half  contracting 
into  a  hard  knot  (Fig.  457),  while  its  outer  re- 
mains lax  and  but  slightly  altered.  This  swell- 
ing has  been  mistaken  for  tumor  of  the  muscle 
of  the  arm.  When  the  one  tendon  breaks,  the 
other  usually  follows  at  a  later  date,  thereby 
clearly  indicating  that  they  give  way  from  some 
disease.  In  a  case  I  treated  in  1858  the  two 
tendons  gave  way  at  the  interval  of  four  months, 
Ruptured  Long  Teudon  of  Biceps.    (Drawing  37^)    and  the   arm   became    black  and  blue  after   the 


798  AFFECTIONS  OF  THE  MUSCLES  AND   TENDONS. 

accident.  The  tendo  Achillis  rarely  snaps.  The  plantaris  does  so  occasionally,  and  causes 
a  peculiar  dragging  of  the  foot  and  eversion.  In  the  case  of  a  man  aet.  27  which  I  saw  a 
few  hours  aftfir  the  accident  this  symptom  was  so  marked  and  peculiar  as  to  make  it 
quite  pathognomonic.  The  rupture  was  caused  by  taking  an  upward  step  of  two  and  a 
half  feet  into  a  vessel  with  a  load  on  his  back.  The  tendon  gave  way  with  a  snap  when 
in  the  act  of  raising  the  posterior  part  of  the  heel  from  the  ground. 

I  have  likewise  the  notes  of  a  case  of  rupture  of  the  tendon  of  the  hiceps  femoris 
which  took  place  in  a  boy  ?et.  8  who  when  hanging  on  behind  a  four-wheeled  cab  had 
one  of  his  legs  entangled  in  the  wheel.  When  admitted  into  Guy's,  directly  after  the 
accident,  the  tendon  of  the  biceps  femoris  was  made  out  to  have  been  ruptured  at  its 
insertion  into  the  fibula  ;  there  was  a  marked  depression  at  this  point,  with  ecchymosis. 
The  limb  was  flexed  and  fixed  on  an  outside  splint,  and  a  good  recovery  ensued,  although 
there  was  some  weakness  of  the  muscles  supplied  by  the  external  popliteal  nerve,  which 
had  apparently  been  injured  at  the  same  time. 

Looking  upon  the  ligamentum  patellae  as  a  tendon,  the  following  example  of  its  rup- 
ture may  be  recorded.  In  1867  I  was  called  upon  to  treat  a  man  ast.  31  for  an  injury  he 
had  sustained  to  his  right  knee  ten  days  previously  while  attempting  to  save  himself  from 
falling  backward.  The  knee  swelled  after  the  accident  and  became  acutely  painful ;  and 
when  I  saw  him  the  patella  was  drawn  up  for  at  least  an  inch,  the  ligament  having  been 
divided.  I  treated  the  case  as  for  fractured  patella,  with  a  posterior  splint,  and  employed 
pressure  to  bring  the  patella  downward  :  but  I  was  unaVjle  to  alter  its  position  to  any 
extent.     The  man  recovered,  however,  with  a  useful  limb. 

Wounds  of  Tendons. 

When  tendons  have  been  divided  in  incised  wounds,  they  separate,  and  their  separated 
ends  adhere  to  their  sheaths,  with  the  necessary  consequence  of  impaired  movements  of 
the  parts  to  which  the  tendon  is  attached.  To  avoid  this,  as  a  primary  treatment  of 
divided  tendons  the  tendons  should  always  be  sutured  with  silk  or  catgut,  the  muscle 
with  which  it  is  connected  relaxed,  and  the  wound  dressed  for  quick  union,  the  part  being 
kept  in  position  by  means  of  a  splint. 

In  June,  1883,  a  woman  aet.  34  had  the  extensor  tendons  of  her  ring  and  little  fingers 
divided  above  the  wrist.  My  dres.ser  enlarged  the  wound  lengthways,  found  the  separated 
ends,  and  .stitched  them  together  with  carbolized  catgut.  He  then  washed  the  wound 
with  iodine  water  and  dressed  it  with  terebene  oil.  Good  repair  followed,  with  movement 
of  the  fingers. 

In  June,  1883,  a  man  ?et.  31  came  under  my  care  with  a  divided  tendo  Achillis  from 
a  broken  water-jug.  The  ends  of  the  divided  tendon  were  separated  for  about  two  inches. 
My  dres.ser,  Mr.  R.  Knaggs,  by  my  direction  exposed  the  tendon  fully  by  a  vertical  incis- 
ion, wa.shed  the  wound  with  iodine  water,  and  sutured  the  tendon  with  one  central  suture 
of  carbolized  catgut  and  two  lateral  sutures  of  kangaroo  tendon.  He  then  extended  the 
foot  and  fixed  it  on  a  splint.  The  wound  was  dressed  with  terebene  oil.  Quick  union 
followed,  and  excellent  repair,  without  suppuration.  In  two  months  the  man  had  a  sound 
leg  and  strong  tendon,  with  perfect  movement  of  the  foot. 

This  practice  of  stitching  important  tendons  ought  always  to  be  adopted. 

There  is  good  reason  to  believe  that  a  divided  tendon  may  be  successfully  cut  down 
upon  several  weeks  after  its  division  and  its  ends  sutured  with  a  good  result. 

In  wounds  where  muscles  and  tendons  unite  by  granulations  .some  stiffness  and  want 
of  power  in  the  part  will  remain  for  a  long  time,  or  even  altogether.  In  healthy  subjects 
it  is  remarkable  how  tendons  at  one  time  fixed  subsequently  free  themselves  from  their 
surrounding  attachments  and  become  free  again.  This  hope  may  always  be  held  out  to  a 
patient  who  takes  a  gloomy  view  of  his  own  prospects. 

Inflammation  of  Muscle 

is  a  recognized  affection,  and  occurs  as  a  consequence  of  some  strain  or  partial  rupture 
of  its  fibres,  as  well  as  independently  of  any  such  cause.  It  is  the  more  common  as  a 
result  of  injury,  and  is  seen  not  seldom  in  the  rectus  abdominis  as  well  as  in  the  psoas 
muscle,  in  which,  as  a  cause  of  psoas  abscess,  I  believe  it  to  be  not  rare.  As  a  result  of 
septicfemia  it  is  frequently  met  with,  and  is  found  in  every  muscle,  even  the  heart.  It 
appears  as  a  more  or  less  acute  affection  of  the  muscle,  and  is  accompanied  by  swelling, 
local  pain,  and  constitutional  disturbance;  suppuration  occurs  in  due  time.     The  symp- 


IMLAMMATloy   OF  MfSCLK 


09 


toms  nircly  come  on  /lircclly  af'ttT  (lit-  injury.  JmiI  pnihaMy  afdr  t.lic  lafisi-  of  sLVt-ral 
weeks,  a.s  a  rorisecjiiciif*'  nl'  sdiiH'  want  of  repair  in  tlic  injured  part,  anil  i'roin  tin;  non- 
ohscrvance  of  the  nceessarv  rest  wliieli  an  injured  muscle  so  much  reijuires  in  the  process 
of  healinir.  When  an  altseess  forms  in  a  njusele,  the  sooner  it  is  opened  the  better,  recov- 
erv  readily  I'nllowinfr,  even  when  the  disease  is  in  sueh  a  museular  or^Mii  as  tin;  tonjrue. 

Intlammation  of  muscle  as  an  independent  afl'e<*tion  is  generally  chronic,  and  in  adults 
is  chieflv  of  syphilitic  origin.  In  inl:int>  it  is  met  with  most  commonly  as  an  affection 
of  the  sterno-mastoid  muscle,  the  hody  oi"  the  muscle  wholly  or  in  jiart  appearing  as  an 
indurated  mass.  It  is  generally  ol»served  soon  after  birth,  and  may  at  times  he  traced  to 
some  injury  sustained  at  that  time.  I  have  seen  it  in  the  offspring  of  syphilitic  parents, 
hut  more  fre»|uentlv  when  no  such  history  could  he  obtained.  In  fifteen  consecutive  ca.ses, 
a  syphilitic  history  was  obtained  oidy  in  one.  These  ea.se.s  rarely  if  ever  suppurate  in 
infants,  but  under  the  use  of  warm  fomentations  and  .some  simple  tonic,  such  as  cod- 
liver  oil,  proceed  to  a  natural  recovery.  I  have  never  seen  a  ease  fail  to  recover  by  these 
means. 

In  the  nirh/  period  of  the  di.sease  the  inflammatory  product  is  cellular;  in  the  /ati r, 
fibrous.  These  points  are  seen  in  Figs.  45S  and  4.")It.  which  have  been  kindly  made  for 
me  by  Pr.  (Joodhart.  Tlu-y  were  taken  from  a  patient  of  Dr.  F.  Taylor  jet.  5  weeks  who 
looked  healthy,  but  had  had  ''  snuffles," 
slight  fissuring  of  the  anus,  and  superficial  I'k;.  458. 

ulceration  of  the  .scrotum.  There  was  no 
history  or  other  evidence  of  syphilis  in  the 
parents.  The  child  died  from  atelectasis. 
The  tumor  in  the  l(/t  muscle  was  only  no- 
ticed in  the  fifth  week  after  birth,  and  the 
rii//tt  muscle  was  never  noticed  to  be  dis- 
eased. The  case  is  rej)orte(l  in  the  /*<if/i. 
Soc.   Trans.,  1875,  vol.  .xxvi. 

The  student  .sluuild  remember  that  this 
affection  appears  as  a  simjile  induration  of 
the  muscle,  and  is,  therefore,  unlike  any 
glandular  or  other  affection. 

Chronic  inflammation  of  the  sterno-mas- 
toid is  likewise  met  with  in  adults,  and,  I 
believe,  chiefly  as  a  consequence  of  syphil- 
itic disease.     It  attacks  the  muscle  in  the 

same  way  as    it    does    others,  such  as  those  Showing  the  Early  or  Cellu- 
n   .1        .  ii,  4.  1   •  /•      lar  Stage.  (I'roni  the  right 

of  the  tongue,  the  e.Ktensor  quadriceps  of  muscle ) 
the  thigh,  the  triceps  of  the  arm.  the  tem- 
poral, masseter,  or  other  Uiuseles,  the  muscle  or  muscles  becoming  infiltrated  more  or  less 
dift'u.sely  with  the  well-known  syphilitic  inflammatory  products.  These  tumors,  when  their 
nature  is  recognized  and  right  treatment  is  employed,  can  be  reabsorVjed  ;  but  if  neglected 
and  left  alone,  after  attaining  their  full  size,  which  is  rarely  great,  they  break  up  and  sup- 
purate, giving  rise  to  deep-seated  abscesses,  which  when  they  have  discharged  externally 
leave  deep,  irregular,  excavated  sores.  In  the  tongue  they  simulate  closely  cancerous 
sores,  many  of  the  cases  of  supposed  cured  cancer  of  the  tongue  being,  doubtless,  of  this 
origin.  In  other  parts  they  have  much  the  aspect  of  the  deep  cellular  membranous  ulcers 
which  have  been  already  described.  As  a  part  of  syphilis  they  always  appear  late  in  its 
course  and  remote  from  the  primary  inoculation.  When  they  appear  in  the  adult,  in  the 
sterno-mastoid  muscle,  they  more  frequently  attack  its  .sternal  end  than  its  body. 

After  the  disease  has  ceased  atrophy  of  the  affected  muscle  is  a  common  consequence. 
Contraction  occasionally  follows,  though  I  have  never  seen  it.  MM.  Rieord  and  Notta 
have,  however,  recorded  examples. 

Recognizing  the  syphilitic  nature  of  this  affection,  the  treatment  should  be  conducted 
on  the  usual  principles;  large  doses  of  the  iodide  of  potassium — say  fifteen  to  thirty 
grains — may  be  given  three  times  a  day  with  advantage,  not  in  such  full  doses  at  first, 
but  by  gradual  increase  from  one  to  five  grains.  Mercury  may  also  be  given,  the  mer- 
curial suppository  once  or  twice  a  day  being  the  best  form.  In  the  chapter  on  Syphilis 
this  practice  will  be  found  described  in  detail. 


The  Late  or  Fibrous  stage. 
(F'roiii  the  left  iiitiscle.i 


800  AFFECTIONS   OF   THE  MUSCLES  AND    TENDONS. 

Atrophy  of  Muscle. 

The  surgeon  can  see  this  under  a  great  variety  of  circumstances.  He  is  the  most 
familiar  with  it  as  a  consequence  of  want  of  use  in  disease  of  the  joints  or  any  other 
aft'ection  in  which  the  limb  is  kept  at  rest,  and  under  these  circumstances  the  muscles 
simply  wa.ste ;  they  undergo  no  other  change  in  structure  and  are  capable  of  complete 
restoration  on  reassuming  their  normal  action. 

In  a  large  number  of  cases  of  infantile  paralysis  the  same  thing  may  also  be  said,  for 
under  the  stimulus  of  galvanism  or  the  continuous  current,  persevered  in  for  many 
months,  the  thinnest  limbs  plump  up  and  the  feeblest  muscles  become  capable  of  perform- 
ing the  work  for  which  they  were  intended.  Indeed,  in  those  cases  where  deformity 
does  not  complicate  the  case  a  good  result  may  be  looked  for. 

After  fevers,  lead  poisoning,  rheumatism,  scrivener's  palsv.  and  alcoholism  the  mus- 
cles may  undergo  genuine  degeneration,  either  granular,  fatty,  or  waxy,  and  according  to 
Lockhart  Clarke  '•  there  is  another  form  of  this  malady,  which  is  known  by  the  name  of 
proc/ressive  muscular  atrophy  (Cruveilhier).  atrop)liie  muf.rnla'irK  gralsKeuse  progres!<ive 
(Duehenne),  and  icastinij  poh>j.  This  curious  disease  differs  in  several  respects  from  the 
other  atrophies.  It  is  always  chronic,  but  of  uncertain  duration,  is  frequently  hereditary, 
capricious  or  irregular  in  its  invasion,  prone  to  spread  from  one  part  to  another  or  become 
general  and  thus  go  on  to  a  fatal  termination.  The  affected  muscles  suffer  different 
degrees  of  wasting  and  assume  a  variety  of  aspects.  Even  in  the  same  muscle  bundles  in 
different  stages  of  atrophy  and  degeneration  may  be  found  at  the  side  of  others  that  have 
retained  their  normal  state.  When  the  wasting  is  extreme  in  all  the  bundles,  a  long 
muscle  may  be  reduced  to  a  mere  fibrous  and  cylindrical  cord  or  to  a  kind  of  tendon,  and 
a  flat  muscle  may  be  reduced  in  the  same  manner  to  a  kind  of  membrane.  In  some 
instances  the  atrophy  may  be  simple — that  is,  the  muscular  tissue  may  be  wasted  to  a 
considerable  degree  without  any  granular  or  fatty  degeneration  ;  but  generally  one  or  both 
of  these  alterations  of  structure  are  found  to  exist  to  a  greater  or  less  extent.  The  mus- 
cle also  changes  and  varies  in  color  according  to  the  nature  and  degree  of  the  atrophy. 
It  is  paler  than  natural ;  occasionally  it  is  quite  colorless,  like  the  flesh  of  fish,  or  it  may 
have  a  faint  yellow  or  ochreous  tint.  Its  consistence  for  the  most  part  is  increased  in 
consequence  of  the  increase  in  the  interfibrillar  connective  tissue.  When  examined  under 
the  microscope,  the  affected  muscles  may  be  seen  to  have  lost  to  a  variable  extent  and 
degree,  or  even  entirely,  the  appearance  of  transverse  and  longitudinal  .striation.  while  in 
a  corresponding  proportion  the  sarcous  or  muscular  element  is  transformed  into  granules, 
which  in  some  instances  are  too  fine  to  be  distinguished  as  separate  particles.  The  gran- 
ules are  soluble  in  acetic  acid.  In  this  odd  affection  the  granular,  fatt}-,  and  waxy  degen- 
erations are  found  side  by  side  "'  (Holmes  s  Si/sf.,  3d  ed.,  vol.  ii.  p.  163). 

Symptoms. — This  disease  is  said  to  appear  more  commonly  in  t]ie  hand  and  right 
upper  extremity,  progressing  upward  to  the  trunk,  and  then  ov^r  it  to  the  lower  extremi- 
ties. It  rarely  commences  in  the  lower  limbs.  It  begins  with  loss  of  power  in  the  part, 
this  loss  gradually  increasing,  but  rarely  with  any  loss  of  sensation.  Want  of  muscular 
co-ordination  soon  appears,  as  well  as  awkwardness  in  the  patient's  movements,  and 
cramps,  twitches,  and  fibrillary  tremors  take  place,  occasionally  with  pain  or  some  cuta- 
neous anaesthesia.  Cruveilhier  believed  that  atrophy  of  the  motor  nerves  was  the  start- 
ing-point of  this  disease,  but  this  theory  is  not  now  entertained.  Lockhart  Clarke  says, 
'•  In  1861  I  discovered  in  the  spinal  cord  removed  from  a  well-marked  case  of  this  disease 
numerous  lesions  of  the  gray  substance,  consisting  chieflv  of  areas  of  what  I  call  granular 
and  fluid  disintegration  ;  and  I  have  seen  the  same  in  other  cases  since."'  This  view  is 
taught  by  Trousseau.  Duehenne,  3Ieryon.  Roberts,  Cohn.  and  others. 

This  disease  is  generally  hereditary,  more  common  in  males  than  in  females,  and  is 
excited  by  excessive  muscular  exertion,  cold,  and  damp,  as  well  as  by  injuries  or  disease 
of  the  spine,  syphilitic  nr  otherwise. 

Treatment. — Removal  of  the  cause  is  the  primaVy  object  :  and  when  syphilis  is  sus- 
pected, special  treatment  should  be  employed.  Tonics  are  always  of  use.  and  arsenic  in 
Dr.  3Ieryon's  hands  has  met  with  good  success.  "  but  of  all  remedies  hitherto  employed 
galvanism  is  undoubtedly  the  most  useful  when  applied  to  the  affected  muscles." 
while  Clarke  states  that  setons  and  blisters  to  the  spine  may  be  employed,  in  the  early 
stage. 

Degeneration    of    muscles    "with    apparent    hjrpertrophy — called 

'■  Duchennes   disease."    after   its    first   describer.   in    !>!")>! — is    a   strange  affection   which 
attacks  children,  but  continues  to  affect  them  for  manv  vears  of  their  vouth.     I  have 


Tl'Mons   I.\   MI'SCLI-:.  HOI 

pniuped  it  amongst  tlie  afl'octiims  nl"  tlic  miisclt's,  Imt  the  ohsorvatioiis  of  I)r.  L.  Clarke 
( Mri/.-C/iir.  Tniiis..  vol.  Ivii.,  1^7 1)  clearly  jilaci'  it  aiiKiiigst  tho  neuroses.  It  In-gin-s 
with  wi-akni'ss  of  tlu'  lowi-r  liinhs,  which  is  lasting  and  passes  on  to  a  progres.sive  enlarge- 
ment of  the  gastrocneniii,  then  of  the  glutei  and  luinltar  muscles,  anil  occasionally  of  all 
the  mu.scles.  These  I'eel  tirni  and  elastic,  and  hard  on  contraction.  After  a  variable 
period — at  times  years — the  paralysis  gradually  increa.ses  and  becomes  more  general. 
"The  patient  is  no  longer  able  to  stand  upright,  the  upper  e.vtremities  become  affected, 
the  eidarged  muscles  rapidly  decrease  in  volume,  and  the  limbs  and  trunk  become  atro- 
phied ni  iiitissr.  lu  this  state  the  patient  may  exist  for  a  considerable  time,  but  he  ulti- 
mately dies  from  inti-nurreut  disease.  Many  of  the  children  afi'ected  with  this  singular 
dis(U(ler  have  dull  intellects  and  are  more  or  less  idiotic  "  (Clarke).  I'atlmlugically.  great 
hyjiertropliy  of  the  connective  tissue  of  the  muscle  is  to  be  found;  the  fibres  themselves 
show  finer  stri;c  and  are  transparent,  and  large  cnllectifjiis  of  fat  cells  also  exist.  Neither 
medically  nor  surgically  does  any  treatment  seem  to  be  of  benefit. 

Writer's  Cramp, 

or  scrivener's  palsy,  is  a  good  example  of  what  Duchenne  has  called  "  functional  impo- 
tence," and  it  is  doubtless  due  to  overuse  or  exhaustion  of  the  muscles  employed.  It 
begins  as  an  aching  of  the  hand  after  prolonged  writing,  with  diminished  facility  in  the 
act.  After  a  time  the  pen  is  held  in  odd  ways  and  with  unusual  tightness,  but  in  spite 
of  this  it  often  falls  from  the  hand.  The  whole  fore-arm  or  arm  soon  shares  in  the  trou- 
ble, and  the  difficulty  in  forming  letters  rapidly  increases ;  tremors  of  the  hand  at  times 
occur.  At  last  the  handwriting  becomes  illegible  or  the  patient  loses  all  power  even  of 
making  his  mark.  With  these  local  symptoms  there  is  often  severe  headache  or  back- 
ache, and  at  times  great  mental  distress. 

In  the  nuijority  (»f  cases  the  inability  to  write  is  the  sole  trouble,  but  in  many  there 
is  equal  difficulty  in  adapting  the  muscles  of  the  hand  to  the  pei'formance  of  any  delicate 
action. 

The  affection  is  to  be  treated  by  rest,  as  guaran-  rio.  46  . 

teed  by  a  splint,  and  later  on,  when  pain  has  passed, 
by  gentle  galvanic  stimulation. 

As  a  help  to  sufferers  the  instrument  figured  (Fig. 
460),  and  suggested  by  Xussbaum  of  Munich,  seems 
of  use  ;  the  eminence  of  its  introducer  is  a  guarantee 
of  its  value.  It  is  framed  upon  the  opinion  that,  what- 
ever the  site  of  the  malady,  there  is  always  spastic 
contraction  of  the  flexors  and  adductors,  with  a  weak 
condition  of  the  extensors  and  abductors.     With   the     ,.     ^        ,  ,    „r  .     , 

,  ,  •        1        />  T  1  >ussbaum  Instrument  for  Writer  s  Cramp. 

bracelet  put  on  as  seen  in  the  ngure,  these  last  mus- 
cles are  strongly  put  into  use,  since  the  in.strument  can  be  worked  only  by  abduction  of 
the  thuml)  and  the  extension  of  the  digital  muscles.     The  patient  may  write  with   the 
instrument   as  much  as  he  likes. 

Tumors  in  Muscle. 

These  are  of  rare  occurrence  and  always  of  a  serious  nature.  They  are  mostly  of  the 
fibrous  or  fibro-cartilaginous  kind.  In  1866  I  excised  one  of  two  years'  growth  from  the 
fleshy  portion  of  the  external  oblique  muscle  of  a  woman  a^t.  31  (Pafli.  Soc.  Trans.,  vol. 
xviii.).  The  tumor  se])arated  the  fibres  of  the  muscle  which  it  infiltrated,  and  micro- 
scopically it  had  all  the  elements  of  the  fibro-pla.stic  tumors.  It  returned  within  the 
year;  and  when  I  last  saw  the  patient,  in  1869.  there  was  a  .second  growth,  the  size  of  a 
cocoanut,  occupying  the  place  of  the  original  tumor.  In  1868,  with  Dr.  Burchell  of 
Kingsland,  I  removed  from  tho  abdominal  muscles  of  a  woman  net.  33  a  myxomatous 
tumor  eight  or  nine  inches  in  diameter,  of  two  years'  growth. 

Cancerous  tumors  may  originate  in,  but  more  frequently  infiltrate,  muscles  as 
secondary  growths  or  by  cxten.sion  from  other  parts.  Surgeons  see  them  in  the  pectoral 
muscles  in  acute  or  neglected  cases  of  cancer  of  the  breast ;  in  the  periosteal  cancer  of 
bone,  as  well  as  in  other  parts.  In  the  tongue  and  lip  they  may  be  regarded  as  new 
growths. 

Hydatids,  likewise,  are  found  in  muscles,  as  in  ever}-  other  tissue,  as  painless,  ten.se, 
globukr  swellings.  So  also  is  that  curious  nematode  worm  the  Trichina  spiralis,  which 
"51 


802  AFFECTIOyS  OF  THE  MUSCLES  AXD   TEXBOXS. 

in  man  seems  to  be  taken  into  the  body  through  eating  the  insufficiently  cooked  flesh  of 
animals  infested  with  it,  particularly  that  of  pigs. 

"  Trichinaj,  as  ordinarily  observed  in  the  human  muscle,  present  the  form  of  spirally- 
coiled  worms  in  the  interior  of  small,  globular,  or  lemon-shaped  cysts  ;  which  latter  appear 
as  minute  specks  scarcely  visible  to  the  naked  eye.  These  specks  sometimes  resemble 
little  particles  of  lime,  and  are  more  or  less  calcareous  externally  according  to  the  degree 
of  degeneration  which  their  walls  have  undergone  ;  these  cysts  are  not,  however,  essen- 
tial "  (Cobbold). 

When  these  worms  are  present  in  large  numbers  in  the  body,  they  give  rise  to  a  dis- 
ease known  as  "  trichiniasis,"  which  is  most  fatal.  Dr.  Boehler  and  Konigsdbffer  of 
Central  Saxony,  who  first  saw  this  disease  according  to  Leuchart.  who  described  it.  state 
that  '■  the  aifection  began  with  a  sense  of  prostration,  attended  with  extreme  painfulness 
of  the  limbs,  and  after  these  symptoms  had  lasted  several  days  an  enormous  swelling  of 
the  face  very  suddenly  supervened.  The  pain  occasioned  by  this  swelling,  and  the  fever, 
troubled  the  patients  night  and  day.  In  serious  cases  the  patients  could  not  voluntarily 
extend  their  limbs,  nor  at  any  time  could  they  do  so  without  pain  ;  they  laj'  mostly  with 
their  arms  and  legs  half  bent — heavilv'.  as  it  were,  and  almost  motionless,  like  logs. 
Afterward,  in  the  more  serious  cases,  during  the  second  and  third  week  an  extremely 
painful  and  general  swelling  of  the  body  took  place.  A  large  proportion  of  the  cases 
died.  Dr.  Thudichum  has  given  an  able  report  on  this  subject  in  the  3Ii-(Jic<il  Officers' 
Report  to  the  Privy  Councif  (1SG4). 

Vascular  tumors  of  muscle  have  been  made  the  subject  of  a  special  paper  by 
IVIr.  C.  de  Morgan  (Brit,  and  For.  Med.-Chir.  Rev.,  1864),  and  Mr.  Teevan  has  published 
an  able  paper  on  tumors  in  muscle  in  the  same  review  for  1874.  These,  however,  are 
very  rare.  The  vascular  tumors  of  erectile  tissue  attack  a  muscle  either  as  a  diffused  or 
encapsuled  growth  or  as  tumors  having  the  appearance  of  varicose  veins  around  the  mus- 
cle. They  are  chiefly,  though  not  always,  congenital,  and  are  generally  found  in  the 
lower  extremities.  They  have  no  definite  clinical  history  beyond  their  gradual  and  pain- 
less increase.  My  colleague.  3Ir.  Howse.  in  1872  exci-sed  such  a  non-encapsuled  growth 
from  the  biceps  muscle  of  the  thigh  of  a  woman  aet.  2.3,  which  was  made  up  of  erectile 
tissue  and  highly  vascular  and  had  been  growing  for  eight  years.  He  excised  all  the 
muscle  that  was  involved,  but  left  its  tendon.  A  good  recovery  ensued,  with  free  move- 
ment of  the  limb. 

Ossification  of  muscle  Tmyositis  ossificans)  is  a  condition  which  must  be  recog- 
nized. At  the  College  of  Surgeons  and  St.  George's  Hospital  preparations  exist  which 
illu.strate  how  the  muscles  of  the  back  may  become  plates  of  bone  and  the  pelvis,  ribs, 
and  scapuhie  the  seat  of  bony  outgrowths.  In  a  smaller  way  the  "  drill  bone  "  of  the 
Prussian  soldier — a  plate  of  bone  in  the  deltoid  muscle — and  in  this  country  the  "  rider's 
bone,"  in  the  origin  of  the  adductor  longus  muscle  of  the  thigh,  are  illustrations. 

Some  years  ago  one  of  my  colleagues  at  Guy's  excised  from  the  body  of  the  deltoid 
muscle  a  piece  of  bone  an  inch  long,  the  growth  of  some  years. 

The  Rider's  Bone. — What  has  been  described  as  "  the  rider's  bone  "  is  probably 
at  first  an  inflammatory  infiltration,  and  subsequently  an  ossification,  of  the  tendon  of 
the  pelvic  origin  of  the  adductor  longus  or  magnus  muscle.  I  had  such  a  case  under 
ob.servation  in  the  person  of  a  medical  friend  set.  44,  who  while  hunting  in  18G9  made  a 
violent  efi"ort  to  grip  his  horse  when  about  to  make  a  long  jump.  The  eff"ort  was  not 
attended  with  any  pain,  but  was  followed  by  much  ecchymosis,  extending  down  to  the 
knee,  and  loss  of  power  in  the  muscles  of  the  part.  When  these  symptoms  had  subsided, 
a  dense  induration  was  felt  in  the  pubic  origin  of  the  right  adductor  longus  muscle, 
which  was  painful  on  manipulation.  As  time  passed  this  induration  not  only  lasted,  but 
became  more  dense ;  and  when  I  first  saw  him,  about  three  months  after  the  accident,  it 
was  clearly  in  the  sheath  of  the  adductor  longus  and  moved  with  it.  It  grew  somewhat 
during  two  years ;  and  when  the  tendon  was  rigid  it  appeared  as  an  outgrowth  from  the 
pubis,  corresponding  to  the  origin  of  the  adductor  longus,  of  about  two  inches  in  length. 
When  the  muscle  relaxed,  it  was  clearly  only  in  the  tendon  and  had  no  bony  origin.  At 
the  present  time  this  gentleman  can  take  his  exercise  as  usual.  There  is  a  distinct  grat- 
ing to  be  heard  and  felt  on  moving  the  tumor,  which  has  not  grown  for  the  last  three 
years.  The  history  of  the  case  is  identical  with  that  given  by  Birkett  (Gut/'s  Hasp.  Rep., 
1868).    Billroth  has  also  described  this  afiection. 

Fig.  461  represents  a  section  of  such  a  bone,  kindly  given  to  me  by  my  friend  Mr. 
Gowlland,  with  a  microscopical  drawing  of  the  same,  made  by  my  colleague,  Mr.  C. 
J.  Svmonds. 


TV M oils   OF   ThWDo.X. 


.S(),3 


'I'lic  liDiic  is  irn-iiiilarly  cciiiical  in  'li:i|ii'  and  is  tlircu  iiiclies  anil  a  lialC  in  lohL'th.    The 
base  is  sdiiu'wiiat  Hatti'iicil  and  uu'asiiifs  tlircc  (|uartfrs  ni"  an  in(di  acrrjss. 

Tho   scctioii   shows  an  uutor   hiyor  of"  ciinipact  Ixjnc,  whicli,  traced  towanl  the  bone, 

Fi(i.  Kil. 


a.  Hyaline  car- 
tilage." 


6.  I'rolilVratiii^; 
carlila^;!'  with  a 
matrix  staining 
with  I'lisiu. 

r.  Hoinains  of 
old  matrix  of 
cartilage,  with 
enclose<l  moilul- 
la  spaces. 

(/.  New  hone 
developed  from 
theeartilajjeand 
arranged  in  ir- 
regular trabec- 
uiie. 


n 


'mww 


a.  Lacunteand 
canaliculi. 


b.  Laiuellie. 


c.  Haversian 
artery. 


Rider's  Bone  seen  in  Section,  with  its  Microscopical  Appearance. 

blends  with  an  irregular  bony  and  cartilaginous  mass.     Many  trabeculfe  divide  the  rest 
of  the  surface  into  a  cancellous  tissue  of  rather  dense  character. 

Microscopical  sections  were  made  from  the  base,  to  show  the  mode  of  growth,  and  on 
reference  to  the  figure  it  will  be  seen  that  a  thick  layer  (only  half  is  represented  in  the 
drawing)  of  hyaline  cartilage  forms  the  surface.  This  contains  more  cells  than  that 
ordinarily  found  in  normal  tissue.  The  deeper  surface  shows  proliferation  of  cells  and 
an  alteration  of  the  matrix.  Irregular  cavities  result  as  in  normal  ossification,  though 
less  regularly,  and  upon  the  old  calcified  cartilage  the  new  bone  is  laid  down  as  in  fo'tal 
hone.  As  in  normal  ossification  also,  all  the  new  material  takes  up  the  eosin.  while  the 
cartiFage  stains  with  logwood — a  chemical  difference  apparently  the  result  of  growth. 

The  small  figure,  sketched  from  a  piece  that  was  ground  down  in  the  dry  state,  shows 
the  lacume  and  canaliculi  as  in  true  bone.    The  lamella?  were  irreg- 
ularly arranged  and  the  canaliculi  and  lacunae  large,  with  a  less  Fig.  462. 
perfect  communication  than  in  normal  bone  (Charters  J.  Symonds). 


Tumors  of  Tendon. 

Besides  ganglion,  other  tumors  are  found  connected  with  tendon, 
and  of  these  the  cartilaginous  and  fibrous  are  the  most  common.  I 
removed  from  the  long  extensor  tendon  of  the  middle  finger  of  a 
boy  <"et.  14  a  fine  example  of  the  former.  Some  are  said  to  ])egin 
as  ganglion,  and  subset^uently  to  con.solidate.  I  have  seen  one  com- 
posed of  bone  and  cartilage  of  two  years'  growth,  removed  from  the 
extensor  tendon  of  the  hand,  which  was  said  to  have  such  an  origin. 
Tumors  with  tendons  passing  through  them  are  not  rare,  and  on  twn 
occasions  I  have  had  to  amputate  the  hand  of  a  child  for  a  cancer- 
ous tumor  occupying  its  palm,  through  which  all  the  flexor  tendons 
passed  (Fig.  462).  In  1867  I  removed  from  a  boy  aet.  3i  a  con- 
genital tumor  the  size  of  a  walnut,  which  evidently  grew  from  the 
theca  of  the  tendon  of  the  long  extensor  muscle  of  the  thumb.    Hand^  (Dorsal 


r  i.i'  the 
aspect.) 


804  AFFECTIONS  OF  THE  MUSCLES  AND   TENDONS. 

The  tendon  passed  through  the  tumor  which  surrounded  it.      Dr.  IMoxon  examined  the 
growth,  which  was  clearly  composed  of  fat  or  condensed  fibro-cellular  tissue,  with  myself. 
The  majority  of  tumors  connected  with  tendons,  however,  are  of  the  nature  of  gang- 
lion more  or  less  indurated. 

Inflammation  of  Tendons. 

As  an  acute  aflfection  this  is  most  serious  and  gives  rise  to  severe  local  and  constitu- 
tional symptoms.  It  is  met  with  as  a  consequence  of  a  severe  strain  or  laceration  of 
tendon,  or  of  some  punctured  or  other  wound  involving  the  sheath.  It  may  begin  in  one 
toe  or  finger  and  spread  upward  to  the  palm,  and  so  on  to  other  tendons,  and  even  up  the 
fore-arm.  The  local  symptoms  are  pain,  with  the  external  evidences  of  inflammation, 
heat,  redness,  and  swelling,  the  swelling  being  deep-seated,  while  the  pain  soon  extends 
up  the  arm  beyond  the  seat  of  mischief.  The  constitutional  symptoms  are  those  of  more 
or  less  severe  pyrexia. 

If  surgical  interference  is  not  brought  to  bear  upon  the  ease  at  an  early  period,  sup- 
puration must  soon  appear,  with  symptoms  of  throbbing  and  aggravated  local  distress,  as 
well  as  the  constitutional  symptoms,  rigors,  excitement,  and  depression  ;  inflammation  of 
the  absorbents  and  their  glands  will  probably  complicate  the  case. 

Under  still  more  neglect  sloughing  of  the  aff"ected  tendons  and  diflFused  inflammation, 
with  suppuration  of  all  the  parts  involved  in  the  disease,  will  ensue.  A  finger,  hand,  or 
fore-arm  may  be  jeopardized  or  sacrificed  if  the  inflammation  be  very  active  or  the  treat- 
ment with  which  it  is  met  insufficient. 

Absorbent  inflammation  and  blood  poisoning  (septicaamia)  are  common  accompani- 
ments of  this  affection. 

Treatment. — This  affection  is  very  amenable  to  surgical  control,  and  a  free  incision 
into  the  swollen  part  is  the  best  means  of  arresting,  its  progress  by  relieving  tension. 
The  operation  not  only  relieves  pain,  which  is  caused  by  the  tension  of  the  fibrous  tissues 
from  the  effusion  beneath,  but  arrests  the  progress  of  the  afl'ection  by  preventing  the 
inflammatory  effusion  burrowing  iip  the  theca  of  the  tendon. 

For  these  objects  a  clean  cut  down  to  the  theca  should  be  made  as  soon  as  hardness 
of  the  parts,  with  external  evidence  of  inflammation,  appears.  If  pus  escape,  the  prac- 
tice must  be  good  ;  but  if  serum  only,  the  operation  will  tend  to  arrest  the  progress  of 
the  affection  at  its  onset,  prevent  the  formation  of  pus,  and  probably  check  the  disease. 
The  incision  should  be  vertical  over  the  middle  line  of  the  finger  and  the  centre  of  the 
tendon,  no  vessel  or  nerve  of  importance  being  there  in  the  way. 

When  suppuration  exists,  the  surgeon  must  follow  up  with  his  lancet  every  line  of 
inflammation  and  suppuration  ;  for  in  no  tissue  does  more  harm  ensue  from  retained 
fluids  than  in  the  fibrous. 

In  the  very  earliest  stage  of  the  inflammation  warm  fomentations,  and  possibly  leech- 
ing, may  be  beneficial.  Elevation  of  the  limb,  the  hand  being  higher  than  the  elbow  and 
the  elbow  than  the  shoulder,  undoubtedly  relieves  pain.  A  saline  purgative  is* often 
serviceable.  But  the  surgeon  must  not  lose  time  by  such  temporizing  means,  for  tension 
of  the  part  means  its  death  by  strangulation  if  not  mechanically  relieved,  and  medicines 
have  no  material  influence  upon  the  affection.  When  suppuration  appears,  tonics  and 
liberal  diet  are  required,  as  well  as  stimulants  carefully  adjusted  to  the  necessities  of  the 
case.  Sedatives  are  always  wanted  in  some  one  of  their  forms.  Morphia  acts  the  most 
rapidly  in  quarter-  or  half-grain  doses  given  subcutaneously.  Water  dressing  or  poultices 
should  be  applied.  In  very  severe  cases,  when  the  powers  of  life  are  failing,  amputation 
may  be  justifiable,  more  particularly  when  the  prospects  are  small  of  giving  a  useful  hand 
or  arm.  For  the  arrest  of  diffused  inflammation  in  the  hand  and  arm  the  occlusion  of  the 
main  artery  of  the  limb  has  been  suggested.  Moore  and  Maunder  have  both  adopted  it 
in  the  upper  extremity,  with  enough  success  to  justify  the  practice.  Bleeding  is  apt  to 
take  place  at  times  during  the  progress  of  the  sloughing  of  the  tendon  ;  and  if  recurrent, 
such  a  complication  is  likely  to  induce  the  surgeon  to  perform  some  operative  act  for  its 
control  upon  the  main  vessel  of  the  extremity.  Before  doing  this,  however,  he  should 
always  remove  any  sloughing  tendon,  as  I  have  known  hemorrhage,  even  of  a  severe 
kind,  to  be  kept  up  by  the  presence  of  a  sloughing  tendon  in  a  part,  and  to  have  been 
arrested  by  its  removal. 


AFFECTioss  or  liviis.i:  Mi'cosj:,  etc. 


«U;j 


Chronic  Inflammation  of  Tendons. 

The  tlu'civ  ol"  tlic  tfiidoiis  oi'  tlic  extt-nsors  of  the  tliiiinl).  of  tlic  teinlo  Afliilli.s,  and  tlio 
loM"  tt'iidoii  of  tilt'  l)ic('])S,  as  of  otlu-r  iiiiisidt'.s,  are  lialde  to  inflame;  and  this  action  is 
attended  hv  ]>ain  and  weakness  on  movinj;  the  niuscdes,  and  at  times  by  s\v<dlin;i.  More 
fre((uentlv,  however,  the  affection  will  show  itstdf  hy  :i  peculiar  cracklinjr  sensation, 
which  may  be  felt  on  ^'raspinj;  the  part  when  the  muscles  are  in  motion.  This  crepita- 
tion, when  it  has  i'ollowed  an  injury,  has  more  than  once  been  mistaken  for  that  of  frac- 
ture ;  yet  it  is  distinct,  and  when  once  felt  oujrht  to  be  reco<^nized.  The  affection  is 
readily' cured  by  rest  of  the  affected  muscles  through  the  application  of  splints,  and  by 
counter-irritation  by  means  of  one  or  more  blisters.  The  inflammation  rarely  goes  on  to 
suppuration  unless  neglected. 

AFFECTIONS  OF  BURS./E  MUCOSA,   SYNOVIAL  CYSTS, 

GANGLION,  ETC. 

Slnijtlr  hiirsn  are  i)rotective  synovial  sacs  found  in  the  subcutaneous  tissue  wherever 
pressure  or  friction  is  j)ersistcntly  present. 

Sj/Horidl  hiirsiv.  are  of  the  same  kind,  and  are  formed  in  the  same  way,  although  situ- 
ated between  bone  and  muscle,  tendon  and  bone,  or  between  muscles,  while  some  synovial 
burs;\)  are  really  xi/noviaf  heniifv,  or  poucliings  of  an  overdistended  membrane  of  a  joint 
into  the  connective  tissue  between  the  muscles.  A  gaiKjUon  is  a  bursal  swelling  directly 
connected  with  the  sheath  of  a  tendon  ;  it  may  either  involve  one  tendon  and  be  local,  or 
many  and  be  diffused. 

When  a  bursa  (simple  or  synovial)  has  an  established  anatomical  position,  it  is  called 
normal  ;  and  when  it  is  a  purely  pathological  production,  accidental.  Any  of  these  bursas 
are  liable  to  inflanie,  suppurate,  or  consolidate. 


Simple  Burs^. 

The  subcutaneous  bursa  over  the  patella  or  its  ligament  is  more  commonly  enlarged 
than  any  other,  and  when  it  is  so  is  known  as  the  "  housemaid's  knee.'  When  it  acutely 
inflames,  suppuration  rapidly  takes  place  ;  and  if  an  external  outlet  for  the  pus  is  not 
soon  established,  diffused  suppuration  around  the  knee  and  over  the  patella  follows. 
Indeed,  most  of  the  cases  of  diffused  suppuration  around  the  knee  have  their  origin  in 
"  bursitis." 

When  the  inflammation  is  less  acute  and  sliows  itself  by  serous  effusion  into  the 
bursa,  it  may  give  rise  to  local  pain  on  pressure  and  a  peculiar  crepitation,  this  crepitation 
often  exi.sting  before  any  perceptible  enlargement  of  the  bursa  has  taken  place. 

In  the  more  advanced  stage,  when  the  effusion  has  increased,  an  encysted  fluctuating 
swelling  will  have  formed,  which  may  be  tense  or  flaccid,  the  degree  of  tension  of  the 
bursa  turning  entirely  upon  the  rapidity  of  the  effusion.  In  more  chronic  examples  the 
bursa  will  appear  harder,  firmer,  and  less  distinctly  fluctuating,  while  in  very  neglected 
or  chronic  cases  it  may  have  so  consolidated  as  to  appear  as  a  solid  tumor,  although  the 
tumor  will  contain  on  section  some  cavity  in  its  centre,  the  mass  appearing  to  be  made  up 
of  concentric  laminte  of  organized  lymph  (Fig.  463).     In  exceptional  cases,  however,  the 


Fig.  463. 


Fig.  464. 


Semi-solid  lUirsa,  laid  Open.    (Guy's  Museum.) 


Bursa  sloughing  from  over  Patella. 


bursa  may  have  completely  consolidated.  These  bursa),  as  a  rule,  contain  .simple  serum, 
although  at  times  the  serum  is  blood-stained,  while  in  other  cases  rice-like  bodies  (organ- 
ized fibrin)   Or  pedunculated  fringe-like  outgrowths  like  loose  cartilages  exist.     When 


806  AFFECTIONS  OF  THE  MUSCLES  AND   TENDONS. 

injured,  these  burs^e  may  become  filled  with  blood,  their  contents  being  grumous  or  like 
coffee-grounds  (ha>matocele).  Bands  of  lymph  cross  the  sac  at  times,  but  more  fre- 
quently they  line  it  in  regular,  onion-like  layers.  In  neglected  cases  this  fibrin  may  die 
and  slough  awa}',  the  bursa  being  cast  out  as  a  whole,  as  in  an  ordinary  cellular  mem- 
branous ulcer  and  in  the  case  from  which  Fig.  4CA  was  taken.  In  syphilitic  subjects  this 
result  is  not  unfrequent. 

On  the  other  hand,  a  bursa  may  increase  by  effusion,  and  by  some  external  cause  rup- 
ture subcutaneously  or  externally,  and  thereby  undergo  a  cure.  In  1870  I  had  a  case  of 
the  former  kind  under  my  care  in  a  man  act.  GO  who  had  a  bursa  the  size  of  a  fist  over  his 
patella,  which  ruptured  on  kneeling.  When  I  saw  him,  the  cellular  tissue  about  the  knee 
was  infiltrated  with  serum,  which  was  subsequently  absorbed,  and  the  bursa  did  not 
reappear. 

What  has  been  described  as  taking  place  in  the  bursa  over  the  patella  may  occur  in 
other  parts,  and  more  particularly  over  the  olecranon  process,  where  an  enlargement  of  the 
bursa  goes  by  the  name  of  the  "  miner's  elbow."  I  have,  however,  seen  them  over  the 
acromion  process  in  men  who  carry  timber ;  over  the  tendon  of  the  extensor  quadriceps 
muscle  of  the  thigh  in  a  woman  who  habitually  started  her  sewing  machine  with  ihe 
knee ;  over  the  tuberosity  of  the  ischium  in  Spitalfields  weavers  ("  weaver's  bottom  ") 
and  in  Thames  lightermen  ;  over  the  dorsum  of  the  foot  in  extreme  cases  of  talipes 
equino-varus  when  the  children  walked  upon  the  part;  over  the  external  malleolus  in 
tailors ;  over  the  malleoli,  and  also  the  instep,  from  the  pressure  of  a  boot ;  over  the  great 
trochanter  of  the  femur  in  a  soldier,  from  pressure  caused  by  sleeping  on  a  board  ;  and 
last,  but  not  least,  over  the  ball  of  the  great  toe  in  cases  of  "  bunion,"  and  in  the  sole  of 
the  foot  over  the  heads  of  the  metatarsal  bones  in  men  who  walk  much  with  short  shoes, 
or  with  some  who  have  contraction  of  the  extensor  tendons  of  the  toes. 

Bursfe  will,  however,  enlarge  or  form  wherever  there  is  pressure,  the  enlargement 
being  in  a  measure  compensatory  to  save  deep  tissues.  Yet  this  rule  does  not  hold  good 
always,  for  I  have  seen  more  than  one  instance  in  which  enlarged  bursas  existed  over 
the  knuckles  of  the  first  phalangeal  joint  of  the  hands  without  any  such  cause. 

Treatment. — In  the  early  crepitating  stage  of  effusion  the  removal  of  all  pressure 
and  the  application  of  a  blister  are,  probably,  sufiicient  to  effect  a  cure,  and  in  more 
advanced  stages  the  repeated  application  of  blisters  is  often  sufficient  to  excite  absorp- 
tion of  the  effused  fluid  and  recovery.  When  these  means  fail  and  the  walls  of  the  bursa 
are  thin,  the  cavity  may  be  tapped  and  the  parietes  of  the  cyst  firmly  pressed  together  by 
means  of  a  pad  and  strapping.  When  the  walls  are  indurated,  this  treatment  is  useless ; 
but  a  cure  may  generally  be  effected  by  the  introduction  of  a  seton,  which  should  be  kept 
in  till  suppuration  is  freely  established.  In  more  solid  cysts  none  of  these  means  are  of 
use  and  excision  is  the  only  sound  practice,  the  surgeon  making  his  incision  over  the  outer 
border  of  the  bursa  in  order  that  the  cicatrix  may  be  out  of  harm's  way.  In  some  few 
instances  where  tapping  has  proved  ineffectual,  the  cyst  may  be  injected  with  thirty  or 
more  drops  of  the  compound  tincture  of  iodine  in  a  drachm  of  water,  as  in  hydrocele. 
When  blood  has  been  effused  into  the  bursa  from  a  blow,  as  indicated  by  its  sudden 
increase,  a  free  incision  into  the  cyst  and  the  evacuation  of  the  clots  may  be  expected  to 
be  followed  by  a  recovery ;  but  this  should  be  done  only  when  its  absorption  does  not 
take  place  by  natural  processes.  When  loo.se  or  pedunculated  bodies  exist  in  a  bursa  and 
cause  distress,  they  may  be  removed  by  means  of  a  free  incision  through  its  walls. 

Synovial  Burs^. 

An  enlargement  of  a  sj-hovial  bursa  is  a  far  more  serious  affection  than  that  which 
has  been  just  described,  as  these  bur.sas  are  situated  about  tendons  or  muscles,  the  articu- 
lar extremities  of  bones  and  joints,  and  in  many  instances,  indeed,  have  direct  communi- 
cation with  joints. 

T/irre  is  a  ihrp  Inrsa  Lr-nrafh  the  (hitoid  ?JH/.sc?e  which  when  inflamed  gives  riscito 
swelling  around  the  shoulder-joint  and  pain  and  crepitation  on  movement,  simulating 
shoulder-joint  mi.schief ;  at  times,  too,  this  bursa  communicates  with  the  joint  through 
the  bicipital  groove  in  which  the  biceps  tendon  plays.  It  may  be  distended  with  serous 
fluid  or  may  contain  loose  bodies  such  as  are  found  in  other  bursas  or  ganglia.  They 
should  be  dealt  with  cautiously,  on  account  of  the  possibility  of  their  communicating  with 
the  joint.  Hence,  blistering  and  absolute  rest  of  the  arm  are  the  best  means  to  employ, 
the  bursas  being  opened  only  when  obstinate  and  when  pouching  exLsts  in  front  of  the 
deltoid  tendon.     From  one  of  these  bursas,  on  two  occasions,  I  have  evacuated  within 


syynviM.  i:ri:s.K.  807 

three  inuiichs  more  tliaii  lialf  a  pint  oi'  hursul  fluid,  cuiituiniiig  iiu'ldn-sccd-likc  Ixulios,  a 
recDVory  sub.stM|ueiitly  taking  place.  Such  an  npcratioii  shouhl,  however,  lie  ihnie  only 
after  j.'rave  consiileration. 

Another  extensive  hursa.  .situated  heneath  the  extenSOr  mUSCleS  of  the  thigh, 
is  not  infVeijuentiy  the  scat  of  acute  or  subacute  intlaniniat  ion  ;  ami  >iiili  cases  have  lucii 
nii>lakcn  for  inHainination  of  the  knee-joint,  'i'lu;  (lia;;nosis  oii^'ht  n<»t,  however,  to  he 
ditfifult.  for  in  the  luirsal  enlarj^einent,  however  ^reat.  the  hul^in;:  of  the  cavity  will  sel- 
dom extend  downward  heyond  the  upper  border  of  the  patella,  and  will  not,  as  in  joint 
disease,  extend  to  cither  side  of  that  bone  or  below  it.  Fluctuation,  moreover,  will  be 
felt  oidy  above  the  joint,  and  not  obli(|ucly  tlirou;_'h  it.  When  the  patient  stands,  the 
dirterence  between  the  distension  of  the  bursal  and  t^iat  of  the  synovial  sac  will  be  also  at 
once  manifested.  With  this  eidarirement  there  may  be  s(»me  stiflnes.s  of  the  joint,  liut 
there  will  always  be  mobility.  This  bursa  at  times  becomes  the  seat  of  supjturation. 
when  the  necessity  of  a  correct  (lia<;nosis  is  more  important  on  account  of  treatment.  In 
all  cases  it  is  necessary  to  maintain  rest,  and  tlie  absorption  of  the  fluid  should  be  pn*- 
moted  l)y  blisters.  In  obstinate  cases,  when  the  bur.sa  is  very  tense,  the  cavity  may  be 
tapped,  and  when  it  sujtpurates  freely  opened  ;  but  neither  of  these  operations  should  be 
uutlcrtaken  without  strong-  necessity.  Suppurative  inflammation  of  the  bur.sa  may  extend 
to  the  joint  with  a  fatal  result.  I  have  tapped  such  a  bursa  in  a  woman  ait.  o5  and  drawn 
off  eifrht  «»unces  of  a  thick,  g:rumoa.s-lor)kin<r.  .semi-purulent  fluid  with  success;  in  a  .sec- 
ond ca.-^c,  a  woman  let.  50,  I  made  a  free  incision  into  the  bursa  and  evacuated  many 
ounces  of  pus  and  blood  such  as  escapes  from  a  luematocele  ;  a  trood  recovery  took  place. 

The  deep  bursa  between  the  Hgamentum  patellae  and  the  bone  is  very  liable 
to  inflame  and  enlarj:e,  which  gives  rise  to  pain  that  is  often  mistaken  for  joint  disease. 
The  pain,  however,  is  always  local  over  the  bursa  and  aggravated  by  the  patient  attempt- 
ing to  raise  the  extended  leg.  It  is  very  troublesome,  and  when  established  can  be  treated 
successfully  oidy  by  means  of  blisters  and  rest  with  the  leg  on  a  posterior  splint. 

The  bur.sa  situated  over  the  Upper  part  of  the  tuberosity  of  the  os  calcis, 

between  the  bone  and  the  tendo  Achillis.  is  sometimes  inflamed,  and  gives  rise  to  a 
marked  projection  in  the  part ;  it  causes  pain  and  lameness.  It  is  to  be  cured  by  absolute 
rest  (the  foot  and  leg  being  fixed  on  a  splint)  and  the  application  of  blisters. 

A  bursa  also  naturally  exists  in  connection  with  and  beneath  the  tendon  of  the 
psoas  muscle  as  it  passes  over  the  arch  of  the  pelvis;  this  may  al.-o  coiumunicate 
with  the  hip-joint.  When  distended  with  fluid,  it  will  give  rise  to  a  swelling  in  the 
upper  part  of  the  thigh  on  the  inner  side  of  the  femoral  vessels,  which  will  be  soft  and 
fluctuating,  but  will  not  receive  any  impulse  on  coughing,  like  a  psoas  abscess,  for  which 
it  is  apt  to  be  mistaken. 

The  bursa  between  the  tendon  of  the  gluteus  maximus  and  trochanter 

may  also  inflame  and  suppurate;  and  when  it  does,  it  gives  rise  to  a  troublesome,  and 
often  dangerous,  aff'ection.  When  suppuration  takes  place,  an  opening  may  be  made, 
which  should  be  free,  but  the  thigh  must  be  well  fixed.  When  suppuration  does  not 
occur  naturally,  the  surgeon  should  be  in  no  hurry  to  open  the  bursa,  but  be  satisfied  to 
keep  the  limb  at  rest  atid  l»listcr  the  swellinc:. 

Synovial  bursas  in  the  popliteal  space  require  a  rather  longer  notice  than 
the  forms  to  which  attention  has  already  been  directed,  since  they  are,  although  common, 
sometimes  diflicult  to  diagnose  and  dangerous  to  treat.  Their  treatment,  however,  as  a 
rule,  is  successful. 

The.se  bursae  may  be  divided,  in  a  clinical  point  of  view,  into  two  classes,  the  /7/-.s< 
including  such  as  are  connected  with  the  sheaths  of  tendons  or  that  encircle  their  in.ser- 
tion,  and  have  no  communication  with  the  knee-joint ;  the  second,  those  that  directly  or 
indirectly  communicate  with  the  joint  and  are  either  synovial  herniae  pouching  from  it  or 
bursas  originating  about  the  tendons  and  communicating  with  it. 

Among  ihe  Jirstt  is  the  normal  bur.sa  which  exists  above  the  head  of  the  fibula  on  the 
outer  border  of  the  popliteal  space  between  the  insertion  of  the  biceps  muscle  and  the 
external  lateral  ligament ;  a  second,  which  may  be  said  to  be  on  the  outer  border,  although 
it  has  a  somewhat  more  central  position,  which  separates  the  external  lateral  ligament 
from  the  tendon  of  the  popliteus  mu.scle  ;  and  a  t/u'rd  on  the  inner  .side  of  the  space  which 
lies  between  the  tendon  of  the  semi-membranosus  muscle  and  the  inner  tuberosity  of  the 
tibia,  the  whole  of  these  bursje  occupying  the  lon-rr  half  of  the  popliteal  space. 

In  the  S'cond  division  there  is  the  smaller  bursa  which  separates  the  outer  head  of  the 
ga.strocnemius  muscle  from  the  outer  condyle  of  the  femur,  and  the  larger  that  normally 
exists  between  the  internal  condvle  of  the  femur  and  the  inner  head  of  the  gastrocnemius 


808  AFFECTIONS  OF  THE  MUSCLES  AND    TENDONS. 

and  semi-menibranosus  muscles,  and  which  generally  sends  a  process  between  these  mus- 
cles, the  smaller  occasionally,  and  the  larger  generally,  communicating  with  the  knee-joint, 
both  of  these  occupying  the  upper  half  of  the  popliteal  space. 

The  larger  bursa  may  have  its  origin  on  the  inner  side  of  the  popliteal  space,  but  as 
it  grows  invariably  encroaches  on  it  and  becomes  central,  and  is  moi'e  frequently  enlarged 
than  any  of  the  other  popliteal  bursas. 

All  these  normal  synovial  burste  may  become  enlarged  under  the  influence  of  over-  or 
prolonged  exertion  or  any  sudden  strain,  the  smaller  ones  increasing  to  the  size  of  a  wal- 
nut and  the  larger  to  that  of  an  orange.  As  they  increase  so  they  become  central,  and 
as  they  assume  a  central  position  difficulties  in  their  diagnosis  may  be  experienced.  They 
may  contain  a  thin,  clear,  or  blood-stained  serous  fluid,  a  tenacious,  synovial,  or  colloidal, 
apple-jelly-like  material,  and,  in  exceptional  instances  may  have  consolidated.  I  have, 
however,  known  this  to  occur  but  once.  It  is  probable  that  the  bursa?  which  have  serous 
contents  do  not  communicate  with  a  joint,  while  those  that  have  synovia  do. 

Diagnosis. — In  a  general  way,  there  ought  not  to  be  any  difficulty  in  making  these 
cases  out,  more  particularly  when  the  different  positions  in  which  they  may  appear  are 
known,  since  their  circumscribed  and  defined  outline,  their  fluctuating  feel  and  mobility 
when  the  leg  is  flexed,  and  their  hardness  and  elasticity  Avhen  fully  stretched,  fairly  cha- 
racterize them.  When,  however,  the  swelling  pulsates  and  a  bruit  is  heard  over  the 
tumor,  some  difficulty  in  diagnosis  may  be  felt,  although  I  can  hardly  understand  how 
such  a  case  could  be  mistaken  for  an  aneurism,  as  on  a  careful  examination  the  bursal 
pulsatile  swelling  could  not  be  emptied  and  refilled  by  the  application  and  removal  of 
pressure  upon  the  afi"erent  artery,  as  would  an  aneurism  ;  neither  would  the  pulsation  be 
so  distinct  nor  the  bruit  so  clear,  for  both  the  pulsation  and  the  bruit  would  have  been 
simply  communicated.  The  position  of  the  bruit,  moreover,  would  have  a  greater  influ- 
ence upon  the  symptoms  in  a  case  of  bursa  than  in  that  of  aneurism  ;  for  whereas,  in  the 
latter,  by  sl'ujhfli/  flexing  the  leg  upon  the  thigh,  the  aneurism  would  become  more 
defined,  its  pulsations  more  marked  and  under  control,  in  bursfe  the  swelling  would 
become  more  flaccid  and  less  distinct.  Extension  makes  the  pulsation  and  the  swelling 
more  distinct  in  the  case  of  bursas,  and  less  so  in  that  of  aneurism. 

With  respect  to  the  diagnosis  of  a  synovial  bursa  which  communicates  with  the  knee 
and  a  true  synovial  hernia,  I  have  not  much  to  add  beyond  the  fact  that  in  the  former 
thei'e  may  be  no  symptons  of  knee-joint  disease,  whereas  in  the  latter  there  will  to  a  cer- 
tainty be  chronic  eff"usion  into  the  joint,  which  probably  will  be  part  of  an  osteo-arthritic 
change. 

When  pressure  upon  the  popliteal  swelling  causes  it  to  diminish  or  disappear,  while 
the  joint  itself  enlarges  and  becomes  fluctuant,  or  more  so  under  the  pressure,  it  is  a 
fair  inference  that  the  joint  and  bursa  communicate ;  although,  when  these  conditions  do 
not  exist,  it  would  be  wrong  to  infer  the  opposite,  for  the  opening  from  a  bursa  is  at  times 
valvular  and  altered  by  position. 

Treatment. — As  an  enlargement  of  these  bursas  always  follows  excessive  muscular 
action  and  strains,  so  by  absolute  rest  of  the  limb,  as  guaranteed  by  a  splint  and  the 
application  of  repeated  blisters,  can  the  bulk  of  them  be  made  to  disappear.  In  obsti- 
nate examples  of  the  first  division  of  cases  tapping  may  be  resorted  to;  whereas  in  the 
second  it  should  be  undertaken  only  where  other  treatment  has  failed,  and  then  with 
extreme  care  by  means  of  the  aspirator.  In  still  more  obstinate  cases,  where  the  limb  is 
rendered  useless,  a  free  incision  may  be  made  into  the  cysts  or  they  may  be  excised  ;  but 
such  desperate  measui'es  are  applicable  only  in  desperate  cases. 

The  first  division  of  cases  may  always  be  boldly  dealt  with,  but  the  second  should  be 
treated  with  extreme  caution. 

Thus,  in  a  case  which  was  under  my  care  some  years  ago,  where  by  repeated  blister- 
ing the  tumor  disappeared  for  a  time  only  to  recur,  a  surgeon  was  induced  to  tap,  and 
subsequently  incise,  the  cyst ;  after  which  acute  suppuration  of  the  part  occurred,  which 
in  the  end  compelled  amputation. 

The  case  of  solid  bursa  already  alluded  to  occurred  in  my  own  practice.  I  mistook 
it  for  a  tumor,  having  punctured  it  with  a  needle  without  obtaining  any  flow  of  fluid.  It 
was  in  a  man  of  middle  age,  had  been  growing  for  about  ten  years,  was  the  size  of  a  fist, 
filled  the  popliteal  space,  and  was  solid  and  movable.  I  found  that  it  was  connected 
with  the  inner  hamstring  tendon  only  when  making  the  attempt  to  remove  it.  On  recog- 
nizing its  nature  I  took  away  a  large  portion  of  the  mass  down  to  its  central  cavity, 
which  was  the  size  of  a  nut,  but  I  left  the  deeper  part.  Suppuration,  however,  subse- 
quently attacked  the  knee-joint,  and  amputation  became  necessary.     I  am  unable  to  point 


GANdl.lnX.  809 

out  liiiw  a  corrcet  (liairnosis  rouM  he  iiiatlc  in  such  a  r-asc  as  this,  hut  tlif  record  of  tlio 
fact  tliat  a  solid  hiirsa  may  exist  in  this  h>cality,  as  well  as  the  uiilortuiiate  result  \vhi(di 
accrued  upon  operatiiui  in  my  case,  may  1)0  of  value.  Holmes  draws  attention  to  a 
valualilc   paper  hv  M.   I^'oudicr  on  this   suKjecl   in  tlic  Archlcfn  (!riii'r(ilis  dc  Mid.  fl.Sijtji. 

Synovial  Cysts. 

In  connection  with  tliis  subject  of  synovial  hernia  it  should  he  stated  that  at  times 
these  hernijo  rupture  and  the  synovial  fluid  escapes  into  the  connective  tissue  of  the  lef^, 
forminj:;  a  synovial  cyst  ;  and  if  Mr.  Wornuild  was  ritjht  when  he  taught  that  the  thin- 
nest point  of  the  joint  cajtsule  was  at  the  spot  at  which  it  partially  encircles  the  tendon 
of  the  poplitcus  muscle,  it  is  more  than  jirohahle  that  it  is  at  this  spot  that  the  fluid 
escapes. 

The  synovial  cyst  may  occu]ty  the  popliteal  space  and  upper  part  of  the  calf  of  tlie 
leg  or  may  be  evident  in  the  calf  of  tlie  leg  only,  projecting  most,  as  a  rule,  on  the  inner 
aspect  of  the  leg,  or  may  be  perceptible  only  at  the  upper  and  inner  part  of  the  leg  as  a 
small  defined  swelling,  not  ap])roachiiig  within  three  or  four  inches  of  any  part  of  the 
knee-joint.  There  need  not  of  necessity  be  any  communicable  fluctuation  between  the 
cyst  and  the  joint. 

These  cysts  are  generally  found  in  joints  that  are  the  seats  of  osteo-arthritis.  and  are 
curable.  They  should  not  be  punctured  or  otherwise  subjected  to  operation  unless  there 
ajipear  strong  reasons  for  so  doing,  inasmucli  as  interference  may  lead  to  acute  inflamma- 
tion and  sup])uration  of  the  knee-joint. 

For  this  information  I  have  to  thank  Mr.  ^lorrant  liaker,  who  has  written  a  valuable 
paper  on  the  subject  in  the  .SV.  Bnrtholomp.wf.  Hoap.  Rrp.  (1877).  It  recalled  to  my 
recollection  several  cases  which  were  doubtless  of  this  afliiction,  and  which  I  did  not 
understand. 

Ganglion. 

This  is  met  with  in  two  forms — the  one  the  more  common  as  an  encysted  swelling  con- 
nected with  the  sheath  of  a  tendon  ;  the  second  as  a  more  diff"used  swelling  involving 
the  theca  of  one  or  of  many  tendons,  those  of  the  wrist  being  the  most  commonly  affected 
and  the  flexors  more  fre(|uently  than  the  extensors.  I  have,  however,  seen  it  in  the 
extensors  of  the  toes  and  mi  the  dorsal  aspect  of  the  foot  beneath  the  annular  ligament 
of  the  ankle,  but  it  may  attack  any  tendon.  Ganglion  is  always  the  result  of  strain  or 
overaction  of  the  tendons.  The  local  ganglion  always  contains  colloidal  apple-jelly-like 
material,  which  is  at  times  crystal-like  in  clearness,  at  others  pinkish.  In  the  diffused 
the  fluid  is  more  like  synovia,  containing  loose  bodies. 

"  The  bur.sae  or  ganglions  which  form  about  the  sheaths  of  the  tendons  at  the  wrist 
appear  to  be  the  cystic  tran.sformations  of  the  cells  enclosed  in  the  fringe-like  processes 

of  the  synovial  membrane  of  the  sheaths Sometimes  they  are  distended   with 

serous  fluid  ;  at  other  times  their  contents  possess  a  gelatinous,  or  even  a  honey-like,  con- 
sistency, which  constitute  a  form  of  meliceris.  Under  some  circumstances  free  fibro- 
cartilaginous-like  bodies,  irregularly  shaped,  composed  of  a  compact  connective  substance, 
form  in  consideral)le  numlters,  more  especially  in  the  ganglionic  enlargement  of  the  .syn- 
ovial bursa  which  surrounds  the  flexor  tendons  of  the  finuers  at  the  wrist"  (Pasret,  Surg. 
Pnth). 

The  localized  form  of  ganglion  is  more  common  on  the  dorsal  aspect  of  the  wrist 
than  anywhere  else,  although  not  rarely  it  is  connected  with  the  flexor  tendons  and 
appears  as  a  globular  or  irregularly  cystic,  tense  swelling  of  the  part.  At  times  it  is 
very  hard,  at  others  fluctuating  and  soft.  When  of  good  size,  it  maj'  be  translucent. 
Pressure  upon  it  to  any  extent  causes  pain  ;  severe  pressure,  sickening  pain — even  faint- 
ing and  vomiting.  Those  in  the  palm  of  the  hand  about  the  head  of  the  metacarpal 
bones  are  the  mo.st  painful.  At  times  ganglion  is  painless,  causing  only  some  weakness 
of  the  wrist. 

A  large  ganglion  occasionally  forms  behind  the  external  malleolus  connected  with  the 
peronei  tendons.      It  should  be  touched  with  care. 

The  diflfused  or  compound  ganglion  varies  in  its  symptoms  according  to  the 
number  of  t<'n(l<>iis  involveil.  When  one  only  is  affected,  it  may  appear  as  a  deep-seated, 
fluctuating,  irregular  swelling  in  the  course  of  the  tendon,  the  amount  of  swelling  and 
defonuity  depending  entirely  upon  its  size.  The  swelling,  when  many  tendons  are 
involved,  will  be  diff"used ;  but  when  the  whole  of  the  flexor  tendons  are  implicated,  it 


810  AFFECTIOXS  OF  THE  .MUSCLES  ASD   TESlJuyS. 

will  occupy  both  the  palm  of  the  hand  and  the  fore-arm  above  the  wrist.  In  the  case 
illustrated  in  Fig.  -405.  taken  from  a  woman  set.  49.  sent  to  me  by  Dr.  Lovegrove,  now 
of  Hythe,  all  the  flexor  tendon.s  were  involved  to  an  extreme  degree.  In  such  cases  as 
these  the  foreign  bodies  commonly  called  '■  melon-seed  or  rice-like  "  bodies  are  usually 
present.  They  may  frequently  be  made  out  to  exist  by  the  surgeon  when  ascertaining 
the  presence  of  fluctuation  from  above  and  below  the  annular  ligament  of  the  wrist  by 
firm  pressure  alternately  applied  in  this  direction,  the  pressure  exciting  a  peculiar  rough 
scrooping  sensation,  caused  by  these  loose  bodies  passing  along  the  thecae  of  the  tendons 
beneath  the  ligament. 

Fig.  465. 


Ganglion  involving  all  the  Flexor  Tendons  of  Hand  and  Wrist. 

Treatment. — The  local  ganglion,  when  first  formed,  may  often  be  cured  by  the  appli- 
cation of  a  blister  and  by  securing  rest  to  the  tendon  by  means  of  some  splint ;  but  when 
it  has  existed  for  some  time,  such  treatment  is  useless.  When  it  can  be  ruptured  by 
pressure  applied  by  grasping  the  flexed  hand  with  both  hands  and  by  one  thumb  super- 
posed upon  the  other  over  the  ganglion,  a  cure  may  often  be  eff"ected.  firm  p)ressure  being 
subsequently  kept  up  by  means  of  a  pad  of  lint  and  strapping.  When  this  fails,  the 
ganglion  should  be  punctured  subcutaneou.sly  b}*  means  of  a  spear-shaped  needle  or  fine 
tenotomy  knife,  its  contents  squeezed  out,  and  pressure  applied  by  lint  and  strapping  as 
before.  When  success  does  not  follow  this  treatment,  a  .silk  seton  may  be  introduced, 
the  hand  being  kept  quiet  on  a  splint,  but  it  should  be  removed  .so  .soon  as  suppuration 
has  been  established.  This  treatment  should  not  be  employed,  however,  until  all  minor 
means  have  failed ;  for  it  is  occasionally  followed  by  difi'used  inflammation  of  the  theca 
of  the  tendon  with  all  its  dangers. 

The  difl"used  or  compound  ganglion  is  dangerous  to  deal  with — that  is.  any  inter- 
ference with  it  may  be  followed  by  severe  inflammation  of  all  thecae  involved,  and  thus 
limb  and  life  be  jeopardized.  But  this  result  is  not  common  when  proper  precautions 
are  taken  to  guard  against  it.  The  risk  of  such  a  thing  should  always,  however,  be  laid 
before  the  patient  by  the  surgeon  before  any  opteration  is  arranged. 

The  only  eff"ectual  way  of  dealing  with  it  is  by  incision.  To  do  this  the  surgeon 
should  for  some  five  or  six  days  before  fix  the  hand  and  fore-arm  upon  a  splint  ;  he 
should  then  make  a  clean  cut  into  the  aff'ected  theca,  free  enough  to  allow  of  the  ready 
escape  of  all  the  ganglion  contents  without  any  forciV)le  manipulation.  When  many 
thecae  are  involved,  more  incisions  than  one  are  called  for.  The  incLsion  should  always 
be  made  in  a  vertical  direction  over  the  tendons,  and  both  above  and  below  the  annular 
ligament  when  the  disease  extends  up  the  arm.  After  the  operation  the  whole  cavity 
should  be  well  washed  out  with  iodine  water  and  the  wound  dressed  with  terebene  oil  or 
iodoform  gauze  and  powder.  A  splint  should  be  kept  on  for  a  week,  after  which  move- 
ment of  the  finger  should  be  allowed  when  the  fear  of  difi'used  suppurative  inflammation 
has  passed  away.  In  the  severe  example  of  the  aff'ection  illustrated  in  Fig.  405  this 
practice  was  adopted  with  success,  and  in  many  others  of  a  less  severe  character  I  could 
record  the  same  result.  I  have  never  had  occasion  to  divide  the  annular  ligament  as 
advised  by  Syme  in  the  E'finfjxrgh  Monthh/  Jovrn.  (October,  1844). 

The  case  illustrated  in  Fig.  4G6  was  mi.«;taken  for  this  aff'ection  ;  it  occurred  in  a  man 
aet.  49.  and  had  been  of  many  years'  duration.  The  swelling  had  the  app)earance  and 
feel  of  the  diffused  ganglion  with  foreign  bodies.  Indeed,  the  sensation  of  the  pre.senee 
of  foreign  bodies  was  marked  between  the  dorsal  and  palmar  surface  of  the  hand.  The 
swelling  was,  however,  entirely  confined  to  the  hand  and  did  not  extend  upward  above 


MM.FnllMATlnSS. 


HU 


the  aiiiiuhir  liLrnliifiit  (Luiicrt,  1SS4.  j).  SKI).  M  v  IViriHl  Mi'.  II.  MMi-ris  t<-IIs  iiic  thai  lio 
lias  seen  two  casrs  (tl'  latty  t miior  ciiinicctctl  willi  llic  iiiciliaii  iktvc  with  clinical  >.yin|i- 
tdiiis  like  tliusc  (U'siTihrd. 

I  (i|i('iMtt'tl  miuii  it  as  for  i.Mii^'^liuii,  and  to  iiiy  siirjirisc  loiirul  tin-  wlmlc   swclliii;:  was 
due  to  the  iireseiice  of  u  diHusctl  li|M)iiiatoiis  tuiiior  situuled   beneath  the  deep  flexor  ten- 


Fui.  4G(;. 


Lipoma,  situated  beneath  tlie  Flexor  Tendons  of  tlie  Hand,  simulating  (ianglion. 

dons  and  coniplctely  stirroundinjr  tlieiu,  dipping  down  ))et\veen  the  bones  to  appear  upon 
their  dorsal  ri'gioii.  1  removed  the  mass  with  much  difficulty  after  a  tedious  dissection, 
washed  the  whole  palm  out  with  iodine  water,  and  puffed  int<»  the  wounds  some  powdered 
iodoform.  1  then  fixed  the  hand  upon  a  dorsal  splint.  Quick  repair  followed  the  o]>era- 
tion  without  constitutional  disturbance  or  suppuration.  Within  three  weeks  the  man  was 
well,  and  returned  home  with  a  hand  in  no  way  impaired  by  the  severe  operation  it  had 
been  subjected  to.  In  this  case  the  fact  that  the  swelling  had  not  extended  above  the 
annular  ligament  ought  to  have  suggested  that  another  cause  than  ganglion  existed  to 
explain  the  symptoms. 


CHAPTER    XXIX. 

DEFORMITIES,   CLUB-FOOT,   AND  OKTHOP.EDIC  SURGERY. 

Malformations. 

Malformations  remain  to  be  considered,  those  of  special  parts  having  already 
received  attention  under  other  headings. 

They  may  roughly  be  classed  as  being  due  either  to  excess,  or  hypertrophy,  or  to 
deficinici/. 

Unnatural  adhesions  between  parts  is  not  rare,  and  maldevelopment  in  some  odd  way 
is  occasionally  met  with. 

As  examples  of  excess  of  development  supernumerary  fingers  or  toes  are  the  most 
common,  the  supernumerary  digits  being  more  or  less  well  formed  or  rudimentary,  either 
appearing  as  skin  appendages  (8,  9,  Fig.  407)  or  being  more  like  cleft  phalanges  with 
common  metacarpal  or  metatarsal  bones  (2,  6,  7,  Fig.  467).  The  thumb  is  very  com- 
monly cleft. 

Thus,  out  of  20  cases  of  supernumerary  fingers  and  toes  consecutively  noted,  8  were 
of  the  thumb  and  4  of  the  fingers  alone,  3  of  the  toes  alone  and  5  of  the  fingers  and  toes 
together,  the  deformity  being  symmetrical  in  (>  of  the  cases.  Occasionally  supernume- 
rary fingers  or  toes  have  perfect  metatarsal  or  metacarpal  bones,  and  more  rarely  the 
haiid  mav  be  double.  The  late  Jardine  Murray  of  Brighton  has  recorded  such  a  case 
{MaJ.-Ch!r.  Tram.,  vol.  xlvi.). 

Hypertrophy  of  extremities  is  met  with,  cither  of  whole  limbs  or  of  parts  of  limbs. 
In  drawing  10,  Fig.  407.  hypertrophy  of  one  finger  is  shown  associated  with  deficiency 
of  others,  but  hypertrophy  "is  a  type  of  the  aff"ection  tljat  is  met  with  in  practice,  whether 
of  a  digit  or  of  an  extremity. 


812 


DEFORMITIES,   CLUB-FOOT,  AND   ORTHOPAEDIC  SURGERY. 


Treatment. — Rudimentary  fingers  and  toes  may  be  fearlessly  excised  when  they 
appear  as  skin  appendages  ;  but  when  they  exist  as  bifid  phalanges,  great  care  is  called 
for  in  their  treatment,  on  account  of  the  frequency  of  there  being  a  common  joint  to  the 
two  digits.     Under  these  circumstances  the  surgeon  should  carefully  consider  the  ques- 

FiG.  467. 


Types  of  Different  Kinds  of  Deformities  of  the  Hands  and  Feet,  witli  a  Drawing  of  a  Child  with  a  Caudal  Appe 

(Taken  from  life.) 

tion  of  amputation  ;  and  if  he  decide  upon  performing  it,  it  will  be  wise  to  cut  oiF  the 
supernumerary  digit  some  little  distance  from  the  joint,  leaving  a  stump,  which,  as  a  rule, 
subsequently  withers. 

Hypertrophied  extremities  may  be  removed  when  they  are  sources  of  great  inconve- 
nience, but  not  otherwise. 

Webbed  fingers  and  toes  are  another  common  deformity.  At  times  all  the 
digits  of  one  or  both  hands  or  feet  are  webbed,  but  more  commonly  only  two  are  involved. 
Thus,  I  have  seen  the  thumb  and  index  finger  webbed  in  one  case  (No.  3,  Fig.  467),  the 
ring  and  middle  fingers  of  both  hands  in  another  (No.  4),  and  again,  in  another,  the 
second  and  third  toes  of  both  feet.  In  one  instance  the  toes  of  one  foot  were  webbed 
and  the  fingers  of  the  hands  more  or  less  truncated.  In  another,  with  webbed  toes  on 
both  feet,  there  was  a  supernumerary  right  thumb.  Indeed,  where  a  disposition  to 
deformities  shows  itself,  several  varieties  of  deformity  may  coexist  in  the  same  subject. 

Treatment. — For  the  hand,  when  the  fingers  are  well  formed,  the  surgeon,  if  possi- 
ble, should  divide  the  web,  but  under  other  circumstances  it  is  more  prudent  to  leave  it 
alone.  When  the  web  is  very  narrow,  there  is  nothing  left  but  to  divide  it ;  but  before 
doing  so  a  good  opening  at  the  base  of  the  cleft  ought  to  be  established,  to  prevent  the 
subsequent  closure  of  the  wound.  This  can  be  eflSciently  effected  by  means  of  the  gal- 
vanic cautery  or  otherwise  and  the  subsequent  introduction  into  the  opening  of  a  piece 
of  aluminium  wire,  the  wire  being  kept  in  till  the  wourid  has  cicatrized  and  become  as 
thoroughly  established  as  an  ear-ring  hole.  When  this  step  of  the  operation  has  been 
effected,  the  cleft  may  be  fearlessly  divided. 

When  the  web  is  broader  and  more  material  exists  for  the  surgeon's  manipulation,  the 
best  plan  to  adopt  is  to  split  the  web  transversely  between  the  fingers  and  to  turn  one  flap 


MM.FOIIMATIOSS.  813 

of  skill  nuiiid  (irif  Chilmt  iiinl  tlic  i.ilicr  flap  rninni  I  lie  .second,  stitcliiiif:  the  edges  of  the 
fl;i]p  til  ilir  skill  lit"  till'  liii<;i'r. 

W^ebbed  toes   need  no  surgical    iiiti  li.  nncc. 

Absence  of  parts  cuniiot  sur;.Meally  lie  remedied.  In  No.  i:5,  Vx^i.  ICT,  there  was 
an  aliseiiee  of  a  tliiiiiili.  Imt  liy  way  <d"  eonipeii.sation  an  extra  tin<rer  was  given.  In  No. 
14  the  riiiir  linger  was  aliseiit.  Iml  llie  imh-x  and  iiii<ldle  fingers  were  hyjuMirophit'd. 

At  other  times  linihs  are  triiiieated  as  if  from  intra-iiterine  amputation,  and  in  rarer 
cases  bones  and  joints  seem  to  lie  (h-Hcieiit.  Tims,  in  a  male  siilijeet  I  had  iiinler  care 
.some  years  ago  the  right  arm  was  shortened,  as  if  ampiitatecl  aliove  the  elhow.  and  the 
right  lower  e.vtreiiiity  was  represented  hy  one  short  lione,  with  a  foot  that  would  have 
been   called   jierieet    il"  the   little   toe   had    not  been   ab.setit. 

These  eases  are  nientioiieil.  however,  only  as  curiosities,  and  are  beyond  the  pale  of 
the  surgeon's  art. 

Claw-like   extremities,  as  represented   in  Nos.  1,  II.  and  iL'.   I'ig.    HIT.  are  very 

curious.      No.   1   represents   the   hands  of  (ieorge  N ,  act.  7  weeks,  the   third   child  of 

well-made  jiarcnts,  the  other  children  being  natural.  Very  little  power  existed  in  the 
claws,  one  finger  alone  being  of  use.  The  child  in  othc-r  respects  was  well  made  and 
intelligent. 

Nos.  11  ami    VI  were  taken   IVom    Edward  K ,  ict.  4,  one  of  eight  children,  three 

being  boys  and  five  girls,  one  brother  having  preei.sely  the  same  deformity.  The  jiarent.s 
were  well  made. 

The  hands  in  No.  11  had  apparently  but  tliree  metacarpal  bones,  the  wrist  and  carpal 
joints  being  normal;  the  solitary  digit  had  much  power.  The  feet  in  No.  12  were  .still 
more  oddly  made.  In  both  the  tarsal  bones  seemed  to  be  natural,  but  on  the  right  foot 
the  metatarsal  bones  were  confused  together.  The  digits  had  good  power.  Nothing  could 
be  suggested  for  the  patient's  benefit. 

Hereditary  Nature  of  Deformities. — The  hereditary  nature  of  deformities  is 
generally  recognized,  though  in  the  history  of  such  cases  it  is  exceptional  for  such  a  tend- 
ency to  be  traced.  When,  however,  it  is  made  out,  it  is,  as  a  rule,  remarkable.  Deform- 
ities, when  inherited,  are  also  generally  of  a  like  kind.  Thus,  deformities  of  the  genital 
organs  are  passed  on  to  succeeding  generations,  as  is  the  disposition  to  harelip  or  webbed 
fingers,  etc. 

Exceptions  to  this  rule  are  met  with.  Thus,  in  a  family  of  twelve  children,  two  out 
of  four  boys  had  harelip  and  fissured  palate,  and  one  out  of  eight  girls  had  hypertrophy 
of  the  right  lower  extremity,  with  atrophy  of  the  right  great  toe.  The  father  of  this 
family  had  a  supernumerary  little  finger  on  one  hand. 

A  female  child,  one  of  five,  the  other  four  being  well  made,  had  hypertrophy  of  the 
two  inner  toes  of  the  left  foot.  They  were  at  five  weeks  old  as  large  as  the  toes  of  an 
adult  and  as  well  made.  The  parents  had  no  deformity,  but  the  father's  maternal  grand- 
father had  a  double  thumb. 

A  boy  had  a  double  thumb  on  one  hand  and  a  web  between  the  .second  and  third  toes 
of  both  feet.      His  father  had  webbed  toes. 

These  exceptions  to  the  rule  above  given  are,  however,  rare. 

As  illustrations  of  the  rule  the  following  eases  have  been  extracted  from  my  note- 
books. 

A  man  had  six  perfect  toes  on  each  foot  and  six  perfect  fingers  on  each  hand.  He 
was  one  of  ten  children,  all  of  whom  had  the  same  kind  of  deformity.  The  parents  of 
these  children  were,  however,  well  made. 

A  female  child  had  left  equino-varus.  She  was  one  of  eight  children,  the  other  seven 
being  well  made.  The  parents  had  no  such  deformity,  but  the  mother  had  two  brothers 
and  one  sister  so  deformed,  and  her  fiither  had  double  talipes. 

A  man  had  scrotal  hypospadiasis  and  was  one  of  nine  children.  Both  his  parents 
were  w^ell  formed  and  no  history  of  deformity  could  be  traced  backward.  One  of  his 
sisters  had  harelip,  while  two  of  his  brothers  were  deformed  as  he  was,  one  having  passed 
as  a  female  till  he  was  eighteen  years  of  age.  Two  other  brothers  and  three  sisters  were 
natural,  but  each  of  these  brothers  had  a  son  a  hypospadiac. 

These  cases  are  very  striking. 

Club-Foot. 

When  paralysis  takes  place  of  a  single  muscle  or  of  a  group  of  mu.scles  functionally 
associated,  the  opposing  muscle  or  group,  losing  antagonism,  acts  uncontrolled,  and.  as  a 


814 


DEFORMITIES,    CLUB-FOOT,   AND   ORTHOPEDIC  SURGERY. 


consequence,  contraction  or  deformity  is  liable  to  be  produced,  the  deformities  resulting 
from  this  class  of  cases  being  designated  paralijtic  distortions. 

When  a  muscle  or  a  group  of  muscles,  from  whatever  cause,  acts  spasmodically  with 
an  active  tonic  contraction  or  a  slow  and  progressive  one,  quite  irrespective  of  the  will  or 
but  slightly  influenced  by  it,  and  in  this  way  overcomes  the  opposing  muscle  or  group  of 
muscles,  deformities  may  likewise  be  produced,  such  cases  being  called  sjjastic  or  !tj)as- 
■modic  distortions. 

In  the  first  class  the  degree  of  deformity  depends  much  upon  the  degree  of  paralysis 
present,  and  in  the  second  on  the  amount  of  spasm  or  contracting  force  of  the  muscles 
involved.  Some  surgeons  would  class  all  deformities  in  the  first  group,  but  this  view  is 
incorrect. 

Both  may  be  congenital  or  acquired.  In  the  congenital  greater  changes  take  place  in 
the  conformation  of  the  bones  than  in  the  acquired,  these  changes  depending  much  upon 
the  intensity  of  the  muscular  action,  but  more  upon  the  period  of  life  at  which  they  com- 
menced. 

"  It  seems  as  if  in  congenital  club-foot  and  analogous  distortions  a  stimulus  or  irritant 
were  present  in  the  medulla  spinalis,  acting  upon  certain  ganglionic  cells  there,  which 
keeps  the  affected  muscle  in  a  state  of  chronic  contraction,  yet  not  sufficient  to  neutralize 
the  stimulus  of  the  will  within  the  limits  of  movement  permitted  by  the  structural  short- 
ening of  the  member.  Many  non-congenital  spastic  conti-actions  appear  allied  to  the  con- 
dition which  prevails  in  some  states  of  chorea,  in  which,  Avhen  the  will  would  permit  or 
cause  contraction  or  relaxation  of  a  particular  muscle,  an  involuntary  influence  excites 
contraction,  interferes  with  and  frustrates  the  voluntary  effort.  In  more  intense  spas- 
modic contractions  the  will  is  entirely  overpowered  before  structural  shortening  super- 
venes to  effect  the  same  end  "  (Little). 

As  an  extra  argument  in  favor  of  this  view  the  fact  may  be  adduced  that  club-foot 
often  coexists  with  other  deformities,  such  as  spina  bifida  and  club-hand,  etc.  ''  Congeni- 
tal and  non-congenital  club-foot  spring  from  analogous  causes." 

When  these  muscular  contractions  are  powerful  enough  or  continue  long  enough  to 
alter  the  natural  position  of  a  part,  deformity  is  said  to  exist,  and  according  to  its  seat  or 
form  a  special  name  is  given  to  it. 

To  Stromeyer  abroad,  as  well  as  to  Little  in  this  country,  we  are  chiefly  indebted  for 
most  of  our  knowledge  on  this  matter,  although  in  more  recent  times  Tamplin,  Lonsdale, 
W.  Adams,  Brodhurst,  and  others  have  added  much  to  the  subject. 

Stromeyer,  however,  in  1831,  only  followed  Delpech  in  1828,  this  great  surgeon  fol- 
lowing a  greater — John  Hunter,  who  in  1794  established  the  principle  of  subcutaneous 
sui'gery  when  he  divided  injuries  to  sound  parts  into  two  divisions  and  established  this 
principle — that  "the  injuries  of  the  first  division,  in  which  the  parts  do  not  communicate 
externally,  seldom  inflame,  while  those  of  the  second  commonly  both  inflame  and  sup- 
purate." 

Club-foot  may  be  divided  into  four  typical  forms : 

Talipes  equinus,  in  which  the  heel  is  simply  draw  up  by  the  contraction  of  the 
muscles  of  the  calf  (Fig.  468)  ;  talipes  varuS,  in  which  the  foot  is  drawn  inward  to 


Fig.  468. 
Talipes    I^quiims 


Fig.  469. 


Conaenital     Vaj'us. 


ong 


■Oz 

Three  Grades  of  Severity. 


different  degrees  (Fig.  460)  ;  talipes  valgUS,  in  which  the  foot  is  turned  out  (Fig. 
471)  ;  and  talipes  calcaneus,  in  which  the  foot  is  drawn  up  and  the  heel  depressed 
(Fig.  472). 

Combinations  of   these  forms  are  commonly  seen.     Thus,  we  have  T.  eqiimo-varus, 
when  the  foot  is  turned  in  and  heel  drawn  up  (Fig.  470)  ;  T.  equino-valgus.  when  the  foot 


t'Ll'H-I-'OOT. 


815 


is  turiH'J  nitf  ami  the  lu'ol  drawn  up,  T.  rdfrmno-ixinis  and  culrttnt'o-vift/us  Ix-in^  tfrnis 
applied  when  tlicheel  is  di-pressi-d  and  the  toot   turned  in  or  out. 

Talipes  varus  is  the  usual  (•on;^enital  form,  hut  any  may  exist,  talipes  eijuinns  and 
cquino-varus  and   valgus  heing  the  more  commcju   acquired  forms. 

In  I'lt/i/iis  the  ])eronei  mu.scles  are  eliiefly  involved  ;  in  variix,  tlie  adductors,  particu- 
larly the  two  tiliials  ;  in  ('(jkiuiis  there  is  contraction  of  the  muscles  of  the  calf  through 
the  teiulo  Atdiillis ;  and  in  rufrniii'iis,  ])aralysis  of  the  same  group. 

(Mul)-foot  is  often  hereditary  and  more  |)rone  t(»  attack  the  male  branches  of  a  family 
than  the  female,  and  in  this  resp(!ct  it  seems  to  follow  the  ordinary  law  of  all  deformities. 
In  a  rase  uiuler  my  care  of  talipes  varus  the  child's  father,  grandfather,  and  great-grand- 
father on  the  father's  side  Juid  congenital  talij)es,  while  none  of  the  feuiale  branches  of 
the  respective  families  were  deformed. 

•'It  is  convenient,  for  practical  purposes,  to  divide  congenital  club-foot  int(j  three 
degrees  of  .severity  :  the  xh'(flitrnl^  that  in  which  the  position  of  the  front  of  the  foot,  when 
inverted,  is  such  that  the  angle  formed  by  it  with  the  inside  of  the  leg  is  greater  than  a 
right  angle,  and  in  which  the  contraction  is  so  moderate  that  the  toes  can  easily  be  brought 
temporarily  by  the  hand  of  the  surgeon  into  a  straight  line  with  the  leg  and  the  heel  be 
depressed  to  a  natural  position.     The  second  class  includes  those  in  which  the  inversion 

Fig.  470. 


C'oaae/i 


Acquired. 


From  Little. 


of  the  foot  and  elevation  of  the  heel  appear  the  same  or  little  greater  than  in  those  of 
the  first  class,  but  in  which  no  reasonable  effort  of  the  surgeon's  hand  will  temporarily 
extinguish  the  contraction  and  deformity.  The  tlilnJ  class  comprises  those  in  which  the 
contraction  of  the  soft  parts  and  displacement  of  the  hard  parts  reaches  the  highest 
degree,  so  that  the  inner  margin  of  the  foot  is  situated  at  an  acute  angle  with  the  inside 
of  the  leg,  sometimes,  or  even  almost  in  contact  with  it.  Cases  of  the  first  and  second 
grades  may  be  respectively  converted  into  the  second  and  third  grades  by  delay  in  the 
application  of  remedies  and  by  the  effects  of  improper  locomotion  "  (Little). 

•  Talipes  rquinns  is  the  most  common  form  of  the  acquired  talipes,  although  Little  posi- 
tively declares  it  is  at  times  congenital.  It  is  found  in  every  degree,  from  the  inability 
to  flex  the  foot  beyond  a  right  angle  to  a  pointing  of  the  toes,  necessitating  the  patient 
walking  upon  the  heads  of  the  metatarsal  bones  and  phalanges,  the  head  of  the  astragalus 
projecting  prominently  on  the  dorsum  of  the'foot.  Fig.  4G8  illustrates  the  medium  and 
extreme  forms. 

Talipes  varus  is  the  more  common  congenital  form.  Fig.  469  illustrates  it  in  three 
degrees  of  severity. 

It  is  very  frequently  combined  with  T.  equinus,  as  seen  in  Fig.  470.  The  arrows  in 
the  figure  indicate  the  direction  of  the  convexity  of  the  tarsus  and  metatarsus  forward 
and  outward ;  the  perpendicular  line  through  the  axis  of  the  limb  shows  the  extent  of 
the  inward  deviation  of  the  metatarsus,  by  which  the  base  of  the  little  toe,  being  brought 
completely  beneath  the  axis,  has  to  support  the  entire  weight  of  the  body  in  walking. 

Talipes  i-afffUH  may  be  of  all  degrees  of  severity  and  may  be  congenital  or  acquired, 
these  two  varieties  presenting  very  different  appearances.  Fig  471  illustrates  the  con- 
genital form  in  two  degrees  of  severity,  and  also  the  acquired. 

Talipes  calcaneus  is  illustrated  in  Fig.  472. 

For  a  full  detail  of  the  anatomical  changes  of  the  foot  under  these  different  condi- 
tions, vide  Adams  in  Pat/i.  Soc.   Tnuis.^  vol.  iii. 


816  DEFORMITIES,    CLUB-FOOT,   ASD   ORTHOPAEDIC  SURGERY. 

Before  considering  the  treatment  of  the.se  affections  it  will  be  well  to  look  into  the 
principle  upon  which  all  interference  must  be  based  and  the  process  by  which  repair  can 

take  place  after  the  division  of  tendon. 

To  Pairet  and  W.  Adams,  in  this  country,  we  are 
chiefly  indebted  for  our  knowledge  of  this  subject, 
and  I  shall  as  much  as  possible  use  Adams's  descrip- 
tion of  this  process,  as  published  in  1860  in  his 
work  on  the  Reparative  Process  af  Human  Tendons 
after  Divhiion,  his  investigations  having  confirmed 
Acm/ircd  \_ji^fc=^  those  of  the  former,  as  well  as  added  to  our  stock 

Co„ffcnifal  of  knowledge. 

Talipes     Calcaneus  When  such  a  tendon  as  the  tendo  Achillis  is  di- 

vided subcutaneously,  the  divided  ends  separate,  in 
an  infant  for  half  an  inch  and  in  an  adult  from  one  to  two  inches,  the  degree  depending 
much  upon  the  healthy  condition  of  the  divided  muscle  and  the  amount  of  movement 
subsequently  permitted  in  the  ankle-joint. 

The  reparative  process  begins  by  increased  vascularity  in  the  sheath  of  the  tendon, 
which  is  followed  by  the  infiltration  of  a  blastematous  material  into  its  meshes,  or  spaces 
between  its  fibrous  elements,  exhibiting  the  development  of  innumerable  small  nuclei,  a 
few  cells  of  large  size  and  irregular  form,  with  granular  contents,  or  perhaps  with  one  or 
more  nuclei,  and  .studded  with  minute  molecules  of  oil,  a  blastematous  material,  in  which 
the  cell  forms  do  not  develop  beyond  the  stage  of  nuclei,  appearing  to  be  the  proper 
reparative  material  from  which  new  tendon  is  developed.  This  nucleated  blastema  soon 
becomes  vascular,  capillary  vessels  having  been  seen  in  it  on  the  eighteenth  day  ;  the 
nuclei  assume  an  elongated,  spindle,  or  oat-shaped  form,  and  are  seen,  after  the  addition 
of  acetic  acid,  to  be  arranged  in  parallel  linear  series.  The  tissue  becomes  gradually 
more  fibrillated,  and  at  last  fibrous,  a  solid  bond  of  union  subsequently  forming  betw^een 
the  divided  extremities  of  the  tendon,  which  is  tough  to  the  touch,  but  to  the  eye  pre- 
sents, even  for  at  least  three  years,  a  grayish,  translucent  appearance,  distinguishing  it  at 
once  from  the  glistening  old  tendon.  This  new  tissue  remains  during  life  as  permanent, 
and  has  little  tendency  to  contract  subsequently.  Adams's  ob.servations  rather  led  him  to 
the  conclusion  that  the  requi-red  portion  of  new  tendon  is  to  be  obtained  during  a  length- 
ened period  of  formation — that  is,  about  two  to  three  weeks,  under  the  ordinary  condi- 
tions of  health  ;  but  in  paralytic  cases,  as  in  others  of  feeble  health,  this  period  may  be 
doubled. 

Adams  informs  us,  also,  that  the  divided  extremities  of  the  old  tendon  take  no  active 
pai-t  in  the  reparative  process  during  its  earlier  .stages,  although  at  the  later  the  cut  ends 
become  rounded  and  their  structure  softened.  They  become  enlarged  and  exhibit  a 
tendency  to  split,  and  thin  streaks  of  new  material  similar  to  that  already  described  are 
seen  between  the  fibres ;  the  ends  are  joined  by  these  means.  At  a  later  period  the  bulb- 
ous enlargement  gradually  diminishes. 

When  a  tendon  is  divided  a  second  time,  there  is  but  little  separation  of  its  ends,  and 
this  is  probably  due  to  adhesion  of  the  new  tendon  to  the  neighboring  fibro-cellular  tis- 
sue;  in  which  fact  is  found  an  explanation  of  the  unsatisfactory  results  of  second 
operations. 

There  is  no  reason  for  believing  that  in  the  treatment  of  deformities  by  tenotomy 
direct  approximation  and  reunion  of  the  divided  extremities  of  the  tendon  must  first  be 
obtained,  and  that  the  required  elongation  is  afterward  to  be  procured  by  gradual 
mechanical  extension  of  the  new  connecting  medium,  as  we  would  stretch  a  piece  of 
india-rubber. 

Gradual  mechanical  extension,  however,  is  required  in  cases  of  long  stahdiiuj,  as  in 
those  of  conffenital  origin,  to  forcibly  overcome  ligamentous  resistance  and  to  separate  the 
ends  of  the  divided  tendons,  as  it  is  in  those  of  parnlyfic  and  non-co)ii/eiiitaI  origin  to  pre- 
vent the  too  rapid  separation  of  the  extremities  of  the  tendon.  The  mechanical  extension 
should  be  carefully  regulated  according  to  the  activity  of  the  reparative  process,  as  indi- 
cated by  the  amount  of  eff"usion  into  the  sheath.  Blood  poured  out  into  the  sheath,  or 
any  inflammatory  action,  interferes  much  with  the  process  of  repair,  any  causes  of  gen- 
eral feebleness,  coldness  of  the  limb,  too  early,  too  late,  or  too  forcible  extension,  having 
a  like  eff'ect.     With  these  remarks  the  operation  itself  may  be  considered. 

Treatment. — "The  indications."  writes  Little,  "are  to  overcome  the  shortening  of 
the  muscles,  ligaments,  fascia?,  and  integuments  on  the  contracted  side  of  the  member,  to 
direct  the  bones  into  their  proper  position,  to  educate  the  patient's  voluntary  use  of  the 


CLUIi-FOOT. 


817 


parts,  to  give  strcnjjtli  to  tin'  muscles  ami  li^raiiieiits  in  the  <'/i»i^>iffff  side  of  the  incinlKir, 
to  I'omliat  the  tciKlciicy  to  rt'lapsc 

To  f'lilHl  tiic  first  iiKliratiniis  iiu'cliaiiical  iiicaiis  an-  nl'tcii  siitViciciit  ;  ami  wln-n  these 
fail  <»r  arc  iiia|i|ili(altU',  the  division  of  the  toiitructcd  stru(;tun;s  is  rt'<|iiirfd.  To  carry 
out  the  other,  luechanieal  Jiieans  are  also  rtf  value,  aided  hy  ireneral  iiieasur<!s,  ami  ujore 
}tartieularly  l»y  jralvariisuj  of  the  wcakeiieil  inusi'Ics.  In  a  larj^e  number  of  eases,  how- 
ever, instruments  are  not  needed,  much  less  temjtomy,  since  in  any  case  of  con<renital  or 
infantile  tali))cs  when  the  foot  can  he  hrouL'ht  int(j  its  normal  position  with  hut  little  force 
a  cure  without  operation  can  with  some  conlidenee  he  pnunistMl. 

In  the  very  simplest  ea.ses  mere  friction  of  the  artected  limh  and  the  daily  extension 
of  the  contracted  tendons  are  often  enou<;;h  to  effect  a  cure,  the  nur.sc  or  parent  iioldin<; 
the  crooked  foot  for  some  ten  or  fifteen  minutes  two  or  three  times  a  day  in  the  required 
position. 

In  the  next  class  of  cases,  which  are  slijihtly  worse  than  the  last,  in  which  tlie  fjot 
can  l)c  hrouiiht  with   jiciitlc  force  into  its  natural  ))lace.  a  cure  can  be  effected  by  means 

of  strapping  adjustcid  in  the  fashion  depicted  below  (Fig. 
Fk;.  478.  473).     The  strapping  must  be  of  a  firm  nature,  that  spread 

I  on  linen  being  the  best,  as  u.sed  at  (jruy's.     The  first  piece 

acts  as  a  kind  of  .splint,  and  the  .second,  on  binding  down 
the  first  to  tlie  ankle,  admits  of  any  amount  of  force  re- 

Fio.  474. 


Mode  of  Stretching  Foot  in  Ta- 
lipes Varus  by  Strapping. 


Buchanan's  Splint  for  Talipe.s. 


quired  to  bring  the  foot  in  or  out,  according  to  the  nature  of  the  case.  In  a  still  more 
severe  form,  where  the  former  method  is  inapplicable,  a  small  tin  splint  covered  with 
leather  with  a  screw  hinge  at  the  ankle,  such  as  that  advised  by  Little  or  made  for 
my.self  by  Milikin  may  be  employed,  the  foot  being  forcibly  brought  into  the  required 
position  and  fixed  there  by  strapping.  Buchanan's  splint,  as  seen  in  Fig.  474.  is  excel- 
lent. 

In  the  worst  forms,  where  by  no  ordinary  force  the  foot  can  be  brought  into  the 
required  position,  the  division  of  the  shortened  tendon,  tendons,  or  fascia  should  be  per- 
formed, no  more  structures  being  divided  than  is  absolutely  essential. 

"  When  deciding  on  the  necessity  of  operation,  the  surgeon  must  not  be  guided  .solely 
by  the  external  configuration,  but  by  the  amount  of  firm  resistance  opposed  to  restoration, 
by  the  depth  of  the  furrows  existing  in  the  .sole  and  behind  and  above  the  heel,  and  by 
the  degree  of  tension  of  the  integuments  above  the  internal  malleolus.  The  deep  clefts 
or  furrows  in  question  denote  intensity  of  contraction  of  muscles  and  closer  adhesion  than 
usual  of  integuments  and  fascia  to  the  subjacent  soft  structures  and  bones.  They  prob- 
ably denote,  also,  that  the  deformity  dates  from  an  early  period  of  uterine  existence  " 
(Little). 

Sayre's  law  upon  this  point  is  very  good.  "Place  the  part  contracted."  he  writes,  "as 
nearly  as  possible  in  its  normal  position  by  means  of  manual  tension  gradually  applied, 
and  then  carefully  retain  it  in  that  position  ;  while  the  parts  are  thus  placed  upon  the 
stretch  make  additional  point-pressure  with  the  end  of  the  finger  or  thumb  upon  the 
parts  thus  rendered  tense :  and  if  such  additional  pressure  produces  r^fffx  cont  met  ions, 
that  tendon,  fascia,  or  muscle  must  be  divided,  and  tlie  point  at  which  the  reflex  spasm  is 
excited  is  the  point  where  the  operation  should  be  performed.  If.  on  the  contrary,  the 
additional  point-pressure  does  not  produce  reflex  contractions,  the  deformity  can  be  over- 
come by  means  of  constant  elastic  tension  ;  and  the  more  you  cut.  the  greater  will  be  the 
amount  of  damage  done"  (  Orthnpffdic  S'irg..  1876). 

In  all   cases  treatment  should  be  commenced  as  soon  as  posslhh'.  and  the  foot  of  the 
youngest  infant  ma}'  be  dealt  with  advantageously  by  manual  extension  a  few  days  after 
birth.     "Within  a  week  extension  by  strapping  may  be  carefully  employed,  the  foot  being 
52 


818  DEFORMITIES,   CLUB-FOOT,  AND   ORTHOPAEDIC  SURGERY. 

looked  to  daily  to  see  that  no  slougliing  or  cutting  of  the  skin  by  the  strai)ping  takes 
place.  In  infants  the  tendons  yield  far  more  readily  than  they  do  as  months  or  years  go 
on,  and  with  care  no  harm  can  accrue  from  simple  mechanical  extension.  Kven  splints, 
carefully  applied,  can  be  used. 

When  tenotomy  is  clearly  a  necessity — that  is,  in  grave  deformities — there  is  no  rea- 
son, in  a  healthy  well-developed  babe,  why  it  should  not  be  performed  within  a  month 
after  birth.  I  have  divided  the  tendo  Achillis  for  a  talipes  varus  with  an  excellent  result 
at  the  end  of  the  first  week,  and  Mr.  Little  has  operated  successfully  within  twenty-four 
hours  of  the  child's  birth. 

The  Operation. 

In  a  large  number  of  cases  of  congenital  varus  the  division  of  the  tendo  Achillis  is 
enough,  the  foot,  after  division  of  the  tendon,  being  generally  capable  of  restoration  to 
the  required  position  by  mechanical  means,  but  in  severe  examples  the  anterior  or  poste- 
rior tibials,  singl}^  or  together,  may  require  to  be  cut.  These  three  tendons  may  be 
divided  at  one  operation  in  average  cases,  though  in  the  severe  Little's  advice  is  good — 
to  deal  with  the  tibial  tendons  first  and  overcome  the  inversion  of  the  foot,  and  at  a  later 
date  to  divide  the  tendo  Achillis.  The  value  of  this  proceeding  consists  in  the  fixed  os 
calcis  offering  a  resisting  point  from  which  the  surgeon  is  enabled  to  stretch  out  and 
unfold  the  contracted  inverted  sole. 

Division  of  the  Tendo  Achillis. — The  patient  should  be  turned  on  the  abdo- 
men and  the  tendon  made  tense  by  means  of  an  assistant.  The  surgeon  should  then 
insert  a  sharp-pointed  or  round  knife  flatwise  from  behind  forward  by  the  side  of  the 
tendon  as  far  as  its  anterior  surface,  when  it  should  be  turned  laterally  in  front  of  the 
tendon  and  its  cutting  edge  directed  backward  toward  the  tendon,  and  with  the  slightest 
sawing  motion  the  tense  cord  may  be  divided,  care  being  observed  to  do  this  completely ; 
otherwise,  failure  will  follow.  During  this  procedure  the  surgeon  should  keep  his  finger 
upon  the  tissue  to  be  divided,  and  immediately  on  the  withdrawal  of  his  knife  close  the 
opening  with  his  finger  or  thumb,  the  assistant  relaxing  the  parts  at  the  moment  he  feels 
resistance  to  cease.  A  dossil  of  lint  should  then  be  applied  to  the  puncture  and  fixed  by 
strapping,  this  dressing  being  left  for  three  days.  If  any  suspicion  exist  of  the  posterior 
tibial  artery  having  been  wounded,  as  indicated  by  arterial  hemorrhage  and  blanching  of 
the  foot,  the  dressing  should  be  left  on  for  at  least  a  fortnight  and  all  mechanical  treat- 
ment postponed.  It  is,  however,  an  exceptional  circumstance  for  any  harm  to  follow  the 
puncture  of  the  artery.  Little,  with  all  his  experience,  informs  us  that  he  has  only  once 
seen  any  trouble  from  this  circumstance. 

After  the  operation  the  foot,  in  its  deformed  position,  should  be  bound  to  a  flexible 
metal  or  other  splint  for  three  or  four  days,  till  the  immediate  eff'ects  of  the  operation 
have  subsided,  when  the  foot  should  be  at  once  brought  to  the  required  position  and 
retained  there  by  splints  and  bandages. 

Division  of  the  posterior  tibial  tendon  should  be  performed  with  the  child 
upon  its  back,  with  the  limb  to  be  operated  upon  rotated  well  outward.  The  surgeon 
should  take  charge  of  the  foot,  and  his  assistant  of  the  knee.  The  tendon  should  be 
divided  about  an  inch  or  an  inch  and  a  half  above  the  extremity  of  the  inner  malleolus. 
In  thin  subjects,  on  abducting  the  foot,  the  tendon  may  be  felt  at  the  spot  indicated  ;  but 
in  fat  per.sons,  and  when  the  tendon  cannot  be  made  out,  the  surgeon  knows  it  lies  along 
the  inner  edge  of  the  tibia,  "  exactly  midway  between  the  anterior  and  posterior  borders 
of  the  leg  on  its  inner  aspect." 

At  this  spot  the  knife  should  be  inserted  perpendicularly  to  the  surface  through  the 
fascia  for  about  half  an  inch,  an  opening  in  the  fascia  being  made  sufficiently  free  to 
admit  of  the  introduction  of  the  probe-pointed  knife,  which  must  next  be  inserted.  This 
knife  can  then  be  introduced  perpendicularly,  close  to  the  bone,  between  it  and  the  tendon 
to  be  divided,  when  its  edge  should  be  turned  toward  the  tendon  and  the  operation  com- 
pleted by  a  slight  sawing  movement.  It  is  not  always  necessary  to  change  knives  during 
this  operation  ;  some  operators,  indeed,  never  do  so.  It  is  safer,  however,  to  adopt  the 
practice  in  fat  subjects  when  some  uncertainty  exists  as  to  the  exact  position  of  the  ten- 
don. As  soon  as  the  tendon  has  been  divided  a  dossil  of  lint  should  be  applied,  as  in  the 
former  operation. 

Some  surgeons  prefer  to  divide  the  tendon  of  the  long  flexor  muscle  at  the  same 
time  ;  as  a  rule,  this  is  unnecessary. 

Division  of  the  anterior  tibial  tendon  can  be  performed  with  the  patient 
lying  on  his  back  and  the  foot  extended,  the  tendon  being  in  this  way  made  prominent  in 


CLVIl-FdOT. 


819 


fnnit  (if  the  imuT  inulleolus.  Tlic  knife  sli<ml«l  ))(•  insertt'd  at  thiH  jioiiit  hehiiul  the  ten- 
iliMi  anil  its  c'djff  turtu-d  forward,  when  the  U\:^\\X  (••ml  can  he  <lividt'd,  tlio  foot  IjoIii^;  at 
once  Ht'Xt'd  and  flu-  |>iin(t iircd  wouml  ('((ViTt'd  with  lint  and  strapping.  It  might  to  he 
ki'|it  ill  a  splint  for  scvt-ral  ilays  alU-r  diviHion  (d"  the  tcmlo  Arliillis. 

Wlii'ii  all  tlii'Si'  tt'iidons  arc  diviilcil  at  the  same  operation,  the  after-treatment  must 
he  the  same. 

Division  of  the  peronei  tendons  for  talijieH  valgus  is  eaHJly  aecomplished  hy 
adduetiiitr  the  foot  aiitl  iiitrodueing  the  knil'e  hehiml  the  external  malleolus,  hetween  thi! 
tendons  and  the  lihiila,  the  tendons  heing  cut,  on  turning  the  edge  of  the  knife  toward 
them,  with  a  sawing  movement.  Some  surgeons  advocate  a  higher  division  of  these  tcndoiiH 
to  uhviate  their  retraction,  union  taking  place  lictweeii  the  teiidcjii  and  the  .sheath. 

It  is  unnecessary  to  describe  the  operation  for  division  of  the  plnntar  fnxcid  or  other 
tendons,  as  the  practice  in  all  should  be  conducted  on  principles  identical  with  those 
already  described. 

Mkciia.nical  Tre.\tment. — However  necessary  these  operations  may  be  in  any 
given  case,  it  ought  to  be  remembered  that  they  are  only  preparatory  to  the  mechanical 

treatment  which  is  subsequently  to  be  carried  out.     That 
Fig.  475.  they  are  not  always  necessary  has   already  been    shown, 

mechanical  treatment  generally  being  amply  sufficient  of 
itself  to  effect  all  the  surgeon  desires. 

In  one  case  after  the  division  of  the  rigid  tendon  or 
tendons  a  cure  may  be  effected  by  means  of  strapping,  as 
already  illustrated  (Fig.  47H)  ;  in  a  second  a  simple  inside 
or    outside    splint   with    strapping    or    bandages    may    be 

Fig.  476. 


Little's  Modification  of  Scarpa's  .Shoe 
for  Talipet^. 


Mr.  Davies-Col ley's  Splint  for  Talipes  Equino- Varus. 


enough  ;  in  a  third  the  simple  splint  figured  in  Fig.  474  answers  every  pui-pose  ;  while  in 
a  fourth  Scarpa's  shoe  is  required  (Fig.  475),  or  some  of  its  modifications.  A  shoe  with 
a  ball-and-socket  heel-joint  which  Messrs.  Krohne  made  for  me  is  .strongly  to  be  recom- 
mended, and  in  Fig.  476  is  another,  suggested  by  my  colleague,  Mr.  Davies-Colley,  which 
for  extreme  examples  of  talipes  is  inexpensive  and  stands  unrivalled. 

In  all  the  principle  embodied  is  the  same — the  separation  of  the  divided  ends  of  the 
tendon  and  the  deposition  of  new  material  between  them.  The  .splint  invariably  should 
be  applied  and  fixed  to  the  foot  in  its  deformed  position  and  the  separating  process  carried 
out  on  the  third  or  fourth  day.  In  many  I  have  brought  the  foot  into  position  directly 
after  the  division  of  the  tendons  with  nothing  but  good  results. 

If  failure  follows  the  first  operation,  a  second  may  be  performed  ;  but  the  hope  of  a 
succes.sful  issue  under  these  circumstances  is  far  from  good. 

Barwell  has  recently  revived  the  old  practice  of  elastic  bands  to  .stretch  the  tendons 
in  lieu  of  dividing  them,  and  in  some  cases  it  is  a  valuable  practice,  but  as  a  substitute 
for  tenotomy  it  cannot  be  recommended. 

There  are,  however,  cases  of  talipes  equino-varus  which  are  amenable  neither  to  sub- 
cutaneous tenotomy  nor  to  mechanical  appliances,  as  well  as  others  which  have  been 
treated  by  these  measures  and  have  failed,  or  which  are  so  severe  as  to  make  it  certain 
that  a  long  interval  of  time  must  of  necessity  be  spent  in  the  attempt  to  bring  about  a 
cure,  even  if  such  a  result  were  probable  or  possible  ;  and  under  these  circumstances 
surgeons  have  sought  for  more  expeditious  and  efficient  means  of  treatment.  With  such 
a  view,  Dr.  Little,  the  pioneer  of  tenotomy  in  this  country,  suggested,  so  long  ago  as 
1854, ''that  in  inveterate  varus  the  treatment  might  well  be  commenced  in  robu.st  sub- 
jects by  ablation  of  the  os  cuboides."  and  the  late  Mr.  S.  Solly  in  1857  carried  the  sug- 
gestion into  effect.'     The  case  not  proving  very  successful,  the  practice   met  with   no 

^Med.-Chir.  Trans.,  1857. 


820 


DEFORMITIES,    CLUB-FOOT,   AND   ORTHOPEDIC  SURGERY. 


encouragement,  and  the  operation  was  not  repeated  till  Mr.  Richard  Davy,  an  old  pupil 
of  my  own,  performed  it  at  the  Westminster  Hospital  in  1874  on  a  boy  set.  15  with  such 
a  "  striking  immediate  result  that  the  sole  of  the  foot  could  with  force  be  placed  in  a 
natural  position,"  and  he  repeated  it  in  1875-76.  In  1872,  Mr.  Edward  Lund  went  a 
step  farther  and  removed  from  a  boy  get.  7  both  astragali  in  a  case  of  severe  double  talipes 
with  some  perceptible  improvement.     This  measure  he  repeated  in  March,  1878.' 

In  October,  1875,  however,  my  colleague,  Mr.  Davies-Colley,  adopted  a  new  method, 
and  on  the  suggestion  of  Mr.  Howse  removed  from  a  boy  aet.  12  a  wedge-shaped  piece 
of  the  tarsus,  without  paying  any  regard  to  its  articulations,  by  means  of  "  an  incision 
three  inches  in  length  along  the  outer  border  of  the  left  foot  from  the  middle  of  the  os 
calcis  to  the  middle  of  the  fifth  metatarsal  bone,  and  a  second  across  the  dorsum  of  the 
foot  from  the  centre  of  this  incision  two  inches  long."'-  Both  feet  were  operated  upon  at 
intervals  of  six  weeks,  and  in  less  than  ten  weeks  from  the  second  operation  the  wounds 
were  quite  healed  and  the  boy  could  walk  without  assistance.  In  November,  1876,  Mr. 
Davy  performed  the  same  operation. 

All  these  proceedings  are  sound  in  principle,  and  in  cases  of  talipes  in  which  minor 
measures  have  been  tried  and  have  failed,  or  in  which  the  probabilities  of  their  success 
are  slight,  and  time  and  expense  are  questions  of  importance,  they  should  be  entertained. 
I  believe,  however,  that  Mr.  Davies-Colley's  operation  is  the  best  for  talipes  equino-varus, 
particularly  when  the  varus  is  worse  than  the  equinus,  though  Mr.  Lund's  operation  is 
probably  of  value  under  the  reverse  conditions.  I  say  this  after  having  had  opportunities 
of  seeing  several  of  Mr.  Davy's  and  one  of  Mr.  Lund's  cases,  and  having  carefully 
watched  throughout  its  treatment  Mr.  Davies-Colley's.  Entertaining  these  opinions,  I 
performed  Mr.  Davies-Colley's  operation  on  June  18,  1878,  and  with  such  a  good  result 
that  I  now  give  drawings  of  the  boy's  foot  before  the  operation  (Figs.  477,  478)  and 
subsequent  to  it,  with  an  outline  of  the  portion  of  bones  removed  (Fig.  479). 


Fio.  477. 


Fig.  479. 


Fig.  478. 


Foot  after 
Operation. 

The  case  was  that  of  a  boy  fet.  12  who  was  born  with  talipes  equino-varus  of  the  right 
foot  and  went  under  surgical  treatment  when  eight  months,  and  again  when  five  years, 
old,  but  with  no  permanent  relief.  On  admission  into  Guy's,  under  my  care,  on  June 
12,  1878,  the  heel  of  the  right  foot  was  much  drawn  up  and  the  foot  so  twisted  inward 
as  to  cause  the  sole  of  the  foot  to  face  the  median  line  of  the  body,  as  in  a  complete  sub- 
astragaloid  dislocation.  The  head  of  the  astragalus  was  very  prominent  and  the  tip  of  the 
inner  malleolus  approximated  the  base  of  the  metatarsal  bone  of  the  gres^t  toe,  the  tubercle 
of  the  scaphoid  being  buried  in  the  abnormal  depression.  By  no  force  could  the  foot  be 
restored  to  a  better  position,  although  the  teiido  Achillis  and  tendon  of  the  posterior  tibial 
muscles  could  be  made  tense.     Under  the  circumstances  described  it  was  tolerably  clear 

'  Brit.  Mt'fl.  Jonvn.,  November  2,  1878. 
'  Med.-Chir.  Trans.,  1877. 


KNOCK-KNEE.  821 

that  I'V  im  toiiotniiiy  or  Jiiccliaiiical  iiiiaiis  (•(nild  any  hope  be  entertained  of  restorinf;  the 
ioot  to  a  >;ott(l  jMisition,  and  I  (•(ni.'«ct|u«iitly  ih-tcniiiiHMl  to  pcrionii  Mr.  Davies-Colley's 
ojHTUtion. 

This  I  (litl  on  .hiiH'  IS,  1S7S,  l)y  an  olili<(iif  T-iiicisioii  ot'thi-  soft  parts  ami  the  appli- 
cation of  a  kfvholi'  saw  ln'iieath  the  tt'iidons  and  soil  parts,  niado  alter  Ksniarcdi  l»anda;_'('.s 
had  lu'«'n  applied  as  a  toiiriii(|ii('t. 

Tlu'  wodu'i-  of  hone  I  took  away  is  represented  in  Ki<_'.  471'  and  was  removed  entire, 
fjreat  eare  hein;^  used  to  protect  the  tendons  and  soft  tissues,  and  particularly  those  of  the 
sole,  hy  the  introduction  of  a  flat  retractor  duriny  the  sawin<^  process. 

The  day  followin<^  the  operation  the  temperature  went  up  to  1M2.4°,  but  fell  the  next 
day.  On  the  third  day,  when  the  wound  was  dres.sed  for  the  first  time,  it  was  !>'J.(i°,  and 
durinjr  the  projrress  of  tlie  case  it  never  deviated  beyond  a  point  or  .so  from  that  degree. 
On  July  11,  the  bones  haviiii;-  fairly  united  and  the  wound  nearly  closed,  Davie.s-CoUey's 
talijies  splint  was  put  on  and  the  limb  swuntr. 

On  Se)>tem]ier  l(t  the  boy  got  up,  and  the  sole  of  the  foot  was  found,  on  his  standing, 
to  be  perfectly  flat.  An  immovable  splint  was  then  applied,  and  the  boy  left  for  the 
country.  On  C)ctober  20  he  returned  to  have  the  tendo  Achillis  divided,  with  the  view 
of  giving  more  movement  to  the  ankle-joint,  and  .some  success  has  followed  the  measure. 
He  can  now  (November  10)  walk  fairly  well  with  his  foot  as  flat  to  the  ground  as  the 
iinaft'ected  one.  I  have  had  three  other  cases  since,  and  seen  about  six  more,  which  have 
been  eijually  successful. 

Spurious  Valgus,  or  Flat-Foot, 

is  a  common  condition  in  feeble  boys  and  girls  who  stand  much  or  take  too  much  exer- 
tion. It  is  due  to  a  giving  way  or  yielding  of  the  plantar  arch  and  fibrous  structures 
of  the  sole  of  the  foot,  '•  the  keystone  of  the  arch  " — the  navicular 
bone — eventually  .sinking  with  the  astragalus  and  inner  cuneiform 
bones.  (  Vide  Fig.  480.)  In  some  cases  there  is  as  a  secondary  con- 
sequence contraction  of  the  peronei  muscles  and  impaired  movements 
of  the  ankle-joint.  This  stretching  of  the  tissues  gives  ri.se  to  more 
or  less  pain,  and  in  extreme  cases  to  inability  to  walk,  or  even  to 
stand.  This  affection  is  constantly  associated  with  lateral  curvature 
of  the  spine. 

Treatment. — In  the  milder  form  of  cases,  when  the  foot  can  read- 
ily be  restored  to  its  normal  position,  a  cure  may  be  brought  about  by      S[iurious\al»uii 
periodical  rest,  gentle  exercise,  and  mechanical  support,  by  means  of 
strapping  or  the  introduction  of  a  firm  pad  or  metal  plate,  to  support  the  plantar  arch, 
into  the  hollow  of  a  boot  made  with  a  straight  inside  edge  and  low  heel.     Tonics  and 
good  air  and  living  and  the  free  movement  of  the  joint  are  essential. 

In  a  worse  class  of  cases  it  is  well  forcibly  to  flex  the  foot  and  restore  the  parts  to 
their  normal  position,  and  then  fix  them  so  by  means  of  a  plaster-of-Paris  bandage. 

In  more  extreme  cases  some  divisions  of  the  tendons  may  be  permissible,  and  in  the 
very  worst  operative  interference  may  be  justifiable.  Dr.  Ogston  of  Aberdeen  has  sug- 
gested the  union  of  Chopart's  joint  by  pegging. 

In  examples  in  which  much  pain  exists  nothing  but  absolute  rest  will  be  of  any  use, 
and  in  such  the  local  signs  of  inflammation  of  the  overstretched  pai'ts  are  often  evident, 
and  therefore  fomentations,  etc.,  may  be  employed. 

Knock-Knee. 

Knock-knee,  like  flat-foot,  is  primarily  due  to  mechanical  yielding  of  the  internal  liga- 
ment of  the  knee-joint  from  want  of  power,  and  at  a  later  date  to  the  overgrowth  of  the 
inner  condyle  of  the  femur  with  the  low^er  end  of  the  diaphysis.  from  the  want  of  the 
controlling  influence  of  pressure  which  normally  is  applied  through  the  leg  bones.  It  is 
found  in  growing  boys  and  girls  who  stand  too  much  and  carry  heavy  weights,  and  in 
those  of  feeble  power  from  either  natural  or  acquired  causes.  It  is  not  rarely  seen  with 
rachitis. 

Treatment. — It  can  be  treated  on  principles  based  upon  the  facts  just  briefly  stated, 
and  not  purely  by  mechanical  means.  To  put  irons  on  the  limb  of  a  feeble  subject  is  a 
mistake  ;  for  where  the  child  is  too  weak  to  support  his  own  frame  without  injury,  to 
give  him  more  to  carry  must  be  hurtful.     Young  children  should  be  taken  off"  their  legs 


822 


DEFORMITIES,   CLUB-FOOT  AND   ORTHOPJEDIC  SURGERY. 


as  much  as  po.s.«-ible  and  proviiU.'(l  with  proper  food  and  such  tmiie  medicines  as  seem 
requisite.  Tlie  weakened  ligaments  should  have  time  given  them  to  contract  and  become 
strong.  Older  cliildren  should  be  limited  in  the  amount  of  exercise,  rest  and  exercise 
alternating  at  regular  intervals.  When  walking  half  an  hour  causes  pain  or  aching, 
something  less  should  be  allowed,  and  so  on.  Exercise  sufficient  to  get  and  keep  the 
muscles  in  order  may  be  allowed,  but  not  sufficient  to  tell  upon  the  weakened  ligaments. 
In  other  cases,  as  an  additional  means,  strapping  the  knees  may  be  of  great  use.  In 
more  severe  cases  splints  or  irons  should  be  employed.  These  latter  instruments  should 
extend  from  the  pelvis  to  the  foot  and  be  well  jointed.  In  very  severe  examples  operative 
interference  may  be  justifiable,  and  the  surgeon  has  a  choice  of  three  measures  : 

1st.  Ogstons  ojieration  of  obliquely  sawing  or  chiselling  off  the  inner  coiuJyle  of  the 
femur  and  forcibly  straightening  the  bent  limb,  which  is  kept  fixed  by  splints  and  band- 
ages during  the  period  of  repair  (Fig.  481). 

2d.  Mnceiven's  uperufion  of  dividing  with  a  saw  or  chisel  the  shaft  of  the  femur  uljove 
the  amdylesi.  forcibly  bringing  the  limb  straight,  and  retaining  it  in  its  new  position  for 

five  or  six  weeks  while  the  bone  unites  t  Fig.  482),  the  cutan- 
FiG.  4sl.  eous  incisions  in  both  these  operations  being  merely  enough 

to  admit  the  cutting  instrument  or  saw. 


Fig.  482. 


Prawing  illustrating  Dr.  Ogston's  Ope- 
ration. I  PJijId  limb  shows  line  of  sec- 
tion of  the  inner  condyle  of  the  fe- 
mur. Z^//,  inner  condyle  brought  to 
required  position.) 


Appearance  of  Limbs  before  and  after  Macewen's  Operation  in  a 
Patient  set.  33.  (The  legs  and  feet  rotated  outward  and  ab- 
ducted.) 


3d.  Tu.'i  forcible  str<Ai(jhfenin(j  of  the  limb,  as  advocated  by  Delore.  pressing  it  .straight, 
and  giving  time  for  repair. 

Of  these  three,  the  second,  or  Macewen's,  is  to  be  preferred,  the  results  being  as  good 
as,  if  not  better  than,  Ogston's  operation ;  and  the  operation  is  attended  with  less  risk, 
tl.c  knee-joint  not  being  opened.  My  colleagues  and  I  have  performed  it  on  many  occa- 
sions, and  always  with  success.  In  the  drawing  above — one  of  the  worst  cases  I  have 
undertaken,  in  an  adult  aet.  33 — the  operation  gave  three  inches  to  the  patient's  height 
(Fig.  482  I. 

Delore's  operation  is  not  to  be  advised,  since  it  means  not  only  the  abruption  of  liga- 
ments, but  often  the  separation  of  epiphyses,  and  with  such  separation  the  dangers  of 
local  disease  .starting  from  the  seat  of  injury,  and  the  probable  arre.st  of  growth  in  the 
limb  as  a  later  consequence.  Farabeuf  and  Mikulicza  have  fairly  established  this  fact 
(6V/.-:.  Med.  de  Paris,  January,  1880). 


Tenotomy  for  Contracted  Limb,  etc. 

Be.sides  all  these  recognized  affections,  there  are  many  other  conditions  in  which 
tenotomy  is  a  valuable  operation.  Thus,  in  the  contracted  limbs  which  are  associated 
with  hip,  knee,  or  other  joint  disease,  it  is  often  necessary  to  divide  the  rigid  and  con- 
tracted tendons  or  muscles  that  forbid  the  limb  being  .straightened  by  the  application  of 
any  ordinary  or  justifiable  force,  while  mechanical  means  can  then  complete  the  object 
the  surgeon  has  in  view.     It  is  better  to  divide  than  to  tear  a  tendon. 

In  1871  I  saw  a  boy  set.  14  who  for  years  had  had  repeated  attacks  of  pain  and  inflam- 
mation about  his  great  toe.  more  particularly  after  overwalking.  He  had  been  under  the 
care  of  many  medical  men.  who  had  treated  him  for  gout.  etc..  but  who  had  never  com- 
pared the  sound  with  the  affected  toe.  When  I  did  this,  the  source  of  the  evil  was  very 
apparent  ;  for  the  long  extensor  tendon  was  clearly  contracted,  and  at  its  insertion   into 


cosTiiAcTins  nF  Till-:  r!S(;i:ns.—i:n!ii>  Arnnrirv.  h23 

thf  base  of  the  extreme  phalanx  tlitie  was  iiuicli  tliickeiiiiig.      I  diviiled  the  tendon,  and 
recovery  at  onee  ensued. 

The  hicep.s  muscle  of  tlie  arm  is  also  at  times  so  contracted  as  to  prevent  extension  ; 
the  adductor  muscles  of  the  tiiigh  are  so  contracted  as  to  cause  j^reat  apparent  shorten- 
ing of  the  lower  extremity,  and,  as  a  result,  limping.  In  both  of  these  cases  tenotomy 
is  of  great  service,  lii  fact,  any  tendon  may  contract  under  the  influence  of  disease,  and 
ret|uire  division. 

Contraction  of  the  Fingers. 

In  this  curious  affection,  which  generally  ajipears  in  the  little  finger  and  subsequently 
involves  the  ring  finger,  and  in  which  the  palmar  fascia  ciiietly,  and  the  flexor  tendons 
secondarily,  juotluce  a  jtcrmaiiciit  contraction  of  first  one  and  then  the  other  linger,  .so  as 
to  draw  them  into  the  j)alm,  some  operation  is  called  for. 

It  often  attacks  Ixtth  hands,  together  or  consecutively.  It  is  said  to  be  found  more 
frequently  in  gouty  or  rheumatic  sul)jects  than  in  others,  but  I  have  failed  to  verify  this 
statement.  It  is  also  difficult  to  trace  the  origin  of  the  disea.se  to  any  local  injury.  In 
fact,  this  affection  is  somewhat  obscure.  It  may  attack  the  middle  finger  or  any  and  all 
of  the  fingers,  but  more  commonly  it  is  the  two  outer.  From  its  .symmetry  it  has  proba- 
bly a  constitutional  and  not  a  local,  origin.  It  is  often  hereditary,  but  ])ossibly  not  more 
so  than  any  other  deformity. 

Treatmknt. — By  fixing  the  contracted  fingers  in  a  flexible  splint  and  gradually 
stretching  them  much  may  be  done,  and  in  .several  cases  I  have  effected  a  complete  cure 
by  these  means.  But  it  is  diflicult  for  men-patients  to  submit  to  this  inconvenience,  and, 
as  a  consequence,  the  surgeon  is  consulted  only  when  the  disease  is  severe  and  the  finger 
by  its  contraction  has  become  u.seless,  if  not  wor.se  than  u.seless.  Under  these  circum- 
stances the  free  division  subcutaneou.sly  of  all  the  tense  tissues  may  be  called  for.  as 
recently  ably  advocated  by  Mr.  W.  Adams  (Bn't.  Med.  Journ.,  June  29,  1878).  His  opera- 
tion and  treatment  are  as  follows  : 

1.  The  subcutaneous  division  of  all  the  contracted  bands  of  the  palmar  fascia  and  its 
digital  prolongations  by  as  many  punctures  as  might  be  necessary,  cutting  from  above 
downward  with  the  smallest  tenotomy  knife. 

2.  Immediate  extension  of  the  contracted  fingers,  the  fingers  and  hand  to  be  bandaged 
to  a  splint. 

3.  The  bandage  not  to  be  removed  until  the  fourth  day,  when  the  punctures  will  be 
found  to  be  healed. 

4r.  Extension  splint  to  be  worn  night  and  day  for  two  or  three  weeks,  and  afterward  at 
night  for  three  or  four  weeks,  motion  being  employed  every  day. 

Dr.  Madeliing  of  Bonn  {BerUner  Klinische  Wochmschrift .  No.  15,  1875)  believes  that 
this  condition  of  finger,  known  as  "  Dupuytren's  contraction."  is  due  to  the  absorption  of 
the  numerous  small  deposits  of  fat  which  in  healthy  young  and  middle-aged  subjects 
exist  between  the  connective-tissue  bands  of  the  palmar  fa.scia  and  the  short  fibres  which 
connect  this  fascia  with  the  superjacent  integument.  This  fascia,  consequently,  under 
the  influence  of  pressure,  falls  into  a  state  of  chronic  inflammation  and  becomes  con- 
tracted. He  then  describes  how  Busch  of  Bonn  treats  such  cases  with  great  success.  In 
a  case,  for  example,  of  contraction  of  the  little  finger,  he  raises  an  angular  skin  flap  from 
the  palm  of  the  hand,  its  base  being  at  the  root  of  the  finger,  and  then  cuts  away.. bit  by 
bit.  the  tense  fa.scia  beneath  as  the  finger  is  being  straightened.  He  then  replaces  the  flap 
and  fixes  it  with  sutures.  The  finger  is  left  free  for  some  days  after  this  operation,  but 
as  soon  as  granulations  appear  a  cylinder  of  wood  is  placed  in  the  palm  for  a  few  days, 
and  after  this  the  finger  is  extended  and  kept  so  by  means  of  a  straight  splint  applied  to 
the  back  of  the  hand.  This  should  be  removed  daily  and  the  finger  moved.  At  the  end 
of  three  or  four  weeks  the  hand  is  left  free.  Dr.  Madeliing  has  never  seen  this  operation 
fail  {Med.  Rev.,  May  26, 1875).  I  have  adopted  this  practice  in  several  cases  with  excel- 
lent results.  In  the  same  way  one  or  more  toes  may  be  so  affected,  and  tenotomy  may 
be  called  for. 

Rigid  Atrophy. 

Muscles  that  atrophy  occasionally  contract  and  become  rigid,  but  this  rigidity  must 
not  be  mistaken  for  the  spasmodic  contraction  of  a  muscle  or  group  of  muscles  that  is  so 
common  in  progressive  disease,  more  particularly  of  joint  disease,  although  it  often  follows 
upon  that  form  :  indeed,  it  seems  generally  to  be  the  consequence  of  some  long-continued 


824  DEFORMITIES,   CLUB-FOOT,  AND   ORTHOPEDIC  SURGERY. 

spasm,  atrophy  following  from  exhaustion,  inflammation  of  the  muscle,  or  what  is  called 
"  rheumatism."'  It  is  seen  more  commonly  in  the  flexor  muscles  of  joints  than  in  any 
other,  and.  as  a  special  afi"ection,  in  some  cases  of  v:ry-neck,  where  the  sterno-mastoid 
muscle  is  at  fault. 

Treatment. — When  the  muscles  are  not  too  rigid,  much  may  be  done  by  rapid  exten- 
sion under  the  influence  of  an  anaesthetic  or  gradually  by  means  of  splints,  manipulation, 
or  india-rubber  bands,  etc.,  suited  to  the  wants  of  the  individual  case.  When  these 
means  are  ineffectual  or  the  parts  too  rigid  to  allow  of  their  application,  the  subcutaneous 
division  of  the  tendon  of  the  muscle  or  muscles  may  be  performed  upon  the  same  prin- 
ciple under  which  tenotomy  is  practised  in  contracted  tendons. 

Wry-Neck  is  an  example  of  this  affection  due  to  a  contracted  sterno-mastoid  muscle. 
It  may  be  that  the  sternal  or  clavicular  origin  may  be  alone  at  fault,  it  being  exceptional 
to  find  both  divisions  of  the  muscle  aff"ected. 

Treatment. — Under  such  circumstances,  when  the  muscle  refuses  to  be  stretched 
by  mechanical  appliances,  the  half  involved  alone  requires  division,  followed  by  extension 
when  union  has  taken  place.  In  these  difficult  cases  it  seems  wise,  as  a  rule,  not  to  bring 
the  divided  ends  of  the  muscle  so  closely  into  contact  as  the  surgeon  usually  does  after 
division  of  a  tendon. 

One  of  the  worst  cases  of  the  kind  I  ever  had  to  treat  was  in  a  child  fet.  7  in  which 

both  origins  of  the  muscle  required  division.     I  brought  the  head  up  to  the  required 

position  on  the  second  day  and  kept  it  there,  an  excellent  result 

Fig.  488.  en.suing.     In  another,  which  I  treated  in  1870,  in  a  child  aet.  6, 

with  Mr.  Duke  of  Battle,  the  muscle  of  the  left  side  was  two 

inches  shorter  than  that  of  the  right  from  contraction  of  its 

sternal  half.     I  applied  extension  on  the  third  day,  after  the 

division  of  the  contracted  portion,  and  brought  the  head  into 

its  right  place,  keeping  up  the  extension  by  means  of  a  piece 

,,y  ,  ~     .^.^         of  india-rubber  band  an   inch  wide,  which  was   fastened  to  a 

Mm/i^   / /  ^^  skull-cap  on  the  opposite  side  of  the  head  and  passed  backward 

^     ^  across  the  shoulders  and  beneath  the  axilla  of  the  affected  side 

to  fasten  to  a  good  thoracic  belt  (Fig.  483). 

These  cases  of  wrj'-neck  due  to  contraction  of  muscles  are 
always  associated  with  some  arrest  of  growth  in  the  upper  and 
lower  jaws  on  the  affected  side. 

3Ir.  de  Morgan  informs  us  ( Mcd.-Cftir.  Rev.,  1866)  that  in  a 
ease  that  failed  to  3'ield  under  such  treatment  he  took  away  a  piece 
of  the  spinal  accessory  nerve  with  permanent  benefit,  the  .sterno- 

Cap  and  Band  for  Extension  in  ^-ii^  •  ^       ^     •  o  -^  1  j      mi.- 

Wry-N'tck.  mastoid  and  trapezius  muscles  being  01  necessity  paralyzed,    ihis 

operation  has  been  repeated,  but  with  only  exceptional  success. 

The  operation  of  dividing  the  sterno-mastoid  muscle,  either  wholly  or  in  part,  at  its 
sternal  or  clavicular  origin,  must  be  subcutaneous  and  requires  much  care,  for  important 
parts  lie  behind  tKe  muscle  which  may  be  injured.  A  punctured  wound  down  to  the 
muscle  should  be  made  over  the  part  to  be  divided  with  a  sharp-pointed  tenotomy  knife ; 
a  blunt-pointed  knife  ought  then  to  be  introduced,  with  its  edge  turned  toward  the  muscle, 
close  to  its  bony  attachment,  and  all  resisting  fibres  divided  by  turning  the  edge  back- 
ward, an  assistant  putting  the  muscles  fully  on  the  stretch  ;  the  muscle  usually  gives  way 
with  a  distinct  snap.  The  thumb  or  finger  must  then  be  applied  to  the  part  and  a  pad 
adjusted,  sufficient  pressure  being  made  to  prevent  bleeding,  but  no  more.  As  already 
stated,  extension  should  be  made  early  in  the  case,  after  the  second  or  third  day,  and  the 
means  adopted  in  the  example  quoted  seems  to  be  the  best ;  it  succeeded,  at  any  rate, 
where  the  usual  instruments  failed. 

When  both  insertions  require  division,  it  should  be  effected  by  two  different  punc- 
tures. Some  surgeons  prefer  to  divide  the  muscle  from  behind  forward,  but  there  is 
greater  risk  of  injuring  the  deep  parts  by  this  practice  than  by  the  one  advised. 

I  need  scarcely  add  that  where  wry-neck  is  due  to  spinal  disease  no  such  treatment  as 
the  above  is  applicable. 


coyrrsioys  ar  joiyjs.  825 


CHA  PTKIl    X  XX. 

CONTUSIONS,  81'1{AL\S,   WOl'MtS,  IN.Jl  lllKS  OF  .JOINTS,  AND 

DISLOCATIONS. 

Sprains  "lay  l>i'  vcrv  slight  or  very  sfiious  iiidiit'ct  injuries.  Tliey  iiielu(l»'  iimre  or 
less  severe  overstreteliiii<;s,  if  not  laeeratiuiis,  of  the  ligaments  that  l»ind  tlie  bones  of  an 
articulation  tt»^etlier,  some  fracture  (tr  tearing  away  of  the  hone  at  the  attachment  of  the 
liL'aments — ••  s])rain  fractures."  In  ehihh'en  untler  ten.  sjirains  of  joint.s  are  liable  to  be 
comjilicated  with  some  epijdiysial  separation  or  incomplete  fracture  near  the  epiphy.sial 
line,  or  some  crushinir  oi'  compression  of  the  spon*jy  bone  tissue.  In  the  more  severe 
instances  are  inchuleil  lacerations  of  the  muscles,  tendons,  and  soft  parts  that  surround 
the  joint.  All  such  accidents  require  rest  and  time  in  their  treatment  in  order  that 
repair  may  be  complete,  since  neglected  sprains  are  often  the  cau.se  of  joint  or  bone 
disease. 

Contusions  of  joints  «s  direct  injuries  always  ought  to  be  regarded  in  a  serious 
aspect,  for  a  large  amount  of  internal  mischief  may  often  be  su.stained  with  very  slight 
external  evidence  of  injury,  and  under  certain  conditions  of  health  a  slight  blow  upon  a 
bone  is  often  enough  to  set  up  seTere  local  action  or  to  excite  chronic  changes  which  may 
involve  the  integrity  of  the  joint.  During  the  period  of  the  growth  of  bone  in  children 
these  observations  have  great  force.  The  nature  of  the  accident  and  the  amount  of  force 
concentrated  on  the  joint  form  the  best  index  to  the  case,  and  under  all  circumstances 
the  prognosis  should  be  guarded  and  the  treatment  cautious. 

Treatment. — ••  In  sprains  of  joints  rest  is  the  first  principle,"'  said  John  Hunter  in 
17S7  (MS.  lectures),  and  at  the  present  day  the  same  words  are  as  pregnant  with  truth 
as  when  then  spoken  ;  indeed,  in  simple  cases  of  sprain  by  such  treatment  alone  will  con- 
valescence be  established.  When  swelling  and  effusion  into  the  joint  ensue  in  the  course 
of  the  second  or  third  day  after  the  accident,  the  evidence  of  internal  injury  is  more 
marked ;  for  such  efi"usion  means  inflammation  or  synovitis,  which  is  to  be  treated  by  abso- 
lute rest,  ensured  by  the  application  of  a  splint,  the  local  use  of  cold  or  warmth,  accord- 
ing to  the  comfort  afforded  by  either,  and  occasionall}'  by  leeches. 

If  swelling  of  the  articulation  follows  immediately  upon  the  injur}',  eff'usion  of  blood 
into  the  joint  is  indicated  with  or  without  fracture,  but  always  with  severe  local  mischief. 
Such  cases  should  be  treated  by  the  employment  of  a  splint,  to  ensure  immobility  of  the 
articulation,  elevation  of  the  injured  joint  with  the  patient  reclining,  and  the  local  appli- 
cation of  a  bag  of  pounded  ice  or  Leiter's  metallic  coil  (Fig.  9),  these  means  being  main- 
tained until  the  hemorrhage  has  ceased,  all  risks  of  inflammation  of  the  joint  are  gone, 
and  repair  appears  to  be  going  on  satisfactorily.  As  soon  as  the  primary  eff'eets  of  the 
sprain  and  all  signs  of  inflammation  have  passed,  the  application  of  pressure  to  the  joint 
by  means  of  a  bandage  or  strapping  with  passive  movement  is  very  striking.  When  the 
joint  is  rendered  very  tense  from  eff'used  blood,  it  may  be  aspirated. 

When  the  muscles  over  the  shoulder-joint  are  severely  bruised  by  a  fall,  much  local 
pain  may  be  produced,  as  well  as  want  of  power  in  the  arm.  exciting  a  fear  of  either  bone 
or  joint  mischief;  but  a  careful  examination  will  show,  if  no  roughness  in  the  examina- 
tion be  used,  that  the  joint  can  be  passively  moved  without  exciting  pain,  although  if  the 
patient  attempts  to  set  the  muscles  in  action  pain  is  produced.  This  point  is  one  of 
clinical  importance,  indicating  that  the  mischief  is  in  the  muscle,  and  not  in  the  articula- 
tion, the  pain  being  excited  by  muscular  action,  and  not  by  joint  movement. 

In  delicate  children  all  falls  upon  the  hip  followed  by  pain  should  be  treated  by  rest 
and  extreme  care,  for  a  large  number  of  cases  of  hip  disease  originate  from  some  such 
trifling  cause  ;  and  there  is  good  reason  to  believe  that  the  majorit}'  of  hip-joint  affections 
might  be  prevented  by  proper  attention  after  .slight  injury. 

After-Treatment. — When  the  immediate  eff'eets  of  the  sprain  have  passed  away, 
the  local  use  of  a  stimulating  liniment  and  moderate  friction  of  the  part  expedites  the 
cure,  and  at  the  .same  time  gives  comfort  to  the  patient.  A  local  warm  bath  at  intervals 
likewise  relieves  the  stiff"ness  of  the  joint.  Whenever  movement  excites  more  than  a 
momentary  pain,  rest  should  be  observed;  and  if  the  pain  continue,  some  chronic  inflam- 
matory change  ought  to  be  suspected  and  treated.  When  weakness  of  the  joint  alone 
remains,  a  good  bandage  or  strapping  around  the  part,  to  give  support,  is  of  great  benefit. 


826  CONTUSIONS,  SPRAINS,  AND    WOUNDS  OF  JOINTS. 

Where  much  hiceration  of  ligament  has  taken  place,  it  is  at  times  necessary  for  the  joint 
to  have  some  permanent  artificial  support,  in  the  form  of  either  a  splint,  felt,  leather  cas- 
ing, or  bandage  ;  fiM-  no  parts  are  repaired  with  less  permanent  power  than  ligaments. 

In  the  wrist,  when  much  swelling  exists,  a  sprain  may  be  mistaken  for  a  fracture  or  a 
fracture  for  a  sprain,  as  fractures  about  the  end  of  the  radius  are  generally  impacted,  and 
not,  consequently,  attended  by  crepitus.  Much  care  is  necessary  in  the  diagnosis  of  such 
cases.  Man}-  sprains  of  the  ankle  are  also  really  cases  of  fracture  of  the  fibula  above 
the  malleolus.  The  popular  notion  that  a  severe  sprain  is  worse  than  a  fracture  is  in  the 
main  true ;  and  when  the  sprain  is  neglected,  the  case  is  always  more  tedious  than  that 
of  a  broken  bone. 

Wounds  of  Joints. 

These  are  always  serious  accidents,  yet  as  a  whole,  if  treated  with  discretion  and  at 
an  early  period  of  their  existence,  they  are  fairly  successful  in  their  issue.  Lacerated, 
incised,  and  punctured  wounds  are  met  with,  and  the  symptoms  that  follow  any  one  of 
these  accidents  are  by  no  means  commensurate  with  the  extent  of  the  local  injury  ;  for 
a  slight  or  punctured  wound  is  often  followed  by  severe  and  destructive  local  changes, 
when  an  extensive  one  heals  without  giving  rise  to  any  mischief. 

A  joint  is  known  to  be  wounded  when  its  contents  escape,  the  oily,  glutinous  nature 
of  synovia  rendering  its  flow  very  manifest.  In  fat  subjects,  however,  wounds  over  joints 
give  exit  to  an  oily  fluid  simulating  "joint  oil,"  but  such  fluid  is  not  sticky  when  rubbed 
between  the  fingers,  as  is  synovia.  Joints  are  sometimes  wounded  without  any  evident 
escape  of  their  contents ;  such  doubtful  cases  are  clinically  to  be  treated  as  cases  of 
wound.  In  every  case  of  wounded  joint,  however  trivial,  and  in  all  doubtful  eases  of 
wounded  joints,  the  2)ro(/)iosis  must  be  very  guarded  and  the  treatment  cautious. 

Treatment. — A  clean  incised  wound  should  be  well  cleansed  with  carbolic  or  iodine 
water  and  its  edges  accurately  adapted  with  sutures ;  a  contused  or  lacerated  one  .should 
likewise  be  well  washed  and  the  joint  syringed:  and  if  the  edges  of  the  wound  are 
brought  partially  together,  sufficient  opening  should  be  left  for  drainage.  The  wound  in 
both  cases  should  be  dressed  with  some  absorbent  antiseptic  dressing  such  as  iodoform  or 
carbolic  gauze.  Probing  must  be  avoided,  and  the  joint  should  be  kept  in  absolute  repose 
by  the  application  of  a  splint.  Cold  should  then  be  applied,  nothing  checking  pain  or 
subduing  inflammation  and  efi'usion  better.  The  cold,  however,  to  be  of  value,  must  be 
persistently  maintained,  as  any  intermission  of  its  use  is  almost  sure  to  be  followed  by 
increase  of  pain  and  efi'usion.  To  seal  hermetically  a  small  wound  with  a  piece  of  lint  soaked 
in  the  compound  tincture  of  benzoin  and  at  the  same  time  apply  cold  is  excellent  prac- 
tice. Should  an  interval  have  passed  between  the  receipt  of  the  accident  and  the  appli- 
cation of  the  cold,  and  much  joint  inflammation  exist  with  con,stitutional  symptoms,  the 
application  of  leeches  to  the  joint,  and  subsequently  of  cold,  is  beneficial.  £n  exceptional 
examples,  where  cold  is  not  tolerated,  warm  fomentations  must  be  substituted.  Opium 
is  always  of  use.  the  patient  being  kept  fairly  under  its  influence  by  one  grain  two  or 
three  times  a  day.  Mercury  is  useless.  In  very  sthenic  cases  antimony  may  be  given, 
and  colchicum  where  gout  is  suspected. 

When  all  acute  symptoms  have  subsided  and  chronic  efi'usion  remains,  the  application 
of  a  blister  or  of  blisters  expedites  the  absorption  of  the  efi'used  fluid,  and  the  benefit  of 
pressure  by  the  adjustment  of  well-applied  strapping  is  very  great.  In  feeble  patients 
tonics  are  required.  Should  suppuration  appear,  active  treatment  is  called  for,  such  as  a 
free  incision  into  the  joint,  or  other  means  which  will  be  considered  under  the  head  of 
"  Suppurating  Joints." 

Extensive  wounds  of  large  joint-e  complicated  with  other  injuries  had  better  be  treated 
by  amputation  or  excision. 

DISLOCATIONS. 

A  joint  is  said  to  be  dislocated  when  the  articular  surface  of  one  bone  is  displaced 
from  another.  When  the  bone  is  wholly  displaced,  the  dislocation  is  called  complete  ;  but 
when  otherwise,  partial  or  incomplete. 

When  a  wound  communicating  with  the  joint  complicates  the  case  it  is  known  as  a 
compound,  and  when  not  so  as.sociated  as  a  aimple.  dislocation. 

Congenital  dislocations  are  cases  of  malformation,  and  the  displacements  of  bones  pro- 
duced from  disease  are  accidental  complications  of  a  more  serious  aff"ection.  In  the  pres- 
ent chapter  neither  of  the.'se  two  conditions  will  receive  attention. 

Flower  and   Morris's   ^liddlesex   Hospital  statistics  (Holmes  s   System,  vol.  i..  3d  ed.) 


DisijxwTioys.  827 

tell  us  that,  out  of  75(1  caaos  of  (lislocatinii  of  the  upper  extremity  treated  in  twenty-six 
years,  20  were  of  the  elavicle,  1(J  of  tin;  seapula,  I)"')  of  the  liuiuerus,  112  of  the  elhow. 
1H7  of  the  thumb,  aud  7S  of  the  phalaii^'es.  At  (iuy's,  during  the  ten  years  endiii;r  with 
1888,  out  of  4(j  disloeatioiis  of  the  lower  extremity,  25  were  of  the  hip,  7  of  tlu;  patella, 
10  of  the  hones  of  the  foot,  and  4  partial  of  the  knee. 

Dislocations  are  mostly  eaused  hy  external  violenee,  hut  tht^y  occasionally  occur 
fioni  Miiisciilar  action,  as  in  dislocation  of  the  lower  jaw.  [  have  known,  however,  the 
head  of  the  Inimcrus  to  he  displaced  hy  the  exertion  uscmI  in  the  violent  throwint:  of  a 
stoni'  and  hv  the  spasm  of  muscles  in  an  epileptic  fit.  I  have  likewise  seen  the  hip-joint 
dislocated  1)V  mere  muscular  action.  Scdioolboys  are  also  familiar  with  the  dishjcation  of 
the  tlunul)  at  the  carpal  joint,  which  some  young  persons  who  jiossess  relaxed  liframents 
are  capahle  of  jjroducing  at  will. 

Laceration  of  tlu^  liganients  more  or  less  complete,  as  well  as  of  the  capsular  ligament, 
is  a  usual  accompaniment  of  all  <lisli)cations,  with  more  or  less  injury  to  the  mu.scles  and 
soft  parts  that  surround  the  injured  articulation.  In  exceptional  cases  the  capsule, 
in.stead  of  being  torn,  may  be  simply  stripped  off  the  bone.  At  times  the  nerves  are 
pressed  upon  or  lacerated  and  the  main  artery  pressed  upon,  stretched,  or  divided.  In 
shoulder  dislocations  the  circumflex  nerve  is  frequently  torn,  and  the  popliteal  artery  is 
injured  in  knee  dislocations.  In  all  joints,  more  particularly  in  the  ankle,  dislocation 
may  be  complicated  with  fracture. 

After  a  dislocation  has  been  reduced  most  of  these  injuries  are  steadily  repaired, 
although  some  weakness  of  the  joint  often  remains,  and  some  impairment  of  mobility. 
When  nerves  have  been  injured,  more  or  less  complete  local  paraly.sis  or  want  of  power 
follows  in  the  muscles  supplied  by  the  injured  nerves. 

When  a  dislocation  has  been  overlooked  or  neglected,  secondary  and,  in  a  measure, 
reparative  changes  take  place  and  a  new  joint  is  formed.  To  effect  this,  new  products 
are  poured  out  around  the  bone  in  its  new  position,  which  organize  and  ossify  (Fig.  484), 
The  cavity  thus  formed  becomes  lined  with  a  dense  layer 

of  fibrous  tissue,  putting  on  the  external  aspect  and  serv-  Fk;.  -484. 

ing  instead  of  cartilage.  The  head  of  the  bone  becomes 
at  the  same  time  altered  in  shape  and  surrounded  by  the 
condensed  cellular  tissue  of  the  part,  which  answers  for  a 
new  capsule.  A  large  amount  of  mobility  is  often  se- 
cured, particularly  in  the  ball-and-socket  joints.  When, 
however,  the  original  articular  cavity  becomes  gradually 
filled  in  with  fibrous  tissue,  the  muscles,  tendons,  and 
soft  parts  that  have  been  torn  or  misplaced  make  fresh 
attachments,  and  ossific  matter  is  deposited  in  the  ten- 
dons. 

How  long  these  secondary  changes  take  to  form  is 
not  vet  decided.     In  some  patients  the\'  doubtless  occur 

■-„.^;^ll,,     .,J    :       „4i  II  "D       11         i        J  XT'  •        False  .Toiut  iifter  Dislocation  of  the  Head 

rapidly  and  in  others  slowly,  as  rJrodhurst  and  J^ournier     of  the  Femur.   (From  .sir  a.  Cooper.) 
both   (*SV.  Gi'orge's  Hasp.  Rep.,  18G8)  record  a  case  in 

which  the  cartilage  of  the  acetabulum  was  found  healthy  and  the  cups  unfilled  three 
years  and  ten  years  respectively  after  a  dislocation.  Cadge  also  records  a  singularly 
instructive  example  (Med.-C/iit:  Trans.,  vol.  xxxviii.)  of  an  unreduced  dislocation  of  the 
head  of  the  femur  upward  between  the  two  anterior  spinous  processes  of  the  ilium  of  six- 
teen years'  standing,  in  which  ''  the  new  bone  was  deposited  in  such  abundance  that  it 
formed  a  new  and  complete  acetabulum — so  complete  as,  indeed,  to  hold  the  thigh  bone 
sus])ended  after  all  the  soft  parts  were  removed  and  make  it  requisite  to  saw  off  a  large 
piece  of  the  new  bone  in  order  to  set  the  femur  at  liberty.  The  new  cavity,  thin  at  its 
walls  and  smooth  on  its  outside,  was  lined  by  a  dense  pearly  white  ti.ssue  which  resembled 
fibro-cartilage.  The  head  of  the  femur  was  still  covered  with  cartilage.  The  old  ace- 
tabulum had  disappeared,  partly  by  the  absorption  of  its  cotyloid  margin  by  a  deposit  of 
new  bone,  and  partly  also  by  a  mass  of  dense  fibrous  tissue." 

Diagnosis  and  Symptoms. — Typical  examples  of  dislocation,  when  seen  at  an  early 
period  of  their  existence,  are  not  difficult  of  diagnosis,  although  partial  and  even  complete 
dislocations  .some  days  after  the  accident,  when  swelling  of  the  parts  has  taken  place,  are 
often  obscure.  The  frequency  with  which  such  cases  are  overlooked,  even  by  good  men, 
forbids  our  saying  they  can  always  be  made  out. 

In  evtri/  casf  of  xuspected  disJoaition  the  surgeon  ahoidd  compare  the  sovnd  tcith  the 
injured  side,  and  in  difficult  cases,  in  young  or  sensitive  subjects,  he  should  make  the 


828  CONTUSIOyS,  SPRAINS,   ASB    WOUSm   OF  JOISTS. 

examination  with  the  patient  anaesthetized.  In  doing  tliis  he  will  at  once  detect  the 
most  obvious  result  of  any  dislocation — deformity — and  be  able  to  make  out  the  direction 
the  displaced  bone  has  taken  :  he.  moreover,  will  see  whether  the  limb  is  longer  or  shorter, 
or  more  abducted  or  adducted,  than  its  fellow.  The  patient  will  have  lost  all  power  of 
voluntary  movement  ;  the  surgeon,  by  manipulation,  will  discover  that  where  mobility 
formerly  existed  such  will  be  seriously  impaired,  and  that  the  attempt  to  obtain  it  causes 
severe  pain.  There  will  be  an  absence  of  crepitus,  unless  some  days  have  passed  since 
the  accident,  when  the  crepitus  of  eflPu.sion  into  the  joint  or  into  the  bursas  about  the  joint 
or  tendons  will  often  be  felt.  JJe/orniif^,  loss  of  the  power  of  voluntary  motion,  and 
impaired  mobility,  coming  on  after  an  accident,  are  the  three  most  marked  symptoms  of 
dislocation.  Indeed,  these  symptoms  by  themselves.  With  the  absence  of  crepitus,  are 
usually  enough  to  enable  the  surgeon  to  diagnose  a  dislocation  from  a  fracture.  They 
are  not  enough,  however,  to  distinguish  it  from  the  separation  of  an  epiphvsis — an  acci- 
dent prone  to  aifect  subjects  under  the  age  of  twenty-one. 

Treatment. — In  all  cases  the  reduction  of  the  dislocation  or  displacement  should  be 
effected  as  soon  as  pos.sible.  delay  being  justifiable  only  when  the  appliances  required  for 
the  purpose  are  not  at  hand  or  the  diagno.sis  is  uncertain.  Most  dislocations,  not  exclud- 
ing those  of  the  hip.  may  be  readily  reduced  directly  after  their  occurrence  by  extension 
or  manipulation  without  the  aid  of  an  anaesthetic  ;  but  when  any  time  has  been  allowed 
to  pass  and  the  immediate  constitutional  effects  of  the  accident  have  subsided,  it  is  a  fair 
question  whether  it  is  advisable  to  attempt  reduction  before  ana}sthetizing  the  patient,  for 
under  the  mo.st  favorable  circumstances,  without  this  aid.  much  force  will  to  a  certainty 
be  called  for,  whilst  with  it  the  gentlest  manipulation  is  often  enough.  Indeed,  I  believe 
it  to  be  wiser  for  the  .surgeon  to  delay  any  attempt  to  reduce  a  dislocation  till  an  anaes- 
thetic can  be  obtained  than  to  make  it  without,  for  the  slight  harm  that  ensues  from  the 
delay  is  more  than  compensated  by  the  great  good  secured  b}'  its  use.  In  no  department 
of  surgery  is  the  benefit  of  anaesthetics  better  demonstrated  than  in  this,  for  where  force 
formerly  reigned  gentleness  now  suffices,  and  where  difficulty  and  pain  were  common 
accompaniments  facility  of  reduction  and  painlessness  are  now  the  rule.  Their  use  has 
superseded  the  old  treatment  by  venesection,  tartar  emetic,  the  string  of  students,  and 
the  pulleys.  Under  their  influence  all  muscular  spa.sm  ceases  to  be  a  force  which  has  to 
be  overcome,  and  the  surgeon  has  .simply  to  replace  the  bone  through  the  rent  in  its  cap- 
.sule  by  such  gentle  manipulative  acts  as  the  special  requirements  of  each  case  appear  to 
indicate.  The  facility,  however,  with  which  a  di.slocation  is  reduced  by  manipulation 
turns  much  upon  the  surgeon's  knowledge  of  the  way  the  di.slocation  was  produced,  for, 
in  a  general  sense,  the  best  way  to  reduce  a  di.slocation  is  to  make  the  head  of  the  bone 
retrace  the  course  it  followed  after  it  had  first  bur.st  through  its  capsule,  the  untorn  parts 
in  the  capsule  being  doubtless  the  main  obstacle  to  reduction ;  muscular  spasm  is  elimi- 
nated by  the  use  of  an  anaesthetic. 

In  neglected  cases  of  dislocation,  where  false  joints  and  adhesions  exist,  force  is  called 
for  to  break  them  down  and  pulleys  may  be  wanted,  but  they  mu-st  always  be  employed 
with  the  greate.st  caution  and  under  a  healthy  fear,  for  not  only  may  the  axillary  artery 
be  torn  and  ligaments  lacerated,  but  worse  injuries  may  ensue  ;  thus,  in  Paris,  in  1864, 
the  fore-arm  of  a  woman  aet.  64  was  torn  off  at  the  elbow-joint  in  the  attempt  to  reduce  a 
dislocation  in  the  humerus,  and  in  London,  more  recently,  the  same  dreadful  accident  has 
taken  place.  Agnew  in  his  Surgery  gives  24  cases  of  injury  of  the  axillary  artery  brought 
about  in  attempts  at  reduction  of  old  dislocations  of  the  humerus,  and  of  these  15  were 
fatal. 

After-Treatmext. — After  the  reduction  of  a  dislocation  the  limb  should  be  kept  at 
rest  and  fixed  by  bandages  on  a  splint ;  Sedillot's  rule  of  '•  simply  placing  the  joint  in  a 
position  the  opposite  of  that  in  which  it  was  when  the  dislocation  occurred  "  is  sound. 
When  any  signs  of  inflammation  .show  themselves,  cold,  in  the  shape  of  ice  in  a  bag, 
should  be  employed  ;  leeches  are  seldom  called  for. 

At  lea.st  three  or  four  weeks  are  required  for  repair  to  take  place  before  any  useful 
free  movement  of  the  joint  can  be  allowed,  although,  when  no  inflammatory  symptoms 
appear,  pas.sive  movement  may  be  permitted  at  the  end  of  two  weeks  ;  in  dislocation  of 
the  hip  no  walking  or  standing  .should  be  permitted  for  a  month. 

When  reduction  cannot  be  accomplished  after  a  reasonable  attempt,' a  second  one  may 
be  made  at  a  subsequent  period  after  the  effects  of  the  first  have  passed — that  is,  if  any 
sound  hope  exi.sts  of  success  being  secured — some  modification  of  the  means  employed 
probably  suggesting  themselves  to  the  surgeon  upon  reflecting  as  to  the  peculiarity  of 
the  case  and  the  cause  of  his  failure. 


DISLIKWTIOSS.  K2t» 

When  tlic  patient  is  ai»  adult,  the  (lirticiiltics  ami  prospects  of  the  rase  should  he  laid 
hi'fdif  hiui  and  his  npiuiiui  taken — not,  however,  as  to  the  desirahility  or  the  reverse  ol' 
the  attempt,  lor  such  an  opinion  hehtngs  to  the  surgeon  and  his  collea^^ues  oidy,  hut  as  to 
the  risks  that  must  he  run  ;  lor  in  many  cases  failure  of  reduction — more  particularly  of 
furcil)le  reduction — is  followed  hy  some  destruction  of  the  new  joint  that  nature  has  par- 
tially formed,  hy  some  inflammatory  chanp;  that  may  end  iti  the  dcstructinn  of  the  joint 
or  in  ri-ndcrinj;  its  usefulness  still  less  pnunisinj;. 

With  respect  to  the  propriety  of  atti-mptin;.'  the  reduction  of  an  (d<l  dislocatio?i  no 
definite  rules  can  he  laid  down,  and  since  an;esthetics  have  heeii  introduced  those  orif^in- 
ally  jriven  hy  Sir  A.  Cooper  and  ireMcrally  lollowed  rei|uiri'  modification.  Sir  A.  Cooper 
frave  three  months  as  a  limit  to  the  atti'inpt  in  the  shoulder,  and  ei^ht  weeks  in  the  hip; 
yet  Seilillot  reduced  a  dislocation  (d"  the  shoulder  more  than  a  year  after  its  rec<;ipt, 
Hrodluirst  on  the  one  hundred  and  seventy-fifth  day.  Smith  H-nited  States)  at  the  s(!venth 
and  tenth  numtli,  whilst  Hreschet  reduced  a  dislocated  hip  on  the  seventy-eifrhth  day, 
Travers  and  my  colleauue,  Mr.  Durham,  at  the  fifth  month,  lilackman  (of  Cirencester)  at 
the  sixth  month.  Vet  such  ca.ses  must  be  rare.  Ball-and-socket  joints  are  ahso  more 
readily  replaced  than  others.  The  best  guides  the  surgeon  possesses  for  his  decision  are 
found  in  the  amount  or  the  absence  of  repair  that  is  present  in  the  dislocated  joint.  When 
the  movement  is  good,  there  is  small  rea.son  for  making  the  attempt  ;  for,  writes  Fergus- 
son,  "  after  three  months  the  use  of  the  limb  is  not,  when  reduced,  greater  than  that 
which  it  would  have  ac((uired  in  its  dislocated  state." 

When  the  movements  are  very  limited,  a  cautious  attempt  to  reduce  the  dislocation  i.s 
hardly  likely  to  be  followed  by  a  bad  result,  at  whatever  period  it  is  made  ;  but,  as  previ- 
ously stated,  the  patient  and  the  surgeon  should  take  counsel  together  on  the  point  and 
share  res])onsihility. 

To  facilitate  the  reduction  of  an  old  dislocation,  it  is  needless  to  say,  .some  anaesthetic 
should  be  em])loyed :  ami  as  a  primary  step  all  adhesions  should  be  bnjken  down  by  free 
rotation  or  forcil)le  movements  of  the  joint.  W^hen  this  has  been  effected,  the  head  of 
the  bone  ought  to  be  replaced  by  manipulation  or  by  slight  extension,  forrible  extension 
being  inadmissible.  When  tendons  are  very  rigid  and  forbid  movement,  they  should  be 
divided  subcutaneously  ;  but  this  should  be  done  some  days  before  reduction  is  fully 
attempted. 

Compound  dislocation  is  one  of  the  most  serious  accidents  that  can  befall  a 
limb,  and  in  the  larger  joints  is  generally  complicated  with  fracture  or  torn  arteries.  In 
the  knee-joint  the  popliteal  artery  is  generally  lacerated,  and  under  such  circumstances 
amputation  is  the  only  resource.  In  the  ankle-joint,  where  the  accident  is  most  commonly 
seen,  the  case  should  be  treated  as  one  of  fracture  and  wounded  joint  by  immovable 
splints  after  its  reduction,  and  the  persistent  application  of  cold.  In  exceptional  cases 
only,  when  the  soft  parts  are  much  injured,  and  in  very  feeble  subjects,  ought  amputa- 
tion to  be  thought  of,  excision  of  the  articular  surface  being  always  a  point  for  considera- 
tion. In  the  elbow,  where  movement  is  of  essential  importance,  excision  had  better  be 
performed  when  the  wound  is  large,  although  recovery  with  movement  of  the  joint  may 
take  place  without  it  in  young  adults.  Under  all  circumstances  the  dislocation  ought  to 
be  reduced,  the  question  of  excision  or  amputation  turning  upon  the  amount  of  mischief 
the  soft  parts  or  bones  have  sustained. 

Compound  dislocations  and  compound  fractures  into  joints  are  clinically  of  very  sim- 
ilar import. 

When  dislocation  and  fracture  coexist,  difficulties  are  often  inet  with,  but  the  reduction 
of  the  dislocation  is  often  possible  by  manipulation  aided  by  anjiesthetics  where  without  it 
is  impossible,  and  I  have  reduced  with  its  aid,  in  one  case,  the  head  of  a  fractured  humerus 
from  the  subglenoid  position,  and  in  another  a  fore-arm  displaced  backward  with  fractured 
arm-bone,  and  afterward  in  each  case  adjusted  the  fracture  with  facility;  I  have  likewise 
seen  the  head  of  the  femur  displaced  upon  the  pubes  pressed  back  into  its  socket,  notwith- 
standing that  a  fracture  of  the  shaft  existed.  I  believe  that  in  the  majority  of  these 
cases  the  dislocation  may  be  successfully  treated  before  the  fracture,  the  fractured  bone 
being  at  the  same  time  moderately  extended.  It  may  be  prudent  in  some  to  apply  splints 
before  attempting  the  reduction  of  the  dislocation,  but  such  a  step  is  not  always  necessary, 
or,  indeed,  advi.sable.  for  with  the  limb  encased  in  splints  the  surgeon  has  less  influence 
upon  the  di.slocated  bone.  When  the  dislocation  cannot  be  reduced,  the  fracture  must  be 
dealt  with  in  the  ordinary  manner.  In  a  case  I  recently  had  under  care,  of  a  woman  aet. 
6G,  in  which  the  head  of  the  femur  was  dislocated  into  the  .sciatic  notch  and  an  impacted 
fracture  of  the  neck  of  the  thigh-bone  coexi.sted,  a  good  limb  was  secured. 


830  CONTUSIONS,  SPRAINS,  AND    WOUNDS  OF  JOINTS. 

Separation  of  Epiphyses. 

In  all  young  patients,  and  in  others  under  twenty,  where  a  dislocation  or  fracture  near 
a  joint  is  said  to  be  present,  the  surgeon  should  suspect  the  injury  to  be  one  of  partial  or 
complete  separation,  with  or  without  fracture  of  an  epiphysis,  and  particularly  when  any 
of  the  joints  of  the  upper  extremity  are  involved;  for,  whilst  dislocation  of  the  shoulder- 
joint  in  children  is  very  rare,  incomplete  separation  of  the  shaft  of  the  humerus  from 
its  upper  epiphysis  is  not  seldom  met  with  (Fig.  543),  and  by  far  the  majority  of  cases 
of  supposed  dislocation  at  the  elbow-joint  in  young  subjects  are  examples  of  displacement 
of  the  lower  epiphysis  of  the  humerus  together  with  the  fore-arm  bones.  The  same 
remarks  are  likewise  applicable  to  the  wrist-joint,  dislocation  of  such  in  young  people 
being  almost  if  not  quite  unknown,  whilst  separation  of  the  lower  epiphysis  is  probably 
comparatively  common.     A  pretty  example  of  this  kind  is  to  be  seen  in  Fig.  549. 

In  the  lower  extremity  these  cases  are  possibly  rare.  I  have,  however,  seen,  several 
examples  of  displacement  of  the  lower  epiphysis  of  the  femur  with  the  tibia  and  fibula, 
and  give  an  example  of  this  accident  in  Figs.  521  and  585,  and  I  believe  that  what  are 
regarded  as  severe  sprains  of  the  ankle  in  children  are  often  due  to  some  displacement 
of  one  or  other  of  the  malleolar  epiphyses,  since  I  have  seen  many  examples  of 
arrest  of  growth  in  limbs  that  had  been  supposed  to  have  been  previously  the  seat  of 
sprains. 

I  have,  moreover,  certainly  seen  two  cases  of  displacement  of  the  foot  outward  with 
the  lower  epiphysis  of  the  tibia,  one  of  which  was  compound,  with  the  ends  of  the  diaphy- 
sis  presenting  through  the  wound.  It  occurred  in  March  21,  1884,  in  a  boy  £et.  15,  from 
the  foot  being  caught  between  the  spokes  of  a  revolving  wheel.  The  parts  were  readily 
restored  to  their  normal  position,  and  a  good  recovery  ensued.  The  epiphysial  cartilage 
in  this  case  seemed  to  be  attached  to  the  diaphysis.  How  far  arrest  of  growth  in  the  bone 
will  ensue  time  must  prove. 

Again,  there  is  good  reason  to  believe  that  some  examples  of  acute  suppui'ation  of 
joints  following  injury  have  been  brought  about  by  this  cause,  and  that  a  partial  or  com- 
plete separation  of  an  epiphysis  in  the  hip,  shoulder,  elbow,  wrist,  or  ankle-joint,  associated 
with  a  tearing  away  of  the  periosteum  from  the  diaphysis  with  which  the  epiphysis  is  asso- 
ciated, is  occasionally  followed  by  acute  periosteal  inflammation  of  the  injured  parts,  com- 
plicated with  suppuration  of  the  contiguous  joint,  and  not  rarely  with  acute  articular 
necrosis. 

Dislocations  of  the  Upper  Extremity. 

Dislocations  of  the  spine  and  lower  jaw  have  been  considered  in  former  chapters 
(pages  237  and  449).     Those  of  the  upper  extremity  will  now  occupy  our  attention. 
Dislocations  of  the  Clavicle. — Dislocations  of  this  bone  at  its  sternal  end  are 
rare  accidents,  though  according  to  Flower  they  form  about  three  per  cent,  of  all  disloca- 
tions of  the  upper  extremity.     They  are  produced  by  violence  applied  to  the  shoulder 
p,  when    the    scapula    is    fixed,   the   clavicle    being   forcibly 

thrown  toward  the  mesial  line.  Dislocation  downward  is 
an  impossibility,  the  cartilage  of  the  first  rib  preventing, 
but  it  may  take  place  ./brii-rf re?,  upward,  or  backward,  and 
may  be  partial  or  complete. 

Dislocation  forward  is  usually  caused  by  some 
violent  pressure  of  the  shoulder  backward,  although  Me- 
lier  (Archives  Gen.  de  Med.,  tom.  xix.)  records  a  case  in  a 
child  where  it  was  produced  by  simply  pulling  the  arm. 
The  head  of  the  bone  in  this  accident  forms  a  marked  fea- 
ture and  cannot  be  mistaken  for  anything  else   (Fig.  485). 

Dislocation  of  Sternal  End  of  Clavicle  ■\\T^  i        t   i         i.-        •  j-    /  '  i    - ; „^ 

Forward.  (Drawing  27-ii,  Guy's  Mus.)    When  the  dislocation  \s  partial,  some  unusual   prominence 

of  the  end  of  the  bone,  on  comparing  it  with  its  fellow, 
will  suggest  its  nature,  the  bone  being  only  covered  with  skin  and  readily  pressed  back. 
When  complete,  the  nature  of  the  accident  will  be  still  better  marked, .and  the  end  of  the 
bone  will  be  usually  found  pointing  downward.  Inflammatory  thickening  of  the  joint 
should  not  be  mistaken  for  partial  displacement. 

Treatment. — There  is  usually  little  or  no  diflSculty  in  reducing  this  form  of  disloca- 
tion by  forcibly  drawing  back  the  shoulder  and  applying  pressure  to  the  displaced  bone, 
though  there  is  great  difficulty  in   keeping  the  bone  in  its  normal  position  ;  indeed,  as  a 


DisLocATfoxs  or  Tin-:  rrrr:n  rxriuiMirv.  831 

riilf,  it  is  (juitf  iiii|i(issil»le  to  dd  tliis  satisfactorily.  In  dik-  case  I  succeedcil  Ity  keep- 
ing; the  |»atii'iit  1)11  liis  bai'k  in  licil  fur  tlni-*'  weeks  with  his  arm  bound  to  liis  side.  A 
pad  in  the  axilhi,  witli  a  tijruve-of'-S  lianchijic  to  keep  tlie  shoulder  outward,  the  elbow 
bein^r  bouiul  to  tlie  .side,  will  do  much  towanl  the  desired  end,  and  a  j»ad  f>f  lint  applied 
outside  the  disjdaeed  end  of  the  elaviele  and  iirinly  fixed  in  position  by  strappinj;  carried 
over  the  shoulder  and  scapula  has  a  very  beneficial  tendency.  Nelaton  advises  the  use 
of  a  conmiou  hernia  truss.  The  sur<;eon.  however,  must  e.vpeet  a  certain  amount  of  fail- 
ure in  the  treatment  of  these  eases,  though  he  may  safely  assure  his  patient  that  the  use- 
fuliu'ss  of  the  arm  will  be  but  little,  if  at  all,  imjiaireil.  I  have  had  one  case  of  this 
dislocation  combini'd  with  fracture  of  the  sternal  end  of  the  b<ine.  in  which  the  dislocation 
was  reduccil  by  manipulation  and  the  arm  bandaijcd  with  a  fiootl  result. 

Dislocation  upward  is  very  rare.  Mal<j;aii:ne  has  recorded  four  such  cases, 
ilaniiltoM  another,  (l(S(ril)C(l  by  Dr.  Rochester  of  Buffalo,  and  Dr.  K.  \\.  Smitli  a  sixth 
(Ditbliii  JoHiitnl  of  Ml  ilicid  Sell  lice,  1S72).  In  18G5  such  a  case  came  under  my  care. 
It  was  in  ii  youn<:;  woman,  a  milliner,  ;et.  20,  who  two  years  before  was  violently  crushed 
in  a  crowd,  the  violence  causing  pain  which  was  referred  to  the  upper  part  of"  her  chest. 
She  was  treated  at  home  and  got  well,  although  with  a  deformity,  for  which  .she  consulted 
me.  On  examining  her  chest  the  sternal  ends  of  both  clavicles  were  felt  above  the  upper 
border  of  the  sternum,  behind  the  sternal  tendons  of  the  sterno-mastoid  muscles,  and  with 
the  slightest  pressure  upon  the  shoulders  the  two  ends  could  be  made  to  meet.  By  draw- 
ing the  .sh(uilders  backward  the  bones  could  be  separated  and  pressed  back  into  wliat 
appeared  to  be  their  normal  position,  but  no  apjiliance  could  keep  them  there.  The 
patient  had  good  movement  in  her  arms  aiul  followed  her  occupation.  I  have  the  notes 
also  of  a  second  case  that  came  under  my  care,  in  18Gr>,  in  which  one  bone  was  displaced; 
it  occurred  in  a  man  j^t.  35,  and  was  produced  by  a  fiill  on  tlie  shrtulder. 

In  the  Guy's  Museum  (1292'-"')  there  is  a  specimen  of  dislocation  of  the  clavicle  at  it.-j 
sternal  end  upward  and  forward.  It  was  taken  from  a  man  ret.  40  who  fell  from  a  height 
and  died  nine  days  later  from  pneumonia. 

Tkkat.ment. — In  the  treatment  of  this  as  of  the  last  form  of  dislocation  there  is  no 
difficulty  in  reducing  it  by  drawing  outward  the  shoulders  and  applying  pressure  upon 
the  bone,  but  there  is  much  in  keeping  the  bone  in  po-sition.  The  best  means,  however,  are 
the  application  of  a  pad  over  the  bone,  the  firm  pressure  of  the  .scapula  against  the  ribs 
by  means  of  broad  bands  of  strapping,  and  the  supine  position.  Under  all  circumstances 
the  surgeon  nuiy  comfort  the  patient  by  the  assurance  that  good  and  useful  movement  of 
the  arm  will  be  secured.      Ovrrlunul  movements,  however,  will  always  be  difficult. 

Dislocation  backward  stands  next  in  point  of  rarity  to  that  of  dislocation 
upward,  and  is  usually  caused  l)y  violence,  forcing  the  shoulder  forw^ard.  or  by  direct 
force.  I  have  seen  but  one  such  case,  in  a  man  aet.  52  who  was  crushed  by  falling  bricks, 
and  in  it  the  dislocation  was  self-reduced  on  the  secend  day,  when  the  man  was  in  bed. 

The  displaced  clavicle  so  presses  at  times  upon  the  trachea  and  oesophagus  as  to  interfere 
with  respiration  and  deglutition.  In  1845  a  sailor  aet.  17  was  admitted  into  Guy's  with 
such  an  injury,  the  dislocation  having  been  caused  by  a  blow  on  the  shoulder.  It  was 
easily  reduced  by  drawing  the  shoulders  back,  and  maintained  in  situ  without  difficulty. 
t]^a.ses  of  this  kind  have  been  recorded  by  Mr.  Brown  of  Callington  (Med.  Gaz.,  1845), 
and  M.  Pellieux,  1834  (Revue  Medicale).  In  one  singular  ca.se  recorded  by  Sir  A. 
Cooper  the  dislocation  was  produced  by  curvatiire  of  the  spine,  and  Mr.  Davie  of  Bungay 
excised  the  .sternal  end  of  the  displaced  bone  to  prevent  death  from  suffocation.  Mr.  C. 
de  Morgan  has  recorded  a  case  in  IToImes's  S?/sfem  in  which,  in  a  girl  a?t.  10,  the  bone 
was  thus  displaced  and  successfully  treated  by  means  of  a  splint  across  the  shoulder, 
with  a  pad  between  it  and  the  spine,  the  shoulders  being  drawn  to  the  splint  by  a  bandage 
and  the  child  kept  in  bed.  The  splint  was  removed  at  the  end  of  a  fortnight,  and  the 
articulation  in  fimr  weeks  became  as  firm  as  that  on  the  other  side  ;  the  arm,  moreover, 
could  be  moved  without  causing  any  ])ain. 

A  separation  of  the  sternal  epiphysis  of  the  clavicle  niay  take  place  and 

be  mistaken  for  dislocation.  This  can.  however,  occur  only  in  voung  life.  Mr.  C.  Heath 
brought  forward  an  example  of  this  kind  in  November,  1882,  before  the  Clinical  Society. 
It  occurred  in  a  boy  aet.  14  who  was  bowling  a  cricket-ball  when  he  felt  something  give 
way  at  his  collar-bone.  AVhen  seen,  the  inner  end  of  the  clavicle  was  unduly  prominent 
and  presented  a  sharp  edge  beneath  the  skin,  between  which  and  the  suprasternal  notch  a 
thin  lamella  of  bone  could  be  felt,  ijuite  unlike  the  smooth  end  of  the  bone  covered  with 
cartilage.  The  bone  fell  into  place  on  laying  the  patient  down,  and  was  kept  in  si((l  by 
means  of  a  plaster-of-Paris  bandage. 


832  CONTUSIONS,   SPRAINS,   AND    WOUNDS   OF  JOINTS. 

Dislocation  of  the  Scapula  ^a-  formerly  called  '•  dislocation  of  the  acromial 
end  of  the  clavicle."   but.  a.s  the  clavicle  is  a  fixed  point,  it  seems  only  consistent  with 

common  sense,   although  not  with  custom,  to  follow  Skey, 
Fig.  486.  Maclise,    and    Flower    and    call    what    have    hitherto    been 

described  as  dislocations  of  the  arromial  end  of  the.  clavicle 
dislocations  of  the  scapula. 

In  the  more  usual  form  of  this  accident  the  acromion 
process  of  the  scapula  is  forced  heneath  the  clavicle.  In  rare 
cases  it  may  be  received  above  it.  Both  are  commonly 
caused  by  direct  violence  to  the  shoulder. 

Symptoms. — The    symptoms   are    well    marked    in    both 
forms ;    the  falling  of  the  .shoulder  and  projection   upward 
of  the  acromial  end  of  the  clavicle  in  one  TFig.  48Gj,  and 
the  projection  upward  of  the  acromion  process  of  the  scapula 
'  \     in  the  other,  prevent  any  mistake  being  made. 
/  Treatment. — In   the  dislocation   of  the   scapula    down- 

ward the  aim  of  the  surgeon  is  to  raise  the  scapula  with  the 

dislocation  of  the  .Scapula   Down-  ii  .i  i-i  \.-   x^   •     -l      ^    ^  ■\^       i 

ward.  fMr.  Poland's  ca.se.;  ai"Di  ^"d  depre.ss  the  clavicle.  which  IS  oest  done  by  drawing 
the  elbow  well  backward  and  applying  a  pad  over  the  clavi- 
cle, the  pad  and  ellxjw  being  fixed  in  position  by  means  of  a  belt  or  plaster-of-Paris 
bandage  passed  over  the  clavicle  and  round  the  elbow.  The  belt  presses  the  clavicle 
downward  and  raises  the  shoulder  and  arm  upward. 

The  parts  fall  into  position  at  times  when  the  patient  assumes  the  horizontal  posture ; 
and  when  this  is  the  case  and  the  position  can  be  maintained  for  two  or  three  weeks,  it  is 
well  to  adopt  it.  At  others  a  pad  fixed  over  the  clavicle  by  means  of  strapping  or  a 
bandage  passed  between  the  axilla  will  suflBce,  but  the  surgeon,  recognizing  the  special 
wants  of  the  case,  must  adapt  his  means  to  meet  them  in  the  best  possible  way.  Oood 
mnveini-nts  of  the  arm  are.  a<  a  rule  acquired  in  time  after  either  of  these  accidents. 

Dislocations  of  the  Humerus  form  at  least  half  of  all  dislocations,  and  a  suf- 
ficient explanation  of  this  fact  is  to  be  found  in  the  globular  form  of  the  head  of  the  humerus, 
the  .shallowness  of  the  glenoid  cavity,  the  free  movement  of  the  articulation,  and  its  liabil- 
ity to  direct  and  indirect  injury. 

In  40  out  of  GO  consecutive  cases,  or  in  two-thirds  of  them.  I  found  a  direct  blow 
upon  the  .shoulder  was  the  cause  of  the  accident,  while  in  the  exceptional  cases  a  fall 
upon  the  extended  arm  or  elbow  or  a  forcible  dragging  backward  of  the  arm  was  the 
assigned  cau.se.  The  accident  is  rare  in  childhood,  although  I  have  seen  an  in.stance  of  it 
at  the  age  of  thirteen,  while  Flower  and  Hulke  have  recorded  a  case  in  an  infant  four- 
teen days  old.  Two-thirds  of  the  cases  are  found  in  men  between  fifty  and  seventy  years 
of  age,  it  being  comparatively  rare  in  women  and  in  young  adult  life.  I  have,  however, 
treated  one  in  a  man  act.  75. 

Analysis  of  Sixty  Consecutive  Cases. 

Out  of  60  cases,  31  were  described  as  suhglenoid.  or  downward.  25  sidjcoracoid,  or 
forward,  and  4  svhspinons,  or  backward;  49  were  in  males,  and  11  in  females.  I  am  dis- 
posed to  think  that  many  of  the  cases  called  subglenoid  were  subcoracoid. 

4  were  in  subjects  under       20  years  of  age. 
17         "  "        between  21  '"  and  50. 

38         "  "  "         51  "  "     70. 

1  aged  75. 

The  head  of  the  humerus  may  be  dislocated — 1.  Dov:nv:ard — svhglenoid ;  2.  Forward 
— subcoracoid  ;   3.   Backuard — sidjspiootis. 

When  the  coracoid  process  has  been  broken  off.  the  head  of  the  humerus  may  be 
displaced  over  the  root  of  the  former,  two  or  three  such  cases  being  on  record.  The 
supracoracoid  and  subdavicular  dislocations  are  very  rare. 

Subcoracoid. — This  is  without  doubt  the  most  common  form  of  dislocation. 
Flower  has  shown  {Patlt.  Hoc,  vol.  xii.)  that  thirty-one  out  of  the  forty-one  specimens 
of  dislocation  of  the  shoulder-joint  found  in  the  London  museums  belong  to  this  class. 
In  it  the  head  of  the  humerus  rests  on  the  anterior  lip  of  the  glenoid  cavity  beneath  the 
coracoid  process,  or  even  more  forward,  the  completeness  of  this  dislocation  turning  upon 
the  amount  of  laceration  of  the  attachment  of  the  posterior  scapular  mu.scles.  "When  they 
are  completely  torn  through  at  their  insertion  into  the  great  tuberosity  of  the  humerus  or 


DISLOCATIOyS   OF   THE    I'I'I'KIt   KXTIIEMITY 


833 


the  tuberosity  is  torn  off,  the  lieud  o\'  the  bone  will  be  more  forward  than  when  they  are  only 
stretched  or  iiartiallv  divided.     Many  of  the  eases  described  by  Sir  A.  Couper  as  dislucation 


Fici.  487. 


Fir;.  4«H. 


Suhccracai/ 


From  Mr.  Flower's  Models,  Middlesex  Hosp.  Mus. 


Subcoracoi'l  J'i-l.M;itii>ii  of  Head  of 
Humerus.    (Drawing  :i7*^.; 


downward  or  as  partial  dislocation  were  doubtless  of  this  kind,  and  many  others  recorded  as 
examples  of  subclavicular  are  nothin<r  more  than  specimens  of  this  variety  (Fig.  487). 

Symptoms. — The  symptoms  of  this  form  of  dislocation,  in  their  general  character,  are 
the  same  as  in  most  others,  such  as  inability  to  move  the  arm.  immobility',  and  pain  often 
passing  down  some  nerve-trunk  and  aggravated  bj*  movement.  On  looking  at  the  part 
and  comparing  the  injured  with  the  sound  side  before  swelling  has  appeared,  some  .strik- 
ing points  will  be  observed,  such  as  flattening  of  the  deltoid,  prominence  of  the  acromion, 
and  a  depression  beneath  it.  Extra  prominence  will  also  be  seen  below  the  coracoid  pro- 
cess, from  the  head  of  the  bone  pushing  forward  the  pectoral  muscle  (Fig.  488)  :  from 
behind,  too,  there  will  be  some  flattening  of  the  .shoulder.  There  will  be  little  or  no 
lengthening  of  the  limb,  but  the  elbow  will  be  found  projecting  more  or  less  from  the 
side  ;  the  movements  of  the  fore-arm  will  Vje  perfect.  On  manipulating  the  shoulder  the 
head  of  the  bone  will  be  felt  beneath  the  pectoral  muscle  in  front  of  the  scapula,  and  from 
the  elbow  it  will  be  made  to  move. 

Dislocation  dowil"Ward,  or  subglenoid,  although  usually  given  as  the  most 
common,  is  probably  second  in  freijuency  to  the  subcoracoid  just  described.  Flower 
asserts  that  nut  one  in  ten  of  all  dislocations  of  the  humerus  can  properly  be  called  sub- 
glenoid. In  it  the  head  of  the  bone  rests  below  the  glenoid  fossa  (Fig.  487).  the  rent  in 
the  capsule  being  at  its  inferior  instead  of  its  anterior  border,  and  the  soft  parts  mechani- 
cally interfering  with  the  natural  tendency  of  the  deltoid,  coraco-brachialis.  and  biceps  to 
draw  the  head  of  the  humerus  upward  toward  the  coracoid  process. 

Symptoms. — The  most  con.stant  are  immobility  of  the  arm,  as  well  as  inability  to 
move  it  without  pain,  with  a  greater  separation  of  the  elbow  from  the  side,  a  more  marked 
flattening  of  the  shoulder,  greater  depression  beneath 
and  extra  prominence  of  the  acromion  than  are  met  with 
in  the  subcoracoid  variety.  The  most  typical,  however, 
are  a  depression  of  the  anterior  fold  of  the  axilla,  from  a 
drawing  down  of  its  attachment ;  a  falling  of  the  breast, 
as  indicated  by  a  lower  position  of  the  nipple ;  the 
marked  presence  of  the  head  of  the  bone  in  the  axilla ; 
the  separation  of  the  coracoid  process  and  the  head  of 
the  malplaced  bone  by  a  space  of  one  to  two  inches  (Fig. 
489)  ;  and  a  clear  elongation  of  the  arm  for  one  and  a 
half  inches. 

Hulke  describes  {flolmeiCs  Si/sfem.  vol.  i.  3d  ed.  p. 
'.•78)  two  rare  examples  of  a  variety  of  subglenoid  dislo- 
cation which  he  saw  in  the  practice  of  the  late  Sir  W. 
Fergusson.  In  Ixith  the  arm  was  strongly  abducted  nud 
raided,  the  elevation  being  so  great  as  to  make  one  patient 
seek  support  of  the  arm  by  grasping  the  end  of  a  stick 
raised  above  his  vertex,  whilst  the  other  rested  his  hand  on 
the  top  of  his  head.  In  neither  could  reduction  be  effected. 
63 


T^iG.  489. 


SuI)u'lenoid  TMslocation  of  .'Sixteen  Weeks' 
Standine.  iTakt-u  from  a  man  aet.  .Vj. 
shiiwint;  depression  of  the  anterior  fold 
of  the  axilla,  falling  of  the  breast,  and 
elongation  of  arm.; 


834 


CONTUSIOSS,  SPBAIXS,  AXD    WOUyDS  OF  JOIXTS. 


Dislocation  Backward,  or  Subspinous. — This  is  next  in  rarity  to  the  last, 

and  in  it  the  head  of  the   bone  rests  beneath  the  spine  of  the  scapula  or  base  of  the 
acromion  (Fig.  490)  ;  the  latter  position  being  a  less  complete  luxation  than  the  former, 


Fig.  490. 


Fig.  491. 


Sui~spLncus 


Sf/h  -  cZar  ■iri/Ia  i 


From  Flower's  Models,  Middlesex  Hospital. 


Subspinous  Dislocation  of  Head  of 
Humerus.    (Taken  from  life.) 


and  more  common.  It  corresponds  to  Malgaigne's  '•  subacromial  "  variety,  this  complete- 
ness of  the  dislocation  depending  upon  the  amount  of  laceration  of  the  muscles  attached 
to  the  bone,  and  more  particularly  of  the  subscapularis. 

Symptoms. — The  symptoms  of  this  accident  are  very  marked.  Looking  at  the  shoul- 
der in  front,  there  will  be  the  flattening  of  the  deltoid  and  prominence  of  the  acromion 
as  usual,  but  there  will  be  a  marked  flattening,  if  not  depression,  of  the  soft  parts  below 
the  coracoid  and  acromion  processes.  The  elbow,  instead  of  being  fixed  away  from  the 
side,  will  be  drawn  to  it  and  forward,  the  fore-arm  generally  pointing  outward.  The  back 
view,  however,  is  the  most  typical,  the  head  of  the  bone  covered  with  muscles  and  soft 
parts  forming  a  prominent  feature  in  the  case  (Fig.  491).  I  had  under  observation  a 
patient  about  thirty  years  of  age  who  could  at  will  dislocate  her  shoulder  in  this  direc- 
tion by  muscular  action.  In  this  dislocation  the  limb  is  said  to  be  slightly  longer  than 
normal,  but  I  have  not  found  it  so. 

Subclavicular  Dislocations,  in  which  .the  head  of  the  humerus  rests  below  the 
clavicle  on  the  sternal  side  of  the  coracoid  process,  are  exceedingly  rare  (Fig.  490).  I 
have  never  seen  a  complete  example.  Malgaigne  informs  us  that  in  it  the  arm  is  pressed 
against  the  chest  with  the  elbow  slightly  removed  from  the  side,  the  head  of  the  bone 
beins:  felt  and  seen  in  its  abnormal  position  and  the  shaft  instead  of  the  head  of  the 
humerus  felt  in  the  axilla.  The  bulk  of  cases  recorded  as  of  the  subclavicular  kind  are 
probably  subcoracoid. 

The  SUpracoraCOid  dislocation  is  a  mixed  form  of  accident,  as  it  is  secondary  to  a 
fracture  of  the  coracoid  process.  Malgaigne  has  recorded  an  example,  and  Holmes,  in 
the  Med.-Chir.  Tram.,  vol.  xli..  a  second,  with  an  account  of  the  dissection  of  the  case, 
the  preparation  being  in  St.  George's  Museum.  He  also  describes  a  third,  which  occurred 
in  the  practice  of  Sir  P.  Hewett. 

Some  points  in  diagnosis  remain  to  be  told,  and  the  most  important  was  pointed  out 
by  the  late  Mr.  T.  Callaway  in  his  excellent  Jacksonian  prize  essay  for  1849,  which  is 
"  that  in  taking  the  vertical  circumference  of  any  shoulder  in  which  dislocation  exists  hy 
means  of  a  tape  carried  over  the  acromion  and  binder  the  axilla  an  increase  of  about  tico 
inches  over  the  sound  side  is  an  invarifdAe  concomitant.'"  He  .should  iiave  added,  however, 
that  this  test  is  applicable  only  to  recent  cases,  and  not  to  such  as  show  muscular  atrophy. 
The  same  author  also  shows  how  elongation  of  the  limb  does  not  take  place — at  any  rate, 
to  any  extent — the  different  accounts  given  by  authors  on  this  point  .depending  upon  the 
fact  that  they  are  content  with  optical  rather  than  actual  mea.surement.  Professor  Dugas 
of  Georgia  has  also  pointed  out  (Southern  Jfd.  and  Sure/.  Journal.  1856)  a  sign  of  dis- 
location of  the  shoulder-joint  that  merits  more  notice  than  it  has  received,  and  I  am 
indebted  to  Dr.  W.  Briggs  of  Nashville  for  calling  my  attention  to  it.  It  is  based  upon  the 
physical  fact  that,  in  consequence  of  the  rotundity  of  the  thoracic  walls,  it  is   impossible  for 


DISLOCATIONS  OF  TIIK   UPPER  EXTREMITY. 


835 


JiotJi  eiiifs  1)/'  (hr  /limit  nis  tu  laiirli  (Id m  n/  t/ir  sniiu'  linn .  "  li"  ilic  fiii^rrrSj  therefore,  of  the 
injured  liiiili  eaii  he  j)hi('eil  hy  the  patient  or  l)y  tlu;  surj^eoii  uj»on  the  souufl  shoulder 
while  tlie  ilhow  touehes  the  thorax — a  condition  that  ohtains  in  thi'  normal  condition  of 
the  joint — there  can  he  no  dislocation.  And  il"  this  cann<it  he  done,  there  inniit  he  one; 
for  no  other  injury  than  a  dislocation  can  induce  this  phy.sieal  impossihility."  Dr.  V. 
Hamilton  has  likewise  shown  (  Lmid.  Mnl.  AVc,  April,  ISTOj  how  in  a  dislocation  a  rule 
will  touch  at  the  same  time  the  acromion  process  and  the  clhow  of  the  injured  side — a 
condition  that  cannot  exist  in  health. 

It  .sometimes  ha])pens  that  the  head  of  the  hone  after  its  apjiarent  reduction  fails  to 
remain  in  position  and  falls  out  again  ;  and  when  this  occurs,  it  becomes  a  question 
whether  some  part  of  the  glenoid  cavity  is  fractured  or  some  other  fracture  exists.  I 
have  recently  seen  a  case  of  dislocation  of  the  head  of  the  humerus  forward  and  down- 
ward in  which  a  portion  of  the  glenoid  cavity  was  broken  off'  and  displaced  downward, 
as.sociated  with  severe  injury  to  the  radio-spiral  nerve.  In  children,  or  young  persons 
under  twenty-one,  the  u])])er  epiphysis  of  the  humerus  may  be  separated,  or,  rather,  the 
shaft  of  the  humerus  may  be  displaced  oft' the  epiphysis,  which  retains  its  normal  position, 
and  under  these  circumstances  the  arm  should  be  most  carefully  manipulated  under  chlo- 
roform, to  make  the  diagnosis  sure.  In  exceptional  cases,  however,  this  slipping  out 
again  is  not  to  be  explained  by  these  complications,  for  in  the  case  of  a  man  ;ct.  75  who 
had  a  dislocation  backward  the  head  of  the  bone  could  not  be  kept  in  position  till  the 
muscles  began  to  act  after  the  eff'ects  of  the  chloroform  had  subsided,  and  I  had  to  hold 
the  bone  in  place  till  the  patient  recovered  and  the  muscles  acted  naturally. 

Treatment. — The  use  of  anresthetics  has  completely  revolutionized  the  treatment  of 
di-slocations,  and  at  the  present  day  nothing  can  usually  be  simpler  than  the  reduction  of 
a  dislocation  of  the  shoulder,  and  what  was  formerly  called  reduction  by  stratagem  is  now 
the  rule.  "  If  you  can  get  a  person  off'  his  guard,"  wrote  Abernethy,  ''you  have  first  to 
put  your  hand  up  to  the  head  of  the  bone,  depress  the  elbow,  and  it  will  sometimes  suc- 
ceed in  putting  it  in;"  and  the  modern  surgeon,  in  describing  the  reduction  of  dislocations 
by  mnnlpuhuion,  might  use  the  saine  language.  To  reduce  a  dislocated  humerus  by  manipu- 
lation  an   anassthetic   is   essential ;    and 

when  the  patient  is  fully  under  its  in-  Fiu.  492. 

flucnce,  as  well  as  in  the  horizontal  po- 
sition, the  surgeon  should  grasp  the 
shoulder  with  one  hand  and  the  flexed 
elbow  with  the  other  (Fig.  492,  A). 
When  the  dislocation  is  subglenoid  or 
subcoracoid,  the  thumb  of  the  surgeon 
may  be  placed  over  the  head  of  the 
bone  and  the  fingers  over  the  spine  of 
the  scapula,  the  thumb  acting  as  a  ful- 
crum ;  Avith  the  other  hand  the  flexed 
elbow  .should  be  drawn  from  the  side 
and  extension  made,  some  slight  rotatory  movement  outward  being  emploj'ed.  When 
extension  has  been  carried  to  its  full  extent,  the  elbow  should  then  be  raised  and  the  arm 
made  to  describe  a  semicircle  in  the  direction  of  the  sternum  and  the  f\\ce,  and  then  sud- 
denly brought  down  to  the  side  of  the  thorax,  the  head  of  the  humerus  at  the  same  time 
being  rotated  inward.  The  thumb  of  the  opposite  hand  should  give  the  right  direction 
to  the  head  of  the  bone  (Fig.  -192,  B).  Should  the  first  attempt  fail,  a  second  may  suc- 
ceed, or  possibly  a  third.  In  the  majority  of  dislocations  of  the  shoulder  this  method 
will  succeed.  In  Philadelphia  this  practice  is  known  as  H.  Smith's  method.  In  the  dis- 
location backward,  or  subspinous,  the  same  method  will  suffice,  but  in  that  ease  the  head 
of  the  bone,  being  behind  the  glenoid  cavity,  refpiires  pu.shing  forward.  Under  such  cir- 
cumstances the  surgeon  .should  stand  slightly  behind  the  patient,  with  one  hand  grasping 
the  axilla,  with  the  thumb  behind,  and  with  the  other  the  elbow,  making  extension ; 
reduction  may  then  be  eflFected  by  drawing  the  elbow  backward  and  rotating  the  bone. 
By  these  means  I  easily  reduced  an  interesting  case  of  dislocation  backward  (subspinous) 
complicated  with  fracture  of  the  ribs  of  the  same  side  and  of  the  opposite  clavicle. 
When  these  moans  fail  or  when  chloroform  is  not  at  hand,  reduction  by  means  of  exten- 
sion with  the  heel  in  the  axilla  should  be  employed,  the  surgeon  with  his  unbooted  heel 
pressing  upon  the  head  of  the  humerus  or  lower  border  of  the  axilla,  and  with  his  hana 
grasping  the  fore-arm  of  the  misplaced  limb  and  making  .steady  extension  ;  .some  slight 
rotatory  movement  often  facilitates  reduction.     The  head  of  the  bone  usually  slips  into 


Extension,  Adduction,  and  Rotation  Outward. 


836 


CONTUSIONS,  SPBAINS,  AND    WOUNDS  OF  JOINTS. 


Clove-Hitch. 


its  place  with  a  perceptible  jerk,  and  the  moment  this  is  felt  all  extension  should  be 
stopped. 

To  facilitate  extension  the  clove-hitch  (Fig.  -493)  may  be  employed,  and  instead  of  the 
heel  Mr.  Skey's  well-padded  iron  knob. 

Mr.  W.  F.  Teevan  informs  me  that  he  has  known  the  third  rib  to  be  fractured  in  the 
attempt  to  reduce  a  dislocation  of  the  head  of  the  humerus  with  the  foot  in  the  axilla. 

If  the  humerus  still  resists,  the  following  plan,  writes  Hulke  (^Hohnea's  Surgery^  vol. 
i.,  3d  ed.),  '■  which  I  have  never  known  to  fail  in  a  recent  dislocation,  may  be  tried.  The 
patient  is  seated  in  a  high  chair,  which  is  placed  about  two  feet  from  the 
post  of  an  open  doorway ;  the  surgeon,  having  his  back  against  the  door- 
post, places  one  foot  upon  the  side  of  the  chair  and  with  his  knee  presses 
into  the  axilla,  and,  with  both  hands  upon  the  shoulder,  steadies  the  pa- 
tient's body  ;  a  jack-towel  is  then  fixed  by  a  clove-hitch  knot  to  the  pa- 
tient's arm,  just  above  the  elbow,  and  by  its  means  two  or  three  assistants, 
placed  on  the  other  side  of  the  doorway,  make  steady  extension  horizon- 
tally outward." 

This  is  only  a  modification  of  Sir  A.  Cooper's  plan  of  bending  the  ex- 
tended arm  over  the  knee,  placed  in   the  axilla  with  the  patient  sitting, 
using  the  humerus  as  a  lever,  and  is  doubtless  a  good  one. 

In  1870,  Kocher  of  Bern  (Berlin  Klin.  Woch.,  No.  9,  1870)  introduced  the  following 
new  and  simple  method  of  reducing  subcoracoid  dislocations,  which  has  been  much  and 
successfully  practised  at  Guy's  : 

With  the  patient  sitting,  the  surgeon  grasps  the  elbow  of  the  affected  limb  with  the 
fore-arm  flexed  at  a  right  angle,  presses  it  firmly  to  the  side  of  the  patient's  chest,  and 
rotates  the  flexed  fore-arm  and  arm  outward  as  far  as  they  will  go — that  is.  until  firm 
resistance  is  experienced.  He  then,  with  the  arm  still  rotated  outward,  carries  the  elbow 
forward  and  inward  over,  but  away  from,  the  chest,  toward  the  median  line  of  the  body, 
and  suddenly  rotates  the  arm  inward,  carrying  the  hand  of  the  aff"eeted  limb  by  this 
movement  toward  the  sound  shoulder.  By  this  last  movement  the  head  of  the  bone  is 
replaced  in  the  glenoid  cavity. 

Mr.  .J.  E.  Kelly  of  Dublin  also  recommends  a  method  of  reduction  which  in  his  and 
his  colleagues'  hands  has  proved  successful  in  twenty-seven  cases.  In  it  the  patient 
should  be  placed  on  his  back  at  the  edge  of  a  couch,  lower  by  three  inches  than  the  great 
trochanter  of  the  operator.  •'  The  operator  places  the  injured  arm  at  right  angles  to  the 
body,  and,  standing  again.st  it  with  his  side  to  the  patient  and  his  hip  pressed  firmly,  but 
not  roughly,  into  the  axilla,  he  folds  the  arm  and  hand  of  the  patient  closely  round  his 
pelvis  and  fixes  the  hand  firmly  by  pressing  it  against  the  crest  of  his  ilium.  The  second 
step,  during  which  the  reduction  is  aflfected.  is  ver}'  simple,  consisting  merely  of  a  rota- 
tion or  version  of  the  surgeon's  bodj'  outward  away  from  the  patient  with  a  force  and 
rapidity  which  necessarily  vary  with  the  peculiarity  of  the  dislo- 
cation, some  yielding  most  readily  to  a  sudden  and  powerful  effort, 
and  others  to  gentle  and  irraduallv  increasing  traction  '"  (Utth/in  Jour- 
nal of  Merl.  Soc,  September,  1882). 

Should  these  means  fail,  success  may  be  secured  by  drawing  the 
arm  vertically  upward,  as  practised  by  White  of  Manchester  in  1704, 
and  recently  advocated  by  Mr.  Lowe  of  Burton-on-Trent  (St.  Barth. 
Rep.,  1870).  In  1SG4  I  succeeded  by  these  means  in  the  case  of  a 
subglenoid  dislocation  of  one  month's  standing  in  a  man  set.  64,  the 
method  of  manipulation  and  extension  having  failed,  and  again, 
more  recently,  in  a  similar  case  of  twenty-four  hours'  standing,  in  a 
gentleman  fet.  30.  when  every  other  means  had  proved  unsuccess- 
ful (Fig.  494).  Mr.  Lowe  places  his  patient  in  a  sitting  posture  on 
the  floor  and  then  stands  behind  him  on  a  sofa,  forcibly  extending 
the  dislocated  arm  upward,  the  scapula  being  kept  fixed  by  the  sur- 
geon's foot.  In  all  cases  the  extension  should  be  gradual  and 
steady,  the  counter-extension  effective;  no  jerking  or  great  force 
should  be  allowed ;  pulleys  are  to  be  looked  upon  as  dangerous  ap- 
pliances :  with  the  use  of  anaesthetics  they  should  be  abandoned. 
In  recent  dislocations  they  are  never  needed,  and  in  the  old  adhesions  should  be  broken 
through  by  forcible  rotation  and  flexion  of  a  joint  rather  than  by  extension. 

Extension  forward  is  at  times  beneficial.  It  proved  successful  in  my  hands  in  a  case 
of  subspinous  dislocation  of  three  weeks'  standing  in  a  man  aet.  75. 


Fig.  494. 


Reduction  by  Extension  of 
Arm  Upward. 


Disi.ocATioss  I  IF  riir:  rrr/:/:  i-:xtremity. 


837 


III  ii  iKirlcctfd  (lisli)rati(iii  u|'  t wriit y-fivr  ilays'  stiiii(liii<r  .Mr.  ("nek  succefclcd  in  1859 
(rn/c  author  On  Discasis  nut/  /njurirs  of  ./(jt'nts,  iKf)!!]  l>y  the  followiiij^  plan,  all  other 
means  liavinj;  failed  :  "  An  air-jiad  made  (if  vulcanized  in<lia-riilil)er  was  jiluced  in  the 
axilla  and  the  arm  Hrnily  l>andatred  t<i  the  siile,  the  air-pad  thus  heinjj;  made;  to  exert  a 
powerful  out  wan!  pressiirr  iipnii  the  head  of  tlie  hone.  Tpon  removing  the  bandage 
upon  the  third  liay  tlie  head  .if  the  hone  was  louml  to  have  returned  to  its  natural 
position.' 

Without  ;iii;estheties  olistaeles  to  the  reduetimi  of  a  (H.-loeatioii  of  the  -houjder  are 
niuseular  spasm  and  tlie  ditlieiilty  of  replacing  the  head  oi'  the  hone  throtigii  the  rent  in 
its  capsular  ligament  ;  with  them,  the  resistance  of  the  muscles  is  an  element  which  has 
not  to  he  considered,  the  second  one  alone  existing.  In  old  dislocations  the  presence  of 
adhesiiuis  is  an  extra  element  of  difficulty. 

AFTKit-'ruK.VT.MKNT. — After  the  reduction  of  a  dislocation  the  arm  should  he  hound 
to  tlie  side  for  a  week  and  kept  at  rest  for  a  fortnight  or  more,  with  the  ohject  of  giving 
time  fiu-  the  lacerated  or  injured  parts  to  repair  and  recover  their  power.  All  violent 
e.xertion  should  he  forhidden,  and  nothing  more  than  passive  motion  should  he  sanctioned 
for  several  months. 

It  happens  at  times  that  the  trunks  of  the  nerves  are  so  injured  a.s  to  give  ri.se  to 
paralysis  of  the  muscles  supplied  by  them.  I  have  seen,  in  one  case,  the  parts  supplied 
by  the  ulnar  nerve  permanently  paralyzed,  and  in  another  those  supplied  by  the  musculo- 
spiral.  It  is  by  no  means  uncommon  to  find  the  circumflex  nerve  so  injured  as  to  be  fol- 
lowed by  a  most  complete  wasting  of  the  deltoid  muscle.  In  many  cases,  however,  in 
which  paralysis  follows  dislocation,  recovery  may  ensue ;  and  in  a  very  marked  example 
I  saw  in  lS7-t,  in  which  paralysis  of  all  the  parts  supplied  by  the  radio-spiral  nerve  was 
most  complete,  recovery  took  place  in  fifteen  months. 

In  neglected  dislocation  of  the  shoulder  it  is  always  a  difficult  question  to  decide  as 
to  the  expediency  of  attempting  reduction.  Sir  A.  Cooper  used  to  .say  that  after  twelve 
weeks'  rest  an  attempt  should  not  be  made,  and  in  a  certain  sense  such  an  opinion  is  cor- 
rect ;  but  there  are  many  cases  of  less  standing  in  which  the  attempt  would  be  wrong,  and 
some  few  of  much  longer  standing  in  which  it  would  be  right. 

Where  good  movement  exi.sts  after  twelve  weeks  there  is  little  need  for  the  attempt, 
unless  under  exceptional  conditions.  When  bad  movement  exi.sts,  or  none  at  all,  the 
attempt  may  be  made ;  for  cases  are  on  record  in  which  reduction  has  been  effected  after 
a  year  or  more. 

Fracture  and  Dislocation  of  the  Head  of  the  Humerus.— Dislocation 

of  the  head  of  the  humerus  is  sometimes  associated  with  IVacture  of  the  neck  of  the 
bone.  It  is,  as  a  rule,  caused  by  a  direct  fall  or  blow 
upon  the  shoulder,  and  it  is  probable  that  the  dislocation 
occurs  first  and  the  fracture  follows.  I  have  seen  two 
undoubted  examples  of  the  injury.  In  one,  a  boy  act. 
10,  the  head  of  the  bone  was  dislocated  backward  be- 
neath the  spine  of  the  scapula,  and  in  the  second,  a  man, 
beneath  the  coracoid  process.  When  the  dislocation  can 
be  reduced  at  once,  as  it  may  by  means  of  an  anajsthetic, 
so  much  the  better.  When  it  cannot,  the  fracture  must 
be  treated  and  the  dislocation  left  alone,  good  movement 
at  times  being  the  result.  In  Fig.  -195  such  a  complica- 
tion existed.  The  preparation  was  taken  from  a  gentle- 
man xt.  64,  three  months  after  the  injury,  before  union 
had  taken  place  at  the  seat  of  fracture. 

It  must  be  remembered  that  cases  of  fracture  of  the 
humerus  about  its  tuberosities,  when  united,  often  sim- 
ulate those  of  dislocation. 

Compound  dislocations  of  the  shoulder 

are  grave  accidents  ;  and  when  the  soft  parts  have  been 
much  injured,  the  best  plan  is  probably  to  resect  the  head  of  the  bone,  although,  when 
the  wound  is  limited  or  clean  and  reduction  easy^  it  may  be  right  to  treat  the  case  as  one 
of  wounded  joint. 

Dislocation  of  the  Elbow. — This  accident  is  most  common  in  early  life,  and 
according  to  the  -^Iiddlesex  Hospital  table  (Holmis'a  Si/st.,  vol.  i.)  more  than  half  the 
cases  occurred  in  boys  between  the  ages  of  five  and  fifteen.  Out  of  33  cases.  Dr.  Ham- 
ilton found  19  in  children  under  fourteen  years  of  age.     At  Guy's  these  proportions  are 


Fig.  495. 

Corel  roifi 


drromion 


Dislocation  of  the  Head  of  the  Humerus 
associated  with  Fracture.  (Prep.  1114*, 
Guy's  Hosp.  Mus.) 


838 


CONTUSIONS,  SrEAINS,  AND    WOUNDS  OF  JOINTS. 


not  quite  so  large  ;  for  out  of  13  cases,  G  were  in  subjects  between  ten  and  twenty,  3 
between  twenty  and  thirty,  3  between  thirty  and  forty,  and  1  between  forty  and  fifty. 
In  only  one  case  was  the  subject  a  woman. 

Both  bones  may  be  displaced  backward,  outward,  inward,  or  forward,  backward  and 
outward,  or  backward  and  inward.  The  aliia  may  be  displaced  backward  alone,  the  radius 
maintaining  its  natural  position,  and  the  head  of  the  radius  may  be  thrown  forward  or 
backward. 

These  dislocations  may  be  more  or  less  complete,  simple  or  compound,  uncomplicated, 
or  complicated  with  fracture  of  one  or  more  of  the  bones  entering  into  the  formation  of 
the  joint;  or  with  fracture  or  displacement  of  an  epiphysis. 

In  point  of  frequency  dislocation  of  both  bones  backward  is  the  most  common,  the 
other  dislocations  of  both  bones  occurring  in  the  order  above  given,  dislocation  forward 
being  so  rare  that  without  a  fracture  its  existence  was  doubted  by  Sir  A.  Cooper ;  but 
Velpeau  and  Canton  have  each  recorded  undoubted  examples. 

The  force  required  to  produce  any  one  of  these  injuries  is  severe.  It  is  generally 
exerted  directly  upon  the  elbow  or  indirectly  upon  the  hand,  by  either  a  fall  or  a  twist. 
To  admit  of  any  dislocation,  there  must  of  necessity  be  much  laceration  of  the  ligaments. 
Symptoms  and  Diagnosis. — These  accidents  are  not  difficult  to  diagnose  when  they 
are  seen  at  an  early  period  of  their  existence,  though  after  the  lapse  of  some  hours  great 
difficulty  may  be  experienced,  owing  to  the  swelling  masking  the  points  of  bone  and  ren- 
dering it  difficult  to  make  out  their  relative  positions. 

The  injured  joint  should  always  be  carefully  examined,  each  point  of  bone  felt  for, 
and  its  relative  position  with  other  points  compared  with  those  of  the  sound  limb.  In 
no  cases  can  the  surgeon  derive  greater  assistance  or  feel  more  forcibly  the  value  of  this 
rule  than  in  dislocations  of  the  elbow.  The  student  should  accustom  himself  to  the 
manipulation  of  healthy  joints  and  learn  where  to  place  his  finger  upon  the  diff'erent 
prominences  and  depressions,  and,  having  learned  the  normal  conditions,  he  will  usually 
find  but  little  difficulty  in  discovering  when  a  displacement  has  occurred. 

When  both  bones  are  dislocated  backward  (Fig.  496),  the  forearm  is  partially  flexed 
and  the  hand  slightly  pronated ;  the  displaced  bones  project  backward  and  make  a  prom- 
inent swelling  with  the  tendon  of  the  triceps,  while  the  con- 
dyles of  the  humerus  can  readily  be  felt  in  front,  pushing 
the  artery  and  soft  parts  forward,  the  inner  condyle  of  the 
humerus  and  the  olecranon  being  far  apart,  and  the  great  in- 
crease in  the  antero-posterior  diameter  of  the  joint  seen  at 
a  glance.  In  thin  subjects  the  olecranon  and  the  head  of 
the  radius  can  readily  be  felt  in  their  abnormal  position  to 
one  another,  and  the  head  of  the  latter  bone  made  through 
the  hand  to  rotate  in  its  new  situation. 

In  the  dislocation  of  the  bones  outward  the  marked 
prominence  of  the  inner  condyle  of  the  humerus  as  seen  from 
behind  is  a  typical  feature  (Fig.  497),  and  with  luxation  of  the  same  bones  inward  the 
external  condyle  is  equally  prominent. 

In  the  rare  form  of  disloca- 
tion forivard  (Fig.  498)  the  loss 
of  the  olecranon  from  its  right 
position,  the  unusual  prominence 
of  the  condyles  of  the  humerus, 
and  the  marked  elongation  of  the 
fore-arm  are  the  chief  features. 
In  dislocation  of  the  ulna 
hackirard  the  pronation  and 
twisting  inward  of  the  hand, 
the  great  shortening  of  the  ul- 
nar side  of  the  fore-arm,  and 
projection  liackward  of  the  ole- 
cranon mark  the  nature  of  the 
accident. 

When  the  head  of  the  radius 
is  displaced  alone  forward  (Fig. 
499)  or  backward,  its  absence 
from  its  natural  position,  as  well 


Fig.  496. 


Dislocation  of    Radius    and    I'lna 
Backward.   (From  Sir  A.  Cooi^er.) 


Fig.  497. 


Fig.  498. 


Clferanan. 


J/irirr 
Cciit/i/le. 

Dislocation  of  the  Right  Radius 
and  Ulna  Outward.  (Posterior 
View.  1 


Dislocation  of  Radius  and  Ulna  For- 
ward. (Canton's  case,  Duh.  Quart., 
August,  1860.) 


DISLOCATIONS   OF   Till-:    ll'I'KJ:   KXTIIKMITY. 


839 


ns  its  pn'Si'iiiT  in  ;iii  iiniKiliiriil  uiic,  can  usually  In-  uiafic  out.      In  llic  forward  dislocation 
till'  rie'xion  id"  tlic  joint  is  liujitcd. 

In  the  liackward  (  Fij;.  500)  the  Uiuvcnionts  luiiy  he  couiidcle  ;   more    coinuionly,  huw- 
fVi'T,  tlu'V  iirc  limited. 


Fio.   190. 


Fio.  600. 


Dislui'alioii  i>r  the  Itmliiis  I'diward.     (I)r:iHiiiLC  'J7"",  (Juy's  IIos- 
jiiial.     I'"roiii  dissecliou.     Mr.  Hilton  s  ease.) 


Dislocaliou   of    tin.-    Ilrail   of   tlif    liadiua 
ISackward. 


TuKAT.MKNT. — Wlieii  the  nature  of  the  dislocation  bus  been  once  reco<rnized,  there  is 
little  dirticiilty  in  its  treatment;  for,  with  tlie  patient  anjcsthetized.  and  the  muscles  con- 
se(|ueiitly  jiaralyzed.  the  reduction  of  any  dislocation  of  the  elbow  by  iitanipulatliju,  or 
rather  by  moulding  the  joint  into  its  right  form,  is  readily  effected.  This  may  usually  be 
d(uie  by  the  surgeon's  bands,  pressure  being  applied  according  to  tbe  wants  of  tbe  indi- 
vidual ca.se,  guided  by  the  known  anatomy  of  tbe  part.  Occa.sionally  extension  of  the 
fore-arm  is  required,  or  tlie  forcible  bending  of  the  fore-arm  over  the  surgeon's  knee  or 
thumb  ;  ])ut  in  the  majority  of  early  cases  the  joint  may  be  moulded  into  its  normal  posi- 
tion. 

Mr.  J.  E.  Kelly  of  Dublin  (^Dnhh'n  Journ.  of  Med.  S'-i.,  July,  1883)  describes  a  method 
of  reduction  in  dislocations  at  the  elbow-joint  worthy  of  consideration,  in  which  the  sur- 
geon, sitting  on  a  table,  fixes  the  patient's  humerus  beneath  one  thigh  and  extends  with 
his  baiuls  the  fore-arm  raised  between  them. 

AVhen  .some  weeks  have  been  allowed  to  pass  without  reduction,  considerable  force 
may  be  rerpiired  to  break  down  the  adhesions,  forcible  flexion  and  extension  being  then 
applicable. 

Up  to  two  months  any  dislocation  of  the  elbow  may  be  reduced,  or  rather  an  attempt 
at  reducti(»n  may  be  made.  After  that  date,  when  useful  movement  has  become  possible, 
the  attempt  had  better  not  be  entertained.  When  no  movement  exists,  it  is,  however,  jus- 
tifiable, but  no  definite  rule  can  be  laid  down  on  this  point,  since  each  case  must  be  judged 
xipon  its  own  merits.  I  have  reduced,  after  nine  weeks,  a  dislocation  of  the  bones  of  the 
fore-arm  backward  with  an  excellent  result,  and  have  failed  after  five.  What  would  be 
justifiable  under  some  circumstances  would  be  unjustifiable  in  others,  the  age  of  the 
patient,  his  position  or  occupation,  and  his  necessities  having  as  great  an  influence  in 
guiding  the  surgeon  as  the  time  that  has  elapsed  after  the  accident  and  the  amount  of  use- 
ful movement  in  the  joint. 

When  both  bones  are  displaced,  or  the  ulna  alone,  the  surgeon  should  grasp  the  fore- 
arm as  a  whole.  When  the  radius  is  the  bone  displaced,  the  extending  force  should  be 
applied  from  the  hand. 

Aftkr-Trkatment. — After  the  reduction  of  the  dislocation  the  arm  should  be  kept 
in  a  splint  and  cold  lotion  or  ice  applied,  according  to  the  amount  of  inflammation  that 
ensues.  When  little  inflammation  follows,  passive  movement  may  be  allowed  iu  about 
ten  days  or  a  fortnight.  After  the  reduction  of  a  dislocation  of  the  head  of  the  radius 
forward  there  is  usually  great  difficulty  experienced  in  keeping  the  bone  in  its  position. 
To  effect  this  I  have  found  the  forced  flexion  of  the  fore-arm  the  best,  the  wrist  and  fore- 
arm being  bound  to  the  arm  by  means  of  a  bandage.  In  a  recent  case  the  benefit  of  this 
practice  Avas  well  displayed. 

When  reduction  of  a  neglected  dislocation  has  been  effected,  it  is  wise  to  fix  the  elbow 
on  an  angular  splint  for  ten  days  or  a  fortnight  and  to  apply  cold  water,  and  after  all 
inflammatory  action  has  subsided  to  allow  of  passive  or.  ])ossiV)ly.  forcible  movements, 
as  a  stiff  elbow-joint  is  a  misfortune  of  no  mean  importance,  and  to  prevent  it  measures 
may  be  employed  which  under  other  circumstances  might  be  considered  rash.  In 
neglected  cases,  where  reduction  is  beyond  all  hope,  the  surgeon  may  use  a  consider- 
able amount  of  force  to  flex  the  fore-arm  to  a  right  angle,  in  which  position  it  should 
be  fixod. 

In  conipmmd  dislocation  of  the  elbow-joint,  where  reduction  is  possible  and  the  wound 


840 


CONTUSIONS,  SPBAINS,  AND    WOUNDS  OF  JOINTS. 


Fig.  501. 


Displacement  of  the  Lower  Epiphysis 
of  the  Humerus  Backward.  (Hutch- 
inson's case.) 


small,  the  case  may  be  treated  as  one  of  wounded  joint — viz.  by  splints  and  the  applica- 
tion of  ice — good  hopes  existing  of  a  sound  recovery  being 
secured  with  movement.  When  the  wound  is  large  and  the 
soft  parts  are  materially  injured,  excision  of  the  joint  should 
be  performed,  the  success  attending  this  practice  generally 
being  very  satisfactory.  When  the  vessels  and  nerves  are 
clearly  so  injured  as  to  preclude  the  possibility  of  a  useful 
limb  being  secured,  amputation  may  be  required. 

In  all  these  dislocations  of  the  elbow  the  surgeon  should 
be  careful  to  ascertain  that  they  are  uncomplicated,  that  no 
fracture  coexists,  or — what  is  more  common  in  young  sub- 
jects— that  no  displacement  of  the  lower  epiphysis  of  the 
humerus  is  present,  such  as  is  shown  in  Fig.  501.  This  can 
be  made  out  only  by  a  careful  comparison  of  the  sound  and 
injured  sides  and  the  appreciation  of  the  crepitus  of  fractvire,  the  crackling  of  eifu.sion, 
and  the  semi-crepitating  feel  of  a  displaced  epiphysis. 

In  June,  1881,  I  had  under  my  care  at  (iuy's  a  boy  set.  9  in  whom  the  lower  e])iphy- 
sis  of  the  humerus,  with  the  bones  of  the  fore-arm,  was  displaced  backward,  and  in  which 
the  anterior  border  of  the  diaphysis  so  injured  the  brachial  artery  as  to  occlude  it.  The 
displaced  bones  were  restored  to  their  position  and  the  arm  was  bound  with  splints.  The 
case  did  well,  and  in  six  weeks  there  was  good  movement  in  the  joint  and  pulsation  had 
returned  in  the  radial,  though  not  in  the  brachial,  artery. 

Dislocations  of  the  W^rist. — These  are  exceedingly  rare  accidents,  the  majority 
of  recorded  cases  of  this  nature  being  fractures  of  the  lower  end  of  the  radius.  What 
is  known  as  "  Colles's  fracture "  is  the  more  common  form  of  accident.  Dupuytren 
pointed  this  out  years  ago,  and  the  truth  of  the  observation  is  now  fairly  recognized. 
When  dislocation  does  occur,  the  hand  is  displaced  either  forward  or  hackward^  the  ends 
of  the  radius  and  ulna  forming  prominent  points  in  the  opposite  positions  and  the  styloid 
processes  of  the  radius  and  ulna  being  recognizable  points  in  a  line  with  the  shafts 
of  the  bones  of  the  fore-arm  (Fig.  502).  This  feature  is  important ;  for  when  the  dis- 
placement of  the  hand  is  due  to  a  fracture  of  the  lower  ends  of  the  radius  and  the  ulna, 
the  styloid  processes  will  be  in  connection  with  the  hand  instead  of  with  the  shafts  of 
the  bones. 

Treatment. — Reduction  by  manipulation  is  readily  performed,  extension  of  the  hand 
and  direct  pressure  upon  the  displaced  bones,  as  a  rule,  effecting  the  surgeon's  purpose. 
The  parts  should  be  kept  in  po.sition  by  an  anterior  and  a  posterior  splint  extending  to 
the  flexure  of  the  fingers.  The  splints  should  be  removed,  however,  as  soon  as  the  parts 
have  become  firm — that  is,  in  about  three  weeks — and  passive  movement  of  the  fingers 
should  be  enforced. 

Dislocation  of  the  lower  end  of  the  radius  with  the  hand  may  take  place 
whenever  the  hand  is  forciby  pronated  or  supinated.  When  forcibly  pronated,  the  ulna 
projects  backward  and  the  radius  and  hand  forward  ;  when  .supinated,  the  reverse  condi- 
tions are  found  to  exist. 

I  have  seen  the  former  accident  but  once,  and  that  case  is  here  figured  (Fig.  503).  It 
was  in  a  woman  a^t.  56  who  was  admitted  into  my  ward  at  Guy's  for  another  affection. 
The  dislocation  had  taken  place  some  months  previously  and  had  never  been  reduced.    It 


Fig.  .502. 


Fig.  503. 


/^v_ 


Dislocation  of  the  Hand  Forward.  (Taken 
from  a  cast  of  :Mr.  Cadge's,  copied  from 
Erichsen's  work.) 


Dislocation  of  the  Hand  and  Iladiii.s  Forward  off  the 
Lower  End  of  the  Ulna. 


was  the  result  of  a  fall  upon  the  dorsum  of  the  hand.  Pronation  and  supination  of  the 
hand  were  limited,  and  the  ulna  was  fixed  in  its  new  position.  The  hand,  although  more 
pronated  than  natural,  was  very  useful. 


DISLOCATIONS   OF   THE    rPrEIl   EXTREMITY.  H41 

Siicli  (lisl(pc;iti<ms  iirr  readily  rc(lucc(l  l)y  cxtciidiiij;  tlic  liaiid  and  ciiipluviii^^  jin-sMirc 
to  till'  displaced  lioiies.  Alter  their  reductidii  anterior  and  |)i)steri<ir  splints  sliouM  be 
applietl  lor  two  or  three  weeks,  to  prevent  the  hones  sli])piii;^  out  of  position  and  to  allow 
the  liiranients  time  to  unite.      \\\  the  ease  liu'^ured  no  tri^atineiit  was  availahle. 

Dislocation  of  the  carpal  bones  is  an  oeeasional  thou^rh  rare  aeeideiit,  and  the 
displaeenu-nt  (d'  the  <>s  nitii/ninn  haekward,  from  a  fall  upon  the  flexed  liaiid,  is  tlie  most 
fre(jiient  iorui.  I  have  known  this  to  tiecur  in  a  woman  during  the  efforts  of  parturition 
in  grasping  a  towel  and  loreihly  bending  tlie  wrists,  the  bone  lieing  pressed  out  of  its 
conneetion.  When  the  accident  occurs,  tlie  prominent  head  of  the  bone  on  the  dorsum 
of  the  wrist  in  a  line  with  the  metacar]ial  bone  of  the  middle  tinger  is  too  marked  a  fea- 
ture to  allow  of  there  being  any  difficulty  in  the  diagnosis.  The  bone,  as  a  rule,  is  easily 
reduced  by  pressure  and  kept  in  position  by  means  of  a  [tad.  This  pad  must  be  main- 
tained ill  position  for  many  weeks  after  the  accident,  to  allow  tiiiK-  for  the  ligaments  to 
con.solidate. 

South,  in  a  note  to  his  translati(»n  of  Chelius,  records  a  case  in  which  the  j}isi/orm 
hone  was  displaced,  while  Fergusson  and  Krichsen  describe  others  caused  bj-  overaction 
of  the  flexor  carpi  ulnaris.  Krichsen  also  mentions  a  di.sloeation  backward  of  the  sfim'- 
IiDiar  bone,  and  in  St.  George's  Hospital  Museum  there  is  a  specimen  of  compound  dislo- 
cation of  this  bone  on  both  sides,  occasioned  by  a  fiill  from  a  height  upon  the  hands,  in 
which  the  bones  were  pressed  out  of  a  wound  in  front  of  the  wri.st. 

Maisonneuve  has  recorded  (^Mem.  de  la  Soc.  de  Chir.,  tome  ii. )  a  case  in  which  the 
second  row  of  carpal  bones  was  di.splaced  backward  from  the  first,  and  Erichsen  another, 
in  which  the  metacarpal  bones  were  displaced  backward  from  the  carpus.  These  acci- 
dents are  very  rare. 

Dislocation  of  the  thumb  at  any  of  its  joints  is  not  unusual.  The  metacnrprd 
hone  may  be  displaced  backward  or  forward  from  the  trapezium,  the  former  being  the 
more  common  accident.  This  dislocation  is  frequently  complicated  with  an  oblique  frac- 
ture through  the  base  of  the  metacarpal  bone.  Sir  A.  Cooper  described  a  dislocation 
inward,  but  gave  no  case.     Dr.   F.   Hamilton  questions  its  occurrence. 

Reduction  of  these  dislocations  by  extension  and  local  pressure  is  usually  readily 
eflFected,  the  bones  being  kept  in  position  b}'  means  of  a  pad  and  a  good  splint  extending 
some  inches  above  and  below  the  displaced  bone. 

Dislocation  of  the  first  phalanx  from  the  metacarpal  hone  is  a  recognized  accident,  the 
displacement  backward  being  the  usual  form.  Dislocation  forioard  is  a  rare  one.  The 
first  form  is  usually  the  result  of  a  fall  upon  the  distal  end  and  palmar  surface  of  the 
thumb,  the  head  of  the  metacarpal  bone  projecting  forward,  the  base  of  the  fir.st  phalanx 
backward,  and  the  extreme  phalanx  being  flexed  upon  the  first.  The  head  of  the  meta- 
carpal bone  in  some  cases  may  be  thrust  foi'ward  through  the  capsule  of  the  joint  and 
caught  betw^een  the  two  heads  of  the  flexor  brevis  muscle,  whilst  in  others,  as  in  one  I 
have  .seen — which  w^as  compound — the  long  extensor  tendon  of  the  thumb  was  hitched 
round  the  ulnar  side  of  the  base  of  the  first  phalanx,  and  thus  prevented  I'cduction.  which 
was  readily  effected  by  forcible  extension,  adduction,  and  rotation. 

Treatment. — In  some  cases  the  reduction  of  this  form  of  dislocation  is  effected  with 
ease  by  simple  extension  or  by  the  pressure  of  the  surgeon's  thumb  upon  the  displaced 
phalanx,  and  for  the  purpose  of  extension  nothing 

equals  in -value  the  Indian  toy  called  a  "  puzzle,"  Fig.  504. 

or  tube  of  plaited  reed  (Fig.  504).  When  this  is 
not  at  hand,  .strips  of  strapping  applied  longitudi- 
nally to  the  distal  digit  and  fixed  by  a  circular 
piece  will  an.swer  the  purpose.  In  some  instances 
all  these  means  fail  and  there  is  yet  much  obscurity 
as  to  the  cause  of  the  difficulty.     The  numerous 

muscles  and  tendons  that  surround  the  joint  doubtless  have  a  powerful  influence,  more 
particularly  the  two  heads  of  the  short  flexor  with  the  sesamoid  bones :  and  when  the 
wound  in  the  capsule  is  small,  the.se  muscles  act  more  powerfully,  the  base  of  the  dis- 
placed bone  or  the  head  of  the  metacarpal  bone  being  held  by  these  parts  "  as  a  button 
is  fastened  into  a  button-hole."'  Under  these  circumstances  success  may  at  times  be 
achieved  by  flexing  the  metacarpal  bone  of  the  thumb  to  an  extreme  degree,  rotating, 
and  then  suddenly  extending  the  displaced  phalanges,  this  manoeuvre,  as  it  were,  freeing 
the  displaced  bone  from  the  many  tendons  and  ligaments  that  .surround  the  joint,  and 
that  doubtless  at  times  interfere  with  its  reduction.  I  succeeded  by  this  method  in  one 
case  where  every  other  had  failed.     My  friend  the  late  Mr.  Sells  of  Guildford  informed 


842 


CONTUSIO^'S,  SPRAINS,  AND   WOUNDS  OF  JOINTS. 


me  that  he  had  with  facility  reduced  several  dislocations  of  this  form  by  forcibly  bending 
the  thumb  back,  so  as  to  tilt  the  base  of  the  phalanx  over  the  head  of  the  flexed  meta- 
carpal bone,  and  then  extending  it.  Both  these  means  have  the  effect  of  relaxing  the 
short  flexor  muscle,  as  pointed  out  by  Prof.  Fabbri.  When  all  such  means  as  have  been 
mentioned  have  been  unsuccessfully  tried,  the  subcutaneous  division  of  the  tendons  and 
ligaments  that  appear  to  prevent  reduction  has  been  practised  with  variable  success  ;  and 
when  this  fails,  excision  of  the  part  has  been  employed.  In  a  case  of  this  kind  of  six 
months'  standing,  where  the  thumb  was  a  useless  member  and  the  seat  of  pain,  I  excised 
the  joint  with  excellent  success,  a  movable  articulation  being  secured,  with  hardly  any 
deformity. 

When  the  bone  is  displaced  foncard,  it  seems  probable,  from  the  dissections  of  ]M.  L. 
H.  Farabeuf  (^Arch.  GeneraJes  de  Medecme,  September,  187G),  that  the  extensor  tendons 
of  the  thumb  being  stretched  on  the  inner  or  outer  side  of  the  metacarpal  bone  is  the 
cause  of  the  difficulty  in  its  reduction,  and  under  such  circumstances  forced  flexion  of 
the  thumb  upon  the  palm,  aided  by  manipulation,  is  generally  enough  to  replace  it. 

Dislocation  of  the  migual phalanx  of  the  thumb  may  take  place  in  either  direction,  for- 
ward or  backward,  the  last  being  the  more  common  ;  and,  the  displaced  bone  being  so 

small,  difiiculty  is  often  felt  in 
applying  extension  to  it.  The 
puzzle  (Fig.  504)  is  the  best 
thing  to  employ  for  the  pur- 
pose, or  Levis's  apparatus  (Fig; 
505).  At  times  pressure  with 
the  thumb  upon  the  displaced 
bone  or  forcible  flexion  will  suc- 
ceed. Hamilton  pithily  advises  "  forced  dorsal  flexion  in  the  case  of  the  backward  lux- 
ation, and  forced  palmar  flexion  in  the  case  of  the  forward  dislocation  "  (8d  ed.,  p.  634). 

Dislocations  of  the  phalanges  of  the  fingers,  like  those  of  the  thumb,  may 

occur  in  two  directions,  the  backward  being  the  more  common.  They  are  readily  made 
out,  and  are  easily  reduced  by  extension  or  by  flexion  and  then  extension. 


Fig.  505. 


Dislocations  of  the  Lower  Extremities. 

Dislocations  of  the  Hip. — These  are  grave  accidents,  and  are  found  mostly  in 
male  adults  between  fifteen  and  fiftv  years  of  age,  but  occasionallv  in  the  young  or  the 
old. 

The  following  analysis  shows  many  of  these  points : 

Out  of  80  consecutive  cases  which  have  occurred  at  Guy's  and  in  my  own  practice,  18 
occurred  in  subjects  under  twenty  years  of  age,  the  youngest  being  five  ;  36  between  the 
ages  of  twenty-one  and  forty,  and  26  had  passed  that  period;  60  were  males,  and  11 
females ;  41  were  on  the  dorsum,  14  into  the  foramen  ovale,  16  into  the  sciatic  notch,  and 
9  on  the  OS  pubis. 

Mr.  Powdrell  {Lancet,  1868)  has  recorded  a  case 


Fig.  506. 


PuriFormis    .  ^  . 


in  which  the  head  of  the  femur 
was  displaced  into  the  foramen 
Fig.  507.  ovale  at  the  age  of  six  months ; 

it  was  reduced  by  manipulation. 
Erichsen  has  recorded  another, 
of  dislocation  on  the  pubes,  in 
a  child  a  year  and  a  half  old. 
I  have  treated  three  cases  of 
dislocation  on  the  dorsum  in 
boys  ast.  5  and  in  a  girl  set.  Sj, 


but  these  are  exceptions.  On 
the  other  hand,  dislocations  may 
occur  in  the  aged.  Malgaigne 
has  recorded  five  between  the 
ages  of  sixty  and  eighty-five, 
and  my  notes  contain  cases 
which    occurred    in    men    aged 

sixty-one.  sixty-four,  sixty-five,  and  seventy-six  ;  but  at  this  time  of  life  fracture  of  the 

neck  of  the  femur  is  more  common. 

The  accident  is  always  the  result  of  violence,  no  slight  force  being  required  to  tear 


Oi^.Hxi. 


Recent  Case  of  Dorsal  Dislocation.         Rent  in  Capsule,  with  Femur  Flexed 
(From  Mr.  Morris's  paper.) 


DISLOCATIOyS  OF   Till-:   LOW  Ell   KXTRKMITIES. 


843 


/ 


tliroimli  till'  liL'aiiitiits  that  Imld  ami  himl  the  IicimI  of  the  ftiinir  in  its  det'i)  pelvic  cup; 
iiuloi'tl,  wi'iv  it  not  t'ur  the  ;j:rt'at  k-vcia^'i-  u['  the  h)\V('r  cxtremil).  the  accident  wijiihl  ])roh- 
ahly  he  a  rarity.  In  i-xceptinnal  instances,  however,  tlic  hone  i.s  disphiced  witli  the 
slij^htest  force.  I  have  had  uncK'r  my  care  a  youii;r  man  whose  reniur  had  been  dishtcated 
a  dozen  times  or  more,  the  smaMest  twist  in  the  limh  causin<.'  its  (hsiocation  hackwanl. 

t'onireiiital  dishications  and  disjilacements  from  disease  are  not  inehKh-cl  in  this  ^'roiip. 

l)ishications  I'rom  accident  are  ol"  various  forms,  Imt  the  division  made  hy  Sir  A  ('oopi;r 
is  ihdiKtless  i)ractically  tlie  best,  if  we  rememher  that  varieties  u\'  each  form  or  jmrtiul 
dislocations  are  met  with  in  i)ractice,  .since  there  is  <.'ood  reason  to  believe  that  the  head 
of  the  thiu:h-bone  may  rest  at  any  jioint  round  its  socket. 

1.  Dislocation  /^^/ra/v/ and  hdrkii^iini  on  the  dorsum  ilii  is  the  most  common. 

2.  Dislocation  luu-h-uiitil,  toward  the  i.^chiatic  or  sciatic  notch — a  variety  of  the  latter — 
stands  third  on  the  list  as  to  fre(|uency. 

o.    Dislocation  tfuicincfinf  and  ininnd  into  the  foramen  ovale  stands  .second. 

4.  Dislocation  upvnril  and /<>nrn id  upon  the  ])ubes  is  about  ecjual  in  frecjuency  to  that 
toward  the  sciatic  notch. 

These  several  forms  of  dislocation  depend  much  upon  the  degree  of  flexion  or  cxten- 
f<ion  and  of  inward  or  outward  rotation  of  the  thigh  at  the  time  of  luxation.  The  head 
of  the  femur  under  most,  if  not    all, 

circumstances,  as  demonstrated  by  .Mr.  Fio.  ^f^^.  Fig.  609. 

Henry  Morris  in  an  able  paper  (JA'/.- 
Cfiii:  TrcDis.,  1ST7),  leaves  the  ace- 
tabulum, when  the  lower  extremity  is 
^//^ducted,  through  a  rent  in  the  cap- 
sular ligament  where  it  is  the  thinnest 
— viz.,  at  the  inner  and  lower  .side  of 
the  joint  (Fig.  5U7),  the  strong  ilio- 
and  ischio-femoral  ligaments  situated 
on  the  anterior,  outer,  and  posterior 
aspects  of  the  joint  and  the  shape  of 
the  acetabulum  preventing  displace- 
ment in  any  other  position.  With  the 
limb  abducted,  however,  the  head  of 
the  femur  is  more  than  half  out  of  the 
acetabulum,  the  ligamentum  teres  is 
quite  loose,  and  all  the  strong  portion 
of  the  capsule  is  relaxed.  Indeed,  Mr. 
Morris  believes  that  it  is  only  in  ab- 
duction of  the  lower  extremity  that  a 
simple  dislocation  of  the  head  of  the 
femur  can  possibly  occur,  and  that  a  dislocation  on  to  the  dorsum  ilii  or  toward  the  sci- 
atic notch  is  due  to  the  amount  of  Ji'xion  and  rotation  of  the  limb  inward  at  the  moment 
of  the  accident,  and  dislocation  on  to  the  pubes  to  extension  and  rotation  onticard ;  al.so 
that  the  degree  of  flexion  and  rotation  of  the  limb  inward  determines  in  any  particular 
instance  whether  the  dislocation  .shall  be  dor.sal  or  ischiatic,  the  latter  variety  occurring 
when  flexion  is  carried  to  an  extreme. 

Direct  dorsal  dislocation  can  be  produced  onl\'  by  immense  violence,  and  is  often  com- 
plicated with  fracture  of  the  acetabulum. 

In  all  ca.ses  the  round  ligament  and  capsule  are  torn  across,  the  muscles  about  the 
joint  being  more  or  less  lacerated. 

Dislocation  on  the  dorsum  ilii,  or  backward  and  upward,  forms  about  half  of 
all  the  cases  of  dislocation  at  this  joint,  and  is  usually  produced  by  some  twisting  move- 
ment of  the  body  or  limb  when  the  latter  is  abducted  or  from  a  crushing  weight  received 
when  in  a  stooping  posture.  It  can  be  recognized  by  the  following  signs — viz.,  the  flexed 
position  of  the  thigh,  the  knee  when  the  patient  stands  projecting  in  front  of  but  above 
the  other ;  the  rotation  inward  of  the  limb,  the  great  toe  resting  on  the  instep  of  the 
opposite  foot ;  the  projection  of  the  great  trochanter  and  its  approximation  to  the  anterior 
superior  spinous  process  of  the  ilium  ;  the  elevation  of  the  fold  of  the  buttock  ;  the 
immobility  of  the  limb  and  the  pain  jiroduced  by  any  attempt  to  abduct  or  to  extend  it ", 
and  the  marked  shortening  of  the  limb — from  an  inch  and  a  half  to  two  and  a  half 
inches  (Fig.  510). 

In  thin  subjects  the  head  of  the  bone  may  be  felt  lying  ujmiii  the  dorsum  ilii.  and  in 


Dislocation  of  the  Head  of  the  Dislocation  of  the  Head  of  the 

Femur  on  I)orsum  Backward  Femur  Backward. 

and  rpward. 

Takeu  from  specimens  in  the  Middlesex  Hospital  Museum,  and 
prepared  by  Mr.  Morris.) 


844 


CONTUSIONS,  SPRAINS,  AND    WOUNDS  OF  JOINTS. 


all  there  will  be  an  unnatural  fulness  of  this  part.  Slight  flexion  and  adduction  will 
usually  be  borne,  while  patients  may  support  the  weight  of  the  body  on  the  injured  limb, 
or  even  walk  upon  it. 

Dislocation  backward  toward  the  ischiatic  notch  forms  about  a  seventh 

of  all  cases  and  may  be  regarded  as  a  variety  of  the  one  just  described  ;  indeed,  Erichsen 


Fig.  510. 


Fig.  511. 


Fig.  513. 


Dislocation  Backward 
on  the  Dorsum. 
(Drawing  30&.) 


Dislocation    into 
the  Sciatic 

Notch.     (From 
Bigelow.) 


Position  when   the    Limbs  The  Limbs  Raised  to  a  Riglit 

are  Extended,  the  Short-  Angle  with   the  Recum- 

ening  being  Slight.  bent  Trunlc,  the  shorten- 

ing being  very  striking. 

(From  paper  by  Dr.  W.  Dawson  of  Ohio,  who  subsequently  wrote 
that  this  test  of  dislocation  had  been  suggested  by  O.  H.  Allis 
in  1874,  Philadelphia  3fed.  Times.) 


Fig.  514. 


describes  the  two  forms  together  as  the  ilio-sciatic.  It  is  characterized  by  the  same, 
though  less  marked,  symptoms.  There  is  less  shortening ;  but  if  the  patient  be  placed 
upon  his  back  and  the  thigh  be  flexed  upon  the  trunk  at  a  right  angle,  then  the  knee  of 
the  dislocated  limb  will  sink  below  that  of  the  other  side  from  one  to  two  inches  (Figs. 
512,  513),  the  trochanter  is  drawn  up  and  rotated  forward,  but  not  to  the  same  extent, 
and  the  head  of  the  bone  cannot  be  felt.  To  the  eye  the  limb 
assumes  much  the  same  position  as  in  the  last  form,  but,  there  being- 
less  shortening,  the  toes  rest  on  the  ball  of  the  great  toe  of  the 
opposite  limb  instead  of  on  the  instep  (Fig.  511).  Bigelow  believes 
that  this  form  of  dislocation  is  due  to  the  protrusion  of  the  head  of 
the  bone  below  the  tendon  of  the  obturator  internus  muscle,  whereas 
in  the  former  kind  the  bone  is  protruded  above  the  tendon.  In  this, 
however,  he  is  wrong,  as  Mr.  Morris  has  shown  that  in  afl  forms  of 
dislocation  the  head  of  the  femur  makes  its  exit  fi-om  the  acetabu- 
lum lielow  this  tendon. 

Dislocation  upon  the  foramen  ovale  or  obturator 

foramen  is  a  very  striking  accident.  Sedillot  as  well  as  Boyer 
believes  that  it  is  the  most  common  of  all  forms,  but  British  and 
American  surgeons  usually  place  it  third  on  the  list.  In  my  own 
table  it  stands  second.  It  is  generally  caused  by  some  forced  abduc- 
tion of  the  knee  or  foot,  the  head  of  the  bone  being  tilted  inward. 
In  the  case  from  which  Fig.  514  was  taken  it  was  caused  by  abduc- 
tion of  the  knee  when  the  girl  (aet.  14)  was  stepping  out  of  an 
omnibus. 

Dislocation  into  the  Fora-  It  is  characterized  by  the  bent  position  of  the  body  and  the 
a  gh-l*^8et '  14 '7'^'^^"  ^'""  pointing  of  the  foot  forward  and  slightly  outward,  the  approxima- 
tion of  the  trochanter  toward  the  mesial  line  and  consequent  flatten- 
ing of  the  hip,  hoUowness  below  the  anterior  superior  spinous  process  of  the  ilium,  the 
absence  of  the  gluteal  fold,  and  the  elongation  of  the  limb  from  one  to  two  inches.  Any 
attempt  at  movement  causes  pain.  The  head  of  the  bone  can  often  be  felt  in  its  new 
position  beneath  the  adductors  (Fig.  515).  The  patient  can  at  times,  however,  walk  with 
such  an  injury. 

Dislocation  upon  the  OS  pubis  is  the  least  common  form  of  dislocation,  and  is 
due  to  forced  extension  and  rotation  outward  of  the  thigh  after  dislocation  by  abduction, 


DISLOCATIONS   OF   'I'llh'   I.OWEll   EXTllEM ITIKS. 


845 


the  pelvis  l)i'iiij;  thrown  forwiinl  :iii(l  tlic  hudy  bent  backward  as  the  head  of  the  feiiiur  is 
wrenched  out  of  the  ,sock(!t  and  then  drawn  upward. 

It  is  marked  by  eversioii  of  the  limb  and  loot  and  abduction,  rotation  backward  of 
the  trochanter,  and  eonsecjueiit  flattening  of  this  region.  The  head  of  the  bone  can 
usually  also  be  I'elt,  if  nut  seen,  as  a  projection   upon  the  os  pubis  (Fig.  51G)  or  on  some 


Fuj.  ")lo. 


Fio.  51G. 


Fio. ol7. 


Dislocation  into  Foramen  Ovale.  Dislocatiou  upon  Os  Pubis. 

(From  Preparations.) 


Dislocation  upon  Os  Pubis. 
(From  Aslley  Cooper.) 


part  of  the  lip  uf  the  acetabulum.  When  thrown  above  the  bone  beneath  Poupart's  liga- 
ment, it  forms  a  very  prominent  projection  beneath  or  to  the  outer  side  of  the  femoral 
artery  (Fig.  517). 

When  the  head  of  the  bone  is  thrown  between  the  anterior  superior  and  inferior 
spines  of  the  ilium  or  between  the  inferior  spine  and  the  acetabulum,  the  head  of  the 
bone  will  be  felt  in  that  position. 

Diagnosis. — With  reasonable  care  and  attention  to  the  special  symptoms  which  cha- 
racterize the  different  forms  of  dislocation,  these  ought  readily  to  be  made  out,  although 
certain  fractures  about  the  neck  of  the  femur  may  present  symptoms  somewhat  similar. 
I  have  seen  two  cases  of  impacted  fracture  of  the  neck  of  the  thigh-bone,  with  the  foot 
inverted  and  the  thigh  flexed,  presenting  symptoms  so  similar  to  those  of  dislocation  into 
the  sciatic  notch  that  the  diagno.sis  could  not  be  made  out  till  the  patients  were  brought 
under  the  influence  of  chloroform,  when  by  gentle  manipulation  the  nature  of  the  accident 
was  discovered,  the  greater  freedom  with  which  the  head  of  the  bone  could  be  made  to 
rotate  in  the  acetabulum  and  the  limp  condition  of  the  limb  under  chloroform  in  the  case 
of  fracture  forming  a  marked  contrast  to  the  immobility  and  permanent  position  of  the 
thigh  in  dislocation.  The  late  Mr.  K.  W.  Smith  {On  Fracture,  1850)  records  also  a  case 
of  fracture  of  the  neck  of  the  femur  which  had  been  mistaken  for  dislocation. 

When,  in  the  adult,  the  displacement  recurs  after  the  apparent  reduction  of  the  bone 
and  the  extending  force  has  been  removed,  the  probabilities  are  that  the  lip  of  the  ace- 
tabulum has  been  broken  off  or  the  head  of  the  femur  fractured  (r/VA  Birkett,  Med.-Chlr. 
Trans.,  vol.  Hi.),  and  when  in  a  child  the  separation  of  the  head  of  the  bone  or  upper  epi- 
physis should  be  suspected,  it  being  quite  impossible,  under  both  these  circumstances,  to 
maintain  the  bone  in  position  except  by  means  of  a  long  splint  or  weight  to  keep  up 
extension.  In  all  cases  of  a  doubtful  nature  chloroform  should  be  given  for  purposes  of 
diagnosis,  the  surgeon  using  the  gentlest  manipulation.  The  sudden  loss  of  mobility,  the 
rigidity  of  the  limb,  the  absence  of  crepitus  and  other  symptoms  of  fracture,  with  the 
positive  signs  of  the  injuries  themselves,  are  suflicient  to  indicate  the  nature  of  the  case. 
Nelaton's  test  for  dislocation  of  the  hip  backward  is.  however,  excellent,  and  consists  of  a 
line  drawn  from  the  anterior  superior  spinous  process  of  the  ilium  to  the  most  prominent 
part  of  the  tuberosity  of  the  ischium.  In  a  normal  joint  the  trochanter,  in  every  position 
of  the  limb,  merely  touches  the  lower  border  of  this  line,  but  in  all  dislocations  where  the 
bone  goes  backward  it  is  sometimes  found  an  inch  above  it. 

Tre.atme.nt. — Sir  A.  Cooper,  with  the  surgeons  of  his  day,  considered  the  muscles 
about  a  joint  as  the  chief  agents  in  drawing  a  displaced  bone  into  its  abnormal  position 


846 


CONTUSIONS,  SPBAINS,  AND    WOUNDS  OF  JOINTS. 


and  as  forming  the  main  obstacle  to  its  reduction,  and,  as  a  consequence  they  relied  upon 
physical  force,  in  the  form  of  pulleys  and  other  complicated  appliances,  as  the  chief 
means  by  which  this  obstacle  could  be  neutralized.  The  modern  surgeon,  with  anaesthet- 
ics in  his  hands,  knows  that  the  muscular  system  has  usually  little  or  nothing  to  do  with 
the  difficulties  that  are  met  with  in  the  reduction  of  a  dislocation,  that  these  are  found  in 
the  ligaments  and  capsule,  and  that  a  large  laceration  in  the  capsule  allows  easy  reduc- 
tion, whereas  difficulties  must  be  experienced  when  the  rent  is  small.  With  chloroform, 
therefore,  all  pulleys  and  mechanical  appliances  can  be  done  away  with — certainly  in 
recent  and  probably  in  old  cases.  In  my  own  opinion  they  are  never  required,  for  adhe- 
sions are  more  readily  broken  down  by  forced  flexion  and  rotation  than  by  simple  exten- 
sion ;  and  if  these  fail,  no  extending  force  will  succeed.  In  dislocations  of  the  hip  the 
reduction  by  flexion  becomes,  therefore,  a  reality,  and  is  one  of  the  greatest  improvements 
in  modern  surgery. 

In  the  dislocations  backward — ilio-sciatic — the  reduction  by  flexion  is  the  correct 
method,  adduction,  circumflexion,  abduction,  and  extension  of  the  limb  being  subse- 
quently and  successively  employed  (Fig.  519).  In  dislocation  into  the  foramen  ovale 
the  reduction  by  flexion  is  likewise  good,  with  subsequent  circumflexion  inward  and 
extension  (Fig.  518.) 

In  sub-pubic  dislocations  the  reduction  by  extension  outward  and  rotation  is  pref- 
erable. 

To  carry  out  this  reduction  by  flexion  and  manipulation,  the  patient  should  be  placed 
on  his  back  on  a  hard  couch  and  thoroughly  ana?stheticized.  The  surgeon  should  then 
grasp  the  ankle  of  the  displaced  limb  with  one  hand  and  the  ham  with  the  other,  flexing 
the  leg  upon  the  thigh  and  the  thigh  upon  the  pelvis,  at  the  same  time  lifting  the  limb  and 
adducting  it  toward  the  opposite  side  of  the  umbilicus.  Having  eff'ected  this  movement, 
the  surgeon  should  by  a  semicircular  sweep  outward  suddenly  extend  the  limb  and  bring 
it  into  a  straight  line  with  the  body  (Fig.  519).     If  one  attempt  fail,  a  second  may  be 


Fig.  518. 


Fig.  519. 


^.s^J^ 


In  Dislocation  into  the  Foramen  Ovale. 
(From  Bigelow.) 


Reduction  by  Manipulation. 


In  Ilio-Sciatic  Dislocation. 


made,  and  in  by  far  the  majority  of  recent  cases  success  will  attend  the  efl'ort.  '■  If  there 
is  any  single  and  best  rule  for  reducing  a  recent  dislocation  of  the  hip,"  writes  Bigelow 
{Lancet,  June  15,  1878),  '•  it  is  to  get  the  head  of  the  femur  directly  below  the  socket  by 
flexing  the  thigh  at  about  a  right  angle,  and  then  to  lift  or  jerk  it  forcibly  up  into  its 
place.  This  rule  applies  to  all  dislocations  except  the  pubic.  Flex  and  forcibly  lift ;  and 
if  this  fail,  flex  and  lift  while  abducting."  No  roughness  should  be  used,  gentle,  well- 
directed  manipulation  being  all  that  is  called  for,  the  Teverage  obtained  through  the  femur 
being  enormous.  Some  slight  rotation  of  the  limb  outward  or  inward,  according  to  the 
necessities  of  the  case,  at  times  facilitates  reduction.  Callender  insists  (Lancet,  1808) — 
and  wisely,  I  think — upon  the  importance  of  not  fulhj  ahducllng  or  rolling  the  limb  out- 
ward, as,  if  this  be  done,  the  head  of  the  bone  is  almost  certain  to  roll  past  the  acetabu- 
lum to  its  inner  side ;  or  if  an  obturator  dislocation  is  under  treatment  and  the  thigh  is 
rotated  inward,  the  head  of  the  femur  will  roll  round  to  the  ischiatic  notch,  just  reversing 
the  movement  which  takes  place  when  an  ischiatic  dislocation  is  improperly  manipulated. 
The  object  of  the  treatment  is  to  use  the  femur  as  a  lever  to  raise  the  head  of  the  bone 
from  its  backward  position  and  allow  the  stretched  muscles  to  act  naturally  and  draw  it 


DISLOCATIOSS   OF   Tin-:   LOW  Ell    I'.XrilF.M  ITIKS.  847 

into  ])laeo,  the  act  of  flexinii  completely  reluxiiij;  the  strorij^  ilio-feiiioral  ligament,  the 
surgeon,  with  his  knowledge  u\'  the  way  iti  wliicii  the  head  <if  the  bone  was  driven  thnnigli 
its  eapsule,  using  his  best  endeavors  to  make  it  retraee  its  steps,  and  enipjoyirig  his  aiia- 
toniieal  knowledge  to  jtress,  elevate,  or  guide  flic  nialplaced  hone  into  its  normal  position. 
The  various  nnivements  adopted  in  reduetii)n  hy  manipulation,  as  well  shown  hy  .Morris, 
serve  to  bring  the  head  of  the  displaced  t'emur  down  to  the  notch  in  tin;  acetabulum  by 
making  it  retrace  the  course  it  took  in  the  process  of  dislocation,  and  then  subse(|uently 
turning  it  back  through  the  rent  in  the  eapsule  by  a  rotation  the  rcver>e  of  that  which 
occurred  during  dislocation.  This  method  of  reducing  dislocations  of  the  hip  is  known 
in  France  as  Depres"  method;  in  America,  as  Keid's.  The  former  employed  it  in  1.SI55 
{riilr  Nelaton's  I'lf/m/.  C/iinin/.,  lS47j,  but  Dr.  II.  IJigelow  has  proved  that  the  credit 
of  the  method  is  really  due  to  Nathan  Smith  of  New  Hampshire  (see  Mt niuirs,  \H\\\). 
In  a  case  of  dislocation  into  the  foramen  ovale  in  a  man  I  failed  in  my  first  attempt  by 
manipulation,  but  in  the  second  I  succeeded  by  the  application  of  the  slightest  pressure 
u|ton  the  head  of  the  bone  ;  and  in  the  case  of  the  girl  fnuu  whom  Fig.  514  was  taken 
the  head  of  the  bone  slipped  into  its  position  by  simply  fle.xing  the  leg  on  the  thigh  and 
the  thigh  on  the  pelvis,  with  such  gentle  pressure  as  I  was  apjilying  for  a  preliminary 
diagnosis. 

In  one  case  of  severe  injury  to  the  joint  that  came  iiiuler  my  care,  where  the  bone 
was  displaced  on  the  dorsum,  on  attempting  its  reduction  by  manipulation  the  head  of 
the  bone  slipped  with  such  facility  round  the  acetabulum  as  to  illustrate  every  typical 
form  of  dislocation  aiul  several  intermediate  or  partial  foi'ms.  In  this  case,  however, 
reduction  was  subsequently  readily  obtained  by  thoroughly  flexing  the  thigh  upon  the 
pelvis  and  Uflinij  the  head  of  the  femur  from  its  false  position  by  extension  forward. 

When  the  rent  in  the  capsule  is  small,  difficulties  may  be  felt  in  reducing  tlie  disloca- 
tion ;  but  when  lai'ge,  little  is  usually  experienced. 

At  times  reduction  is  thought  to  have  been  accomplished  when  redislocation  appears 
after  the  limb  has  been  left  alone,  and  under  these  circumstances  it  is  probable  that  the 
head  of  the  bone  had  only  partially  been  replaced  through  the  rent  in  the  capsule.  In 
other  cases  of  this  kind  which  refuse  to  remain  hi  siftl  there  is  reason  to  believe  that  the 
lip  of  the  acetabulum  has  been  fractured,  or,  in  young  subjects,  that  the  head  of  the 
femur  has  separated  at  the  epiphysial  line  of  junction  with  the  neck.  Still,  without  these 
explanations,  cases  are  met  with  in  which  it  is  quite  impossible  to  keep  the  limb  in  posi- 
tion after  its  reduction.  In  some  cases  the  reduction  of  the  dislocation  occurs  by  simple 
muscular  movement  when  the  patient  is  in  bed.  I  have  seen  several.  When  reduction 
by  flexit)n  has  failed  or  is  inapplicable,  that  by  extension  should  be  employed,  and  in  the 
pubic  form  of  dislocation  no  other  should  be  used.  It  should  be  practised  with  the  patient 
under  the  influence  of  an  anaesthetic  and  on  his  back,  and  as  follows  :  The  pelvis  should  be 
fixed  by  a  perineal  band  well  padded  and  adjusted,  and  the  limb  extended  in  the  line  of 
its  position  to  draw  the  head  of  the  bone  out  of  its  bed.  The  surgeon  .should  then  either 
elevate  the  bone,  to  allow  the  muscles  to  act  upon  it,  or  abduct,  adduct,  or  rotate  inward 
or  outward,  according  to  the  special  want  of  the  individual  case.  In  some  cases  the 
simple  extension  of  the  limb  with  the  unbooted  heel  of  the  surgeon  placed  firndy  in  the 
perinanim  will  answer  every  purpose. 

After-Tkeatment. — After  the  reduction  of  a  dislocation  the  legs  should  be  fastened 
together  and  no  moven)ent  allowed  for  three  weeks,  and  then  only  gentle  movement ;  for 
if  this  rule  be  not  attended  to,  redislocation  may  occur.  In  a  case  under  my  care  of  dis- 
location into  the  foramen  ovale,  in  a  young  woman,  after  reduction  had  been  effected, 
redislocation  occurred  on  the  tenth  day  from  crossing  the  leg  over  the  opposite  knee  in 
attempting  to  cut  the  toe-nails  of  the  affected  limb. 

Splints  are  hardly  called  for  in  the  majority  of  ca.ses,  although,  should  secondary  inflam- 
mation follow  or  much  local  mischief  complicate  the  case,  they  should  be  applied,  with 
either  ice  or  hot  fomentations,  the  surgeon  selecting  the  application  that  gives  most 
relief. 

Old  dislocations,  in  a  general  sense,  should  be  left  alone,  since  in  the  hip  difficul- 
ties of  reduction  are  always  felt  and  danger  is  not  rarely  met  with.  During  the  first  three 
weeks  reduction  is  rarely  difficult  and  may  always  be  tried ;  indeed,  within  the  month 
good  hopes  attend  the  attempt.  I  have  seen  a  dislocation  on  the  dorsum  reduced  on  the 
thirty-fifth  day  with  an  excellent  effect.-  Dr.  H.  Croly  of  Dublin  told  me  in  1879  of  a 
case  of  dislocation  on  to  the  pubis  in  which  reduction  was  eff"ected  on  the  thirty-ninth  day 
by  manipulation  after  an  attempt  with  pulleys  had  failed.  Success  has,  however,  been 
recorded  in  exceptional  cases  up  to  the  sixth  or  eighth  week,  or  even  after  six  months, 


848  CONTUSIONS,   SPRAINS,   AND    WOUNDS   OF  JOINTS. 

but  failure  has  more  frequently  followed  the  attempt.  My  colleague,  Mr.  Durham,  in 
1873  reduced  one  after  the  fifth  month.  Fergusson  states  that  after  three  weeks  he  has 
never  seen  a  successful  attempt.  Sir  A.  Cooper  fixed  eight  weeks  as  the  limit  of  time  up 
to  which  the  attempt  should  be  made,  and  without  the  use  of  anaesthetics  he  was  doubt- 
less right.  When  reduction  has  failed,  good  movement  may  often  be  secured  after  the 
lapse  of  time.  The  dangers  attending  attempts  at  reduction  are  not  theoretical.  Inflam- 
mation and  destruction  of  the  joint  are  no  infrequent  consecjuences.  and  fracture  of  the 
bone  has  been  recorded  by  many  surgeons.  Dislocation  of  the  knee  or  rupture  of  its 
ligaments  has  likewise  taken  place  from  the  extension  employed,  and  with  a  fatal  result. 

When  fracture  of  the  femur  is  associated  with  (lislocation  of  the  hone,  the  latter  should, 
when  possible,  be  reduced  by  manipulation.  In  1860  I  saw  my  colleague,  Mr.  Birkett, 
reduce  with  the  greatest  facility  a  dislocation  of  the  head  of  the  femur  on  the  ramus  of 
the  pubis  in  a  boy  aet.  12  when  the  femur  was  broken  below  the  trochanter,  the  bone 
slipping  into  place  on  the  application  of  gentle  well-directed  force.  Similar  cases  have 
been  recorded  by  Bloxam  and  M.  Etene. 

If  the  reduction  of  the  dislocation  by  these  means  has  failed,  some  hope  remains  that 
when  the  fracture  has  united  a  better  success  may  be  secured.  Sir  A.  Cooper  has  related 
an  example  in  which  reduction  by  means  of  extension  was  effected  five  weeks  after  the 
accident  in  a  youth  about  seventeen. 

Effects  of  Dislocation. — The  sciatic  nerve  may  be  injured  at  times  in  a  dislocation 
of  the  hip,  and  as  a  conse(iuence  paralysis  may  ensue.  Morris  shows  in  his  paper  how 
this  comjdication  is  caused,  while  Maclise  in  his  illustrations  gives  a  drawing  illustrating 
how  the  nerve  may  be  stretched,  and  Hutchinson  (^Med.  Thnes,  1866)  recorded  a  case  in 
which  the  paralysis  was  permanent. 

Dislocations  of  tlie  Patella. — These  are  not  common  accidents,  but  seven  occurred 
at  Gruy's  in  ten  years.  When  they  occur,  they  are  genei'ally  caused  by  muscular  action, 
though  at  times  by  the  application  of  direct  force.  They  are  most  commonly  met  with 
outward^  occasionally  inward,  and  very  rarely  edgeways..  When  the  ligamentum  patellae 
has  been  torn  across,  the  patella  is  drawn  upward ;  and  authors  have  described  this  acci- 
dent as  dislocation  upward. 

The  dislocation  outicard  is  usually  seen  in  women,  in  whom  the  femora  have  a  more 
oblique  inward  direction  than  in  most  men,  or  in  knock-kneed  subjects,  the  bone  resting 
flat  on  the  outer  condyle  of  the  femur  or  on  its  outer  edge ;  in  the  former  case  the  outer 
edge  of  the  patella,  and  in  the  latter  the  inner,  tilts  forward.  The  knee  is  usually  slightly 
flexed ;  it  looks  broader  and  flatter,  but  the  unnatural  position  of  the  cap  marks  the 
nature  of  the  accident.  In  1868  I  saw  this  accident  in  a  male  child  ten  months  old  ;  the 
patella  rested  on  the  outer  side  of  the  condyle  of  the  femur  and  was  readily  reduced. 

Dislocation  iinrard  is  very  rare  and  easily  recognized.  It  is  always  due  to  direct  vio- 
lence to  the  outer  border  of  the  bone. 

Both  these  accidents  are  attended  with  laceration  of  the  synovial  capsule. 

Treatment. — Reduction  is  readily  effected,  usually  by  raising  the  heel  of  the  limb,  to 
relax  the  extensor  muscles  of  the  thigh,  and  manipulating  the  displaced  bone  into  its 
position,  the  elevation  of  its  depressed  edge  being  generally  enough  to  allow  the  muscles 
to  restore  it  to  its  right  place.  A  splint  should  then  be  applied,  as  well  as  a  bag  of  ice 
for  a  few  days  till  all  inflammatory  action  has  subsided,  the  knee  being  strapped  up  sub- 
se(|uently  for  a  month  or  more,  to  give  time  for  the  ligaments  to  unite  firmly.  These 
dislocations,  however,  are  very  prone  to  recur  on  the  slightest  cause,  and  many  patients 
are  obliged  to  wear  for  life  a  firm  leather  knee-cap  to  guard  against  such  a  contingency. 

Dislocation  of  the  bone  edgeways  is  a  very  uncommon  accident.  I  have  seen 
only  one  such  instance,  and  in  it  the  patella  appeared  to  show  its  articular  facet  inward, 
its  inner  edge  presenting  forward  beneath  the  stretched  skin.  It  was  in  a  middle-aged 
woman,  and  the  displacement  was  produced  by  a  direct  blow  upon  the  knee  from  a  fall 
off"  a  chair.      Mayo  has  recorded  an  instance  in  which  the  bone  had  turned  almost  round. 

This  dislocation  is  readily  known  by  the  peculiar  appearance  of  the  joint. 

Treatment. — In  my  own  case  reduction  was  effected  with  ease  on  raising  the  leg  and 
turning  the  patella  into  its  right  position  with  the  fingers.  Flower  succeeded  on  bending 
the  knee  only  after  chloroform  had  been  given.  Cases  have  been  recorded  where  reduc- 
tion was  impossible,  even  after  the  subcutaneous  division  of  the  tendon  and  ligament  that 
is  attached  to  it,  and  other  rough  means ;  but  these  were  employed  before  chloroform  was 
introduced,  which  must  be  their  excuse.  Under  an  anaesthetic  it  is  probable  that  by 
manipulation  the  bone  will  usually  be  reduced  ;  if  not,  it  had  better  be  left  alone.  Some 
sudden  muscular  effort  miijrht  be  of  service. 


DISLOCATIOSS   OF   Tin:   I.OWEIl    KXTUEMITIES. 


849 


¥u,.  .")'J(i. 
Pal  tlln 


Exfl  ronHyle  of  femur 


Partial  Dislocation  of  the  Left  Tibia  and  Fibula  For- 
ward.   (Taken  from  a  man  wt.  2:5.) 


Dislocation  of  the  Knee-Joint.-  'I'lii-  arciilcnl  run  .ici'm-  (.nlv  Inim  <:rciit  viu- 
li'iici',  till'  liiiaiiicnls  that  l)iiiil  the  hdiR-s  to;j:cthi'r  \n'\u<i  very  Htroii;^  ;  yt-t  it  d<jes  occur, 
the  tihiii  hciiit;  tlisjihici-d  huc/i-irnni,  fonrnnl.  or  litlrrnllij.  Kuur  (ixaiiiph's  (jccurriMl  at 
(Juv  s  ill  tell  years.  Wlieii  jutr/id/,  ii(t  eoiniilieatidii,  a.s  a  nil(!,  exist.s,  ami  tlu?  lateral  i.s 
iisiiallv  of  tlii.s  nature;  when  cuin/tfitr,  the  snl"t  pari  ahitut  the  j(»int  and  the  liljnm.s  tis.sue.s 
within  are  often  .so  injured  as  to  render  it  a  ;rreat  ((uestion  whether  the  joint,  or  even  the 
liiiili.  can  he  saved.      The  hackward  and  forward  dislocations  are  usually  of  this  kiiul. 

l)|.\iiNtisis. — When  the  |iopliteal  artery  or  vein  is  injured  or  ruptured.  aiii|)Utatioii 
of  the  liiiil)  inav  he  ealli'd  for,  this  necessity  beiiif^  rendered  more  than  prohahle  when 
the  circulation  throu^di  the  vessels  is  not  speedily  restored  after  the  reduction  of  the  dis- 
location or  when  a  swollen  ciuidition  of  the  limb  remains. 

TuK.VT.MKNr. — The.se  dislocations  arc  readily  dia^nio.sed  by  the  peculiar  deformity  they 
display,  and  are  easily  reduced  by  extension  and  tlu;  application  of  pressure  where  pres- 
sure is  needed.  In  the  case  from  which  Fiir-  ;')-'• 
was  taken  jiulsation  in  the  ve.s.sels  was  arrested, 
but  it  returiietl  on  the  reduction  of  the  dislo- 
cation, and  recovery  with  complete  movement 
of  the  joint  was  ohtaiiie(l.  After  the  parts  have 
been  replaced  in  tlieir  normal  positi(tn  splints 
should  be  adjusted  and  cold  applied,  for  second- 
ary inflammation  is  almost  sure  to  follow.  In 
rare  cases  the  displacement  is  permanent  and  the 
limb  is  left  u.seful.  Thus,  in  a  man  xt.  20  under 
my  care  the  left  tiltia  and  fibula  were  displaced 
partially  inward  five  years  before  I  saw  him  from 
a  fall  in  wrestling.  The  inner  condyle  of  the 
femur  rested  on  the  outer  articular  facet  of  the  tibia,  and  the  head  of  the  fibula  seemed 
to  rest  between  the  condyles  of  the  femur.  The  man  liad  good  though  not  complete 
movement  of  the  joint,  could  walk  well  and  carry  loads. 

A  displacement  of  the  lower  epiphysis  of  the  femur  with  the  leg-bones  may  be  mis- 
taken for  dislocation  of  the  knee,  and  in  young  subjects  where  this  latter  accident  is  sup- 
posed to  have  taken  place  the  surgeon  should  always  consider 
the  probability  of  the  injury  being  of  the  former  kind.  In 
Fig.  521  this  accident  is  well  illustrated  ;  it  was  taken  from  a 
boy  ji3t.  10  who  w'as  under  my  care  at  Guy's  some  years  ago. 
The  epiphysis  had  been  displaced  inward  off  the  shaft  of  the 
femur  and  rotated  inward,  and  the  lower  end  of  the  diaphy.sis 
of  the  femur  was  nearly  through  the  soft  parts  on  the  outer 
side  of  the  limb.  The  parts  were  restored  to  their  normal 
position  by  manipulation  and  extension  and  the  limb  was  fas- 
tened on  a  splint ;  a  good  recovery  with  perfect  movement  of 
the  joint  was  the  result.  In  some  cases  fracture  coexists,  and 
in  exceptional  examples,  where  the  end  of  the  diaphysis  ])ro- 
jects  through  the  soft  parts,  its  resection  may  be  required  to 
allow  of  its  reduction. 

Compound  dislocations  of  the  knee  are  generally  so 
serious  as  to  necessitate  the  removal  of  the  joint.  The  attempt 
to  save  it  should  be  made  in  exceptional  cases  only  ;  ampu- 
tation or  excision   mav  be  selected. 

Dislocation  of  "the  head  of  the  fibula  is  occasion- ^P'";«jio'j^and  Rotation  ^inward 

all V  met  with.  I  have  seen  but  three  examples — one  when  Femur,  with  the  Lcs  Hones,  from 
dressing  for  the  late  Mr.  A.ston  Key,  and  two  since.  It  is  f!'om'atl.y*'it*'iar"''"  ^'^'"^^'^ 
generally  caused  by  some  violent  adduction  of  the  foot,  with 

abduction  of  the  knee,  the  head  of  the  fibula  tearing  through  its  ligamentous  attach- 
ments and  becoming  displaced  outward. 

DiACXOSis. — The  accident  can  be  readily  recognized  by  the  projection  of  the  bone. 
It  should  be  treated  by  the  application  of  a  pad  and  pressure  over  the  part  suflicient  to 
keep  the  bone  in  its  place,  the  limb  being  flexed  when  necessary,  to  relax  the  biceps 
femoris.  The  pressure  should  be  maintained  for  at  least  two  months  if  good  success  is 
to  be  looked  for;  as  a  rule,  the  bone  never  quite  resumes  its  former  position,  the  head 
projecting  more  than  usual.  This  deformity,  however,  does  not  appear  to  weaken  the 
limb  to  any  great  extent. 
54 


Fig.  521. 


850 


CONTUSIONS,  SPRAINS,  AND    WOUNDS  OF  JOINTS. 


Dislocation  of  the  interarticular  fibro- cartilages  (.semilunar)  is  a  recog- 
nized accident.  It  is  produced  by  some  sudden  twist  of  the  knee  with  tlie  foot  everted, 
and  generally  in  subjects  who  have  relaxed  joints  or  such  as  have  been  the  seat  of  some 
chronic  synovitis.  The  inner  cartilage  seems  more  liable  to  displacement  than  the  outer. 
Symptoms. — The  symptoms  of  the  accident  are  well  marked.  A  patient,  when  walk- 
ing, accidentally  catches  his  foot  against  a  stone  or  in  rising  from  a  kneeling  position  is 
seized  with  a  sudden  sharp,  sickening  pain  in  the  knee  ;  the  joint  becomes  at  once  fixed 
in  a  semiflexed  position  and  any  attempt  to  move  it  only  excites  some  pain.  When  the 
first  agony  has  subsided,  a  painful  spot  is  usually  left,  where  the  projecting  cartilage 
may  be  felt,  or  even  seen  ;  and  if  the  "  internal  derangement  of  the  joint,"  as  it  was  orig- 
inally called,  is  left  untreated,  synovitis  or  effusion  into  the  joint  will  soon  show  itself. 
When  these  symptoms  follow  such  an  accident  as  has  been  described,  the  cartilage  has 
probably  been  torn  from  its  attachment  to  the  tibia  and  been  doubled  in  or  displaced. 

Mr.  J.  F.  Knott  in  an  able  paper  (BhI>.  Joiini.  of  Med.  Sci.,  June,  1882,  p.  479)  has 
shown  that  in  "  the  combined  twisting  and  lateral  movement  conveyed  to  the  knee  at  a 
moment  when  the  ligaments  are  as  lax  as  possible  the  margin  of  the  condyle  of  the  femur 
is  Jerked  over  the  edge  of  the  internal  semilunar  fibro-cartilage.  The  immediate  result  is 
pressure  of  this  structure,  which  is  increased  when  the  resulting  pain  brings  about  spas- 
modic contraction  of  the  surrounding  muscles." 

Treatment. — The  best  practice  consists  in  the  forced  flexion  of  the  joint,  the  slight 
rotation  of  the  leg  outward,  and  sudden  extension,  pressure  with  the  thumb  upon  the 
cartilage  above  the  edge  of  the  inner  condyle  of  the  tibia  during  the  flexion  and  extension 
often  being  of  use.  When  success  attends  this  manoeuvre,  the  joint  moves  smoothly  and 
without  pain,  and  the  patient  will  at  once  be  able  to  move  the  joint  freely.  At  times  the 
reduction  of  the  displaced  cartilage  is  attended  with  a  decided  snap.  After  its  reduction 
the  joint  should  be  kept  in  a  splint  and  such  means  employed  as  the  symptoms  that  fol- 
low indicate,  for  more  or  less  inflammation  often  ensues,  requiring  ice,  cold  lotions,  leech- 
ing, and  rest.  When  active  symptoms  have  subsided,  it  is  well  to  restrain  the  movements 
of  the  joint  by  means  of  a  knee-cap  or  strapping,  as  a  recurrence  of  the  accident  is  liable 
to  follow  upon  the  least  occasion.  I  have  on  several  occasions  thought  that  disease  has 
been  excited  when  this  measure  has  been  omitted,  and  I  once  saw  anchylosis  follow. 
Permanent  lameness  is  by  no  means  uncommon.  When  the  surgeon  fails  to  reduce  the 
displaced  cartilage,  the  patient  at  times  suddenly  gains  relief  by  its  spontaneous  reduc- 
tion during  some  accidental  movement.  In  other  cases  the  cartilage  resumes  its  normal 
condition  more  slowly.  In  1873  I  saw  a  case  of  this  kind  where  spontaneous  reduction 
always  occurred  after  its  displacement.  It  was  in  a  gentleman  a3t.  30,  and  the  inner  carti- 
lage projected  beyond  the  head  of  the  tibia  in  a  most  marked  manner.  The  patient  should 
be  kept  in  bed  and  allowed  only  to  move  the  limb,  not  to  stand  upon  it.  When  this  result 
is  not  secured,  the  joint  should  be  strapped  up,  to  restrain  movement. 

Dislocations  of  the  Ankle-Joint. — Such  an  accident  uncomplicated  with  rup- 
ture is  rare  ;  that  is,  dislocation  of  the  foot 
ontvmrd  is  generally  associated  with  frac- 
ture of  the  fibula,  and  dislocation  Invard 
with  fracture  of  the  tibia,  or  both  malleoli 
may  be  broken.  Pure  dislocations  of  the 
foot  foricard  or  hachward^  however,  may 
occur.  These  dislocations  are  given  in  the 
order  of  their  frequency,  and  are  usually 
produced  by  some  violent  twist  or  bend- 
ing of  the  foot  when  the  patient  is  jump- 
ing, or  by  some  violent  impulse  of  the  body 
with  the  foot  fixed. 

Dislocation  of  the  foot  o?'^;/-arf?  is  better 
known  as  "  Pott's  fracture"  (Fig.  522),  the 
fibula  being  usually  broken  two  or  three 
inches  above  the  external  malleolus.     It 
is  caused  by  a  violent  bending  of  the  foot 
outward  with  the  foot  everted,  its  outer 
ward,  with  Fracture  edffe  beins  raised  and  the  inner  turned 
(lp."coopefr^"'-  downward  on  the  ground.     At  times  the 
extremity  of  the  inner  malleolus  is  broken 
off"  and  displaced  outward,  with  the  foot  and  astragalus.     Under  all  circumstances  the 


Fig.  522. 


Fig.  523. 


External  Appearances  of  Foot  in 
Pott's  Fracture.  (Taken  from 
Pott's  work.) 


Dislocated     Foot    In- 


DISLOCATIOyS  OF  THE  LOW'KIl   IIXTIIIIMITIES. 


851 


Fig.  0-24. 


IcnvtT  I'lid  *A'  tlu'  tihiii  or  imicr  m:illtiiln<  lniiiis  a  proiiiiiiciit  prnjcctiDri  iiiwanl.  Iea<liii<: — 
or  »</,sl('a(liiit: — Sir  A.  Cuopor  ami  his  copyists  to  iIi'slmmIjc  this  acci<lt'iit  as  (ii.shjcutioii  of 
tho  tihia  iiiwaril.  At  thi;  scat  of  fracture  of  the  Hlxila  a  depression  exists.  Wheii  the 
force  is  coiitimicil  hcyoiid  the  point  necessary  to  cause  tlie  ilisphu-cnicnt  mentioned,  the 
h)\ver  end  of  tlie  tibia  may  he  made  to  project  throujiii  the  soft  j»arts  and  tlius  jrive  rise 
to  ji  compnuiiil  lUslitciitinii.  In  still  more  severe  cases  tho  e. \t rem i tics  of  both  tibia  and 
fibula  may  be  made  to  project,  the  foot  being  completely  turned  outward.  Exceptional 
cases  occur  in  which  the  foot  is  turned  out  of  its  socket  between  the  malleoli  witliout 
any  accompanyinii:  iVacture. 

Dislocation  of  the  foot  inwunl  (Fig.  523)  is  the  counterpart  of  the  last-described  acci- 
dent, and  is  caused  by  violence  that  turns  the  foot  inward  with  its  outer  edge  to  the 
ground.  It  is  usually  associated  with  an  ol)li(|ue  fracture  of  the  inner  malleolus  and  di.s- 
plact'ment.  The  force  n^quired  to  lu-oducc  this  dislocation  is  very  great,  the  tibia  being 
a  far  stronger  bone  than  tlie  fibula  ;  the  accidiuit.  C(»nsc<|Mently,  is  less  common.  The  end 
of  the  fibula  is  often  fractured  and  drawn  outward  with  the  astragalus.  At  times  the 
astragalus  is  also  fractured.  The  accident  is  known  by  the  in- 
version of  the  foot,  the  sole  looking  inward,  and  by  the  projec- 
tion of  the  external  malleolus,  this  ))romincut  symptom  having 
led  Sir  A.  (^^oper  to  describe  it  as  dislocation  of  the  tibia  out- 
ward. 

When  the  force  is  continued  or  more  severe,  either  the  fibula 
or  the  fractured — or,  rather,  exposed — ends  of  both  tibia  and  fib- 
ula may  be  made  to  project  through  an  external  wound ;  in  still 
uiore  severe  cases  I  have  seen  this  more  than  once,  and  in  one  a 
sound  recovery  ensued,  with  a  movable  joint.  It  was,  however, 
in  a  boy  ivt.  12.  I  simply  reduced  the  dislocation  after  washing 
and  dressing  the  wound,  and  fixed  it  in  splints. 

Dislocation  of  the  foot  fxakicurd  (Fig.  52-1- )  was  called  by  Sir 
A.  Cooper  dislocation  of  the  tibia  and  fibula  forward.  It  is  usu- 
ally caused  by  the  violent  propulsion  of  the  lower  end  of  the 
leg-bones  forward  when  the  foot  is  fixed,  and  is  readily  recog- 
nized by  the  shortening  of  the  anterior  surface  of  the  foot  and 
the  proportionate  elongation  of  the  heel,  with  some  pointing  of 
the  toes  as  well  as  prominence  of  the  lower  end  of  the  tibia.  At 
times  the  fibula  is  fractured  and  the  point  of  bone  carried  backward  with  the  astragalus. 

This  accident  is  rare,  it  being  more  common  to  meet  with  fracture  of  both  malleoli 
and  displacement  of  the  foot  and  broken  fragments  backward. 

In  1802  I  was  called  to  treat  a  very  marked  case  of  this  kind  in  a  man  aet.  32.  The 
astragalus  with  the  foot  seemed  to  have  been  shot  eompleteh'  out  of  its  socket,  and  the 
extremities  of  the  tibia  and  fibula  projected  so  far  forward  as  almost  to  rupture  the  soft 
parts  covering  them.  The  accident  was  caused  by  wrestling.  The  dislocation  was 
reduced  by  flexing  the  leg  on  the  thigh  and  by  manipulation,  but  no  means  could  be 
found  to  maintain  the  bones  in  position  till  the  tendo  Achillis  was  divided  and  the  leg 
placed  on  its  side  and  fixed  on  an  outside  splint.  3Ir.  Cock  (G)ii/\<  Rep.,  1S55)  has 
recorded  a  case  of  the  same  accident  in  a  boy  xt.  16.  where  the  same  difficulty  was  expe- 
rienced. He  divided  the  tendo  Achillis  and  bound  the  foot  in  splints,  and  a  good  result, 
as  in  my  case,  was  obtained. 

Dislocation  of  the  foot  forward  is  probably  more  rare  than  the  last,  and  is 
generally  only  partial.  It  has  been  described  as  dislocation  of  the  tibia  backward,  and  is 
known  by  ])recisely  the  opposite  symptoms  to  those  last  described.  The  heel  is  shortened 
and  the  foot  lengthened,  the  upper  surface  of  the  astragalus  being  capable  of  recognition 
by  the  fingers.  Poland  records  such  a  case  {Guys  Rep.,  1855)  in  which  the  whola  foot 
was  much  elongated,  and  the  posterior  part  of  the  astragalus  was  caught  in  the  anterior 
part  of  the  tibia  and  fibula  and  wedged  in  tightly.  Reduction  was  efli'ected  only  after  the 
division  of  the  tendo  Achillis. 

Tre.vt.mknt. — The  lateral  dis])lacements  of  the  foot  are  not  difficult  of  reduction  by 
extension  and  well-directed  manipulative  force.  The  flexion  of  the  knee  facilitates  this 
operation  by  relaxing  the  muscles  of  the  calf. 

To  keep  the  bones  in  position  a  Macintyre  or  flat  posterior  splint  extending  up  to  the 
popliteal  space,  with  foot-piece  and  two  side  splints,  all  well  padded,  are  sufficient  as  a 
rule,  the  surgeon  using  his  judgment  as  to  the  amount  of  pressure  and  padding  that  may 
be  demanded.     In  some  cases  where  it  is  a  very  difficult  matter  to  keep  the  parts  quiet, 


Dislocation  of  the  Foot   Rack- 
ward.    (Cast  165,  Guy's  Mus.) 


852  CONTUSIONS,  SPRAINS,  AND    WOUNDS  OF  JOINTS. 

from  the  action  of  the  gastrocnemii  muscles,  the  tendo  Achillis  should  be  divided,  the 
foot  after  this  simple  operation  being  perfectly  passive  and  entirely  in  the  hands  of  the 
surgeon  to  place  and  to  keep  in  any  required  position. 

The  limb  should  subsequently  be  slung  in  a  proper  swing,  Salter's  being  the  best.  In 
hospital  practice  two  or  more  pieces  of  bandage  slinging  the  splints  to  the  cradle  answer 
well.  In  the  displacement  of  the  foot  forward  or  backward  the  same  kind  of  treatment  is 
applicable,  but  in  these  accidents  it  is  expedient,  as  a  rule,  to  divide  the  tendo  Achillis  at 
once.  This  should  be  done  at  any  rate  when  the  slightest  disposition  to  displacement  is 
found  to  exist,  the  treatment  of  the  case  being  by  this  operation  rendered  more  simple 
and  certain. 

The  splints  should  be  retained  for  at  least  six  weeks,  and  afterward  passive  movement 
should  be  allowed.  The  patient  should  not  bear  any  weight  on  the  limb  for  another 
month. 

The  treatment  of  compound  dislocation  of  the  anJde-joint  cannot  be  reduced  to  any 
definite  rules.  Each  ease  must  be  treated  on  its  own  merits.  In  young  and  healthy  sub- 
jects more  may  be  attempted  in  the  way  of  saving  the  joint  than  in  the  old  or  cachectic. 
When  a  small  wound  exists,  operative  interference  is  only  exceptionally  needed  ;  but 
when  a  large  one  with  projection  of  the  bones,  it  is  a  question  whether  the  better  practice 
lies  in  the  reduction  of  the  dislocation  after  cleansing  the  projecting  bones  or  in  their 
resection.  When  the  bones  cannot  be  reduced  by  ordinary  force,  their  resection  becomes 
a  necessity.  When  the  bones  are  much  crushed,  their  resection  should  always  be  under- 
taken ;  indeed,  it  is  a  general  feeling  in  my  own  mind  that  in  compound  dislocations,  as  in 
compound  fractures  with  a  large  wound,  it  is  wiser  to  resect  the  ends  of  the  projecting 
bones  than  to  reduce  them.  Amputation  of  the  foot  should  be  performed  only  when  the 
soft  parts  and  the  bones  are  much  injured  and  the  age  of  the  patient  or  his  want  of  power 
forbids  the  hope  that  a  recovery  with  a  useful  limb  can  be  secured.  Before  any  attempt 
at  reduction  is  made  the  parts  should  be  thoroughly  cleansed.  After  the  reduction  of 
the  dislocation,  whether  simple  or  compound,  the  application  of  ice  or 
Fig  525.  cold  is  of  great  value,  or  the  treatment  by  irrigation.     In  the  suppura- 

tive stage  the  latter  practice  is  probably  the  better  of  the  two.  When 
the  wound  is  of  only  a  limited  nature,  it  may  be  sealed  at  once,  either 
by  lint  soaked  in  blood,  or,  what  is  better,  by  the  compound  tincture 
of  benzoin.  The  joint  in  such  cases  may  be  washed  out  with  a  weak 
solution  of  carbolic  acid  (one  part  in  forty)  or  iodine  water  before  the 
wound  is  sealed.  Opposite  the  wound  an  interrupted  splint  should  be 
employed. 

Secondary  amputation  may  be  called  for  in  these  cases,  on  account 
of  gangrene  or  a  fiiilure  in  nature's  efforts  to  effect  repair,  etc. 

Dislocation  of  the  tibia  and  fibula  at  their  lower  ar- 
ticulation, with  a  forcing  of  the  astragalus  upward 

between  the  two  bones,  is   an  accident  which  must  be   recog- 
nized (Fig.  525),  and  is  usually  produced  by  a  jump  from  a  height  on 
the  foot  or  feet.     I  saw  a  good  example  of  it  in  1869,  in  both  feet  of  a 
T..  ,     ,.       f  i  ,  ,„      man  fet.  55  who  fell  from   a  scaffold.     The  malleoli  were  widely  sepa- 

Dislocation  ol  Ankle —  iinioipp  i  •  •  c  Ix. 

Astragalus  between  rated  and  projected,  the  depth  of  the  toot  from  the  extremities  or  the 
O^ast  160,  &iy's  MusO  malleoli  was  lessened,  and  the  movements  of  the  foot  were  almost  gone. 
No  fracture  could  be  made  out.  It  was  impossible  to  move  the  bones 
from  the  position  in  which  they  were  wedged,  although  all  means  were  used.  Yet  a  good 
recovery  took  place,  though  with  stiff  joints.  I  have  seen  a  like  case  since  in  a  man  who 
jumped  from  a  high  window,  but  in  it  some  fracture  of  the  astragalus  complicated  the 
injury;  the  man  did  well. 

Dislocations  at  the  tarsal  joints  are  met  with  in  practice,  although  but 
rarely.  They  are  difficult  to  diagnose,  and  still  more  difficult  to  classify,  since  they  are 
so  variously  described  by  different  writers.  The  first  to  be  noticed  is  snhastragaJoid  dis- 
location of  the  foot ^  in  which  the  astragalus  maintains  its  normal  position  with  the  tibia  and 
fibula,  but  loses  it  with  respect  to  the  rest  of  the  foot.  Mr.  Arnott  communicated  to  the 
London  Med.  Gazette  (vol.  xv.,  1837,  p.  588)  the  report  of  a  case  in  which  he  and  Mr.  A. 
Shaw  recognized  the  nature  of  the  accident ;  but  the  possibility  of  such  an  accident  was 
doubted  till  Mr.  Pollock  in  1859  (Med.-Chir.  Trans.,  vol.  xlii.)  published  two  cases;  one 
occurred  in  Mr.  Keate's  practice  in  1823,  and  in  it  the  os  calcis  and  scaphoid,  with  the 
other  foot-bones,  were  displaced  outirard  off  the  astragalus.  In  the  other,  which  occurred 
in  his  own  practice,  the  same  bones  were  dislocated  inward.     A  dissection  of  this  case  is 


DISLUL'ATIOSS   OF   TlIK  LOW'Kll    hXmh'MJTIh'S. 


853 


Fi(i.  020. 


given.  Til  Koiito'.s  ca.se  tlie  foot  wa.s  everte<l  and  tin;  head  <tf  the  astra^alu.s  projected  on 
tlie  inner  .side  of  the  instej).  In  Polhicii'.s  the  loot  was  inverted,  .so  that  the  soh;  tnrncd 
inwuril  as  in  varns  ;  thi'  external  inaUeoIns  was  very  proniinent  and  the  astra^^alns  pm- 
jeeted  on  the  other  sitK'.  In  sunie  instances  tlie  snrfaees  of  tlie  foot  arc  maintained  in 
their  ri^^lit  line.  In  Mr.  I'uUock.s  case  reduction  was  found  to  In-  inipossihh"  till  the 
ten<h>  Achillis  had  heen  divided,  wlien  it  was  readily  aeconi|tlislied.  in  an  aide  paper  he 
advocates  this  practice  whenever  difficulty  of  reduction  of  the  inward  or  outward  dislo- 
cation, simple  or  compound,  is  experienced,  and  shows  that  the  division  of  the  j)osteri(*r 
tihial  tendon  is  occasionally  called  for  in  the  outwanl.  Mr.  Turner  of  Manchester  had 
l)reviously  advocated  the  same  practice  ( 7/7(/i.s.   I*ror.   Mi</.  and  Snrg.  Jssoc,  vol.  ix.). 

In  1882  a  man  ;ot.  3(i  came  under  my  care  with  disjtlacement  of  the  foot  outivard  off 
the  astrairalus  and  slight  eversion  of  the  foot.  The  head  of  (he  astragalus  j>rojected 
thnuijih  a  large  wound  in  the  soft  parts  above  and  within  the 
tu))ercle  of  the  scaphoid  and  above  the  tendon  of  the  ])osterior 
tibial  muscle.  Keduction  was  found  impossible  until  a  portion  of 
the  head  of  the  bone  was  removed,  wdien  the  parts  were  re|daced 
and  the  case  went  on  to  a  satisfactory  conclusion,  with  movement 
in  the  ankle-joint. 

An  atlmirable  paper  on  this  subject  has  been  pul»lislied  by  Sir 
W.  .MacC'ormac  (^V.  Thomas  s  Hasp.  Rep.,  1872).  The  woodcut 
produced  (Fig.  526)  is  taken  from  it,  from  which  it  will  be  seen 
that  ''  the  foot  was  violently  inverted  and  adducted,  its  position 
being  like  that  of  talipes  varus.  The  sole  of  the  foot  looked 
inward  and  was  nearly  vertical ;  the  outer  edge  of  the  foot,  with 
the  patient  erect,  would  rest  partially  upon  the  ground.  The  great 
toe  pointed  toward  the  arch  of  the  opposite  foot.  The  inner  l)or- 
der  of  the  foot  was  somewhat  shortened  and  more  concave,  while  DLsiocation  of  Foot  inward 

,,  ,  ^1  ill  1  -p  1         ii  otl'tho -Xstracalus.    (After 

the  outer  was  more  convex  than  natural  and  appeax'ed  as  it  length-      \v.  MacCormac.) 
ened.     The  outer  malleolus  was  very  prominent,  while  the  inner 

could  not  be  perceived,  so  deeply  was  it  buried.  Neither  malleolus  was  fractured,  and 
this  would  seem  to  be  almost  characteristic  of  this  form  of  injury.  The  rounded  head 
of  the  astragalus,  completely  dislodged  from  the  .scaphoid,  was  resting  subcutaneously 
over  the  calcaneo-cuboid  articulation.  The  prominence  cau.sed  by  the  head  was  .somewhat 
masked  by  swelling  of  the  soft  part  just  below  it.  The  skin  covering  the  head  was  so 
tensely  stretched  that  it  seemed  ready  to  burst,  and  a  circular  slough  sub-sequently  formed 
at  the  spot.  The  outline  of  the  head  could,  however,  be  ea.sily  traced,  and  the  finger,  on 
being  passed  upward  beneath  the  external  malleolus,  readily  felt  the  cartilaginous  surface 
of  tlie  large  posterior  articulating  facet  of  the  astragalus.  Most  of  it  was  quite  subcu- 
taneous, and  its  external  margin  rendered  the  .skin  very  tense.  The  interos.seous  ligament 
had  been  ruptured.  The  tuberosity  of  the  scaphoid  stood  out  prominently  and  a  depres- 
sion could  be  felt  behind  it.  The  motions  of  the  foot  were  very  limited."'  3IacdonnelI 
of  Dublin  {Diib.  Jonm.,  1839)  published  a  case  in  which  the  same  bones  were  displaced 
backward,  where  the  heel  projected,  and  a  marked  prominence  existed  on  the  dorsum  of 
the  foot,  with  an  abrupt  descent  in  front  on  the  tarsus. 

In  1862  I  had  to  amputate  the  foot  of  a  man  fet.  24  for  a  compound  dislocation  of 
the  foot  hackicard  off  the  astragalus,  with  fracture  of  the  calcis.  When  seen,  the  foot 
was  turned  inward  and  much  fore-shortened  and  there  was  a  bony  eminence  in  front  of 
the  external  malleolus,  which  turned  out  to  be  the  displaced  anterior  third  of  the  os  calcis. 
The  accident  was  caused  by  the  man's  foot  becoming  wedged  between  the  spring  and  the 
step  of  a  locomotive  and  his  body  falling  outward.  On  dissection  the  astragalus  was 
found  in  its  normal  position,  between  the  malleoli,  but  with  its  head  resting  on  the 
scaphoid  bone,  between  the  tendon  of  the  tibialis  anticus  on  its  inner  side  and  of  the  long 
common  extensor  on  the  outer.  On  the  outer  side  of  the  foot  the  displaced  portion  of 
the  OS  calcis  was  resting  on  the  dorsal  surface  of  the  cuboid  bone :  the  rest  of  the  calcis 
was  completely  dislocated  backward,  its  upper  and  posterior  articular  facet  projecting 
beyond  the  astragalus.  The  extreme  end  of  the  external  malleolus  was  broken  off.  The 
peronei  tendons  maintained  their  position  behind  the  external  malleolus,  but  were  much 
stretched. 

M.  Pari.se  {Annahs  de  la  Chintrf/.,  1845)  gives  an  instance — which  is  apparently 
unique — of  dislocation  forward,  in  which  marked  elongation  of  the  foot  existed  and  the 
projection  of  the  heel  was  effiiced. 

All  these  dislocations  are  rare.     The  first  example  of  dislocation  inward  that  I  have 


85-1  CONTUSIONS,  SPRAINS,  AND    WOUNDS  OF  JOINTS. 

seen  was  recorded  b}"  Mr.  Cock  in  Guf/^s  ffonp.  Rep.  for  1855.  with  a  drawing;  but  in  my 
work  On  the  Joints  (1859)  I  published  (Case  85)  an  example  of  dislocation  of  the  foot 
outward,  with  a  description  of  the  dissected  extremity,  which  had  occurred  in  the  practice 
of  Mr.  Aston  Key  in  1845.  The  foot  was  amputated,  reduction  being  impossible.  The 
ankle-joint  was  perfect.  The  os  calcis  with  the  foot  was  displaced  outward.  The  tendon 
of  the  tibialis  posticus  was  found  in  front  of  the  tibia  holding  down  the  astragalus.  The 
posterior  tibial  nerve  was  violently  stretched  over  the  astragalus.  The  limb  was  removed 
for  tetanus,  and  the  symptoms  immediately  disappeared  after  the  amputation.  A  large 
number  of  these  cases  are  compound,  and  in  some  they  are  complicated  with  fracture  of 
the  fibula.  Broca  (^Mem.  de  la  Societe  de  Chirurg.,  tome  iii.),  out  of  thirteen  examples 
of  dislocation  outward,  gives  nine  as  compound. 

This  dislocation  may  be  diagnosed  from  displacement  at  the  ankle-joint  and  dislocation 
of  the  astragalus  itself  by  the  fact  that  extension  and  flexion  are  present ;  from  fractures 
about  the  ankle  by  the  absence  of  crepitus,  together  with  the  positive  signs  of  the  inju- 
ries themselves. 

Treatment. — Reduction  should  be  attempted  only  with  the  patient  anaesthetized,  and 
under  such  an  influence,  by  extension  and  manipulation,  success  may  be  looked  for.  When 
difficulties  are  experienced,  Turner  and  Pollock's  suggestion  of  dividing  the  tendo  Achillis, 
and  even  the  posterior  tibial  tendon,  or  any  other  tendon  when  it  is  clearly  interfering  with 
the  replacement  of  the  bones,  should  be  followed.  "When  these  means  fail  and  the  stretched 
skin  gives  way,  the  case  must  be  treated  as  one  of  a  compound  nature  and  the  astragalus 
partially  is  excised,  the  foot  being  subsequently  well  confined  in  splints  and  ice  applied.' 
Occasionally  amputation  may  be  demanded,  or  Syme  or  Pirogoff's  more  partial  operation. 
Dislocations  of  the  Astragalus  alone  are  said  to  be  more  common  than  the 
former  accidents.  I  have  seen  several  such,  but  I  am  disposed  to  think  I  have  mistaken 
some  cases  of  sub-astragaloid  dislocation  for  dislocation  of  the  astragalus.  Pollock  believes 
the  pure  dislocation  of  the  astragalus  to  be  very  rare. 

The  bone  may  be  shot  out  of  its  socket  foricard,  backward,  and  even  latcralJi/.  and  in 
rarer  examples  rotated  on  its  axis. 

In  the  dislocation  /b/7carc/  the  head  of  the  bone  projects  from  between  the  malleoli,  in 
some  being  shot  inward  so  as  to  form  a  marked  eminence  beneath  the  internal  malleolus, 
in  others  outward.  In  such  an  accident  the  heel  remains  in  its  normal  position  and  all 
movement  of  the  ankle-joint  is  lost. 

The  dislocation  backward,  of  which  Phillips  (^Med.  Gaz.,  183-4)  and  Turner  have  cited 
examples,  is  indicated  by  the  remarkable  projection  which  suddenly  appears  above  the 
heel,  pressing  out  the  tendo  Achillis  by  the  shortening  of  the  foot  and  the  prominence  of 
the  tibia  in  front. 

Dislocation  of  the  astrar/a/us  laternd//  to  be  complete  must  be  compound  (Fig.  527), 
and  when  incomplete  at  first  will  probably  become  complete  at  a  later  period  through 

sloughing  of  the  soft  parts.     It  is  generally,  but  not 
Fig.  527.  always,  complicated  with  fracture  of  one  or  other  of 

the  malleoli.  Boyer  has  recorded  a  case  of  dislocation 
of  the  astragalus  inward  in  which  no  such  complica- 
tion existed,  and  in  Gni/'s  Reports  for  18G1  (p.  293) 
I  recorded  an  example  of  dislocation  of  the  bone  out- 
tvard  in  a  man  ast.  51  in  which  both  malleoli  were 
entire  ;  the  astragalus  had  been  fractured  and  turned 
completely  out  of  its  bed  and  was  found  hanging  to 
the  wound  below  the  external  malleolus.  I  removed 
the  broken  fragments  at  once  and  brought  the  foot 
Compound  Disloc.itioiT^the  Astragalus,      into  a  good  position  ;  a  complete  recovery  w^ith  a  stiflf 

joint  ensued.  Sixteen  years  after  the  accident  the 
man  walked  about  without  the  aid  of  a  stick  and  with  no  other  inconvenience  than  that 
occasioned  by  a  stiff"  joint,  which  he  maintained  was  a  very  slight  matter.  Fig.  528  illus- 
trates a  case  of  dislocation  of  the  bone  outward,  complicated  with  fracture  of  the  fibula. 
Rotation  of  the  bone  often  coexists.  Mr.  Barwell  has  written  (Med.-Chir.  Trans.,  vol. 
Ixvi..  1883)  an  interesting  paper  upon  this  subject,  and  gives  a  case  in  which  he  resected 
the  astragalus  with  a  good  result.  He  tells  us  '•  the  bone  may  be  turned  either  horizon- 
tally, so  that  its  long  axis  looks  across  the  joint  and  at  right  angles  to  its  normal  posi- 
tion," and  this  he  would  call  version,  "or  it  may  turn  over  sideway  upon  its  antero- 
posterior axis,  which  might  be  termed  torsion."  That  Mr.  Barwell  is  right  there  can  be 
no  doubt.      In   1878  I  removed  from   the  inner  side  of   the  ankle-joint  of  a  man   the 


DTSLOCATTOyS  OF  Till-:  I.oWKR   F.XTI'J'.M ITIE.S. 


855 


Six 
-ur- 


l-io. 


nocrosfil  upjHT  half  of  the  astrii^alus  tliat  had   its  articuhir  facet   lookinj;  inward, 
nidiiths  previously  lie  had  received  an  injury  to  liis  ankle  which  was  rcfrartlcMl  hy  tin 
^leons  who  treated  him  as  one  of  i'racture  of  the  le^. 

Tkf:at.mknt.  —  In  simple  dislocation  of  the  astrajralus,  when  the  l)OMe 
can  he  re|>laced  hy  manipulatiun,  iiothiiiji;  more  is  neetlcd  ;  hut  such  a 
result  cannot  always  he  secured.  When  it  cannot,  even  under  chhiro- 
form.  the  tendo  Achillis  should  he  divided.  In  1H(;2  I  was  called  to 
see  a  man  ;et.  liS  who  had  fallen  on  his  feet  from  a  hciirht  of  four 
yards,  and  whose  riirht  astra<;alus  was  shot  forward  completely  out  of 
its  socket  and  nearly  hurst  throuirh  the  skin.  In  this  ca.se  (dilortjform 
had  heen  iriven  and  every  kind  of  manipulation  and  e.vtension  emploved 
hy  competent  men  to  reduce  the  hone  without  effect.  I  divided  the 
tendo  Achillis,  extended  the  foot  fully,  and  applied  f^entle  jiressure  to 
the  projecting  astragalus,  when  the  bone  slipped  hack  readily  into  its 
place.  Some  crepitus  was  felt,  however,  and  I  believe  a  horizontal  frac- 
ture of  the  astragalus  coexi.sted.  the  upper  surface  and  head  of  the 
bone  having  been  displaced  forward.  The  foot  was  fixed  in  side  splints, 
and  a  good  recovery  ensued  with  a  movable  joint. 

When  the  displaced  bone  cannot  be  restored  to  its  normal  position  Djsiwation  of  the  As- 
directly  after  the  accident,  it  is  now  fairly  a  settled  question  that  it  traealus  outward, 
should  not  be  removed  till  after  the  tissues  have  sloughed.  8ir  A.  Fibula.  (Cast  lei.j 
Cooper  strongly  advocated  this  practice,  and  Broca  has  since  supported 
him.  showing  by  an  analysis  of  cases  that  in  3G  examples  of  irreducible  simple  luxation 
in  which  the  bone  was  removed  at  once,  one-fourth  were  fatal,  while  in  A'i  in  wliich  the 
bone  was  left  alone  only  '1  deaths  took  place;  in  2  amputation  was  performed:  in  IG  the 
bone  was  removed  after  sloughing,  and  all  recovered  ;  in  23  no  operation  was  called  for, 
recovery  taking  place  with  a  useful  limb. 

In  all  coTupound  dislocations  of  the  astragalus  the  removal  of  the  bone  .should  always 
be  effected. 

Dislocations  of  the  other  tarsal  bones  have  been  recorded.  Malgaigne 
relates  two  cases  of  (/islorafion  of  the  calcic  outward,  the  bone  forming  a  projection 
beneath  the  external  malleolus  and  beyond  the  cuboid  articulation.  In  18G5  I  saw  a 
case  of  Mr.  Birkett's  at  Guys  in  which  the  left  scaphoid  hone  was  displaced  inward  and 
formed  a  very  marked  projection.  It  was  readily  reduced  by  pressure  under  chloroform 
at  a  moment  when  the  distal  end  of  the  foot  was  drawn  outward.  I  have  the  notes  also 
of  a  case  of  dislocation  of  the  Internal  cuneiform  bone  upward  with  the  metatarsal  bone 
of  the  great  toe  in  a  man  a:;t.  24 ;  of  a  second,  in  a  man  jet.  80,  in  wliich  the  same  bones 
were  displaced  inward,  the  accident  having  been  produced  by  a  weight  falling  on  the 
outer  ankle  when  the  foot  was  resting  on  the  great  toe.  In  both  reduction  was  readily 
effected  with  a  good  result. 

Holthou.se  informs  us  that  the  internal  cuneiform  bone  may  be  .separated  from  all 
its  articulations  and  thrown  upward  and  inward.  The  three  cuneiform  bones  are  also 
sometimes  luxated  together  upward,  and  without  much  difficulty  may  be  reduced  by 
pressure. 

The  scaphoid  and  cuboid  bones  may  also  be  displaced.  Malgaigne  has  described  this 
accident  as  a  middle  tarsal  dislocation  ;  Liston  has  described  it  in  his  Prartical  Snrrjery, 
and  Sir  A.  Cooper  in  his  work  On  Dislocations. 

Dislocations  of  the  metatarsal  bones  may  likewise  occur.  In  1854  I  saw  a  case, 
recorded  by  Mr.  Cock  (Gni/s  Rep..  1855),  in  which  the  entire  metatarsus  appeared  to 
have  been  .separated  from  its  attachment  to  the  cuneiform  and  cuboid  bones  and  thrown 
on  the  dorsal  surface  of  the  instep,  where  their  bases  could  be  seen  and  felt.  The  inter- 
nal cuneiform  and  navicular  bones  appeai-ed  to  have  been  likewise  injured.  The  injury 
was  the  result  of  a  crush  from  the  wheel  of  a  railway  wagon.  All  Mr.  Cock's  efforts  at 
reduction  failed,  but  a  good  foot  was  .secured,  and  the  man  subsequently  returned  to  his 
work  as  a  laborer  on  the  railway. 

In  March,  1884,  a  man  jet.  36  came  under  my  care  with  displacement  of  the  three 
inner  metatarsal  bones  upward  and  outward,  caused  by  the  passage  over  the  foot  of  the 
wheel  of  a  cart  loaded  with  a  ton  and  a  half  of  bricks.  Under  chloroform  and  by  manip- 
ulation the  bones  were  readily  reduced,  and  a  good  result  ensued.  I  suspected  at  the 
time  there  was  a  fracture  of  the  third  bone. 

Dr.  Hetzig  (Si/dtn.  Soc.  Bien.  Rrp..  18G5-66).  who  gives  us  an  analysis  of  29  cases 
of  these  tarso-metatarsal  dislocations,  states  that  13  were  of  single  bones,  16  of  the  entire 


856 


CONTUSIONS,  SPRAINS,  AND    WOUNDS  OF  JOINTS 


metatarsus,  some  of  these  being  lateral  and  others  vertical,  as  in  Cock's  case.     In  the 
former  greater  inconvenience  follows,  from  a  failure  in   reduction. 

Dislocations  of  the  phalanges  are  less  common  than  those  of  the  finger  and 
chiefly  occur  upward,  from  direct  violence  to  the  ends  of  the  toes,  and,  as  a  rule,  are  com- 
pound. The  great  toe  is  the  one  usually  injured,  and,  as  in  the  thumb,  considerable  diffi- 
culty is  at  times  met  with  in  its  reduction,  the  ligaments  and  many  tendons  around  the 
joint  aifording  an  explanation  of  this  fact.  Such  a  case  should  be  treated  in  the  same 
way  as  dislocation  of  the  thumb.  Reduction  must  always  be  effected,  when  possible,  by 
extension  and  well-directed  pressure  ;  forced  flexion  or  extension  sometimes  facilitates  the 
process. 


Congenital  Malformations  (Dislocation)  of  Joints. 

It  has  been  the  habit  of  authors  to  describe  cases  included  under  the  above  heading 
as  examples  of  didocation,  but  it  is  clearly  more  correct  to  regard  them  as  malformations, 
for  as  met  with  in  the  shoulder,  clavicle,  wrist,  and  lower  jaw  they  are  ahvays  associated 
with  a  want  of  development  in  the  bones  and  paralysis  of  the  muscles  of  the  part. 

In  Hip-Joint. — When  seen  in  the  hip,  there  is  likewise  good  reason  to  believe  that 
congenital  deficiencies  are  also  present,  as  the  anatomical  facts  which  bear  upon  the  point 
support  this  view  ;  one  such  is  given  by  Cruveilhier  in  the  second  plate  of  the  second  vol- 
ume of  his  Pathological  Anatomy,  where  an  engraving  of  a  skeleton  in  which  this  congen- 
ital displacement  existed  shows  it  to  be  the  result  of  a  want  of  depth,  from  incomplete 
formation,  of  the  acetabulum,  and  another  is  furnished  by  a  valuable  preparation  in  the 
Middlesex  Hospital  Museum  (Prep.  12,  Series  3),  in  which  there  is  practically  no  acetab- 
ulum, but  a  strong  capsule  and  a  well-developed  head  of  the  femur,  without  a  ligamentum 
teres. 

Dr.  A.  G.  Drachman  (^London  Med.  Rfc,  May  18,  1881)  reports  a  case  of  a  child  born 
of  a  mother  with  this  deformity,  who  died  on  the  seventh  day,  in  which  the  left  acetabu- 
lum was  considerably  shallower  than  normal  and  the  ring  of  cartilage  was  turned  outward 
at  the  superior,  posterior,  and  outer  part,  forming  an  inclined  plane  over  which  the  head 
of  the  femur  glided  upward  and  backward  on  the  ilium.  The  whole  of  the  left  side  of  the 
pelvis  was  atrophied  and  the  atrophy  extended  to  the  head  of  the  femur,  which,  as  well  as 
the  head  of  the  bone  on  the  right  side,  was  small. 

Mr.  Barker  pointed  out  in  a  discussion  at  the  Roy.  Med.  and  Chir.  Soc,  November 
17,  1883,  that  in  the  Musee  Dupuytren  the  specimens  .showed  either  absence  of  the  liga- 
mentum teres  or  its  lengthening  to  a  mere  cord  two  and  a  half  inches  long. 

This  congenital  displacement  of  the  hip  is  by  no  means  an  uncommon  affection,  and  is 
often  mistaken  for  hip  or  spinal  disease,  more  particularly  when  one  joint  alone  is  impli- 
cated. It  aff"ects  both  joints  in  one-third  of  all  cases,  and  occurs  in  female  rather  than  in 
male  children  in  the  proportion  of  5  to  1.     It  is  found  also  in  those  who  are  in  all  other 

respects  well  in  health  and  perfect  in  form, 


Fig.  529. 


Fig.  531. 


and,  although  it  has  been  boldly  asserted 
that  "  it  is  beyond  doubt  that  this  disloca- 
tion is  produced  at  birth  through  downward 
force  applied  to  the  thigh  in  endeavoring  to 
hasten  the  birth  in  breech  presentations,"  no 
evidence  has  been  published  to  support  the 
view.  On  reviewing  my  own  experience  I 
must  add  that  it  does  not  in  any  Avay  en- 
courage such  an  opinion,  for,  whilst  in  no 
case  have  I  been  able  to  learn  that  a  breech 
birth  took  place,  I  heard  in  the  majority 
that  a  natural  birth  occurred. 

Symptoms. — The  symptoms  of  the  dis- 
placement are  very  marked,  and  in  its 
double  form  are  well  shown  in  the  forego- 
ino-  drawino-s,  taken  from  life  (Figs.  529, 

Congenital  Displace-  e.i?,N      ,,  V,  •  i     •  i       i 

nient  of  Head  of  530),  the    most    conspicuous    being    lorclo- 
Left  Femur.  gjg    ^    peculiar    breadth  of   hips,  rounding 

(Posterior  view.)       „     ,      K  ,  .  r.     i  i     i 

of  the  buttock,  rotation  of  the  whole  ex- 
tremity and  foot  inward,  and  slight  flexion  of  the  thigh — in  fact,  the  symptoms  of  dorsal 
dislocation  of  the  hips. 


Case  of  Congenital  Di.splacement  of 

both  Femora. 

Anterior  view.  Side  view. 


o.\  in.\c'rriu-:s. 


857 


I  Ik- 

liiiil) 
once 

h'V(,-l 


Till-  Ii»nl()sis  is  produced  in  llicsc  cusi^s  in  tin-  saiiio  way  a.s  it  is  in  tln'  accidfiitul 
dorsal  dislocatinii  or  the  accniiriMl  (iis|ilact'iiiciit  i\\'  tlu;  licad  of  tlii;  fi;iiiur  in  hip  disease, 
and  i-an  1)0  ofiact'd  by  cK-vatinn  u\'  tln'  liiiil>  uilli  liir  patient  in  tiie  linrizuntal  pdsitiun,  as 
in  tliose  cases  (  Fij^s.  (i(»!»,  (ill). 

'Pile  nniveinents  of  the  joint  are  L'nod.  at  tinio  peileit.  and  <rive  rise  to  no  pain, 
head  oi'  the  femur  also  rotates  smoothly  on  the  ilium. 

When  one  joint  <»nly  is  attected  (Fig.  Tiin),  there  will  he  shortcniiirr  of  tin- 
tor  alxiiit  an  iindi.  and  on  coinjtarinj;  the  affected  with  the  sound  side  it  will  he  at 
seen  that  ilii>  >lii(rleiiinu  is  in  tlu;  tlii>rh  and  that  the  troclianter  is  drawn  up  to  the 
of  tin'  anterior  superior  spine  of  the  ilium. 

The  walk  of  a  patient  witli  a  douhh;  disjtlacenient  is  verv  curious  ;  it  is  a  kind  of 
''roll."  not  unlike  that  of  a  woman  who  has  some  loosening  of  her  sacro-iliac  joints  or 
very  liroad  lii|)s,  when  going  up  stairs,  wliile  a  ])atient  with  a  single  affected  joint  limps 
and  has  an  awkward  gait  wlii(di  has  often  led  parents  ami  others  to  susjtect  hip  or  spinal 
tlisease,  more  particularly  when  hy  overuse  of  the  malformed  joint  jtairis  are  exciteil. 
C)ccasionally  the  muscles  of  the  affectt'd  limh  or  liinhs  are  weak,  hut  this  is  nn-t  with  only 
in  exce])ti<inal  cases. 

Tkkat.mk.n't. — Xothing  can  he  recommended  witli  the  view  of  cure,  for  art  cannot 
supply  a  natural  deticiency  or  make  up  for  a  defect  of  structure  in  the  bones  of  the  joint. 
Still,  surgery  can  do  much  toward  the  prevention  of  additional  trouble  by  exercising  the 
muscles  of  the  limb  and  body  without  fatiguing  them,  forbidding  excessive  standing  or 
walking  during  the  years  of  growth,  and  attending  to  the  general  health. 

^Mechanical  ap])liances  are  to  be  condemned  as  useless,  if  not  worse.  They  have  been 
employed  on  a  wrong  ))riuciple — or,  rather,  on  a  want  of  due  appreciation  of  the  conditions 
of  parts — and  therefore  with  only  a  vague  hope  that  they  may  do  good.  These  observa- 
tions ajiply  as  much  to  the  use  of  an  extension  apparatus  as  to  operative  interference, 
although  with  more  force  to  the  latter. 


CHAPTER     XXXI. 

ox  FRACTURES. 

When  a  bone  is  broken,  it  is  said  to  be  fractured ;  when  the  skin  and  soft  parts  cov- 
ering in  the  broken  bone  are  whole,  the  fracture  is  iiimple  or  subcutaneous  ;  when  a 
•wound  exists  commmu'cating  icith  the  broken  bone,  whether  the  wound  be  caused  directly 

Fig.  532. 

DeiitatL'il  or  CoiuiniiiuttMl.        Oblique  and  Multiple. 


Coinplete  I'lactiires.     (Prep.  Guy's  Hosp.  Mus.) 

by  the  same  force  that  produced  the  fracture  or  indirectly  by  the  bone  perforating  the 
skin,  the  fracture  is  compound.  A  simple  or  compound  fracture  is  said  to  be  complete 
when  the  solution  of  continuity  is  complete  ;   incomplete,  when  the  bone  is  only  cracked, 


858 


ON  FRACTURES. 


fissured,  or  heiit,  as  in  green-stick  fracture,  where  the  bone  is  spliiitered  on  its  convex  sur- 
face, and  not  on  its  concave  ;  sjiliiiiered,  when  only  a  portion  of  the  bone  is  cut  off,  either 
by  a  sabre  wound,  in  machinery,  or  by  some  local  injury  chippinj;-  off  the  edge  of  a  bone ; 
fissur&d,  when  the  line  of  fracture  extends  partially  or  wholly  through  the  bone  and  no 
separation  of  the  fragments  exists  ;  impacted,  when  one  end  of  the  broken  bone  is  driven 
into  and  fixed  in  the  other.  A  bone  may  also  he  perforated  by  a  gunshot  or  punctured 
wound. 

A  complete  fracture  may  be  transverse,  oblique,  longitudinal,  spiral,  dentate,  or 
comminuted  ;  multiple  of  the  same  bones  or  of  contiguous  bones,  of  separate  or  distinct 
bones  {vide  Fig.  532).  All  fractures  may  likewise  be  complicated  with  other  injuries, 
those  into  joints  being  the  most  important.  Fractures  and  separations  of  epiphyses  are 
also  intimately  connected,  but  fractures  may  occur  at  any  age,  while  separation  of  the 
epiphyses  is  rarely  found  in  subjects  above  twenty-one. 

A  fracture  may  be  met  with  at  every  period  of  life ;  indeed,  it  may  occur  in  ntero  from 
some  external  violence  ;  and,  when  the  accident  has  taken  place  some  time  antecedent  to 

birth,  repair  may  have  gone  on  to  completion,  al- 
though in  most  cases  Avith  deformity,  the  vis  medi- 
catrix  natnrse  being,  as  Billroth  well  observes,  a  bet- 
ter physician  than  surgeon.  I  have  seen  this  in  an 
infant  who  was  born  with  a  humerus  bent  at  right 
angles,  evidently  from  a  repaired  intra-uterine  frac- 
ture. During  the  delivery  of  a  foetus,  by  turning 
Incomplete  Fraet^urej^f^^the  Oavicle.    (From  t],^  g,,.^ft  of  a"  femur,  tibia,  or  fibula  may  be 'displaced 

from  one  or  both  of  its  epiphyses.  By  liyperabduc- 
tion  of  the  femur  the  upper  epiphysis  of  the  bone  is  likely  to  suffer,  and  by  traction  on 
the  foot  those  of  the  lower  end  of  the  tibia  and  fibula  (Dr.  Alexander  Simpson,  Edinh. 
Med.  Journal,  June,  1880  ;  M.  Delore,  Diet.  Encycloped.  des  Sciences  3IediraJes,  iv.  201, 
1879).  The  fractures  of  infancy  are  comparatively  rare  and  are  commonly  incomplete, 
or  "  green-stick."  Fig.  533  illustrates  this  in  the  clavicle  and  Fig.  534  in  the  parietal 
bone.  The  latter  was  taken  from  a  child  aet.  8  months  who  was  thrown  out  of  a  peram- 
bulator on  the  pavement.  No  symptoms  of  brain  disturbance  followed  the  accident  at 
any  time.     The  drawing  was  taken  on  the  second  day  following  the  accident.     The  case 


Fig.  533. 


Fig.  534. 


Fig.  535. 


yy 


M 


Incomplete  Iraeture  of  the  Parietal  Bone  of  Infant. 


Impacted  I  latliire  of  the  Neck  of  the 
Thigh-Hone.  (Taken  from  a  man  jet. 
G4,  who  recovered  from  the  accident.) 


occurred  in  the  practice  of  Mr.  Harris  of  South  Hackney.  In  some  such  eases  as  these 
the  depression  in  the  bone  may,  as  time  passes,  be  gradually  pressed  out,  but  in  others  it 
is  permanent. 

Fractures  in  the  adult  are  mostly  complete,  though  an  incomplete  fracture  may  occur. 
Impacted  fractures  (Fig.  535)  are  chiefly  found  in  the  aged,  the  bones  at  this  period 
of  life  being  more  brittle  than  they  are  in  younger  subjects.  They  are  commoifh^  met 
with  in  the  neck  of  the  femur  and  the  lower  end  of  the  radius,  although  they  occur  in 
the  neck  of  the  humerus  and  other  parts.  Thus,  in  Fig.  578  is  illustrated  an  impacted 
fracture  of  the  shaft  of  the  femur.     Many  comminuted  fractures  are  doubtless  due  to 


CAUSES  OF  IRArrrRKS.  859 

impaction  of  one  frafjjniont  of  lume  into  the  (itlicr.  and  t<i  the  subsequent  splitting  of  the 
latter. 

Men  are  more  exposed  to  fractures  than  women,  on  aeeount  of  thi-ir  more  eonstant  lia- 
liililvto  injury,  ami  those  hones  suftt'r  the  most  that  are  the  m<ist  exposed  to  external 
vioh-nci-  ;  henee  tlie  fre((ueney  of  fracture  of  the  lower  extremities. 

Hones  in  .scune  suhjeets  are  very  hrittle  aiul  break  from  slijrhi  causes  ;  frnijUltus  ossinm 
is  then  said  to  exist.  This  condition  miiy  be  hereditary.  These  btjiies,  however,  as  a 
rule,  unite  rapidly.  In  Auj;ust,  ISrtli,  I  .saw  a  case  of  fracture  of  the  neck  of  the  thifrh- 
bone  which  took  place  wlien  a  woman  Jct.  83  was  slowly  walkin}^  from  her  bed  to  a  chair. 

Diseased  bones  are  always  predisposed  to  fracture  from  sli<rht  causes,  more  particu- 
larly the  rickety  and  cancerous,  aiul  likewise  bones  that  are  weakened  by  the  presence  of 
tumors  or  some  svphilitic  or  other  inflammatory  affection. 

In  diseased  or  brittle  bones  muscular  action  may  be  enoufrh  to  cause  fracture.  Thus, 
I  have  known  a  thiuh  to  be  fractured  in  turninir  in  bed,  in  an  epileptic  attack,  and  in 
swinging  it  over  the  side  of  a  cart ;  the  humerus  in  the  act  of  embracing  a  wife,  an<l  in  a 
man  Jct.  2(!  from  throwing  a  stone;  the  clavicle,  from  lifting  a  heavy  weight;  the  ribs,  in 
coughing;  the  radius,  from  wringing  clothes;  and  every  surgeon  knows  how  fre<juently 
the  patella,  and  more  rarely  tlie  olecranon,  are  broken  from  muscular  spasm.  Mr.  Parker 
records  {Xew  York  Joiini.  i>f  Med.,  July,  1S52,)  a  case  in  whicli  a  dentist  aet.  38  broke 
his  humerus  while  drawing  a  tooth.  Mr.  J.  Anningson  of  Burnley  has  recorded  a  case 
of  a  woman  xt.  A'l  in  which  the  upper  three-fourths  of  the  tubero.sity  of  the  calcis  was 
fractured  and  displaced  upward  by  niu.seular  action  (Brit.  Med.  Jo>trn.,  January  20, 1878). 
Mr.  Ball  likewise  records  a  similar  case  (Dublin  Path.  Societi/^  November,  1880). 

Patients  with  disease  of  the  nerve  centres  are  very  prone  to  suffer  from  fracture. 
Davey  in  1842  noted  the  fact  that  lunatics  often  so  suffered,  and  the  frequency  of  broken 
ribs  from  slight  causes  in  lunatic  subjects  can  be  explained  by  this  liability.  Weir  Mitch- 
ell in  1873  (American  Journ.  of  Med.  Science^  July)  first  called  attention  to  the  connec- 
tion between  fracture  and  locomotor  ataxy  and  suggested  impairment  of  nutrition  as  the 
cause.  Later  on  Charcot  emphasized  the  fact,  and  at  the  same  time  noticed  how  rapidly 
repair  took  place  in  the  broken  bones. 

''  From  a  review  of  the  observations  made  on  the  bones  of  two  insane  patients."  writes 
Dr.  Omerod  (.SV.  Bart.  Hasp.  Rep..  1870),  "it  may  fairly  be  inferred  that  the  brittleness 
of  the  ribs  depended  on  a  morbid  condition  of  the  bones,  and  that  this  condition  was 
general,  affecting  different  parts  of  the  osseous  system  eoincidentally,  though  more  marked 
in  the  ribs  than  in  some  other  more  compact  bones.  The  process  was  essentialU"  one  of 
absorption  of  the  internal  structure  of  the  bone,  the  osseous  tissue  being  replaced  by  an 
excessive  deposit  of  the  fatty  matters  normally  existing  in  its  interior.  Thus  the  usually 
invisible  membrane  lining  the  Haversian  canals,  and  forming  the  coats  of  the  vessels 
lying  there,  was  thickened  into  a  membrane  of  cognizable  structure  and  dimensions.  The 
space  for  this  thickening  was  obtained  by  removal  of  the  innermost  concentric  laminae, 
and  from  this  point  a  change  was  propagated  which  resulted  in  or  tended  to  the  removal 
of  each  entire  Haversian  system.  In  the  whole  bone  there  was  a  loosening  of  the  mutual 
connection  of  the  laminiv  and  an  obscure  disintegration  of  the  osseous  structure  it.self, 
and  a  general  infiltration  of  oily  matter  into  the  substance  which  had  intruded  itself 
within  the  Haversian  canals,  and  into  whatever  part  of  the  compact  structure  of  a  bone 
could  find  room  for  it." 

In  confirmation  of  these  views  I  may  mention  that  I  attended,  with  the  late  Dr. 
Black  of  Canonbury,  a  middle-aged  lady  the  subject  of  dementia  and  epilepsy  who  in 
nine  or  ten  fits,  none  of  them  having  been  violent,  broke  a  bone,  and  on  several  occasions 
two.  The  fractures  took  place  by  mere  muscular  action  when  the  patient  was  in  bed,  and 
rej)aired  well — indeed,  as  well  a.*  if  the  subject  of  them  had  been  quite  healthy. 

The  immediate  cause  of  fracture  is  usually  some  direct  violence  applied  to 
the  part,  or  it  may  be  indirect,  the  bone,  under  some  bending  force,  giving  way  at  its 
weakest  point — ''  in  the  line  of  e.rte)t.'<i()n,  not  that  of  eanipresiiion  "  (Teevan). 

Indirect  fractures  are.  as  a  rule,  of  the  simplest  kind,  unless  complicated  with 
joint  dislocation  ;  when  compound,  the  soft  parts  are  mostly  injured  by  the  protrusion  of 
the  fractured  bone. 

Fractures  the  result  of  direct  violence  are  always  the  most  severe,  the  same  vio- 
lence that  breaks  the  bone  injuring  the  soft  parts  over  it,  and  often  Assuring  and  com- 
minuting it. 

The  mode  of  production  of  a  fracture  is,  consequently,  a  point  of  great  practical 
importance,  alike  for  diagnosis,  for  prognosis,  and  for  treatment. 


860  OX  FRACTURES. 

Symptoms. — The  diagnosis  of  a  fracture  is  usually  easy,  though  in  exceptional  cases 
it  is  difficult,  if  not  impossible.  It  is  easy  when,  after  a  blow  or  fall  attended  by  the 
sensation  of  something  giving  way,  deformity  is  found,  with  inahiliti/  to  move  the  limh, 
and  on  manipulation  abnormal  mohUity  of  the  injured  limb  exists,  with  crepifjis  from  the 
rubbing  of  the  broken  fragments  together ;  when  jx///i  attends  any  attempt  at  movement 
and  siceUing  rapidly  follows  the  accident ;  and  when  shortening  exists,  which  is  remedied 
bv  extension. 

The  diagnosis  is  difficult  when,  as  in  impacted  fracture-^,  abnormal  mobility  and  crepi- 
tus are  absent  and  only  slight  but  fixed  deformity  exists,  when  local  pain  and  shortening 
are  the  only  symptom.s.  and  when  the  nature  of  the  accident  is  the  only  guide  ;  when  a 
transverse  fracture  of  such  a  bone  as  the  tibia  exists  without  displacement  and  with  no 
fracture  of  the  fibula  ;  when  the  fracture  is  into  or  in  the  neighborhood  of  a  joint 
and  there  is  much  swelling  of  the  injured  part;  and  when  a  fracture  and  a  dislocation 
coexist. 

It  is  always  difficult,  and  at  times  impossible,  to  make  out  a  simple  fissure  of  a  bone, 
cranial  or  otherwise,  and  the  same  may  be  said  of  a  fracture  of  the  pelvis  or  thorax  ; 
such  injuries  as  these  can  be  made  out  only  by  the  natural  symptoms  of  fracture,  as  they 
are  called,  and  by  such  as  are  referred  to  the  contents  of  the  cranial,  thoracic,  or  pelvic 

cavities. 

When  a  bone  is  broken  near  a  joint  and  effusinn  into  it  follows  the  injury,  the  sur- 
geon should  suspect  the  presence  of  a  fissure  of  the  bone  into  the  articulation  ;  and  when 
a  V-shaped  fracture  of  the  lower  third  of  the  tibia  is  present,  the  V  occupying  the  internal 
or  suhcutaneovs  mrfuce  of  the  bone,  and  not  the  crest  {vide  Fig.  594).  this  complication 
is  to  be  looked  for. 

It  is  sometimes  difficult  to  diagnose  a  fracture  from  a  separated  epiphysis. 

When  a  fracture  is  transven^e  (Fig.  532.  A),  there  may  be  no  or  only  some  slight  lat- 
eral displacement ;  when  oblique  (Fig.  532.  D),  there  will  probably  be  some  shortening  of 
the  limb,  from  the  drawing  up  of  the  lower  portion  of  the  limb,  or  riding,  as  it  is  called, 
of  one  end  over  the  other.  At  times  there  will  be  rotation  of  the  limb,  and  in  com- 
minuted fractures  separation  of  the  ends  of  the  bone  (Fig.  532.  C).  The.se  points  will 
be  greatly  determined  by  the  character  of  the  fracture,  the  bone  that  is  involved,  and  the 
amount  of  muscular  action  that  influences  the  fracture. 

In  parallel  and  conjoined  bones  of  which  only  one  is  broken  the  deformity  that  exists 
is  likely  to  be  less  marked  than  where  a  single  'bone  is  broken,  for  under  these  circum- 
stances' the  non-fractured  bone  tends  to  neutralize  the  action  of  the  muscles  through 
which  deformity  or  contraction  usually  takes  place.  Muscular  action  is  undoubtedly  the 
main  cause  of  "deformitv.  tonic  action  of  the  muscles  existing  under  all  circumstances, 
and  spasmodic  action  when  the  muscles  are  irritated  by  fragments  and  attempts  at 
reduction. 

Muscular  spasm  being  the  main  cause  of  deformity  and  shortening  of  the  limb  after 
fracture,  it  becomes  an  important  point  to  recollect  in  treatment  that  the  peculiar  deformity 
associated  with  any  .special  form  of  fracture  can  be  obviated  by  neutralizing  the  action  of 
the  muscles  that  produce  it.  Thus,  in  fractures  of  the  humerus  above  the  insertion  of 
the  deltoid,  the  action  of  the  latter  muscle  will  be  to  draw  the  lower  fragment  up  and 
outward,  while  the  pectoral  muscle  has  a  direct  influence  in  drawing  in  the  upper  frag- 
ment. In  fractures  of  the  humerus  heloic  the  insertion  of  the  deltoid  the  tendency  of 
this  muscle  will  be  to  draw  the  upper  fragment  outward,  and  the  brachialis  anticus  has 
an  equally  powerful  tendency  to  draw  the  lower  half  forward.  In  fractures  of  the  thigh- 
bone below  the  minor  trochanter,  the  psoas  and  iliacus  muscles  naturally  draw  the  upper 
fragment  forward  and  rotate  it  outward,  and  in  fracture  of  the  condyles  the  gastrocnemii 
have  a  powerful  tendency  to  draw  the  lower  end  backward. 

When  a  bone  is  fissured,  and  not  displaced,  the  periosteum  not  being  divided,  there 
will  be  but  little  displacement :  in  children  this  condition  is  often  found. 

Crepitus,  or  the  grating  sensation  caused  by  the  rubbing  of  the  ends  of  the  broken 
bones  together,  is  a  most  valuable  sign  of  fracture,  and  when  detected  during  the  exam- 
ination of  a  limb  supposed  to  be  fractured  the  diagnosis  is  made  clear ;  but  when  other 
symptoms  of  fracture  sufficient  for  a  diagnosis  are  present,  it  need  not  be  looked  for.  In 
impacted  fractures,  as  of  the  hip.  it  can  be  felt  only  on  loosening  the  impacted  fragments, 
and  consequentlv  by  doing  irremediable  harm  ;  this  error  is  serious  and  should  be  avoided. 
In  incomplete  fractures  crepitus  is  also  absent.  In  fact,  every  fracture  or  suspected  frac- 
ture should  be  manipulated  with  the  utmost  gentleness,  in  order  that  as  little  displace- 
ment and  local  injury  may  be  inflicted  as  possible,  for  the  bulk  of  fractures  can  be  made 


COMPOUND  FRACTURES.  8(51 

out  with  I'lTtiiiiity  without  crejiitus.  As  a  syiuptKin.  however,  it  is  always  of  f:reut 
value. 

The  erepitus  of  eft'usidii  or  of  tin-  thcc;e  of  tt-ndoiis  must  not  he  niistiikeii  for  that  of 
a  hrokeu  hone.  It  is  a  soft  ert-jiitus  rather  than  a  hanl  ouf.  as  in  hone.  liursal  crepitu- 
tion  is  jiartieularly  liable  to  mislead. 

When  some  swellintr  follows  immediately  upon  the  aeeident,  it  means  ruptured  hlood 
vessels,  arterial  or  venous.  When  it  oeeurs  within  a  few  hours,  it  is  due  t<i  inflammatory 
eflusion. 

In  all  eases  of  supposed  displacement  the  normal  condition  of  the  limb  must  he  inijuired 
into  and  the  sound  eompan-d  with  the  affeeted,  for  in  more  cases  than  one  I  have  known 
a  natural  or  old  accjuired  deformity  in  a  liml>  mistaken  for  one  cau.sed  by  an  accident,  and 
attempts  have  been  made  to  restore — or,  rather,  to  reduce — the  parts  to  their  supposed 
normal  condition. 

pRtxJNosis. — Simple  fractures,  as  a  rule,  do  well.  At  Guy's,  in  six  years,  out  of  469 
cases  of  sim]>le  fracture  of  the  thigh,  17  died,  or  8.5  per  cent. ;  of  888  examples  of  simple 
fracture  of  the  leg.  8  died,  or  not  1  per  cent.  ;  of  123  cases  of  fractured  patella,  there  was 
no  death. 

The  .same  statistics  inform  us  that  one-tenth  of  all  cases  of  fracture  of  the  thigh  are 
com|Miiiiiil.  as  are  also  oiic-tiftli  of  all  fractures  of  the  leg. 

Compound  fractures  are  always  serious  accidents,  those  of  the  ujiper  extremity 
being  less  fatal  than  those  of  the  leg.  and  these  less  so  than  those  of  the  femur.  Thus, 
at  (.iuys,  in  six  years,  out  of  iH  cases  of  compound  fractures  of  the  arm  and  fore-arm,  16, 
or  17  per  cent.,  died,  or  1  in  6  cases;  out  of  202  cases  of  compound  fracture  of  the  leg, 
56,  or  27.7  per  cent.,  died,  or  1  in  4  cases ;  and  out  of  52  cases  of  compound  fracture  of 
the  thigh,  19,  or  86.5  per  cent.,  died,  or  1  in  3,  the  mortality  increasing  by  10  per  cent, 
in  each  group.  These  statistics,  however,  but  roughly  indicate  the  risks  of  the  different 
accidents,  as  they  include  smashes  of  limbs  with  the  compound  fractures. 

As  a  cause  of  death  after  fracture  of  the  long  bones  Professor  Czerny  of  Freiburg  has 
proved  in  an  able  paper  (^BerUner  Klinische  Woc/ienschriff,  Nos.  44  and  45)  that  "  fat  embo- 
lism" is  to  be  taken  into  account,  the  fluid  fat  of  the  bones  being  taken  up  by  the  veins 
and  carried  to  the  central  organs* — brain,  lungs,  and  kidneys,  etc. — and  thus  causing  death. 
This  result,  he  states,  is  a  common  cause  of  death  when  a  bone  is  much  fissured  and  the 
cancellous  tissue  laid  open,  as  in  the  V-shaped  fracture  of  the  tibia,  and  more  particularly 
when  this  is  compound.     He  does  not  inform  us  how  this  accident  can  be  avoided. 

Treatment. — The  principles  of  the  treatment  of  fractures  are  very  .simple,  though 
the  practice  is  often  very  difficult.  To  restore  a  bone  to  its  normal  position  and  to  keep 
it  there  by  means  of  surgical  appliances,  or,  as  John  Hunter  expressed  it  in  1787,  "to 
place  the  parts  in  a  proper  position  by  art — that  is,  as  near  their  natural  position  as  possi- 
ble— and  to  keep  them  so.  '  are  simple  rules  to  be  observed,  but  to  carry  them  out  often 
demands  the  highest  surgical  skill  and  ingenuity ;  and  yet  the  whole  treatment  of  frac- 
tures is  really  comprised  in  these  two  indications. 

In  examining  a  fracture  the  greatest  care  is  requisite,  and  only  sufficient  manipulation 
should  be  allowed  to  ascertain  the  seat  of  the  fracture,  the  li/ie  of  its  direction,  and  the 
tendency  a  fragment  may  have  to  ride  in  any  direction,  this  special  tendency  being  the 
one  point  to  be  remembered  in  the  treatment.  These  points,  moreover,  should  be  made 
out  at  the  single  examination  prior  to  treatment,  for  repeated  examinations,  Avhether  liy 
the  responsible  surgeon  or  by  his  assistants,  are  to  be  condemned,  as  they  can  only  do 
mischief  by  exciting  more  local  irritation  than  is  necessary  and  adding  to  the  injury 
which  the  muscles  and  soft  parts  have  already  sustained.  For  this  reason  when,  after  an 
accident,  a  fracture  is  suspected  to  have  taken  place,  the  surgeon  or  bystanders  should  do 
no  more  than  bind  the  limb  to  some  immovable  apparatus,  such  as  a  wisp  of  straw,  a 
bundle  of  sticks,  or  two  pieces  of  wood  fixed  by  a  handkerchief,  till  the  sufferer  has  been 
carried  home  and  placed  in  the  position  in  which  he  is  to  be  treated.  When  the  lower 
extremity  is  the  affected  part,  the  injured  limb  may  be  bound  to  the  sound  one.  the  latter 
acting  as  a  splint. 

In  compound  fracture  the  same  precautions  are  necessary.  Bleeding  should  be 
arrested  by  the  application  over  the  wound  of  a  pad  or  bandage  kept  in  position  by  means 
of  pressure  and  the  elevation  of  the  limb,  while  in  more  severe  cases  the  tourniquet  or 
some  local  pressure  over  the  main  artery  may  be  called  for. 

If  these  precautions  are  not  observed  on  the  field,  many  lives  may  be  lost  from 
hemorrhage,  simple  fractures  may  be  turned  into  compound,  while  compound  fractures 
may  be  made  worse. 


862  ON  FRACTURES. 

When  a  patient  is  placed  in  bed  where  he  is  to  be  treated,  the  fracture  ought  to  be 
manipulated  and  its  position,  nature,  and  peculiar  tendency  made  out,  and  when  made  out 
to  be  "  set,'  or  put  up,  at  once.  The  only  exception  to  this  rule  is  when  time  has  been 
allowed  to  pass  before  treatment  is  commenced  and  much  oedema  or  swelling  of  the 
injured  extremity  exists,  then  it  is  better  to  fix  the  injured  limb  raised  upon  a  pillow, with 
a  long  sand  bag  on  either  side,  to  act  as  a  splint,  and  possibly  a  third  round  the  foot,  the 
pillow  and  Side  sand  bags  being  firmly  bound  together  by  a  strip  of  bandage  and  the 
whole  forming  an  immovable  apparatus,  Mr.  Aston  Key,  indeed,  was  so  fond  of  this 
mode  of  putting  up  fracture  of  the  leg  that  in  my."  dresser"  days  it  was  the  usual  mode 
of  treating  them  all  through  their  course — that  is,  for  the  first  month  or  five  weeks,  till 
they  could  be  put  up  in  some  starch  or  other  immovable  apparatus  and  the  patient 
allowed  to  get  up.  The  method  is  comfortable  and  satisfactory  to  the  patient,  but  it 
wants  closer  attention  on  the  part  of  the  surgeon  than  can  often  be  given. 

In  "  setting  "  a  fracture  some  care  is  needed,  and  the  opposite  and  corresponding  limb 
should  always  be  before  the  surgeon  as  a  guide.  Inquiries  should  also  be  made  as  to  the 
condition  of  the  limb  before  the  accident — whether  it  was  deformed  or  shortened  from 
any  previous  fracture  or  disease,  congenital  or  otherwise  ;  for  I  have  known  an  injured 
leg  to  have  been  likewise  violently  and  unnecessarily  manipulated  to  restore  a  supposed 
fractured  bone  to  a  position  that  it  could  not  be  made  to  assume  on  account  of  some  natu- 
ral deformity,  and  likewise  a  fractured  thigh  subjected  to  like  rough  treatment  to  bring 
it  down  to  the  level  of  its  fellow,  when  an  irremediable  shortening  existed  from  a  former 
fracture. 

In  extending  a  broken  limb  to  restore  the  bones  to  their  normal  position,  the  upper 
portion  should  be  firmly  held  by  an  assistant  to  make  counter-extension,  and  the  muscles 
attached  to  it  relaxed  by  placing  the  limb  in  a  slightly  flexed  position  ;  a  second  assistant 
or  the  surgeon  may  then  extend  the  fractured  end,  while  the  latter  gently  manipulates 
the  fracture,  to  make  out  its  points.  The  extension  should  be  steady  and  free  from  all 
jerks  and  violent  movements,  gentle  lateral,  rotatory,  or  other  movements  being  given  as 
required  to  restore  the' displaced  portion  of  bone,  the  pressure  of  the  thumb  or  finger 
being  freely  used  to  bring  about  an  accurate  coaptation  or  setting  of  the  fragments ;  for 
the  surgeon  must  remember  that  muscular  contraction  is  better  overcome  by  continued 
extension  than  by  temporary  force,  and  that  for  the  treatment  of  fractures  generally  mode- 
rate extension  continuously  applied  is  preferable  to  forcible  extension  in  any  of  its 
forms.  The  inhalation  of  chloroform  at  times  is  a  valuable  aid  in  the  reduction  of  a 
fracture.  * 

If,  when  the  fractured  bones  have  been  reduced,  muscular  spasm  is  so  severe  as  to 
render  it  impassible  to  keep  them  in  situ — a  condition  which  is  not  uncommon  in  fracture 
of  the  leg — the  tendon  of  the  ofl^ending  muscle  may  be  divided.  In  otherwise  intractable 
fracture  of  the  leg  there  is  no  operation  of  greater  value  and  attended  with  less  evil  than 
the  division  of  the  tendo  Achillis.  In  a  general  way,  however,  the  muscular  spasm  ceases 
after  the  first  three  or  four  days. 

When  the  fracture  has  been  reduced  and  by  manipulation  coaptated  or  "  set,"  splints 
or  other  mechanical  appliances  are  necessary  to  keep  the  bones  in  their  normal  position  ; 
and  the  simpler  these  appliances  are,  the  better,  so  long  as  they  fulfil  their  purpose. 
These  splints  should  always  be  well  padded,  and  the  pads  so  adju.sted  as  to  fit  into  the 
iaequalities  of  the  limb  and  protect  it  from  any  local  pressure.  They  should  be  firmly 
and  immovably  fixed  to  the.  limb  by  inelastic  straps  or  bandages,  and  the  seat  of  fracture, 
as  a  rule,  should  be  left  exposed  for  the  surgeon's  examination,  in  order  that  the  fracture 
may  be  readjusted  if  displacement  take  place.  To  cover  up  a  broken  bone  by  bandages 
or  splints  is  a  mistake.  The  position  of  the  bone  during  the  progress  of  repair  should 
always  be  open  to  view,  the  former  practice  being  based  on  hope,  the  latter  on  certainty. 
Pott's  rule,  that  the  splints  should  include  the  joint  above  as  well  as  below  the  fracture, 
is  sound,  though  it  cannot  always  be  followed.  Every  joint,  however,  should  be  fixed 
when  by  its  action  the  broken  bone  is  rendered  movable. 

When  one  bone  is  broken  in  a  limb  where  double  bones  exist,  the  second  acts  as  a 
splint  and  keeps  up  extension.  Under  these  circumstances  a  simpler  apparatus  is 
required  to  keep  the  fractured  bone  quiet  and  restrain  the  action  of  the  muscles  that 
move  it  than  under  other  circumstances. 

Extension  is  a  valuable  and  necessary  adjunct  to  other  treatment,  and  should  be  kept 
up  by  means  of  weights,  pulleys,  or  such  other  appliances  as  the  ingenuity  of  the  sur- 
geon may  suggest.  These  means  however,  will  be  described  in  the  treatment  of  special 
fractures. 


TRKATMEyr  OF  Fli.K'TriiFS.  863 

After  the  settinj?  of  the  fracture,  the  CHseiituiI  jMiint  to  be  observed  in  its  treatment 
is  thi'  iuiuiobility  of  tlie  brolieii  bone;  and  next  to  this,  its  exposure  U>  observation  dur- 
ing; the  prof^ress  of  repair  to  render  certain  that  the  ))one  has  maintained  its  right  posi- 
tion. 

TliKATMKNT  oK  Cdmi^mmi  FKACTriiES. — The  tftat MU'iit  of  Compound,  is  similar  to 
that  of  sim|)le  IVactures.  ji/ns  the  treatment  of  the  woujid  with  its  complications  ainl  the 
broken  frairmeiits  or  jjrojectini;  jiortions  of  bone,  "  but  rixt  of  the  bone  is  tlie  great  object 
we  have  to  aim  at"  (.John  Hunter,  1787). 

These  fractures  shnuM  be  ''set"  in  the  .same  way  as  the  simple,  great  care  bein<; 
observed  in  the  manipulation  that  tlie  s(»ft  |)arts  are  not  more  injured;  lottse  fragments  of 
broken  bone  must  l)e  taken  away.  ])rojectiiig  porti<jns  excised,  and  the  Itone  reduced,  the 
wound  being  enlarged  when  necessary  to  facilitate  this  act  ;  the  injured  parts,  too,  ought 
to  be  thontughly  cleansed  and  all  wounded  vessels  twisted  or  ligatured  ;  the  bones  should 
then  be  fixed  immovably  by  means  of  splints,  interrupted  s]»lints  often  being  rerjuired. 
J  When  the  wound  is  not  very  extensive,  it  should  be  .sealed  by  means  of  a  piece  of  lint 
saturated  with  blood,  or,  what  is  better,  with  the  compound  tincture  of  benzoin.  If  the 
carbolic  acid  dressing  is  employed,  the  wound  should  be  well  washed  with  a  weak  solution 
of  one  part  in  a  hundred  and  dressed  under  the  spray.  The  wound  should  be  interfered 
with  as  little  as  possible,  since  now,  as  when  the  following  words  were  uttered.  '■  the 
great  mischief  and  bad  success  arising  in  the  treatment  of  compound  fractures  is  the 
dressing  them  every  day  and  applying  fresh  poultices,  which  neces.sarily  move  the  end.s 
of  the  bones.      The  lioib,  if  possih/e,  should  iieirr  be  moved  "  (John  Hunter.  M.S.  lect.,  1787). 

When  the  soft  parts  are  much  crushed  and  the  large  vessels  and  nerves  injured, 
amputation  may  be  called  for,  more  particularly  in  old  subjects. 

In  compound  fractures  ''  scarcely  any  amounnt  or  form  of  fractured  bone  alone," 
writes  Skey  {Operative  Snrtj.),  "  would  justify  the  immediate  resort  to  the  knife  if  taken 
singly,  even  supposing  the  bone  fractured  extensively  into  a  large  joint;  for  in  such  a 
case,  although  anchylosis  of  the  joint  would  probably  occur,  it  would  prove  a  lesser  evil 
than  that  of  amputation.  Superadded  to  a  compound  or  comminuted  fracture  of  bone, 
the  injury  may  be  rendered  yet  more  serious  by  extensive  laceration  of  the  muscles.  In 
considering  this  latter  condition  much  will  depend  on  the  kind  of  laceration — whether  the 
muscles  are  merely  cut  asunder  or  whether  contused  or  torn,  and  whether  this  injury 
involves  a  few  only  or  the  majority  of  the  muscles  of  the  limb.  Again,  we  must  exam- 
ine with  great  care  the  condition  of  the  vessels.  Is  the  main  trunk  whole  ?  we  nnght 
ask  in  the  supposed  case  of  fracture  of  the  thigh,  or  in  that  of  the  leg.  Is  the  posterior 
tibial  artery  torn  ?  Is  the  limb  colder  than  its  fellow,  or  is  the  temperature  considerably 
lower  than  the  rest  of  the  body  ?  If  .so,  probably  one  or  more  arteries  are  divided. 
What  is  the  condition  of  the  nerves?  Does  sensibility  extend  to  the  toes?  If  not,  pro- 
bably the  nerve  is  divided  also.  If  the  evidence  of  the  integrity  of  both  artery  and  nerve 
fail  and  the  sinking  temperature  of  the  limb  and  the  loss  of  sensibility  continue  to 
increase,  we  have  no  alternative  but  amputation." 

If  a  doubt  exist  in  the  mind  of  the  surgeon  as  to  the  necessity  of  immediate  amputation, 
he  should  wait,  unles,-  the  patient  bo  old,  in  which  ease  let  him  act  promptly. 

Simple  fractures  into  joints  require  special  treatment,  as  in  a  large  number  of 
cases,  although  not  in  all,  some  impaired  mobility  of  the  joint  will  ensue ;  for  this  reason 
the  joint  itself  should  be  placed  at  the  most  useful  angle  and  so  fixed. 

Compound  fractures  into  joints  generally  demand  excision  or  amputation.  In 
the  iipj»  r  extreniity.  when  there  is  any  hiijie  of  saving  the  limb,  excision  is  doubtless  the 
better  operation.  In  the  loicer  the  expectant  treatment  is  certainly  better  than  excision, 
and  probably  better  than  amputation  if  the  parts  are  not  so  injured  as  to  render  ampu- 
tation at  once  a  neces.sity,  and  if  the  age  and  general  condition  of  the  patient  justify  an 
attempt  to  save  the  limb  ;  but  the.se  points  will  again  have  to  be  considered  among  the 
special  fractures.     In  gunshot  wounds  these  views  are  now  generally  entertained. 

The  Fracture  Bed. — The  best  is.  without  doubt,  a  good  horsehair  mattress  placed 
on  a  bedstead  with  a  firm  bottom  ;  buf  where  this  does  not  exist,  a  board  beneath  the 
mattress  is  a  good  substitute.  A  canvas  bottom,  however  tightly  corded,  always  yields, 
and  a  feather  or  ordinary  spring  bed  is  not  to  be  sanctioned.  The  woven  wire  mattress 
is  excellent. 

The  sheet  covering  the  bed  should  be  stretched  and  kept  smooth  several  times  daily, 
so  that  no  '•  ruck  "  takes  place,  bedsores  being  more  frequently  caused  by  such  than  by 
pressure.  In  fracture  of  the  lower  extremity  the  head  of  the  patient  should  not  be  raised 
too  high,  the  use  of  one  small  pillow  being  ample. 


864  ON  FRACTURES. 

Splints  made  of  wood,  iron,  felt,  or  perforated  zinc  may  be  employed,  and  the  differ- 
ent forms  will  be  given  when  the  special  fractures  are  considered.  As  a  rule,  the  simpler 
in  construction  they  are.  the  better  ;  and  before  adapting  one  to  the  broken  limb  it  is  well 
to  fit  it  to  the  sound.      The  splints  should  invariably  be  quite  clean. 

Pads. — All  splints  should  be  well  padded  and  their  edges  carefully  protected.  The 
pads  should  consequently  be  well  fitted,  broad,  and  overlapping  the  sides.  The  best 
materials  for  these  are  tow  or  fine  oakum,  cotton  or  sheep's  wool,  or  strips  of  thick  flannel 
enclosed  in  a  casing  of  soft  linen  or  lint.  The  pads  should  be  first  fixed  to  the  splint  by 
tapes,  or,  what  is  better,  by  some  pieces  of  strapping. 

Besides  wooden  and  iron  splints,  the  "immovable  apparatus"  for  fractures  is  a  very 
favorite  one,  and  the  material  employed  may  be  left  to  the  fancy  or  convenience  of  the 
surgeon. 

In  fractures  of  such  single  bones  as  the  fibula  or  tibia,  where  no  displacement  exists, 
their  primary  treatment  by  some  immovable  apparatus  is  very  valuable,  the  limb  being 
either  put  up  at  once  before  swelling  has  appeared  or  as  .soon  as  the  swelling,  etc..  has 
sub.sided.  In  other  cases  it  is  inexpedient  to  employ  it  for  at  least  ten  or  fourteen  days, 
until  swelling  has  gone  and  a  certain  amount  of  repair  taken  place.  In  the  fracture  of 
long  bones,  such  as  the  femur,  it  is  better  to  postpone  its  application  until  union  is  com- 
plete. Some  excellent  surgeons — and  among  them  Erichsen — employ  the  immovable 
apparatus  from  the  very  first.  The  mode  of  its  application  is  as  follows:  In  all  cases  the 
limb  should  be  cleansed  and  carefully  dried,  the  bone  itself  being  well  protected  by  cot- 
ton-wool or  a  flannel  bandage.  The  bandage,  with  the  stiffening  material,  is  then  to  be 
prepared,  and  should  be  put  on  as  smoothly  as  possible,  no  more  "  turns"  being  employed 
than  are  absolutely  necessar}'. 

Splints  of  gutta-percha,  millboard,  leather,  Cooking's  poroplastic  or  hatter's  felt,  or 
perforated  zinc  may  be  employed  as  additional  supports  when  complete  immobility  is 
demanded.  The  first  five  materials,  after  having  been  cut  to  pattern,  should  beforehand 
be  well  softened  by  immersion  in  hot  water  or  hot  air  and  then  moulded  to  the  limb  ;  the 
zinc  should  be  carefully  cut  to  fit  it  and  well  adjusted.  These  splints  should  be  applied 
over  the  cotton-wool  or  flannel  bandage,  and  the  prepared  bandage  then  bound  round. 
When  starch  is  used  (Seutin's  bandage),  it  should  be  exterior,  two  or  three  coats  being 
employed.  The  same  may  be  said  when  the  icJu'te  of  e<ig  ov  dextrine  is  employed.  When 
ffum  and  cliaJk  are  used,  the  same  mode  ought  to  be  followed,  the  mixtVire  consisting  of 
equal  parts  of  finely-powdered  gum  and  chalk  made  into  the  consistence  of  thick  paste  by 
the  addition  of  boiling  water  gradually  stirred  into  it.  This  bandage  is  more  solid  than 
the  starch. 

Mr.  de  Morgan  prefers  the  glue  bandage^  the  best  French  glue,  after  having  been 
soaked  in  cold  water  and  melted  in  a  glue-pot,  being  applied  like  the  starch  ;  the  addition 
of  about  one-fifth  of  methylated  spirit  to  the  solution  of  glue  hastens  the  drying. 

When  plaster  of  Paris  is  employed,  the  bandage  should  be  of  some  loose  texture,  and 
that  made  of  book  muslin  or  crinoline  is  probably  the  best.  It  should  be  prepared  be- 
forehand by  well  rubbing  fresh  dry  powder  into  its  texture,  and  should  be  made  ready 
for  use  by  being  thoroughly  wetted  in  a  bowl  of  water  for  two  or  three  minutes,  some 
additional  plaster  being  rubbed  with  water  into  the  bandage  as  it  is  unrolled,  to  strengthen 
the  whole. 

When  the  surface  is  extensive,  the  setting  of  the  plaster  may  be  delayed  by  the  addi- 
tion of  a  little  size  or  stale  beer  to  the  water  with  which  it  is  mixed,  while  salt  and  the 
use  of  warm  water  increase  the  rapidity  with  which  the  plaster  sets. 

The  day  following  the  application  of  this  bandage  a  coating  of  flour  paste,  gum,  or 
even  a  coating  of  varnish,  may  be  applied,  to  prevent  chipping. 

In  the  appendix  to  the  Army  Medical  Report  for  1869,  Mr.  Moffitt  describes  the 
Bavarian  mode  of  putting  up  a  fracture  in  an  immovable  apparatus — a  mode  which 
deserves  to  be  more  widely  known  than  it  is.  I  have  tested  it  well,  employing  gum  and 
chalk  instead  of  plaster  of  Paris,  and  can  strongly  recommend  it ;  being  simple,  it  can  be 
applied  very  quickly,  and  is  most  effective.  It  is  now  in  general  use  at  Guy's,  and  is 
applied  as  follows  :  The  materials  required  to  make  it  are  a  piece  of  stout,  coarse  "  house- 
flannel  "  which  has  been  shrunk,  some  precipitated  chalk,  mucilage  of  gum  acacia,  a  good- 
sized  cradle,  and  a  stout  needle  and  thread.  When  it  is  applied  to  the  leg  for  fracture, 
two  equal-sized  pieces  of  the  flannel  are  first  cut,  long  enough  to  reach  from  the  lower 
border  of  the  patella  to  three  inches  below  the  heel,  and  in  breadth  about  six  inches 
more  than  the  circumference  of  the  calf,  so  as  to  allow  the  edges  to  overlap  for  about 
three  inches  when  the  flannel  is  folded  round  the  leg.     One  of  these  pieces  should  now 


TUKATMI'yr  OF  FRACTURKS. 


865 


Bavarian,  or  Iniinovable.  Splint. 

a,  First  layer  of  llaiiiii-l,  a|i|>lii-(l  to  liinli.    fj,  Second  layer, 
atiout  to  be  applif'l. 


lie  ;i]iiilii'il   to  flic  \o'^,   its  centru  corrL'siMHnliiif^  with   the  ctMitro  of  tin;  fall",  and  its  two 

flaps   linnit;ht    ti<,^htly   toirctliiT  over  tlu;   Hkiii  ( Ki^.   5!{(i),  where  they  shouhi   be   liniily 

stitched  toirether,  the  stitches  lieiiij:;  inserted 

eluse  ti»  the  hone.      The   stitches   must   he 

hct;iin    at   the    u])|»er  ]>:irt,  carried  <h)wn   to 

the  hollow  of  the  instep,  and  then  fastened 

ort".      Ilavinj;  arrived  at  this  point,  the  ne.\t 

thinjr  is  to  see  that    the   fi»ot    is  at  a   riuht 

anirle   with   the   lei:;;  if    left   alone,   it    will 

jirohahly   he  at    a    very   ohtu.se   anji^le,   and 

eonsiderahle   force  is   sometimes   neees.sary 

to  bring  tlie  toes  up,  whieli   must  be  done 

jiow  or  not  at  all.     The  stitching  must  ne.xt 

be  begun  on  the  sole  of  the  foot,  commencing 

at  the  toes  and  ])roceeding  toward  the  heel, 

the  flannel  being  tightly  dragged  downward. 

The  stitching  along  the  sole  of  the  foot  being  eomjdeted,  the  remaining  piece  along 
tlie  dorsum  of  the  foot  may  next  be  stitched,  and  after  this  there  can  be  no  fear  of  the 
foot  changing  its  position. 

The  limb  will  now  be  tightly  encased  in  a  layer  of  flannel  the  edges  of  which  are 
Iving  in  adaptation  in  front  of  the  leg.  The  flannel  along  the  sole  of  the  foot  to  within 
an  inch  of  the  stitches  should  next  be  cut  off  and  the  edges  turned  l)ack.  At  present 
the  superfluous  flannel  along  the  front  of  the  leg  and  dorsum  of  the  foot  should  not  be 
interfered  with,  but  the  limb  slung  up  to  the  cradle  by  three  or  four  pieces  of  bandage 
pinned  or  stitched  to  the  adapted  edges  of  flannel  in  front  of  the  leg  (Fig.  530).  Thi.s 
will  have  the  effect  of  stretching  the  flannel  and  making  it  more  closelj'  adapt  itself  to 
the  shape  of  the  calf,  ankle-joint,  etc.,  and  allow  the  gum  and  chalk  to  be  easily  applied. 
The  ne.xt  thing  is  to  make  a  thick  paste  of  the  gum  and  chalk,  the  consistence  of  honey, 
by  stirring  them  together  in  a  basin,  which  should  be  spread  thickly  over  the  surface  of 
the  flannel  with  a  brush  or  rubbed  in  with  the  palm  of  the  hand,  care  being  taken  that 
it  enter  all  the  little  inecjualities  of  the  flannel.  Having  done  this,  apply  the  outer  layer 
of  flannel,  placing  it  just  as  the  first  was  placed,  with  its  centre  corresponding  with  the 
median  line  of  the  calf,  folding  its  edges  closely  around  the  leg  and  bringing  them  up 
together  in  front  over  the  edges  of  the  previous  layer.  Keep  them  also  in  position  in 
front  by  about  half  a  dozen  stitches,  put  through  at  intervals  down  the  leg  close  to  the 
shin.  Along  the  sole  of  the  foot  this  layer  of  flannel  may  at  once  be  neatly  finished  ofi" 
by  turning  in  the  edges  and  joining  by  stitches.  The  whole  should  now  be  left  suspended 
to  the  cradle  for  about  twenty-four  hours  to  dry.  at  the  end  of  which  time  it  may  be  taken 
down  and  the  splint  removed  from  the  leg  by  cutting  up  the  stitches  along  the  front  of 
the  leg  and  dorsum  of  the  foot  with  a  pair  of  scissors,  aided  by  forcibly  separating  the 
adjacent  edges  of  flannel. 

It  now  only  remains  to  trim  up  the  splint  by  cutting  off  the  superfluous  edges,  bind- 
ing them  with  strips  of  leather  made  adhesive  by  being  spread  with  resin  plaster,  and 
inserting  evelet-holes  at  equal  distances  all  down,  so  as  to  lace  the  splint  up  the  front 
(Fig.  530,  A). 

If  the  splint  is  required  for  a  hiee-joint.  some  modification  of  the  above  plan  is  neces- 
sary. It  will  not  do  to  suspend  the  limb  to  a  cradle  by  the  edges  of  the  flannel,  as  in 
the  previous  case,  but  the  patient  should  be  seated  in  a  chair  before  a  fire  with  the  heel 
resting  on  another  chair.  Then  the  fir-st  layer  of  flannel  should  be  tightly  applied,  its 
edges  being  brought  up  together  in  front  and  stitches  inserted  close  to  the  leg.  The 
gum-and-chalk  paste  may  now  be  thickly  spread  over  the  surface  of  this  flannel  and 
covered  in  by  a  second  layer  of  flannel,  exactly  as  in  the  previous  case.  This  .second 
layer  may  be  fastened  in  front  by  a  few  stitches  and  the  whole  allowed  to  dry.  When 
quite  dry,  the  adjacent  edges  of  flannel  may  be  forcibly  separated  and  the  stitches  divided 
with  scissors.  Lastly,  the  superfluous  edges  may  be  cut  off",  two  semilunar  pieces  cut 
out  for  the  patella,  the  margins  bound  with  leather,  and  eyelet-holes  inserted  for  lacing 
up  in  front.  To  apply  the  splint  to  the  hip-joint  it  is  necessary  that  the  first  layer  of 
flannel  should  surround  the  pelvis  as  high  as  the  crests  of  the  ilium,  and  also  the  aflfected 
thigh.  It  should  then  be  stitched  along  the  outer  side  in  one  continuous  seam  and  the 
superfluous  edges  allowed  to  remain  in  apposition.  The  gum-and-chalk  paste  must  then 
be  applied,  some  difficulty  being  probably  experienced  in  applying  it  over  the  sacrum, 
but  the  patient  must  be  rolled  first  to  one  side  and  then   to  the  other.     While  this  is 

55 


866  ON  FRACTURES. 

being  done  the  second  layer  of  flannel  should  be  lying  underneath  (so  as  to  protect  Vw^ 
bed),  which  may  then  be  adapted  and  fastened  closely  by  a  few  stitches  along  the  line 
of  the  previous  sutures.  When  the  whole  is  dry,  it  may  or  may  not  be  found  necessary 
to  rip  it  up  and  insert  eyelet-holes.  If  the  .splint  fit  closely,  without  causing  any  undue 
pressure,  the  edges  may  be  cut  oft"  close  and  the  whole  allowed  to  remain  as  it  is ;  but  for 
the  sake  of  cleanliness,  especially  in  children,  it  is  generally  better  to  cut  up  the  stitches 
along  the  outer  side,  bind  the  edges  with  leather,  and  lace  it  up,  so  as  to  allow  the  splint 
to  be  removed  as  often  as  recjuisite. 

When  extra  stiffness  is  required  in  any  of  these  splints,  the  inner  surface  of  the 
second  layer  of  flannel  may  be  covered  with  the  chalk  paste  before  it  is  applied  ;  some 
strips  of  tin  or  a  piece  of  gutta-percha  which  has  been  moulded  to  the  part  should  be 
introduced  between  the  two  layers  of  flannel.' 

Mr.  Croft  has  suggested  a  very  excellent  modification  of  the  Bavarian  which  is  much 
used.     It  is  made  as  follows : 

1.  A  piece  of  house-flannel  or  an  old  shrunk  blanket,  or  any  suitable  substitute,  is 
selected.  The  pieces  may  be  shaped  by  measurement,  taking  the  circumference  of  the 
limb  above  and  below  the  knee,  at  the  biggest  part  of  the  calf^  just  above  the  ankle-joint, 
from  the  front  of  the  ankle-joint  round  the  heel  to  the  front  again,  and  at  the  middle  of 
the  metatarsus.  The  flannel  of  each  splint  should  be  in  width  half  an  inch  less  than 
half  the  circumference  at  any  of  those  points.  The  width  of  the  two  splints  should  be 
one  inch  less  than  the  circumference  of  the  limb  at  any  corresponding  part ;  it  should  be 
long  enough  to  extend  from  above  the  knee  to  the  middle  of  the  metatarsus.  Four  pieces 
are  required — two  for  each  splint.  2.  Two  bandages  of  common  mu.slin  are  prepared,  each 
five  to  six  yards  long  and  two  inches  and  a  half  in  width.  3.  A  handful  or  two  of  good 
dry  plaster  is  mixed  with  water  to  the  consistence  of  thin  cream.  4.  The  inside  pieces 
of  flannel  may  be  laid  on  the  table  or  bed,  the  outer  surface  being  upward.  5.  The  out- 
side pieces  are  to  be  soaked  in  the  pla.stei-  .separately  and  laid  out  on  their  respective 
in.side  pieces. 

Whilst  traction  is  kept  up  and  the  ends  of  the  broken  bones  are  maintained  in  appo- 
sition, the  splints  are  to  be  applied  and  smoothed ;  then  the  bandage  is  to  be  put  on. 
Traction  is  to  be  maintained  during  the  hardening  of  the  plaster.  The  latter  takes  place 
in  about  three  minutes.  Next,  the  limb  should  be  laid  on  a  large,  soft  pillow,  the  toes 
directed  upward,  and  the  knee  a  little  bent.  In  the  application  of  the  bandage  great 
caution  should  be  observed  that  it  is  not  drawn  tightly  anywhere  and  that  no  one  turn 
of  the  bandage  is  tighter  than  another.  The  support  is  to  be  equal  everywhere.  The 
two  splints  should  not  meet  by  about  half  an  inch  down  either  the  front  or  the  back. 
The  intervals  are  spanned  by  the  dry  porous  muslin  ;  at  the  sides  the  bandage  is  fixed 
to  the  splints  by  the  plaster,  which  oozes  into  it  from  the  outer  layer  of  flannel.  If  it 
become  necessary  next  day,  or  later,  to  ease  the  splints  or  to  inspect  the  limb  at  any  spot. 
the  bandage  can  be  slit  up  with  scissors  along  the  middle  line  in  front.  One  or  both  of 
the  splints  can  then  be  eased  from  the  limb  and  readjusted  by  the  addition  of  another 
bandage.  It  is  undesirable  wholl}"  to  remove  the  splints.  They  are  hinged  together  at 
the  back  by  the  muslin  bandage  which  spans  the  interval  there.  The  trimming  of  the 
ap[>aratus  may  be  done  as  soon  as  the  plaster  shall  have  hardened.  Should  the  surgeon 
be  short-handed  with  regard  to  assistance,  he  may  apply  the  outside  splint  first  and  lightly 
bandage  that  on  ;  and  when  that  splint  has  nearly  hardened,  he  may  put  on  the  inside 
one.  As  swelling  subsides  and  the  splints  become  more  or  less  loose  an  additional  band- 
age should  be  put  on.  At  the  end  of  ten  days,  if  the  patient  be  convalescing,  the  out- 
side bandage  may  be  gummed  or  a  fresh  gummed  bandage  rolled  on.  That  apparatus 
will  last  until  splints  are  no  longer  needed.  At  the  end  of  a  fortnight  or  three  weeks,  as 
the  case  may  be,  the  patient  may  leave  the  hospital  for  his  own  home. 

This  mode  of  treatment  is  admirably  adapted  to  oblique  fractures  accompanied  by  dis- 
placement of  the  tibia,  to  cases  of  Pott's  fracture,  and  to  comminuted  fractures. 

In  cases  of  compound  fracture  an  opening  suitable  to  the  wound  may  easily  be  made. 
This  splint  is  as  good  for  joint  cases  as  for  those  of  fracture ;  indeed,  it  is  by  far  the  best 
immovable  apparatus  we  possess. 

Mr.  Hyde  has  introduced  a  "  leather-felt-splint "  of  great  value  which  is  readily 
applied,  is  light  and  strong,  and  rarely  requires  to  be  used  with  starch.  Cocking's  poro- 
plastic  splint  answers  the  same  purpose,  the  splint  becoming  soft  on  immersion  in  hot  air 
or  water,  and  hard  again  within  a  few  minutes  of  its  removal.  If,  when  moulded,  it  fails 
to  fit  exactly,  it  can  be  softened  locally  by  the  application  of  a  hot-water  sponge. 

'  I  am  indebted  to  a  valued  pupil — ^Ir.  W.  H.  Harsant — for  the  above  description  ff  the  splint. 


RF.i'Mii  or  rnirrrnKS.  867 

Mr.  L.  Tail  ( J/"/.  Time*,  IHtJ.j)  has  su]L'p-st«<l  tin-  use  nf  paraffin  f(ir  the  Hanie  jmr- 
p(»>i'.  the  melted  paraihii  heinji  kept  licjuid  hy  the  iiniiiersinii  of  the  hnwl  coiitainiti;:  it  in 
hot  water,  the  haiiihitre  a.x  it  i.s  hein^'  applied  liein;:  made  t<»  pa.><.»  through  the  rn|iiid  paraffin, 
inehint:  at  lM.'>°  to  lli(i°  F.     Two  or  more  coats  of  paraffin  may  f>e  paint<-d  over  tlie  wliole. 

Tfie  liniiid  f;las.s — si/imfe  nf'  fmftis/i — may  als<i  l)e  u.sed.  tlie  .srdution  f»ein;.'  painted  over 
tlie  Imndatre  witli  a  Itnish.  I  have  u.-ed  it.  and  like  it.  hut  not  so  miicli  as  tin-  splint  I 
have  de.serilteil. 

By  way  of  raiition  it  sfjouhl  he  state<l  that  all  stareh.  chalk.  an<l  plaster-of-I*aris  splint.s 
contraet  on  drvinL'.  and  from  sueli  contraetioiis  I  have  known  harm,  and  even  ;.'anj:n-ne. 
to  follow.  To  LTUard  airaiiist  this  eontini.'ei:cy  wlieii  f»anilaj:es  are  used  eotton-wooj  sliould 
be  applied  fre<-Iy  around  the  linil>.  althoUL'h  in  the  Bavarian  .splint  thi.s  preeaution  is  not 
called  fiir. 

On  tliis  aeeount  the  practice  of  usin<r  these  splints  as  a  primary  application  in  the 
treatment  cd"  fractures  is  dan^'erous  ;  for  when  swelling  to  any  extent  takes  place,  the 
pressure  may   he   most   harmful. 

When  pain  or  swelling  of  the  limb  follow.s  the  application  of  any  r(f  these  splints, 
tluv  shfiuld  be  at  once  removed,  the  whole  Ixdng  cut  up  with  .strong  .sei.s.sors  from  end  to 
end.  evelets  being  subse(|uently  introduced  for  laces  to  draw  them  together  again,  or  straps 
and  buckle-  may  be  employed. 

Repair  of  Fractures. — !»  children  broken  Vjones  repair  rapidly,  four  weeks  being 
ample  time  for  the  whole  process  to  be  perfected,  while  in  the  aged  ten  weeks  or  more  may 
be  needed.  Kejiair  goes  on  more  rapidly  when  the  broken  ends  of  the  bones  are  i)laced 
and  kept  in  position  than  when  they. are  apart  or  not  kept  at  perfect  rest.  When  bones 
are  maintained  accurately  in  position  or  are  impacted,  direct  union  ensues,  as  in  the  .soft 
parts;  but  when  movement  is  allowed,  reparative  material  is  poured  out  around  the  broken 
fragments  and  the  provisional  callus  of  authors  or  the  ensheathing  callus  of  Paget  is  formed, 
which,  acting  as  a  temporary  splint,  keeps  the  Vjones  in  po.sition  till  they  unite  by  means  of 
the  permanent  callus.  The  best  repair  of  a  fracture  is  the  direct ;  and  when  provisional 
callus  exists,  some  mobility  of  the  broken  bone  has  been  allowed,  to  a  certainty.  This 
addition  to  our  knowledge  is  due  to  Sir  J.  Paget,  for  until  his  day  a  provisional  callus 
was  always  looked  upon  as  a  necessary  means  for  the  repair  of  every  fracture.  We  now 
know  it  is  present  only  when  mobility  of  the  fragments  interferes  with  direct  repair,  and  in 
proportion  to  the  amount  of  provisional  callus  may  the  extent  of  mobility  be  estimated. 

When  a  bone  is  broken,  blood  is  effused,  the  amount  depending  upon  the  degree  of 
injury  to  the  soft  parts  and  the  amount  of  comminution  of  the  bone ;  it  is  exceptional  to 
find  f)lood  between  the  broken  bones.  In  simple  fracture  the  periosteum  may  be  oidy 
torn  across:  in  the  comminuted  it  is  more  extensively  injured,  while  in  incomplete  frac- 
tures it  is  probably  always  entire. 

After  a  simple  fracture  some  slight  inflammatory  exudation  may  be  poured  out 
around  the  broken  bone,  which  in  healthy  subjects  is  very  limited  and  unattended  by  any 
constitutional  symptoms.  In  more  complicated  cases  or  in  cachectic  subjects  the  effusion 
mav  be  extensive  and  constitutional  .symptoms  with  febrile  disturbance  severe.  Under 
favorable  conditions  this  inflammatory  material  will  be  absorbed  with  the  effused  blood. 
The  true  reparative  material  is  poured  out  about  the  sixth  or  ninth  day.  and  when  no  di-s- 
placement  exists  it  will  be  effused  only  between  the  ends  of  the  V>roken  bones ;  when, 
however,  the  bones  are  comminuted,  it  will  be  more  diffused.  When  they  are  misplaced, 
it  will  be  still  less  defined  :  and  when  the  periosteum  is  much  separated  or  torn,  it  will  be 
poured  out  around  the  bones  as  a  provisional  callus.  The  true  reparative  products  are 
chieflv  poured  out  by  the  periosteam  and  endosteum.  though  the  soft  parts  around  at 
times  add  their  quota.  In  the  flat  bones  the  ossification  of  this  reparative  material  has  a 
preliminary  fibrous-tissue  stage,  and  in  the  long,  after  the  blood  has  been  absorbed,  the 
ceil  infiltration  passes  on  to  the  formation  of  connective  tissue,  or  iteoplttsm.  which  subse- 
(juently  ossifies,  in  rare  cases  passing  through  the  stage  of  fibro-cartilage.  In  chil- 
dren it  is  probable  that  the  cartilaginous  stage  always  precedes  the  osseous,  while  in 
adults  the  bone  is  poured  out  at  once,  which  is  probably  always  the  ca.se  in  all  rapidly- 
repairing  fractures. 

Ossification  may  take  place  in  the  periosteal  blastema  or  in  the  endosteal,  or  in  both, 
the.se  points  being  greatly  determined  by  the  relative  position  of  the  broken  ends  of  the 
shaft  of  the  bone  and  the  comminution  of  the  fragments,  great  displacement  and  separa- 
tion of  the  fragments  being  bridged  over  or  cemented  together  by  irregular  masses  of 
connecting  bone  ti.ssue. 

When  immobilitv  of  the  broken  bones  has  not  been  maintained,  the  bone  cement  or 


868 


ON  FRACTURES. 


provisional  callus  will  be  very  extensive.  In  the  ribs,  where  it  is  impossible  to  prevent 
movement,  there  is  always  some  ensheathing  callus;  indeed,  Dupuytren's  ring  of  provis- 
ional callus  is  constant.  In  the  clavicle  also  it  is  common.  In  other  bones  it  will  vary 
with  the  amount  of  movement  that  has  been  allowed  in  their  treatment.  When  the 
movement  is  very  great,  the  process  of  ossification  will  not  go  on  kindly  and  ligamentous 
or  fibrous  union  will  remain,  giving  rise  to  an  ununited  fracture,  and  occasionally  a  false 
joint  is  formed.  (A  splendid  example  of  this  is  repre.sented  in  Fig.  537.)  The  rapidity 
with  which  ossification  or  true  bony  union  is  obtained  in  fracture  depends  much  on  the 
degree  of  immobility  ensured  to  the  broken  bones  and  on  the  constitutional  power  of  the 
patient. 

The  periods  in  which  the  several  parts  of  the  reparative  process  are  usually  completed 
after  fractures  of  adult  human  bones  are  reckoned  thus  according  to  Paget :  To  the  second 
or  third  day  after  the  injury,  inflammation  in  and  about  the  parts;  thence  to  the  eighth 
or  tenth,  seeming  inaction,  with  subsidence  of  inflammation  ;  thence  to  about  the  twen- 
tieth, production  of  the  reparative  material  and  its  gradual  development  to  its  fibrous 
or  cartilaginous  condition  ;  thenceforward  its  gradual  ossification — a  part  of  the  process 
which  is  most  variable  as  to  both  time  of  commencement  and  rate  of  progress,  and  which 
is  probably  rarely  completed  before  the  ninth  or  tenth  week. 

In  open  or"  compound  fractures  repair  goes  on  very  much  in  the  same  way  as 
in  simple  ;  when  they  are  made  simple  by  sealing  the  wound,  precisely  the  same  process 
goes  on.  When  the  wound  is  left  open  and  suppuration  takes  place  in  the  soft  parts 
around  the  broken  fragments,  repair  goes  on  through  granulation,  the  granulation  tissue 
subsequently  ossifying  and  passing  into  bone  cells ;  the  process  of  repair  under  these  cir- 
cumstances is  thus  more  gradual  than  w^iere  the  reparative  material  is  poured  out  between 
the  broken  bones  and  proceeds  directly  to  ossify. 

At  times  after  a  simple  fracture,  but  more  commonly  after  a  compound,  the  fractured 
bone  inflames,  and  as  a  result  the  broken  fragments  die  wholly  or  in  part ;  repair  is 
retarded  and  cannot  be  perfected  until  the  necrosed  bone  has  been  cast  oif  or  renioved. 
In  comminuted  compound  fracture  this  result  is  more  common  than  in  less  complicated 
cases.  In  gunshot  injuries  of  bones  this  comminution  of  the  bone  is  the  chief  point  of 
diiference  between  them  and  other  compound  fractures. 

Compound  fractures,  as  a  rule,  require  for  their  repair  three  or  four  times  the  period 
required  in  simple. 

Ununited  fractures  are  met  with  when  from  any  local  or  general  cause  ossific 
union  is  delayed  or  does  not  take  place  between  the  broken  ends  of  the  bones,  and  in  by 
far  the  bulk  of  cases  this  is  the  result  of  a  want  of  that  complete  rest  and  quiet  which 
is  so  essential  for  the  ossific  union  of  a  broken  bone.  When  the  ends  of  the  broken  bone 
are  kept  asunder,  ossific  union  is  likewise  sure  to  be  retarded  or  prevented,  and  also  when 
any  muscle  or  fascia  is  placed  between  the  broken  fragments.  In  feeble,  cachectic,  and 
syphilitic  subjects  the  same  want  of  repair  may  likewise  be  met  with. 

Failures  in  the  reparative  process  depend,  therefore,  on  some  failure  in  the  general 

power  of  the  patient,  want  of  care  in  the  local  treatment 
of  the  case,  or  on  some  local  cause.  The  union,  however, 
is,  as  a  rule,  simply  delayed. 

Hamilton  calculates  that  such  delayed  union  occurs 
once  in  500  cases,  but  this  average  I  believe  to  be  too  high. 
It  is  chiefly  found,  according  to  Norris  (Ainr-r.  Jonrn.  of 
Med.  Scinice.<i,  1842),  in  the  thigh,  leg,  arm.  fore-arm,  and 
lower  jaw.  I  have  seen  it,  however,  in  the  clavicle  and  in 
the  ribs,  and  cases  are  recorded  in  which  it  was  met  with 
in  the  spine. 

In  the  majority  of  cases  the  union  of  the  broken  bones 
is  by  fibrous  tissue  which  has  failed  to  ossify.  In  Prep. 
1110*",  Guy's  Museum,  this  condition  is  well  exemplified, 
the  ends  of  the  bone  being  pointed  and  firmly  joined  by 
ligamentous  tissue.  The  length  of  this  tissue  varies  in 
difl"erent  cases.  In  exceptional  instances  the  ends  of  the 
bone  are  rounded  and  enclosed  by  a  strong  capsular  liga- 
ment, and  thus  a  false  joint  is  formed,  which  is  well  exemplified  in  a  specimen  of  frac- 
ture of  the  fore-arm  (Guy's  Museum,  1119'"),  but  still  better  in  that  of  the  humerus 
(Prep.  1110*^  Fig.  537),  in  which  the  ends  of  the  bone  are  studded  with  fibro-cartilage 
and  complete  movement  existed. 


Fig.  537. 


inHumeruii 

Prep.  1110«5,  Guy's  Mus. 


RESECTlny  IS  FRACTURES.  869 

III  iimrt'  rare  caM-s  tlurt-  i>  a  total  absence  ot'   all  iinititir^  medium. 

Tkkatmknt. — Hc'jranliiig  a  larjre  majority  "f  casi-s  of  ununited  fracture  as  examples 
of  delav«^'d  union  due  to  a  want  of  that  alisolute  immobility  of  the  fractured  limb  which 
is  so  necessary  for  its  repair,  the  most  essential  point  to  be  observed  in  treatment  i.s  the 
application  of  an  absolutely  immoyable  ajtparatus.  which  may  be  found  in  one  of  the  forms 
of  splint  described  as  immoyable.  such  as  that  of  starch.  e;.'j:  and  flour,  chalk,  plaster  of 
Paris,  or  lii|uid  ^dass.  with  t:utta-percha.  millboard,  zinc,  or  felt,  the  joints  abi»ve  and 
below  the  broken  lione  being  included  in  the  apparatus,  while  tonic  treatment  is  at  the 
same  time  <d>seryed. 

When  the  limb  is  thus  firmly  fixed,  rest  and  tlie  non-use  of  the  limb  is  scarcely  neces- 
sary ;  indeed,  under  certain  circum.stances.  the  moderate  use  of  the  limb  .seems  to  be 
beneficial,  and  in  seyeral  cases  under  my  care  repair  seems  to  have  been  ha.stened  by  such 
a  license.  John  Hunter  saw  the  truth  embodied  in  these  remarks,  having  asserted  in 
17^17:  "When  the  uniting  process  in  fracture  is  backward,  the  parts  should  not  be  kept 
at  perfect  rest.  I  have  seen  fractures  of  the  lesr  which  would  not  otherwi.se  unite  do  .so 
after  patients  were  up  on  their  legs,  the  fractured  bones  being  well  supplied  with  iron 
splints,  etc."  ( .^IS.  lect.).  When  these  means  fail,  the  ends  of  the  bone  may  be  well 
rubbed  together  to  excite  action  before  the  reapf)lication  of  splints  or  subcutaneou.sly 
scored  with  a  tenotomy  knife,  while  in  still  older  cases  the  bones  may  be  fastened  together 
by  means  of  wire  sutures  or  drilled  and  secured  with  ivory  pegs,  the  credit  of  this  latter 
suggestion  being  due  to  Dieffenbach.  Dr.  Physick  of  New  York  years  ago  (1804)  sug- 
gested the  introduction  of  a  seton  between  the  ends  of  the  broken  bones,  and  Xorris 
reports  that  good  success  has  followed  the  practice,  5-4  out  of  72  ca.ses  being  succe.s.sful. 
The  object  of  the  treatment  is  to  excite  local  action  between  the  fragments:  and  when 
this  is  secured,  the  seton  may  be  removed.  With  the  same  view  Malgaigne  introduced 
acupuncture  needles  between  the  bones,  and  Miller  and  M.  Blandin  subcutaneously 
scraped  with  a  tenotomy  knife  the  ends  of  the  bones  or  the  connective  ti.ssue. 

Resection  has  also  been  practised,  and.  according  to  Xorris.  with  success  in  37  out 
of  tl-t  ca.-es.  The  operation,  however,  is  formidable,  and  should  be  undertaken  only 
where  there  is  no  hope  of  minor  measures  being  successful,  the  ends  of  the  fragments 
being  far  apart  and  the  condition  of  the  limb  such  as  to  render  some  ri.sk  justifiable  to 
gain  the  desir^ed  end.  I  have  performed  this  operation  for  ununited  fractures  of  the 
femur  and  humerus  with  excellent  results,  in  some  cases  wiring  the  bone  together. 

Dr.  H.  J.  Bigelow  of  Harvard  has.  however,  met  with  considerable  success  in  detach- 
ing the  periosteum  for  about  half  an  incb  from  the  extremities  of  the  aflPected  bone  with 
the  muscles,  taking  off  the  ends  of  the  bones  and  securing  the  resected  portions  together 
by  .strong  wire  p»assed  through  half  the  thickness  of  the  shaft  of  either  fragment ;  the 
periosteal  flaps  may  also  be  united  by  sutures.  The  limb  should  then  be  fixed  on  a  splint. 
The  wire  can  be  left  in  place  without  fear  from  two  to  six  months.  He  cured  ten  out  of 
eleven  cases  where  this  operation  was  performed  (American  Journ.  of  Med.  Science.".  1867). 

It  occasionally  happens  that  a  fracture  which  had  united  becomes  disunited  after 
fever,  .scurvy,  or  other  enfeebling  cause,  and  I  have  had  one  very  marked  case  of  this  in 
the  person  of  a  young  lady  who  had  her  thigh  fractured  abroad 
and  subse'iuently  became  the  subject  of  tropical  fever.     In  her  Fig.  538. 

case,  although  the  bond  of  union  completely  gave  way.  she  sub- 
se^juently  obtained  a  firm  limb  by  means  of  local  immobility  and 
constitutional  tonics.  These  cases  ought  to  be  classed  with  others 
in  which  the  cicatrices  of  burns  or  old  ulcers  break  down  under 
some  enfeebling  influence  and  heal  under  tonic  and  general  hygi- 
enic treatment.  In  the  treatment  of  all  the-e  cases  time  ought 
not  to  be  estimated  too  closely. 

The  deformities  that  follow  badly  iinited  frac- 
tures at  times  reijuire  surgical  treatment  :  and  when  the  sur- 
geon is  consulted  during  the  first  few  weeks  of  the  case,  an 
anaesthetic  should  be  given  and  the  bone  refractured  and  set  in 
a  good  position,  it  being  fjuite  justifiable  to  employ  considerable 
force  to  attain  this  end.  In  young  subjects  this  refracture  is 
rarely  attended  with  difiiculty.  though  in  the  adult  it  is.  CEster- 
len  and  Skey  were  strong  advocates  for  this  practice,  the  former 
having  employed  it  up  to  the  twenty-fourth  week,  and  the  latter  Hyperostosis  of  the  Tibia, 
on  a  boy  set.  15  thirteen  months  after  the  fracture. 

When  the  bone  has  united  too  firmly,  to  permit  of  refracture,  it  should  be  divided  by 


870  OS  FRACTURES. 

a  subcutaneous  section  or  by  some  cutting  operation.  Key  Ji'l  this  latter  operation  in 
the  leg  in  1839  (Gki/'s  Hosp.  Rep.,  Series  1,  vol.  iv).  The  subcutaneous  section  should 
be  performed  in  a  similar  way  to  that  adopted  by  W.  Adams  in  dividing  the  neck  of 
the  thigh-bone  with  a  saw  or  chisel. 

These  operations,  however,  are  to  be  undertaken  only  when  the  local  deformity  f& 
great  and  the  limb  useless. 

In  the  incomplete  or  green-stick  fractures  of  infancy,  if  the  bone  be  not  straightened, 
strange  deformities  ensue.  In  the  case  depicted  in  Fig.  538  such  a  result  was  to  be  seen, 
the  bent  tibia  and  fibula  having  been  much  thickened  by  the  deposition  of  bone  in  the 
concavity  of  the  arch,  the  bone  measuring  across  its  centre  six  inches.  It  was  taken 
from  a  girl  twelve  years  old.  I  am  now  disposed  to  think  this  case  was  really  one  of 
hyperostosis  of  bone,  which  may  or  may  not  have  followed  a  fracture. 

SPECIAL  FRACTURES. 
Fractubes  of  the  Upper  Extremity. 

Fractures  of  the  cranium  and  spinal  column  have  already  received  attention  ;  those 
of  the  lower  jaw  have  been  described  in  page  450,  and  those  of  the  nose  and  sternum  in 
Chapter  XVII. 

Fracture  of  the  clavicle  is  generally  the  result  of  indirect  violence,  such  as  a 
fall  upon  the  shoulder;  and  vrhen  of  direct,  it  is  usually  compound  or  comminuted.. 
Hamilton  and  Gurlt  record  examples  from  muscular  action,  and  I  have  seen  one  in  a  man 
fet.  44  (who  had  had  syphilis  nine  years  before)  from  simply  lifting  a  heavy  weight  from 
the  ground.  The  bone  broke  near  the  sternal  end  with  a  snap,  and  a  good  recovery  fol- 
lowed. The  case  was  brought  under  my  notice  by  Mr.  Couling.  now  of  Brighton,  when 
house-surgeon  at  Guys.  The  statistics  of  the  Middlesex  Ho.spital.  as  compiled  from  the 
experience  of  sixteen  years  by  Messrs.  Flower  and  Hulke  (Boliins'.^  S^Kfem.  vol.  i.  3d 
ed.).  prove  the  clavicle  to  be  more  frequently  broken  than  any  other  single  bf»ne.  the 
radius  standing  next  in  order,  although,  including  fracture  of  the  radius  with  the  ulna, 
the  fracture  of  the  clavicle  stands  second.  Half  the  recorded  eases  occurred  in  children 
under  five  years  of  age. 

The  bone,  as  a  rule,  is  broken  about  its  centre,  and  the  line  of  fracture,  with  rare 
exceptions,  is  oblique  from  without  inward  and  from  before  backward,  the  inner  fragment 
having  commonly  a  tendency  to  ride  over  the  outer,  the  outer  falling  downward  and  back- 
ward. 

Fractures  at  either  extremity  also  occur,  and  one  of  the  sternal  end  when  vertical 
may  be  mistaken  for  a  separation  of  the  body  of  the  bone  from  its  sternal  epiphysis ; 
when  oblique,  downward,  or  upward,  such  an  error  can  hardly  occur. 

Symptoms. — The  symptoms  are  generally  well  marked.  There  will  be  inability  to 
move  the  arm  freely,  with  pain  in  the  attempt,  the  patient  supporting  the  arm  of  the 
affected  side.  On  comparing  the  shoulders  of  the  two  sides  the  joint  on  the  aff'ected  one 
will  be  placed  lower  and  more  forward  than  on  the  sound  side,  and  at  the  same  time  will 
be  drawn  nearer  to  the  median  line  of  the  body,  even  to  the  extent  of  an  inch  when  the 
di.splacement  is  great.  On  passing  the  finger  over  the  broken  bone  some  depression  and 
corresponding  elevation  of  the  broken  fragments  will  be  detected;  and  when  the  exami- 
nation is  made  after  the  expiration  of  days,  there  will  be  also  eff"u.sion  of  much  solid  mate- 
rial. Crfpilus  can  sometimes  be  detected,  but  it  need  not  be  looked  for.  this  symptom, 
with  the  amount  of  displacement,  depending  much  upon  the  line  of  the  fracture  and  its 
situation. 

Dr.  R.  Smith  of  Dublin  points  out  (Treatise  on  Fracture,  1850  i  how  in  fractures  of 
the  acromial  end  of  the  bone  between  the  conoid  and  trapezoid  ligaments  there  is  scarcely 
any  displacement  of  either  fragment,  and  under  these  circumstances  the  diagnosis  has  to 
be  made  by  the  pain  produced  on  pressure  over  the  broken  point,  and  by  the  crepitus 
educed  by  the  movement  of  the  bones  in  opposite  directions  through  the  fingers.  He 
also  shows  how  in  fracture  external  to  the  trapezoid  ligament,  the  inner  fragment  being 
drawn  upward  by  the  trapezius  muscle,  the  displacement  is  great. 

In  children  incompJetf  fractures  of  this  bone  may  occur  (Fig.  533). 

Fractures  of  the  clavicle  are  sometimes  comminuted  and  compound,  and  occasionally 
complicated  with  some  severe  injury  to  the  vessels  beneath.  In  the  case  of  the  late  Sir 
R.  Peel  the  accident  was  followed  bv  a  pulsating  blood  tumor  which  was  supposed  to 
have  been   due  to  a  rupture  or  laceration  of  some  large   vein,  probably  the  subclavian, 


sriyiAi.  ii:.\rTri:i:s.  «7] 

wliili',  IVom  tlu>  scvfri'  jiaiii  that  altfiidid  the  injury,  soiih'  of  the  norvo.s  of  the  bnurhial 
)iii'.\iis  wiTc  hflii'Vt'tl  to  liavc  hccu  iiijiircil.  Mr.  Krichs»;ii  has  n-conlcd  {Brit.  M^il.  Jimni., 
.Ill lie  7.  1S7M)'  "  •''"^''  '"  which  tlif  Mihchiviaii  vein  was  cornpn'sstMl  hy  a  f'rajrnieiit  of  a 
hroki'ii  fhivic'le,  and  in  which  ainjuitation  of  the  shoulder-joint  was  perforjncd  on  tlie  six- 
teenth day  ;  and  I  have  seen  one  in  whidi  a  hrokeii  ehivicle  was  ioUoweil  by  arrest  of 
pulsation  in  the  artery  of  the  corresponding:  arm.  At  St.  (ieor^e's  Hospital  there  is  a  speci- 
men in  which  the  i-nd  of  the  fractured  hone  was  driven  throufrli  the  internal  juj^ular  vein. 

Fractures  nl'ljoth  clavicles  have  also  })een  recorded.  F  have  seen  this  inori'  than  once 
ill  children. 

'I'kk.vTMK.NT. — -Daily  experience  proves  that  fractures  (d"  tin;  clavicle  unite  without 
anv  treatment,  and,  moreover,  palpable  deformity  too  often  shows  tiiat  where  treatnit-nt 
has  been  employed  the  union  is  neither  perfect  nor  satisfactoi-y.  Daily  experience  like- 
wise proves  that  in  most,  if  not  all,  cases  of  fractun*  of  the  clavicle  the  bones  I'all  widl 
into  place  on  the  ])atieiit  assuminji  tlie  nicumbent  jiosition.  In  yountr  ladies,  and  in 
others  where  it  is  a  matter  of  importance  to  jireveiit  deformity,  the  recumbent  position 
in  bed  niav  be  maintained  for  about  three  weeks,  till  union  has  fairly  taken  place;  but 
children  and  men  will  rarely  be  found  willin<r  to  follow  such  a  lin«  of  treatment,  and 
happily  it  is  not  recpiired,  for  nearly,  if  not  quite,  equally  jrood  results  will  be  secured  by 
imitatinjr  what  takes  place  on  the  patient  assuming  the  recumbent  posititjn — viz..  by  fix- 
ing the  lower  blade  of  the  scapula  to  the  chest,  binding  down  its  angle  to  the  thorax,  and 
thus  )>reventing  the  tilting  forward  and  rotation  of  the  bone  through  which  the  deformity 
takes  place. 

The  ])lan  I  have  ado])ted  for  some  years  is  to  place  a  pad  over  the  blade  of  the  scapula 
below  its  spine,  and  to  bind  the  bone  firmly  to  the  thorax  by  means  of  broad  strips  of 
strapi)ing  obliquely  encircling  half  the  chest  from  the  spine  to  tlie  sternum,  at  the  same 
time  sup])orting  the  affected  arm  in  a  sling  and  drawing  the  hand  upward  toward  the 
op))osit(?  shoulder.  The  same  method  is  also  advocated  by  Dr.  E.  Ilartshorne  of  }*enn- 
sylvania.  Whilst  the  strapping  is  being  fixed  the  scapula  should  be  well  tilted  backward 
by  elevating  the  arm.  or  the  patient  should  be  kept  in  the  recumbent  position.  When 
this  practice  cannot  be  followed,  the  elbow  should  be  brought  forward  to  a  point  ])elow 
the  nipple  of  the  affected  side  and  the  hand  drawn  over  the  opposite  shoulder.  The  old 
plan  of  fixing  the  pad  in  the  axilla  and  using  a  figure-of-8  bandage  has  no  advantage,  and, 
moreover,  causes  much  discomfort  to  the  patient. 

The  axillary  pad  of  Desault  is  at  times  serviceable  and  may  be  employed,  being  ea.sily 
fixed  by  a  broad  piece  of  strapping  made  to  encircle  the  shoulder.  In  addition  to  the  pad. 
Professor  Gordon  of  Belfa.st  (Dnh/iu  Qunrf.,  1859)  recommends  the  injured  arm  to  be 
extended  downward  and  firmly  fixed  to  the  body  by  a  bandage,  permanent  extension 
being  kept  up  by  means  of  a  band  fastened  above  to  the  fore-arm.  flexed  at  right  angles, 
and  below  around  the  perinseum  or  upper  part  of  the  thigh. 

Sayre's  method,  applied  as  follows,  is  cei'tainly  valuable  : 

Take  two  strips  of  adhesive  plaster,  two  and  a  half  inches  wide  for  an  adult.  Pass 
one  strip  around  the  arm  at  the  junction  of  the  lower  and  middle  third,  one  end  of  the 
strip  being  united  behind  the  arm  to  the  same  strip  which  is  to  be  passed  around  the 
body,  making  a  loop  and  leaving  an  open  space  at  the  posterior  part  of  the  arm.  This 
loose  loop  arrangement  prevents  strangulation.  Then  draw  the  arm  back,  to  bring  the 
pectoralis  major  muscle  upon  the  stretch  ;  but  the  acromial  end  of  the  clavicle  still  rides 
under  the  sternal  fragment  or  end.  Now  secure  the  arm  back  by  passing  the  long  end 
of  the  strip  of' adhesive  plaster  around  the  body,  bringing  it  two  or  three  inches  under 
the  arm  of  the  opposite  side,  across  the  thorax,  and  fastening  it  to  itself  .somewhere  about 
the  middle  of  the  back.  Care  must  be  taken  not  to  draw  the  arm  too  far  back,  but  just 
sufficient  to  put  the  ])ectoralis  major  on  the  stretch.  Then  take  the  other  stri])  of  adhe- 
sive i)laster  and  make  a  slight  longitudinal  slit  in  the  centre,  to  admit  the  point  of  the 
elbow  ;  flex  the  arm  at  an  acute  angle  over  the  chest,  drawing  it  ujnvard.  forward,  and 
inward,  and  thus  reduce  the  fracture.  After  bringing  both  fragments  of  the  bone  into  a 
direct  line,  .secure  the  arm  in  this  position  by  first  placing  the  centre  of  the  elbow  in  the 
longitudinal  slit  in  the  adhesive  plaster,  passing  one  end  of  the  strip  across  the  back 
diagonally  to  the  opposite  shoulder,  then  bringing  the  anterior  end  of  the  .strip  up  along 
over  the  flexed  arm  and  the  hand,  over  the  chest,  and  listening  it  to  the  posterior  end  of 
the  strip  at  the  shoulder.  If  this  plan  be  carried  out  carefully,  it  will  yield  a  perfect 
result  without  deformitv. 

Fractures  of  the  scapula  are  probably  always  the  result  of  direct  violence, 
although  a  fracture  of  the  neck  of  this  bone  may  be  produced  by  a  fall  upon  the  shoulder. 


872 


ON  FRACTURES. 


Fig.  539. 


Fracture  of  Scapula. 
(Prep.  109/2",  Guy's  Mus.) 


The  ho<f^  of  the  bone  may  be  fissured  in  any  direction  (Fig.  539),  though  much  dis- 
placement is  rare. 

In  this  accident  mobility  of  the  broken  bone  and  crepitus  may  usually  be  made  out 
by  manipulation,  though  in  fat  subjects  and  when  effusion  exi.sts  the  diatrnosis  may  be 
difficult. 

Treatment. — A  broad  pad  carefully  adju.sted  and  kept  in 
position  by  means  of  broad  strips  of  plaster  encircling  half  the 
thorax,  the  arm  being  kept  quiet  and  the  elbow  raised  in  a  sling, 
is  usually  sufficient  treatment,  although  a  good  shield  of  gutta- 
percha or  felt  may  be  sometimes  beneficial. 

The  ((crom  ion  process  may  be  fractured  across  its  base  or  in 
an}-  other  part ;  and  when  it  is  so,  the  outer  fragment  is  gener- 
ally drawn  downward  with  the  arm,  producing  a  dropping  of  the 
shoulder.  The  accident  can  readily  be  made  out.  on  tracing  the 
spine  of  the  scapula  outward,  by  the  deformity,  the  break  in  the 
normal  line  of  the  bone,  and  the  local  pain,  if  not  by  the  separa- 
tion of  the  fragments.  There  are  also  loss  of  power  in  the  arm 
and  altei'ation  in  its  outline. 

Treatment. — It    should    be  treated  by  raising  the   elbow 
by  means  of  a  good  sling  or  bandage,  a  small  axillary  pad  and 
a  circular  bandage  binding  the  arm  to  the  thorax.     The  union, 
however,  is  often  ligamentous,  it  being  impossible  to  keep  the 
fragments  of  bone  closeh*  in  apposition. 

Fractures  of  the  conicoid  process  are  remarkably  rare.  I  have  seen  but  one  decided 
instance,  and  that  in  a  girl  fet.  15  or  16,  the  result  of  a  blow.  There  were  local  pain  and 
crepitus  to  denote  the  injury,  with  displacement  of  the  process,  the  point  of  which  was 
drawn  downward  by  the  biceps  muscle,  and  its  base  projecting.  Dr.  Pauli  of  Luton 
kindly  gave  me  the  notes  of  a  case  that  occurred  in  a  girl  set.  14  from  a  fall  on  her 
shoulder.  There  were  marked  mobility  of  the  coracoid  process  and  crepitus,  but  no 
deformity.  There  was  pain  in  the  part,  increased  by  any  movement  of  the  arm.  This 
accident  is  more  commonly  associated  with  dislocation  of  the  humerus. 

Treatment. — The  mu.scles  attached  to  the  process  must  be  relaxed,  the  biceps  by 
flexing  the  fore-arm,  and  the  coraco-brachialis  by  drawing  the  arm  forward  and  inward. 
In  this  po.sition  the  arm  should  be  bound  by  a  bandage,  the  bone 
itself,  if  possible,  being  restored  to  its  normal  position  by  manip- 
ulation. 

Fractures  of  the  neck  of  the  scapula  or  of  the  ijlenoid  fossa 
must  be  rare.  Sir  A.  Cooper  described  such  cases,  but  since 
Malgaigne  showed  how  the  .symptoms  described  might  be  pro- 
duced by  dislocation  of  the  shoulder  with  fracture  of  the  glenoid 
cavity,  some  doubt  has  been  thrown  upon  the  question  of  a  sim- 
ple fracture  of  the  neck  of  the  bone  ever  occurring.  In  Guys 
Museum  (Prep.  1097*^)  there  is  a  specimen  of  fracture  of  the 
neck  (Fig.  5-10),  and  in  the  Royal  College  of  Surgeons  there  is  a 
second,  .the  third  being  recorded  in  Du  Verney  ( Truite  <les 
Maladies  des  Os,  1751).  .Sir  A.  Cooper  gives  the  flattening  and 
.sinking  of  the  shoulder,  the  prominence  of  the  acromion,  the 
elongation  of  the  arm.  and  the  presence  of  crepitus  as  the  chief 
symptoms,  the  head  of  the  humerus  being  felt  in  the  axilla.  He  also  relates  how  the 
arm  may  be  replaced  in  its  normal  position  and  again  displaced  on  allowing  the  arm  to 
drop,  this  symptom  being  the  chief  one  of  diagnosis  between  the  supposed  accident  and 
dislocation  ;  but  when  dislocation  of  the  head  of  the  humerus  exists  with  fracture  of  the 
glenoid  fossa,  the  same  symptoms  are  found.  The  subject,  therefore,  requires  further 
elucidation.  In  suspected  ca.ses  of  this  kind  the  elbow  should  be  raised,  in  order  to  press 
the  head  of  the  bone  well  upward  into  position,  and  kept  there  by  sling  and  bandage. 

I  have  seen  a  case  of  dislocation  of  the  head  of  the  humerus  downward  and  for- 
ward complicated  with  a  fracture  of  the  lower  portion  of  the  glenoid  cavity,  the  broken 
piece  being  drawn  downward. 

Fractures  of  the  humerus  form  about  one-seventh  of  all  fractures,  anxl  are 
about  half  as  frequent  as  fractures  of  the  clavicle  and  scapula  together.  They  are  com- 
monly the  result  of  direct  violence,  and  occasionally  of  muscular  action.  They  may  be 
divided  into  fractures  of  the  head  and  tuberosities,  shaft  and  condyles. 


Fracture  of  tlie  Neck  of  the 
Scapula. 


SP1':(  I A  L   /'AM  (  TURKS. 


873 


Fifi.  o42. 


1/ 

Greater  TnhircsilV 
Fracture  of  the  Head 
and  Tul)fri>sitii-s  of 
the  Humerus.  I  Viy- 
hiiid's  case.) 


Iiii|>aoted  I  racture 
of  the  Head  of  the 
Humerus.  (I'rep. 
1113i",(iuy'8Mus.) 


Krac-turo.'*  iiiv(ilviii<;  tlio  hutil  and  tiiht roslliis  are  usually  the  result  nt"  a  Idnw  (»r 
fall  iiiMiu  the  shduldcr,  altlioiijrii  (ircasidually  tlii-y  f'<tlli»w  falls  on  the  elbow.  In  a 
case  that  came  iimler  my  <'ai"e  in  1S77  ami  <lieil  from  other  iiijiiries  the  ;:reater  tuherosity 
was  erushetl  off  and  tlisplaeed  upward  IVoni  a  fall  iipon  the  shoulder.  This  aeeident  eouhl 
never  have  l)een  niiide  out  during  life.  In  all  eases  the  direction  of  the  violence  is  an 
ini|>ortant  point  to  discover,  as  hy  it  the  surjreon  ohtains  the  he.st  guide  to  tin;  position  of 
the  frairnients  as  well  a.s  to  the  nature  of  the  injury. 

When  the  line  ol'  fnicture  follows  that  of  the  nniitmiilinl  in(h%  it  is  intracap.sular  :  and 
when  this  occurs,  the  head  of  the  hone  may  he  completely  separated  and  left  as  a  foreif^n 
liotly  in  the  joint;  yet  such  ca.ses  are  very  rare. 
In  others,  such  as  Fiir.  541  illustrates,  the  head  is 
separated  and  the  tuherosity  fractured ;  more  com- 
monly, however,  the  fracture  is  iiti/tacOd.  either 
the  lower  fra.Lrment  hein;z  driven  into  the  head 
of  the  hone  or  the  head  driven  into  the  neck,  the 
greater  tuherosity.  as  a  rule,  being  broken  (Kig. 
54:i).  Dr.  H.  Smith  of  Dublin  states  that  when 
this  accident  exists  the  arm  is  shortened,  the  acm- 
inion  process  projects,  the  shoulder  loses  its  round- 
ed form,  the  shat't  of  the  humerus  approaches  the 
acromion,  and  the  head  of  the  bone  cannot  be  felt. 
When  the  tuberosity  is  broken  off,  crepitus  may 
be  detected. 

In  ISCiS  I  saw  such  a  case  in  a  woman  ret.  oD 
who  had  fallen  on  the  shoulder  nineteen  days  previously,  the  ca.se  having  been  treated  as 
one  of  contusion.  Shortening  in  the  arm  of  three-( quarters  of  an  inch  and  a  distinct 
prominence  of  bone  with  thickening  could  be  felt  between  the  acromion  and  coractyid 
processes,  while  the  head  of  the  bone  rotated  freely  in  the  glenoid  cavity.  In  it  there 
was  some  flattening  of  the  deltoid.  A  good  I'ecovery  took  place  with  permanent  short- 
ening. 

I  saw  also  a  similar  case  in  I8(Jo.  in  an  old  man  jet.  82,  in  which  good  repair  took 
place. 

More  conunonly  a  fracture  about  the  head  of  the  bone  means  a/rucfure  in  the  line  or 
a  separation  of  the  epiphysitis  the  epiphysis  including  the  head  and  the  tuberosities.  This 
accident  is  generally  the  result  of  a  fall  on  the  elbow,  and  the  .symptoms  of  the  accident 
are  tolerably  distinct.  The  head  of  the  bone  can  be  felt  in  its  normal  position,  but  is  not 
movable  on  rotating  the  shaft,  while  the  end  of  the  displaced  shaft  is  usually  sent  for- 
ward.    When  fractured,  the  bone  presents 

a  sharp  edge  and  outline ;   but  when  di.s-  ^^'^-  '^'^^■ 

placed — an  accident  that  can  occur  only  in 
suVjjects  under  twenty-one — the  end  of  the 
bone  appears  rounded  and  slightly  convex. 
It  is,  njoreover,  drawn  forward  by  the 
action  of  the  pectoral  muscles  and  made 
to  project  beneath  the  coracoid  proce.ss  in 
a  marked  and  characteristic  manner.  In 
Fig.  543,  taken  from  a  male  patient  of 
mine  jet.  IG.  this  position  is  well  seen. 

When  the  separation  is  complete,  the 
displacement  will  be  very  marked  ;  when 
partial,  it   will   be  etiually   characteristic; 

!      .     •  ..:■    1      T      1  J.      £•   ^\  IP...       Separation  of  Shaft  of  Humerus  from  I  nper  Epiphrsis. 

but   in   partial   displacement  oi   the   shait  n       r  •-  . 

some  molnlity  of  the  head  of  the  bone  will  exist.  In  this  accident  the  shaft  may  be  at 
times  replaced  by  manipulation.  "  but  the  moment  the  parts  are  abandoned  to  the  uncon- 
trolled action  of  the  muscles  the  deformity  recurs  '  (R.  Smith). 

When,  after  a  separation  of  the  upper  epiphysis  or  fracture  through  the  tuberosities 
or  neck  of  the  bone,  the  upper  end  of  the  diaphysis  or  the  lower  fragment  of  the  broken 
bone  is  drawn  inward  and  forward  by  the  pectoral  muscles,  the  case  may  simulate  that 
of  dislocation.  The  mistake,  however,  should  not  be  made,  as  in  the  early  period  of  the 
accident  increased  mobility  of  the  bone  and  crepitus  should  be  enough  to  indicate  its 
nature,  and  in  the  later  period,  when  the  deformity  produced  by  the  end  of  the  lower 
fragment  is  visible,  the  accident  is  palpable. 


874 


ON  FRACTURES. 


Fig.  544. 


When,  in  fracture,  impaction  of  either  fragment  exists,  no  crepitus  will  be  felt  unless 
forcible  movement  be  made,  when  it  may  b6  elicited.  Care,  however,  should  be  observed 
in  seeking  for  this  information,  as  a  forcible  separation  of  the  impacted  bones  is  a  fatal 
error.  The  accident  is  generally  to  be  made  out  by  the  nature  of  the  injury,  the  short- 
ening of  the  limb,  the  absence  of  crepitus,  and  the  movement  of  the  head  of  the  bone  on 
making  gentle  rotation  of  the  shaft. 

Treatment. — In  fractures  of  the  anatomical  neck,  when  the  head  of  the  bone  is 
driven  into  the  tuberosity  and  shaft,  as  in  all  other  forms  of  impacted  fracture,  union 
will  go  on  if  the  impacted  bones  are  not  displaced  by  manipulation.  The  surgeon,  there- 
fore, has  only  to  apply  some  simple  splint,  such  as  an  anterior  and  posterior  or  lateral,  or 
iStrumeyer's  cushion  (Fig.  561),  to  maintain  rest.  The  same  treatment  is  applicable  in 
fracture  or  separation  of  the  epiphyses  when  the  bones  have  been  replaced.  In  the  case 
illustrated  in  Fig.  5-43  a  capital  arm  existed. 

Fracture  of  the  surgical  neck  of  the  humerus  below  the  tuberosities  is,  however,  prob- 
ably the  most  common  form  of  accident,  and  the  line  of  fracture  may  be  transverse  or 
oblique  (Fig.  544).  In  it,  when  the  bone  is  broken  above  the  insertion  of 
the  pectoral  muscle — its  usual  seat — the  lower  fragment  is  drawn  imcard 
toward  the  chest,  whilst  the  upper  fragment  is  drawn  upward  and  otit- 
icani  by  the  muscles  that  are  inserted  into  the  tuberosities.  The  bone 
projects  forward  or  backward  according  to  the  direction  of  the  fracture, 
the  direction  greatly  depending  upon  that  of  the  force.  The  more  oblique 
the  line  of  fracture,  the  greater  the  deformity.  Impaction  of  the  broken 
fragments  may  occur  in  this  as  in  the  last  fracture,  the  lower  usually 
penetrating  the  upper. 

Treatment.- — ^The  nature  of  the  accident  having  been  ascertained  and 
the  question  of  impaction  or  non-impaction  decided,  the  treatment  becomes 
simple  ;  for  in  the  impacted  fracture,  whether  of  the  anatomical  or  the 
surgical  neck,  the  aim  should  be  to  keep  the  impacted  bones  in  position 
and  to  prevent  their  being  loosened,  so  that  natural  processes  may  effect 
a  cure  in  a  month  or  six  weeks  with  a  limited  degree  of  deformity,  and  in 
a  non-imjiacted  fracture  the  first  aim  is  to  bring  the  bones  into  as  good 
apposition  as  possible  and  to  keep  them  there  by  means  of  splints  and 
position.  In  doing  this  the  tendency  of  the  fracture  has  to  be  considered, 
which  is  that  the  lower  fragment  is  drawn  inward  by  the  pectoral  muscle  and  the  upper 
fragment  outward  by  the  scapular  muscles.  The  best  plan  to  carry  out  these  objects  is 
to  fix  the  arm  between  an  inside  right  angular  and  an  outside  straight  splint,  the  former 
extending  from  the  axilla  to  the  wrist  and  the  latter  to  the  elbow,  the  two  being  well 
bound  together.  It  is  a  dangerous  practice  simply  to  place  the  fore-arm  in  a  sling  and 
bind  the  arm  to  the  side.  When  much  injury  to  the  soft  parts  or  any  wound  exists,  it  is 
an  excellent  plan  to  draw  the  arm  outward  from  the  body  at  half  a  right  angle  and  to 
rest  it  on  the  splint  with  the  fore-arm  partially  flexed,  care  being  taken  that  the  lower 
fragment  is  not  drawn  too  far  inward,  or  to  bind  it  on  Stromeyer's  cushion. 

At  other  times  a  good  gutta-percha,  felt,  or  leather  casing  moulded  to  the  shoulder 
and  arm  is  very  efficient,  or  a  bent  leather  splint,  the  angle  being  well  pressed  into  the 
axilla,  with  one  half  fixed  to  the  arm  and  the  other  to  the  thorax. 

In  all  these  cases  the  surgeon  should  explain  to  the  patient  that  some  impairment 
of  the  mobility  of  the  limb  may  be  expected,  and  some  shortening  in  impacted  frac- 
tures. 

Fracture  of  the  greater  tuberosity  is  a  recognized  accident,  and  is  usually 
associated  with  dislocation  of  the  humerus  forward,  the  scapular  muscles  drawing  the 
tubero.sity  backward.  Dr.  R.  Smith,  in  his  excellent  work  On  Fractures,  gives  a  descrip- 
tion of  two  of  these  cases.  He  describes  a  remarkable  increase  in  the  breadth  of  the 
articulation,  the  projection  of  the  acromion  and  flattening  of  the  deltoid,  as  the  most 
striking  features  of  the  injury.  He  also  draws  attention  to  the  vertical  sidciis  correspond- 
ing to  the  bicipital  groove,  formed  by  the  head  of  the  bone  on  the  inner  side  and  the  dis- 
placed tuberosity  on  the  outer,  as  one  of  the  eharacteri.stic  symptoms. 

Fractures  of  the  shaft  of  the  humerus  are  common,  and  more  readily  made 
out,  as  well  as  more  succes.sfully  treated,  than  any  other  fracture.  When  oblique,  they 
are  frequently  followed  by  some  degree  of  shortening ;  but  this  result  is  of  little  practi- 
cal importance,  as  it  interferes  but  slightly  with  the  functions  of  the  hand.  Such  frac- 
tures are  as  commonly  the  result  of  direct  as  of  indirect  violence,  muscular  action  being 
by  no  means  an  uncommon  cause.     I  have  already  mentioned  an  instance  in  which  it 


Fracture  of  the  Sur- 
gkiil  Neck  of  the 
Humerus.    (Prep. 

11073:.) 


srKciM.  I'liArrriiKS. 


875 


if  tlic  iililii|nity  and  it.s  position. 


splint  for  1-ractiirt;  at  the  Shaft  of  the 
II1111K.T11.S. 


opcmiiil  ill  ;i  man  iliirin;,'  a  marital  ♦'inlirarc,  ami  a  .second  produced  by  throwiiifr  a  hall, 
ijoiisdaii',  .Mal^raij^nt'.  Hamilton,  and  others  have  reeord»'d  similar  instances. 

When  the  IVaetnre  is  transverse,  there  is  no  dis|)lacement ;  when  ohlii|UC,  the  tendency 
of  the  lower  fVairment  to  ridt;  will  depend  upon  the  line 
When  the  line  fd"  IVaetnre  is  helow  the  insertion  ol"  the 
deltoid,  the  iippi'r  rrairmeiit  will  have  li  tendency  to  he 
drawn  outward;  when  ahove  this  ]ioint,the  upper  I'ra^- 
nient  will  he  attracted  inward  hy  the  jiectoral  muscles, 
the  lower  I'rai^nnent  hcinir  «lrawn  tipward  and  outward 
hy  the  deltoid. 

Loss  of  power  in  the  arm,  niohility  ol'  the  lioin!, 
crepitus,  local  pain,  and  deformity  are  ample  symptoms 
to  indicate  the  accident.  An  error  in  diagnosis  ouirht 
not  to  occur. 

TliK.VT.MK.NT. — This  is  not  really  difficult,  althoujih, 
from  the  fact  that  ununited  fracture  is  more  fre(|uently 
found  in  this  hone  than  in  any  other,  it  would  appear 
as  if  the  practice  were  less  successful.  Agnew  states 
that  out  of  085  eases  of  non-union  of  hone,  21  !l,  or 
about  )V1  jier  cent.,  were  of  tlie  humerus.  1  would  ex- 
plain the  fact  hy  the  want  of  a  due  appreciation  of 
Hoyer's    rule    of   treatment — viz.,   to    keep    the   joints 

above  and  below  the  l)roken  bone  in  absolute  rest;  for  in  fractures  of  the  anu  tlie  com- 
mon practice  of  ajiplyiiiLT  sjdints  to  it  and  allowing  perfect  freedom  to  the  action  of  the 
fore-arm  is  to  be  condemned,  because  in  moving  tlie  fore-ariu  the  triceps  and  brachiali.s 
anticus,  with  the  biceps,  have  as  powerful  an  action  upon  the  humerus  as  upon  the  bones 
of  the  forearm. 

In  the  primary  treatment  of  all  fractures  of  the  arm  it  is  a  wise  and  scientific  practice 
to  keep  the  fore-arm  at  rest,  which  is  best  done  by  the  application  of  soiue  angular  splint 
extending  from  the  .shoulder  or  axilla  to  the  wrist,  associating  with  it  a  posterior  or  ante- 
rior short  splint  reaching  from  the  shoulder  to  the  elbow  (Fig.  o-tS).  After  about  two 
or  three  weeks  the  angular  splint  may  be  removed  and  .some  immovable  one  applied,  the 
fore-arm  being  left  free. 

Any  s])lints  that  secure  immobility  of  the  broken  bone  after  its  ends  have  been  coap- 
tated  by  manipulation  must  be  regarded  as  beneficial,  and  no  splints  can  do  this  effectu- 
ally that  allow  freedom  of  movement  of  the  fore-arm.  AVhen  two  lateral  splints  appear 
the  more  adaptetl  to  keep  the  bones  in  position,  they  must  be  angular,  to  include  the 
elbow,  and  lient  at  a  right  angle. 

The  incomplete  or  green-stick  fractures  of  children  are  well  treated  by  milllioard. 
gutta-percha,  or  felt  splint  after  the  bone  has  been  restored  to  its  normal  position. 

In  putting  up  fractures  of  the  arm  care  should  be  observed  not  to  press  upon  the 
musculo-.spiral  nerve  as  it  winds  round  the  bone,  especially  when  the  line  of  fracture  cor- 
responds to  its  position. 

Fractures  involving  the  lower  end  of  the  humerus,  whether  transverse 

above  or  vertical  through  the  condyles,  or  both  together,  whether  complicated  with  sepa- 
ration of  the  epiphysis  or  some  di.splacement  of  the  bones  of  the  fore-arm,  are  always  dif- 
ficult to  a  diagnose  and  to  treat ;  and  when  the  joint  is  involved,  either  by  the  fracture 
running  into  it  or  by  disjilacement,  there  is  usually  some  subsefjuent  imperfection  in  its 
movement. 

Fractures  above  the  condyles,  where  the  bone  is  tliin  and  expanded,  whether  in  the 
child  or  in  the  adult,  or  separation  of  the  lower  epiphysis  (an  accident  of  early  life),  are 
usually  jiroduced  by  some  fall  upon  the  elbow.  "When  the  line  of  fracture  is  oblique 
from  behind  forward,  the  action  of  the  biceps  and  brachialis  anticus  has  a  tendency  to 
draw  the  fore-arm  with  the  lower  fragment  upward  and  forward.  "When  the  line  of  frac- 
ture is  obli(|ue  from  before  backward  and  upward,  the  lower  fragment  of  bone,  with. the 
bones  of  the  fore-arm.  is  apt  to  be  drawn  backward  by  the  action  of  the  triceps,  thereby 
giving  ri.se  to  the  external  appearance  of  a  di.<location  of  the  bones  of  the  fore-arm  back- 
ward, since  there  is  the  same  projection  of  the  olecranon  process  and  hollowness  above  it. 
the  same  projection  of  the  lower  end  of  the  humerus  forward,  with  the  pressing  forward 
of  the  artery,  in  both  accidents.  There  is,  however,  this  great  distinction  between  the 
fracture  and  dislocation,  so  well  expressed  by  8ir.  A.  Cooper:  In  fracture  there  is  "  the 
removal  of  all  marks  of  dislocation  on  extension  and  their  return  as  soon  as  extension  is 


876  ON  FRACTURES. 

discontinued  ;"'  crepitus  of  a  marked  kind  i.s  felt  where  a  fracture  is  present,  and  of  a 
suppressed  kind  where  a  displacement  of  tlie  epiphysis  exists,  whereas  in  dislocation  no 
crepitus  is  present  and  there  is  marked  immobility  of  the  bones,  the  bones  of  the  fore-arm 
and  the  condyles  of  the  humerus  having  lost  their  natural  relative  position.  Malgaigne 
also  jiointed  out  that  in  fracture  there  will  be  a  shortening  between  the  acromion  process 
and  the  internal  condyle,  whereas  in  dislocation  there  will  be  none.  In  fracture  the  ante- 
rior projection  of  the  end  of  the  humerus  is  aljove  the  fold  of  the  elbow  and  not  .so  broad 
or  riiinnl  a.<  in  ili-lncatimi.  wlu've  it  is  biloir  it. 

Fracture  of  the  condyles  into  the  joint  is  a  grave  accident  and  likely  to  be 

followed  by  some  stiffness  of  the  joint.     It  may  be  oblique  in  any  direction,  the  outer  or 

the  inner  condyle  being  fractured  or  associated  with   a  transverse  fracture  of  the  bone 

(Fig.  546).     The  existence  of  the  fracture  can  be  made  out  by  manipulation,  the  amount 

of  displacement  varying  with  the  character  of  the  injury.     Crepi- 

FiG.  546.  tus  can  also  be  detected   by  grasping  one  or  other  condyle  and 

moving  the  broken  fragment,  while  rotation  of  the  radius  often 

gives  rise  to  it  when  the  external   condyle  is  involved.     Flexing 

the  ulna  also  produces  it  when  the  internal  condyle  is  affected. 

All  these  fractures  into  the  elbow-joint  are  rapidly  followed 
by  effusion,  which  often  ma.sks  the  symptoms  and  renders  the  di- 
agnosis difficult  and  uncertain.  Under  these  circumstances  no 
diagnosis  should  be  attempted  until  by  rest  and  cold  applications 
the  effusion  has  been  absorbed  and  a  full  examination  can  be  sat- 
y?/ r/Z/T^"'''"^'    ^  isfactorily  made.     A  few  days  are  usually  enough  for  this  change 

Humtrus.  to  take  place.     In  rare  cases  the  inner  condyle  is  simply  chipped 

Comminuted  Fracture  of  the  off.  the  joint  not  being  implicated.     I  have  recentlv  had  a  case  of 

•  ondvles  of  the  Humerus,    .ii-i-  ■  i-ii  i  "..  -. 

fPrep.  iii2"5.)  the  kind  in  a  woman  in  which  the  ulnar  nerve  was  injured. 

Treatment. — In  all  these  cases  of  fractures  involving  the 
condyles  of  the  humerus,  whether  into  the  joint  or  not,  the  fragments  .should  be  brought 
into  position  by  extension  upon  the  fore-arm  when  needed,  with  manipulation,  and  an 
anterior  jointed  rectangular  splint  applied,  the  upper  half  of  the  splint  being  well  passed 
up  the  arm  and  the  lower  to  the  wrist.  In  some  cases  a  posterior  arm  splint  projecting 
down  to  the  olecranon  process  is  of  use,  the  whole  being  well  bound  together  and  to  the 
limb.  The  joint,  as  a  rule,  may  be  left  exposed  for  external  applications.  8ome  sur- 
geons prefer  from  the  first  an  immovable  casing  of  gutta-percha  or  felt,  while  others 
like  lateral  leather  or  pasteboard  splints,  but  I  think  it  preferable  to  leave  the  joint 
exposed. 

In  children  the  bones  unite  in  about  three  weeks,  and  in  adults  after  a  month  ;  con- 
.sequently.  all  splints  should  be  removed  at  the  end  of  these  periods  and  passive  move- 
ment allowed.  Hamilton,  however,  in  his  great  work  On  Fractures,  states  his  belief  that 
passive  movement  ought  to  be  commenced  within  seven  days  and  perseveringly  employed 
until  the  cure  is  accomplished.  He  does  not  admit  the  use  of  splints  after  this  period, 
believing  that  the  new  material  has  steadied  the  fragments  and  that  the  danger  of  dis- 
placement is  but  little,  while  the  prevention  of  anchylosis  demands  early  and  continued 
motion. 

Fractures  of  one  or  other  of  the  condyles  of  the  humerus,  complicated  with  dislocation 
of  the  bones  of  the  fore-arm,  occasionally  occur ;  and  when  they  do,  they  are  difficult  to 
diagnose,  and  more  difficult  to  treat.  In  the  following  case  the  cause  of  die  difficulty  of 
reduction  was  explained  by  the  fact  that  the  external  articular  facet  of  the  humerus  had 
been  vertically  displaced  and  the  head  of  the  radius  was  in  contact  with  the  inner  artic- 
ular facet,  whilst  the  ulna  worked  upon  the  internal  condyle.  The  case  was  that  of  a 
boy  aet.  10  who  fell  upon  his  hand,  with  his  arm  extended,  from  a  horse's  back,  the  force 
having  been  carried  through  the  radius  to  the  outer  condyle.  The  injury  was  regarded 
at  the  time  as  one  of  T-fracture  of  the  humerus.  When  I  saw  the  boy,  six  weeks  after 
the  accident,  the  injury  seemed  to  be  one  of  dislocation  of  the  bones  of  the  fore-arm 
inward,  with  great  thickening  of  the  external  condyle.  The  arm  was  much  extended. 
As  reduction  was  impossible,  resection  was  carried  out  with  a  good  result. 

The  preparation  and  drawing  (Fig.  547)  show  that  the  external  condyle  had  been 
broken  and  vertically  displaced.  The  head  of  the  radius  and  the  ulna  were  both  dis- 
placed inward  and  well  locked  by  processes  of  bone,  explaining  very  clearly  the  difficulty 
in  reduction.  The  coronoid  process  of  the  ulna  was  in  contact  with  the  outer  portion  of 
the  internal  condyle,  and  its  outer  edge  with  the  inner  margin  of  the  trochlear  surface  of 
the  humerus. 


si'/yiAL  i-i:.\'rin/:s. 


H77 


l'"i<i.  .J47. 


Till'  licail  of  tln'   rjHliuH  rotatf<l  oii  tin-  dis|tla(H'<l  inntT  half  of  the   artii-iilur  lacct  <if 
till-   laiiiK'ni.s,  witli   its  oiitcM-  cdj^t'  in  c-oiitact  with  tlie  di.sphiccMl 
external  iMOulylo.      The  oh-craiioii  fossa  was  partially  tilh-d  up. 

Aftt-r  fraftiirc  of  the  huiiieriis,  as  of  other  hoties.  arrcjst  of 
urowth  iiiav  follow.  I  have  seen  such  an  arrest  of  jrrowth  in 
the  humerus  of  a  wouuin  to  the  extent  of  three  ami  a  half 
inehes  alter  a  fracture  of  the  siialt  which  occurreil  when  she 
was  aliout  eitrht  years  of  ajje  (  Kij;.  O-lHj.  I  have  alsit  reconleil 
[(t'lii/s  //iisit.  /'i/i.,  1,S(>2)  a  ease  of  a  woman  iot.  iJO  in  whiih. 
with  a  stilV  shouhler-joinf ,  the  humerus  was  fivi;  inches  shorter 
than  its  fellnw.  the  shorteninjr  havinjr  folhtwed  som<!  injury  to 
the  upper  part  of  the  Ixuu'  duriuj;  infancy.  In  the  first  ease 
the  arrest  of  growth  was  jirohahly  due  to  some  injury  to  the 
nutrient  artery  of  the  l>oMe  ;  in  tlie  second,  to  injury  to  the  epi- 
]>hysial  cartihiire  at  the  upper  part  of  the  shaft. 

Fractures  of  the  Bones  of  the  Fore-arm. — These 

form  aliout  tw(»-tiftlis  of  all  fractures,  lialf  the  eases  consisting:; 

of  fracture  of  the  radius  alone,  a  fourth  of  fracture  of  the  ulna.  iC       c 

inclinlinir  the  olecranon  process,  and  the  remaininjr  fourth  of  the  i'i-'i>iacedaii.i«  ..ruiiiiinK.M  hrac- 

,        '  ,  ,.        '  ,.     ,  ,.  1       I         .  ..1         1  tiireof  tilt-  l,..tt<r  Kpiphysisof 

two  hones  totretlier.  traeture  ot  the  radius  and  ulna  together  be-     the  Huiiktu.s,  »iili  Dislnatiou 

ing  alMMit  ciiual  in  fn'(iii.>iii-y  to  that  of  the  clavicle.  ofthel{a.liu;*aM<l  ru.alnwar.l. 

Fracture  of  the  radius   niay  take  place  at  its  head,  neck,  .shaft,  or  lower  end. 

When  of  the  neck  or  shaft  and  transverse,  the  fragments  of  bone  are  usually  loo.se,  yield- 


D'lSI-tiU'il 

cvndifl' 


Fig.  548. 


Ki^hl    IIUIIILTU:: 


Arrest  of  Urowth  in  the  Humerus  after  Fracture  in  earlv  life. 


Left  Humerus. 


ing  on  manipulation  a  distinct  crepitus,  the  head  of  the  bone  being  felt  not  to  rotate  in 
its  position  ;  but  when  the  head  of  the  bone  is  fissured  longitudinally,  no  such  symptoms 
will  be  present. 

In  a  case  of  injury  to  the  right  upper  extremity  in  a  man  ret.  30,  complicated  with 
brain  mischief,  which  came  under  my  care  in  1877,  there  was  an  impacted  Colles's  frac- 
ture of  the  right  radius  and  a  vertical  fracture  of  the  head  of  the  same  bone  into  the 
joint.     He  had  evidently  fallen  from  a  height   upon  his  right  hand  and  head. 

Fractures  of  the  foicfr  cud  of  the  bone  are  of  a  very  variable  nature.  They  are.  as  a 
rule,  caused  by  a  fall  upon  the  outspread  liand  with  forcible  extension  backward,  but  they 
may  be  due  to  a  fall  upon  the  back  of  the  hand  with  the  wrist  flexed.  Many  of  them  are 
impacted,  the  compact  shaft  of  the  bone  being  driven  into  the  cancellated  carpal  extrem- 
ity ;  and  when  impaction  does  not  exist,  it  is  frequently  from  comminution  of  the  lower 
fragment.  In  possibly  half  of  the  cases  of  Colless  fracture,  however,  there  is  no  impao- 
tion,  the  end  of  the  radius  being  fractured  and  rotated  backward.  In  young  people  a 
separation  of  the  epiphysis  backward  may  occur  (Fig.  540). 

Fractures  of  the  lower  end  have  always  been  of  special  interest.     Colles  of  Dublin 


878 


OX  FRACTURES. 


first  described  them  in  1814  (Edin.  Med.  and  Surg.  Jovrnol'),  and  such   injuries  are  now 
generally  known  as  "  Colles's  fracture."     Dr.  K.  W.  Smith  has  done  much  to  draw  atten- 
tion to  their  nature  in  hi.s  work  On 
Fig.  549.  Fracture,  where  he  explains  the  cha- 

FiG.  550. 


Vertical  Section  of  Radius,  Kpiphysis,  and  .Soft  Parts,  showing 
Separation  and  Backward  Displacement  of  the  Lower  Epiphysis 
of  I  be  Radius.     (Taken  from  a  boy  Kt.  10.) 


Fracture  and  Backward  Rotation  of  the  Lower 
End  of  the  Radius,  with  Impaction  of  the 
rpper  Fragment.  (From  a  patient  of  Mr. 
Lucas.  I 


racteristic  deformity  by  muscular  action.  Fius.  551,  552  show  the  appearance  of  the 
wri.st.  with  displacement  of  the  broken  end  and  hand  backward ;  Fig.  553  shows  fracture 
with  displacement  forward. 

Callender  in  an  able  paper  (.SV.  Bartli.  Rep.,  1865)  showed  that  Voillemier,  Malgaigne, 


Fig.  551. 


Fig.  552. 


Colles's  Fracture  of  Lower  end  of  Rad- 
ius and  Displacement  Backward. 
(Dorsal  view.  From  Dr.  R.  W.  Smith.) 


Fracture  of  Radius  and    Displacement   Back- 
ward. (Side  view.     From  Dr.  R.  W.  Smith.) 


Fig. 


Fracture  of  Radius  and  Displacement  For- 
ward. (From  R.  \\.  Smith. j 


and  Nekton's  views  are  often  correct,  and  that  impaction  rather  than  muscular  action  i.s 
the  true  explanation  of  the  deformity. 

'•  The  radius  is  first  broken ;  then,  by  the  momentary  continuance  of  the  force  in  the 
direction  of  the  falling  body,  forward  and  outward,  the  shaft  is  driven  into  the  carpal  end. 

burying  itself  chiefly  from  the  dorsal  surface  toward 
the  palm,  and  toward  the  outer  or  the  inner  side.  In 
a  great  number  of  cases  this  impaction  so  fixes  the 
fragments  that  they  cannot  be  unlocked,  and  the 
deformity  is  permanent"  (Callender).  The  thirty-six 
specimens  of  fracture  of  the  lower  end  of  the  radius 
which  the  mu.seums  connected  with  the  London 
schools  of  medicine  contain  clearly  manifest  that  the 
cause  of  each  deformity  is  the  impaction  of  the  prox- 
imal in  the  distal  portion  of  the  broken  bone. 
Gordon,  however,  has  demonstrated  from  twenty-seven  specimens  in  the  Belfast 
Museum  that  impaction  is  not  constant.  In  nineteen  of  his  examples  there  was  oblique 
fracture  of  the  bone  from  before  backward  and  upward,  and  in  eight  the  fracture  was 
transverse.  He  believes  Colles's  fracture  is  "caused  by  the  f;tll  upon  the  palm  of  the 
hand,  the  fall  forcing  the  hand  backward,  putting  the  anterior  carpal  ligaments  and  flexor 
tendons  violently  on  the  stretch,  wrenching  off  by  the  •'  cross-breaking  strain'  the  lower 
end  of  the  radius,  tilting  it  backward,  with  alteration  of  the  aspect  of  its  carpal  surface, 
and  the  bearing  of  the  carpus  upon  it,  leaving  a  gap  between  the  fragments  in  front." 
He  likewise  thinks  that  fractures  produced  by  a  fall  on  the  back  of  the  hand  with  the 
wrist  flexed  are  often  impacted. 

The  fracture  is  usually  placed  about  half  an  inch  or  an  inch  above  the  wrist-joint,  and 
the  lower  fragment  or  epiphysis  is  displaced  backward.  It  is.  moreover,  so  displaced  that 
the  articular  facet,  in.stead  of  looking  downward,  forward,  and  inward,  is  made  by  rotation 
to  look  downward,  backward,  and  outward.  The  outer  side  of  the  fracture  toward  the 
styloid  process  is  rotated  more  than  the  inner,  the  strong  ligaments  uniting  this  with  the 
ulna  holding  the  bone  more  in  position.  On  this  account  the  lower  fragment  is  often  also 
broken  vertically,  giving  rise  to  greater  deformity  as  well  as  to  shortening  of  the  bone  on 
its  outer  border.  In  rare  examples  the  fracture  of  the  radius  is  complicated  with  disloca- 
tion of  the  scaphoid  bone  forward.  Dr.  Cameron  (GJas.  Journ..  March.  1875)  of  Gla.sgow, 
and  Mr.  Knott  (Surg.  Soc.  of  Ireland.  January.  1881)  of  Dublin,  both  give  examples  of 


SPECIAL  ri:.\<rri:/:s. 


879 


liu.  O'-ll. 


Fractured  Knd  of  Hadius  and  Stvloid  Process 
of  the  riiia,  (Prep.  ]l}>^'.i 


Fig.  5-35. 


this.     Ill  sdiiu'  iMM's  the  finl  ul'ilie  lioiie  i.s  cniiiiiiiniitcd  ((iiiy  s  Mu.seuiu,  lllll'-'j.  and  V'l^. 
.'»."» I  illustrates  a  i-a.»c  ol"  iVacture  oi'  liotli  radii    fVniii  a  fall  on  tlu-  liaiid.-i. 

hi Ati.vn.'Sls. — Till'  dia-iiiusis  of  tlii.s  aofitlciit  i>  imt  diHicult  ;  iiiderti.  tlie  aspect  of  the 
wrist  may  lu'  .said  to  hi-  charactiM-istic.  "  The  jmstorior  surface  of  the  liiuh,'  wrote  Colics, 
••  presents  ii  coiisidcralilt!  dcforiiiity ;  for  a  depression  is  to  lie  .»een  in  the  fore-arm  about 
an  inch  and  a  half  aliove  the  end  of  the  Imiie.  whilst 
a  eoiisideralile  swelliiii;'  occupies  the  wrist  and  meta- 
carpus ;  indeed,  the  carpus  and  ha.se  of  the  metacar- 
pus appear  to  he  thrtiwn  backward  so  much  as  on  first 
view  to  e.xcite  a  suspicion  that  the  radius  has  been 
dislocated  forward.  On  viewinj;  the  anterior  surface 
of  the  limb  we  ob.serve  a  considerable  fulness,  as  if 
caused  by  the  flexor  tendons  beinf;  thrown  forward  ; 
this  fulness  extends  upward  to  about  one-third  of  the 
lenirth  of  the  fore-anu.  and  tenniiuites  below  at  the 
upper  edf^e  of  the  annular  lijrament  of  the  wrist.  The 
extremity  of  the  ulna  is  seen  [irojectinfr  toward  the 
palm  and  inner  edjre  of  the  limb."  (  I'/V/r  Fig.  5-49. j 
The  amount  (}f  deformity  turns  upon  the  amount  of 
displacement  of  the  broken  fra,<;inent.s.  There  will  be  pain  in  the  part,  increased  by  pres- 
sure on  the  seat  of  fracture,  and  about  the  internal  lateral  ligament,  the  movement  of  the 
joint  being  rendered  impossible.  On  feeble  movement  of  the  hand  the  head  of  the  radius 
will  be  felt  to  rotate  when  the  fracture  is  an  impacted  one  ;  crepitus  will  be  either  ab.sent 
or  very  indistinct,  and  can  only  be  well  brought  out  by  loosening  the  broken  bones.  In 
rare  cases  these  fractures  are  compound,  the  end  of  the  shaft  of  the  radius  projecting  for- 
ward. More  commonly,  however,  the  ulna  is  made  to  protrude.  Both  these  conditions 
existed  in  the  case  from  which   Fig.  560  was  taken. 

Treatment. — In  all  fractures  of  the  radius  it  is  essential  to  keep  the  hand  at  rest, 
and.  as  a  consequence,  all  splints  should  extent!  at  any  rate  down  to  the  base  of  the  fin- 
gers. In  fractures  of  the  neck  or  shaft  the  elbow  should 
be  bent  at  right  angles  and  the  hand  held  midway 
between  pronation  and  supination,  tw^o  well-padded  broad 
splints  extending  down  to  the  lingers  being  firmly  fixed 
on  by  strapping,  broad  bands,  or  a  roller  (Fig.  555). 
When,  as  in  fractures  of  the  shaft,  there  is  a  disposi- 
tion for  the  fragments  to  fall  inward,  some  extra  pad 
may  be  employed. 

The  splints  should  be  removed  after  three  weeks  and 
freedom  given  to  the  hand,  movement  of  the  muscles 
being  encouraged ;  shorter  splints  or  some  immovable  apparatus  should  also  be  substitu- 
ted down  to  the  wrist  whilst  union  is  being  consolidated.  Lateral  pressure  of  the  bandages 
must  always  be  avoided. 

In  fractures  of  the  lower  extremity  of  the  radius  the  old-fashioned  jiistol-shaped  splint 
is  still  in  favor  -with  some,  its  object  being  to  keep  the  hand  and  wrist  adducted.  and 
thereby  to  counteract  the  deformity  that  .so  commonly  attends  this  form  of  fracture. 
Some  surgeons,  and  more  particularly  the  American,  apply  it  to  the  palmar,  and  others, 
including  Nelaton,  to  the  dor-sal.  aspect,  with  a  shorter  second  splint.  I  am  no  believer 
\j)    its   virtues;    for    if  the    fracture  be  P      ..„ 

impacted  and  the  fragments  are  not 
loo.sened,  it  is  u.seless.  as  union  has  only 
to  go  on  between  the  imjiacted  fragments 
for  a  cure  to  be  efl'ected  ;  and  when  the 
fragments  are  loosened  and  the  bones 
brought  into  apposition  by  extension  and 
manipulation,  the  pistol  splint  is  not 
wanted  ;  indeed,  it  is  probably  injurious, 
causing  displacement  of  the  broken 
bones.  A  well-padded  broad  anterior 
splint  reaching  to  the  roots  of  the  fin- 
gers, with  a  dorsal  splint,  answers  every  arrs-pm  . 
purpose,  the  wants  of  the  individual  case  determining  the  amount  and  position  of  the 
extra  padding.     The  best  splint  is  without  doubt  that  known  as  Carr's  splint  (Fig.  556). 


Splints  for  Fracture  of  lore-Arm 


Dr.  Goidon's  Spliut  for  Colles's  Fracture. 


880  ON  FRACTURES. 

It  is  about  eleven  and  a  half  inches  long  and  two  inches  wide.     The  anterior  portion  has 
an  irregular  convex  surface,  to  fit  into  the  concavity  of  the  lower  side  of  the  radius,  and 

the   posterior    is    flat ;  connected   with   the 
Fig.  55/.  anterior   an    oblique   cross-bar    four    inches 

long  is  fixed  for  the  patient  to  grasp.  When 
padded  and  nicely  fixed  with  strapping  or  a 
bandage,  it  is  eflScient  and  comfortable. 

Dr.  Gordon  of  Belfast  has  introduced  a 
splint  that  has  found  favor.  It  "  consists 
of  the  body,  the  ulnar  and  bevelled  portions, 
with  a  curved  back  splint  (Fig.  557).  The 
lower  end  of  the  ulnar  portion  is  curved 
forward  and  hollowed,  to  receive  the  inner 
border  of  the  flexed  hand,  with  a  slit  for 
the  carpal  strap.  The  bevelled  portion  is 
secured  to  the  body  of  the  splint  nearly  half  an  inch  internal  to  its  margin  ;  it  is  cut  oflF 
obliquely  from  without  inward  and  from  below  upward  ;  it  is  applied  to  the  palmar  sur- 
face of  the  upper  fragment,  which  it  is  its  ofiice  to  fix.  The  lower  end  of  the  back  splint 
is  much  curved  forward.  This  curve,  with  a  thick  pad,  is  necessary  to  enable  it  to  press 
the  base  of  the  metacarpus,  the  carpus,  and  the  lower  end  of  the  lower  fragment  v:eU  for- 
ward  for  the  restoration  of  the  natural  aspect  of  the  carpal  surface  and  the  concavity  of 
the  radius  '  (^Gordon  on  Fractures  of  Baduis.  etc..  p.  2-4,  1875). 
The  fore-arm  should  be  well  supported  by  a  sling. 

After  this  form  of  fracture  the  wrist-joint  rarely  recovers  its  normal  movement,  some 
deformity  permanently  remaining  ;  and  of  this  the  patient  ought  to  be  warned.  I  have 
recently,  however,  had  under  care  (June,  1878)  a  case  of  double  compound  Colles's  frac- 
ture in  which  a  recovery  took  place  without  any  deformity. 

Fractures  of  the  ulna  are  almost  always  the  result  of  direct  violence,  the  mid- 
dle and  lower  parts  of  the  shaft — the  thinfter  portions — usually  suflfei'ing.  In  these  cases 
there  is.  as  a  rule,  little  displacement ;  and  when  it  exists,  it  is  of  the  lower  fragment. 
On  manipulation  crepitus  is  usually  present,  with  local  pain.  Fracture  of  the  oh-crnnon 
process  is  a  verv  frequent  accident  fi'om  a  fall  or  blow  upon  the  elbow  or  a  sudden  action 
of  the  triceps.  In  it  there  is  always  more  or  less  displacement  of  the  end  of  the  process ; 
and  the  smaller  the  piece,  the  greater  the  displacement,  the  base  of  the  process  being  held 
well  in  position  bv  the  fascia  covering  the  bone  and  the  periosteum.  Fracture  of  the  coru- 
noid  process  (Guy's  Museum,  1119'^^j,  with  or  without  dislocation  of  the  ulna  backward, 
has  also  been  described,  though  very  rare.  In  the  case  from  which  Fig.  559  was  taken 
it  coexisted  with  fracture  of  the  head  of  the  radius.  The  styloid  process  of  the  ulna 
may  likewise  be  broken  and  displaced  forward  or  backward,  and  is  generally  caused 
by  a  fall  upon  the  hand ;  it  is,  consequently,  a  frequent  accompaniment  of  Colles's 
fracture. 

Treatment. — In  fractures  of  the  shaft  the  treatment  is  simple,  the  radius  acting  as 
a  splint  and  preventing  shortening.  The  surgeon  has  only  to  see  that  the  broken  bone 
is  kept  quiet  and  that  the  fragments  are  in  position.  This  is  well  done  by  means  of  well- 
padded  anterior  and  posterior  splints,  the  hands  being  fixed  in  a  po.sition  midway  between 
pronation  and  supination,  Carr"s  splint  being  the  best. 

In  fractures  of  the  coronotd  process  the  fore-arm  should  be  kept  flexed,  to  relax  the 
brachialis  anticus  muscle,  which  is  inserted  in  it,  and  in  fractures  of  the  olecranon  nearly 
sitraiglit.  to  relax  the  triceps,  through  which  the  separation  of  the  fragments  takes  place. 
The  splint  may  be  strapped  on  or  fixed  by  strapping,  and  in  severe  cases  an  immovable 
apparatus  is  advisable. 

Some  separation  of  the  fragments  very  frequently  remains  after  fracture  of  the  ole- 
cranon, which  increases  when  the  arm  is  used  too  soon,  the  power  of  the  arm  being  con- 
sequently weakened.  Passive  movement  of  the  arm.  however,  should  always  be  permitted 
about  five  weeks  after  the  accident,  all  violent  effiijrts  being  condemned. 

Fracture  of  both  radius  and  ulna  occurs  about  as  frerjuently  as  fracture 
of  the  ulna  alone,  but  not  a  quarter  so  often  as  fracture  of  the  radiu.s-.  Direct  violence 
is  the  usual  cause,  a  fall  upon  the  hand  being  more  commonly  followed  by  fracture  of  the 
radius  than  by  that  of  the  two  bones. 

Malgaigne  has  recorded  instances  of  this  accident  from  muscular  action.  In  infants 
the  r/rern-i^tick  or  incomphte  fracture  of  both  bones  is  not  infrequent. 

The  fracture  may  be  transverse,  oblique,  or  comminuted,  and  the  displacement  of  the 


SPECI. \ L   I'llA CTVllES. 


881 


Fig.  .>j8. 


Radius  aud  I'lna 
(oiiMilidaled  after 
Fracture.      i  I'rep. 


frujriiK'iit  luav  vary  vastly  aceoriliii;.'  to  the  »linctii)ri  and  violence  of  the  force  which  pro- 
iluccil  it. 

Tlu'si'  fractnri'.s  arc  readily  made  out  and  not  often  ilifficult  to  manage,  although  at 
times  the  .siirgcon.s   ingenuity   i.s  ta.xed  to  prevent  deformity. 

Tkk.vtmk.nt. — Tndcr  all  circumstances  the  fore-arm  .should  be  flexed  and  the  hand 
kept  in  the  scmi-pronc  jiosition.  Two  vlih;  splints  should  be  employed,  well  jjadded,  broad, 
and  coming  down  to  the  roots  of  the  fingers,  the  surgeon  so  arranging  his 
jiads  as  to  j»revent  deformity  and  to  neutralize  the  peculiar  tendency  of 
the  fracture.  When  the  parts  are  bandaged  too  tightly,  the  bones  may 
be  pres.scd  together,  and  con.solidation  takes  place  as  a  whole,  with  con- 
se»|uent  loss  of  moti«in,or  the  two  bones  may  be  braced  together  by  some 
bony  isthmus  (Fii;.  55S).  Lmfir  nil  rirciimstunits  t/ic  j'r<icliii<-  shoiilJ  he 
put  ii/t  with  tltf  hdinl  .tupinotnl,  the  dorsal  splint  being  first  applied,  and 
then  the  |>almar,  the  fore-arm  being  semiflexed.  When  fracture  of  the 
ratlins  antl  ulna  takes  place  above  the  wrist-joint,  the  .symptoms  may 
simulate  those  of  dislocation;  but  the  greater  mobility  of  the  lower  ends 
of  the  bones,  crepitus,  and  local  pain  ought  to  forbid  the  error  being 
acted   upon. 

Fracture  of  the  carpal  bones  can  occur  only  from  direct  vie- 
lence.  .snna'  crushing  force  lieing  the  usual  form.  It  may  be  difficult  to 
tliagnose,  as  the  same  force  that  produced  the  fracture  will  to  a  certainty 
have  injured  the  soft  parts  around  the  bones.  Hapjdly,  however,  the 
treatment  of  any  severe  injury  to  the  wrist  should  be  such  as  will  serve 
for  all ;  for  the  api)lication  of  an  anterior  sjdint,  as  well  as  cold  lotions 
and  absolute  rest  of  the  injured  part,  ought  always  to  be  observed  in  all  clear  as  in 
doubtful  cases,  and  with  these  a  good  result  may  generally  be  secured. 

Fracture  of  the  metacarpal  bones  i->  not  rare.  It  is  commonly  caused  by 
some  blow  when  fighting  or  otlicr  furni  of  direct  violence.  Thus,  it  is  most  frequent 
in  the  right  first  and  fifth  bones.  Dr.  E.  H.  Bennett  of  Dublin  has  shown  (Dub.  Joitrn, 
*>/  Med.  Sri.,  January.  1882)  that  in  the  commonest  form  the  fracture  passes  obliquely 
through  the  base  of  the  bone,  detaching  the  greater  part  of  the  articular  facet  and  allow- 
ing the  body  of  the  bone  to  be  displaced  with  the  thumb  backward.  It  is  rarely  compli- 
cated with  much  displacement.  In  young  subjects  the  head  of  the  bone  or  epiphysis 
may  be  displaced.  It  should  be  treated,  as  all  fractures.  '•  with  brains,"  the  pads  and 
splints  being  so  applied  as  to  fulfil  the  wants  of  the  individual  case.  In  the  majority  a 
simple  pad  placed  on  the  palm,  with  an  ajiterior  splint,  may  be  sufficient.  In  one  case 
Malgaignes  plan  of  placing  a  thick  compress  under  the  head  of  the  bone  and  a  second 
over  the  dorsal  projection,  with  two  broad  splints  across  the  hand,  may  be  called  for;  in 
another  Sir  A.  Cooper's,  of  binding  the  flexed  fingers  over  a  ball,  may  fulfil  the  necessary 
requirements;  but.  as  a  rule,  an  anterior  splint  and  jialmar  pad  carefully  adjusted  supplies 
every  want  and  is  sufficient,  the  surgeon  remembering  that  the  palmar  surfaces  of  these 
metacarpal  as  well  as  phalangeal  bones  are  concave. 

Fracture  of  the  phalanges  is  usually  compound,  although  it  may  be  simple, 
and  is  easily  diagnosed  and  readily  treated.  A  simple  anterior  splint  is  all  that  is  required, 
a  dorsal  being  rarely  called  for,  a  piece  of  wood  .serving  for  the  pur- 
pose, though  a  thin. piece  of  perforated  zinc  is  preferable.  The  splint 
should  be  fixed  on  with  strapping,  a  coating  of  the  compound  tincture 
of  benzoin  rendering  all  firm  and  immovable. 

In  compound  fracture  into  the  elbo^w -joint,  when  the  parts 

are  much  injurLMl.  excision  is  pmbablv  the  wisest  step  to  adopt,  as  by  it 
convalescence  is  hastened  and  a  good  arm  with  a  movable  joint,  as  a 
rule,  given,  whereas  a  recovery  by  natural  processes  without  operation 
will  probably  end  with  anchylosis  after  a  tedious  process  of  suppura- 
tion. When  the  injury,  however,  is  not  severe  and  the  patient  young, 
excision  is  not  called  for,  a  recovery  with  a  movable  joint  being  pos- 
sible. I  have  had  several  excellent  examples  of  this  under  my  care 
during  the  last  few  years.  In  aged  sulijects,  however,  amputation 
may  be  required,  and  in  the  one  from  which  the  preparation  (Fig.  559^ 
was  taken  such  a.  step  was  demanded.  The  drawing  illustrates  an 
uncommon  form  of  accident^ — comminuted  fracture  of  the  head  of 
the  "radius  and  fracture  of  the  coronoid  process. 

Coraponnd  fractures  of  the  arm  and  fore-arm  ought  to  be  treated  upon 


Fig.  559. 


Fracture  of  the  Coto- 
noid  Process  and 
Head  of  Radius,  pro- 
duce<l  liy  a  Fall  u|W)n 
the  IClb'ow.  (Taken 
from  a  woman  xt. 
To.) 


882 


ON  FRACTURES. 


the  same  principles  as  the  simple — that  is.  when  the  injury  is  not  sufficient  to  necessitate 
amputation  or  excision  the  bones  should  be  brought  into  apposition  and  kept  there  by 
means  of  splints,  interrupted  or  not,  the  wounds  being  covered  either  by  lint  soaked  in 
blood,  or,  what  is  better,  by  the  compound  tincture  of  benzoin.  It  may  be  added  that 
the  injury  should  indeed  be  great  to  necessitate  amputation,  it  being  justifiable  to  incur 
some  extra  risk  to  save  the  hand. 

In  a  severe  case  of  compound  comminuted  fracture  of  the  humerus  caused  by  the 
passage  of  a  rifle  bullet  through  the  bone  in  a  young  man,  which  came  under  my  care  at 

Fig.  560.  Fig.  561. 


Compound  DiMocation  of  Ulna 
and  Shalt  of  Iladius  I  orward, 
with  Displacement  of  the 
Lower  Epiphysis  of  the  Ra- 
dius Backward. 


Stromeyer's  Cushion  (from  MacCormac).    With  straps  applied. 

Guy's,  good   success   attended   the  immediate   sealing  of  the 
wound  with  benzoin  and  the  application  of  the  splint.     The 
man  left  the  hospital  in  three  months  with  a  firmly-united  bone 
and  a  good  sound  arm.     In  such  a  ca.se  as  that  represented  in 
Fig.  560;  where  displacement  of  the  lower  epiphysis  of  the  radius 
and  dislocation  of  the  ulna  existed,  amputation  was  demanded. 
I  have  little  to  add  to  what  has  already  been  given  in  the  way  of  treatment  of  com- 
pound fractures  of  the  humerus  beyond  an  allusion  to  Stromeyer's  cu.shion.  which  com- 
mends itself  to  attention  as  much  by  the  eminence  of  its  advocate  as  by  its  usefulness. 
It  was  introduced  to  our  notice  by  Sir  William  MacCormac  (Fig.  561). 

The  cushion  may  be  described  as  triangular  and  wedge-shaped.  At  its  thickest  end 
it  measures  four  inches  in  depth,  and  from  this  point  gradually  thins  down  for  a  length 
or  fourteen  or  fifteen  inches.  The  elbow  rests  on  the  thick  end,  while  the  thin  rests  on 
the  side  of  the  chest.  The  cushion  is  readily  fastened  in  its  place  by  a  tape  round  the 
neck  and  the  body  ;  and  when  this  simple  apparatus  is  applied  the  arm  rests  beautifully 
supported  and  in  excellent  position.  Whilst  lying  in  bed  nothing  beyond  the  ordinary 
dressings  are  required  for  the  wound  ;  and  if  the  patient  has  to  be  transported  from  one 
place  to  another  or  is  fit  to  walk  about,  this  can  be  arranged  with  the  utmost  facility,  as 
cushion,  arm,  and  all  can  be  bound  by  a  broad  bandage  to  the  body  and  thus  form  an 
immovable  whole.  Stromeyer  considered  this  cu.shion  to  be  "the  most  valuable  appliance 
he  had  invented  during  his  life."  I  have  used  it  for  fracture  and  dislocation  of  the 
humerus  and  for  shoulder-joint  disease  with  great  advantage,  and  have  adapted  straps  to 
it  to  hold  the  arm  and  fore-arm  in  position. 

Compound  dislocation  and  fracture  of  the  phalangeal  joints  require 

a  distinct  consideration,  and  the  .slight  constitutional  svniptunis  which  such  injuries  induce 
enable  the  surgeon  to  treat  them  on  purely  local  considerations. 

To  dwell  on  the  importance  of  the  integrity  of  the  hand  as  a  whole  or  to  adduce  argu- 
ments to  show  the  necessity  of  saving  as  much  as  possible  of  the  thumb  and  fingers  is 
unnecessary,  since  these  rules  of  practice  are  now  acknowledged  ;  yet  such  have  their 
limit,  as  anchylosis  of  some  of  these  joints  may  prove  an  impediment  rather  than  an 
advantage  to  the  free  use  of  the  hand,  and  a  stifi"  finger  to  a  man  in  one  business  may 
be  most  detrimental,  while  to  one  in  another,  if  bent,  it  may  be  of  service. 

With  the  thumb,  however,  the  above  rule  may  be  considered  absolute,  and  an  attempt 
should  invariably  Vje  made  to  save  the  joints  and  as  much  as  possible  of  the  injured  parts, 
it  being  often  better  in  compound  fractures  to  leave  the  bone  to  granulate  than  to  remove 
it  ;  for  the  use  which  may  be  made  of  the  stump  of  a  thumb  or  of  one  fixed  by  anchy- 
losis can  be  appreciated  only  by  those  who  have  been  fortunate  enough  to  witness  such 
instances. 

With  the  fingers  this  rule  will  not  hold  so  good,  since  it  often  happens  that  the  loss  of 
a  finger  will  be  found  of  less  inconvenience  than  a  stifi"  one.  In  a  general  point  of  view, 
a  stiff  metacarpo-phalangeal  joint  to  a  laboring-man  is  an  impediment,  while  to  a  gentle- 
man it  may  be  of  service  and  at  the  same  time  preserve  the  comeliness  of  the  part.     A 


FiiAcrriiEs  or  riii:  ijt\\'i:n  kxtiuimity.  883 

8tifl'  fir^l  |i!i;il;iiiiri';il  jniiit  will  Ik-  iiiust  iprcjinlicial  in  sniiic  frailcs.  wliilc  in  hIIkts  it  is  (if 
sliu'lit  iin|Mirt;iiic('.  A  stifV  joint  lictwti-n  tin-  cxtninr  iili;il:in;rcs  is  nin-ly  oj'  niu<  li 
nmniriii . 

Till-  pationt.  liowfViT,  slimild  he  consiiltiMl  Ity  tlir  snrpNiti  in  all  these  cases  and  the 
treatment  ailapted  ti>  tlie  wants  nf  the  individual,  since  a  fiositictti  that  may  be  f^ood  fur 
one  may  he  had  for  aiinther.  and  nu  one  imsition  is  applicalth^  to  all.  It  is  too  common 
to  find  men  applyiiiLr  at  liundun  h(»s)iitals  to  have  tin^n-rs  remi»ve<l  that  have  heen  savetl, 
but  lixed  at  bad  aiiiriis.  the  stiff  lini:t  r  bein^  an  iniprdiniint  to  the  free  performance  of 
their  trade. 

In  compound  fractures  and  dislocations  cd'  tlx;  thumb  htose  frafrments  of  bone  sh<»uld 
be  removed  and  joints  excised  ;  as  much  us  possible  (»f  the  soft  parts  should  be  saved  and 
the  wound  left  to  natural  processes  for  repair.  To  amputate  a  thumb  for  injury  ought  to 
be  a  very  rare  ojieratiou.  In  those  injuries  to  the  fingers  the  same  priticiples  of  practice 
should  be  adojited,  although  modiKed  by  the  wants  of  the  individual  case.  To  .save  a 
finger  and  to  amputate  it  monthsafter  on  account  of  sfune  stiffness  of  joint  or  malposition 
is  to  waste  time.  When  a  joint  has  been  oitened  and  anchylosis  must  be  looked  for  after 
a  natural  recovery,  the  propriety  of  making  tlie  attempt  should  be  discussed  before  the 
practice  is  decided  upon,  wlu-n,  if  the  decision  be  in  i'avor  of  a  conservative  practice,  the 
injured  parts  should  In-  adjusteil  and  fixed  by  means  of  a  splint  in  the  most  favorable 
position. 

In  most  subjects  the  straight  is  a  forced  and  inconvenient  position,  and  not  that  ever 
assumed  hy  nature  with  the  hand  at  rest.  The  best  is  the  slightly  bent,  when  the  thumb 
and  fingers  can  touch  at  their  tips,  or  that  wliich  the  hand  naturally  assumes  when  at  rest. 
In  exceptional  cases,  however,  exceptional  positions  may  be  required.  I  have  for  years 
acted  upon  this  principle,  and  always  with  advantage. 

The  best  splint  for  fingers  is  a  piece  of  perforated  zinc.  It  i.s  thin  and  can  be  bent  to 
the  reiniired  curve  without  trouble,  as  well  as  readily  fixed  on  with  strapping  or  lint 
saturated  in  tincture  of  benzoin. 

Fractures  of  the  Lower  Extremity. 

Fractures  of  the  pelvis,  as  of  the  cranium,  spine,  and  thorax,  are  of  importance, 
inasmuch  as  tlie  visceral  contents  are  involved;  but  when  no  such  complications  exist,  the 
injury  is,  comparatively,  not  dangerous. 

Fracture  and  dislocation  of  the  bones  commonly  occur  together  and  may  be  regarded 
as  alike  in  a  clinical  point  of  view. 

The  anterior  portion  of  the  crest  of  the  ihum  is  not  rarely  broken  from 
direct  violence,  and  the  accident  is  not  serious.  Eest  in  bed,  to  keep  the  abdominal 
muscles  quiet,  and  the  application  of  a  pad  with  strapping,  a  mould  of  gutta-percha,  or  a 
broad  ])elvic  belt  when  displacement  exists,  are  the  ordinary  surgical  means  required. 

Fracture  of  the  pelvic  basin  itself  is  usually  the  result  of  some  crushing  force, 
the  weakest  jtart  ))reaking.  such  as  the  rami  of  the  pubes.  In  other  cases  there  will  be 
some  si'iiaraiion  of  the  pubic  bones  at  the  symphysis  or  other  fracture  of  the  brim.  In 
many  the  injury  will  be  complicated  with  laceration  of  the  urethra.  In  the  ca.se  of  a 
female  jct.  i^U,  which  I  had  under  care,  the  bones  were  displaced  on  the  right  side  for 
more  than  an  inch,  when  a  curious  deformity  resulted,  the  pelvic  bones  with  the  adductor 
muscles  being  curved  out,  leaving  a  hollow  on  the  inner  side  of  the  thigh. 

In  another,  sent  to  me  by  Dr.  Bennett  of  Builth,  in  a  female  child,  great  separation  of  the 
pelvic  bones  was  present,  the  whole  pelvic  organs  having  been  pres.sed  out  of  the  outlet  of 
the  pelvis  by  the  crushing  force.  The  large  intestine  for  about  a  foot,  uterus,  bladder,  etc., 
were  all  in  view,  the  whole  perin.ieum  having  been  ruptured.  The  drawing  (Fig.  562) 
shows  the  child's  condition  when  I  saw  her  fourteen  months  after  the  accident.  How 
the  child  escaped  with  life  was  a  mystery,  the  perinaeum  being  gone,  the  bowels  protrud- 
ing, and  the  bones  of  the  pelvis  widely  apart.  Such  a  case  is  enough  to  show  how  great 
an  injury  tlie  pelvis  may  occasionally  sustain  without  causing  death.  As  an  example  of 
fractured  jtelvis  Fig.  563  may  be  referred  to. 

Di.\(iN(»sis. — The  greatest  care  is  necessary  in  examining  the  subject  of  a  suspected 
fracture  of  the  pelvis,  yet  the  diagnosis  can  generally  be  made  from  the  nature  of  the 
force  employed,  its  direction,  and  the  complications  that  exist.  Urethral  complication 
is  the  most  common  in  the  male,  and  ought  to  be  treated  as  already  described  at  p. 
698.  As  an  illustration  of  the  practice  there  recommended,  in  June,  1875,  a  boy  aet. 
7  was  admitted  under  my  care  into  Guy's  Hospital  with  fracture  of  the  pubic  bones  and 


884 


ON  FRACTURES. 


laceration  of  the  urethra,  accompanied  witli  prol'use  liemorrhage  and  retention,  for  which 
catlieterisni  was  ineftectual,  and  death  seemed  imminent.  I  consequently  made  a  free 
incision  into  the  periiu>jum  down  to  the  lacerated  urethra  upon  a  grooved  staft',  and  a 
rapid  recovery  took  place  after.  Under  all  circumstances  the  utmost  quiet  must  be 
enforced ;  for  if  the  surgeon  is  unable  to  restore  the  fractured  bones  to  their  normal  posi- 


FiG.  562. 


Fio.  503. 


Fracture  of  the  Pelvis  in  a  Child,  with  Separation  of 
I'ubes,  Prolapse  of  Rectum  and  Uterus. 


Fracture  of  Pelvis. 
(Prep.  No.  llo4,  Guy's  Hosp  Mus.) 


tion,  at  any  rate  he  must  do  nothing  to  render  their  displacement  greater  or  to  increase  the 
risk  of  visceral  injury.  Where  support  by  means  of  a  bandage,  strapping,  or  casing  of  gutta- 
percha or  some  other  substance  gives  comfort  or  seems  called  for,  it  should  be  applied  ; 
but  in  general  "absolute  rest  and  such  treatment  as  the  complication  may  require  are  all 
that  is  necessary.  In  two  cases  I  have  seen  obstruction  of  the  iliac  artery  associated 
with  fractute  of  the  brim  of  the  pelvis.  In  one  the  vessel  was  so  stretched  as  to  cause 
laceration  of  its  inner  and  middle  coats  and  obstruction,  which  were  followed  by  gangrene 
of  the  corresponding  limb.  In  the  other  the  obstruction  lasted  three  weeks,  when  pulsa- 
tion returned  and  the  patient  recovered. 

Fracture  of  the  acetabulum  from  the  head  of  the  femur  being  driven  against 
the  bone  has  been  recorded.  Earle,  in  the  nineteenth  volume  of  the  Mf'd.-Chir.  Trans., 
adduced  a  case  in  which  the  pelvis  was  broken  into  its  three  anatomical  portions.  Sir  A. 
Cooper  and  Travers  have  recorded  others.  Moore,  also,  in  the  thirty-fourth  volume  of 
the  same  Transactions^  has  given  another,  with  a  drawing,  as  figured  here  (Fig.  5G4). 
When  the  head  is  driven  into  the  pelvis,  as  illustrated  in  the  drawing,  there  will  be 
deformity  of  the  hip,  inability  to  move  the  limb,  with  pain  in  the  attempt,  and  crepitus. 
Travers  believed  that  acute  pain  on  pressure  upon  the  projecting  spine  of  the  pubes  and 
inability  on  the  part  of  the  patient  to  maintain  the  erect  posture  after  pelvic  injury  are 
diagnostic  of  fissure  of  the  acetabulum. 

A  fracture  of  the  Up  of  the  acetaLu/inn  is  probably  present  in  such  cases  of  dislocation 
of  the  hip  as  become  displaced  again  after  reduction,  the  head  of  the  bone,  having  nothing 

to  restrain  it,  slipping  out  of  its  cup.  In  these  cases  the  re- 
duction of  the  dislocation  is  usually  attended  with  crepitus, 
followed  by  redislocation  on  the  removal  of  the  extending 
force.  It  should  be  treated  by  fixed  extension,  as  in  frac- 
ture of  thigh-bone,  and  some  circular  pelvic  pressure.  This 
accident  is  move  frequently  associated  with  dislocation  of 
the  head  of  the  femur  backward  than  with  any  other. 

Fracture  of  the  sacrum  may  be  regarded  clinically  like 
tliat  of  the  pelvis  ;  it  is  always  the  result  of  direct  vio- 
ence. 

Fractures  of  the  Loioer  Extremitij. — From  hospital  sta- 
tistics these  fractures  appear  to  be  more  common  than  those 
of  the  upper  extremity  ;  but,  as  the  majority  of  cases  of 
fracture  of  the  upper  extremity  are  treated  as  out-patients, 
of  which  no  records  are  kept,  the  conclusion  is  weakened  by 
a  fallacy.  The  Middlesex  Hospital  statistics,  compiled  by 
Lonsdale  and  H.  Morris  for  sixteen  years,  tell  us  that  there 
are  1206  examples  of  fracture  of  the  lower  extremity  to  1932  of  the  upper,  proving  that 
fractures  of  the  upper  extremity  are  twenty-three  per  cent,  more  frequent  than  those  of 
the  lower. 


Fig.  564. 


Head  of  Femur  driven  through  Ace- 
tabulum. (Med.-Chir.  Trans.,  vol 
xxxiv.) 


FRACTl'Iih'S   OF  nil-:   LOW  Eli    EXTREMITY.  885 

Fractures  of  the  femur  lorm  altout  one-fourth  of  all  fractures  of  the  lower 
extrcriiitv,  and  IVaetures  of  ihc  neck  ahout  one-fifth  of  the  fractures  of  the  l)one.  They 
may  !••'  tliviiU'tl  into  those  (1  j  of  the  mrlc  or  nji/nr  ni<i,  (2)  of  the  s/m/f,  and  (:{)  of  the 
loici  r  or  liuiili/ltir  <  ml . 

Fracture  of  the  neck  or  upper  end  existed  in  \  l  out  ..f  li  17  consecutive  cases 
admitted  into  (Juy's,  ur  in  one-lift h  of  all  cases.  It  is  more  fre(|uent  in  the  old  than  in 
the  yonn-,',  proliahly  iVom  the  impaired  nutrition  of  the  hone,  tlic  cortex  in  the  ajjced  heing 
always  thinner  and  the  caiieeUi  lartrer.  I  have,  however,  seen  it  in  a  boy  set.  12  and  a 
munjut.  liT.  Staidey  and  Hamilton  have  recorded  examples  at  even  an  earlier  a<:e.  In 
Guy's  Museum  there  is  a  specimen  taken  from  a  child  ;ut.  \)  (l^rep.  11S4;. 

When   the  fracture  involv(!s  the   neck   near  tlu;  head  of  the   Itone,  it  has  been  called 
iiifrd-vii/isiilar  (  Fi<j;s.  ')<!.')  and  .jTO)  ;  when  the  base  of  the  neck  near  the  trochanters,  rxtra- 
ciif>sit/iir ;  but  in  these  the  joint  is  <ienerally  involved,  the  line  of 
fracture,  as  a  rule,  being  obli(|ue  from   the   neck  witliin   to  the  Fi«-  ^'C^^- 

base  of  the  neck  without  the  ca])sule.      Both  ffjrnis   may  be  ini- 
paeteil ;   the  former  is  so  fre<|uently,  the  latter  frenerally. 

In  the  fractures  of  the  neck  near  the  head  of  the  bone  the 
neck  of  the  bone  is  usually  driven  into  the  liead  (  Fig.  570).  In 
the  fractures  of  the  base  of  the  neck  the  neck  is,  as  a  rule,  driven 
into  the  shaft  (Figs.  "jlJo,  5(!(5,  5(i7).  In  exccptiomil  cases  the 
impaction  is  double  (Fig.  571). 

Fractures  of  the  narrow  part  of  the  neck  of  the  femur  are 
generally  caused  by  Indirect  violence,  such  as  tripping  in  the  car- 
pet;  fracture  of  the  base  of  the  neck  by  direct,  such  as  a  fall 
upon  the  trochanter.  When  the  posterior  ridge  of  bone  pene- 
trates the  trochanter,  there  will  be  eversion  of  the  foot,  the  outer  ,  ,, 
surface  of  the  trochanter  looking  backward,  and  the  anterior  .sur-  L.'^ 
face  of  the  neck  will  be  felt  as  a  prominent  projection  beneath  intra-Capswiar  i-racmre  of  the 
the  rectus  muscle.  When  the  anterior  ridge  of  bone  penetrates  Ligameiitous  Kepair.*^ '''^""^ 
the  lower  fragment,  the  foot  will  be  straight  or  inverted,  the  sur- 
face of  the  trochanter  will  look  outward,  and  a  great  fulness  will  be  felt  behind  the  tro- 
chanter. Should  the  limb  be  much  addncted  when  the  patient  falls  upon  the  trochanter, 
the  lower  border  of  the  neck  may  be  driven  into  the  trochanter,  as  seen  in  Figs.  535, 
5GG  ;  and  should  the  limb  be  much  nhdncfed  when  the  fall  takes  place,  the  fracture  will 
probably  be  in  the  narrow  part  of  the  neck,  and  therefore  unimpacted  and  intra-capsular, 
\Yhen  the  penetration  of  the  neck  is  great,  the  trochanter  will  be  broken  off  and  there 
will  be  no  impaction,  but  the  usual  unimpacted  fracture  of  the  neck. 

With  these  facts  before  us,  the  best  division  of  fractures  of  the  neck  of  the  femur 
for  practical  purposes  seems  to  be  into  i\iQ  impacted  s^nA.  unimpacted. 

Sir  A.  Cooper  recognized  this  fact  of  impaction  to  a  degree,  though  he  did  not  quite 
see  its  importance,  when,  in  describing  fractures  of  the  upper  part  of  the  thigh-bone  he 
wrote,  "  The  fracture  is  placed  at  the  root  of  the  neck  of  the  thigh-bone,  the  trochanter 
is  split,  and  the  neck  of  the  bone  is  received  into  its  cleft.  It  fref(uently  happens  in  this 
injury  that  the  fracture  of  the  neck  of  the  thigh-bone  is  complicated  with  an  injury  of 
the  trochanters,  major  and  minor ;  the  neck  of  the  thigh-bone  is  forced  at  times  into  the 
cancelli  of  the  major  trochanter."  To  the  late  Professor  R.  W.  Smith  of  Dublin  the 
thanks  of  the  profession  are  unquestionably  due  for  having  given  prominence  to  this  class 
of  cases,  and  in  his  valuable  work  on  fractures  in  the  vicinity  of  joints,  published  in 
1850,  will  be  found  nearly  all  that  is  known   about  the   subject. 

I  am  fully  prepared  to  endorse  his  opinions  and  to  agree  with  him  '■  that  all  extra- 
capsular fractures  are  in  the  first  instance  also  impacted  fractures."  I  believe,  moreover, 
that  many  so-called  intra-capsular  fractures  and  all  mixed  forms  are  primarily  of  a  like 
kind,  and  "  that  it  depends  principally  upon  the  violence  with  which  the  injury  has  been 
inflicted  whether  the  neck  of  the  bone  shall  remain  implanted  between  the  trochanters, 
or  whether  these  processes  shall  be  so  completely  .separated  from  the  shaft  of  the  femur 
as  to  allow  of  the  escape  of  the  cervix  from  the  cavity  which  it  had  formed  in  the  reticu- 
lar ti.ssue  of  the  lower  fragment.  If  the  force  had  not  been  very  great,  the  neck  of  the 
femur  remains  wedged  in  between  the  trochanters  and  one  or  both  of  these  processes  are 
split  off  from  the  shaft ;  and  if  the  fibrous  structures  around  the  neck  of  the  bone  and 
trochanters  have  not  been  injured,  these  broken  portions  of  the  trochanters  are  still  held 
firmly  in  their  places  and  the  cervix  does  not  become  loosened  (Fig.  566)  ;  but  if  the 
force  has  been  considerable,  the  impulse  prolonged,  the  bone  in  a  state  of  senile  atrophy. 


886 


OX  FRACTURES. 


or  if,  as  frequently  liappens,  the  patient  in  endeavoring  to  rise  falls  a  second  time,  then, 
under  these  circumstances,  the  trochanters  are  not  only  broken  from  the  shaft  of  the 
femur,  but  are  so  far  displaced  and  separated  from  their  connection  with  the  soft  parts 
that  the  cavity  or  socket,  as  it  were,  into  which  the  superior  fra,i>nients  has  been  received, 
is  destroyed ;  the  impacted  cervix  thus  set  free  no  longer  opposes  the  ascent  of  the 
inferior  fragment,  and  the  case  then  presents  the  characters  of  the  ordinary  extra-cap- 


FiG.  566. 


Fig.  567. 


Impacted  Fracture  of  the  Neck  of  the  Thigh-Bone. 
(From  the  museum  of  my  father,  the  late  Mr.  T.  E. 
Bryant.     Prep.  Guy's  Mus.",  llSV^s.) 


Comminuted  Fracture  of  the  Upper  Fart  of  the  Thigh- 
Bone  from  the  Neck  being  driven  into  the  Shaft.  (Prep. 
119-),  Guy's  Mus., 


sular  fracture  with  great  shortening  of  the  limb  ""  (Fig.  567).  In  fact,  the  ordinary 
fracture  of  the  base  of  the  neck  of  the  thigh-bone  is  primarily  an  impacted  fracture,  the 
impacted  bones  in  some  cases  being  loosened  by  a  second  fall,  in  others  by  excess  of  vio- 
lence I'eceived  in  the  original  accident,  and  in  too  many  by  the  manipulation  of  tlie  surgeon 
in  his  anxiety  to  make  out  the  presence  of  a  fracture  hy  the  detection  of  crepitus.  Indeed, 
this  seeking  for  crepitus  in  cases  of  fracture  .is  a  practice  fraught  with  danger.  In  frac- 
tures of  the  neck  of  the  thigh-bone  it  is  not  only  unnecessary,  because  the  diagnosis  of 
the  case  can  be  made  out  without  it,  but  it  is  unjustifiable,  as  the  attempt  to  find  it  in 
every  case  of  impacted  fracture  is  often  attended  with  irreparable  mischief. 

Symptoms. — The  diagno.sis  of  fracture,  impacted  or  otherwise,  is  a  point  of  con- 
siderable importance,  but  that  of  an  impacted  fracture  is  particularly  so.  since  it  is  not  to 
be  disputed  that  the  recovery  or  degree  of  lameness  of  many  a  patient  depends  upon  a 
correct  appreciation  of  the  value  of  such  symptoms  as  usually  exist  in  this  variety  of 
fracture,  and  that,  too,  in  a  very  critical  period  of  the  case.  Should  an  error  in  diagnosis 
be  made  and  the  case  being  one  of  impacted  fracture  be  overlooked,  violent  manipulative 
efforts  will  probably  be  made  to  reduce  the  supposed   dislocation  or  to  set  the  supposed 

fracture,  or,  what  is  equally  probable. 
Fig.  568.  to  decide  the  question  between  the  pres- 

ence of  the  two  by  the  detection  or 
non-detection  of  crepitus.  As  a  con- 
sequence of  this  violence  the  impacted 
bones  will  to  a  certainty  be  loosened, 
if  not  woi-se  disturbed,  and  the  case 
will  be  changed  from  one  in  which  the 
bones  were  placed  favorably  for  union 
and  recovery  into  another  in  which  a 
very  different  set  of  circumstances  has 
to  be  encountered  and  a  less  favorable 
progno.sis  has  to  be  given. 

Happily,    however,    the    diagnosis 
of  these  cases  is  not  difficult,  and  the 
symptoms   that  indicate  the  presence 
of  an  impacted  or  non-impacted  frac- 
Figure   showing  how  the  Trochanter  of  the  Fractured  Bone  is   ture    are    fairly    characteristic.       Those 
Drawn  Upward  nearer  the  Anterior  Superior  ."^pine  of  the  Ilium.       „  ,.        *^  .  ^    ^    £■       ^ 

A,  Normal  length  of  ba.se  of  ilio-femoral  triangle  (Fig.  569).  B,  ot  an  ordinary  nou-impactecl  tracture 
Shortened  base  of  ilio-femoral  triangle.  C,  Horizontallevel  of  „f  ^\.a  rippl-  nf  tlio  tliio-Ti  Vinnp  in  anv 
fractured  bone.    D,  Horizontal  level  of  sound  bone.  ^^   ^  .^    ^^^^    "'   ^"^     , .  ^       .     ,.  ^• 

position  are  some  slight  indirect  or 
violent  direct  force  ;  a  slxortenincj  of  the  limb  from  one  to  two  and  a  half  inches  ;  rotation 
outuyrrd  of  the  limb,  with  eversion  of  the  foot  from  mere  gravity  ;  inability  to  ravie  the 


I'liACTi'iiEs  or  Tin:  i.owiai  ExrnF.Mirv 


887 


llnth  on  tin*  part  of"  tlu'  |iali('iit,  Itut  jin-atcr  iiiovi-iiifiit.s  of  tlic  liiiili  l»y  the  Mirj^tion's 
haiul.s  ;  nin/Zin;/,  ai-conliii;:;  to  tin;  cliaraotcr  of  loicc  t-inployc-il  ami  (iiiic  after  iiijurv  ",  j"tin 
and  oi'i-asioiial  ntfiifus.  In  rafe  ca.sfs  of  iioii-iiiipaclcil  frartiin-  of  I  lie  m-ck  the  fo<it  may 
lie  inverted  and  the  thij;h  even  flexed.  Those  of  an  impaeled  IVaeture  are  a  hlow  or 
/<///  itfiDii  thr  frnr/ninfrr,  followed  hy  u  more  or  less  complete  loss  uf  p<ni:cr  in  tin:  limb; 
sliDiti  itimj  to  the  extent  of  half  an  ineh  or  one  inch  ;  a  jLad,  rctrttil,  invirfrif,  or  Kfr<iii//tt 
]iosition  of  the  foot,  which  moderate  extension  will  nnf  rectify:  and  when  the  impaction 
is  jfreat,  an  appnjxiination  of  the  <j;reat  trochanter  to  the  median  line  of  the  Ixjdy  (Fig. 
5()S).  The  head  of  the  hone  will  rotate  in  the  aeetahnlnm.  and  the  trochanter  with  it, 
the  rotation,  however,  of  the  trochanter  taking  place  through  an  arc  of  a  circh;  of  which 
the  head  nf  tlic  hone  is  the  centre,  instead  of  ujion  the  axis  of  the  shaft,  as  in  detaclutd 
fracture  of  the  neck.  There  will  he  imlistinct  or  inj  crepitus.  ].,it(;al  pain  will  always  be 
felt  on  pressure  behind  the  trochanter,  and  local  thickening  within  a  few  days  of  the  acci- 
dent. 

When,  iVnni  the  direction  id'  the  I'orce  applied  to  the  troehaiitt-r.  t\ie  j>'js/r,i>/r  wall  of 
the  neck  is  driven  into  the  inter-trochanteric  line,  the  limb  will  Ix-  rotated  outward  and 
the  foot  rrt>rt>'<f ;  and  when  the  (inferior  wall  is  driven  into  the  bone,  there  will  be  invention 
of  the  limb.  The  former  I'orm  of  accident  is  far  more  common  than  the  latter,  on  account 
of  the  greater  thinness  of  the  ])osterior  wall. 

To  make  out  the  existence  of  shortening  of  the  neck  of  the  thigh-bone  and  its  amount, 
Nelaton's  line  is  most  inconvenient,  since  it  necessitates  the  semi-rotation  of  the  patient 
over  toward  the  sound  side,  and  consequently  it  includes  the  risk  of  causing  displacement 
of  the  bones.  My  own  test-line  has  no  such  objection  and  can  be  applied  to  the  patient 
in  the  horizontal  posture.  I  have  used  it  for  many  years  and  found  it  of  great  value ; 
indeed,  as  a  proof  of  its  use  I  may  add  that  forty-two  consecutive  cases  of  fracture  of 
the  neck  of  the  thigh-bone  admitted  into  my  wards  to  the  end  of  1883  (the  average  age 
of  tlie  patients  being  seventy)  left  the  hospital  with  union  of  the  broken  bones  and  use- 
ful limbs.  Only  one  patient,  ;^t.  79,  died,  and  she  did  so  witli  the  fracture,  though  not 
from  it,  but  from  sloughing  of  the  skin  in  her  lumbar  region  from  injury  sustained  at  the 
time  of  the  accident.  In  two  oidy  of  the  forty-two  ca.ses  was  there  any  bedsore,  and 
these  gave  no  trouble.  All  were  treated  with  the  double  splint  (Fig.  573).  The  diag- 
nosis of  all  these  cases  had  been  made  by  means  of  the  test-line  I  now  describe,  and  with 
the  gentlest  manipulation  {Lancet^  January  22,  187G). 

For  purposes  of  demonstration  I  have  described  it  as  the  base  of  the  ilio-femoral 
triangle  (C  B,  Fig.  5G9),  the  two  sides  of  the  triangle  being  made  up  of  two  lines  drawn 
from  the  anterior  superior  spinous  process 
of  the  ilium,  one  of  them,  A  C,  being  ver- 
tical and  traversing  the  outside  of  the  hip 
to  the  horizontal  plane  of  the  body,  and  the 
second,  A  B,  impinging  on  the  tip  of  the 
trochanter  major  and  c(jrresponding  in  the 
normal  conditi(»n  of  the  hip-joint  to  the  an- 
terior half  of  Nelaton's  test-liue  for  dislo- 
location  of  the  head  of  the  femur  back- 
ward. 

The  test-line  C  B  for  fracture  or  short- 
ening of  the   neck  joins  the  two  at  rlaht 

„      7°  j.„xu„  *■      1  r  1        i.      J    i?  The  Ilio-Femoral  Rectangle,  A  B  r.    r  B,  test-line  for  frao- 

anyles  to  the  vertical  line  and  extends  from  tare  or  shortening  of  the  neck  of  the  thigh-bone. 

it  to  the  trochanter.     Any  shortening  of 

this  line,  on  comparing  it  with  the  same  taken  on  the  uninjured  side,  indicates  with  pre- 
cision a  shortening  of  the  lu'ck  of  the  thigh-bone ;  and  when  the  shortening  has  imme- 
diately followed  an  injury,  fracture  of  the  neck  of  the  thigh-bone,  impacted  or  otherwise, 
is  certain.  Compared  with  this  line,  all  other  measurements  are  uncertain.  By  its  use 
manipulations  of  the  injured  limb  are  rendered  unneces.sary.  For  practical  purposes  the 
vertical  line  A  C  and  the  test-line  C  B  are  alone  reiiuired.  To  coni]iare  the  two  sides  of 
the  !)ody  it  is  necessary  to  see  tliat  the  pelvis  is  .straight. 

-"^ly  friend  Mr.  H.  Morris  has  likewise  a  ready  method  of  measuring  those  parts, 
will -h  he  calls  the  bi-trochanteric  measurement.  (See  Ilofnies's  S^sf.,  vol.  i.  3d  ed.  p. 
1003). 

The  symptoms  thus  described,  taken  as  a  whole,  may  be  looked  upon  as  pathogno- 
monic of  an  impacted  fracture  ;  for,  although  there  are  other  injuries  to  the  hip-joint 
which  may  give  rise  separately  to  manv  of  the  symptoms  detailed,  there  are  none  in 


Fig.  569. 


888 


ON  FRACTURES. 


which  all  or  most  are  found  combined.  There  is  no  injury  to  the  hip-joint  in  which  the 
head  of  the  femur  rests  and  can  be  made  to  rotate  in  the  acetabulum,  and  in  which  imme- 
diate shortening  is  ever  found,  with  the  exception  of  a  fracture,  and  there  is  no  form  of 
fracture  that  occurs  under  like  circumstances,  with  the  exception  of  the  impacted,  that  is 
not  accompanied  by  crepitus  that  can  be  readily  detected,  with  complete  ever.^ion  of  the 
foot,  marked  shortening,  and  loss  of  power  over  the  limb. 

These  points  are  well  brought  out  in  a  paper  in  the  Med.  Times  of  1869.  in  which  I 
gave  a  careful  analysis  of  fourteen  cases. 

When  sudden  increase  in  the  amount  of  shortening  takes  place  some  days  after  an 
injury  to  the  hip.  the  separation  of  the  impacted  bones  and  the  drawing  up  of  the  lower 
fragment  should  be  suspected  ;  and  when  some  gradual  shortening  follows,  it  signifies  the 
absorption  of  the  injured  neck  of  bone. 

The  eversion  of  the  limb,  as  found  in  the  non-impacted  fracture,  is  due  to  the  simple 
weight  of  the  broken  limb,  aided  by  the  action  of  the  powerful  external  rotator,  and  pos- 
sibly of  the  adductor,  muscles.  The  po.sition  of  the  limb  in  the  impacted  fracture,  whether 
slightly  everted,  straight,  or  inverted,  is  determined  by  the  impaction  of  the  anterior  or 
posterior  wall  of  the  neck,  and  by  the  fact  that  the  foot  will  be  fixed  by  the  impaction  in 
the  position  in  which  it  existed  at  the  time  of  the  accident. 

In  non-impacted  fracture  of  tc.3  narrow  end  of  the  neck,  or  true  intra-capsular  frac- 
ture, there  is  usually  less  shortening  than  in  the  non-impacted  fracture  of  the  base,  this 
symptom  depending  in  both  of  these  cases  upon  the  amount  of  separation  of  the  fibrous 
covering  of  the  broken  bone.  In  the  former  crepitus  is  also  less  distinct.  In  both  these 
forms  the  shortening  will  be  made  to  disappear  by  extension,  whilst  in  the  impacted,  in 
any  of  its  varieties,  no  such  efiect  will  be  produced  by  ordinary  force. 

It  can  only  be  by  carelessness  that  a  contused  hip  is  mistaken  for  a  fractured  thigh, 
impacted  or  otherwise.     I  have,  however,  known  this  error  to  be  committed. 

•■  The  practical  importance  of  readily  identifying  this  fracture."  writes  Bigelow  in  his 
valuable  monograph  on  the  hip,  ••  lies  in'  the  fact  that  its  progress,  as  regards  both  time 
and  good  union,  is  in  general  more  favorable  than  that  of  the  unimpacted  fractures:  that, 
though  it  is  a  comparatively  common  and  disabling  accident,  it  may  exhibit  little  deform- 
ity; and  lastly,  that  the  object  of  extension  in  its  treatment  is  to  steady  the  limb,  and  not 
to  draw  it  down." 

Treatment. — If  it  were  as  distinctly  understood  as  it  should  be  by  all  students  and 
practitioners  that  a  fracture  of  the  neck  of  the  thigh-bone  can  be  diagnosed  without  seek- 
ing for  crepitus,  that  all  but  the  gentlest  manipulation  of  an  injured  hip  is  likely  to  prove 
injurious,  and  that  any  attempt  to  elongate  the  limb  by  forcible  extension,  to  flex  it,  or 
to  rotate  it  with  the  view  of  restoring  it  to  its  natural  position  is  likely  to  be  followed  by 
a  breaking  up  of  the  impacted  bones,  and  consequently  by  irreparable  injury,  the  treat- 
ment of  these  cases  would  be  as  satisfactory  in  its  results  as  it  is  simple  and  our  work- 
houses would  be  occupied  with  fewer  cripples.  If.  moreover,  it  was  recognized,  as  it 
should  be.  that  many  intra-capsular  and  all  extra-capsular  fractures  unite  when  rightly 
treated,  every  case  of  fracture  of  the  neck  of  the  femur,  impacted  or  non-impacted,  intra- 
or  extra-capsular,  in  the  young,  middle-aged,  or  old.  would  be  treated  as  if  repair  and 
union  were  sure  to  take  place  if  the  parts  are  kept  at  rest  and  in  apposition,  and  in  the 


Fig.  570. 


Fio.  571. 


Impacted  Intra-<"apsular  Fracture  of  the  Xeck  of 
1  enuir  Repaired.  (Ca-e  of  the  late  Mr.  T.  E. 
Brvant.     Prep.  118750,  Guv's  Mus.; 


Doubly  Impacted  Fracture 
of  the  Xeck  of  the  Thigh- 
Bone. 


large  proportion  of  cases  the  hopes  of  the  surgeon  will  not  be  disappointed.  (  Vide  statis- 
tics of  my  own  cases,  p.  887.)  In  the  purely  intra-capsular  fracture  union  may  take 
place,  osseous  in  many  cases  (Fig.  570),  fibrous  in  more  (Figs.  565  and  57-4).     In  a  few 


riiAcrritEs  of  riii'.  i.owi'.it  f.xtiif.mity. 


889 


there  will  lie  ruuie,  owiiij;  to  a  total  sepunitioii  of  the  liead  of  the  bone  from  its  attach- 
iiieiits  or  to  the  feehh;  piiwer  or  ape  ol"  the  patient,  or  because  the  broken  fragment 
receives  too  little  nourishment  to  allow  of  suDicieiit  reparative  material  bein;r  poun-il  out. 
or  because  the  fractured  bones  have  not  been  kept  sufficiently  at  rest  and  in  apposition. 
I'ndcr  these  circumstances  the  head  ol'  the  femur  will  be  loose  in  the  acetabulum,  with 
its  broken  surface  smoothed  into  a  cup-shaped  cavity,  where  tlic  r<»und(.'<l  cud  df  the 
broki'u   neck   (d'  the  femur  plays  as  in  a   false  joint. 

In  the  impacti'd  fractures  union  ought  to  be  looked  for  if  the  broken  frajrnient.s  are 
left  aloiu'  and  not  loosened  by  a  caniless  or  too  curious  manipulation. 

In  the  non-impacted  extensi(»n  is  to  l)e  more  thoroughly  employed.  The  best  splint 
for  tliese  purpo.ses  is  my  double  one  (Fig.  'u?,).     By  it,  in  the  non-impacteddrac-turc.  the 

Fig.  572. 


Gurdon  Buck's  Method  of  applying  Exton.sion  in  a  Case  of  Fracture  of  the  Neck  of  the  Thigh-Rone. 

limb  should  be  brought  down  to  a  level  with  its  fellow  and  maintained  there  by  means 
of  the  elastic  extension  pulley  ;  by  its  means  both  limbs  are  kept  parallel,  no  pressure  is 
applied  over  the  trochanters,  abduction  or  adduction  of  the  limb  is  prevented,  and  exten- 
sion is  maintained.  With  this  splint  no  perineal  band  is  required  if  the  foot  of  the  bed 
is  raised  two  or  three  inches. 

In  the  impacted  fracture  enough  extension  is  required  to  neutralize  muscular  action, 
but  no  more. 

Gurdon  Buck's  method  of  applying  extension  to  the  limb  by  means  of  weights  has 
found  great  favor  of  late  years  in  America  and  this  country,  and  is  doubtless  very  good 
and  simple,  the  counter-extending  force  being  applied  by  means  of  a  perineal  band  of 
india-rubber  tubing  fastened  to  the  head  of  the  bedstead  or  splint,  while  the  limb  is 
steadied  by  means  of  long  sand-bags  applied  laterally,  or  short  thigh-splints  (Fig.  572). 
This  plan,  however,  has  the  disadvantage  of  not  preserving  sufficient  immobility  of  the 
broken  bones,  and  ought,  therefore,  to  be  employed  only  in  conjunction  with  the  lone 
splint. 

Sir  A.  Cooper's  plan  of  placing  the  patient  on  a  double  inclined  plane  has  few  advan- 
tages when  union  is  to  be  looked  for,  and  even  the  broad  well-padded  belt  which  he 

Fig.  573. 


Double  Splint  for  Fracture  of  the  Shaft  or  Xeck  of  the  Thigh-Rone  and  Hip  Disease. 

applied  around  the  pelvis  in  order  to  keep  the  broken  fragments  closely  together  cannot 
be  recommended  ;  still  where  the  long  splint  cannot  be  worn  the  inclined  plane  may  be 
substituted. 

When  the  necessary  confinement  to  the  supine  position  cannot  be  tolerated  and  bed- 
sores appear,  it  may  be  necessary  to  give  up  the  long  splint,  and  under  these  circum- 
stances it  is  wise  to  fix  the  hip,  pelvis,  and  thigh  in  some  strong,  immovable  casing 
similar  to  that  employed  in  hip  disease  (Fig.  623),  the  limb  being  kept  extended  by 


890 


Oy  FRACTURES. 


means  ot 

Fig.  o74 


weights  attached  to  the  foot  during  the  setting  of  the  material.     The  casing 

mav  be  of  plaster  of  Paris,  leather, 


Fig. 


».'• 


-  =^ 


y 


PYacture  of  the  Xeek  of  the 
Thigh-Bone  within  the  Cap- 
sule"; Repair  of  Fracture  Vjy 
Means  of  Bone.  Fibrous  Tis- 
sue, and  Fibro-Cartilage :  Ab- 
sorption of  the  Xeek  of  the 
Bone.  (Prep,  removed  from 
woman  aet.  60  who  had  re- 
ceived the  injury  five  years 
before..! 


Femur  of  the  Opjjosite  Side, 
showing  the  -Amount  of  Bone 
AbsorbSi. 


felt,  perforated  zinc,  or  flannel,  with 
starch  or  gum  and  chalk. 

To  allow  the  patient  to  get  up 
without  any  apparatus  is  not  only  to 
give  up  all  hope  of  a  cure  by  union, 
but  to  add  to  the  local  irritation,  as 
the  broken  fragments  will  grate 
,,  ,v  -  .  :y/     against  one  another  and   irritate  the 

w      ,', .  ,1  ''  ' "  '■       soft  parts  around,  often  causing  se- 

>  V    V\L  •  ■'  '  .'--f/  ygpg  local  and  constitutional  disturb- 

ance. Under  all  circumstances,  how- 
ever, immobility  of  the  broken  bone 
is  to  be  ensured. 

Interstitial  absorption  of 
the  neck  of  the  bone  is  some- 
times met  with  after  fracture,  and  in 
Fig.  574  the  fact  is  well  illustrated, 
the  neck  of  the  bone  having  almost 
entirely  disappeared,  as  will  be  seen 
at  once  on  comparing  a  section  of  the  injured  bone  with  that 
of  the  uninjured  from  the  same  subject  (Fig.  275).  It  is  said 
also  to  take  place  after  a  contusion  without  any  fracture  in 
osteo-arthritis  :  how  far  it  may  occur  otherwise  is  an  open  ques- 
tion. My  own  impression  is  that  in  all  such  cases  some  fracture  existed,  though  it  is  diffi- 
cult to  prove  the  truth  of  such  an  opinion.     The  question  requires  further  elucidation. 

Fractures  through  the  trochanter  occasionally  occur— Sir  A.  Cooper  describes 
them  as  oblique  fractures  not  implicating  the  neck  of  the  bone — and  can  be  made  out  by 
the  immobility  of  the  lower  portion  of  the  bone  whilst  the  upper  part  is  fixed,  and  by 
the  other  signs  of  fracture,  such  as  crepitus,  etc.  They  should  be  treated  like  fractures 
of  the  neck. 

Separation  of  the  epiphysis  of  the  head  of  the  bone  has  been  described. 

South  has  recorded  such  cases  in  his  CIieh')is'.<  Surgeri/.  and  Post  of  New  York  in  the 
Xiiv:  York  Journal  (vol.  iii.).  but  no  preparation  exists  to  deuion.strate  the  fact.  It  is 
doubtless  possible  in  the  young,  and  would  be  known  by  some  such  symptoms  as  those 
of  fracture  of  the  neck,  crepitus  being  exchanged  for  what  South  calls  a  '•  distinct  dummy 
sensation  "  on  rotating  and  extending  the  limb.  As  a  consequence  of  disease  it  will  be 
described  in  a  later  chapter. 

Separation  of  the  epiphysis  of  the  trochanter  major  is  a  more  definite 

accident,  and  doubtless  has  occurred.     Sir  A.  Cooper  recorded  a  case  which  Mr.  Aston 

Key  had  observed,  and  the  diagnosis  was 
Fig.  576.  Fig.  577.  verified  after  death.     In  it.  however,  the 

''  detached    fragment    was    not    displaced, 

but  held  in  position  by  means  of  its 
fibrous  and  tendinous  coverings ;  the 
separation  was  the  result  of  direct  local 
violence  :  abduction  of  the  limb  caused 
great  pain,  but  all  other  movements 
were  allowed.  The  preparation  exists 
in  the  Guy's  Museum  (1105)  and  is 
here  figui-ed  (Fig.  576).  A  like  case 
occurred  in  the  practice  of  the  late  Mr. 
Poland,  at  Guy's,  in  1871,  which  through 
his  kindness  I  saw.  It  occurred  in  a  boy 
fBt.  12  from  a  direct  blow,  and  was  cha- 
racterized by  a  projection  and  thickening 

of  the  trochanter  (Fig.  577).    Similar  instances  have  also  been  published  by  Dr.  Roddick 

of  Montreal  (^Cannda    Med.  aud  Surg.  Jounial.  November,  1875),  Mr.  McCarthy  (Pafh. 

Trans..  1874).  and  Agnew  in  his  Surgerr/. 

Fracture  of  the  Shaft  of  the  Femur. — This  may  take  place  in  any  part, 

but  is  more  common  in  the  centre  than  elsewhere,  and  as  a  consequence  of  indirect  vio- 


Fracture  of  the  Epiphysis  of  the  Major  Trochanter. 
Mr.  Aston  Key's  case.  Appearance  during  life. 

(Prep.  1195.  Guy's  Mus.i  (Mr.  Poland's  case.) 


rii.\rrriu:s  or  riii:  L<i\\i:n  i:\"nu:Mrry. 


«91 


leiit'i' ;  it  niay  nccur.  liiiwcvor,  as  a  result  nl"  liiicct  I'nrcc,  and  iiion;  rarely  of  muscular 
action.  Kroin  this  cause  I  have  seen  it  i'nnu  the  swiii;;iiijr  ol"  the  linih  ov<;r  the  side  of  a 
cart  ill  the  act  of  ilesceiidiiif^.  and  in  an  e|iilc|»tic  |)atient  from  tiie  .spasm  of  the  muscles 
with  the  patient  in  Itcd.  1  have  known  it  also  to  take  place  IVoin  the  same  cause  when 
t-ancer  ol'  the  hone  existed. 

The  fracture  may  he  fr<insiersi\  i>//fi(/iir  in  any  direction,  rv77<Vv//,  t/i'iifutnf,  rniiimiinit' ,1^ 
or  iiiifiiiiftii,  the  nature  of  the  force  and  its  direction  deterininin^  these  points.  A  sharp 
lilow  is  likclv  to  lie  followt-d  l»y  a  transverse  fracture  ;  a  crushin<^  force  by  a  comminuted 
one;  an  imlircct  fracture  prohahly  will  he  nl)li(|ue,  aceordin;:  to  the  natural  heiid  in  the 
lower  jiart  of  the  limit.  In  the  upper  third  the  hone  may  he  broken  obliijut,'  I'roin  above 
ami  in  front  downward  and  outward,  and  from  impaction  id'  the  lower  extremity  into  the 
upper  the  latter   fratiincnt    mav  be  coniminutrd.  the   Ixme   splitting  .secondarily   upward 

l-'i(i.  57 «. 


Impacted  Fracture  of  the  Shaft  of  the  Femur  produced  by  a  Fall  upon  the  Knee  in  a  Man  at.  83. 

into  the  neck.  Dr.  E.  II.  Bennett  of  the  Dublin  I'niversity  has  written  an  intere.sting 
paper  on  this  form  of  fracture  (Brif.  Mxl.  .Iniirn.,  June  2(),  1880).  In  the  middle  of  the 
bone  a  lateral  obli(|uity  is  the  most  common  ;  in  the  lower  third  an  oblit|uity  from  behind 
forward.  Fractures  may  also  be  double  in  the  same  bone,  or  compound.  In  the  ca.se 
illustrated  (Fig.  578)  the  fracture  was  impacted,  the  upper  fragment  having  been  forced 
into  the  hollow  of  the  lower,  which  it  split.  It  occurred  in  a  patient  under  my  care  in 
1S7G,  ;i}t.  88,  from  a  fall  down  an  area  upon  his  knee.  The  man  died  on  the  twenty- 
ninth  day,  from  kidney  disease  (Pafli.  Soc.  Traiix.,  vol.  xxix.,  1878). 

The  displacement  that  takes  place  turns  much  upon  the  line  of  the  obliquity  and  the 
position  of  the  fracture.  In  fracture  below  the  lesser  trochanter  the  upper  fragment  is 
prone  to  be  drawn  forward  by  the  action  of  the  psoas  and  iliacus  muscles  and  outward  by 
the  external  rotators.  In  fractures  above  the  condyles  the  lower  fragment  is  apt  to  be 
drawn  backward  Ity  the  unantagonized  action  of  the  gastrocnemii  muscles.  In  fractures 
of  the  centre  of  the  shaft  the  deformity  dej)ends  on  the  line  of  oblitjuity.  Rotation  out- 
ward of  the  lower  fragment  is  found  in  nearly  every  case. 

DiAONosLS. — There  i.s  usually  no  difficulty  in  diagnosing  a  fracture  of  the  shaft,  the 
following  symptoms  being  usually  present:  A  fall  or  injury,  followed  by  loss  of  power  in 
the  limb;  shortening,  which  extension  can  rectify;  deformity,  probably  angular ;  extra 
mobility  of  the  lower  part  of  the  injured  limb;  crepitus;  and  probably  the  projection  of 
one  end  of  a  fragment  with  eversion  of  the  foot.  When  the  fracture  is  transverse,  the 
shortening  will  rarely  be  marked ;  when  it  is  oblique,  the  direction  of  the  angular  deform- 
ity often  indicates  the  line  of  the  obliquity. 

In  young  children,  where  the  fracture  is  incomplete,  shortening  with  bowing  of  the 
limb  after  an  accident,  and  an  indistinct  .sensation  of  yielding  on  manipulation,  with  or 
withotit  a  peculiar  crackling  sensation,  indicate  the  nature  of  the  accident. 

Treat.mknt. — The  fragments  having  been  carefully  adjusted  by  means  of  extension 
and  gentle  manipulation,  the  mechanical  treatment  of  these  fractures  consists  in  the  main- 
tenance of  extension  by  means  of  some  applied  force  and  the  complete  rest  of  the  coap- 
tated  bones,  gentle  compression  of  the  aftected  part  sometimes  being  beneficial.  To  assist 
the  surgeon  toward  these  ends  some  antvsthetic  may  be  used  if  the  pain  be  severe  and  it 
is  impossible  by  other  means  to  keep  the  patient  at  rest  and  any  spasmodic  action  of  the 
muscles  interferes  with  the  surgeon's  aims. 

For  many  years  past  I  have  used  no  other  splint  than  the  double  one  seen  in  Figs.  573 
and  620,  and  mo.st  surgeons  who  have  employed  it  once  adopt  it.  It  does  not  shift  from 
its  place,  because  the  interruption  over  the  trochanter  renders  it  comfortable  ;  it  keeps 
the  fractured  limb  still  and  maintains  it  parallel  with  its  fellow :  extension  can  be  care- 
fully and  easily  regulated  by  means  of  the  extension  elastic  pulleys,  and  no  perineal  band 
for  counter-extension  is  needed  ;  the  results,  moreover,  which  have  attended  its  u.se  are 
excellent.     Thus,  out  of  100  cases  consecutively  treated  in  my  wards  with  this  sjdint,  in 


892 


ON  FRACTURES. 


52  there  was  no  shortening,  in  SC  there  wa.s  half  an  inch  or  under,  and  in  12  only  was 
there  one  inch.  Four  other  cases  died  :  1,  aet.  81,  from  senility  ;  1,  aet.  83,  on  the  twenty- 
ninth  day,  from  kidney  disease  ;  1,  set.  40,  from  abscess  of  the  lung,  on  the  twenty-third 
day  ;  and  1,  aet.  45,  from  delirium  tremens,  on  the  eighth  day. 

At  other  schools  other  iueans  are  adopted,  according  to  the  fancy  of  the  surgeon  and 
the  fashion  of  the  school.  Thus,  in  ho.-^pitals  where  the  Scotch  influence  is  great  Listen's 
long  splint  is  the  one  usually  employed,  which  should  extend  well  up  into  the  axilla  and 
several  inches  below  the  foot  (Fig.  579),  without  foot-piece.  It  ought  to  be  well  padded 
and  supplied  with  a  soft  perineal  band,  such  as  a  leather  strap  or  a  piece  of  india-rubber 
tubing.  The  ankle  and  instep  should  be  well  protected  from  pressure  by  cotton-wool  and 
the  retaining  bandage  applied  with  equal  pressure. 

Fig.  579. 


Fig.  580. 


Listen's  Long  Splint,  with  a  Foot-Piece  Attached,  with  Weights  for  Extension,  in  Fracture  of  the  Neck  of  the 

Thigh-Kone. 

Where  the  long  splint  is  employed.  Desault's  splint,  with  a  foot-piece  (Fig.  592),  and 
the  addition  of  a  cross-bar  for  steadiness,  should  be  preferred.  The  splint  may  be  of 
.wood  or  metal  and  made  with  a  slide,  so  as  to  be  adjusted  to  different  patients.  All  long 
splints,  however,  without  an  interruption  over  the  trochanter,  as  seen  in  Fig.  573,  to 
guard  against  pressure,  are  inefficient  and  most  uncomfortable. 

In  fractures  of  the  upper  third,  where  the  upper  fragment  is  apt  to  tilt  forward  and 
be  rotated  outward,  the  double  inclined  plane  is  often  of  great  value.  It  should  be 
employed,  however,  only  when  the  long  splint  fails  to  fulfil  the  objects  the  surgeon  has 
in  view.     It  is  daily  dropping  out  of  use. 

A  splint  full  of  promise  was  introduced  in  1875  into  practice  at  Guy's  Hospital  fFig. 
580)  from  the  Marine  Hospital,  Greenwich,  and  is  still  used  by  some  of  my  colleagues. 
It  is  a  modification  of  one  invented  by  the  late  Dr.  J.  T.  Hodgen  of  St.  Louis.  T'nited 
States  (Treat,  on  Mil.  Sxrrj.,  hy  F.  H.  Hamilton,  1865,  p.  411).  for  gunshot  fracture.?, 
and  is  made  of  galvanized  iron  wire  (No.  2).  In  it  the  injured  limb  may  be  supported 
on  a  piece  of  flannel,  which  is  slung  to  the  iron  rod,  or  upon  pieces  of  bandage.  Exten- 
sion is  kept  up  by  means  of  the  strapping  attaching  the  foot  of  the  injured  limb  to  the 

lower  cross-bar  of  the  splint, 
and  through  the  suspending 
cords  and  pulleys.  •  The 
counter-extension  is  main- 
tained by  the  weight  of  the 
limb  above  the  fracture  and 
weight  of  the  body.  The 
splint,  as  .seen  in  Fig.  580, 
is  most  comfortable  to  the 
patient,  and  an  old  house- 
surgeon,  Mr.  J.  F.  Fry, 
reports  (Guy's  Gazette.^  De- 
cember 11,  1875)  that  out 
of  seventeen  cases  of  frac- 
ture of  the  thigh  consecu- 
tively treated  with  the 
\  splint,  the  average  amount 
of  shortening  was  less  than 
half  an  inch,  and  that  in 
six  cases  there  was  not  any. 
I  have  found,  however,  after  _ 
a  lengthened  trial  of  this 
splint,  that  a  much  larger  amount  of  callus  is  thrown  out  about  the  seat  of  fracture  than 
is  met  with  when  the  bones  are  kept  perfectly  at  rest,  as  they  are  by  the  double  splint 


Dr.  J.  Hodgen 's  Suspension  Splint,  as  used  at  Guy's. 


FiLirrnn.s  <>]■■  jjij-:  i.owkii  kxtukmity. 


893 


(Fij;.  f)";?),  and  cdiicIuiIi'  fmin  this  fact  that  thuro  is  iiiori-  mobility  of  the  ends  of  the 
})r()keii  l)()iu'  hy  the  oiu'  form  of  tn>atm<-tit  than  liy  tlie  otlier.  I'ndor  such  circumstuiiceit 
I  have  discarded  llodj^cii's  splint  in  the  treatment  of  fractures  <jf  tlie  thifjh  for  the 
doulih'. 

Ilodiren's  splint  >liuiil(l  nut  he  confonndiil  with  Natliaii  Smiths,  which  is  made  of 
wire  applied  to  the  niitrrior  anrjucc  of  the  lVaetiire<l  linih.  which  is  suspended  to  it  hy 
rollers  (  KiL'.  'j'.tS). 

When  the  fracture  is  compound,  an  interrupted  splint  may  he  employed.  In  addition 
to  the  ion-:  splint,  short  additional  splints  applied  in  front,  or  at  the  inner  side  r)f.  or 
behind,  the  thi<rh.  as  the  want  of  the  individual  case  may  su<xjiest,  are  of  frreat  value  to 
ensure  jrreater  steadiness  of  the  broken  bone.  In  no  case  sliould  the  seat  of  fracture  be 
covered  in.     The   bandage   should   stop   brlow.  and   if  nece.s.sary  recommence  above,  it. 


Fig.  581. 


/■fj'.rtfti  1 1  mil 


liiclifi  riibirr 
Accumulator 


Rcji  t  with    C,  nt  f nit  en  i  r  /•.  r 
ExCfnsion    cf  iiffected    limb 

Mr.  Campbell  de  Morgan's  .Splint,  with  Elastic  Extension. 


To  prevent  the  bandage  slippiiiir  after  it  lias  been  applied,  it  is  a  good  plan  to  give  it  one 
coating  of  paste  or  glue. 

Many  modifications  of  the.se  means  might  be  mentioned.  Thus.  Paget  has  very 
generally  employed  Busks  long  splint,  in  which  a  joint  exists  opposite  the  hip,  which 
enables  tlie  patient,  after  union  has  taken  ])lace,  to  sit  up  without  affecting  the  thigh- 
bone. The  late  Mr.  C.  de  Morgan  of  the  Middlesex  Hospital  applied  the  extension  to 
the  fractured  limb  by  means  of  a  force  carried  from  the  foot  through  a  pedal  cross-bar 
to  a  long  splint  applied  to  the  opposite  limb  (Fig.  581). 

Sir  W.  Fergus.son  was  wont  to  apply  his  counter-extension  from  a  strong  stay  of  jean, 
carefully  fitted  to  the  upper  third  of  the  opposite  thigh,  from  which  a  band  extended 
in  front  and  behind  to  the  upper  end  of  the  splint,  thus  doing  away  with  the  perineal 
pad. 

During  the  application  of  the  long  splint  steady  traction  .should  be  maintained  on  the 
injured  limb  by  a  competent  a.ssistant.     When  muscular  spasm  is  severe,  .some  surgeons 
have  advised  temporary  pressure  on   the   femoral   artery  in   the   groin. 
It  is  said  to  .stop  the  spasm  in  all  cases;  and  whenever  I  have  tried  it. 
it  answered  well. 

Vertical  Extension. — In  infants  and  children  under  three 
years  of  age  fractures  of  the  thigh  are  treated  with  difficulty,  for  anv 
immovable  apparatus  is  constantly  dirtied  from  urine,  feces,  etc.,  and 
re(|uires  to  be  changed,  and  the  good  that  would  otherwi.se  be  experi- 
enced is  thus  neutralized.  On  this  account  Paget  and  Callender  have 
within  the  last  few  years  treated  many  cases  of  fracture  of  the  thigh 
in  children  without  splints,  all  apjiaratus  being  dispensed  with.  '■  the 
child  being  laid  on  a  firm  bed,  with  the  broken  limb,  after  .setting  it. 
bent  at  the  hip  and  knee,  and  laid  on  its  outer  side  '  (Sf.  Bnrtli. 
Hosp.  Rvp..  18(57  '.  I  do  not  recommend  this  practice,  but  would 
advise  instead  that  the  injured  limb  of  the  child,  with  the  sound  one. 
be  flexed  at  a  right  angle  with  the  pelvis,  fixed  by  some  light  splint 
and  hoisted  upward  to  a  cradle,  hook,  or  bar  above  the  bed  TFig.  5S2). 
By  these  means  the  weight  of  the  body  acts  as  a  con.stant  counter-extend- 
ing force,  the  child  can  be  well  looked  to  for  purpo.ses  of  cleanliness,  and  -t^ 
a  irood  result  may  be  expected.  Kiimmell  of  Hamburg  (BerUn  Klin.  Fracture  of  the  Ftinui 
Worh..  Xo.  4.  1882)  holds  this  method  of  vertical  extension  in  frac-  veS/ixtSn." 
tured  thighs  in  infants  to  be  the  best.  He  .says,  though  wronglv.  it 
was  first  tried  by  Sehede  of  Berlin  in  1S77.  and  publi.shes  a  list  of  twenty-eight  cases  so 
treated  in  infants  under  two  years.  In  justice  to  Guy's,  however.  I  must  state  that  I 
began  this  form  of  practice  at  Guy's  Ho.spital  in  1870.  and  have  before  me  a  list  of 
twenty-eight  cases  so  treated  since  in  children  varying  from  eight  months  of  age  up  to 
five  years ;  later  than  that  age  I  prefer  the  double  splint. 


894 


ON  FRACTURES. 


Fig.  583. 


Splints  of  gutta-percha,  felt,  or  leather  may  he  iised  with  the  weight-s  when  they  can 
be  applied,  some  immovable  apparatus  being  adjusted  after  the  second  week  ;  indeed,  in 
some  cases  this  immovable  apparatus  may  be  applied  at  once,  care  being  taken  that  the 
limb  is  kept  well  extended  during  its  application  and  setting.  The  Bavarian  flannel  splint 
is  the  best  (Fig.  536). 

In  adults,  also,  after  the  fourth  week,  this  same  immovable  apparatus  may  be 
employed  with  advantage,  the  patient  gaining  greater  freedom.  Some  surgeons  think 
so  well  of  this  plan  as  to  advise  its  use  in  fracture  of  the  thigh  from  the  very  first. 
Erichsen,  its  ablest  advocate,  says  (Science  and  Art  of  Surgeri/,  p.  225)  :  "  The  starched 
bandage  may  be  employed  in  most  cases.  The  limb  should  be  evenly  and  thickly  envel- 
oped in  a  layer  of  cotton  wadding ;  a  long  piece  of  strong  pasteboard  about  four  inches 
wide,  soaked  in  starch,  must  next  be  applied  to  the  posterior  part  of  the  limb  from  the 
nates  to  the  heel.  If  the  patient  be  very  muscular  and  the  thigh 
large,  this  mu.st  be  strengthened,  especially  at  its  upper  part,  by 
having  slips  of  bandage  pasted  upon  it ;  two  narrower  strips  of 
pasteboard  are  now  placed,  one  along  each  side  of  the  limb,  from 
the  hip  to  the  ankle,  and  another  shorter  piece  on  the  fore  part  of 
the  thigh.  A  double  layer  of  starched  bandage  should  now  be  ap- 
plied over  the  whole  with  a  strong  and  well-starched  spica  (Fig. 
583)  ;  it  should  be  cut  up  and  trimmed  on  the  second  or  third  day 
and  then  reapplied."  With  such  an  apparatus  Erichsen  has  treated 
many  fractured  thighs,  in  both  adults  and  children,  without  confine- 
ment to  bed  for  more  than  three  or  four  days,  and  without  the 
slightest  shortening  or  deformity  being  left.  The  points  to  be  espe- 
cially attended  to  are  that  the  back  splint  be  very  strong,  at  the 
upper  part  especially,  and  that  the  spica  be  well  and  firmly  ap- 
plied, .so  that  the  hip  and  the  whole  of  the  pelvis  be  immovably 
fixed. 

Fractures  of  the  condyles  necessarily  involve  the  joint, 
and  these  may  be  transverse,  oblique,  or  vertical  (Fig.  584).  In 
subjects  under  twenty-one  tlte  loixrv  epiphyaU  mny  he  stepdra ted  from 
the  shaft,  thus  simulating  a  transverse  fracture  (Fig.  585)  or  a  dislo- 
cation (Fig.  521). 

These  cases  are  serious  on  account  of  the  joint  complication,  as  some  stiffness  of  the 
Joint  generally,  but  not  always,  follows  this  result,  depending  upon  the  amount  of  inflam- 
matory action  that  takes  place  after  the  injnry.      When  the  head  of  the  tibia  is  fractured 

into  the  joint,  the  same  observations 
are  applicable.  In  these  cases  the  pos- 
terior splint,  as  suggested  by  Macln- 
tyre  (Fig.  597),  is  probably  the  best, 
the  knee  being  slightly  flexed.  When 
joint  complication  exists,  the  applica- 
tion of  ice.  or  probably  some  leeches, 
may  be  required. 

In  exceptional  instances  the  upper 
fragment  of  bone  is  driven  into  the 
lower,  thereby  giving  rise  to  an  im- 
pacted fracture.  These  cases,  like 
other  impacted  fractures,  generally  do 
well  by  simple  rest. 

In' all  eases  involving  joints   passive  motion    should   be 
Fraftureof  the  >haft  of  the  Femur,  allowed  at  the  end  of  five  or  .«ix  weeks. 

Nathan  Smith  of  New  York  advocates  the  use  of  an  an- 
terior splint  composed  of  a  single  piece  of  iron  wire  of  the 
thickness  of  a  No.  11  catheter,  which  is  carefully  bent  to 
the  inequalities  of  the  limb  and  fastened  to  it  by  means  of  strapping  and  bandages,  the 
limb  being  subsequently  suspended  to  the  ceiling  by  a  cord  connected  with  the  wire 
above  and"^  below  the  knee,  extension  being  made  through  this  cord,  and  the  counter- 
extension  by  so  raising  the  foot  of  the  bed  as  to  tilt  the  body  toward  its  head  (Fig. 
598). 

In  fractures  of  the  lower  third  above  the  condyles,  where  the  gastroc- 

nemii  muscles  tend  to  draw  the  lower  fragment  backward  into  the  popliteal  space,  some 


From  Erichsen. 


Fig.  584. 


Separation  of  the  Ki)ii>hy- 
>i>  (Prep.  llilU-i'',  Guy's 
Mus.j 


with  Longitudinal  Fissure  through 
the  Condyles  into  the  Knee-joint. 
(Prep.  12()0,  (iuv'sMus.i 


rn.irrrnr.x  of  tiii:  lower  i'xtiiemity.  895 

Pirjrc(nis  jm-fi-r  tlie  use  of  the  iiidiiifd  jdaiu  .  ami  wlit'ic  the  bones  cannot  he  otliorwise 
kejit  in  aji|Misiiion  it  is  jnolcilily  a  sound  |iraetice.  liut  what  I  Vjelieve  to  he  a  hetter  one 
is  tlic  (livi.-i<in  (<1"  ihe  tendo  Achillis  and  tlie  suhseijuent  use  of  the  h»n<;  ihjuhle  splint. 
The  divisinii  of  the  tendon  jiaralyzcs  the  gastroeiieniii.  and  thus  alhjws  the  surgeon  to 
hrin<;  tiie  hones  into  a  jrood  jiosition  and  t<»  deal  witli  them  as  with  an  ordinary  IVaeture. 
I  have  tau'rht  tliis  for  many  years,  and.  havinir  tested  its  value  in  three  eases,  ean  pro- 
nounee  the  ])raetiee  to  he  j^ctod.  My  friend  .^Ir.  Treves  of  the  Lotidon  Hospital  followed 
the  practiee  in  1SS2  (lin'f.  M<il.  Jomn.,  Kehruary  17,  18H3),and  it  has  likewise  been  prac- 
tiseil  hv  Hr.  Morris  of  Boston,  in  Anieriea.  with  sueeess  (lioslun  Mn/.  uikI  Siii</.  Jomn.. 
Noveniln'r  li!*,  1S77). 

Compound  Fractures  of  the  Thigh. — These  are  desperate  accidents,  and 
take  jilace  in  the  jtroportion  of  one  to  every  six  or  seven  ca.ses  of  fracture  of  the  femur; 
and  when  they  occur,  hall"  the  ))atients  die.  They  should  be  treated,  where  possible,  on 
conservative  principles,  and  amputation  should  be  performed  oidy  when  the  .soft  parts, 
with  the  vessels  and  nerves,  are  so  injured  as  to  forbid  any  reasonable  hope  of  recovery. 
Conservative  practice  should  have  full  scope,  in  young  subjects  especially,  and  when  any 
doubt  ujion  the  necessity  of  amputation  exists,  the  surgeon  had  better  decide  upon  trying 
to  save  the  limb,  although  in  the  aged  an  opposite  practiee  should  be  adopted. 

Army  surgeons,  however,  advise  the  propriety  of  practising  conservatism  for  gunshot 
fractures  in  the  upper  third  of  the  thigh  and  amputati(tn  for  all  fractures  of  the  middle 
and  lower  thirds,  the  nature  of  gunshot  injuries  to  those  parts  precluding  all  hoj)e  of  a 
natural  recovery.  All  modern  army  surgeons — English.  American.  French,  and  (ierman 
— agree  upon  this  point,  and  endorse  Dupuytrens.  Hennen's,  Larrey's,  and  Guthrie's 
opinion  that,  in  gunshot  wounds  of  the  thigh,  •'  in  rejecting  amputation  we  lo.se  more  lives 
than  we  save  limbs."  and  ''  that  in  the  exceptional  cases  which  result  in  consolidation  the 
condition  of  the  limb  is  not  encouraging." 

Amputation  of  the  thigh  for  compound  fracture  is  most  fatal,  two  out  of  three  dying. 
In  the  upper  third  of  the  thigh  the  mortality  is  still  greater. 

It  is  from  this  fact  alone  that  army  surgeons  have  advised  the  conservative  treatment 
of  ccjmpound  fractures  of  the  upper  part  of  the  femur,  and  Mr.  Erichsen  has  been  led  to 
assert  that  amputation  in  the  upper  third  of  the  thigh  for  compound  fracture  is  an  unjusti- 
fiable oiieration. 

When  amputation  is  not  at  once  called  for.  the  wound  should  be  thoroughly  cleansed 
with  some  iodine  or  other  antiseptic  lotion,  and  all  foreign  bodies,  with  loose  fragments 
of  bone,  removed;  the  projecting  portions  of  bone  should  be  excised,  bleeding  arrested, 
and  the  wound  sealed  with  blood  or  the  compound  tincture  of  benzoin  :  a  .splint  should 
be  applied  at  once,  moderate  extension  employed,  and  the  case  treated  on  general 
principles. 

Fractures  of  the  Patella. — These  are  usually  transverse,  from  a  sudden  action 
of  the  quadriceps  femnris  under  a  violent  effort  to  prevent  the  body  falling  backward, 
the  knee  being  at  the  time  partially  bent.    ?^uch 

fractures    are    met   with   chiefly   near,   though  F'^-  ■^'^"• 

mostly   below,   the   centre  of  the  bone ;    they  ^--::-rv_      w;<<?v^^t^  y"^-  ^,-^^te^^ 

may.  however,  occur  at  any  part,  even  in  the  \^^^^^^^^  ^j>—  ■'■<g^^'^'^*^,^^i^ 
extra-articular  portion  of  bone.     In  some  ca.ses         „,.,    ,.  ,„     ,,    ^T.       ,t^\ 

,       ,  11  1       1  1  Multiple  F  racture  of  Patella,     i  Prep.  r212SO.) 

both  pateliJB  are   broken,  together  or  con.secu- 

tively  ;  in  rarer  instances  the  same  patella  may  be  broken  more  than  once.  I  have  had 
such  a  case  in  a  man  in  whom  one  patella  had  been  broken  twice  and  the  other  three 
times,  and  in  the  Guys  Museum  there  is  a  preparation  (Fig.  586)  from  my  fathers  mu- 
seum in  which  the  bone  had  been  broken  transversely  into  four  fragments.  proVjably 
from  different  injuries  or  from  some  direct  force,  each  fragment  having  a  ligamentous 
union. 

These  transverse  fractures  are  at  times,  although  rarely,  the  result  of  direct  violence. 
The  French  and  American  surgeons  believe  them  to  be  so  very  frequently.  Direct  vio- 
lence to  the  patella,  however,  is  more  commonly  followed  by  what  is  called  a  starred  or 
vertical  than  by  a  transverse  fracture,  and  in  these  cases  there  is  rarely  much  separation 
of  the  fragments.  In  transverse  fracture  the  separation  is  sometimes  very  great,  this  fact 
mainly  depending  upon  the  amount  of  muscular  action  at  the  time  of  fracture.  It  is, 
however,  greatly  increased  by  the  effusion  of  blood  that  follows  the  injury,  and  later  on 
of  inflammatory  exudation.  At  a  still  later  period  it  is  increased  from  a  yielding  of  the 
ligamentous  tissue  by  flexing  the  leg  before  firm  union  has  taken  place. 

Out  of  2.'5  consecutive  cases  which  passed  under  my  care,  in  7,  on  convalescence,  the 


896 


ON  FRACTURES. 


Fig. 587. 


Fracture  of  the  Patella.    Separation  of 
Fragments. 


1  IG    588 


union  was  so  close  as  to  have  been  reported  as  bony  ;  in  9  there  was  separation  of  only  a 
quarter  of  an  inch  ;  in  8,  of  half  an  inch  ;  in  1,  of  one  inch.  In  all  of  these  the  move- 
ments of  the  joint  were  perfect. 

Dtagnosis. — The  diagnosis  of  the  transverse  fracture  is  rarely  difficult,  the  nature 

of  the  violence,  the  sudden  loss  of  power  of  the  limb, 
the  distinct  separation  of  the  fragments,  and  the  bulg- 
ing of  the  synovial  sac  between  the  divided  portions  of 
bone  being  characterteristic.  In  the  stanrd  fracture  the 
different  pieces  of  bone  may  be  made  out.  In  the  ver- 
tical the  diagnosis  may  be  more  difficult,  and  can  be 
made  out  only  by  manipulation.  In  exceptional  cases 
where  either  the  ligamentum  patellge  or  the  tendon  of  the 
extensors  above  the  patella  is  broken  some  difficulty  may 
be  felt,  but  such  accidents  are  very  rare.  When  the  trans- 
verse fracture  is  little  more  than  a  fissure,  no  separation  will  be  found,  the  amount  of 
separation  being  determined  by  the  extent  of  laceration  of  the  fibrous  and  tendinous  cov- 
erings of  the  bone.  When  the  laceration  is  partial  and  the  separation  slight,  there  is  a 
better  hope  of  a  bony  or  close  union  than  when  the  laceration  is  complete  and  the  separa- 
tion great.  It  should  be  known,  however,  that  union  by  bone  may  take  place,  although 
probably  but  seldom  ;  that  union  by  strong  ligament,  with  about  half  an  inch  of  separa- 
tion, is  more  common  ;  and  that  non-union  is  exceptional.  William  Adams  in  the  Path. 
Trans,  (vol.  xiii.)  informs  us  that  out  of  31  specimens  he  examined,  15  were  examples  of 
ununited  fracture,  12  of  true  ligamentous  union,  and  -4  doubtful.  In  the  ununited  the 
separation  was  very  great ;  in  the  ligamentous  it  was  rarely  beyond  an  inch  and  a  half. 
In  the  ununited  the  separated  fragments  were  connected  with  each  other  by  only  a  single 
layer  of  fibrous  tissue. 

That  bone  union  now  takes  place  is  generally  recognized.     In  Prep.   1211",  Guy's 
Museum  (Fig.  588),  taken  from  my  father's  museum,  the  fact  is  well  exemplified.     The 
specimen  has  been  fully  described,  with  remarks,  by  the  late 
Mr.  W.  King  in  the  Gkt/'s  Hasp.  Rep.  (Series  i.  vol.  vi.) 

In  the  starred  or  vertical  fractures  osseous  union  is  gener- 
ally secured,  these  cases  being  rarely  attended  with  complete 
laceration  of  the  periosteal  or  fibrous  coverings  of  the  bone. 

Treatment. — In  all  cases,  as  well  as  in  every  form,  of 
fractured  patella,  a  long  well-padded  posterior  splint  with  a 
foot-piece  extending  from  the  tuberosity  of  the  ischium  to  the 
foot  should  at  once  be  adjusted,  the  knee-joint  being  left  un- 
covered by  the  bandage.  To  the  knee-joint  cold  should  be 
applied,  for  as  a  direct  consequence  of  the  accident  blood  is 
very  apt  to  be  eff'used,  and  as  a  secondary  efl"ect  synovial 
inflammation  with  eff"usion  is  almost  sure  to  ensue.  Should 
Fracture  of  Patella  United   by  the  joint  be  hyper-distended  with  blood,  such  may  be  removed 

Anterior  surface.  Vertical  section,    by  the  aspirator. 

It  has  generally  been  the  custom  to  raise  the  heel  with  a 
view  to  destroy  the  action  of  the  extensor  muscles,  but  it  is  now  more  generally  believed 
that  no  good  is  derived  from  such  a  measure  ;  as  a  consequence,  the  horizontal  position 
of  the  limb  is  usually  employed,  the  body  being  raised.  The  fragments  should  be  brought 
together  at  the  same  time  as  much  as  possible  by  the  fingers  of  the  surgeon,  and  later  on 
by  some  apparatus.     To  do  so,  however,  while  blood  exists  to  any  extent  or  the  synovial 

capsule  is  distended  with  inflammatory  effusion 
Fig.  589.  is  not  wise,  since  any  attempt  to  draw  the  bones 

together  under  these  circumstances  can  result 
only  in  tilting  forward  the  surfaces  that  are  re- 
quired to  be  brought  into  apposition,  with  no 
good  effect. 

For   a   few   days,    therefore,    until    all   in- 

Accumulator.  ^ r  ,;•" '   "*■-      flaiumatory  action  has  subsided,  the  surgeon 

«..i;„f  <•.,.  !?-„„♦    „   (•  ti     r.  *  11       ■.x^T'^    .■  o         should  rest  satisfied  by   simply   pressing  the 

splint  for  Fracture  ot  the  Patella,  with  Elastic  Com-  ,  .,,■'       n  ii 

pression.  parts   together   witli    his    fanners :    and    when  , 

b;  S^r'slrapprngSd  t^f  m      "''""""•         tliis  result  has  been  secured.^the  two  portions 

may  be  drawn  together  by  means  of  strips  of 
plaster  diagonally  applied,  of  india-rubber  bands  covered  with  wash-leather  attached  to 


FRAcrrnKs  of  tiif  i.nwFi:  FxriiFMrrv.  h97 

honks,  which  hiivc  ht-cii  iiiscrti'il  at  iiitcrviil.s  of  an  inch  on  citlicr  side  of"  tlic  hplint.  or, 
wliat  is  Ix'ttcr,  by  means  ol'  clastic  coni|trcssion  as  shown  in  Kijx.  '>M1). 

Maliraignc's  hooks,  whidi  are  composed  of  ibur  ehiws  drawn  together  hy  a  screw,  liave 
been  much  employed,  and  are  doubtless  efl'eetual,  bnt  from  the  fact  that  they  jtenetrate 
tlie  soft  parts  and  painfully  and  forcibly  draw  the  broken  fragments  together  they  are 
objectionable,      (iood  n-snlts  have,  however,  been  reported  frouj  their  use. 

As  snoii  as  all  inflammatory  action  of  the  joint  has  subsided  and  the  bones  are  fairly 
in  ])usition  such  an  immovable  apparatus  as  the  flannel  I'avariaii  splint  may  be  ajiplied, 
the   patella   being   left    exposed  or  not   as   the 

surgeon    may    think    fit.      When   the   bone   is  Yu,.->'M). 

bandaged  over,  care  must  lie  taken  not  to 
pn-ss  upon  it,  as  I  luxve  known  secondary 
suppuration  with  necrosis  and  joint  complica- 
tion of  a  serious  nature  thus  ensue.  Eriehseii 
uses,  as  a  rule,  tlie  starch  liandage.  and  speaks 
highly  of  it.      lie  applies   it   over  a  pad  fixed 

above   the  fractured   Ikimc   with   a   tigure-of-8  ,^^    ^    ,,, 

,         ,  /1II1  a    •  t    ^  •  the   Middlesex   Iio.->i)itaI   Siilint   for   Fracture  of   the 

bandage.     C.  Heath  removes  fluid   by  aspira-  iWiia. 

tion,  applies   a   ]daster-of-Paris  bandage  over 

cotton-wool,  and  allows  liis  patient  to  get  up.  Whatever  apparatus  is  employed,  it  should 
be  kept  on  for  five  or  six  weeks  at  least ;  and  when  removed,  some  light  leather  or  felt 
casing  should  be  substituted.  It  is  hazardous  to  allow  the  patient  to  flex  the  limb  under 
three  months  and  to  give  it  freedom  under  a  year;  for  the  united  ligament  is  apt  to  be 
stretched  and  ehmgated,  and  the  limb  weakened.  An  apparatus  to  limit  the  movement 
of  the  joint  should  be  w'orn  after  this  accident.  One  made  by  Ilawksley  and  long  used 
at  the  Middlesex  hosjiital  is  excellent  (Fig.  590).  "  It  is  applied  as  soon  as  the  patient 
is  allowed  to  get  up,  and  the  degree  of  flexion  is  gradually  increased  from  time  to  time 
by  filing  away  the  shoulder  of  ^he  joint  of  the  splint." 

Within  recent  times  surgeons  have  advocated  the  primary  treatment  of  these  frac- 
tures by  wiring  the  fractured  bones  together,  and  succes.ses  have  been  obtained — .some 
excellent,  others  indifferent,  few  better  than  the  average  obtained  by  the  treatment  above 
described.  Sir  J.  Lister  has  been  amongst  the  most  successful.  So  far  as  I  can  make 
out,  the  first  case  recorded  is  by  Dr.  Uhde  of  Brunswick  (^Deutsche  Medicia  nnd  Woch<ns., 
April  27,  1878).  I  cannot  recommend  this  practice  to  be  universally  adopted.  It  is 
eminently  hazardous;  and  when  we  know  that  in  the  majority  of  cases  of  fractured 
patella  treated  without  operation  results  are  obtained  which  in  exceptional  cases  alone 
interfere  with  life's  duties,  the  treatment  by  operation  stands  condemned  as  a  rule  of 
practice. 

In  32  ca.ses  of  old  fvacture  of  the  bone  Avhich  have  been  admitted  into  Guy's  for 
other  injuries,  in  28  the  limb  was  in  all  ways  useful ;  in  4  only  was  it  weak,  and  in  these 
•4  the  separation  between  the  fragments  was  half  an  inch  in  2,  one  inch  in  1,  and  two 
inches  in  the  fourth  ;  whereas,  in  the  patients  with  useful  limbs,  one  man  could  go  up  a 
ladder  with  two  hundredweight  on  his  shoulder,  another  acted  as  porter  in  a  fish-market, 
a  third  was  a  lighterman,  two  were  coal  porters,  a  sixth  was  a  sailor,  a  seventh  a  carman, 
an  eighth  a  marine  engineer.  In  one  man  with  a  perfectly  useful  limb  the  fragments 
were  three  inches  apart;  in  another,  who  could  walk  well,  both  bones  were  fractured  and 
the  fragments  two  inches  apart.  In  a  cellarman  who  had  good  use  of  his  leg  the  separa- 
tion was  four  inches.  In  the  majority  of  the  good  limbs  the  separation  was  about  half 
an  inch.  Upon  the  whole,  the  result  of  the  accident  was  most  satisfactory  and  enough 
to  justify  the  ordinary  modes  of  treatment  employed. 

In  examples  of  neglected  cases  of  fracture  where  a  great  separation  of  the  fragments 
exists,  and  the  knee  is  consequently  so  weak  as  to  be  useless,  such  an  operation  as  has 
been  described  may  be  justifiable,  but  under  other  circumstances  I  cannot,  as  a  teacher, 
regard  it  otherwise  than  as  a  rash  and  hazardous  proceeding. 

Compound  Fractures  of  the  Patella. — These  are  grave  accidents,  one-fourth 
of  the  cuse.s  dying.  Poland  in  an  able  paper  read  before  the  Royal  Med.  and  Chir.  Society 
(1870)  gave  an  analysis  of  85  such,  and  clearly  proved  that  in  all  cases  we  should 
attempt  to  .save  the  limb  and  adopt  the  ordinary  treatment  as  for  simple  fractures  of  the 
patella.  To  this  end  the  wound  should  be  well  washed  with  iodine  water  or  carbolic  acid 
lotion  and  accurately  closed  by  sutures,  and  inflammation  ought  to  be  subdued  by  the 
constant  application  of  cold.  If  suppuration  sets  in,  free  incisions  should  be  made  into 
57 


898 


ON  FRACTURES. 


Fig.  591. 


the  joint,  and  amputation  resorted  to  only  when  the  powers  of  the  patient  fail  to 
repair  the  injured  joint.  Detached  fragments  of  bone  should,  however,  be  removed  at 
once. 

Out  of  the  85  cases  collected  by  Poland,  there  were  20  deaths  and  65  recoveries ;  in 
31  of  these  there  was  more  or  less  complete  anchylosis  of  the  joint ;  20  recovered  with 
movement,  -t  were  resected,  and  5  amputated.     The  joint  suppurated 
in  43  out  of  the  65  cases  of  recovery,  and  in  all  the  fatal  cases. 

In  March,  1883,  I  saw  a  man  set.  56  who  after  a  compound  com- 
minuted fracture  of  the  patella  had  necrosis  of  about  a  quarter  of  the 
bone.  He  made  a  good  recovery  after  the  removal  of  the  dead  bone, 
and  had  almost  complete  movement  of  the  joint.  The  case  occurred 
in  the  practice  of  Mr.  Wilson  of  Grantham. 

Fractures  of  the  Leg. — These  are  about  twice  as  frequent  as 
those  of  the  thigh.  At  Guy's.  1090  cases  were  admitted  in  six  years, 
against  541  of  the  thigh  ;  and  of  these  202,  or  one-fifth,  were  com- 
pound. Of  the  simple  cases  not  one  per  cent,  died  from  all  causes, 
and  of  the  compound  twenty-seven  per  cent,  succumbed. 

Both  bones,  as  a  rule,  are  fractured,  the  fibula  alone  being  broken  in 
about  one  case  in  six,  and  the  tibia  in  about  one  in  seven.  Lonsdale's 
statistics  indicate  the.se  points.  These  fractures  are  more  commonly 
met  with  in  adult  than  in  child  life. 

In  fractures  of  both  bones  those  of  the  upper  half  are  usually  the. 

Arrest  of  Growth  i     ^^^^^^  ^f  direct  violencc — fractures  of  the  lower  half  of  indirect,  such 

Shaft  of  Eight  Tibia  as  the  twistinsT  of  the  foot  or  leir  from  a  fall  or  a  jump. 

of'"Fib!;ir?onowin|         In  fractures  of  the  tibia  alone  the  line  of  fracture  is  fre- 

injury  to  Upper  Epi-  quently  transverse,  and  from  this  cause  there  is  sometimes  difficulty  in 

fore^  in  Child  tet' 8.     making  the  diagnosis,  the  nearer  the  fracture  to  the  knee,  the  more 

transverse  being  the  line.     These  fractures  arise  chiefly  from  direct 

violence.     They  may  so  unite  as  to  leave  no  external  trace  of  injury  ;  indeed,  they  may 

be  attended  with  so  little  displacement  that  the  line  of  the  bone  is  never  broken.    I  have 

seen  more  than  one  patient  walk  upon  the  fractured  limb  directly  after  the  accident,  and 

in  one  case  the  man  went  up  a  whole  flight  of  stairs  to  his  ward  with   but  a  slight  limp. 

In  another,  under  my  care  in  1874,  a  woman  with  a  fractured  tibia  and  fibula  went  about 

for  a  week.     In  a  mouiuu-iegal  point  of  view  these  facts  are  important.     When  the  shaft 

has  been  separated  at  its  upper  epiphysis,  some  arrest  of  growth  may  take  place ;  and 

such  a  result  is  illustrated  in  Fig.  591. 

Fracture  of  the  fibula  is  more  common  than  that  of  the  tibia,  particularly  in 
its  lower  third ;  and  I  uelieve  that  in  many  examples  of  what  are  called  bad  sprains  a 
fracture  exists.  Fracture  in  the  upper  two-thirds  is  usually  caused  by  direct  violence, 
but  it  may  be  by  indirect,  such  as  a  wrench  or  twi.st  of  the  ankle-joint ;  under  such  con- 
ditions the  fracture  will  be  oblique  ;  in  the  lower  third  the  violence  is  commonly  indirect, 
such  as  a  lateral  twist  or  a  forcible  eversion  of  the  foot.  With  pedal  ('/(version,  the  extrem- 
ity of  the  tibia  is  mostly  broken  off".  When  with  this  fracture  the  foot  is  displaced  outward 
and  its  outer  edge  raised,  the  accident  is  known  as  "  Pott's  fracture  "  (Fig.  522),  and  under 
these  circumstances  the  external  ligament  remains  entire,  the  force  being  concentrated 
against  the  fibula  from  two  to  three  inches  above  the  malleolus  ;  the  internal  ligament, 
however,  is  ruptured  or  the  inner  malleolus  is  fractured.  Displacement  of  the  foot  is 
not  necessarily  an  attendant  upon  the  fracture.  It  seems  to  be  the  result  of  some  con- 
tinuation of  the  primary  fracturing  force  or  of  some  additional  force,  such  as  that  of  an 
attempt  to  walk.  In  the  indirect  fracture  the  line  of  fracture  is  probably  oblique,  the 
obliquity  being  determined  by  the  direction  of  the  force. 

Dl.\GNOSis. — In  fracture  of  either  of  the  leg-bones  alone  the  diagnosis  may  be  .some- 
what difficult,  and  more  particularly  when  no  displacement  is  present.  Crepitus  may  .at 
times  be  made  out  by  a  forcible  attempt  to  move  or  bend  the  lower  fragments,  or  by 
some  sudden  inversion  or  eversion  of  the  foot :  but  in  trying  for  this  the  surgeon  should 
be  careful  not  to  do  harm.  Local  pain,  however,  caused  by  pressure  with  the  thumb  over 
the  seat  of  fracture,  and  linear  ecchymosis  a  few  days  after  the  accident,  are  valuable  helps 
to  diagnosis  in  these  as  in  all  other  kinds  of  fracture. 

Protracted  or  repeated  examinations  of  the  injured  limb  should  always  be  avoided-; 
they  only  add  to  the  mischief. 

Treatment. — In  fractures  of  either  of  these  bones  a  natural  splint  is  always  found 


FRACTURES  OF  THE  LOWER   EXTREMITY. 


899 


Fig.  594. 


in  the  saiiu'  b<jne;  consefjuently,  shorteniiifr  or  deroriuity  rarely  follows  the  accident, 
the  surgeoM  lias  to  do  is  simply  to  apply  some  sj)lii»t  to  ensure  rest 
to  the  broken  bone  and  to  tlie  mu.seles  that  move  the  foot — to  the 
inside  of  the  lejr  when  the  fifrula  is  broken  (Fig.  5!>3),  and  to  the 
outside  when  the  tibia  (Kijr.  oH-);  tiie  splints  should  have  a  foot- 
piece.  In  fraetures  of  the  lower  third  of  the  fibula  the  foot  may 
be  drawn  inward,  the  bandaj_'e  bein^r  applied  from  without  inward, 
but  in  manv  instances  nothing  more  is  called  for  than  absolute 
rest.  In  otlier  cases  a  thiek  jtad  is  often  of  use  opposite  the  .seat 
of  fracture.  In  no  ca.se  should  the  banda<re  cover  the  fracture. 
After  the  lapse  of  a  few  days,  or  at  most  a  week,  when  all  swell- 
intr,  with  other  evidence  of  local  injury,  has  subsided,  the  limb 
mav  with  advanta<;e  be  put  uj)  in  some  immovable  apparatus. 

In  cases  of  Pott's  fracture,  or  dislocation  of  the  foot  outward  with 
fractured  fibula.  Pott  used  to  place  the  patient  on  the  affected  side 
with  the  injured  limb  flexed,  fixing  the  leg  upon  an  outside  splint, 
an  inner  splint  being  likewise  very  usually  applied.  A  Vjetter  plan, 
however,  is  found  in  the  posterior  and  two  lateral  splints,  with  a 
swing,  as  seen  in  Fig.  596,  this  mode  of  swinging  the  limb  being 
a  very  good  substitute  for  Salter's  swing  (Fig.  597). 

Fractures  of  both  bones  occur  in  every  variety,  and  the  most  common  is  the 
transvoiM'.  abuut  throe  inches  above  the  ankle;  but  every  form  of  oblifjue,  dentated, 
comminuted,  and  vertical  fracture  is  met  with  (Fig.  532).  When  near  the  joints,  the 
vertical  into  the  joint  is  by  no  means  rare.  The  surgeon  in  his  first  examination  of  the 
fractured  limb  should,  if  possible,  make  out  the  line  of  obliquity  of  the  fracture  and  the 
teiuhnci/  one  or  other  of  the  fragments  may  have  to  ride  in  any  one  direction,  always 
observing  the  utmost  gentleness  in  his  manipulation. 

When  the  tibia  is  broken  at  the  junction  of  its  middle  and  lower  thirds,  and  the 
extremity  of  its  upper  fragment  on  its  inner  or  subcutaneous  surface  presents  a  V-shape 
(Fig.  594),  the  surgeon  may  expect  to  find  a  fissure  in  the  lower  fragment 
of  bone  starting  from  the  apex  of  the  V  and  running  in  a  spiral  direction 
inward,  backward,  and  outward  round  the  inner  edge  of  bone,  across  its 
posterior  surface  toward  the  lower  articular  facet  where  the  tibia  and  fibula 
articulate,  the  fissure  then  passing  horizontally  inward  across  the  lower  ar- 
ticular facet  of  the  tibia  to  the  posterior  border  of  the  inner  malleolous  to 
join  the  one  on  the  posterior  aspect  of  the  bone,  thereby  cutting  off  a  tri- 
angular fragment  of  the  tibia  at  its  lower  extremity. 

This  variety  of  fracture  is  generally  produced  by  some  sudden  twist  of 
the  body  when  the  foot  is  fixed. 

It  may  be  suspected  during  life  when  joint  complications  are  associated 
with  the  fracture.  It  was  first  described  by  M.  Gosselin  (^Gazette  des  Hopi- 
taux,  1855). 

When  compound,  it  is  generally  of  a  serious  nature,  and.  according  to 
Gosselin,  should  be  treated  by  amputation.  Dr.  R.  M.  Hodges  of  America 
goes  so  far  as  to  say  that  by  such  a  practice  alone  can  the  patients  life  be 
saved  (^Boston  Med.  (iiid  Sitrff.  Journcd.  January.  1877).  Death  usually 
takes  place  from  pyjemia  in  cases  that  are  left  alone. 

I  am  not  disposed,  however,  to  go  so  far  in  this  direction,  though  I  fully 
recognize  the  serious  nature  of  these  cases  and  believe  that  they  claim  the 
surgeon's  anxious  attention. 

In  transver.se  fractures  there  is  rarely  deformity.  In  the  oblique  it  is 
a  common  result,  the  upper  extremity  of  the  lower  portion  of  bone  pro- 
jecting,, as  a  rule,  the  lower  fragment  being  rotated  outward  from  the 
great  tendency  the  foot  has  toward  eversion. 

Symptoms. — The  symptoms  of  fracture  of  the  leg  are  too  plain  to  be  v-shaped  Frac- 
overlooked.     The  tibia  being  a  superficial  bone,  any  solution  of  continuity      *"^tc^^  T'i^?*' 

,       .      .  o     1       f  r.   -^  ■         •  111"  1  /.     1  •  with. "spiral  Pis- 

or  deviation  oi  the  line  oi  its  spine  is  readily  made  out,  the  nature  oi  the      sures.    (Figure 
accident,  loss  of  power,  deformity,  and  crepitus  helping  the  diagnosis.     In      preparaflon* of 
fractures  near  the  joint  it  n;ay  at  times  be  difficult  to  make  out  whether      <ios*eiin.    now 
the  bone  is  fractured  into  the  joint  or  not ;  and  when  a  doubt  exists,  cau-      museum.^ 
tion  in  prognosis  and  treatment  should  be  ob.served.     In  fractures  close  to 
the  ankle  accompanied  with  displacement  dislocation  may  be  roughly  simulated,  but  the 


900 


ON  FRACTURES. 


slightest  care  ought  to  detect  the  true  nature  of  the  case  ;  the  facility  with  which  the 
displacement  of  the  parts  is  rectified,  the  fact  that  the  malleoli  retain  their  normal  rel- 
ative position  with  the  foot,  and  that  the  ankle-joint  moves  with  facility,  proves  that  the 
displacement  is  due  to  broken  bones,  and  not  to  dislocation  of  the  joint.  AVhen  the 
lower  epiphysis  of  the  tibia  is  displaced  with  the  foot,  there  may  be  some  difficulty  in 
making  out  the  true  state  of  the  case,  but  such  an  accident  can  occur  only  in  children  ; 
it  will  appear  as  a  transverse  fracture,  but  with  no  sharp  edge  of  bone,  as  is  usual  in 
fracture,  while  replacement  of  the  displaced  fragments  wull  not  give  rise  to  the  ordinary 
crepitus  of  broken  bone,  but  to  a  more  subdued  sensation. 

When  a  wound  complicates  the  case,  the  diagnosis  is  readily  made. 
Treatment. — It  is  wise,  in  fractui-e  of  the  leg  as  of  other  bones,  to  "  set "  the  frac- 
ture and  to  put  the  injured  limb  into  the  right  position  with  good  splints  as  soon  as 
possible. 

.    In  a  general  way,  for  fractures  of  the  lower  two-thirds  of  the  bones  the  best  apparatus 
is  a  straight,  flat,  and  not  too  broad,  metal  or  wooden  posterior  splint  (Fig.  595j  with  a 

Fig.  595. 


Process  of  Setting  a  Fracture  of  the  Leg. 

rectangular  foot-piece  and  two  broad  lateral  splints  (Fig.  596),  all  being  well  padded  and 
firmly  fixed  by  broad  strips  of  strapping,  broad  bands  of  inelastic  webbing  or  bandages, 
the  seat  of  fracture  being  left  exposed,  if  possible,  for  observation.  In  Fig.  596  the 
whole  apparatus  is  illustrated  wuth  an  interrupted  splint  as  for  compound  fracture.  In 
reducing  a  fracture  of  the  leg  the  knee  .should  be  partially  flexed  or  held  by  an  assistant, 
the  surgeon  manipulating  the  lower  portion  (Fig.  595). 

During  the  putting  ap  of  the  fracture  the  limb  must  be  kept  extended  and  the  broken 
bones  maintained  in  position,  it  being  a  good  plan  to  fix  the  foot  and  limb  at  first  to  the 

posterior    splint,  and    subsequently 
Fig.  596.  to  apply  the  lateral.     The  leg  after- 

ward should  be  slung  to  a  cradle  by 
bandages  (Fig.  575),  or  Salter's 
cradle  may  be  used  (Fig.  597). 
When  any  wound  in  the  soft  parts 
exists,  as  in  compound  fracture,  the 
corresponding  lateral  splint  should 
be  interrupted,  as  shown  in  Fig. 
596. 

When  the  fracture  is  close  to 
the  ankle-joint  and  any  difiiculty  is 
experienced  in  keeping  the  broken 
^  bones  in  position  from  the  spa.smodic 
action  of  the  tendo  Achijlis,  the 
tendon  should  be  divided.  This 
simple  operation  at  once  permits  the 
parts  to  be  adjusted  with  admirable 
facility  and  renders  the  retentive  apparatus  of  real  value,  while  it  allows  natural  processes 
of  repair  to  go  on  uninterruptedly,  the  divided  tendon  and  broken  bones  undergoing 
repair  together. 

When  the  fracture  is  near  or  into  the  knee,  a  posterior  splint  such  as  that  of  Maclri- 
tyre  or  Amesbury  may  be  employed ;  indeed,  some  employ  this  splint  for  most  fractures 
of  the  leg  (Fig.  597). 


Apparatus  for  Fixing  and  Swinging  a  Fracture  of  the  Leg. 


FRACTURES  OF  TlIF  LOWER  EXTREMITY. 


1)01 


In  setting  ativ  IVactnn'  nf  ilu-  U-^  the  opiiD.sitc  liiiil»  sliniiM  be  exposed  as  a  guide  and 
an  iii(|uirv  made  to  prevent  error  a>  to  the  existenee  of  any  natural  or  aefjuired  delormity. 
The  foot  shouhl  ^.'eiierally  be  phieed  at  rijrht  an;zles  with  the  h--:.  with  the  sole  flat  to  the 
foot-pieee,  i-are  being  observed  that 
till'  heel  d(H's  not  fall  and  the  lower 
fragment  of  bone  etinset|Uently  tilt 
upward.  The  heel  should  also  be 
well  protected  from  pressure  and  the 
foot  covered  and  protected  with  cot- 
ton-wool. '•  Take,  therefore,  "  writes 
Paget  (Laiiof,  February  27.  ISOD), 
"the  foot-pieee  of  the  splint  as  the 
guide  for  the  position  of  the  foot  ; 
and  if  you  but  .see,  in  the  manage- 
ment of  fractures  of  the  leg.  that 
the  foot  of  the  ])atient  and  the  foot- 
pieee  of  the  back  si»lint  fairly  corre- 
spond, it  is  hardly  possible  f<jr  the 
limb  to  fall  into  any  defective  meth- 
od of  repair.  (_'orrespondence  be- 
tween  the  axis  of  the  foot  and  of 


Maclntyre's  Si)Iiut  and  -Salter's  Swinj;. 


the  foot-piece  ensures  that  there  shall  be  no  rotation  or  version,  either  outward  or  inward. 
Then,  again,  you  should  be  careful  that  the  foot  touches  the  foot-piece  by  the  three  balLs 
of  the  sole — the  ball  of  the  heel,  the  ball  of  the  great  toe.  and  the  ball  of  the  little  toe." 
Dr.  Shrimpton  of  Paris,  acting  upon  Dr.  Nathan  Smiths  suggestion  of  an  anterior  wire 
splint,  has  applied  it  to  fractures  of  the  leg  with  success.  He  employs  a  splint  composed 
of  double  wires  an  inch  and  a  half  apart,  held  together  by  four  transverse  bars  and  applied 
by  means  of  straps  to  the  front  of  the  leg,  as  illustrated  in  Fig.  59S  (Luiicef,  lS72j,  the 


Fig.  598 


^X 


B 


7 


Nathan  Smith's  Anterior  Wire  Suspension  Splint,  with  Dr.  Shrinipton's  Moditication  of  it  below. 

limb  being  subsequently  slung  in  a  vertical  direction,  as  Esmarch  slings  his  patient's  leg 
in  disease  of  or  after  operations  upon  the  ankle.  After  the  limb  has  been  kejjt  in  splints 
for  about  a  month  some  immovable  apparatus,  such  as  the  flannel  Bavarian  (Fig.  536), 
may  be  substituted  and  the  patient  allowed  to  get  up,  moving  about  with  crutches  for 
another  month.  When  there  is  little  or  no  displacement  and  little  swelling,  as  soon  as 
the  immediate  effects  of  the  injury  have  passed  away  the  immovable  splint  may  be  at 
once  applied — that  is.  after  the  first  week — the  wants  of  the  individual  ca.se  being  the 
only  guide  to  its  treatment.  When  the  bones  are  comminuted  and  some  loose  portion 
has  a  tendency  to  ride  or  rise  out  of  its  position,  the  application  of  a  pad.  with  sufficient 
local  pressure  to  keep  the  parts  in  position,  may  be  employed.  When  much  effusion  of 
blood  or  local  action  takes  place,  ice  or  cold  lotion  may  be  used  as  an  application.  Con- 
stitutional symptoms  can  be  treated  as  they  arise. 

Compound  fractures  of  the  leg  ought  to  be  adjusted  in  the  same  way  as  the 
simple,  care  being  taken  to  have  an  interruption  in  the  splint  corresponding  to  the  wound 
(Fig.  5l)tj).  When  the  wounds  are  extensive,  the  posterior  hollow  splint  of  Maclntyrc  or 
any  of  its  modifications  may  be  used  with  advantage. 

When  the  bones  are  comminuted,  the  loose  pieces  should  be  removed,  the  wound 


902  ON  FRACTURES. 

cleaned  and  sealed  with  a  pad  saturated  with  blood,  the  compound  tincture  of  benzoin,  or 
carbolic  acid,  as  already  described ;  at  a  later  period  of  the  case,  when  inflammation  and 
suppuration  take  place  about  the  seat  of  fracture,  a  free  incision  should  be  made  down  to 
the  bone  and  any  necrosed  fragment  removed.  This  operation  gives. relief  to  pain  and 
expedites  recovery. 

When  the  injury  to  the  soft  parts  is  great  and  the  large  ve.s.sels  or  the  joint  are 
involved,  amputation  may  be  called  for. 

About  one  in  every  three  cases  of  fracture  of  the  leg  is  compound,  the  average  mor- 
tality of  the  compound  being  also  about  one  in  three.  Of  those  amputated,  about  sixty 
per  cent,  are  fatal. 

When  amputation  is  called  for,  a  primary  operation — /.  c.  one  performed  during  tike 
first  three  day.s — is  better  than  a  later  one. 

Fractures  of  the  foot,  commonly  the  result  of  some  crushing  force,  are  always 
serious  on  account  of  the  injury  the  soft  parts  have  sustained  in  common  with  the  bones. 
When  not  so  complicated,  severe  fractures  of  the  bones  of  the  foot  as  well  as  other  bones 
will  recover  by  rest  and  the  application  of  cold  lotions,  etc. 

Fracture  of  the  OS  Calcis  may  occur  by  a  fall  from  a  height.  It  is  seldom  associ- 
ated with  any  displacement  and  undergoes  excellent  repair  when  natui-al  processes  are 
left  to  themselves.  In  exceptional  cases  the  broken  fragment  may  be  drawn  up  by  the 
action  of  the  gastrocnemii  muscles,  and  under  such  circumstances  the  leg  must  be  kept 
flexed  and  the  foot  extended  to  keep  the  fragments  in  position  by  some  outside  splint. 
Under  these  circumstances,  however,  the  foot  rarely  recovers  completely  its  natural  use. 

Fractures  of  the  astragalus  also  occur  from  some  fall  or  violence,  and  are  often 
compound.  I  had  a  case  some  years  ago  in  which  the  upper  surface  of  the  bone  with  its 
head  was  split  off"  and  forced  through  the  skin,  and  a  second  in  which  the  bone  was  cru.shed 
into  fragments  and  extruded  from  below  the  external  malleolus.  In  the  former  the  soft 
parts  were  so  injured  that  amputation  was  performed,  while  in  the  latter  recovery  took 
place  by  natural  processes  with  a  stiff  but  good  limb. 

Simple  fracture  may,  however,  occur,  and  I  am  disposed  to  think  it  is  more  common 
than  is  supposed;  but  the  injury  is  difficult  to  diagnose,  particularly  when  no  displace- 
ment coexists.  I  have  had  occasion  in  two  cases  to  remove  from  boys  who  had  acute 
inflammation  of  the  bone  and  joint,  following  an  injury,  the  whole  of  the  necrosed  upper 
articular  surface,  with  half  the  thickness  of  the  astragalus,  and  in  both  good  results  fol- 
lowed. The  piece  I  removed  in  both  instances  looked  as  if  it  had  been  fractured,  and 
subsequently  died.  I  have  also  recently  (1878)  removed  from  the  inner  aspect  of  the 
ankle  of  a  man  the  upper  half  of  the  astragalus  that  had  been  fractured  six  montlis  pre- 
viously, rotated,  and  so  displaced  as  to  present  its  upper  articular  facet  inward.  The  case 
had  been  reported  at  a  sister-hospital  as  one  of  fracture  of  the  tibia  and  fibula.  The  frac- 
tured bone  had  subsequently  inflamed  and  died. 

Compound  fracture  of  the  metatarsal  and  phalangeal  bones  should  be  treated 
on  ordinary  principles,  the  immediate  dressing  of  the  wounds  with  the  compound  tincture 
of  benzoin,  to  exclude  all  air  and  place  the  wound  as  much  as  possible  under  the  condi- 
tion of  a  subcutaneous  one,  being  absolutely  indicated.  When  parts  irreparably  injured 
require  to  be  taken  away,  no  healthy  structures  ought  to  be  sacrificed  in  order  to  perform 
a  named  operation. 

COMPLICATED  FRACTURES. 

Extravasation  of  Blood. 

Fractures  are  very  often  complicated  with  rxfravasafion  of  hlood,  and  then  difficulties 
may  be  experienced  in  deciding  whether  the  blood  comes  from  an  artery  or  from  a  vein. 
In  compound  fracture,  however,  the  difficulty  of  diagno.sis  is  less  than  in  the  simple,  since 
the  florid  character  of  the  flowing  blood,  its  pulsatile  stream,  and  its  capability  of  being 
arrested  by  pressure  on  its  cardiac  side  indicate  its  arterial  source.  In  simple  fractures  the 
difficulty  is  sometimes  very  great,  particularly  when  the  limb  is  distended  with  blood  and 
there  is  no  pulsation  in  the  swelling.  When  the  vessels  below  the  seat  of  injury  pulsate 
naturally,  the  blood  has  probably  a  venous  origin  ;  but  when  pulsation  is  not  felt,  there 
is  no  reason  to  jump  to  the  conclusion  that  arterial  laceration  has  taken  place,  as  the 
arteries  may  be  simply  pressed  upon  by  the  eff"used  blood.  When  the  swelling  itself 
pulsates,  the  diagnosis  is  simplified ;  for  such  pulsation  generally  means  that  a  traumatic 
aneurism  has  formed  and  some  large  artery  been  ruptured.     In  a  clinical  point  of  view, 


COMl'Ll(ATi:n  rilACTUHES.  903 

however,  tli<>  (jucstion,  liappily,  is  >i(tt  very  iiiiitcriul,  as  surpeons  an;  now  tolcralily  well 
agreed  as  tit  the  |»rarti(M-  tn  !•<•  |.urMi(<l. 

Tkkatmknt. — 111  compound  fractures  the  injured  vessels  shoultl  Ik'  tie<l  or 
twisted,  and  the  wound  should  lie  eiilar^H'd  Inr  this  jiurjiose  when  neeessary  ;  and  even 
where  such  a  praetiee  is  iinpossiltle,  and  fVoin  the  nature  ^A'  the  t'raeture  an<l  eondition  of 
the  soft  parts  it  is  prohahle  that  the  liinli  may  he  saved,  the  main  artery  .should  he  tied 
hitrher  up.  as  fractures  heal  well  with  a  diminished  supply  u{'  hlood.  Vears  aj^o,  when  a 
student.  I  reini-inher  a  ease  of  Mr.  liranshy  Cooper  in  whieh  a  eotapound  fraeture  <jf  the 
lej;  was  e<»mplieated  with  a  laceration  of  the  femoral  artery,  and  the  artery  was  secure<l  at 
the  .s«.'at  of  injurv-  liejtair  went  on  in  the  fraeture  as  well  a.s  in  any  ca.se  I  ever  witnes.sed. 
Mr.  liranshv  Cooper  has  also  recorded  in  his  SiDylnil  J'Jssm/s  a  ease  of  fracture  of  tlie 
femur  where  the  femoral  artery  was  lipitured  for  a  ruptured  popliteal  artery,  and  recov- 
ery took  place  in  si.x  weeks. 

In  the  autumn  of  1S7H  a  youth  a't.  l!^  came  under  my  care  with  a  compound  fraeture 
of  the  condyles  of  the  humerus  into  the  elhow-joint,  and  an  injury  to  the  brachial  artery 
about  its  centre  sufficient  to  arrest  all  circulation  throufrh  it.  The  wound  into  the  joint 
was  extensive,  but.  as  my  dresser  had  sealed  it  well  with  lint  soaked  in  the  compound 
tincture  of  benzoin  before  I  saw  it,  I  thouL'ht  it  wise  to  leave  the  case  to  nature.  The 
youth  went  on  well  without  one  bad  sym]itom,and  left  the  hospital  with  a  movable  joint. 
1  am  disposed  to  attribute  the  well-doiuir  of  this  case  to  the  fact  that  the  brachial  artery 
was  obstructed. 

When,  however,  the  condition  of  the  limb  at  the  seat  of  fracture  is  such  as  to  forbid 
aiiv  hope  of  its  recovery  being  entertained,  primary  amputation  ought  to  be  performed  ; 
if  a  doubt  e.\ists  as  to  the  probability  of  the  limb  being  saved,  the  artery  should  be 
secured  in  or  above  the  wound,  and  amputation  should  be  performed  as  a  secondary 
operation  if  the  attempt  fail  to  save  the  limb,  the  chances  of  a  successful  result  in  pri- 
mary and  secondary  amputation  being  about  e((ual. 

In  simple  fracture,  when  there  is  great  effusion  of  blood  and  Jio  pulsation  in  the 
swelling  or  vessels,  the  expectant  treatment  is  the  right  one  to  adopt,  the  injured  limb 
being  kept  at  rest  and  elevated  and  cold  applied.  When  pulsation  in  the  swelling  is  felt 
and  it  is  clear  that  arterial  laceration  has  taken  place,  the  same  practice  ought  ahso  pri- 
marily to  be  adopted,  since  every  hospital  surgeon  knows  that  these  cases  often  do  well 
under  such  treatment.  I  can  recall  several  where  it  was  as  clear  as  symptoms  could  define 
that  with  fracture  of  the  bones  of  the  leg  severe  arterial  laceration  existed,  and  yet  a  good 
recovery  ensued.  To  cut  down  at  the  seat  of  injury  and  secure  the  wounded  artery  is 
what  no  one  at  the  present  day  advocates,  although  John  Bell  laid  it  down  as  a  law  that 
such  a  rule  should  be  followed  ;  but  to  do  so  above  the  seat  of  injury  is  one  that  com- 
mends itself  to  the  surgeon's  attention  when  it  is  clear  that  some  treatment  is  requi-site 
for  the  wounded  ves.sel,  and  that  the  fracture  and  parts  around  are  progressing  toward 
recovery.  When  gangrene  of  the  limb  threatens,  it  would  be  as  unscientific  as  it  is  use- 
less to  adopt  this  practice,  amputation,  under  such  circumstances,  being  alniic  applica))le. 

SuM.MARY. — By  way  of  summary,  it  would  appear  that  in  compound  fracture 
complicated  with  arterial  hemorrhage  the  vessel  ought  to  be  secured — if  possible,  in  the 
wound,  if  not,  above  it — and  that  primary  or  secondary  amputation  should  he  resorted  to 
only  when  the  local  injury  forbids  any  hope  of  a  natural  recovery  being  entertained. 

In  simple  fracture  the  expectant  treatment  should,  as  a  rule,  lie  adopted.  If, 
from  the  progressive  character  of  the  hemorrhage,  interference  is  absolutely  demanded, 
the  artery  should  be  secured  above  the  fracture,  and  amputation  had  recourse  to  when 
gangrene  of  the  limb  follows.  Pressure  upon  the  afferent  artery  is  a  practice  that  also 
demands   attention. 

In  exceptional  cases  it  may  be  expedient  to  cut  down  upon  the  wounded  vessel  at  the 
seat  of  injury. 

Fractures  implicating  Joints. 

These  are  generally  grave  injuries,  though  in  simpft'  fractures  the  worst  effect  that  is 
usually  to  be  looked  for  is  some  stiffness  or  anchylosis  of  the  articulation.  Yet  this 
result  is  not  constant,  and  a  movable  joint  is  not  rarely  secured.  As  a  matter  of  precau- 
tion, however,  the  surgeon  should  warn  the  patient  of  the  risk  and  be  careful  always  to 
adjust  the  fracture  and  limb  in  the  most  useful  position  for  a  stiff  joint.  Such  cases 
require  very  careful  treatment,  absolute  immobility  of  the  injured  bone  and  articulation 
being  essential  points  to  be  observed  ;  the  joint,  if  inflamed,  must  be  treated  upon  ordi- 


904  OX  FRACTURES. 

nary  principles.  Passive  movement  of  the  joint  should  be  commenced  after  the  lapse  of 
four  or  five  weeks. 

Compound,  fractures  into  joints  are  among  the  most  serious  cases  the  surgeon 
has  to  treat,  and  in  the  lower  extremity  generally  require  amputation.  In  the  knee- 
joint  this  practice  is  the  best  when  the  wound  is  great  and  the  fracture  severe,  though 
exceptional  cases  are  on  record  in  which  excision  has  been  employed.  In  less  severe 
examples  an  attempt  to  save  the  member  may  be  made,  secondary  amputation  being  per- 
formed when  ill-success  follows.  The  same  rules  are  applicable  in  these  cases  as  in 
wounds  of  joints,  a  simple  fissure  of  bone  adding  but  little  to  the  danger,  while  severe 
comminution  reduces  the  prospects  of  success  to  a  minimum. 

In  compound  fracture  into  the  ankle-joint  without  displacement  no  operation  is  usually 
called  for,  since  good  results  are  obtainable  by  conservative  treatment. 

In  compound  fracture  of  the  shoulder-  and  elbow-joints  amputation  is  rarely  required 
unless  the  parts  are  irreparably  crushed  or  the  patient  is  so  old  as  to  forbid  any  hopes 
of  recovery  being  entertained.  Yet  in  many  cases  excision  should  be  undertaken,  as  it  is 
wiser  to  excise  the  articulation  at  once,  with  the  view  of  securing  movement,  than  to  look 
for  a  recovery  by  natural  processes  where  anchylosis  must  be  expected,  unless,  indeed, 
the  wound  is  small,  the  injury  to  the  bones  slight,  and  the  patient  young. 

In  compound  fracture  of  the  wrist  no  operation  is  required,  as  a  general  rule. 

Summary. — By  way  of  summary,  compound  fractures  into  joints  should  be  regarded 
as  cases  of  wounded  joint  and  treated  accordingly,  the  amount  of  bone  comminution  and 
displacement  having  an  important  influence  in  determining  the  question  and  nature  of 
operative  interference  when  such  may  be  called  for. 

In  large  joints,  where  excision  is  inexpedient  or  dangerous,  amputation  must  be  had 
recourse  to ;  in  others,  where  excision  is  a  sound  operation,  it  should  be  preferred.  In 
the  ankle-  or  wrist-joint,  where  the  articular  ends  of  the  bones  project,  they  should,  except 
in  young  subjects,  be  removed. 

Comminution  of  bones  is  a  complication  that  requires  a  few  observations, 
although  in  shup/e  fractures  it  does  little  more  than  render  difiicult  the  treatment  of  the 
case  and  increase  the  risk  of  some  shortening  or  deformity.  When,  however,  it  is  the 
result  of  a  direct  force  from  a  "  spent  ball  "  or  other  projectile,  the  comminution  may  be 
very  great ;  the  bone  also  may  be  fissured  and  with  the  soft  parts  contused,  the  danger 
of  the  case  under  these  circumstances  being  much  aggravated,  not  only  from  the  direct 
effect  of  the  injury,  but  from  the  ostitis  that  is  so  liable  to  follow. 

In  compound  fracture  bone  comminution  has.  too.  an  important  influence  for  harm, 
adding  greatly  to  the  risks  and  dangers  of  suppuration  and  diminishing  the  probabil- 
ities of  a  successful  result,  since  each  piece  of  bone  often  acts  as  an  irritant  and  retards 
recovery,  and  the  fragments  too  often  subsequently  die.  It  is  always  well,  therefore,  in 
these  cases  to  remove  the  detached  portions,  and  when  the  extremities  of  the  bones  are 
ragged  to  excise  them.  Large  pieces  of  bone,  however,  that  are  held  by  their  periosteal 
coverings  must  not  be  interfered  with.  This  .splitting  and  comminution  of  bone  is  mo.st 
frequently  met  with  in  gunshot  wounds,  the  conoidal  bullet  of  the  present  day  splinter- 
ing far  more  than  the  round  one  of  former  times. 

In  all  cases  of  compound  fracture  where  difficulty  is  experienced  in  reducing  the  pro- 
jecting ends  of  the  broken  bone  the  best  course  is  to  remove  them  with  a  saw,  particu- 
larly when  they  are  sharp ;  comminuted  fragments  should  also  be  taken  away.  When 
much  bone  has,  however,  been  removed,  the  surgeon  should  be  careful  not  to  separate 
the  parts  too  much,  for  fear  of  want  of  union. 

The  subject  of  dislocation  and  fracture  has  been  discussed  in  the  chapter  on  dislo- 
cation. 

Fracture  from  gunshot  wounds  will  receive  attention  in  the  chapter  devoted  to  gun- 
shot injuries. 


DISEASES  or  THE  JO  [NTS.  905 


CHAPTER   XXXir. 

DISKASKS    OF    TIIK    JOINTS. 

General  Remarks. 

To  assert  that  safe  and  scientific  surgery  can  only  be  based  on  sound  pathology  may 
ap|H'ar  to  be  a  somewhat  trite  observation  ;  nevertheless,  it  is  true — so  true,  indeed,  that 
it  caiiiKit  be  impressed  too  forcibly  on  all  who  seek  or  profess  to  practise  our  profession. 
Moreover,  it  should  be  the  aim  of  every  surgeon  whose  duty  it  is  to  practise  and  to  teach 
to  dom(»nstrate  the  truth  of  the  assertion  and  to  establish  his  practice  upon  such  a  scien- 
tific l)asis.  It  is  with  this  feeling  that  I  now  pro])ose  to  consider  the  pathology  of  joint 
disease  and  to  explain  iM-iefly  the  changes  which  the  tissues  undergo  during  infiammation 
and  the  results  to  which  those  changes  lead,  setting  aside  for  the  present  disputed  points 
of  pathology  and  reserving  for  future  consideration  the  suljject  of  tumors  involving  j<jints. 

Diseases  of  a  joint  generally  commence  as  an  acute  or  chronic  inflammation  of  the 
bone  or  synovial  membrane,  although  in  the  progress  of  any  case,  and  particularly  when 
disorganization  of  a  joint  has  taken  place,  both  tissues  become  affected,  the  extent  to 
whicii  either  will  be  involved  greatly  depending  upon  the  seat  of  the  original  disea.se. 
When  it  has  begun  in  the  synovial  membrane  and  gone  on  to  produce  disorganization  of 
the  joint,  the  bones  will  in  all  probability  be  found  to  be  affected  only  on  their  articular 
facets ;  the  deeper  structures  will  not  have  been  involved.  When  the  bones  are  the  orig- 
inal seat  of  the  mischief,  and  the  inflammatory  process  has  spread  from  them  to  the  .syn- 
ovial membrane  and  disorganization  of  the  joint  taken  place,  the  chief  pathological  changes 
will  be  .seen  in  the  osseous  tissue,  and  either  the  whole  or  a  part  of  the  articular  e])iphysi8, 
if  not  a  portion  of  the  shaft,  will  be  involved  in  the  disease,  lender  both  circumstances 
the  cartilage  covering  the  articular  facets  will  have  disappeared.  When  the  bones  are 
the  primary  seats  of  disease,  the  cartilages  are  shed  more  rapidly,  as  the  articular  carti- 
lages derive  most,  if  not  all,  of  their  nourishment  through  the  bones ;  and,  as  a  conse- 
(juen;ce,  any  perversion  of  nutrition  and  inflammatory  changes  of  this  tissue  at  once  show 
themselves  in  the  cartilages. 

Practically,  there  is  no  such  thing  as  a  primary  di.sease  of  the  articular  cartilages,  no 
such  process  as  so-called  ulceration  of  cartilage,  independently  of  disease  of  other  tissues. 
When  the  cartilages  undergo  a  change,  it  is  always  secondary  to  some  affection  either  of 
the  synovial  membrane,  when  it  is  slow  and  partial  in  its  action,  or  of  the  bone,  when  it 
is  rapid  and  complete.  It  should  be  remembered,  however,  that  disease  in  the  synovial 
memVn-ane  of  a  joint  cannot  exist  for  any  time  or  be  of  any  severity  without  involving 
its  ligaments  or  the  cellular  tissue  with  which  it  is  surrounded.  Nor  can  inflammatory 
di.sease  exist  for  any  period  in  the  ai'ticular  extremity  of  a  bone  without  more  or  less 
affecting  its  periosteal  covering.  It  should  be  added,  too,  that  there  is  good  reason  to 
believe  that  either  bone  or  synovial  disease  may  be  .started  by  a  severe  sprain  or  laceration 
of  ligaments  at  their  osseous  or  periosteal  attachments. 

Before  proceeding  to  consider  the  changes  the  different  tissues  undergo  from  the  inflam- 
matory process,  it  will  be  well  to  ask  whether  there  is  such  a  disea.se  as  strumous  disease 
of  a  joint,  strumous  disease  of  the  synovial  membrane  or  bone. 

If  I  were  to  answer  this  question  according  to  custom,  as  indicated  by  the  free  appli- 
cation of  the  term  to  joint  disease,  I  should  unquestionably  say  that  it  was  a  common 
affection  ;  for  there  are  few  chronic  changes  of  a  joint  that  are  not  so  designated,  and  it  is 
rare,  in  a  delicate  child,  to  meet  with  any  chronic  affection  of  a  joint  which  is  not  regarded 
by  some  as  a  strumous  disease.  Indeed,  from  the  constant  use  of  the  phrase,  it  might  be 
thought  that  the  term  ••  .strumous  disease  '  had  .some  definite  meaning  or  conveyed  some 
definite  idea — that  the  affection  so  designated  was  of  a  special  kind,  could  be  recognized 
by  special  features,  and  possessed  definite  pathological  characteristics.  Yet  it  can  hardly 
be  said  that  such  is  practically  the  ca.se  ;  for  if  we  look  for  the  points  of  difference 
between  the  so-called  strumous  disease  and  the  chronic  inflammatory  affections,  we  shall 
fail  to  find  them,  since  they  are  not  clinicall}'  to  be  distinguished  or  practically  to  be  sepa- 
rated. Indeed,  I  am  more  than  satisfied  that  the  so-called  strumous  disease  of  a  joint  is 
nothing  more  than  a  chronic  inflammation  of  the  bones  or  the  synovial  membrane,  or 
both,  that  the  pathological  changes  in  the  afiected  tissues  are  such  as  are  clearly  traceable 


906  DISEASES  OF  THE  JOINTS. 

to  a  low  form  of  inflammatory  action,  and  that  they  difl"er  in  no  single  pathological  point 
from  the  inflammatory  changes  found  in  other  parts.  It  is  true  that  such  afi'ections, 
being  of  a  low  type,  differ  from  other  inflammatory  actions  of  a  more  healthy  charac- 
ter, but  that  they  are,  nevertheless,  inflammatory  there  can  be  no  doubt.  Practically, 
therefore,  it  would  be  well  to  expunge  this  term  "  strumous  "  in  respect  to  joints  from  our 
vocabulary,  as  its  use  certainly  misleads  by  making  the  student  believe  that  the  term  has 
a  definite  meaning  when  it  has  not.  and  by  encouraging  the  idea  that  the  disease  to  which 
it  is  applied  has  a  constitutional  more  than  a  local  origin,  and  is  consequently  incurable. 
Of  this,  however,  I  am  sure— that  so-called  strumous  disease  of  a  joint  is  as  curable  and 
as  amenable  to  treatment  as  any  other  chronic  inflammatory  disease.  In  saying  this, 
however.  I  do  not  dispute  the  fact  that  pathologically  we  do  at  rare  intervals  find  tuber- 
cular deposit  in  some  of  the  tissues  building  up  a  joint,  and  particularly  in  the  bone  ;  but 
I  must  repeat  what  I  wrote  many  years  ago  in  my  work  on  diseases  of  the  joints — that 
"  such  preparations,  being  so  rare,  are  to  be  regarded  as  pathological  curiosities."  They 
are  discovered  also  accidentally,  and  cannot  be  clinically  recognized  by  any  characteristic 
features  from  other  cases  of  chronic  inflammation  of  the  bone.  It  would  be  well,  there- 
fore, to  give  up  the  term  in  scientific  discussion,  or,  if  it  be  used  at  all,  to  use  it  in  the 
same  sense  as  the  words  "tumors,"  rheumatism,"  and  "fever"  are  now  employed — as  a 
broad  general  term  that  includes  many  afi'ections  and  covers  much  ignorance. 

With  these  general  remarks,  I  now  pass  on  to  consider  the  changes  the  diflTerent  tissues 
entering  into  the  formation  of  a  joint  undergo  in  the  inflammatory  process. 

Pathological  Changes  which  take  Place  in  the  Synovial  Membrane 

FROM  Inflammation. 

In  a  pathological  point  of  view,  inflammation  of  the  synovial  membrane  may  show 
itself  in  two  distinct  ways — firstly,  in  change  of  function  ;  secondly,  in  change  of  struc- 
ture. The  first  change  may  take  place  without  the  second,  but  the  change  of  structure 
necessarily  includes  an  alteration  in  the  function.  The  best  examples  of  the  first  class 
of  cases,  in  which  a  change  of  function  is  the  most  prominent  point,  are  seen  in  every-day 
practice  in  cases  of  so-called  chronic  or  subacute  synovitis,  where  excess  of  secretion  in 
a  joint  is  the  main  symptom,  and  in  w^hich  this  secretion  may  be  reabsorbed  and  leave  no 
trace  of  disease  behind  ;  W'hilst  the  best  illustrations  of  the  second  class,  in  which  change 
of  structure  is  the  main  point  of  clinical  as  well  as  of  pathological  importance,  are  seen  in 
the  pulpy  disease  of  the  synovial  membrane.  Between  the  two  great  classes  of  cases, 
however,  there  are  doubtless  many  links ;  for  example,  in  acute  synovitis  we  have  change 
of  structure  even  to  more  or  less  complete  disorganization,  and  in  chronic  synovitis  fre- 
quently repeated  we  have  change  of  structure  such  as  gradually  pases  into  the  pulpy 
synovial  disease.  It  would  thus  appear  that  in  acute  inflammation  of  the  synovial  mem- 
brane we  have  pathologically  a  series  of  changes  that  diff"er  somewhat  from  those  seen  in 
chronic  inflammation,  and  that  while  the  acute  form,  it  is  true,  pas.ses  into  the  chronic  by 
imperceptible  gradations,  the  two  classes  of  cases  are,  nevertheless,  very  distinct.  Acute 
inflammation  of  a  synovial  membrane  in  its  early  stage  is  pathologically  represented  by 
what  my  notes  of  cases  clearly  illustrate — a  more  or  less  minute  injection  of  the  capillary 
vessels,  passing  on  to  a  velvety  appearance  of  the  synovial  surface,  a  flocculent  surface 
or  one  covered  with  fine  fringes  of  lymph,  while  in  the  more  acute  cases  the  synovial 
membrane  may  have  disappeared  by  ulceration  or  sloughing  or  have  so  softened  down  as 
to  be  destroyed  on  the  slightest  touch.  In  the  former  class  of  cases  there  will  be.  clini- 
call)%  increase  of  secretion  in  the  joint,  severe  local  pain,  and  heat  with  surgical  fever ; 
while  in  the  latter  there  will  be  acute  suppuration  and  the  synovial  membrane  may  show 
any  one  of  the  conditions  already  indicated,  or  they  may  have  disappeared,  pus  and 
broken-up  membrane  alone  remaining  to  indicate  the  local  severity  of  the  action  as  well 
as  the  destructive  nature  of  the  aff"ection. 

In  intermediate  or  less  acute  cases  other  changes  may  be  seen,  but  they  are  not  less 
marked.  In  one,  the  notes  of  w^hich  are  before  me,  there  was  visible  to  the  eye  a  local 
patch  of  capillary  injection,  and  beneath  it  could  be  made  out  a  superficial  granular 
change  of  structure  in  the  cartilage,  In  another  an  eff"usion  of  a  firm  fibrinous  layer  of 
lymph  over  the  surface  of  the  synovial  membrane  and.  articular  cartilage  showed  itself, 
and  this  membrane  could  be  raised  from  its  bed  and  peeled  oflP — not  only  off"  the  synovial 
capsule,  but  also  off"  the  articular  cartilage ;  and  beneath  this  membrane  fine  radiating 
capillary  vessels  passing  from  the  margin  of  the  articular  cartilage  toward  the  centre 
were  clearly  visible.     In  this  case,  moreover,  after  a  section  was  made  through  the  spot 


I'ATHOLOCy   OF  JOIST  DISEASES.  907 

of  injected  inembranc  and  cartilajri'  down  to  tlic  Itonr,  tlu;  .s\v<dl('n  Iay«'r  of  membrane 
jiassinj;  over  tin-  eartilujre  was  clearly  visible,  as  well  as  tlie  granular  degeneration  of  tlie 
eartilage  l)eneatli  ;  and  this  membrane  eoiibl  )»e  separate*!  from  its  cartilaginous  connection 
by  means  of  needles.  It  occurred  in  a  child,  but  it  seems  to  me  to  be  sufficient  to  prove 
by  means  of  pathology  what  aiiatfuny  has  hitherto  failed  to  settle — viz.,  that  a  layer  of 
membrane  passes  over  the  articular  cartilage.     I  have  seen  the.se  <'hanges  more  than  once. 

The  changes  that  take  place  in  the  synovial  membrane  in  subacute  and  (dironic  syno- 
vitis remain  tu  be  noticed,  and  tliey  are  (essentially  of  the  .same  jtathologieal  character  an 
those  we  have  been  just  considering,  though  they  differ  in  this  great  point — that  the 
synovial  membrane  is  not  destroyed,  but  becomes  thickened  in  various  degrees  by  the 
intiltration  within  its  walls  and  upoji  its  surface  of  inflammatory  product;  and  this  thick- 
ening may  be  so  great  that  the  synovial  membrane  may  be  represented  by  a  tissue  an  inch 
in  diameter.  It  will,  however,  be  found  only  in  cases  in  which  repciated  attacks  of 
inflammation  have  taken  place  and  many  layers  of  lymph  have  been  deposited  upon  and 
in  the  affected  tissue.  The  layi;rs  may  not  be  deposited  rapidly  one  after  another  by  con- 
secutive attacks  of  chronic  inflammatory  action — for  they  may  be  the  result  of  di.sease 
which  has  sjiread  over  many  years — but  they  will  always  represent  an  inflammatory  action 
of  a  chronic  nature  which  at  uncertain  intervals  has  attacked  the  joint,  and  on  each  occa- 
sion left  l)ehind  it  pathological  evidence  of  its  presence  by  an  inflammatory  infiltration. 
In  delicate  and  so-called  strumou.s  subjects  the  product  will  be  soft  and  pulpy,  and  in  the 
syphilitic  firmer  and  fibrous. 

It  is  with  such  changes  as  these  tuat  all  cases  of  the  gelatiniform  or  gelatinous  dis- 
ease of  the  .synovial  membrane,  as  well  as  the  pulpy  disease  of  Sir  B.  Brodie,  are  uncjue.s- 
tionably  to  be  classed.  Both  are  of  the  same  nature  pathologically  and  clinically — at 
least,  all  my  own  investigations  have  led  to  this  conclusion.  I  shall  therefore  employ  the 
phrase  "  pulpy  disease  of  the  synovial  membrane  "  to  designate  the  changes  which  ensue 
in  chronic  inflammatory  synovial  disea.se.  The  term  is  short  and  as  expressive  as  any- 
other,  besides  being  one  with  which  the  profession  is  familiar. 

Pathological  Changes  which  the  Articular  Cartilages  undergo 

FROM  Disease. 

The  most  important  point  the  practical  surgeon  should  recognize  when  considering  the 
pathology  of  the  articular  cartilages  has  reference  to  the  fact  that  there  is  no  primary 
disease  of  its  structure,  since  pathological  anatomy  teaches  us  that  all  the  changes  found 
in  it  are  secondary  to  some  other  affection,  and,  in  the  generality  of  cases,  to  disease  in 
the  articular  extremities  of  the  bones.  There  is  no  such  disease,  therefore,  as  primary 
"  ulceration  of  the  cartilages,"  and  when  the  cartilages  are  diseased,  they  are  so  from 
the  extension  of  mischief  from  the  bone  beneath  or  from  the  synovial  membrane  around 
or  upon  them. 

Much  has  been  written  about  the  cartilages  under  the  idea  that  they  were  liable  to 
special  diseases,  and  much  error  has  consequently  crept  into  joint-pathology,  the  authority 
of  great  names  such  as  Brodie,  Key,  and  others  having  helped  to  encoiirage  this  idea. 
Modern  investigation,  as  carried  out  by  Redfern,  Goodsir,  and  others,  has.  however,  cor- 
rected this  erroneous  notion,  and  an  improved  pathology  has  clearly  .shown  that  the  dis- 
eases of  the  cartilages  are  secondary  to  diseases  of  other  ti.ssues. 

Some  years  ago,  when  describing  the  results  of  my  own  investigations,  I  divided 
these  affections  into  the  fdttt/,  the  Jihroita,  and  the  (jranular  degenerations,  and  nothing 
that  has  been  observed  since  has  led  me  to  doubt  the  accuracy  of  this  classification  ; 
indeed,  additional  experience  has  confirmed  its  truth.  I  am  not  about  to  enter,  however, 
into  a  minute  description  of  the  diff'erent  changes,  for  they  can  be  read  elsewhere  ;  but  it 
may  suffice  for  my  present  purpose  to  remind  the  reader  that  the  fathj  degnteraflon  of 
the  articular  cartilages  is  found  in  joints  that  have  been  deprived  of  their  natural  func- 
tion.s  from  any  cause — from  non-use  in  the  majority  of  cases,  but  in  many  from  bad 
nutrition  ;  that  it  is  found  in  common  with  the  same  change  in  the  bones  or  other  tissues. 
This  fatty  degeneration  can  be  recognized  with  tolerable  facility  by  the  naked  eye,  for 
the  cartilage  so  aff"ected,  instead  of  possessing  its  natural  white  pearly  aspect,  will  appear 
somewhat  transparent,  with  an  undulating,  unef|ual,  although  smooth,  surface.  When 
cut,  it  will  feel  softer  than  usual,  and  may  be  three  or  four  times  its  natural  thickness. 
At  times  it  may  even  be  "  pulped  "  by  firm  pressure  with  the  finger,  and  be  separated  from 
the  bone  with  more  than  usual  facility.  Microscopically,  also,  it  will  present  character- 
istic features.     The  natural  cartilage  corpscules  will  have   become  changed  into  fat  and 


908  DISEASES  OF  THE  JOISTS 

granule  cells  in  various  degrees,  and  the  hyaline  matrix  will  be  filled  with  cavities  vary- 
ing from  the  healthy  standard  to  large  spaces.  These  spaces,  moreover,  will  be  filled  with 
the  elements  of  fatty  degeneration,  into  which  the  healthy  corpuscles  will  have  changed. 
This  fatty  degeneration  takes  place  in  most  joints  that  have  not  been  used,  but  rarely 
from  disease  of  the  joint  itself.  When,  however,  a  joint  so  changed  becomes  the  sub- 
jecL  of  inflammation,  disorganization  of  the  articulation  rapidly  follows  ;  for  such  a  degener- 
ated tissue  has  no  power  of  resisting  disease  and  disappears  when  attacked  by  it  rapidly. 

The  fibrous  degeneration  of  the  articular  cartilage  is  a  disease  of  a 

peculiar  character.  I  believe  it  to  be  associated  with  only  one  disease  of  a  joint,  which 
is  "  osteo-arthritis."  It  is  very  gradual  in  its  progress  and  is  not  characterized  by  any 
definite  symptoms.  It  can  be  recognized  pathologically  in  its  earliest  stage  by  the  loss 
of  the  natural  glistening  aspect  of  the  cartilage  of  a  joint,  the  smooth  surface  of  which 
disappears  and  looks  rough.  Small  fissures  involving  more  or  less  of  its  thickness  next 
appear,  which  sometimes  extend  down  to  the  bone,  and,  as  a  rule,  are  thicker  in  the  cen- 
tre ;  they  occasionally  radiate  outward.  The  cartilage  seems  gradually  to  become  thin, 
and  after  a  time  to  disappear,  exposing  the  articular  surface  of  the  bone,  which  probably 
will  have  undergone  the  calcareous  degeneration.  Microscopically,  the  principal  change 
that  is  seen  in  tliis  disease  is  the  gradual  alteration  of  the  hyaline  structure  into  fibre. 
The  cartilage  corpuscles  at  the  first  will  be  found  interspersed  between  these  fibres,  but 
at  a  later  date  to  have  changed  into  granules.  At  the  last  stage  nothing  but  fibres  may 
be  found ;  and  when  this  condition  exists,  the  total  and  rapid  disappearance  of  the  struc- 
ture will  not  be  far  distant. 

The  granular  degeneration  of  the  articular  cartilage  is  the  most  import- 
ant afi"ection  of  this  tissue.  It  is  the  one  most  commonly  found  in  joint  affection,  and 
seems  to  be  the  direct  consecjuence  of  a  perverted  nutrition  in  the  bone  or  synovial  mem- 
brane from  disease  of  these  structures.  Though  of  a  simple  nature,  it  shows  itself  in 
many  ways,  and  without  microscopical  investigation  it  must  have  appeared  unintelligible. 
In  its  different  forms  it  has  doubtless  led  good  observers  to  describe  it  as  an  ulceration 
of  cartilage,  for  under  certain  conditions  the  cartilage  presents  a  worm-eaten,  excavated 
appearance  not  unlike  that  which  ulceration  might  produce. 

The  disease  is  essentially  a  granular  degeneration,  first  of  the  natural  cartilage  cells 
imbedded  in  the  hyaline  mati-ix,  and  secondly  of  the  hyaline  matrix  itself.  Let  a  carti- 
lage cell  undergo  this  granular  degeneration,  and  the  granules  by  accumulation  and  mul- 
tiplication form  a  cavity  in  the  hyaline  matrix.  Let  this  cavity  burst  on  the  surface  of 
the  cartilage  into  the  joint,  and  an  excavation  is  formed  which  can  be  seen  by  the  naked 
eye,  and  a  so-called  ulcer  is  produced.  Let  this  change  take  place  toward  the  margin  of 
the  articular  cartilage,  and  we  find  an  explanation  of  Mr.  Key's  observations  upon 
so-called  ulceration  of  this  tissue  in  certain  forms  of  inflammation  of  the  synovial  mem- 
brane of  the  joint.  Let  this  change  take  place  near  the  bones  as  a  result  of  disease  in 
their  articular  ends,  and  we  find  an  explanation  of  the  general  condition  of  the  cartilages 
in  the  bulk  of  joint  diseases  ;  for  when  the  bones  entering  into  the  formation  of  a  joint 
are  so  affected  as  to  interfere  with  the  nutrition  of  the  articular  cartilages,  the  cartilage 
may  either  present  the  worm-eaten  appearance  all  over  or  in  part,  or  it  may  have  been 
shed  from  its  bony  attachment,  when  it  will  be  found  to  be  lying  upon  the  bone  as  a  for- 
eign body  in  the  joint.  In  an  early  stage  of  disease  this  granular  degeneration  may  be 
detected  only  by  a  microscopical  examination,  although  when  it  follows  upon  disease  of 
the  bone  the  cartilage  will  always  be  found  to  peel  from  off  its  articular  facet  with  unus- 
ual facility. 

In  synovitis,  also,  the  surface  of  the  cartilage  in  contact  with  the  inflamed  membrane 
will  be  found  similarly  involved.  Should  the  disease  be  local,  as  is  at  times  seen  in  cases 
of  injury  to  an  internal  ligament  such  as  the  ligamentum  teres,  the  change  in  the  carti- 
lage will  be  local  only  ;  but  when  general,  the  whole  surface  of  the  cartilage  may  be 
involved.     In  acute  disease  acute  degeneration  follows,  as  is  evidenced  by  daily  practice. 

Pathological  Changes  in  the  Bones  the  Result  of  Inflammation. 

Inflammation  of  the  articular  extremities  of  a  bone  is  a  very  common  disease — proba- 
bly the  most  common  we  have  to  deal  with  in  connection  with  joints  ;  for  it  would  appear 
to  be  the  cause  of  most,  if  not  of  all,  of  those  cases  of  disease  of  the  articulations  which 
we  find  in  children  and  have  been  described  as  strumous  or  scrofulous  disease  of  a  joint. 
Some  years  ago,  when  writing  on  this  subject,  I  stated  that  "  I  cannot  for  one  moment 
doubt  that  the  majority  of  the  cases  which  are  described  by  surgeons  as  strumous  or  scrof- 


IWTlloLoaV  OF  JOIST  DISEASES. 


909 


Fig.  599. 


ulous  disease  of  a  joint  of  the  artieular  extremities  of  the  Vjones  depend  upon  a  chronic 
infhininiation  in  the  Ijoiic,"  and  all  the  experience  I  have  since  {gained  has  tended  to  eon- 
tirni  nie  in  tiiis  opininn.  I  lidieved  then,  as  I  believe  now,  that  the  disease  in  its  origin 
and  projrress  is  iiifianiniatiM y.  and  tliat  it  is  as  cnralde  as  any  other  h)cal  affection.  It  is 
important  to  hear  this  invariahly  in  mind  when  examining;  or  treating  a  case  of  disease  of 
a  joint,  j)articiihirly  when  it  is  found  in  a  .so-caMed  strumous  or  cachectic  sultject  ;  for  if 
we  reiiard  the  diseasi'  as  a  constitutional  one,  we  are  apt  to  think  it  ouglit  to  he  treated 
on  "general  principh's,  antl  to  ncj^lect  the  local  means  hy  which  alone  a  f^ood  recovery  can 
be  secured. 

Let  us  now  in((uire  into  the  changes  that  the  lione  undergoes  during  this  inflammatory 
or  wrongly-called  strumous  atlection. 

The  most  striking  is  probably  the  earliest,  which  is  the  expansion  of  the  articular 
extremity  ;  and  iji  some  cases  this  will  be  very  great,  and  generally  uniform.  The  articu- 
lar extremity  of  the  aftected  bone  or  the  epiphyses  of  all  the  bones  entering  into  the  for- 
mation of  the  joint  will  appear  to  be  rounded  and  generally  enlarged.  Upon  making  a 
section  of  a  bone  thus  affected  it  will  be  found  softer  than  natural ;  indeed,  it  may  be  so 
soft  as  to  allow  a  knife  to  divide  it,  or  even  to  break  or  crush  it  on  firm  pressure.  To 
the  eye  the  section  will  appear  more  vascular  than  natural,  the  cancellated  portions  more 
cancellated,  the  celFs  enlarged,  and  the  bony  septa  radiating  from  the  shaft  in  a  broad, 
palm-like  fashion.      The  cells  will  also  be  found  filled  with  a  pinkish  serum. 

If  the  disease  continue  and  the  inflammation  be  of  a  healthy  type,  parts  of  the  bone 
will  ap))ear  denser  and  more  indurated  than  the  remainder  ;  its  cancelli  will  be  filled  with 
inflammatory  products  which  have  organized,  and  the  bone  will  appear  on  section  as  a 
dense  and  ap]»arently  bloodless  mass  surrounded  by  other  vascular  cancellated  tissue. 
Should  the  inflammation  be  of  an  unhealthy  character,  diffused  suppuration  within  the 
l;)one  will  take  place,  and  death  of  the  bone,  wholly  or  in  part,  follow.  Under  these  cir- 
cumstances the  disease  will  probably  have  become  a  genuine  joint  affection,  and  have 
extended  to  the  synovial  membrane  of  the  joint  and  set  up  disease  within  its  substance. 
This  extension  of  disease  will  show  itself  by  effusion  within  the  joint,  by  pulpy  thicken- 
ing of  the  synovial  membrane  and  of  the  cellular  ti.ssue  around 
the  articulation.  Up  to  this  point  the  disease  has  been  local,  in- 
volving only  the  articular  extremities  of  the  bones,  and  has  not  at- 
tacked the  proper  joint  structures,  and  appears  also  to  be  perfectly 
curable.  But  at  this  stage  of  the  disease  the  articular  cartilages 
will  have  become  affected ;  for  when  the  inflammatory  action  has 
continued  for  any  period  and  not  shown  any  indications  of  subsi- 
dence, but,  on  the  contrary,  has  either  assumed  an  unhealthy  cha- 
racter or  interfered  with  the  nutrition  of  the  articular  lamella  of 
bone  upon  which  the  cartilages  rest,  the  articular  cartilage  will  to  a 
certainty  undergo  a  granular  degeneration  upon  the  surface  in 
apposition  with  the  bone,  become  loosened  from  its  attachment, 
and  be  thrown  off  or  shed  (Fig.  599);  or  it  may  degenerate  in  patches 
and  present  to  the  eye  an  irregular  excavated  surface.  If  the  dis- 
ease be  chronic,  the  cartilage  will  degenerate  slowly  and  be  as  slowly 
loo.sened  from  its  osseous  base,  when  it  may  readily  be  lifted  off  the  Drawing;  ((;.  >f.  w-'m  made 

■,  ,  .       ^  ^       -tf  A        ^•  1  •  1    .1  -1  to -show  the.'>hed(liiiK0f  llie 

bone  by  any  nistrument.     it  the  disease  be  more  rapid,  the  cartilage      Articular  cartilage  in  (Jsti- 
will  likewise  be  shed  more  rapidly,  raised  as  a  blister  off  the  bone,      **^" 
or  found  l3'ing  upon  it  as  a  foi'eign  body.     Under  the  microscope  it  will  appear  to  have 
undergone  the  granular  degeneration. 

When  the  disease  is  acute,  the  cartilage  may  disappear  Fig.  600. 

altogether,  having  Iteen  shed  from  its  osseous  base  and  be- 
come rapidly  degenerated. 

The  articulating  surface  of  the  bone  during  this  time 
may  appear  in  some  cases,  as  in  inflammation,  only  extra- 
vascular  ;  in  others  it  may  be  rough  or  so-called  ulcerat- 
ing ;  while  in  a  third  class  the  articulating  facets  will  have 

been  shed  wholly  or  in  part.       In  a  still  worse  class  pieces     Transver.se  section  of  the  Humerus  above 

of  necrosed  bone  involving  more  or  less  of  the  articular      the(on(i.vies.  siiowing  New  Bone  de- 

...   ,  1  -i      •        1  1  -ii         posited  Ipeiieatli  Periosteum,  undergo- 

extremitv  will  be  seen,  while  in  the  worst  an  abscess  will       ing  Kareiactiun  and  thus  simulating 
have  made  its  way  into  the  joint  from  the  diseased  artic-      Jpe^UeTorMfj.'Walid^f."  ^™™  * 
ular  extremity.     In  all   these  conditions   the   cartilages 
will  have  disappeared  and  the  joint  become  disorganized.     These  pathological  remarks 


910  '  DISEASES  OF  THE  JOINTS. 

are  applicable  to  every  articulation — to  the  hip  as  much  as  to  the  knee,  and  to  the  shoulder 
as  to  the  elbow. 

In  all  chronic  cases  of  ostitis  there  will  be  found  more  or  less  deposit  upon  the  bone 
underneath  the  periosteum,  and  some  good  surgeons  believe  that  it  is  solely  by  such 
deposit  that  the  clinical  symptoms  of  enlargement  of  bone  are  to  be  explained.  My 
friend  Mr.  C.  Symonds  has  ably  supported  this  view  (Brit.  Med.  Journ.,  December  8, 
1883). 

The  drawing  (Fig.  600)  shows  how  subperiosteal  bony  formations  subsequently  rar- 
ify,  so  as  to  simulate  true  bony  enlargement,  the  cancellous  appearance  being  due  to 
the  widening  of  the  canals  in  the  compact  tissue  thi'ough  absorption  of  the  bony 
walls. 

Clinical  Symptoms  associated  with  these  Pathological  Changes. 

The  symptoms  by  which  these  pathological  changes  which  have  been  described  can 
be  recognized  vary  according  to  the  formation  and  surroundings  of  each  joint,  but  in 
their  general  character  they  are  the  same. 

Any  inflammation  of  the  synovial  membrane,  of  whatever  kind,  always 

shows  itself  within  a  few  hours  or  days  of  its  origin  by  effusion,  and  consequently  by 
distension  of  the  articulation,  while  in  the  knee,  ankle,  elbow,  wrist,  shoulder,  and  other 
joints  this  clinical  condition  makes  itself  manifest  in  a  way  which  cannot  be  misinter- 
preted. The  synovial  sac  becomes  enlarged  and  distended  by  the  effusion,  so  that  it 
bulges  between  the  bones  and  gives  an  outline  to  the  joint  unlike  that  furnished  by  any 
other  condition.  In  the  hip-joint  similar  changes  take  place,  but  they  are  not  quite  so 
palpable,  though  they  can  be  made  out  by  careful  examination,  and  particularly  by  a 
comparison  of  the  affected  with  the  sound  side — a  point  of  practice  which  should  never 
be  omitted  in  the  examination  of  any  injured  or  diseased  joint;  the  soft  parts  in  front 
of  the  joint  will  be  more  prominent  and  full ;  pain  will  be  produced  by  gentle  pressure 
made  upon  the  part,  particularly  behind  the  great  trochanter,  where  a  soft  swelling,  which 
will  be  manifest  to  the  eye,  will  also  exist  in  lieu  of  the  natural  depression.  Even  fluc- 
tuation may  be  detected  through  the  joint  on  careful  palpation.  At  any  rate,  to  the  eye 
and  hand  there  will  be  clearly  some  extra  fulness  of  the  soft  parts  sufficient  to  lead  a 
surgeon  to  suspect  the  true  nature  of  the  disease. 

In  disease  of  the  articular  extremities  of  the  bones  a  different  clinical 

condition  will  be  present.  At  the  commencement  of  the  disease,  and  sometimes  for  a 
lengthened  period,  which  varies  in  each  case,  an  aching  of  the  part  is  the  only  local 
symptom.  This  aching  may  be  of  greater  or  less  intensity,  and  depends  much  on  the 
severity  of  the  disease.  It  is  too  often  regarded  as  "growing  pains"  or  rheumatism. 
What  I  wish  now  to  note  is  that  local  pain  is  the  first  clinical  symptom,  and  not  effusion, 
and  that  there  is  no  enlargement  of  the  affected  joint.  As  the  disease  progresses,  how- 
ever, an  enlargement  may  be  detected,  which  in  the  hip  can  be  made  out  by  manipula- 
tion, whereas  in  the  knee  or  other  joints  it  may  be  visible  to  the  eye.  It  will  show  itself 
as  an  apparent  enlargement  of  the  bone,  a  thickening  or  expansion  of  the  osseous,  and 
probably  of  the  periosteal,  structure  unlike  that  existing  in  synovial  disease ;  there  will 
be  no  fluctuation,  no  soft  yielding  of  the  parts,  but  clearly  a  thickening  of  the  osseous 
structure  of  the  articular  extremity  of  the  bone,  while  the  soft  parts  covering  in  the 
enlarged  bone  are  quite  natural.  With  this  aching  of  the  part  there  may  also  be  increase 
of  heat  as  an  early  symptom,  yet  this  symptom  is  not  constant,  although  it  is  fairly 
uniformly  so ;  it  may,  however,  be  intermittent.  As  a  rule,  it  shows  itself  as  a  general 
periodical  flushing  of  the  part. 

In  chronic  synovitis  which  leads  to  joint  changes  the  joint  may  probably 

be  gently  moved  without  exciting  pain  or  spasm  of  the  muscles  that  move  the  articulation. 
Pressure  upon  the  part  with  the  fingers  will  probably  excite  it,  although  moderate  pres- 
sure of  one  bone  against  the  other  may  be  made  without  giving  rise  to  any  indication  of 
distress. 

In  diseases  of  the  bone  entering  into  the  formation  of  the  joint 

these  clinical  conditions  do  not  all  exist.  The  joint  may  be  moved  quietly  without 
exciting  pain,  but  the  attempt  will,  as  a  rule,  excite  spasm  of  one  or  more  of  the  groups 
of  muscles  which  move  the  articulation.  Moderate  manipulation  also  will  be  well  borne. 
Firm  pressure  upon  the  bone,  so  as  to  bring  the  two  articular  surfaces  in  contact,  will 
always  excite  pain  ;  not  the  pressure  produced  by  a  jar,  such  as  in  the  hip  is  caused  by 
a  sudden  blow  upon  the  foot  or  trochanter — for  such  a  mode  of  investigation   must  be 


nrsEASFs  OF  special  joists.  911 

looktMl  upon  iis  niiiiih  ami  sniucwliat  uiircrtaiii  ;  iiidi-cd,  it  is  almost  siiro  to  excite  in  the 
])atit'iit  a  start  ami  an  i-xpressioii  of  pain — Itut  tlio  pntssuro  which  is  ])ro(lufed  by  u  stuady 
i'oive  ajiiilicd  by  the  hand  tn  the  trochanter  toward  the  pelvis  or  through  the  tor»t  to  the 
articular  extremitiiis  of  the  hones;  a  ))ressure  which  in  synovial  distnise  rarely,  if  ever, 
gives  rise  to  j)ain,  but  in  osteal  disease  invariably  excites  it. 

These  syniptoius  in  the  two  classes  of  casi-s  ajtpear  clearly  to  indicate  the  two  distinct 
aftections  in  tlieir  early  stage.  They  apply  to  all  articulations,  and  may  be  thus  sum- 
marized : 

Sr.M.MAHV. — In  synovial  disease  >wclliMg  is  the  earliest  clinical  symptom,  with 
more  or  less  fluctuation,  each  joint  showing  this  in  its  (nvn  way.  As  a  rule,  this  swelling 
is  unattended  with  much  pain.  Pressure  on  the  joint  causes  ])ain,  although  gentle  in<tve- 
ment  maybe  made  without  increasing  it  or  exciting  spasm  of  the  muscles  which  surround 
the  joint.      Inter-articiilar  pressure  can  generally  l)e  tolerated. 

In  articular  ostitis  pain  is  the  earliest  and  most  constant  symptom — pain  of  an 
aching  character,  varying  in  intensity  and  generally  increased  by  firm  local  pressure. 
Tiiere  will  be  no  visible  enlargement  of  the  part  for  .some  weeks  or  months,  and  no  fluc- 
tuation. Gentle  movement  generally  excites  spasm  of  muscles  about  the  joint,  and  inter- 
articular  pressure  always  increases  this  and  cause.s  pain.  Increased  heat  also  exists  about 
the  parts  and  is  of  an  intermittent  character. 


DISEASES  OF  SPECIAL  JOINTS. 

Disease  of  the  Hip-Joint. 

Authors  have  hitherto  led  their  readers  to  look  upon  disease  of  the  hip-joint  as  a 
special  or  peculiar  affection,  and  to  regard  it  pathologically  and  clinically  as  distinct  from 
disea.ses  of  the  other  joints.  Such,  however,  is  not  the  case,  for  diseases  of  the  hip-joint 
differ  in  no  single  pathological  point  from  those  of  any  other  articulation. 

It  has  also  with  too  much  confidence  been  described  as  a  ".strumous  disease."  as  if 
all  diseases  of  the  hip-joint  or  of  any  joint  were  generally  of  this  nature  or  found  in  sub- 
jects who  are  only  of  a  strumous  diathesis — as  if  all  had  a  constitutional,  and  not  a  local, 
origin. 

Hip-joint  disease  is  a  local  disease  and  is  mostly  set  up  by  local  causes.  It  is,  more- 
over, as  amenable  to  local  treatment  as  any  other  affection.  "  It  occurs  very  frequently 
in  strumous  children,"  says  Mr.  Holmes — "  a  circumstance  which  has  led  to  its  being 
denominated  'strumous;'  but  it  seems  to  have  no  necessary  connection  with  struma, 
unless  so  wide  a  signification  be  assigned  to  that  somewhat  vague  term  as  would  render 
the  designation  itself  unmeaning.  If  by  struma  be  meant  a  state  of  the  system  which 
renders  the  subject  of  it  prone  to  the  deposit  of  tubercle  in  the  viscera.  I  think  that  there 
is  good  reason  for  asserting  that  morbus  coxarius  often  attacks  children  who  are  not 
strumou.s — i  e.,  who  do  not  displa}'  any  such  tendency  to  the  deposit  of  tubercle — and 
therefore  that  no  decisive  proof  of  any  strumous  tendency  is  afforded  by  the  presence  of 
the  affection.  If,  on  the  contrary,  struma  be  defined  as  that  condition  of  the  system 
which  disposes  its  subjects  to  the  development  of  low  inflammations  of  various  kinds, 
then  it  is  difficult  to  see  what  is  the  significance  of  the  designation."  It  would,  therefore, 
be  well  to  discard  the  erroneous  notion  that  hip  disease  has  its  origin  in  a  constitutional 
cause,  for  till  that  is  effected  the  local  treatment  is  likely  to  be  disregarded  or  looked 
upon  as  of  secondary  importance,  whereas  all  who  have  much  experience  in  the  treatment 
of  these  cases  will  admit  that  local  treatment  cannot  be  made  too  prominent  a  feature.  It 
should,  therefore,  be  looked  upon  clinically  as  a  local  affection  and  one  to  be  treated  by 
local  means,  such  constitutional  treatment  being  employed  as  the  general  condition  of  the 
patient  may  appear  to  warrant,  the  same  principles  of  practice  being  applicable  in  these 
cases  as  have  been  found  of  value  in  other  joint  affections. 

Hip  disease,  unfortunately,  is  a  very  common  affection,  and  my  own  statistics  inform 
me  that  it  forms  about  thirty  per  cent,  of  the  joint  cases  admitted  into  a  metropolitan 
hospital.  It  is  also  an  affection  of  child-life,  for  out  of  360  cases  of  which  I  have  notes, 
<)2  per  cent,  or  nearly  two-thirds,  occurred  in  children  under  ten  years  of  age.  and  four- 
fifths  in  patients  under  twenty — that  is,  it  occurred  during  the  period  of  the  growth  and 
development  of  the  bone,  and  not  during  that  of  its  full  maturity.  This  point  will  be 
seen  on  reference  to  the  following;  table : 


.::d  « 
97 

:;as€ 

*  -  223  cases,  or  61.9  per  cent, 
or  23.8  per  cent. 

86 

27 

or  7.5    " 

13 

or  3.6 

11 

or  3 

912  DISEASES  OF  THE  JOISTS. 

Tahle  showing  the  Agts  at  tchich  Hip  Disease  commenced. 

Four  vears  and  under 

Between  6  and  10  vears  of  age     . 

"       11    "20' 

"       21    "     30  "  .         . 

"       31    "    40  "  .         . 

Above   40  years  of  age 

Of  these  cases,  230  were  collected  by  me  when  acting  as  registrar  at  Guy's  from  1853 
10  18G1,  and  130  are  from  the  notes  of  cases  which  have  been  under  my  own  care. 

It  is  found  in  the  male  and  female  subject  in  equal  proportions,  but  appears  to  attack 
the  left  more  frequently  than  the  right  limb,  sixty  per  cent,  of  my  cases  having  occurred 
on  the  left  and  forty  on  the  right  side ;  and  this  proportion  is  very  similar  to  that  pub- 
lished by  Mr.  Lonsdale  in  the  Lancet  for  September  8.  1855.  where,  out  of  112  cases  of 
deformity  of  the  hip.  65  were  of  the  left  and  47  of  the  right  side. 

Pathology. — It  has  been  already  stated  that  in  a  pathological  point  of  view  hip  dis- 
ease differs  in  no  respect  from  that  of  other  joints  and  is  not  a  strumous  affection, 
although  it  mav  occur  in  strumous  subjects.  It  may  also  be  repeated  that  it  is  a  very- 
rare  thing  to  find  strumous  or  tubercular  matter  in  a  diseased  hip-joint.  Excluding  new 
growths,  disease  of  the  hip  consequently  means  inflammation  of  the  bones  or  soft  parts 
entering  into  the  articulation,  and  in  at  least  two-thirds  of  the  cases  inflammation  and 
necrosis  of  bone. 

In  the  pathology  of  joints  few  points  probably  have  been  more  disputed  than  the  seat 
of  the  disease  in  hip-joint  affection,  and  I  believe  the  difficulty  has  been  entirely  raised  on 
the  mistaken  notion  that  the  nature  of  the  affection  was  different  from  that  of  other  joint 
diseases.  We  have  never  heard  much  importance  placed  upon  the  point  in  diseases  of 
the  knee-,  shoulder-,  or  other  joints.  The  question  as  to  the  origin  or  not  of  disease  of 
the  knee  in  the  crucial  ligaments  or  of  disease  of  the  shoulder  in  the  long  tendon  of  the 
biceps  has  never  been  very  warmly  discussed.  And  yet  we  find  men  gravely  discussing 
the  question  as  to  the  origin  of  hip  disease  in  the  ligamentum  teres.  3Iy  much-respected 
teacher,  the  late  Mr.  Aston  Key.  laid  great  stress  on  this  point,  and  believed  that  it  was 
from  that  ligament  and  its  attachments  that  disease  of  the  hip-joint  generally  proceeded. 
Pathologv  has.  however,  made  gi-eat  advances  since  those  days,  and  we  now  know  that 
•disease  in  a  joint  (hip  or  other)  may  have  its  origin  in  the  bones  which  form  the  joint  or 
in  the  soft  parts  or  ligaments  that  hold  them  together.  Experience,  moreover,  has  taught 
us  that  we  may  have  an  acute  inflammation  of  the  synovial  membrane  rapidly  going  on 
to  complete  disorganization  of  the  ligaments,  cartilages,  and  soft  parts  of  the  joints,  and 
even  causing  death  of  the  bones  entering  into  its  formation.  The  inflammation  may  be 
so  acute  as  to  render  it  difficult  at  the  post-mortem  examination  to  read  the  pathological 
facts  correctly ;  for  when  such  changes  as  these  take  place,  it  is  fairly  open  to  question 
whether  the  iniSammation  originated  in  the  synovial  membrane  and  spread  to  the  bones, 
:artilages.  and  ligaments,  causing  their  destruction,  or  whether  it  began  in  an  osseous 
centre  and  extended  to  the  joint.  This  difficulty  is  experienced  when  the  disease  has  been 
so  severe  as  to  cause  a  division  of  the  pelvic  bones  into  their  original  segments  or  a  sep- 
aration of  the  epiphysis  of  bone  forming  the  head  of  the  femur  from  its  normal  attach- 
ment to  the  neck. 

When  the  bones  of  the  joint  are  equally  involved  in  acute  di.sease.  it  is  probable  that 
the  mischief  began  in  the  synovial  membrane  and  spread  to  the  bone.  But  when  we  find 
one  bone  morediseased  than  another — e.  g..  the  femur  than  the  acetabulum,  or  vice 
irrsa — it  is  probable  that  acute  inflammation  originated  in  it  and  spread  to  the  soft  parts. 
These  points,  however,  are  to  be  looked  upon  as  only  feeble  indications,  and  not  as  definite 
guides  upon  which  an  opinion  may  be  formed.  In  chronic  disease  of  the  hip-joint  the 
question  as  to  the  seat  of  the  original  disease  is  not  so  easily  answered,  and  yet.  from 
what  I  have  observed,  clinically  and  pathologically,  the  question  is  not  one  impossible  to 
answer.  When  a  joint  is  disorganized,  its  ligaments  and  cartilages  gone,  and  the  articu- 
lar surfaces  of  the  bone  exposed,  or  perhaps  diseased,  there  may  be  some  difficulty  in 
decidins  as  to  the  particular  tissue  in  which  the  inflammation  originated  ;  but  when  a  sec- 
tion of  "the  bone  is  made — e.  g..  the  head  of  a  femur  or  the  head  of  a  tibia — and  a  cavity, 
a  sequestrum,  or  a  suppurating  bone  is  found  communicating  with  the  joint,  probabilities 
certainly  point  to  the  bone  as  being  the  original  seat  of  the  disea.se.  But  it  may  be 
asserted  that  in  such  in.stances  no  one  doubts  the  cause  of  the  joint  disease,  since  the 
pathological  conditions  clearly  prove  it ;  yet  the  clinical  histories  of  such  cases  differ  in 
DO  single  point  from  those  of  others  in  which,  perhaps,  the  same  very  marked  evidence 


DISEASES  OF  SI'ECIM.  .InlSTS. 


013 


of  disease  is  not  to  be  seen — that  is,  if  the  joint  he  cxuuiined  on  its  surface  only.  Indeed, 
tit  examine  a  i>athoIo<;ieal  specimen  of"  a  hone  or  of  a  diseased  joint,  it  is  ahsohitely  neces- 
sary to  make  a  vertical  section  through  the  h<ine,  since  to  h>ok  at  it  I'ronj  the  joint  .surface 
is  most  fallacious  and  an  (i|iininii  furnicd  from  the  appearance  thus  aci|iiire(l  is  too  likely 
to  he  erroneous. 

If  \Vf  make,  then,  a  section  of  the  hone  in  chronic  disease  of  the  joint,  we  shall  find 
in  a  larire  uiimher  of  ca.ses,  especially  in  the  youn^'.  hypenemia  of  its  articular  extremity 
and  condensation,  if  not  suppurati(»n  or  necrosis,  fronj  chronic  inflammatory  action  (V\^. 
tlOl  )  ;  in  fact,  we  shall  Hud  marked  evidence  of  articular  ostitis  in  <ine  of  its  stapes,  for 
diiulitless  (lurinir  youiiLT  lite  this  is  the  most  common  fnrni  of  disea.se  which  precedes  joint 
mischief  and  fntin  which  joint  disease  proceeds.  This  opinion  is  al.so  corroborated  hy  tin* 
fict  that  in  our  museums  almost  every  s])ecimen  of  chronic  joint  di.sease  reveals  advanced 
hunc  mischief  extendinj;  heyond  the  surface  and  {generally  involvinj;  more  or  less  of  the 
articjilar  ends  of  the  hone  which  enter  into  the  formation  of  the  joint.  In  our  Guy's 
Museum  this  point  is  very  strongly  displayed,  and  on  lookinjr  over  other  museums  and 
copious  notes  of  joint  ca.ses  the  .same  truth  is  apparent. 

At  times,  however,  the  disease  may  primarily  commence  in  the  epiphysial  cartilage 
situated  between  the  head  of  the  femur  and  its  neck,  the  epiphysis  as  a  con.sequence 
being  thrown  off  (Kig.  (502).     This  jtathological  observation  must  be  looked  upon  as  of 

Fig.  cm.  Fig.  002. 


Necrosis  of  the  Head  of  the  Femur,  with  Seques- 
trum in  it.s  Xeck.    (Prep.  ISl.sS,  (iuy's  Mus.) 


Separation  of  Epipliysis  forming  the  Head 
of  Femur,    ((iuy's  Mus.,  Prep.  ISI-t*".) 


great  clinical  importance  ;  for  if  the  majority  of  cases  of  joint  disease  is  to  be  attributed 
to  the  extension  of  an  inflammatory  action  from  the  articular  extremity  of  a  bone  to  the 
other  tissues,  it  becomes  a  question  of  urgency  to  recognize  the  disease  of  the  bone  in  its 
early  stage  in  order  to  prevent  its  progress  to  the  tissues  upon  which  the  integrity  of  the 
joint  itself  depends,  and  clinically  there  is  good  reason  to  believe  that  such  can  fre- 
quently be  done.  In  the  hip-joint  it  may  be  difficult — po.s.sibly  more  difficult  than  it  is 
in  disease  of  other  articulations  that  are  not  so  well  covered  in  with  soft  parts,  such  as  the 
knee — but  it  can  be  made  out  with  care  and  discrimination  even  in  the  hip.  And  here  it  may 
be  well  to  consider  the  clinical  features  upon  which  our  diagnosis  should  be  determined. 

DlAGNCSis. — The  neees.sity  of  making  a  correct  and  early  diagnosis  of  hip  disease 
would  scarcely  require  illustration  did  not  daily  experience  indicate  that  it  is  not  suffi- 
ciently recognized.     The  early  sym])toms  of  the  affection,  consequently,  are  important. 

When  a  child,  after  injury  to  the  hip.  has  joint  pain,  and  possibly  limps,  and  these 
symptoms  persist  after  all  external  evidence  of  injury  has  passed  away,  there  is  some  rea- 
son to  suspect  the  presence  of  joint  mischief.  When  this  pain  is  increased  by  inter- 
articular  pressure,  either  by  means  of  the  hand  applied  over  the  trochanter  or  by  the 
patient  standing  or  walking,  the  suspicion  should  be  strengthened.  When  swelling  of 
the  parts  can  be  made  out  and  .some  bulging  of  the  synovial  membrane,  as  shown  by  a  fulness 
behind  the  trochanter  and  in  the  groin,  is  found  to  exist,  combined  with  tenderness,  syno- 
vial inflammation  is  rendered  probable;  and  when  persistent  pain  without  effusion  is  the  more 
prominent  symptom,  aggravated  by  firm  inter-articular  pressure,  bone  mischief  is  indicated. 
When  these  symptoms  appear  after  some  fever  or  illnes.s — or,  indeed,  without  any  such  cause 
— they  are  of  no  less  importance,  although,  probably,  they  are  more  liable  to  be  overlooked. 

As  a  clinical  point  of  primary  importance  all  joint  pain  claims  attention,  and  particu- 
larly in  hip-joint  cases:  and  when  this  is  referred  to  the  knee,  the  surgeon  must  not  be 
misled.  Limping  of  any  kind  alwaj's  indicates  something  wrong — probably  very  wrong 
— more  particularly  when  combined  with  joint  pain  aggravated  by  inter-articular  pressure. 
5S 


914 


DISEASES  OF  THE  JOINTS. 


Spasm  of  the  muscles  arotind  the  joint  is  a  symptom  of  great  significance  and  a  means  that 
nature  adopts  to  ensure  immobilit}-  of  the  afiected  articulation  ;  in  some  cases  it  will  be 
so  severe  as  to  forbid  all  movement,  but  in  others  it  is  less  marked :  at  one  time  it  will  be 
confined  to  one  group  of  muscles,  such  as  the  flexors,  when  the  position  of  the  limb  will 
be  determined,  while  at  others  the  rotators  or  abductors  will  be  afiected  ;  but  whenever  it 
is  met  with,  there  is  probably  some  afi"eetion  of  the  joint  itself  or  of  the  bones  that  enter 
into  its  formation.  When  doubt  exists  as  to  muscular  spasm  being  the  cause  of  joint 
immobility,  an  anaesthetic  should  be  used,  as  all  spasm  ceases  under  its  influence,  and  the 
head  of  the  bone,  by  manipulation,  rotates  with  more  or  less  facility  and  smoothness 
according  to  the  amount  of  joint  mischief  that  is  present. 

Position  of  Limb  as  a  Means  of  Diagnosis. — In  the  diagnosis  or  treatment  of  hip 
disease  there  is  no  point  which  deserves  closer  attention  than  the  position  of  the  limb,  and 
I  am  disposed  to  think  it  has  not  received  that  attention,  since  experience  has  proved  that 
most  of  the  cases  of  deformity  met  with  after  a  natural  cure  of  the  disease  are  due  to  a 
want  of  appreciation  of  its  importance. 

In  one  case  the  limb  will  appear  elongated,  but  on  measurement  no  real  lengthening 
will  be  detected,  the  apparent  elongation  being  due  to  the  tilting  upward  of  the  pelvis  on 


Fig.  605. 


Fig.  606. 


Apparent  Shortening  of  the  Limb  in  Hip  Disease  caused 
liv  .Adduction. 


Fig.  603. 


Fig.  604. 


Fig.  607 


Fig. 


Fig.  6<J3. — Apparent  Elonnaiion  of  the  Left  Lower  Extremity  in  Hip  Disease  on  the  Left  Side,  due  to  .Induction  of 
the  Limb  and  the  necessary  Tilting  Upward  of  the  Pelvis  on  the  .Sound  Side  to  allow  the  Abducted  Limb  being  brought 
Into  a  Line  with  the  Body.' 

Fig.  604. — .Itducted  Position  of  the  Diseased  Left  Limb  when  the  Pelvis  has  been  brought  into  its  Natural  Position 
at  Right  Angles  to  the  Spine. 

Fig.  6<>o. — Position  of  Patient  when  Standing  with  Disease  of  the  Left  Hip-Joint  and  an  Jdducted  Limb.  (The 
pelvisis  tilted  up  on  the  affected  side  and  the  limb  thereby  apparently  shortened. 

Fig.  606. — Position  of  the  Adducted  Limb  when  the  Pelvis  is  brought  Straight. 

the  sound  side,  either  from  the  patient  naturally  throwing  all  the  weight  of  the  body  on 
that(  side  to  take  ofi"  pressure  from  the  aflfected  one  or  from  muscular  spasm  causing 
abduction  of  the  limbs  i  Figs.  603.  GO-t  >.  In  another  case  the 
pelvis  on  the  aff"ected  side  will  be  drawn  up  and  tilted  slightly 
backward,  the  thigh  becoming  adducted  and  more  or  less 
flexed  upon  the  pelvis  (Figs.  605.  606),  or  in  some  cases 
rotated  outward  from  the  spasmodic  contraction  of  the  mus- 
cles that  move  the  hip.  In  other  and  more  advanced  cases 
genuine  shortening  of  the  limb  may  take  place  from  either  real 
loss  of  substance  in  the  head  or  neck  of  the  bone,  or,  in  excep- 
tional cases,  from  di.slocation  of  the  head  of  the  femur  upward 
and  backward  <  ilio-ischiatie)  :  and  in  rarer  examples  the  neck 
and  shaft  of  the  femur  may  be  separated  and  displaced  up- 
ward and  backward,  the  epiphysial  head  of  the  bone  being  left 
in  the  acetabulum.  This  probably  occurred  in  the  case  from 
which  Figs.  607.  60S  were  taken.  Where  the  joint  is  flexed, 
some  spinal  deformitv  (lordosis)  will  exist  when  the  patient 
Displacement  oi  Femur.    ^Taken   gt^uds   or  lies:    but  this  apparent   spinal   curve  will,  however. 

from   »\  illiara  D ,  set.  H.  lOl-  '  rr  f  .,  . 

lowine  disea-^  of  five  years'   even  in  the  worst  cases,  at  once  disappear  when  the  patient 
m«"emlitiIthe%inS)  '^"''  is  placed  On  his  back  and  the  limb  raised  (Figs.  609,  610)  or 


DISEASES   or  SI-ECIAL  .InlSTS. 


915 


wlu'ii  lie  stamls  witli  tin-  k'j;  flexed  (Ki<j:.  \\\'l).      Aiiparciit  el<)ii;:ati<iii  oi"  the   liriih   under 
all  "irciiiustaiires  means  it.s  ff/>duetii»ii  ;   sliDrtciiiii^'  ol"  the  liiiil)  impliey  //'/ductioii  ;  flexion 

I'k..  ti(»<». 


Fig.  609. — Lordosis  of  Spine,  as  seen  with  Patient  tlie  Subject  of  Hip  Disease  in  Recumbent  ^o^itloll,  witii  ?emur 
flexed  at  Angle  of  V.V\  degrees. 

Kig.  611). — Lordosis  Kllaced  by  I'.levatiug  tlie  Fle.xed  Limb. 


gives  rise  to  lordosis.  These  conditions  necessarily  follow  any  attempt  of  the  patient  to 
bring  the  sole  of  the  nialplaced  limb  down  to  the  ground. 

FlatleniiKi  of  the  links,  as  seen  in  hip  disea.se,  is  due  to  a  wasting  of  the  glutei  mus- 
cles from  want  of  use,  this  symptom  boeoniing  more  marked  when  the  thigh  is  slightly 
flexed,  the  trochanter  rotated  outward  and  the  foot  inward. 

Disease  of  the  Hip-Joint  attended  with  Suppuration. — These  are  the 

worst  cases  of  joint  disease.  I'nr  sujipiirariuii  oi'  a  joint  L;enerally  means  its  disorgani- 
zation ;  and  when  the  disea.se  has  its  seat  in  the  bone,  necrosis  or  some  serious  inflam- 
matory change  is  indicated.  Under  these  circumstances  all  free  movement  of  the  head 
of  the  bone  will  probably  have  long  disappeared  and  more  or  less  anchylosis  or  natural 
repair  have  taken  place,  for  in  joint  affections  reparative  and  disea.sed  actions  run  much 
together.     The  limb  may  be  found  in  any  position,  the  flexed  and  adducted  position  of 

the  thigh  being  the  most  common,  particularly 
Fig.  611.  Fig.  612,  in  neglected  cases,  as  illu.strated  in  Fig.  G13; 

but  at  times  the  thigh  will  be  rotated  outward, 
and  even  abducted.  When  sinuses  exist,  a 
probe  may  detect  diseased  bone.  When  the 
pelvis   is   involved   in    the   disease,  a  finger 

Fig.  613. 


Lordosis  of  Spine  in  Hip  Disease  from  Flexion  of  Thigh. 

Flu.  (ill. — Ancbylosis  of  Left  Hip  at  VM°,  jiroduciug  Lordosis;  when  Patif.i  i-  •nik. 

Fill.  612. — Lordosis  remedied  by  raising  limb. 

Fig.  6i:?. — Disorganization  of  llip-.Ioint.    (From  patient,  Sarah  B ,  set.  22,  July,  1870.    Ejccision  of  the  joint  was 

performed  in  this  case,  and  a  good  result  followed.; 


pas.sed  into  the  bowel  will  often  detect  any  swelling  about  the  floor  of  the  acetabulum. 
When  dislocation  is  present,  the  symptoms  will  indicate  its  form. 

All  ca.ses,  however,  of  suppuration  about  the  joint,  even  when  associated  with  disease 
of  the  joint,  are  not  to  be  regarded  as  a  direct  result  of  disorganization  of  the  articu- 
lation, since  it  is  quite  certain  that  inflammatory  mischief  may  exist  in  the  joint  and  sub- 
side, and  yet  be  followed  b}'  suppuration  in  the  cellular  tissue  about  the  part ;  and  in  this 
opinion  pathological  does  but  confirm  clinical  observation.     There  may  be  some  difficulty 


916 


DISEASES  OF  THE  JOINTS. 


in  making  out  such  cases  during  life,  but  I  have  no  doubt  as  to  their  existence.  In  the 
hip  they  are  the  more  common. 

Prognosis. — When  hip  disease  can  be  arrested  in  its  early  stage,  a  complete  recovery 
may  take  place,  more  particularly  when  it  has  its  origin  in  synovial  inflammation,  although 
when  due  to  articular  ostitis  and  the  disease  has  been  of  long  standing  a  recovery  will 
probably  ensue  with  anchylosis.  When  the  joint  has  suppurated  and  a  natural  recovery 
follows,  it  must  be,  in  the  large  majority  of  cases,  with  fibrous  or  soft  anchylosis,  and  in 
the  minority  with  bony.  In  the  3Iedical  Times  and  Gazette  for  18G9  I  illustrated  all 
these  points  fully  by  a  series  of  cases. 

A  very  beautiful  example  of  bony  anchylosis  is  represented  in  Fig.  ()14. 

It  sometimes  happens,  when  articular  ostitis  has  attacked  the  head  and  neck  of  the 
femur  in  childhood  and  recovery  has  taken  place  with  either  a  movable  or  an  anchylosed 
joint,  that  some  arrest  of  growth  in  the  bone  may  be  the  result.     I  have  seen  this  in  a 


Fig.  614. 


Fig.  615. 


Synostosis  of  Hip- Joint.  (Taken  by  my  father,  the  late  Mr. 
T.  E.  Bryant,  from  a  man  tet.  42  who  had  had  a  stitF  joint 
for  thirty  years.     (Prep.  131S*8^  Guy's  Mus.) 


Arrest  of  Growth  in  the  Neck 
of  Femur  as  a  result  of  Artic- 
ular Ostitis. 


child  who  had  been  under  my  care  when  five  years  of  age  for  articular  ostitis,  from  which 
she  perfectly  recovered  ;  the  femur  on  the  affected  side  at  the  age  of  eight  was  an  inch 
shorter  than  its  fellow,  the  trochanter  nearer  the  median  line  of  the  body  and  the  anterior 
superior  spinous  process  of  the  ilium  ;  the  seat  of  the  shortening  was  clearly  in  the  neck 
of  the  femur,  which  had  been  arrested  in  its  growth  (Fig.  615). 

Diagnosis. — The  diagnosis  of  hip  disease  is  to  be  made  after  a  careful  estimation  of 
the  value  of  the  symptoms  as  a  whole,  and  not  upon  one  or  more  supposed  typical  symp- 
toms. The  limping  of  a  child  with  infantile  paralysis  of  the  leg  has  been  confused  with 
that  from  disease  of  the  hip,  but  the  wasting  of  the  limb  and  the  absence  of  pain  ought 
to  prevent  such  an  error.  The  pain  of  spinal  disease,  of  psoas  abscess,  of  sub-iliac  abscess, 
of  some  glandular  affection  of  the  groin  associated  with  limping,  and  nerve  pain  extend- 
ing down  the  limb,  may  mislead,  but  the  knowledge  of  these  facts  may  prevent  the  repe- 
tition of  such  mistakes.  A  congenital  displacement  of  the  head  of  the  femur  has  been 
frequently  mistaken  for  the  affection.     (  Vide  p.  850.) 

Disease  of  the  bursa  connected  with  the  psoas  muscle  in  front  of  the  joint,  which  at 
times  communicates  with  it,  may  render  the  diagnosis  difiicult,  but  the  pain  on  pressure 
in  front  of  the  joint  which  exists  in  disease  of  the  bursa,  and  the  pain  on  pressure  behind 
the  trochanter  in  hip  disease,  are  enough  to  distinguish  the  two.  Disease  of  the  bursa 
beneath  the  gluteus  maximus  muscle  may  also  at  times  simulate  hip  affection,  but  with 
care  the  two  affections  can  be  distinguished. 


Diseases  of  the  Knee-Joint. 

This  joint  is  probably  more  frequently  the  seat  of  disease  than  any  other,  and  in  hos- 
pital practice  my  own  statistics  tell  me  that  it  forms  forty  per  cent,  of  the  joint  cases 
admitted  into  Guy's.     The  greater  liability  of  the  knee  to  injury,  the  thinness  of  its 


l>ISi:.lSi:s    OF  SI'ICCIAI.    JOISTS. 


917 


Fig.  (;if3. 


iiiitiinil  cnvcriiiL'.  and  tin-  cinMiilicatiMl  I'uriiiat ion  >t\'  ilic  jnint  tou-ctlicr  inolmlil y  afi'urd  tlie 
(riif  fxplaiiatidii  (if  this  I'act.  It  i>  nirt  with,  iiiorcDvcr,  in  patients  (if  a  inon;  mature  a<ro 
tliaii  hip  disease,  sixty-two  per  iiiil.  nl"  hip  eases  and  oidy  thirly-twn  (d"  knee  disease  licinf^ 
I'niuid  in  ehildren  iiuih'r  ten.  it  must  he  admitteil.  hnwever,  that  the  knee  wlien  once 
diseased  is  K-ss  likidy  to  underj;o  a  natural  cure,  and  muidi  less  a  eure  hy  anchylosis,  than 
any  »»ther  articulation.  This  is  jirohahly  to  he  explaineil  anatomically  hy  the  existence 
(d"  the  iiiter-arlicular  tihro-cartilatres,  which,  while  in  a  healthy  joint  they  tend  to  keep  it 
healthy,  in  a  diseased,  hy  iorhiddiii^'  tlie  contact  (d'  the  two  hom-s.  render  it  difficult  for 
anchylosis  to  take  place,  since  they  must  he  at  least  partially  ^'ot  rid  of  by  some  suppu- 
ration or  other  chanjje  before  anchylosis  can  be  .secured. 

When  diseased,  there  is  no  joint,  however,  in  which  the  (•han;_a'S  can  be  better  recog- 
nized, or  the  clinical  evidence  of  disease  in  the  synovial  im  inbraiie  or  bones  be  made  out 
with  irreater  facility. 

Ill  synovitis,  acute,  subacute,  or  clironic,  the  synovial  sac  becomes  distended;  the 
natural  tlimples  or  do]>ressions  which  in  health  exist  on  either  side  of  the  patella  soon  dis- 
appear, and  in  their  places  a  bulging  of  the  synovial  mcndjrune  will 
be  both  seen  and  felt  (Fig.  Hid).  The  patella,  too,  becomes  pressed 
forward,  and  on  palpation  may  be  felt  to  float  as  upon  a  water-bed,  ;/ 
aiul  readily  made  on  pressure  to  dip  upon  the  condyles  of  the  femur  u^ 
which  lie  beneath.  The  extensor  ujuscles  above  the  patella  likewi.se 
will  bo  raised  by  the  distended  sac  and  the  soft  parts  below  the  pa- 
tella down  to  its  ligament  will  pniject,  distinct  fluctuations  being  felt 
not  oidy  across  the  joint  from  side  to  side,  but  in  an  ubli(|ue  direction 
from  above  downward. 

Acute  synovitis  of  the  knee,  except  as  a  part  of  so-called  rheu- 
matic fever  or  pyjiemia,  is  rarely  met  with,  unless  as  the  result  of  a 
wound  or  the  extension  of  suppurating  disease  into  the  cavity.  It 
is  a  most  sevei'e  affection,  and  unless  speedily  arrested  by  ice,  leech- 
ing, or  those  means  suggested  in  the  chapter  on  wounds  of  joints, 
ends  in  the  destruction  of  the  joint,  and  too  often  in  the  forfeiture 
of  the  patient's  life. 

When,  after  suppuration,  life  is  spared  and  the  joint  goes  on  to 
repair,  anchylosis  may  be  secured  ;  and  in  puerperal,  rheumatic,  or  pyaemic  cases  this 
result  is  not  rarely  met  with,  the  joint  undergoing  the  whole  series  of  changes  in  a  few 
months.  This  subject,  however,  will  receive  attention  in  the  chapter  on  the  suppuration 
of  joints. 

In  subacute  synovitis — a  far  more  common  form  than  the  acute — the  local  symptoms 
are  the  same,  but  the  constitutional  are  far  less  severe,  whether  the  disea.se  be  caused  by 
some  local  injury  or  by  some  general  cause,  such  as  gout,  gonorrhoea,  rheumatism,  or  syph- 
ilis ;  it  moreover  almost  always  terminates  in  recovery. 

To  chronic  synovitis  the  same  remarks  are  applicable.  This  affection  is  often  known  as 
"  hydrops  articuli,"'  or  simple  dropsy  of  the  joint,  the  chief  symptom  being  an  excess  of 
fluid.  In  many  of  these  cases,  however,  this  eff"usion  into  the  joint  is  associated  with 
(tther  changes,  such  as  are  known  to  exist  in  what  is  now  recognized  as  a  special  affec- 
tion— the  chronic  rhinmafic  orthritis  or  osten-arthritis.  In  it  the  joint  becomes  so  stretched 
by  the  eff'usion,  and  the  ligaments  at  last  become  so  useless,  that 
the  leg  may  be  made  to  move  about  as  a  flail  in  every  direction. 
In  a  large  number,  however,  plates  of  bones  will  be  found  in  the 
synovial  membrane  or  about  the  articular  ends  of  the  bones,  as 
well  as  bony  outgrowths  or  fringes  of  ossific  matter  from  the  mar- 
gins of  the  articular  fiicets,  together  with  other  changes,  to  which 
attention  will  be  directed  in  the  proper  place.  It  is  well,  however, 
to  remember  here  that  a  large  number  of  the  cases  of  chronic 
synovitis  or  h3'drops  articuli  are  really  examples  of  the  peculiar 
disease  known  as  rheumatic,  or  ''  osteo-arthritis." 

In  the  articular  ostitis  of  the  knee-joint  the  expanded 
bones  are  .soon  made  out  on  comparing  the  sound  with  the  affected 
limb,  for  the  articulation  thus  affected  acquires  a  special  shape 
which  is  not  to  be  misinterpreted,  the  condyles  of  the  femur  and    Appearance  of  a  Knee  the 

1  '  •-'  Scat  01  Articul&r  Ostitis 

head  of  the  tibia  assuming  a  globular  form,  the  soft  parts  covering 

in  the  bones  being  healthy  and  movable  and  no  eff'usion  exi.sting  in  the  joint  (Fig.  617). 

At  times  a  joint  so  affected  will  become  two  inches  larger  than  its  fellow  ;   when  eff'usion 


Appearance  of  the  Knee- 
Joint  in  l^vnovitis. 


Fig.  (517. 


918  DISEASES   OF  THE  JOIXTS. 

is  present,  the  extension  of  the  inflammatory  action  from  the  bone  to  the  joint  itself  is 
indicated,  the  case  being  clearly  a  more  severe  one. 

The  condyles  of  the  femur  or  head  of  the  tibia  alone  may  also  be  the  seat  of  suppura- 
tive disease,  of  an  acute  or  chronic  abscess,  the.se  local  bone  abscesses  being  probably 
more  common  in  the  head  of  the  tibia  than  elsewhere.  Under  these  circumstances  the 
enlargement  will  be  confined  to  the  bone  affected  until  the  abscess  burrows  into  the  cavity 
of  the  joint,  when  the  joint  becomes  inflamed.  This  suppuration  may  occur  with  or  with- 
out necrosis.     Fig.  634  illustrates  a  case  in  which  diseased  joint  followed  necrosis. 

In  the  pulpy  disease  of  the  synovial  membrane  the  local  symptoms  by  which  the 
affection  is  tn  lie  diagiiused  are  likewise  characteristic.  In  typical  cases  neither  expanded 
bones  nor  dilatation  of  the  synovial  sac  with  fluid  is  present,  but  the  different  points  of 
bone  which  are  always  to  be  made  out  in  a  healthy  joint  are  obscured,  if  not  undistin- 
guishable ;  they  are  covered  in  with  a  soft  solid,  yielding  on  palpation  over  the  articular 
ends  of  the  bones,  and  more  particularly  around  the  patella,  a  doughy  sensation.  No 
fluctuation  is  to  be. detected,  as  a  rule:  and  when  fluid  exists,  it  will  clearly  be  in  a  thick- 
ened capsule.  At  times  this  pulpy  thickening  of  the  synovial  membrane  is  a  secondary 
affection  due  either  to  .some  articular  ostitis  or  to  repeated  attacks  of  synovitis.  It  may 
also  occur  as  part  of  a  syphilitic  disease,  from  the  effusion  of  gummy  material  around  the 
joint.  What  Collis  described  as  syphilitic  joint  I  believe  to  be  of  this  nature — viz.,  the 
pulpy  disease  in  a  syphilitic  subject,  possibly  complicated  with  periosteal  thickening. 

Diseases  of  the  Ankle-Joint. 

Nothing  particular  is  to  be  noticed  in  the  diseases  of  this  joint ;  their  pathology  is 
identical  with  that  of  all  other  joints,  synovial  mischief  being  possibly  more  common  than 
affections  of  the  bone.  EffHision  into  the  joint  is  readily  detected  by  the  swelling  and 
consequent  pressing  forward  of  the  extensor  muscles  of  the  foot,  by  the  fluctuation 
between  the  malleoli  in  front,  and  at  times  behind,  and  along  the  borders  of  the  tendo 
Achillis.  Bone  enlargement  is  readily  seen  by  the  expanded  malleolus  or  malleoli.  Bone 
abscess  may  occur  in  either  malleolus  or  in  the  astragalus. 

The  pulpy  disease  makes  itself  known  by  some  such  swelling  as  is  found  in  synovitis, 
but  the  swelling  will  not  be  due  to  fluid,  but  to  the  presence  of  the  lowly-organized  tissue 
found  in  the  disease,  showing  itself  in  a  doughy  swelling  around  one  or  both  of  the  mal- 
leoli and  beneath  the  extensor  tendons. 

Disease  of  the  Tarsal  and  Metatarsal  Joints 

— or,  rather,  nf  the  liones  and  joints — is  very  common  :  for  it  is  in  the  bones,  as  a  rule,  that 
the  disease  begins,  the  joints  becoming  involved  secondarily.  Disease  in  tlie  joint  hfticeen 
the  astragalus  and  as  calcis  mny.  however,  be  found  alone,  and  I  believe  that  such  disease 
is  commonly  the  result  of  some  lateral  sprain  of  the  ligaments  that  hold  these  bones 
together,  lateral  sprains  of  the  foot  being  more  likely  to  be  felt  at  this  articulation  than 
at  the  ankle,  as  the  astragalus  is  held  so  firmly  between  the  malleoli.  Disease  in  this 
joint  is  to  be  recognized  by  the  swelling  being  heneotli  the  malleoli,  the  pain  produced  by 
any  lateral  movement  of  the  heel  or  foot,  and  occasionally  by  the  grating  of  roughened 
bone.     The  movements  of  the  ankle-joint  will  be  uninvolved. 

Disease  of  the  other  tarsal  or  metatarsal  bones  is  indicated  by  the  enlargement  of  the 
bones,  as  well  as  by  the  position  of  the  sinuses  leading  down  to  them.     The  scaphoid 

bone  and  joints  are  frequently  affected,  this  bone  being  the 
keystone  of  the  antero-po.sterior  arch  of  the  foot ;  and  when 
the  scaphoid  is  affected,  the  disease  very  commonly  extends 
to  the  cuneiform  bones,  there  being  but  one  synovial  capsule 
common  to  the  scaphoid  and  the  three  cuneiform  Vjones. 

The  form  of  the  foot  in  these  cases  is  very  peculiar.     ••  It 

assumes."  writes  Erichsen.  "  a  remarkable  bulbous  or  clubbed 

appearance :  the  fore  part  and  dorsum  of  the  foot  are  greatly 

swollen,  glazed,  and  possibly  perforated  by  sinu.ses  discharging 

thin  unhealthy  pus"  (Science  and  Art  of  Surtieri/).     When 

Appearance  of  Foot  after  the  Re-  necrosed.  these  four  bones  mav  be  removed  and  a  good  foot 

Td'^fh^eVcun^ff  Bo?.e>^'^'  left.     As  a  single  bone  the  cuboid  is  also  not  rarely  diseased, 

and    may    be    taken    away   without    any   detriment.     In    the 

case  figured  (Fig.  618)  the  scaphoid,  three  cuneiform,  and  cuboid  bones  were  removed, 


DISEASES  OF  SPECIAL  JOISTS.  919 

ami  an  exci-llfiit  loot  rciiiaiiicd.  I  removed  tlieiu  t'ntni  a  boy  act.  8  by  simply  enucleating 
till'  diseased  and  ilead  hniics  i'loiii  their  beds,  and  disturbinL'  tlie  periosteum  and  stif't  part.s 
as  little  as  possible. 

Of  the  metatarSO-phalangeal  joints,  that  of  the  <:reat  toe  is  the  one  most  fre- 
(|ueiitlv  diseased,  either  iVuni  iMJiirv  <>r  ntlnrw  i.-e  .  and  when  so  affeeted.  it  is  troublesome  to 
deal  with.  There  is  some  reason  to  believe  that  the  burs;u  about  the  .sesamoid  IxMies  at 
tin-  ball  of  the  too  are  oeeasionally  the  .source  of  the  evil. 

When  dead  bone  exists  in  these  joints,  it  may  be  removed,  and  in  some  eases  the  joint 
mav  be  excised  with  a  trood  result.  1  have  done  this  on  many  occa.sions,  and  in  several 
a  movable  joint  was  seeureil.  (ianti/  attections  of  this  joint  are  very  common,  and  may 
ujo  on  to  disori^anization.  Disea.se  of  the  joint  as  a  result  of  a  neglected  bunion  is  not 
rare,  but  such  eases  will  be  treated  of  in  another  page. 

Disease  of  the  Pelvic  Joints 

is  often  overlooked  nr  mistaken  for  hip  or  spina!  disea.se,  yet  it  has  features  of  its  own. 
It  is  more  eomnionly  met  with  in  adults  than  in  children,  and  after  parturition  than  as  a 
result  of  local  injury.  It  is  usually  chronic.  It  may  be  secondary  to  disease  of  the  bones 
that  form  the  joint.  In  its  early  stage  it  is  characterized  by  pelvic  or  gluteal  pains  which 
are  aggravated  by  exercise,  relieved  by  rest,  and  often  put  down  as  rheumatic.  Lameness 
is  generally  present,  with  a  very  peculiar  unsteady,  rolling  gait.  Local  tenderness  will 
generally  be  manifested  on  digital  pressure  over  the  joint,  and  pain  is  excited  by  separat- 
ing or  pressing  upon  the  iliac  wings ;  swelling  along  the  line  of  joint  may  also  be  visible. 
The  thigh  may  or  may  not  be  flexed,  but  it  will  be  made  to  move  freely  when  the  pelvis 
is  fixed.  As  the  disease  progresses  suppuration  will  appear  either  in  the  gluteal  region 
over  the*  sacro-iliac  joint  or  in  the  pelvic  ;  and  when  the  thigh  is  permanently  flexed,  pel- 
vic suppuration  is  indicated.  It  is  to  be  di.stinguished  from  hip  disease  by  the  fact  that 
there  is  free  movement  of  the  femur  in  the  acetabulum  when  the  patient  is  recumbent, 
and  no  spasm  of  pelvic  muscles  is  experienced.  There  is,  moreover,  no  swelling  behind 
the  trochanter  or  pain  on  pressure  in  the  part.  In  no  stage  of  the  disease  will  there  be 
any  shortening  of  the  limb. 

Treatment. — In  the  treatment  of  this  affection  the  same  principles  are  applicable  as 
in  that  of  other  joints,  rest,  tonics,  good  food  and  air  being  essentials.  As  soon  as  sup- 
puration can  be  made  out  an  incision  should  be  made,  to  prevent  burrowing :  and  when 
dead  bone  is  present,  it  should  be  removed.  I  have  taken  awa}'  large  pieces  of  bone  from 
this  joint  with  great  benefit. 

Disease  of  the  Simphysis  pubis  is  very  rare,  and  I  have  seen  it  but  twice. 
One  of  the  cases  was  in  a  man  who  some  months  before  coming  under  my^  care  was 
believed  to  have  fractured  his  pelvis  and  lacerated  his  urethra.  When  I  saw  him, 
sinuses  existed,  running  down  to  and  into  the  joint,  but  no  dead  bone  could  be  felt. 
In  Guy's  Museum  there  is  a  preparation  (1314^°)  in  which  the  synchondrosis  is  ossified 
and  carious,  and  a  second  (1314*")  in  which  complete  anchylosis  is  present,  with  new 
bone. 

Disease  of  the  coccygeal  joint  is  at  least  as  rare  as  that  of  the  pubic,  although 
well-marked  cases  have  been  recorded.  It  can  readily  be  made  out  by  thickening  over 
the  joint  and  pain  produced  by  any  movement  in  the  bone;  in  some  cases  a  distinct  grat- 
ing can  be  felt  with  the  finger  in  the  rectum  on  attempting  to  move  the  part. 

When  the  disease  is  clearly  established  and  the  joint  disorganized,  the  best  practice  is 
probably  the  removal  of  the  bone  ;  and  when  this  is  not  advisable  or  practicable,  the  coc- 
cygeal muscles  had  better  l)e  divided  by  a  subcutaneous  inci.sion,  to  give  rest  to  the  joint, 
but  under  these  circumstances  the  cure  must  be  slow.  The  pains  of  saero-coccygeal  joint 
disease  are  much  .simulated  by  what  Sir  J.  Simpson  described  (Med.  Times.  1859)  as  coc- 
cydj'nia,  which  is  met  with  in  women  when  any  of  the  coccygeal  muscles  are  brought  into 
action  by  walking,  running,  rising,  defecating,  or  sneezing.  This  affection  may  be  cured 
by  the  subcutaneous  section  of  the* coccygeal  muscles. 

Coccygeal  anchylosis  may  occur  between  the  .sacro-coccygeal  articulation  or  between 
any  of  the  segments  of  the  coccyx,  or  between  all  of  them.  The  bones  may  retain  their 
normal  position  or  be  so  misplaced  as  to  cause  the  point  to  be  directed  forward  or  back- 
ward, the  former  direction  being  more  common. 

When  this  forward  condition  is  present,  there  may  be  some  impediment  to  natural 
labor,  but  not  of  necessity,  since  Smellie  ( SyiL  Sm-.^  vol.  ii.  p.  8)  says,  in  the  two  cases 
he  had  seen.  "  the  women  were  as  easily  delivered  as  those  in  whom  the  coccvx  is  mova- 


920  DISEASES   OF  THE  JOINTS. 

ble."  When  difficulty  is  found,  the  bones  should  be  fractured,  the  labor  being  aided  by 
forceps  if  necessary. 

Diseases  of  the  Joints  of  the  Upper  Extremity. 
Diseases  of  the  Sterno-Clavicular  Joint. — Suppuration  of  this  joint  in 

pyaemia  is  common,  though  as  an  independent  disease  it  is  very  rare.  I  have  seen  but 
two  examples  of  it,  which  ended  in  disorganization.  In  syphilitic  subjects,  however, 
inflammation  about  the  joint  is  not  unfrequent,  but  such  cases  rarely  suppurate.  The 
disease,  when  it  occurs,  is  easily  recognized,  the  joint  being  superficial. 

Disease  between  the  sternal  segments  has  been  recorded  by  Hilton.  I  have  seen  but' 
two  examples  of  it,  and  both  were  complicated  with  substernal  abscess  and  necrosis. 
Local  pain,  increased  on  pressure,  and  the  movement  produced  on  coughing,  with  swell- 
ing, indicate  the  disease. 

Diseases  of  the  shoulder-joint  are  comparatively  rare  and  form  a  very  small 
proportion  of  the  joint  cases  admitted  into  a  hospital,  the  majority  of  such  cases  being 
treated  outside.  Synovitis,  however,  in  all  its  forms,  is  found  in  this  joint,  as  well  as 
cases  of  articular  ostitis,  etc.     The  joint  has  no  special  disease. 

When  disorganization  and  suppuration  take  place,  the  matter  burrows  down  the  bicip- 
ital groove  and  generally  makes  its  appearance  in  front  of  the  insertion  of  the  deltoid 
muscle ;  at  times,  however,  it  bursts  posteriorly  or  burrows  beneath  the  pectoral  muscle. 
If  recovery  take  place  with  anchylosis,  a  wonderfully  useful  limb  is  often  secured, 
the  scapula  allowing  an  amount  of  movement  which  is  sufficient  for  most  of  the  duties 
of  life,  though  it  rarely  admits  of  any  action  above  the  shoulder.  When  disease  takes 
place  at  the  junction  of  the  upper  epiphysis  and  shaft  and  suppuration  follows,  the  abscess 
burrows  in  the  same  way,  and  much  difficulty  may  be  experienced  in  the  diagnosis  of  the 
case,  although  the  thickening  about  the  neck  of  bone  under  these  circumstances  is  gene- 
rally greater  than  in  joint  trouble.  When  inflammation  of  the  bursa  placed  beneath  the 
deltoid  muscles  exists,  some  of  the  symptoms  of  shoulder-joint  disease  ai'e  present ;  but 
the  fact  that  the  least  action  of  the  deltoid  muscle  excites  pain  in  bursal  disease  when 
the  movement  of  the  arm  by  the  surgeon  does  not,  and  that  the  joint  moves  freely, 
although  possibly  attended  with  a  sense  of  crepitation,  ought  to  suggest  its  nature. 

Diseases  of  the  elbow-joint  are  of  great  importance,  as  the  value  of  the  hand 
is  greatly  dependent  upon  the  integrity  of  the  elbow,  and  a  stifl"  elbow-joint  is  a  serious 
detriment.  In  their  general  pathology  they  are  the  same  as  similar  diseases  in  any  other 
joint. 

Synovitis  makes  itself  known  by  the  general  enlargement  of  the  joint,  as  well  as  by 
the  sense  of  fluctuation  on  either  side  of  the  olecranon  process.  Pulpy  disease  is  recog- 
nized by  the  presence  of  the  doughy,  semi-fluctuating  products  that  have  been  poured 
out  in  the  same  position.  Articular  ostitis  can  be  recognized  by  the  expanded  bones. 
In  a  general  way  elbow-joint  cases  do  well,  recovery  taking  place  with  movement  in 
the  majority,  while  in  the  minority  a  natural  cure  takes  place  by  anchylosis,  with  or  with- 
out external  suppuration. 

The  amount  of  movement  that  may  at  times  be  secured  after  a  natural  recovery  from 
a  suppurating  joint  is  very  good.     Fig.  619  was  taken  from  a  boy  a3t.  19  who  had  had  a 

disorganized  joint  treated  by  free  incisions  when  ten 
Fig.  619.  years  of  age.     In  it  the  head  of  the  radius  was  dis- 

placed outward.  He  had  as  much  movement  as  the 
drawing  indicates.  In  many  cases  useful  flexion  and 
extension  are  often  secured,  as  well  as  pronation  and 
supination,  and  in  some,  while  these  latter  movements 
are  preserved,  the  ulna  and  humerus  are  firmly  fixed, 
together ;  and  when  so,  the  value  of  the  hand  is  but 
little  diminished.  In  several  of  my  own  cases  I  have 
found  the  rotation  of  the  radius  perfect  after  many 

Drawing  illustrating  the  Amount  of  Flexion 

after  Recovery  from  Suppuration.  years. 

But  as  these  good  results,  which  may  follow  a  cure 
by  natural  processes,  cannot  be  calculated  upon,  it  is  doubtless  a  wiser  course  to  submit 
the  majority  of  cases  of  disorganized  elbow-joint  to  opei'ative  interference — not  so  much, 
probably,  to  remove  a  disease  that  is  incurable  by  natural  processes  as  to  procure  move- 
ment and  prevent  anchylosis. 

Disease  of  the  wrist-joint  is  not  so  common  as  that  of  the  carpal    bones  and 


o.v  Tin:  Tin:  ATM  EST  ASi>  criu:  OF  .inisr  f>/si:.{si:.  9-21 

i'ar|M)-|ilialaii^'i':il  joiiit.s;  Init  when  it  has  start«-(l  in  oik-  i>\'  tlii»si'  jiarts.  it  is  very  prone 
\o  lit'  |ini|ia;ratf(l  tti  otluTs.  Wlu'ii  siip|iuratitin  takes  jilacf,  tlic  pus  iA'lvu  burrows  freely 
betwei'ii  the  Icndons.  but  as  lnu«;  as  necrosed  bout-  does  not  exist  to  prevent  recovery  a 
>r{HH\  n-sult  may  be  looked  lor.  althou<rli  jimbably  with  some  amount  of  stifliiess  or  even 
aiichvlosis.  When  neemsed  bone  keeps  up  tlie  irritation,  it  shoubl  In-  removed.  To  assist 
reeoverv  the  hand  shtuihl  be  se<'ured  liy  a  splint  in  the  position  intermecliate  between  pro- 
nation and  su|iination.  such  a  one  beint;  the  liest.  When  the  hand  is  left  alone,  it  is  too 
apt    to   assuinr    the    prone    position — ,i    by    no   means   <;ood   one. 

Disease  of  the  raclio-ulnar  joint  is  rarely  met  with.  In  a  reeent  ease  of  a 
middh'-aired  man  tliat  eame  under  my  eare  it  appeared  to  follow  overaetion  ami  jrave  ri.se 
to  severe  loeal  jiain  and  <:eneral  disturbance.  It  was  fcdlowed  by  suppuration  and  relieved 
by  a  free  incision  on  the  dorsal  aspect  of  the  wrist  ilowii  to  the  joint.  The  case  terminated 
by  anchylosis. 

Diseases  of  the  phalangeal  joints  arc  in  their  nature  like  those  of  other 
joints  and  must  be  dealt  with  u|>on  similar  jirincijilcs,  synovitis,  pulpy  disease,  and  bone 
disease,  with  or  without  disorganizati<m,  being  found  in  all.  When  the  disea.se  is  confined 
to  the  synovial  membrane  and  the  joint  has  not  disorganized,  a  recovery  with  movement 
may  be  secured  by  good  treatment.  When  a  natural  cure  by  anchylosis  only  can  be 
looked  for.  the  ((uestion  of  the  removal  of  the  finger  may  be  entertained  as  a  matter  of 
expediency  ;  for  a  stiff  nietacarpo-phalangeal  joint  is  a  serious  detriment,  while  at  the 
proximal  phalangeal  joint  anchylosis  is  less  injurious,  and  least  so  at  the  terminal  one. 

In  the  thumii  am]iutation  is  rarely  to  be  thought  of;  for  when  recovery  by  anchylosis 
from  di.sease  of  the  distal  jilialangeal  joint  is  [u-oltable.  a  good  thumb  may  be  secured, 
though  the  same  result  in  tlie  metacarpo-phalangeal  joint  is  so  inconvenient  that  the 
operati(m  of  excision  is  probably  preferable.  But  every  ca.se  must  be  treated  on  its  own 
merits  and  according  to  its  own  special  wants. 

The  position  of  the  patient,  his  occupation,  age,  etc.,  should  have  a  powerful  influence 
in  guiding  the  surgeon  to  a  decision. 

ON  THE  TREATMENT  AND  CURE  OF   JOINT   DISEASE. 

In  the  treatment  «f  joint  disease  the  most  important  point  a  surgeon  has  to  bear  in 
mind  is  its  curability,  since  clinical  experience  affords  convincing  evidence  that  under 
judicious  management  a  large  proportion  of  joint  cases  can  be  guided  succes-sfully  to 
a  conjplete  recovery  with  either  movement  of  the  joint  or  anchylosis.  It  is  in  exceptional 
cases  only  that  operative  interference  is  required. 

The  recollection  of  these  facts  is  a  constant  encouragement  to  the  surgeon  to  perse- 
vere with,  and  to  the  patient  to  submit  to,  the  necessary  means  adapted  to  secure  either 
of  these  ends,  while  it  in  no  way  tends  to  discourage  operative  interference  when  the 
course  or  the  severity  of  the  disease  affords  sufficient  evidence  that  surgical  interference 
is  expedient  or  necessary. 

All  pathological  evidence  likewise  tends  to  the  support  of  these  conclusions,  for  no 
one  can  have  carefully  examined  joints  that  have  been  treated  by  either  excision  or 
amputaticui.  or  others  that  have  failed  to  go  on  toward  a  successful  issue,  without  being 
struck  by  the  vast  amount  of  repair  that  exists  side  by  side  with  the  disease  and  by  the 
apparently  limited  character  of  the  latter,  and  also  without  feeling  that  in  many  cases 
where  a  capital  operation  had  been  performed  sim]>l('r  operative  interference  would  prob- 
ably have  been  successful,  or  that  none  at  all  was  really  required. 

At  the  .same  time,  it  must  be  borne  in  mind  that  while  in  a  pathological  sense  disease, 
on  account  of  its  limited  nature  or  reparable  character,  may  need  no  interference,  yet  in 
a  clinical  aspect  a  very  opposite  conclusion  may  reasonably  have  to  be  drawn,  since  the 
disease,  by  its  progressive  and  weakening  tendency,  may  have  demonstrated  that  the 
powers  of  the  patient  were  incompetent  to  provide,  even  in  limited  disease,  the  stimulus 
needed  for  repair. 

In  the  treatment  of  joint  disease,  however,  it  is  not  always  a  question  as  to  the  possi- 
bility or  the  impossibility  of  securing  a  successful  i.ssue  by  simply  aiding  natural  efforts, 
since  questions  of  expediency  come  before  the  surgeon  as  to  the  wisdom  of  making  the 
attempt  or  as  to  whether  better  results  might  not  be  secured  by  surgical  interference. 

Surgeons,  moreover,  who  look  upon  a  stiff  elbow-  or  .shoulder-joint  as  a  serious  incon- 
venience and  an  unsatisfactory  result  of  treatment,  consequently  advocate  early  excision 
of  a  joint  with  the  view  of  obtaining  movement,  and  those  who  have  little  belief  in 
natural  processes  guided  by  art  bringing  about  anchylosis  in  disease  of  the  knee,  or  who 


922 


DISEASES  OF  THE  JOINTS. 


think  that  the  time  occupied  in  the  attempt  is  badly  spent,  advocate  a  like  practice. 
While  some  surgeons  are  always  satisfied  with  a  cure  of  the  disease  by  natural  efforts 
assisted  by  art,  and  remove  by  operative  measures  joints  or  parts  of  joints  when  these 
natural  processes  have  proved  themselves  incompetent  to  effect  a  cure,  others  maintain 
that  in  a  large  number  of  cases  these  natural  processes  lead  only  to  an  undesirable  end, 
and  that  it  is  not  expedient  to  trust  to  them.  Arguments  of  expediency  also  are  used, 
and  in  recent  times  have  gained  in  importance,  more  particularly  as  brought  to  bear  upon 
the  question  of  a  cure  with  a  stiff  joint  when  a  prolonged  interval  of  time  must  of  neces- 
sity be  required  to  secure  the  end.  In  some  cases  such  arguments  are  of  weight  and 
worthy  of  consideration,  although  as  a  broad  rule  of  practice  it  is  dangerous  to  adopt 
them,  for  in  the  majority  of  cases  natural  processes  guided  by  art  are  followed  by  results 
which  leave  little  to  be  desired,  and  are  secured  without  the  risks  which  are  attached  to 
all  operative  interference.  These  points,  however,  will  come  out  better  when  the  treat- 
ment of  individual  joints  has  to  be  considered,  and  to  which  attention  will  now  be  drawn. 


Fig.  620. 


Treatment  of  Disease  of  the  Hip-Joint. 

The  average  total  duration  of  a   case  of  hip  disease  in  which  recovery  takes  place 
withrmt  external  suppuration  is  three  years,  and  v-ith  suppuration  four. 

So  long  as  suppuration  or  other  disorganizing  change  in  the  joint  has  not  appeared  a 
good  hope  of  a  recovery  with  a  useful  articulation  may  be  entertained,  and  so  long  as  the 
disease  is  in  the  synovial  membrane  the  probabilities  of  a  recovery  with  a  movable  joint 
are  great.'  In  a  large  number  of  cases  where  time  has  been  allowed  to  pass  and  disease 
has  gone  on  to  produce  degenerative  changes  in  the  articular  cartilages  recovery  with 
anchylosis  is  to  be  looked  for,  anchylosis  without  suppuration  being  more  common  after 
articular  ostitis  than  after  synovial  disease  (vide  paper  by  author  in  Med.  Tim  en,  July  and 
August,  1869).  When,  however,  disease  originates  in  the  epiphysis  of  the  head  of  the 
bone  or  in  the  epiphysial  connective  cartilage  betweeen  the  epiphysis  and  shaft,  the  pros- 
pects of  a  recovery  with  movement  are  slight  unless  the  mischief  be  checked  in  its  early 
stage  ;  for  in  the  former  case  the  articular  cartilage  which  derives  its  nourishment  mainly 
from  the  bone  soon  undergoes  degenerative  changes  that  can  be  repaired  only  by  pro- 
cesses ending  in  anchylosis,  and  in  the  latter  the  epiphysis  is  often 
cast  off  as  a  foreign  body  when  recovery  can  take  place  only  on 
.  its  exfoliation  or  removal. 

In  both  classes  of  cases,  however,  the  treatment  is  in  a  measure 
the  same — that  is,  the  joint  is  to  be  at  rest  and  all  inter-articular 
pressure  is  to  be  avoided,  for  "  in  diseases  of  the  joints  rest  cannot 
be  too  much  insisted  upon"  (John  Hunter,  1787);  and  for  these 
ends  the  application  of  a  splint  is  essential, 
that  form  of  splint  being  the  best  which 
keeps  the  joint  quiet,  the  pelvis  at  its  nor- 
mal angle  to  the  spinal  column,  and  the 
affected  limb  from  being  either  adducted 
or  abducted  ;  without  doubt  these  points 
are  best  preserved  by  the  double  splint  fig- 
ured in  573,  620.  Children,  with  this  splint 
well  adjusted,  can  be  moved  with  the  great- 
est facility  and,  even  when  there  is  acute 
joint  disease,  with  very  little  suffering. 
When  the  acute  symptoms  have  subsided 
and  the  disease  is  clearly  going  on  to  repair, 
Thomas's  splint  is  good.  (  Vide  Fig.  621.) 
The  hip  splint  consists,  of  a  long 
piece  of  malleable  iron,  one  inch  by  a 
quarter  for  an  adult  and  three-quarters  of 
an  inch  by  three-sixteenths  for  children, 
extending  from  the  lower  angle  of  the 
i.oubie  Splint  with  Elastic  sboulder-blade  to  the  centre  of  the  calf  of 
Extension,  as  appiieii    in  the  leg,  to  which  an  iron  oval  chest  hoop 

Disease  of  the  Paght  Hip-  ^^^^^^-        f„^^j.  ^^^^^  j^g,  ^i,.^,^    ^j^^    ^^^  Thomas's  Post^erior  Splint  ^ 
■'"'"'^-  .  o  ....  ,  applied  lor  Hip  Disease. 

Circumference  is  nrmly  riveted  at  the  upper 

end,  and  two  half  hoops  to  support  the  thigh  and  calf,  as  seen  in  Fig.  621. 


Fig.  621. 


Ti:i:.\rMi:sr  a\i>  crni-:  of  .kust  disease.  ;»2.3 

Tlic  vertical  inni  liaiwl  is  farcfiilly  iiiihIcIIciI  to  tin-  outliiii!  of  the  trunk  and  Iiinl»  ami 
tlu'  clifst  lion|»  fitted  t(t  till'  sdiind  side,  liiit  away  tVuin  tlic  diseased.  'J'lie  wlirdc  sliould  l»e 
well  padded  and  bound  to  the  body,  itassin-;  in  the  direction  ol'  the  sound  side  over  tlie 
|)(isteri(»r  surf'aee  ;  and  it"  this  is  ettii-ieutly  done,  the  diseased  liinh  will  he  well  supported, 
and  the  patient,  il"  a  ehild.  can  readily  he  nioveil  tVoin  room  to  room. 

The  curve  (d"  the  instrument  may  re(|uire  alteration  from  time  to  time  as  the  flexed 
limh   hccomcs   extended   and   the   curved   spine   straijrht. 

Sir  ('.  i?ell  clearly  saw  the  necessity  (»f  rest,  and  was  so  impressed  with  it  as  to  make 
till'  followini;  ini^enious  suir<i;estion  :  "  I  have  ol)served  that  jiatients  who  have  hip  disease 
recover  when  anidivlosis  cd"  the  joint  takes  jdace,  when  the  hones  l)eeome  fixed  and  imnmv- 
alde.  l"\»undini:  upon  this,  I  attempted  Ity  various  contrivances  to  form  an  instrument  which 
mi^ht  kee]i  the  l)ones  at  ))erfect  resf,  but  so  <ireat  is  the  tendency  in  this  joint  to  motion 
that  I  have  never  yet  succeeded.  No  instrument  has  ever  been  effectual  in  keepin;^  the 
tliiii:h  and  trunk  fixed.  "  '•  I  have  been  led  to  think  that  an  operation  mi^ht  be  j)erforined 
here  ;  that  ti  cut  niii/fif  f>r  iiuidf  to  ixposc  f/ie  iipin  r  iiart  of  tin-  finnu-  and  tin;  nedc  he  sinm 
f/iri>in/h — not,  you  will  ol)serve,  to  take  away  the  head  of  the  bone,  as  done  by  Mr.  White 
with  success,  f/i(f  to  jinnn't  it  to  ninaiii  at  rest  and  to  form  an  adhesion  with  the  acetabulum. 
In  this  case  a  joint  will  be  formed  where  the  bone  has  been  divided  "  (Lond.  Mid.  (joz.. 
January  12,  182S;   "  Hip  Disease's."  l)y  Sir  C.  [then  Mr.]  Bell). 

When  suppuration  has  appeared,  recovery  with  anchylosis  can  alone  be  looked 
for,  thoujjh  where  diseas(>d  bone  exists  this  result  cannot  be  expected  unless  the  disea.sed 
bone  is  cast  off  or  removed.  AVhen,  however,  an  abscess  has  been  the  result  of  clironic 
changes  in  a  pulpv  synovial  mem]»rane.  the  com])lete  disorpuiization  of  the  joint  need  not 
as  a  necessary  consequence  be  eoiitem])lated,  althouirh  where  it  has  followed  disease  in 
the  articular  extremities  of  the  Itones  (articular  ostitis)  it  is  more  than  probable  that  the 
articular  cartilajres,  with  the  liuanients  and  synovial  capsule,  will  have  been  completely 
dei^troyed.  Under  the  former  circumstances,  therefore,  when  the  sup]iuration  has  taken 
place  as  a  conseijuence  of  synovial  disea.se,  recovery  may  ensue  with  soft  or  fibrous 
anchylosis,  or  even  with  some  degree  of  movement,  whilst  under  the  latter,  though  fibrous 
anchylosis  may  supervene,  osseous  anchylosis  can  occur  only  after  the  cartilages  with  the 
articular  lamellfv;  of  bone  have  entirely  gone  and  there  is  no  necrosed  bone  left  to  keep 
up  the  disea,se  ;  for  with  this  complication  a  natural  recovery  cannot  take  place  till  the 
source  of  irritation  has  been  discharged  by  natural  processes "or  removed  by  art. 

When  suppuration  occurs  in  a  hij)-joint,  though  recovery  may  follow  with  partial 
movement,  there  is  but  one  result  a  surgeon  can  reasonably  look  for  and  strive  to  secure, 
and  this  is  anchylosis.  If  the  history  of  the  case  and  the  clinical  symptoms  indicate  that 
the  disease  began  in  the  synovial  membrane  and  that  the  suppuration  was  the  result  of 
pathological  changes  in  that  tissue  alone,  the  hope  of  securing  this  result  is  very  good, 
since  the  di.sease  in  the  joint,  however  extreme  it  may  be, 
under  the.se   circum,stances   is   probably   only   superficial  and  J' if--  ''--■ 

does  not  involve  the  bones  to  any  extent,  .so  that  a  good 
recovery  with  a  stiff  joint  may  fairly  be  anticipated.  If,  how- 
ever, the  history  of  the  ca.se  and  the  clinical  .symptoms  indi- 
cate disease  of  the  bones,  the  probabilities  of  the  same  result 
taking  place  will  rest  upon  the  amount  of  the  disease.  If  the 
disease  in  the  bone  be  superficial,  a  natural  cure  by  anchylo.sis 
may  be  looked  for,  since  dead  bone,  if  not  too  large,  and  even  V 

the  epiphysis,  may  be  discharged  externally  and  a  good  re-  \  \ 

covery  follow.     When,  however,  disea.se  in  the  bone  is  exten-  [^  -  flj 

sive  (Fig.  G22).  or  a  seiiuestrum  is  so  placed  jn  the  centre  of   Head  of  Femur  Altered  by  Di 
the  bone  as  to  keep  up  irritatiim  and  interfere  with  repair,  as     e^se=    Renioyed    by  Excision. 

1  •      T^-       n,>i       1  '  .        .  o  -11  1  Prep.  131839.) 

IS  shown  in  ing.  hdl.  the  surgeon  s  active  interference  will  be 

imperatively  demanded  ;  and  it  may  be  added  that  it  is  never  practised  with  better  results. 
Fnder  all  circumstances,  however,  the  first  point  in  treatment  is  to  secure  the  com- 
plete immobility  of  the  limb,  which  can  be  ensured  by  splints :  extension  should  likewise 
be  kept  up  by  lueans  of  weights  or  elastic  forces.  In  one  case  a  long  outside  splint  may 
be  enough,  while  in  another  the  weight  is  sufficient.  In  very  chronic  cases  an  immovable 
casing  of  leather,  gutta-percha,  felt,  wire,  perforated  zinc,  or  other  appliance,  such  as  the 
fancy  or  ingenuity  of  the  surgeon  suggests,  is  the  best,  absolute  immobility  of  the  joint, 
prevention  of  inter-articular  pressure,  tonic  treatment,  liberal  regimen,  good  air,  and  time 
being  essential  conditions  for  a  successful  issue.  Fig.  62.3  represents  a  good  apparatus 
to  ensure  immobility  when  the  patient  is  in  bed.  though  the  double  splint  figured  620  is 


924 


DISEASES  OF  THE  JOINTS. 


better,  for  with  it  pressure  over  the  trochanter  is  guarded  against,  abduction  and  adduc 
tion  of  the  affected  limb  are  prevented,  the  pelvis  is  fixed  at  a  right 
angle  to  the  spinal  column,  and  the  external  malleolus  of  the  affected 
side  is  kept  in  a  line  with  the  hip ;  elastic  extension  is  likewise  well  main- 
tained by  means  of  an  accumulator  acting  through  a  cord  working  over 
a  pulley  inserted  in  the  cross  foot-piece.  Mr.  C.  de  Morgan's  long  splint 
(Fig.  581)  is  also  good  applied  to  the  side  of  the  sound  limb,  through 
which  he  likewise  applied  all  counter-extension. 

When  malposition  such  as  arises  from  flexion,  abduction,  or  adduc- 
tion of  the  thigh  exists — a  position  which  would  be  detrimental  to  the 
patient's  welfare — it  is  essential  that  it  should  be  remedied  before  the 
plan  of  treatment  already  laid  down  is  carried  out ;  and  so  long  as  no 
anchylosis  has  taken  place  or  the  union  is  soft  there  is  a  good  prospect 
of  this  being  effected.  For  this  pui'pose  an  anaesthetic  should  be  given 
and  the  thigh  slowly  but  surely  brought  to  a  straight  line  with  the  body 
and  there  fixed,  any  inflammation  caused  thereby  being  checked  b}'  the 
local  application  of  cold.  At  times,  however,  active  disorganizing  changes 
and  bad  results  follow.  When  displacement  or  dislocation  of  the  joint 
exi.sts,  it  is  often  in  the  surgeon's  power  to  reduce  the  dislocation,  and 
then  to  treat  the  case  as  one  of  the  ordinary  kind.  In  the  case  from 
which  Fig.  624  was  taken  the  boy  was  eleven  years  old  ;  the  disease  had 
been  acute,  and  the  dislocation  was  on  the  ilium.  Its  reduction  was 
readily  effected  under  chloroform,  and  a  good  result  followed.  A  weight 
of  six  or  seven  pounds  was  enough  to  keep  the  limb  in  position,  and  the  counter-exten- 
sion was  well  applied  on  the  opposite  side  of  the  pelvis.  If,  however,  I  had  now  the  treat- 
ment of  this  case,  I  should  employ  the  double  splint  with  elastic  extension. 

When  the  displacement  is  of  long  standing  and  the  natural  cure  of  the  disease  has 
gone  on  to  its  end,  it  is  not  wise  to  interfere  and  thus  run  the  risk  of  undoing  what 
nature  has  well  done,  as  many  of  these  ca.ses  of  supposed  dislocations  are  not  of  this  kind, 
but  .simply  a  shortening  of  the  neck  of  the  bone  from  the  absorption  or  destruction  of 
the  head  or  epiphy.sis  of  the  femur,  or  at  times  of  the  acetabulum.  Drs.  ^larch  and 
Sayre  of  New  York  deny  the  existence  of  a  dislocation,  but  in  this  they  are  wrong.     It 


Immovable      Casing 
of  Hip  Disease. 


Fig  624. 


Fig.  625. 


Fig.  626. 


V -^ 


Anchylosis  of  Hip-.Toint, 
with  Femur  at  Right  An- 
gles to  Pelvis,  before 
Operation.  iCase  of  Bov 
set.  15.) 


Position  of  Limb  after  Adams's 
Operation  as  Performed  by  Au- 
thor. 


does  occur,  although  rarely.  In  the  case  from  which  Fig.  624  was  taken  it  was  very 
clear. 

In  exceptional  in.stances  the  displacement  of  the  limb  is  due  to  a  separation  of  the 
neck  of  the  bone  from  the  epiphysis,  which  is  left  fixed  in  the  acetabulum  or  is  cast  off. 
This  condition  is  illustrated  in  Figs.  607,  608. 

When  anchylosis  has  taken  place  at  a  bad  angle — at  such  an  angle  as  seen  in  Fig.  625 
— any  attempt  at  forcible  flexion  with  the  view  of  breaking  down  the  adhesions  must  be 


tiu:atmi:\t  .\\n  mii-:  ur  joist  disicask. 


925 


P'iG.  02S. 


looked  u|)(»ri  as  fiitil.-  ami  iinjustiHahlf,  altliniiirli  it  may  Im-  rifrlit  to  (•onsider  tlie  propriety 
of  iiiiproviiii,'  tlif  position  of  the  liiiil)  Ity  s(Uiie  snr;,Mcal  procedure  :  and  for  this  oltject 
several  snru'ical  operations  have  heeii  devised.  Thus,  in  IS".').  M.  Tillaux  presented 
before  the  Siirj^ieul  Soeit-ty  ol"  I'aris  a  women  ivX.  '.VI  the  subject  of  bony  anchylosis  of 
the  hip-joint,  with  the  limb  tle.xed  and  rotated  inward,  for  whom  he  had  with  suece.s.s 
J'onihli/  f'ntrtitixt  thv  mil:  uf  tlif  hnitf.  He  efl'ected  this  when  the  woman  was  und<-r  chlo- 
roform by  usiiif^  considerable  force,  the  bone  j.'ivin;.'  way  with  u  hnnl  crack.  He  subse- 
<|Uentlv  treatecl  the  case  as  one  <tf  fracture,  and  at  tin;  end  of  two  months  the  jiatietit  had 
a  strai^'ht  limb.  .M.  Tillaux  described  the  result  as  njilcHdltl,  and  considered  the  practice 
infinitely  preferable  to  the  operation  of  .subcutaneous  .section  of  the  neck  of  the  bone. 
Tlu-  operation   is  doubtless  of  value  in  certain   ca.ses  and   worthy  of  consideration. 

In  lSt)!»,  Mr.  W.  Adams  {lirit.  Mnl.  Joiinnil,  iSTOj  successfully  treated  a  case  of 
this  nature  by  subcutaneous  division  of  the  neck  of  the  thiirh-bone  by  means  of  a  fine 
saw,  and  since  then  many  operati(»ns 

of    the   kind   have    been    performed  Fig.  027. 

with  irood  success. 

I  have  performed  this  operation 
in  a  dozen  cases,  and  with  so  much 
success  that  I  believe  it  to  be  the 
best  when  the  femur  has  a  neck  to 
be  divided. 

The  instruments  re(|uired  for  the 
operation  are  such  as  tho.se  figured 
(Fig.  627).     The  operation   itself  I 

give  in  Mr.  Adams's  words :  '"  I  entered  the  tenotomy  knife  a  little  above  the  top  of  the 
great  trochanter,  and,  carrying  it  straight  down  to  the  neck  of  the  thigh-bone,  divided 
the  mu.scles  and  opened  the  capsular  ligament  freely.  Withdrawing  the  knife.  I  carried 
the  small  saw  along  the  track  made — pursuing  this  by  pressure  of  the  fingers — .straight 
down  to  the  bone,  and  sawed  through  it  from  before  backward, 
in  the  direction  represented  in  Fig.  d'lS.  which  shows  the  saw 
applied  to  the  anterior  surface  of  the  neck  of  the  bone.  The 
section  of  the  bone  was  accomplished  in  four  minutes.  Xo 
hemorrhage  followed,  and  a  good  recovery  took  place  with  a 
stiff  limb."  When  the  saw  is  used,  it  should  be  held  at  an  an- 
gle of  135°  to  the  line  of  the  shaft  of  the  femur  (Fig.  ti28). 
Some  surgeons  use  a  narrow  chi.sel,  but  I  prefer  the  saw. 

In  my  cases  the  neck  of  the  thigh-bone  was  readily  divided 
in  less  than  five  minutes  and  the  wound  above  the  trochanter 
healed  in  a  few  days,  the  patients  walking  in  eight  weeks.  I 
have  had  one  patient,  a  girl  {\;t.  11,  in  whom  both  hips  were 
anchylosed  in  a  flexed  position  against  the  abdomen,  one  being 
adducted  and  the  other  rotated  outward.  On  one  side  T  divided 
the  neck  of  the  femur  and  on  the  other  the  shaft  below  the  tro- 
chanters, and  with  such  a  good  result  that  the  patient  can  now, 
six   months  after  the   second  operation,  walk   by  the   aid  of  a 

stick  and  sit  with  comfort.  i 

-J 

I  did  not  attempt  to  obtain  movement  in  any  of  my  cases,  Drawing  showing  the  Line  of 
having  been  well  satisfied  with  the  results  secured,  although  I  section  of  the  Neck  of  the 
am  (juite  alive  to  the  fact  that  my  friend  Mr.  Luiul  of  Man-  mtioil.  "'^  '"  '''"**  ^^ 
Chester  had  operated  with  such  success  upon  a  man  who  had 

both  hip-joints  anchylosed  in  a  straight  line  with  the  body,  and  as  a  consequence  could 
not  sit,  that  after  the  operation  excellent  motion  was  obtained  in  each  hip-joint,  and  the 
man  could  sit  up  in  a  chair  with  the  body  nearly  perpendicular  and  the  thighs  comfort- 
ably placed  on  the  seat ;  he  could  moreover  support  the  weight  of  the  body  upon  the  legs 
(Bn'f.  Med.  Joitnt.,  January  29.  1870). 

When  there  is  no  neck  of  the  femur  to  be  divided,  or  when  the  muscles  and  soft  parts 
about  the  minor  trochanter  of  the  bone  are  so  contracted  and  rigid  as  to  render  it  proba- 
ble that  the  shaft  of  the  femur  cannot  be  brought  down  to  a  right  line,  (rants  operation 
(Lnucef.  December  1,  1S72)  should  be  performed — that  is,  the  femur  should  be  divided 
by  a  small  valvular  wound  subcutaneously  below  the  trochanter,  by  means  of  either  the 
saw.  as  emidoved  by  Adams,  or  the  chisel,  as  suggested  bv  Volckmann  and  advocated  by 
Maunder,  the  same  care  to  exclude  air  being  employed  in  the  operation  as  has  been 


926 


DISEASES  OF  THE  JOINTS. 


advi.sed  in  Adams's.  Both  these  operations  are  superior  to  that  of  Barton,  who  divided 
the  femur  between  the  trochanters,  and  to  that  of  Sayre,  who  excised  a  wedge  of  bone 
from  between  them. 


Fig.  629. 


Splint  for  Diseased  Knee-Joiut. 


Treatment  of  Diseases  of  the  Knee-Joint. 

This  may  be  taken  as  a  type  of  the  treatment  of  all  joint  diseases. 
Acute  synovitis  is  usually  the  result  of  a  wound  and  should  be  treated  according  to 
the  principles  laid  down  in  a  former  page — viz.,  by  rest  and  ice  locally  and  uiiium  internally. 
When  disorganization  of  the  joint  ensues,  free  incision  and  irrigation  are  called  for ;  few  cases 
are  more  serious  in  their  local  as  well  as  their  general  effects,  as  life  is  often  endangered,  and 
recovery  with  a  stiff  joint  must  be  regarded  as  favorable.  Wlieii  the  disease  is  the  result 
of  septicemia  or  rupture  of  an  abscess  into  the  joint,  no  better  success  can  be  expected. 
In  subacute  and  chronic  forms  of  synovitis  a  good  result  may,  as  a  rule,  be 
promised,  and  the  treatment  must  be  regulated  by  the  cause  of  the  disease.  In  traumatic 
cases  the  local  application  of  cold  or  warmth  according  to  the  amount  of  comfort  one  or 
other  affords,  and  immobility  by  means  of  splints,  are  the  best  means  to  use.  When  all 
inflammation  has  subsided  and  a  relaxed  condition  of  joint  remains,  gentle  support  by 
means  of  wtU-applied  strapping  is  a  valuable  adjuvant. 

In  other  cases  the  application  of  a  blister  to  either  side  of  the  joint,  as  well  as  the 
internal  administration  of  the  iodide  of  potassium,  with  or  without  bark  or  quinine,  accord- 
ing it  the  necessities  of  the  patient,  is  of  great  use.  When  gout  appears  to  be  an  element 
in  the  affection,  it  is  advisable  to  administer  colchicum,  lithia,  and  other  remedies  approved 

in  that  disease.  AVlien  the  case  appears  to  have 
a  rheumatic  origin,  alkalies  such  as  the  bicar- 
bonate or  citrate  of  potash,  etc.,  may  prove 
.serviceable  ;  and  when  there  is  any  reason  to 
suspect  syphilitic  taint  in  the  constitution,  it  is 
necessary  to  employ  such  treatment  as  is  pecu- 
liar to  such  diseases — viz..  the  iodide  of  potas- 
sium or  sodium,  or  some  mercurial. 

In  very  chronic  and  ob.stinate  cases  para- 
centesis of  the  joint  by  means  of  the  aspirator  may  be  performed,  and  in  the  hands  of 
some  has  yielded  marvellous  success.  Sir  J.  Fayrer  was  one  of  its  strongest  advocates; 
having  shown  {Indian  Med.  Gaz.,  1869)  that  in  the  chronic  and  subacute  forms  much 
good  is  often  obtained  by  the  operation  if  care  be  taken  to  exclude  the  air  by  carefully 
closing  the  puncture  and  fixing  the  joint  on  a  splint,  the  drawing  off  of  the  fluid  afford- 
ing instantaneous  relief.  I  have  performed  this  operation 
on  many  occa.sions  with  good  results  when  the  tension  of 
the  joint  was  extreme  ;  it  is  a  practice,  however,  that 
ought  to  be  followed  with  great  caution. 

The  pulpy  disease  of  the  synovial  membrane  is  a 
very  obstinate  affection,  and,  though  fairly  curable  with  a 
movable  joint  in  its  early  stage,  and  occasionally  so  in  a 
later,  is  always  tedious  and  unsatisfactory. 

In  its  treatment  the  absolute  immobility  of  the  joint 
is  most  es.sential.  This  may  be  guaranteed  by  the  appli- 
cation of  a  well-adapted  splint  (Fig.  629)  reaching  from 
the  foot  two  thirds  up  the  thigh,  or,  what  is  far  better, 
Thomas's  knee-splint  (Fig.  630),  composed  of  a  padded 
ovoid  iron  ring,  three-eighths  of  an  inch  thick,  to  fit  well 
up  in  the  groin,  and  two  vertical  iron  rods,  ending  in  a 
patten  about  four  inches  below  the  foot,  with  an  inter- 
mediate foot-piece  (Figs.  630,  631).  An  apron  of  basil 
leather  is  stretched  between  the  iron  bars  for  the  affected 
limb  to  rest  upon,  in  which  slits  are  made  for  the  inser- 
tion of  a  bandage  to  keep  the  limb  and  s))lint  together. 
When  the  patient  gets  up,  the  splint  is  suspended  by  a 
■strap  buckled  to  the  ovoid  thigh-ring  and  passed  over  the 
shoulder  of  the  sound  side  ;  and  when  he  walks  upon  the 


Fig.  630. 


Fig.  631. 


Thomas's   Knot 
.Splint. 


Knee-Splint  as  Ap- 
plied 
Liml 
ten  on 


to     Left  splint,  a  patten  has  to  be  fitted  to  the  foot  of  the  opposite 
,'n  Kight.''''*"  limb,  to  maintain  the  level  of  the  body  (Fig.  (J31). 


Ti:i:.\TMi:.\T   ixn  cn:i:  of  joist  diskasi:.  liiiT 

When  the  kiH'f  is  imifli  Hexed,  a  eiishioii  or  pad  .should  he  placed  In  liind  the  knee, 
which  unfolds  itself  hy  a  frradual  proeess  of  extension. 

As  the  disease  improves  and  ti»e  dependent  position  of  the  limb  becomes  allowable  the 
patient  can  j^et  about  by  means  of  a  patten  on  the  ojiposite  limb.  The  introduction  of 
this  patten  for  the  above  purposes  is  worthy  of  all  prai.se.  y^^,   ,,.,., 

As  Ion;;  as  any  heat  (U*  perioilic  flushing  of  thf  j<iint 
exists  the  limb  must  be  kept  raised  ami  warm  moist  appli- 
cations applied  by  strips  o['  lint  surrounding  the  joint. 
After  these  symptoms  have  subsided  and  the  [»njducts  of 
inflammation  alone  remain,  well-appliecl   pressure  by  moans 

of    Strapl.ini:     is    of    ":reat      value.         Mr.     Marshall     \l.(liir,t^         bavarian  Splint  a^  complc-ted  for 
..'',.  1111         <■     1        /•  1       •  ln.seai»e  iif  the  Kiiet-. 

May  "J.).  1>^(_)  speaks   luglily  oi   the  nve  per  cent.  soluti(»n 

of  the  tdeate  of  mercury  in  oleic  acid  as  an  ajjplication,  and  my  experience  of  its  use  has 
been  satisfactory.  Blisterinir  and  firing  in  this  aficction  seem  to  be  of  little  value.  In 
the  very  chronic  stage  of  the  disease  the  Bavarian  flannel  splint  (Figs.  b'M'i,  ^)?i'l)  or 
some  other  good  casing  may  be  employed. 

The  constitutional  treatment  in  »11  stages  of  this  affection  is  essentially  tonic,  as  the 
subjects  of  it  are  always  feeble  and  often  strumous ;  iron,  quinine,  bark,  cod-liver  oil, 
good  food,  and  fresh  or  sea  air  are  essential  elements  of  succes.sful  treatment. 

By  these  means,  so  long  as  suppuration  has  not  .set  in,  a  cure  may  be  affected,  although 
many  months  may  be  reijuired  for  its  attainment. 

When  suppuration  appears,  the  same  principles  of  practice  are  applica})le.  When 
small  deposits  of  pus  form,  from  the  breaking  down  of  some  portion  of  the  pulpy  ti.ssues. 
and  make  their  way  externally  toward  the  skin,  and  not  into  the  joint,  they  may  be 
evacuated,  and  a  good  result  still  ensue.  But  when  the  joint  becomes  disorganized  from 
the  same  cause,  ((uestious  ari.se  as  to  the  expediency  or  possibility  of  saving  the  joint ;  but 
this  subject  will  claim  attention  in  the  chapter  on  suppurating  joints. 

In  articular  ostitis — a  di.sea.se  readily  made  out  in  the  knee  when  simple  expan- 
sion of  the  bones  (Fig.  <J17)  and  an  aching  pain  and  heat  are  the  local  symptom.s — all 
walking  or  standing  should  be  po.sitively  interdicted,  everything  like  inter-articular 
pressure  forbidden,  and  fomentations  of  warm  water  applied  two  or  three  times  a  day,  or 
strips  of  wet  bandage  covered  by  a  handkerchief  of  elastic  tissue  or  oil  silk  kept  around 
the  joint.  Some  speak  highly  of  blisters,  moxas,  and  counter-irritants,  which  I  rarely 
employ,  having  long  found  the  above  practice  preferable. 

When  heat  has  left  the  joint,  the  aching — miscalled  "  growing  " — pains  di.sappear, 
and  clinical  evidence  tends  to  show  that  all  inflammatory  action  has  subsided,  the  results 
or  products  of  inflammation  alone  remaining,  local  pressure  as  applied  by  strapping  not 
only  gives  comfort  to  the  patient,  but  appears  to  help  the  absorption  of  the  inflammatory 
products  and  the  subsequent  cure  of  the  disease. 

Constitutional  treatment,  however,  must  not  be  forgotten,  and  tonics,  as  a  rule,  are 
needed,  cod-liver  oil  combined  with  the  .syrup  of  the  phosphate  or  iodide  of  iron  being  a 
suitable  prescription  for  children.  W^hen  the  appetite  is  bad,  quinine  may  be  given  ;  at 
other  times,  iron  or  other  tonic.  Good  food  and  good  air  are  as  nece.ssary  in  this  as  in  all 
other  joint  cases.  The  use  of  the  iodine-evaporating  box  should  not  be  omitted.  Mer- 
cury is  unnecessary. 

In  the  early  stage  of  articular  ostitis  splints  are  not  required,  as  the  joint  is  not  itself 
diseased  and  passive  movement  of  the  articulation  will  not  do  harm  ;  all  inter-articular 
pressure,  however,  .should  be  avoided,  and  for  this  purpose  extension  by  means  of  weights 
or  elastic  extension  is  very  valuable.  In  a  more  advanced  stage,  however,  when  the 
disease  has  .so  progressed  in  the  bones  as  to  have  set  up  some  degenerating  process  in  the 
cartilages  and  the  synovial  membrane  has  become  involved,  as  indicated  by  eff"usion  or 
the  pulpy  synovial  thickening,  the  use  of  the  splint  is  essential. 

In  neglected  cases,  when  the  joint  has  been  allowed  to  assume  an  abnormal  position — 
the  most  common  being  that  of  flexion,  with  some  amount  of  rotation  inward  or  outward 
— and  in  still  worse  cases,  where  dislocation  of  the  tibia  and  fibula  backward  has  taken 
place,  the  deformity  must,  if  possible,  be  remedied  by  gradual  extension.  This  should  be 
employed  by  means  of  a  posterior  screw  splint  or  the  application  of  a  constant  gentle 
force  exerted  through  one  of  the  many  in.struments  that  have  been  made  with  the  view 
of  pressing  the  femur  backward  and  the  head  of  the  tibia  forward.  Manual  extension 
exerted  under  chloroform  employed  with  care  rarely  does  much  harm  ;  forcible  and  sud- 
den extension  cannot  be  recommended,  as  it  is  followed  at  times  by  severe  local  action 
and  suppuration.     In  exceptional  ca.ses  it  may  be  required. 


928  DISEASES  OF  THE  JOINTS. 

Anchylosis. — When  a  knee-joint  has  to  he  fixed,  the  hest  position  is  one  of  sh'ght 
flexion,  or  that  which  a  man  naturally  assumes  when  he  stands  at  ease.  But  anchylosis  is 
more  difficult  to  secure  in  the  knee-  than  in  any  other  joint,  on  account  of  the  presence  of 
the  inter-articular  fibro-cartilages.  which  prevent  the  bony  surfaces  from  coming  in  contact. 
Moreover,  these  cartilages,  when  diseased,  are  most  difficult  of  repair,  no  tissue  undergoing 
a  reparative  process  more  slowly  or  imperfectly.  It  is  doubtless  from  a  knowledge  of  these 
clinical  truths  that  some  surgeons  despair  of  securing  anchylosis  in  the  knee,  and  even 
doubt  its  occurrence,  and  are  led  to  interfere  by  operation  oftener  than  others.  Anchylosis 
of  the  knee — good  solid  ossific  union  of  the  bones  as  well  as  fibrous  anchylosi.s — does, 
however,  occur,  and  when  secured  is  of  great  value.  It  gives  a  limb  which  is  far  supe- 
rior to  any  that  follows  excision,  and  is,  as  a  rule,  obtained  without  the  dangers  of  an 
operation,  although  possibly  with  the  expenditure  of  more  time.  I  have  the  notes  of 
many  such  eases,  and  in  the  Me'7.  Times  (187<»)  I  published  a  series,  in  some  of  which 
this  resiilt  took  place  with  and  in  others  without  suppuration. 

Diseases  of  the  Ankle-Joint 

should  be  treated  on  precisely  the  same  principles  as  those  laid  down  for  the  knee,  the 
best  position  of  the  foot  being  at  an  angle  slightly  exceeding  that  of  a  right  angle. 

Diseases  of  the  Shoulder-Joint, 

in  their  progress  and  treatment,  are  very  similar  to  those  of  other  joints.  When  the 
shoulder  has  to  be  fixed,  a  leather  casing  including  the  scapula  and  humerus  is  a  good 
apparatus,  the  elbow  being  supported  at  the  same  time.  The  arm  should  be  allowed  to 
hang  parallel  to  the  trunk,  with  the  elbow  slightly  away  from  the  chest ;  and  for  this  pur- 
pose 8tromeyer"s  cu.shion  is  of  great  value  (Fig.  561). 

Diseases  of  the  Elbow-Joint 

can  usually  be  managed  with  greater  ease  than  any  other,  a  splint  applied  in  the  flexure 
of  the  joint  passing  well  down  to  the  hand,  to  keep  the  radius  in  a  position  intermediate 
between  pronation  and  supination,  being  the  be.«t.  If  the  hand  is  left  unsupported,  it  is 
certain  to  assume  the  prone  position,  which,  as  a  rule,  is  undesirable.  Dislocation  of  this 
joint,  except  at  the  head  of  the  radius,  which  is  often  displaced  backward  and  somewhat 
outward,  rarely  takes  place  as  a  result  of  disease. 

Before  fixing  the  joint  at  an  angle  it  is  well  in  most  cases  to  consult  with  the  patient, 
for  in  some  the  straight  position  is  the  more  desirable.  In  the  case  of  a  painter  I  had 
under  care  a  flexed  elbow  would  have  lost  him  his  occupation.  In  another,  of  a  barge- 
man, the  joint  was  fixed  at  a  right  angle,  with  the  hand  pronated.  to  hold  the  oar.  A 
carpenter  asked  me  to  fix  his  left  elbow  at  an  obtuse  angle,  and  a  haycutter  nearly 
straight.     In  all  these  instances  any  other  position  would  have  been  most  detrimental. 

In  disease  of  the  wrist  and  carpus  the  same  position  of  the  hand  should  be  main- 
tained as  in  disease  about  the  elbow. 

In  disease  of  the  phalangeal  joints,  when  anchylo.sis  is  to  be  obtained.  I  have 
of  late  years  always  fixed  the  diseased  extremity  at  such  an  angle  as  will  allow  its  point 
to  come  in  contact  with  the  top  of  the  thumb,  having  invariably  found  the  straight  posi- 
tions of  the  finger  vei-y  inconvenient.  In  this  position  the  fingers  are  more  useful  and 
less  in  the  way,  and  the  deformity  is  less  observed.  In  these  cases  the  best  material  to 
use  as  a  splint  is  a  piece  of  zinc  or  tin.  which  is  firm.  thin,  and  takes  up  little  space. 

ON   OPERATIVE   INTERFERENCE— EXCISION   AND   AMPUTA- 
TION—IN JOINT  DISEASE. 

General  Remarks. 

In  the  treatment  of  joint  disease,  next  to  the  preservation  of  life,  the  aim  of  the  sur- 
geon is  to  preserve  the  natural  movements  of  the  articulation,  and.  when  that  hope  has 
gone,  to  save  the  limb.  If  this  end  can  be  obtained  with  a  stiff"  joint,  the  result  in  dis- 
ease of  the  lower  extremity  may  be  regarded  as  satisfactory,  and  even  in  the  upper  a  stiff" 
shoulder-  or  elbow-joint  at  a  useful  angle  is  not  so  bad  a  result  as  some  would  endeavor 
to  lead  us  to  believe. 


<n'i:n.\'nvi:  is'n:ni''i:iii:s<'i:~i:x<'isi<>s  asi>  ami'I'tation.         !)29 

Wlicii  iKMtlii-r  nf  tlu'sc  »'ii(ls  apitears  pmbahlL',  pns.sihlu,  or  expediiMit  fruin  the  extent 
of  the  luciil  disease,  the  <.'ein'ral  want  of  power  of  (he  patient,  or  the  neeessities  of  the  indi- 
vidual ease,  tlie  <|uestion  of  operative  interference  eonies  lielore  the  surgeon,  and  he  has  to 
deeiih'  on  the  expediency  ol"  an  incision  into  thi-  joint,  the  removal  of  dead  bone  iVoni  <jr 
excision  of  the  joint,  or  amputation  ;  and  to  work  out  the  many  jioints  involved  in  the 
solution  of  these  (|uestions  is  a  task  of  dilhculty,  since,  from  joints  havin;r  a  ditferent  value 
in  the  human  body,  a  iorm  of  practice  which  is  applicable  to  one  may  be  inexpedient  to 
anotlu-r.  'J'his  diflicultv,  moreover,  is  doubtless  a^r^ravated  by  the  different  value  which 
surLji'ons  jtlace  on  different  forms  of  practice  and  the  different  estimation  in  which  they 
reirard  natural  processes.  One  who  has  j^reat  I'aitli  in  natural  processes  in  the  cure  <jf 
disease,  ami  particularly  (»f  joint  disease,  will  attempt  to  save  a  limb  that  another  will 
condemn,  since  he  reirards  as  wroni;-  any  practice  that  interferes  with  a  natural  recovery 
sti  lon<r  as  any  reasonable  hope  exists  of  securing  such  a  result,  and  believes  that  a  cure 
by  anchylosis,  however  ae(|uired  and  however  long  a  time  may  be  passed  in  securing  it, 
is  worth  the  attempt.  Another,  who  has  stronger  faith  in  surgical  treatment,  will  exci.se 
a  joint,  believing  it  to  be  inexpedient  to  attempt  to  obtain  a  natural  cure,  even  if  it  may 
be  gained,  when  by  excision  an  etjually  good,  if  not  a  better,  result  can  be  .secured  in  a 
shorter  time  ;  and  a  third,  looking  upon  both  forms  of  practice  as  too  protracted  and 
uncertain,  will  remove  the  diseased  parts  by  amputatif)n,  under  tlie  conviction  that  a 
more  certain  as  well  as  a  more  rapid  recovery  will  be  .secured  by  .such  a  process. 

To  lay  down  any  definite  rules  upon  operative  interference  in  joint  disea.se  generally 
is  conse(|uently  an  impossibility,  since  each  joint  has  its  own  .surgery. 

It  may.  however,  be  stated  as  a  starting-point  that  no  surgical  operative  interference 
is  justifiable  unless  a  joint  has  sujtpurated  or  become  disorganized,  and  that  amputation 
should  be  thought  of  oidy  when  all  minor  measures  are  inapj)licable  and  it  is  necessary 
to  remove  the  disease  to  save  life.  The  larger  the  joint,  the  greater  the  dangers  of  opera- 
tive interference. 

Treatment  of  Suppuration  of  the  Hip-Joint. 

In  the  treatment  of  a  suppurating  hip-,  as  of  any  other  joint,  it  is  important  to  ensure 
a  free  vent  for  all  discharge,  as  pent-up  pus  is  always  injurious ;  with  this  view  a  free 
incision  into  an  ab.scess  connected  with  the  hip  or  the  free  opening  of  a  sinus  through 
which  pus  slowly  flows  is  sound  practice.  In  the  residual  abscesses  of  repairing  joint 
disease  it  is  well,  however,  not  to  incise  unless  they  show  a  tendency  to  increase,  since 
many  often  spontaneously  dry  up.  When  these  abscesses  are  interfered  with,  the  pus 
should  be  drawn  off  with  the  aspirator. 

Removal  of  Necrosed  Bone  from  and  Excision  of  the  Hip-Joint. 

When  the  presence  of  dead  bone  can  be  made  out  in  a  suppurating  hip-joint,  there  can 
be  no  question  about  the  propriety — nay,  the  necessity — for  its  removal,  since  it  is  certain 
that  so  long  as  dead  bone  ren)ains  to  keep  up  irritation  a  cure  by  natural  processes  is  impos- 
sible. If  this  can  be  effected  by  means  of  a  free  incision,  nothing  more  is  needed;  when 
the  OS  innominatum  is  involved,  there  is  a  greater  reason  in  favor  of  the  removal  of  the 
sequestrum.  An  operation  undertaken  upon  the  hip-joint  under  these  circumstances  is 
scarcely  more  dangerous  than  an}'  severe  operation  for  necrosed  bone,  and  in  all  proba- 
bility is  less  so.  The  joint,  as  a  joint,  has  to  a  certainty  disappeared  altogether,  and  a 
free  incision  into  it  will  hardly  add  to  the  dangers  of  the  case.  In  a  large  number  of 
cases,  however,  this  cannot  be  made,  and  under  such  circumstances,  when  a  cure  by  nat- 
ural processes  cannot  be  looked  for,  the  best  practice  lies  in  excision  of  the  head  of  the 
femur;  and  if  the  acetabulum  is  superficialh'  affected  or  stripped  of  its  cartilage  (the  dis- 
ease being  probably  .secondary  to  that  in  the  femur),  it  will  undergo  a  natural  repair  as 
soon  as  the  cau.se  of  its  di.sea.se  has  been  removed. 

When  the  presence  of  dead  bone  cannot  be  made  out,  or  the  weight  of  evidence  tends 
to  show  liiat  there  is  no  such  complication  to  interfere  with  a  natural  recovery,  the  ques- 
tion of  exci.sion  of  the  head  and  neck  of  the  femur  may  have  to  be  con.sidered.  Those 
who  argue  again,st  its  adoption  assert,  and  with  some  truth,  that  while  all  these  cases  of 
hip  disease  are  capable  of  a  natural  repair  in  patients  who  have  good,  or  even  tolerably 
good,  reparative  powers,  yet  in  those  who  have  not  the  operation  of  excision  must  natu- 
rally fail,  since  as  much  power  is  probably  needed  to  effect  a  cure  after  excision  as  is 
demanded  for  the  natural  repair  of  an  uncomplicated  suppurating  or  disorganized  joint. 
5y 


930  DISEASES  OF  THE  JOINTS. 

To  these  latter  remarks,  however,  I  am  disposed  to  demur  ;  and  while  ready  to  admit 
that  in  all  cases  of  disorganized  hip-joint  in  which  there  is  no  disease  of  the  bone  to  inter- 
fere with  recovery  a  natural  cure  may  be  fairly  looked  for  so  long  as  the  powers  of  the 
patient  keep  up  and  no  signs  of  failure  make  their  appearance,  yet  when  these  signs  show 
themselves,  or  evidence  is  adduced  that  in  the  battle  of  disease  the  reparative  are  "^^eaker 
than  the  morbid  processes,  and  treatment  fails  to  turn  the  scale  in  their  favor,  the  expe- 
diency of  performing  excision  cannot  be  disputed.  The  removal  of  the  source  of  irrita- 
tion acts  beneficially  upon  the  patient,  and  after  the  operation  of  excision  many  a  case 
has  gone  on  to  recovery  which  unoperated  upon  would  eventually  have  proved  fatal,  the 
patient  being  worn  out  by  suppuration  and  exhaustive  efforts  to  repair. 

For  the  most  reliable  facts  connected  with  the  operation  of  excision  of  the  hip-joint.  I 
must  refer  to  the  report  of  the  committee  of  the  London  Clinical  Society  published  in  the 
fourteenth  volume  of  their  Transactions  (1881).  In  it,  amongst  much  valuable  material, 
are  certain  conclusions  based  upon  a  careful  analysis  of  203  cases  of  excision,  of  2(j<) 
other  cases  in  which  suppuration  existed,  and  of  124  in  which  no  such  complications 
appeared,  making  a  total  of  587  cases.  Where  excision  was  performed  the  mortality  was 
40  per  cent.,  against  33.5  per  cent,  treated  by  rest  and  extension,  etc.  A  large  propor- 
tion of  the  deaths  in  both  classes  was  from  tubercular  meningitis.  I  have  lost  but  5  out 
of  30  eases- operated  upon,  arid,  although  I  cannot  say  that  in  the  25  surviving  all  had 
useful  limbs,  I  am  within  the  truth  when  I  assert  that  the  majority  had.  while  without 
the  operation  recovery  was  impossible. 

Mr.  Holmes,  too,  in  his  excellent  work  on  ChlhJrens  Diseasex,  gives  us  19  cases,  of 
which,  in  a  general  way,  one-third  died  from  the  operation,  another  third  recovered  with 
useful  limbs,  and  the  remaining  third,  although  not  cured,  derived  great  benefit  from  the 
operation. 

On  analyzing  Hodges'  and  Good's  cases  as  to  the  influence  of  age  upon  the  operation, 
some  valuable  facts  may  be  recorded ;  and  out  of  46  of  Hodges'  cases  operated  upon 
under  ten  years  of  age,  15  died,  or  33  per  cent. ;  of  37  cases  between  eleven  and  twenty 
years  of  age,  21  died,  or  57  per  cent. ;  of  12  cases  operated  upon  between  twenty-one 
and  thirty  years  of  age,  7  died,  or  60  per  cent.  ;  and  of  6  cases  operated  upon  over 
thirty  years  of  age,  5  died,  or  83  per  cent.  The  analysis  of  Good's  cases  indicates  the 
same  truths ;  for  of  the  cases  operated  upon  under  twelve  years  of  age,  40.6  per  cent, 
died ;  between  twelve  and  twenty  years  of  age,  60  per  cent,  died  ;  and  between  twenty 
and  fifty-eight  years  of  age,  76  per  cent.  died. 

Excision  for  hip  disease  in  young  life,  therefore,  is  by  no  means  a  fatal  operation,  two 
out  of  three  recovering,  while  from  ten  to  thirty  years  of  age  something  less  than  half 
recover,  but  after  that  period  it  is  full  of  danger.  The  operation  of  excision,  like  ampu- 
tation, lithotomy,  or  any  other  great  operation,  is  more  dangerous  as  age  increases.  The 
important  fact  that  children  beyond  infiincy  bear  severe  operations  well  should  ever  be 
before  us,  though  it  is  of  equal  importance  to  remember  that  it  is  in  young  life  we  meet 
with  the  best  success  in  the  expectant  treatment  of  hip-joint  as  of  other  disease. 

With  the  fact,  therefore,  before  us — that  in  selected  cases  excision  of  the  head  of  the 
femur  is  not  only  a  justifiable,  but  a  good,  operation — let  us  briefly  consider  under  what 
circumstances  it  should  be  performed  ;  and  from  the  general  facts,  as  learned  from  statis- 
tics, we  find  two  great  results  come  out  clearly  :  that  in  childhood  the  operation  is 
attended  with  success,  two  patients  out  of  three  recovering,  while  in  adult  life  it  is 
attended  with  great  danger,  at  least  two  out  of  three  patients  dying.  In  the  former  case, 
consequently,  the  operation  may  be  entertained  under  circumstances  which  in  the  latter 
would  render  it  unjustifiable.  When,  then,  should  excision  of  the  hip  be  performed? 
And,  first  of  all,  when  should  it  not? 

Excision  is  not  required  where  suppuration  or  disorganization  of  the  joint  has  not 
taken  place,  because,  so  long  as  this  condition  is  kept  off  by  surgical  as  well  as  by  medi- 
cal skill,  a  solid  hope  exists  that  a  cure  of  the  disease  may  be  secured,  though  by  anchy- 
losis. 

It  should  not  be  performed  when  all  evidence  tends  to  show  that  the  bones  entering 
into  the  formation  of  the  joint  are  neither  extensively  involved  nor  wholly  or  in  part 
necrotic,  and  where  the  general  condition  of  the  patient,  under  proper  treatment,  is  fairly 
maintained. 

It  should  not,  moreover,  be  entertained  for  disorganization  of  the  hip-joint  the  result 
of  synovial  disease,  unless  very  obstinate  and  extensive  and  the  general  health  of  the 
patient  is  clearly  yielding  to  the  disease,  nor  should  it  ever  be  performed  for  acute  sup- 
purative disease. 


077.7;.  1 77 1 !■:  iSTi:nFi:i'j:s(  •h'^i:x(  •is/n.\  . i  sd  . i  mitt. i  rins. 


!):31 


Fig.  633. 


Kxcisinii  >liniil(l  always  be  entertained  wIh-h  it  is  clear  that  exten.sivo  bone 
iiii.scliici"  fir  pariial  nccnisis  i-xists,  it  l»i-iii^'  tnlcraldy  ccrtaiu  utnlcr  wiich  circuiiiHtaiiccs 
that  a  ciiri'  l»v  natural  pritci'SHOs  is  liij^hly  iiii|ir(ihalilc  ;  when  siipiniratioii  is  jier.sistent  in 
spite  dl"  <^'(mm1  treatment  ;  when  the  <reneral  heahh  id"  the  patient  is  eh-arly  l)cinjr  sappeil 
by  the  h>eal  di.sease.  wiiether  that  disease  he  in  tlie  Imnes  (»r  the  synovial  niemhranes,  or 
in  hiith  ;  when  intrapelvie  ahseoss  euniplicates  the  case;  ami  in  the  majority  of  eases  in 
which  displacement  of  I  lie  head  of  the  lemur  exists. 

Ol'KK.viio.v. — The  opi-ration  of  excision  is  liest  performed  by  a  sli;.ditly-curved  incis- 
ion extendinii  I'rom  two  to  three  inches  almvc  the  trochanter  alonjr  its  posterior  border  t(» 
two  to  three  inches  below,  more  room  bein<r  obtained  when  ref|uircd  in  exceptii^nal  cases 
at  the  upjier  angle  of  the  wound  V)y  a  cross-incision.  By  this  incision  tlierc  is  ample 
room  for  the  rapid  exposure  and  enucleation  of  the  head  and  neck  oi"  the  bone,  and  .sub- 
sequently for  I'rce  drainaire. 

Some  sur<;eons  remove  only  the  1h  ad  and  neck  of  the  femur;  others  take  itway  the 
trochanters  as  well.  The  amount  (»f  bone  does  not  appear  to  be  a  point  of  much  import- 
ance, since  excellent  results  havi'  been  obtained  after  both  forms  of  practice.  In  the 
removal  of  the  bone  the  chain  saw  is  often  of  great  use,  but  I  prefer  to  saw  through  the 
bone  before  removing  it  with  Adams's  saw.  For  excisions  of  joints  or  bones  generally 
my  friend  and  pujiil  .Mr.  (Jowan  has  invented  a  valuable  and  ingenious  instrument;  it  is 
composed  of  a  pair  of  biting  forceps  for  holding  the  bone,  and  a  saw  which  works  upon  a 
rotating  .shield  fixed  to  the  forceps.  By  it  a  bone  can  be  divided  when  seized  with  rapid- 
ity ami  safety.  (  Vldr  Fig.  ()33.)  The  surgeon  should  preserve  all  the  soft  parts  around 
the  bone  as  much  as  po.ssible  ;  and  when  the  periosteum  can  be  .saved,  so  much  the  better 
Dr.  8ayre  of  New  York,  who  has  paid  spe- 
cial attention  to  these  cases,  describes  his 
operation  as  follows  ( Brit.  Med.  Journ., 
July,  1871 ) :  "  When  the  disease  has  gone 
on  to  another  stage  where  sinuses  have  oc- 
curred and  discharge  pus,  when  a  pi'obe 
leads  down  to  dead  bone,  there  is  nothing 
to  be  done  but  to  exsect  it  by  making  a 
small  incision  above  the  trochanter  major, 
midway  between  it  and  the  crest  of  the 
ilium,  over  the  top  of  the  acetabulum — a 
semilunar  incision,  the  belly  of  the  curve 
covering  the  posterior  part  of  the  trochan- 
ter major,  going  straight  down  to  the  bone 

^//,v.»y,  the  periosteum  ;    youthen    pull  the    oowan-s  Mon  .Saw.    (Can  be  worked  on  either  side  of 

soft  tissues  on  one  side,  and,  taking  a  small  the  forceps.) 

but  strong  curved  bistoury,  go  as  far  round 

the  bone  on  each  side  as  you  can  reach,  at  right  angles  to  your  first  incision,  .w  as  to 
divide  tlie  periusteiim  cnmplete.li/.  You  then  take  a  strong,  firm  periosteal  elevator  with  a 
large  handle  and  the  end  slightly  curved,  and  go  into  this  little  triangle ;  you  peel  off  the 
periosteum,  and.  as  a  matter  of  course,  all  the  muscles  with  it  ;  by  opening  the  joint  thor- 
oughly and  turning  the  head  of  the  bone  out  the  periosteum  is  peeled  off  from  the  inner 
portion  ;  you  then  saw  off  the  bone  above  the  trochanter  minor,  taking  away  the  head 
and  neck  of  the  bone  with  the  trochanter  major.  After  the  operation,  if  you  keep  the  leg 
pulled  out  to  its  ])roper  length  by  putting  on  a  pair  of  wire  breeches,  you  can  send  the 
patient  out  into  the  air  the  next  day."  I  have  given  this  operation  in  Dr.  Sayre's  own 
words,  and  am  di.sposed  to  think  as  well  of  it  as  of  his  general  treatment  of  hip  disease. 
His  wire  breeches,  however,  I  have  never  used. 

When  the  acetabulum  is  diseased — that  is,  necrosed — it  may  be  removed.  In  many 
of  my  own  cases  I  removed  large  portions  of  the  bone,  and  in  one  the  whole  floor,  with 
a  good  result ;  indeed,  there  is  reason  to  believe  that  when  the  bone  can  be  removed  the 
case  is  not  rendered  more  hopeless,  for,  as  Holmes  has  well  pointed  out,  there  is  always 
a  strong  fascia  which  separates  the  floor  of  the  acetabulum  from  the  cavity  of  the  pelvis 
and  prevents  all  contact  with  the  viscera  or  their  cellular  connections. 

After-Tre.\tmext. — After  the  operation  the  wound  had  better  be  left  open  to  gran- 
ulate, whilst  good  extension  should  be  applied  during  the  whole  healing  process  and  for 
some  weeks  subsequently.  My  results  since  I  have  followed  this  practice  have  far 
exceeded  those  I  obtained  previoush'.  ]My  own  double  interrupted  splint  is  the  best  for 
the  purpose  (Figs.  572,  620).     As  soon  as  the  parts  have  thoroughly  healed  passive  move- 


932  DISEASES  OF  THE  JOINTS. 

ment  may  be  allowed,  and  it  is  remarkable  to  what  an  extent  useful  movement  is  often 
secured,  the  patient  being  able  not  only  to  walk  upon  the  limb,  but  to  flex,  abduct,  and 
adduct  it  nearly  as  well  as  he  did  before,  shortening  being  the  only  fault. 

xVniputation  at  the  hip-joint  may  be  entertained  in  hip  disease  when  all  hope  of  a 
cure  by  natural  processes,  however  ably  assisted  by  art,  has  been  abandoned,  and  when 
the  powers  of  the  patient  admit  of  a  reasonable  hope  of  recovery,  also  in  cases  where  excis- 
ion has  been  performed  and  failed.     Under  these  circumstances  it  is  often  very  successful. 

Excision  of  the  hip-joint  for  gunshot  or  other  traumatic  afl'ections  of  the  joint  cainiot 
be  recommended.  The  report  of  Dr.  Otis,  in  the  admirably  got-up  circulars  of  the  War 
Department  of  Washington  (No.  2),  proves  this  to  demonstration  ;  for  out  of  85  cases, 
only  8  recovered,  90  per  cent,  having  proved  fatal.  At  the  same  time  he  shows  that 
neither  by  the  expectant  treatment  nor  by  amputation  do  better  results  ensue.  He  con- 
cludes that  excision  of  the  hip  may  be  performed  in  uncomplicated  cases  of  gunshot  frac- 
tures of  the  joint — that  if  unsuccessful  it  relieves  pain  and  is  attended  with  less  risk  than 
amputation,  although  life  is  probably  prolonged  for  a  longer  period  by  the  expectant  treat- 
ment. Professor  Langenbeck,  however,  shows  in  his  able  essay  on  gunshot  wounds  of 
the  hip-joint,  as  translated  by  J.  West  of  Birmingham,  that,  while  of  88  cases  in  which 
conservative  treatment  was  employed  71  per  cent,  died,  out  of  31  cases  treated  by 
resection  83  per  cent.  died. 

Treatment  op  Suppuration  of  the  Knee-Joint. 

It  may  safely  be  asserted  that  in  no  case  of  inflammatory  disease  of  the  knee-joint  in 
which  disorganization  has  not  taken  place  should  the  idea  of  operative  interference  be 
entertained,  as,  so  long  as  this  change  is  warded  off",  a  reasonable  hope  of  a  cure  with 
either  a  movable  or  a  stiff"  joint,  and  consequently  with  a  useful  limb,  exists.  Excep- 
tional cases  may  be  seen  in  which  this  rule  is  inapplicable,  but  they  are  rare. 

When,  however,  suppuration  has  taken  place,  the  question  of  operative  interference 
naturally  siiggests  itself;  and  the  surgeon  considers  whether  natural  processes  are  com- 
petent to  conduct  the  case  to  a  successful  issue,  whether  the  local  disease  is  of  such  a 
nature  as  to  be  incurable  unassisted  by  art,  or  the  general  powers  of  the  patient  are 
sufficient  to  bear  up  against  the  demands  that  of  necessity  will  be  made  upon  them  in  the 
progress  of  a  natural  cure,  and  last,  but  not  least,  if  it  is  expedient  to  make  the  attempt. 

These  questions  require  for  their  solution  much  knowledge,  thought,  and  judgment,  a 
careful  weighing  of  the  probabilities  of  the  case  and  of  the  cause  of  the  disease.  When 
the  disease  is  in  the  synovial  tissue  alone  and  the  powers  of  the  patient  are  good,  a  cure 
by  natural  processes  assisted  by  art  is  generally  to  be  secured,  for  pathologically  in  such 
cases  there  is  no  reason  why  recovery  should  not  take  place,  whereas,  on  the  other  hand, 
when  the  disease  has  originated  in  the  bone,  spread  to  the  synovial  membrane,  and  been 
followed  by  disorganization  of  the  joint,  a  cure  by  natural  processes  is  so  improbable  that 
the  removal  of  the  diseased  part  by  some  operation  is  generally  demanded,  for  patholog- 
ically good  reasons  exist  why  recovery  cannot  take  place,  and  clinically  this  observation 
is  borne  out. 

It  is  true  that  in  suppuration  of  a  joint  from  synovial  disease,  pulpy  or  otherwise,  the 
result  of  a  so-called  rheumatism  settling  in  the  knee,  or  of  a  puerperal  synovitis,  a  trau- 
matic synovitis,  a  gonorrhoeal  synovitis,  or  any  other,  a  cure  with  anchylosis  is  by  no 
means  uncommon  ;  yet  in  all  these,  during  their  acute  stage,  the  danger  is  always  great, 
and  it  often  becomes  a  question  whether  an  amputation  is  not  needed  to  save  life  or  to 
give  the  patient  a  chance.  Amputations,  however,  undertaken  for  acute  suppurative  dis- 
ease are  mostly  fatal,  and  operations  of  excision  are  likewise  equally  unsuccessful.  Indeed, 
I  hardly  think  either  of  these  operations  justiflable  under  such  circumstances,  and  in  this 
opinion  most  are  agreed.  What  I  believe  to  be  a  better  practice  is  making  a  free  incision 
into  the  joint — free  enough  to  let  out  the  pus  that  it  contains,  as  well  as  to  allow  a  free 
escape  of  all  as  it  forms — and  the  introduction  of  a  drainage  tube,  together  with  the  daily 
washing  out  of  the  joint  with  iodine  water.  No  retention  of  pus  should  be  allowed  under 
any  circumstances. 

When  suppuration  has  been  set  up  in  a  joint  from  the  degeneration  of  the  pulpy 
synovial  disease,  the  benefit  of  a  free  incision  is  very  great,  and  it  should  be  practised 
with  a  good  hope  of  success  before  any  other  operative  measure  is  undertaken.  When, 
however,  suppuration  in  a  joint  has  followed  the  extension  of  inflammatory  mischief 
from  the  bones,  the  hope  of  securing  a  good  result  v.athout  operative  interference  is  very 
slender,  since,  as  a  rule,  dead  bone  exists  in  the  joint  to  keep  up  irritation,  and  as  long  a 


opr.iiATivi:  isrinrr.iiKSCK—KXCvnoy  asi>  amittatios. 


\y.v:\ 


it  remains  a   rccnvcrv  is  very  iiii|in)liiililc.      It    is   tnif   iiatiin-   <lncs   inucli    in    many  cases 
toward  (liis  end.  lint  sin-  is  laiciy  (•(iniiiett-nt  to  i-flcct  tlif  cure  without  sur;:icai  aid. 
In  the  l'i)lhiwinir  eases  these  [mints  arc  W(dl  seen: 

Cask. — Diskask  m-  tiik  KM:K-dniNT— Sii-imkatihn — Ukmov.m-  ok  Nkcro.skf)  Bonk 
i-iioM    iiii:  Joint — I{k<o\ki!V   uiiii   Anciivi.osis. 

James  W ,  :ct.    17,  came   unch-r  my   care  in    May,  iStiti.  fur  disease  in   liis  right 

knee-joint,  of  one  year's  duration,  which  had  Inllowed  a  lall  upon  the  part.  Swelliiif^ 
appeared  «lireetly  after  tiie  accident,  attended  l>y  severe  constitutional  (listury>ancc  and 
local  pain.  Suppuration  also  rapidly  followed,  and  several  lar<re  openings  made  their 
aitpearanee  eight  weeks  after  the  accident.  When  I  saw  him,  the  joint  was  enlarged 
from  inflammatory  thickening  of  the  soft  parts,  and  was  clearly  undergoing  anchylosis. 
The  sinuses  were  discharging,  and  a  probe  passed  into  one  readily  detected  dead  bf)ne  in 
the  joint.  In  Septemher  the  num  was  admitted  into  Guy's  under  my  care,  and  on  Octo- 
ber IS,  througli  a  mrtderate  incision  made  on  the  inner  side  of  the  patella,  two  flat  piece.s 
of  what  were  clearly  the  articular  facets  of  tlie  tibia  were  removed,  liapid  recovery  and 
firm  anchylosis  of  the  joint  followed. 

Cask. — Diskask  ok  tiik  K.nkk-Joixt  as  a  Co.vskquence  ok  Aktkilak  Ostitis  op 
TiiUA — Hkmovai.  ok  Sequestrum  from  Bonk — Recovery  with  an  Anciiylosed 
Joint. 

Henry  \\ ,  ;et.  14,  came  under  my  care  at  Guy's  Ilosjiital  on   May  17,  18(j7,  for 

extensive  di,sease  of  the  shaft  of  the  right  humerus  and  head  of  the  left  tibia,  with  sinuses 
which  had  existed  for  several  years.  The  left  knee  had  been  enlarged  from  eff'u.sion 
for  a  year,  but  had  never  suppurated.  When  admitted,  there  was  necrosis  of  the  shaft 
of  the  humerus,  and  likewise  of  the  head  of  the  tibia,  while  dead  bone  was  readily  felt 
with  a  probe  in  both  parts.  In  the  tibia  the  bone  was  clearly  near  the  joint,  which  was 
enlarged  from  expanded  bone  and  thickening  of  the  soft  parts  around.  There  was  no 
eff'usion  in  the  joint  and  hardly  any  movement  in  the  articulation.  In  November,  1807, 
I  removed  a  mass  of  diseased  bone  from  the  tibia  and  fixed  the  leg  upon  a  splint.  In 
January,  1808,  I  removed  from  the  arm  a  sequestrum  which  included  nearly  the  whole 
shaft  of  the  humerus,  and  a  good  recovery  ensued.  In  six  months  the  patient  left  the 
hospital  with  a  stiff  knee  and  a  sound  arm. 

Case. — Disease  of  the  Knee-Joixt  as  a  Result  of  Articular  Ostitis  endixg  in 
Necrosis — Amputation — Recovery. 

Edward  L ,  ;v>t.  14,  came  under  my  care  at  Guy's  Hospital  on  September  8, 1868, 

for  disease  in  the  left  knee-joint  of  seven  years'  standing,  which  had  been  discharging  for 
many  years.  On  admission  the  left  knee-joint  was  completely  dis- 
organized and  much  enlarged  ;  it  was  also  partially  anehylosed. 
Below  the  joint  a  sinus  existed  leading  into  the  head  of  the  tibia, 
and  through  this  sinus  dead  bone  was  felt.  The  boy's  health  was 
very  bad,  and  it  was  clear  that  nothing  but  amputation  could  be 
entertained.  His  urine  was  albuminous.  The  operation  was  per- 
formed on  September  17,  and  a  good  recovery  ensued.  On  ex- 
amination of  the  joint  w^hich  was  disorganized  the  head  of  the 
tibia  was  found  to  be  perforated  with  a  channel  which  led  from 
the  joint  to  a  mass  of  necrosed  bone,  and  the  articular  facet  of  the 
tibia  was  likewi.«e  necrosed.  The  disease  in  the  joint  clearly  had 
been  secondary  to  the  disease  in  the  bone.  The  preparation  is 
depicted  in  Fig.  034,  and  the  drawing  well  shows  the  condition  of 
the  tibia. 


Fifi.  ()34. 


f! 


J 


Remarks. 

These  three  cases  well  show  the  results  of  articular  ostitis 
when  passintr  on  to  necrosis  in  the  knee-joint  and  fairlv  indicate  Abscess  of  Tibia  burrowing 

. ,       ,  . '  1      ^  •-  .  •  ,        111  1-  ■  1        T     ^u      £    ".L  inlo  Knee-.Toint,  with  >e- 

the  kind  ot  practice  that  should  be  applied,      in  the  first  case  na-      crosis. 

ture  had  done  her  utmost  toward  obtaining  a  cure,  the  knee  of 

the  patient  being  on  admission  partially  anehylosed ;  and  had  it  not  been  for  the  presence 


934  DISEASES  OF  THE  JOINTS. 

of  the  necrosed  articular  facets  of  the  tibia,  a  complete  natural  recovery  would  have 
taken  place.  The  surgeon's  duty  in  this  case  was  clearly  to  remove  from  the  joint  what 
seemed  to  be  the  sole  obstacle  to  a  natural  recovery — the  necrosed  bone ;  and  the  com- 
plete success  of  the  treatment  justified  the  step,  for  the  boy  ultimately  had  an  admirable 
limb.  In  the  second  case  the  disease  was  of  precisely  the  same  character,  and  natural 
processes  had  also  done  their  utmost  toward  the  establishment  of  a  cure,  but  the  presence 
of  necrosed  bone  in  this  case,  as  in  the  former,  interfered  with  the  recovery  and  pre- 
vented its  realization.  On  the  removal  of  the  bone  from  outside  the  joint  natural  pro- 
cesses went  on  without  interruption  toward  the  attainment  of  their  end.  and  a  complete 
recovery  with  anchylosis  was  obtained.  In  the  last  case  the  same  cause,  articular  ostitis, 
and  the  same  result,  disorganization  of  the  joint,  were  clearly  present ;  but  the  local  dis- 
ease in  the  bone  was  too  extensive  to  allow  of  any  hope  of  good  being  derived  from  its 
removal,  while  the  general  condition  of  the  patient  was  too  precarious  to  allow  of  the 
attempt.  As  a  consequence,  the  only  operative  interference  that  seemed  justifiable  was 
carried  out.  and  the  issue  of  the  case  was  all  that  could  be  desired.  In  disorganization 
of  a  knee-joint,  therefore,  the  result  of  articular  ostitis,  of  an  ab.scess  in  the  epiphysial 
extremity  of  the  bone  bursting  into  the  joint,  of  disease  in  the  epiphysial  cartilage 
between  the  shaft  and  epiphysis,  or  of  a  .sequestrum  in  one  or  other  of  the  bones  entering 
into  its  formation,  some  operative  measure  is  usually  required ;  and  when  the  diagnosis 
of  the  case  is  tolerably  clear,  the  practice  ought  to  be  decided,  as  delay  cannot  be  of  any 
use.  The  disease  must  be  removed.  What  ought  that  practice,  then,  to  be?  Should  it 
be  excision  or  amputation  ?  Let  us  refer  to  facts  to  help  us  toward  a  solution  of  these 
points.  I  have  a  table  of  294  cases  of  nmputation  of  the  tliigJi  for  chronic  disease  of  the 
knee-joint  at  various  ages,  and  Sir  W.  MacCormac  tabulates  137,  the  total  making  431. 
Of  these.  96  died  and  .335  recovered,  the  mortality  being  22  per  cent.,  or  1  in  5.  On 
referring  to  Dr.  Hodges  work.  I  find  178  cases  of  excision  of  the  knee  undertaken  solely 
for  chronic  disease  of  the  knee,  of  which  70  died  and  108  recovered,  the  mortality  of 
excision  being  39  per  cent.,  or  1  in  2*  cases.  In  this  comparison  the  circumstances  are 
exactly  similar,  both  operations  being  undertaken  for  chronic  joint  disease,  and  the  mor- 
tality is  exactly  double.  In  my  table  of  amputations  I  have  carefully  guarded  against 
any  fallacy  and  have  included  only  my  own  statistics.'  Mr.  Callenders.-  Sir  W.  MacCor- 
mac's.'  and  Mr.  Holmess.*  all  of  which  are  equally  indisputable  ;  and  in  the  table  of 
excisions  I  have  gone  to  Dr.  Hodges'  work,  who.  to  make  this  point  certain,  states  that, 
with  three  exceptions  performed  for  acute  inflammation  of  the  articulation,  excision  of 
the  knee  has  probably  never  been  undertaken  for  any  other  than  chronic  disease  or  white 
swelling.  Mr.  Swain,  the  author  of  the  Jacksonian  prize  essay  on  ••  Excision,"  and  a 
warm  advocate  of  the  operation,  has  given  us  .statistics  on  this  subject,  and  from  his  book 
(pp.  62  and  64)  I  have  extracted  the  following  facts :  Up  to  1865  there  had  been  316 
cases  of  excision  of  the  knee.  Of  this  number.  85  died,  or  26.8  per  cent. ;  9  of  these 
died  after  amputation,  which  had  been  performed  in  39  cases  after  excision.  Since  1865, 
74  cases  are  given.  25  of  which  died  from  the  operation,  or  33.7  per  cent.  ;  4  also  died 
out  of  11  that  underwent  subsequent  amputation;  in  all,  29  cases  out  of  the  74  died,  or 
39  per  cent.  Mr.  Swain  gives  us  also  a  select  list  of  cases  numbering  82,  of  which  15 
died  from  the  effects  of  the  operation,  while  4  others  recovered  after  amputation.  We 
have  thus  472  ca.ses  of  excision  of  the  knee,  and  129  deaths,  or  27.3  per  cent.,  13  of 
these  being  after  amputation  :  41  other  cases  underwent  amputation  and  recovered.  Tak- 
ing the  whole  number  of  472  cases,  302.  or  63.9  per  cent.,  recovered  after  excision  ;  41, 
or  8.7  per  cent.,  recovered  after  secondary  amputation  ;  129,  or  27.3  per  cent.,  died  after 
excision.  The  mortality  from  excision  was  thus  greater  than  from  amputation  in  the 
same  class  of  cases,  the  relative  proportion  being  27  to  22  per  cent.  '■  It  is  also,"  adds 
Holmes.  "  a  .somewhat  suspicious  feature  in  Mr.  Swain's  table  that  all  the  302  recoveries 
are  claimed  as  being  with  useful  limbs.  If  the  information  had  been  at  all  adequately 
full,  there  would  surely  have  been  a  category  of  recoveries  with  the  limb  more  or  less 
useless."'  since  it  is  a  well-known  fact  that  in  many  cases  in  which  it  seemed  perfect  at 
first  the  utility  of  the  limb  becomes  destroyed  by  subsequent  changes.  In  childhood 
suspension  of  growth  is  not  an  unfrequent  result  :  and  when  the  whole  epiphyses  are 
removed,  it  is  to  be  looked  for.  It  is  true  that  Mr.  Swain  gives  somewhat  different  results 
from  the  same  statistics,  as  he  actually  numbers  amongst  the  recoveries  after  exci.<ion  all 
cases  that  subsequently  underwent  amputation,  thus,  of  course,  giving  a  far  too  favorable 
coloring  to  the  operation  he  is  advocating. 

'  Med.-Chtr.  Tranx..  vol.  xlii.  '  Ibid.,  vol.  xlvii. 

3  Dub.  Quart.,  August,  1868.  *  St.  George's  Hosp.  Rep.,  1866. 


<)]'i:i!.\'n\i-:  isteiu'EIiesck-kxcisios  .\m>  ami'CTatios.         \y.\h 

If,  lloweViT,  we  look  to  //"■  rrsiills  nf  Imtli  iijhiiiIIoiis  us  pnfunittil  nl  dij]t'if'ii(  jirriods 
of  11  lift — a  point  ol"  coiiiparisoii  of  iiuiuoiise  iiiiportaiire,  altlioii<:li  «'iitir('ly  i^'iiortMl  by 
Mr.  Swaiii  ami  other  ailvocati's  of  oxcisioii  faiid  I  wisli  its  ailvot-atcs  would  (•(disider  well 
tlii'se  points,  and  not  pass  tlit-ni  by  as  of  no  iniportaiifc) — the  loMowinfr  striking  result 
eoines  out  :  In  my  own  tahle  of  amputations  for  chronic  diseases  of  the  knee  in  ])atients 
under  twenty  years  of  ajre.  out  id'  (ill  eases,  oidy  \\  died,  or  4.!r{  per  eeiit..  or  1  in  21}  cases. 
In  excision  for  the  same  class  of  ca.ses  performed  at  the  same  period  of  life,  out  of  D7 
cases,  27  died,  or  27. S  per  cent.,  or  1  in  W'i,  the  difl'ereiit  de;:rees  of  mortality  of  the  two 
operations  under  twenty  years  of  ajre  beinj;  as  4.i>  per  cent,  to  27. S  per  cent  .  minion 
hi  ill'/  iitiirlif  sfviii  fiinrs  us  /ntul  as  iinijnt/itfitjii  ifiiriin/  /joiiiir/  lijr.  It  may  thus  fairly  be 
a.sked  whether  the  advantayes  of  excision  are  so  jrreat  as  to  justify  its  performance  in  the 
majority  «d' cases  (d"  disease  of  the  knee  at  that  ajre.  In  amputations  undertaken  between 
twi'uty-one  and  forty  years  of  aire  for  chronic  joint  disease,  out  of  1 1'J  cases.  .'IS  died,  or  'A'l 
per  cent.,  or  1  in  !> ;  in  excision,  undertaken  under  similar  circumstances,  out  of  74  cases, 
'M  died,  (»r  r)2.7  per  cent.,  or  more  than  1  in  every  2  cases,  the  difference  between  the 
niiM'tality  of  the  two  o])erations.  ■'!2  per  cent,  and  r)2.7  per  cent.  resi)ectively,  being  20  per 
cent,  against  excision. 

Summary. 

It  would  thus  appear  that  it  is  in  young  adult  life  that  excisions,  although  always 
more  fatal  than  amputation,  are  the  most  justifiable  ;  that  in  childhood  they  are  far  too 
dangerous  ;  while  in  patients  j)ast  middle  age  all  admit  their  inapplicability.  And  yet  it 
must  be  admitte<l  that  excision  of  the  knee-joint  is  a  good  operation,  and  that  by  it,  when 
successful,  a  far  better  limb  is  given  than  after  amputation.  The  truth  must  be  recog- 
nized, however,  that  the  o])eration,  as  hitherto  practised,  is  much  more  fatal  than  ampu- 
tation, although  it  may  with  confidence  be  asserted  that  the  ca.ses  in  which  amputation 
has  been  performed  are,  as  a  rule,  far  more  severe  than  tho.se  in  which  excision  has  been 
practised  ;  for  the  advocates  of  excision  are  disposed  to  operate  at  a  somewhat  earlier 
period  of  disease  than  the  advocates  of  amputation — that  is,  the  former  often  remove  a 
disease  they  believe  it  is  inexpedient  to  leave  to  be  cured  by  natural  processes,  whilst  the 
latter  remove  a  limb  only  when  all  hope  of  a  natural  cure  has  passed  away  and  the  opera- 
tion is  a  necessity  to  save  life.  Are  the  advantages  of  excision,  therefore,  so  great  as  to 
justify  a  surgeon  submitting  a  patient  to  an  extra  risk  in  order  to  secure  them?  As 
hitherto  practised,  and  as  a  general  rule  in  surgery,  I  have  no  doubt  in  answering  in  the 
negative.  In  exceptional  cases  the  risk,  it  is  true,  may  be  run,  but  excision  as  a  rule  of 
practice  does  not  appear  to  be  sound.  Whether  better  results  would  not  be  .secured  by 
an  earlier  operation  is  an  open  question.  Prof.  Humphry's  cases,  recently  published,  and 
those  of  my  colleague,  Mr.  Howse,  rather  tend  to  .show  they  would  ;  for  after  excision 
undertaken  with  a  patient  in  good  health,  or  at  least  not  worn  out  by  suppurative  mis- 
chief, a  good  result  may  fairly  be  expected.  But  is  the  risk  of  the  operation  when  per- 
formed under  these  favorable  circumstances  so  slight  as  to  justify  the  surgeon  in  throw- 
ing aside  the  hope,  and  perhaps  fair  expectation,  of  securing  a  recovery  by  natural  pro- 
ce.sses  ?  Is  excLsion  of  the  knee  to  be  an  operation  of  expediency  and  not  of  necessity  ? 
AVe  want  facts  to  prove  this  fully,  but  as  far  as  present  experience  goes  it  .seems  to  show 
that  if  the  operation  is  to  be  a  successful  as  well  as  a  general  one  in  surgery  it  mu.st  be 
undertaken  at  a  somewhat  earlier  period  of  disease  than  that  at  which  the  question  of 
amputation  has  to  be  mooted — that  it  should  be  performed  before  surgical  fever  has 
reduced  the  powers  of  the  patient  and  complete  disorganization  of  the  joint  has  taken 
place.  In  fact,  it  should  imt  be  practised  when  an  operation  is  demanded  to  save  the  life 
of  a  patient — for  under  such  circum.stances  a  better  chance  is  given  by  amputation — but 
when  the  local  disease  is  found  to  be  steadily  progressing  in  spite  of  treatment  and  dis- 
organization is  threatening.  As  a  substitute  for  amputation  undertaken  in  extreme  dis- 
ease to  save  life,  facts  tell  against  the  practice  ;  as  an  operation  of  expediency  to  gain 
time,  the  few  facts  we  possess  tell  in  its  favor.  From  recent  experience  I  am  dispo.sed  to 
to  think  that  under  these  circumstances  excision  is  a  successful  and  satisf\\ctorv  ojteration. 
In  doubtful  cases  amputation  is  the  more  desirable,  as  it  is  the  safer,  operation  :  and, 
since  the  great  object  of  our  profession  is  to  prolong  and  save  life,  other  objects  ought 
always  to  be  subsidiary  to  this  great  aim.  In  acute  suppuration  of  the  knee  excision  is 
never  successful.  Excision  for  gunshot  wounds  has  been  proved  to  be  most  unsatisfac- 
tory ;  indeed,  as  a  practice  in  such  cases  it  seem^;  hardly  justifiable.  In  compound  dislo- 
cation it  has  been  succes.sful.  Canton  and  M.  Spillman  have  published  such  cases,  but 
upon  the  whole  the  evidence  we  possess  is  not  much  in  its  favor  in  traumatic  cases. 


936 


DISEASES  OF  THE  JOINTS. 


Resection  in  cases  of  deformity  as  a  consequence  of  disease  is  probably  a  better  field  f  r 
the  operation,  and  Drs.  Barton  and  Buck  of  New  York  have  demonstrated  its  value, 


The  Operation. 

The  best  incision  is  that  practised  by  Fergusson  and  suggested  by  Park — a  straight 
one  across  the  joint  below  the  patella  from  the  posfen'or  edge  of  one  condyle  to  the  cor- 
responding part  of  the  other.  When  the  tissues  over  the  knee  are  bad,  the  incision  may 
be  curved,  forming  a  flap.  The  old  H-shaped  incision  is  now  rarely  practised.  Humphry 
follows  Mackenzie  in  making  the  semicircular  incision  with  the  convexity  downward,  and 
Bickersteth  of  Liverpool  mabss  a  vertical  incision  on  the  inner  side  of  the  patella.  The 
joint  should  be  opened  at  once  by  dividing  the  ligamentum  patellae  and  the  capsule  of 
the  joint,  an  assistant  flexing  the  leg  fully  upon  the  thigh,  thereby  facilitating  this  part 
of  the  operation.  The  soft  parts  ought  then  to  be  turned  back  off  the  patella  and  that 
bone  removed,  there  being  no  object  in  leaving  it,  but  many  reasons  for  its  removal.  The 
joint  having  been  fi'eely  exposed  by  the  division  of  the  lateral  and  other  ligaments  and 
by  the  forcible  projection  of  the  condyles,  the  lower  two-thirds  of  the  cartilaginous 
extremity  of  the  femur  is  to  be  excised,  care  being  taken  not  to  injure  the  popliteal 
vessels  which  lie  in  close  contact  })ehind  ;  the  whole  of  the  epiphysis  should  not  be 
removed.  This  section  is  usually  made  at  right  angles  to  the  shaft  of  the  bones,  but 
lately  it  has  been  suggested  that  the  surface  of  the  femur  should  be  made  convex  and 
that  of  the  tibia  concave,  or  that  of  the  femur  should  be  made  wedge-shaped  to  les-^en 
the  risk  of  any  shifting  of  the  bone.  To  make  the  section,  the  bow  saw  known  as 
•Butcher's  is  the  best ;  the  section  should  be  made  from  behind  forward.  In  both  bones, 
when  possible,  it  is  well  not  to  encroach  upon  the  epiphysial  cartilage.  In  dividing  the  bone 
care  is  required  not  to  strip  off  the  periosteum  above  the  line  of  section.  When  the  sur- 
faces are  not  healthy  or  do  not  come  together  well,  another  section  may  be  made,  it  being 
a  point  of  primary  importance  that  a  perfect  adjustment  of  the  bones  should  be  secured. 
To  aid  this  the  osseous  suture,  as  first  employed  by  Gurdon  Buck  and  practised  by  Nela- 
ton  and  some  English  surgeons,  is  to  be  recommended.  All  bleeding  ought  to  be  arrested 
by  ligature  or  torsion  of  the  vessels  or  by  hot  antiseptic  sponges  (a  point  much  insisted 
on  by  Prof.  Humphry)  and  the  parts  brought  well  together  by  sutures,  some  immovable 
apparatus  being  adjusted  before  the  patient  is  taken  from  the  operating-table.  The  splint 
I  prefer  is  the  one  figured  below  as  used  by  my  colleague,  Mr.  Howse.     It  is  made  of 

Fig.  635. 


Splint  for  Excision  of  TCnee. 
1.  Splint:  Z,  sliding  bar;  X,  foot-piece.    2.  Linib  fixed  in  splint  after  operation:  A,  mattress;  B,  water-bed  with  pipe 
(C);  D,  waxed  bandage;  K,  longitudinal  band  to  support  heel  fixed  by  strapping  (E);  H,  band  to  support  splint; 
G,  pillow. 

tinned  iron,  and  the  limb  is  fixed  in  it  by  a  waxed  bandage.  Dr.  P.  Heron  Watson 
employs  with  the  plaster  of  Paris  an  anterior  iron  suspension  rod.  Salter's  swing  is 
an  invaluable  adjunct. 

Dr.  Humphry  first  fixes  the  limb  upon  a  posterior  splint  and  foot-piece,  then,  uniting 
the  edges  of  the  Avound  by  sutures,  he  applies  well-padded  long  splints  to  the  sides  of  the 


( ) I 'i:i: .1771  •/•;  / .v ti:i! fi:ii i:s< 'ic—L'Xf 'isioy  am>  .\mitt.\ tios. 


■>i 


Miiili,  till-  wiMiinI  liriii::  li'lt  t'.\|iiisc(l.  'I  :iiii  very  pai-ticiilar,  "  lie  writfs  (  JAf/.-^ '////•. 
Tidiix.,  V(il.  Hi.),  •to  ailjiisl  tilings  well  and  liriiily  in  tlic  first  iiistaiic-f.  ami  am  very 
utiwilliii;,'  to  (listurl)  tlic  liinli  artcrwanl.  Indct'il,  I  rif(|iit'iitly  (h)  not  n-imivt!  any  iif  the 
bamlaj^cs  or  splints  I'm-  live.  six.  <ir  more  weeks,  and  liy  tliis  care  and  jteriect  (juiet  I 
endeavor  to  |>ronioie  ininiediate  union.  This  iierl'eet  (|iiiet  and  ahstineiici!  IVoin  removal 
of  the  hanihiLTes  first  ajijdied  is.  I  eonsich-r,  a  very  important  item  in  the  treatment.  It  is 
0((Uallv  important  not  to  discontinue  tiie  splints  till  tlu!  hones  are  (piite  firmly  united — 
till  tlu'  patient  can  raise  tlu'  limit  from  the  hed  liy  its  own  muscles  without  any  move- 
ment hcini;  pcrceptihle  hetweon  the  tihia  and  femur.  It  is  neces.sary  to  make  (|uit(!  sure 
of  tliis." 

Dr.  Humphry  adds  that  ''excision  of  the  knee  is  not  an  operation  oi'  much  dan<rer," 
hut  it  must  he  rememhered  that  he  has  little  or  no  faith  in  the  cure  l)y  natural  processes. 
He  helieves  such  a  cure  in  the  hulk  of  cases  to  he  hardly  wftrth  the  attempt,  and  advises 
that  excision  should  he  employed  early,  so  a.s  to  hrinj:-  ahout  hy  operation  tliat  condition 
which  wt-  would  uladlv  see  attaiiie(l  without  such  interference. 


Foot    iifier  Ueiiioval  of  Xecrosed 
Astragalus  from  a  Child  set.  i'>. 


Suppuration  of  the  Ankle-Joint. 

When  the  inihlc-joint  has  underjione  disoriianization  and  is  suppuratinfr,  the  benefit  to 
be  gained  by  a  free  incision  into  the  joint  is  very  great,  a  cure  with  a  movable  articulation 
being  often  obtained  by  these  means.     When  this  end  is  not 
secured,  a  recovery  by  anchylosis  may  be  looked  for,  it  being  Fifi.  63*!. 

exceptional   for  any  more   active  interference  to   be  required 
except  when  the  bones  are  extensively  involved. 

When  necrosis  of  one  of  the  bones  entering  into  the  forma- 
tion of  the  joint  is  present,  recovery  may  be  looked  for  on  the 
removal  of  the  diseased  bone.  In  the  case  illustrated  in  Fig. 
63G  I  removed  the  necrosed  upper  lialf  of  the  astragalus  witb 
an  admirable  result,  and  a  good  foot,  with  some  amount  of 
movement,  was  secured. 

Under  these  circumstances  excision  of  the  joint  has  been 
practised,  and  with  success.  I  have  performed  this  operation 
on  three  occasions,  and  in  two  with  a  good  result ;  in  the 
majority  of  cases  of  disorganized  ankle-joints  I  have  obtained 
good  results  by  the  expectant  treatment  and  free  incision. 
Excision  may  be  expected  to  be  successful  when  the  disease 
is  limited  to  the  articular  surfiices  of  the  bones,  and  it  is  in  such  that  the  treatment  by 
incisions  and  the  expectant  principle  is  so  successful.  When  the  disease  is  very  exten- 
sive, it  is  still  a  question  whether  amputation  is  not  probably  a  better  practice.  Stokes, 
however,  has  collected  51  cases  of  excision.  38  of  which  were  successful,  and  in  the 
Dublin  Quart,  for  1870  an  excellent  example  by  Dr.  Murney  may  be  referred  to. 

In  cases  of  injury,  of  compound  dislocation,  and  fracture  into  the  joint  excision  is 
probably  a  sound  operation.  Mr.  H.  Lee  has  recently  adopted  it  in  two  cases,  and  Lan- 
genbeck  has  practised  it  freely  with  success.  Hancock  {Lancet.,  18(57)  gives  nineteen 
successful  examples  of  the  operation,  quoting  Heyfelder  and  Jaeger's  practice  in  its  sup- 
port.    In  such  cases,  however,  it  seems  well  to  practise  it  as  a  secondary  operation. 

With  respect  to  the  operation  itself.  I  may  quote  Hancock's,  as  practised  in  1851.  and 
given  by  Barwell  with  recent  improvements. 

The  foot  is  first  laid  on  its  inside  and  an  incision  made  over  the  lower  three  inches  of 
the  posterior  edge  of  the  fibula.  When  it  has  reached  the  lower  end  of  the  malleolus,  it 
forms  an  angle  and  runs  downward  and  forward  to  within  about  half  an  inch  of  the  base 
of  the  outer  metatarsal  bone.  The  angular  flap  is  reflected  forward  ;  the  fibula,  about 
two  inches  above  the  malleolus,  is  thus  sufficiently  cleared  of  soft  parts  to  allow  cutting 
forceps  to  be  placed  over  it.  when  the  bone  then  can  be  nipped  in  two  and  carefully  dis- 
sected out,  leaving  uncut  the  tendons  of  the  peronei  longus  and  brevis.  The  foot  must 
then  be  turned  over.  A  similar  incision  should  be  made  on  the  inner  side,  the  portion  in 
the  foot  terminating  over  the  projection  of  the  inner  cuneiform  bone.  The  flap  ought 
then  to  be  turned  back  and  the  sheaths  of  the  flexor  digitorum  and  posterior  tibial  ten- 
dons exposed,  the  knife  being  kept  close  to  the  bone,  avoiding  the  artery  and  nerve.  The 
internal  lateral  ligament  should  be  severed  carefully  close  to  the  bone  :  aiul  the  foot  is 
now  twisted  outward,  when  the  astragalus  and  tibia  will  present  at  the  inner  wound.  A 
narrow-bladed  saw  inserted  between  the  tendons  into  the  inner  wound  will  project  through 


938  DISEASES  OF  THE  JOINTS. 

the  outer.  The  lower  end  of  the  tibia,  and  then  the  top  of  the  astragalus,  should  be  sawn 
ofl'  in  a  proper  direction.  The  only  vessel  that  may  require  tying  is  one  of  the  lower 
branches  of  the  peroneal  artery.  The  wound  can  be  closed  with  sutures,  except  that 
part  opposite  the  breach  of  osseous  matter,  and  the  leg  and  foot  placed  in  a  splint  with  a 
foot-board  and  cold  water  applied.  Mr.  Hancock  points  out  the  superiority  of  total  over 
partial  excision  of  the  joint.  Mr.  Hey  of  Leeds  in  1706  was  the  first  surgeon  who 
resected  the  lower  ends  of  the  tibia  and  fibula  for  compound  dislocation,  and  Moreau  in 
1792  for  disease.  Hancock,  however,  was  the  first  to  resect  the  joint  as  a  whole.  This 
operation  has  grown  in  favor  during  the  last  few  years,  and  in  select  cases  is  doubtless 
beneficial. 

Suppuration  op  the  Shoulder-Joint. 

Suppuration  of  the  shoulder-joint  is  as  successfully  treated  by  free  incisions  into  and 
the  removal  of  necrosed  bone  from  the  joint  as  the  same  affection  of  any  other  articula- 
tion, and  only  when  this  treatment  has  failed  or  is  inapplicable  are  more  severe  measures 
required. 

In  the  case  from  which  Fig.  637  was  taken  the  disease  had  evidently  commenced  as 
an  abscess  in  the  head  of  the  bone,  which  had  made  its  way  into  the  joint  and  downward 

through  the  soft  parts  to  a  point  below  and  behind  the  inser- 
tion of  the  deltoid  muscle.  It  had  existed  for  a  year  before 
I  treated  it,  and  nothing  but  excision  was  applicable,  since 
the  abscess  cavity  contained  a  small  sequestrum  which  could 
not  get  out.  After  the  operation  the  patient  had  a  good 
arm. 

Excision  of  the  shoulder-joint — or,  rather,  of  the 
head  of  tlie  humerus— is  an  excellent  operation  in  gunshot 
wounds  of  the  joint,  in  compound  dislocation,  or  in  cases  of 
disease  where  a  cure  by  natural  processes  has  failed  after 
judicious  treatment,  owing  either  to  the  extent  of  disease  in 
the  bone  or  to  the  general  feebleness  of  the  patient's  powers. 
'■  The  ultimate  results  of  excision  of  this  joint,  whether  for 
injury  or  disease,  are  very  satisfactory,"'  says  Hodges,  but 
Head  of  the  Humerus  removed  by     thev  are  uot  more  SO  than  the  ultimate  results  of  a  cure  by 

Operation,  sliowini;  au  Abscess  .•        ,  -.i  i      i      •         j?  i.    ^ 

Cavity  ut\  in  its  Centre,  with     natural   processes,  even   with  anchylosis;   lor,  whatever  may 
Small"  se^iuestrum   and  ' Sinus     j^g  the  capabilities  of  an  arm  after  excision,  thev  are  equalled 

burrowing  Downward.  t  tt     t         i       n       •  •        i 

alter  a  natural  cure.  Under  both  circumstances,  in  the  ma- 
jority of  cases,  almost  every  movement  can  be  effected  except  any  overhand  one,  since 
the  arm  cannot  be  rai.sed  above  the  .shoulder.  A  man  whose  shoulder  I  excised  fourteen 
years  ago  was  a  coachman  in  1872  and  could  drive  a  pair  of  horses  with  ease.  A  man 
upon  whom  Mr.  Key  operated  was  subsequently  able  to  carry  on  his  occupation  as  a  ham- 
merman at  a  large  engineer's,  and  another  case,  operated  upon  by  the  same  surgeon 
twenty-one  years  before,  in  June,  1869,  could  '•  .shoe  horses  with  any  man."  and  as  a 
blacksmith  felt  no  want  in  his  arm. 

In  gunshot  injuries  to  the  shoulder  excision  is  now  a  recognized  operation,  the  experi- 
ence acquired  in  the  American  war  having  decided  the  point.  Dr.  Otis  (Circular  0)  has 
recorded  that  in  252  cases  of  primary  excision,  23  per  cent,  died  ;  and  in  323  secondary, 
38  per  cent.  ;  primary  excisions  being  thus  more  successful  than  secondary. 

In  cases,  also,  of  tumors  involving  the  head  of  the  bone,  other  than  cancerous,  excision 
is  an  operation  of  value. 

Operation. — The  best  incision  is  the  vertical,  from  the  acromion  process  through  the 
thickness  of  the  deltoid  down  to  its  insertion.  Some  make  an  anterior  in  front  of  the 
deltoid.  N^laton  used  the  transverse  and  Aston  Key  the  deltoid  flap.  When  the  ver- 
tical incision  is  made  down  to  the  bone,  its  head  should  be  successively  rotated  outward 
and  then  inward,  the  surgeon  making  a  transverse  cut  across  the  tuberosities  to  divide 
the  insertions  of  the  scapular  muscles.  The  capsule  may  then  be  divided  and  the  head 
of  the  bone  turned  out  of  the  wound  and  resected  through  the  tuberosities.  The  long 
tendon  of  the  biceps  needs  no  special  attention,  as  in  cases  of  disease  it  has  probably  long 
gone  or  become  fixed  to  the  groove,  and  after  resection  of  the  joint  is  of  no  value.  When 
the  glenoid  cavity  is  diseased — that  is,  when  dead  bone  is  detected  in  it — it  .should  be 
removed  ;  but.  in  a  general  way.  it  requires  no  treatment.  AVhen  the  vertical  incision  is 
employed.it  is  expedient  to  make  an  opening  po.steriorly  through  the  soft  p.irts,  at  a  point 


OPERA Tivi:  isti:i:fi:}:i:sl'K-i:x< •isjox  am>  ampi'tatios. 


!);i9 


C'(»rri'S|»itiuliiii;  to  tlic  upiKT  end  of  tin-  hiiinenis.  Ii»r  tlie  purposes  of  (Jraiiia^c,  this  opeii- 
iiii;  buiiij;  ki'pt  piitiiit  by  mi'uiiK  of  u  (Iniiiiu'ro  tubt;.  Whatever  vessels  art;  divided  should 
Ite  twisted,  ami  the  |>osterior  eireuuiflex  artery  at  times  pives  trouble.  After  the  ojxra- 
tiou  the  arm  should  l)e  ahdueted  and  placed  on  a  pillow,  the  ed«;es  of  the  wound  earefully 
hroutrht  tojrether.  and  wafer  dressinfr  or  dry  lint  aiijilied.  As  soon  as  repair  has  iairly 
taken  jilaee  the  patii-nt  may  -^et  up.  the  arm  Iteinj;  well  supjiorted  in  a  slin<_'.  Three  or 
four  mnnths.  however,  are  usually  recjuireil  before  a  useful  arm  is  secured. 

In  this  operatiiin  .M.  Oilier  makes  mueh  of  preservinir  the  ]»eriosteum,  turnin;:  it  back 
off  the  bone  with  all  the  soft  parts  by  means  of  raspatories ;  this  is  not  so  <liffi(ult  in  cases 
of  disease  as  mijrht  be  faneieil.  A  cut  with  a  strong'  knife  down  to  the  bone  should  .so 
divide  all  the  soft  tissues  over  the  bone  as  to  <rive  admission  to  the  edire  of  a  rasj»atory 
for  the  jturpose  of  turninu:  them  back.  Oilier  has  d(»ne  this  on  four  oecasi(tns  with  suc- 
cess. In  reseetini;  the  bone  no  more  need  V>e  removed  than  is  neces.xary  beyond  the  head 
and  half  the  tuberosities;  but  when  the  section  is  not  healtliy,  ani>tl»er  may  be  iiiaih.-. 
Four  or  five  inches  of  bone  have  been  removed  in  some  cases,  and  yet  a  useful  limb 
remained. 

Suppuration  of  the  Elbow-Joint. 

Tliere  is  a  irreat  dit^erence  amon<rst  sur<reons  as  to  the  treatment  of  a  suppurating 
elbow-joint.  In  the  Scotch  school  excision  is  emjdoyed  very  freely,  under  the  belief  that 
a  better  arm  more  generally  follows  such  a  practice  than  results  from  a  cure  by  natural 
processes,  and  that  a  joint  with  better  movement  is  secured  in  a  shorter  time.  I  cannot 
say  that  1  agree  in  this  opinion,  for  in  elbow-joint  di.sease,  where  pus  is  let  out  by  free 
incisions  and  good  reparative  power  is  present,  recovery  with  a  movable  joint,  and  one 
admitting  of  jn-onation  and  supination  of  the  hand,  is  by  no  means  uncommon.  In  other 
cases  anchylosis  of  the  humero-ulnar  joint  may  take  place  at  a  good  angle  and  pronation 
and  supination  of  the  hand  be  retained — and  when  this  is  the  case,  the  issue  so  far  as  the 
usefulness  of  the  hand  is  concerned  is  excellent — while  in  another  class  anchylosis  of  both 
bones  may  take  place  with  a  very  useful  arm  ;  and  this  result  is  secured  by  no  greater 
expenditure  of  time  than  is  required  for  repair  after  excision,  and  without  the  risks  of  an 
operation.  In  synovial  disease  ending  in  disorganization  this  termination  is  far  from  being 
uncommon.  Indeed,  in  such  cases  exci.sion  is  rarely  called  for.  In  bone  disease  ending  in 
necrosis,  however,  the  same  rules  do  not  apply,  for  under  such  circumstances  no  operation 
is  of  greater  value  than  excision  (Fig.  638).  In  Fig.  638  the  disease  was  necrosis  of  part 
of  the  humerus  ;  in  Fig.  639  necrosis  of  the  head  and  neck  of  the  radius. 


Fig.  639. 


Parts  Removed  after  Disorganization  of  the 
Elbow-Joint  as  a  Result  of  Necrosis  of 
Humerus. 


Necrosis  of  the  Head  and  Neck  of  the  Radius,  fol- 
lowed bv  nisortranizatioti  of  the  Elbow-JoiBt. 
^Removed  by  resection  from  a  man  set.  36.) 


In  all  cases  of  disease  of  the  elbow-joint  in  which  natural  processes  are  incompetent 
to  effect  a  cure  excision  should  be  performed,  amputation  being  had  recourse  to  only 
when  excision  is  inapplicable  or  has  failed.     In  ca.ses  of  compound  dislocation  or  fracture 


940 


DISEASES   OF  THE  JOINTS. 


Fig.  610. 


J 


Vertical  Incision  for 
Excision  of  the  El- 
bow-Joint. (From 
Maunder.) 


into  the  joint  excision  is  an  excellent  operation,  and  to  gunshot  wounds  the  same  observa- 
tions apply.  Amputation  of  the  arm  for  injured  elbow  ought  to  be  performed  in  qu'te 
exceptional  cases.  Several  inches  of  bone  may  be  taken  away  in  the  operation.  Mr. 
Tudor  of  Dorchester  removed  five  inches,  the  patient  sub.se(|nently  having  an  arm  capable 
of  extensive  motion  in  every  direction,  and  with  which  he  could  lift  a  heavy  chair  ( J/er/.- 
Chir.  Trans.,  1858). 

Operation. — The  best  incision  is  the  vertical  one  over  the  olecranon  process,  as  prac- 
tised by  Langenbeck  and  the  French  surgeons,  extending  from  three  inches  above  to  two 
below  the  joint,  the  incision  dividing  all  the  tissues  down  to  the  bones.  The  soft  parts 
should  then  be  carefully  separated  from  the  bones  and  drawn  aside,  the  ulnar  nerve  being 
raised  from  the  inner  condyle,  with  the  inner  half  of  the  triceps  tendon  and  fascia.  i\o 
frauiiverse  incision  across  the  triceps  tendon  should  he  made,  it  being 
a  vei*y  important  thing,  as  recommended  by  Dr.  R.  Hodges  of  Amer- 
ica (^Hammond's  Essays,  186-1)  and  demonstrated  by  Maunder  (Brit. 
M(d.  Journal,  1871),  to  retain  the  triceps  tendon  and  fascia 
z:;^^^^^^  as  it  passes  over  the  olecranon,  with  the  fascia  of  the  fore-arm  and 

^ ^-^  '    anconeus  muscle,  a  thick  body  of  muscle  and  fascia  being  in  this  way 

retained,  extending  from  the  arm  above  to  the  fore-arm  below,  which 
adds  materially  to  the  extending  power  and  subsequent  value  of  the 
limb  (Fig.  (J4()).  The  articular  ends  of  the  bones  should  then  be 
turned  out  and  removed.  The  surgeon  need  not  be  too  sparing  in  his 
sections.  In  all  cases  the  whole  of  the  articular  facets  should  be 
resected ;  and  when  the  bone  at  the  point  of  section  is  not  quite 
healthy,  a  second  piece  had  better  be  removed.  "  If  only  the  extreme 
ends  of  the  bones  be  sawn  oflp.  anchylosis  will  most  likely  take  place  ; 
while  if  the  amount  above  prescribed — viz.,  the  whole  condyloid 
extremity  of  the  humerus  and  all  the  sigmoid  cavity  of  the  ulna,  with 
the  head  of  the  radius,  or  even  little  more  on  both  sides — be  taken 
away,  free  motion  may.  under  favorable  circum.stances.  be  expected  "  (Fig.  641 )  {Holmes  s 
System,  vol.  v.).  I  have  at  times  regretted  not  having  excised  enough  of  bone,  and  par- 
ticularly of  the  humerus ;  indeed,  I  strongly  advise  the  surgeon  in  all  cases  to  be  free  in 

his  section  of  this  bone,  more  particularly 
in  excisions  for  anchylosis.  When  pos- 
sible, it  is  well  to  preserve  the  insertidus 
of  the  biceps  and  brachialis  anticus  tendons 
by  pressing  them  back  from  the  bones.  To 
preserve  the  periosteum  in  the  operation,  as 
advocated  by  Oilier  and  Langenbeck,  does 
BMsosock^ joint  -^  ^^^  appear  from  published  facts  or  scien- 

Splint  for  Excision  of  the  Elbow,  the  .'Splint  allowing  everv   ^.z.  •  .^i.  ,.  p   • 

movement.  '   titic  reasonings  to  be  a  matter  or  import- 

ance. 
After-Treatment. — After  the  operation,  all  hemorrhage  having  been  arrested  by 
torsion  and  the  application  of  cold  or  very  hot  water,  or.  what  is  preferable,  iodine  water 
(gij  ad  Oj,  this  mixture  checking  capillary  bleeding),  the  edges  of  the  wound  should  be 
brought  together  at  their  ends,  a  drainage  tube  introduced,  and  the  arm  fixed  at  an 
obtuse  angle  upon  such  a  screw  .splint  as  that  made  for  me  and  figured  above  (Fig.  641, 
the  splint  allowing  every  movement),  moderate  pressure  being  applied  and  maintained 
for  a  few  hours  by  means  of  a  bandage.  Absolute  rest  should  be  maintained  till  the 
wound  has  fairly  healed  and  the  powers  of  the  patient  have  been  restored,  when  passive 
movement  should  be  commenced  with  pronation  and  supination  of  the  hand,  the  object 
of  this  operation  being  not  only  to  remove  the  disease,  but  to  obtain  a  movable  joint. 
When  anchylosis  follows,  the  operation  in  a  measure  is  unsuccessful,  for  it  has  failed  in 
one  of  its  greatest  advantages.  In  the  most  favorable  cases  the  amount  of  movement 
that  is  obtained  is  all  that  could  be  wished ;  indeed,  it  is  little  less  than  that  of  the 
healthy  joint.  In  some  cases,  however,  the  joint  is  too  loose,  like  a  flail ;  in  others  it  is 
stiff;  whilst  in  another  class  flexion  and  extension  are  good,  but  pronation  and  supination 
fail.  In  Mr.  Syme's  case  of  a  man  who  had  acted  as  a  railway  guard  up  to  the  time  of 
his  death,  nine  years  after  the  operation,  when  the  joint  was  dissected,  the  ulna  and 
humerus  were  united  by  ligamentous  union,  and  the  end  of  the  radius  was  polished  oflf 
and  placed  on  the  humerus  and  ulna  upon  a  material  much  resembling  cartilage.  If  the 
ulnar  nerve  be  injured,  much  wasting  of  the  muscles  must  occur;  if  divided,  union  of  the 
ends  may.  however,  take  place.     Syme  has  recorded  such  a  case.      When  disease  returns, 


Fig.  041. 


(>ri:n.\rivF.  i.\'n:nii:nKycK^h'xcisio\  .wd  .\Mri"r.\T/o.\.        941 

a  st'fntid  rt'si-rtioii  imiv  l>f  |ii'rlnriin'i|,  ami  t-vt-n  u  tliinl.  WIkmi  «Ic!hI  Imiii!  follows,  it  may 
In;  miioVfd  ;  indeed,  iiotliiii;^  sliould  Ix-  left  iiiitrie<|  liefore  uiii|(iitii(i()ii  is  pructi.sed.  I 
have  ju-rlnriiied  the  it|ierati<iii  tweiit  \ -live  times,  and  liavu  never  had  to  resect  a  Hccoiid 
tinn-  or  to  am|iiitali',  and  i:i  two-thinis  of  the  eases  ;;ood  movement  was  «ihtaim'd. 

Partial  resections  of  tiie  eihow  have  hithertfi  heeii  condemned,  j)asl  experience  having 
inilieatetl  that  thev  almost  always  end  in  ani-hylosis  of  the  joint.  In  iHtil,  liowever, 
my  eolleairiie,  Mr,  Uirkett,  excised  the  olecraimn  for  local  disease  followin<;  an  injury, 
tile  man  re«'overinu:  after  many  incmths'  treatment  with  a  slightly  movahle  articulation  ; 
and  1  have  recently  (1S77)  done  the  same  in  a  harrow-man  ;t't.  iJS.  the  patitMit  recovering 
with  a  joint  tixed  at  a  very  ohtnse  angle,  with  limited  movement.  I  have  likewise 
removed  the  necrosed  olecranon  process  from  a  disorganized  elhow-joint  of  a  woman  with 
a  good  result,  the  humerus  and  ulna  suhsi'ijiiently  anehylosing,  while  the  radius  and  hand 
retained  all  their  movements.  Fnuu  the  results  of  partial  res(;ctions  in  other  ji^iuts 
as  well  as  in  the  elhow  I  helieve,  however,  that  with  our  proent  improved  methods  of 
treating  wounds  these  partial  operations  are  valuahle. 

Suppuration  of  the  Wrist  and  Carpal  Joints. 

In  this  affection  o|>erative  interference  is  rarely  called  for  beyond  free  incisions  for  the 
evacuation  of  ]ient-up  j>us  and  renu)val  of  dead  bone,  recovery  being  aided  by  the  ab.so- 
lute  immobility  of  the  hand  and  fingers  and  such  constitutional  remedies  a.s  the  wants  of 
the  individual  case  .suggest.  When,  however,  such  means  fail  or  the  local  disease  is  too 
extensive  or  severe  to  allow  of  a  natural  rectjvery,  excision  of  the  joint  should  be  j)er- 
formed  ;  Lister,  Hancock,  and  others  have  liad  successful  examples.  The  best  method 
of  performing  the  operation  is  that  of  Langenbeck,  by  means  of  a  single  free  incision 
over  the  dorsum  of  the  wrist  extending  along  the  centre  of  the  metacarpal  bone  of  the 
index  finger.  IJy  this  incision  the  lower  part  of  the  radial  artery  is  avoided  and  ample 
room  given  for  the  completion  of  the  operation.  Through  the  opening  made  the  carpal 
bones  can  readily  be  turned  out  and  the  bases  of  the  metacarpal  bones,  with  the  extremi- 
ties of  the  radius  and  ulna,  exci.sed,  the  tendons  of  the  wrist  being  held  aside  with  ea.se. 
In  performing  this  operation  I  have  been  struck  with  the  facility  with  which  it  can  be 
effected,  and  believe  it  to  be  preferable  to  the  comparatively  difficult  and  complicated 
method  suggested  by  Lister,  which  is  to  be  commenced  by  an  incision  made  in  front  over 
the  second  metacarpal  bone  internal  to  the  tendon  of  the  extensor  secundi  internodii  pol- 
licis  and  running  along  the  back  of  the  carpus,  internal  to  the  same  tendon  as  high  as  to 
the  base  of  the  styloid  process  of  the  radius ;  the  .soft  parts,  including  the  exten.sor 
secundi  internodii  and  the  radial  artery,  being  cautiously  detached  from  the  bone,  exter- 
nal to  this  incision,  and  the  tendons  of  the  radial  extensors  of  the  wrist  being  also  severed 
from  their  attachments,  the  external  bones  of  the  carpus  will  be  ex])osed.  When  this 
has  been  done  sufficiently,  the  next  step  is  to  sever  the  trapezium  from  the  other  bones 
with  cutting  pliers,  in  order  to  facilitate  the  removal  of  the  latter,  which  should  be  done 
as  freely  as  is  found  convenient.  The  operator  now  turns  to  the  ulnar  side  of  the  inci.s- 
ion,  and  cleans  the  carpal  and  metacarpal  bones  as  much  as  can  easily  be  done.  The 
ulnar  inci.sion  is  then  made  ;  it  should  be  very  free,  extending  from  about  two  inches 
above  the  styloid  proces.ss  down  to  the  middle  of  the  fifth  metacarpal  bone  and  lying 
near  the  anterior  edge  of  the  ulna.  The  dorsal  line  of  this  incision  is  then  raised  along 
with  the  tendon  of  the  extensor  carpi  ulnaris.  which  .should  not  be  isolated  from  the  .skin, 
but  cut  as  near  its  insertion  as  possible.  Afterward  the  common  exten.sor  tendons  should 
be  raised  and  the  whole  of  the  posterior  aspect  of  the  carpus  denuded  until  the  two 
wounds  communicate  freely  together,  though  the  radius  is  not  as  yet  cleaned.  The  next 
step  is  to  clean  the  anterior  aspect  of  the  ulna  and  carpus,  in  doing  which  the  pisiform 
bone  and  hooked  process  of  the  unciform  are  severed  from  the  rest  of  the  carpus,  the 
firmer  with  the  knife,  and  the  latter  with  the  cutting  pliers.  In  cleaning  the  anterior 
aspect  of  the  carpus  care  must  be  taken  not  to  go  so  far  forward  as  to  endanger  the 
deep  palmar  arch.  The  ligaments  of  the  internal  carpal  bones  being  now  sufficiently 
divided,  they  should  be  removed  with  blunt  bone  forceps;  next,  the  end  of  the  ulna  is 
made  to  protrude  from  the  incision  and  .sawn  off  as  low  down  as  is  consistent  with  its 
condition,  but  in  any  case  above  its  radial  articulation.  The  end  of  the  radius  can  then 
be  cleaned  sufficiently  to  allow  of  its  being  protruded  and  removed.  If  this  can  be  done 
without  disturbing  the  tendons  from  their  grooves,  it  is  far  better.  If  the  level  of  the 
section  is  below  tlie  upper  ])art  of  the  cartilaginous  facet  for  the  ulna,  the  remainder  of 
the  cartilage  must  be  cut  away  with  the  pliers.     The  operator  next  attends  to  the  meta- 


942  DISEASES  OF  THE  JOINTS 

carpal  bones,  which  are  pushed  out  from  one  or  the  otlier  incision  and  cut  off  with  tlie 
pliers,  so  as  to  remove  the  whole  of  these  cartilage-covered  portions.  The  trapezium 
bone,  which  was  left  in  the  early  stage  of  the  operation,  can  now  be  carefully  dissected 
out,  so  as  to  avoid  any  injury  to  the  tendon  of  the  flexor-carpi  radialis  or  to  the  radial 
artery,  and  the  articular  surface  of  the  first  metacarpal  bone  then  becomes  exposed  and 
removed.  Lastly,  the  cartilaginous  portion  of  the  pisiform  bone  is  taken  away,  but  the 
non-articular  part  is  left,  unless  diseased,  in  which  case  it  should  be  entirely  removed. 
This  remark  applies  to  the  hooked  process  of  the  unciform.  No  tendons  are  divided  in 
this  operation  except  the  extensors  of  the  wrist. 

After-Treatment. — In  order  to  ensure  motion  of  the  fingers  passive  movements 
should  be  performed  from  a  very  early  period  after  the  operation.  For  this  purpose  Lis- 
ter places  the  limb  in  a  splint  with  the  palm  of  the  hand  raised  by  a  wedge  of  cork  fixed 
below  it,  so  that  the  joints  of  the  fingers  can  be  moved  without  taking  the  limb  off  the 
appar.atus.  When  the  splint  is  removed,  some  flexible  support  is  recjuired  for  some  time. 
(  Vide  Lister's  paper,  Lancff,  1865.) 

Excision  of  the  joints  of  the  thumb  requires  no  description,  and  may  be 
made  by  a  vertical  dorsal  incision  that  interferes  but  little  with  the  tendons  of  the  part. 
The  operation  is  very  good,  and  should  always  be  performed  where  possible  for  disease  or 
injury.  I  have  done  it  on  many  occasions  with  a  good  result,  and  at  times  recovery  has 
been  followed  by  movement.  In  the  case  of  a  man  with  neglected  dislocation  in  which 
I  performed  it,  hermetically  sealing  the  wound  with  lint  and  the  compound  tincture  of 
benzoin,  rapid  recovery  followed  with  a  movable  joint.  In  a  second  case,  in  which  I 
excised  the  phalangeal  joint  of  the  thumb,  a  like  result  ensued. 

Amputation  in  Joint  Disease 

ought  never  to  be  resorted  to  until  all  hope  of  a  cure  by  natural  processes  has  been  given 
up  or  failed — until  incision  into  or  the  removal  of  necrosed  bone  from  the  joint  has  been 
deemed  unsuitable,  excision  of  the  joint  inexpedient  or  inapplicable,  or  the  progressive 
nature  of  the  disea.se  and  its  sapping  powers  reveal  the  fact  that  if  the  disease  be  not 
removed  the  life  of  the  patient  is  likely  to  be  sacrificed.  In  amputating  for  joint  disease, 
as  for  injuries,  tutuors,  or  other  causes,  the  principles  of  "the  least  sacrifice  of  parts" 
should  be  followed,  and  no  more  of  the  body,  under  any  circumstances,  ought  to  be  taken 
away  than  the  necessities  of  the  case  demand.  To  carry  out  this  principle  the  surgeon 
may,  in  pathological  amputations,  fearlessly  divide  tissues  infiltrated  with  organized 
inflammatory  products,  and  even  cut  through  the  walls  of  suppurating  cavities  or  dis- 
eased joints,  more  pj^rticularly  to  save  amputating  above  a  joint.  The  value  of  this 
practice  I  have  fully  illustrated  (Laucef,  January  23,  1875). 

Amputation  for  disease  of  the  hip,  shoulder,  and  elbow-joint  is  performed  only  in 
exceptional  cases,  and  for  the  knee  and  ankle  it  is  yearly  becoming  less  common.  Yet 
it  is  a  valuable  operation  in  proper  cases,  as  well  as  the  means  of  saving  many  lives.  The 
mortality  of  amputation  for  chronic  knee-joint  diseases  at  Guy's  Hospital  is  only  1  in  7, 
and  in  young  people  under  twenty  years  of  age  1  in  20.  In  amputation  for  disease  of 
the  knee,  where  the  end  of  the  femur  is  sound  and  the  articular  facet  alone  diseased,  the 
surgeon  should  sacrifice  as  little  of  the  thigh  as  possible  ;  the  amputation  should  be  almost 
at  the  joint,  and  the  femur  divided  through  its  condyles,  or  just  above,  as  in  Stokes's  ampu- 
tation ;  a  higher  section  of  bone  should  be  made  only  when  the  necessity  of  the  case 
demands  it.  In  disease  of  the  ankle-joint,  when  excision  and  every  smaller  operation, 
such  as  the  removal  of  dead  bone,  has  been  put  aside,  Pirogoff 's  operation  should  be 
employed  in  preference  to  amputation,  if  the  calcis  with  the  integument  over  it  be  sound, 
or  Syme's  amputation  unless  the  disease  of  the  articular  end  of  the  tibia  is  too  extensive. 
To  amputate  a  sound  foot  for  disease  confined  to  the  ankle-joint  is  a  measure  which  can 
be  justified  only  by  peculiar  circumstances,  and  as  a  general  practice  it  is  to  be  con- 
demned. Amputation  of  the  arm  for  diseased  elbow  is  still  less  justifiable,  unless  the 
local  disease  is  too  extensive  to  allow  of  excision  or  the  powers  of  the  patient  are  t'oc 
feeble  to  admit  of  the  attempt. 

LOOSE  CARTILAGES  IN  THE  JOINTS. 

Loose  bodies,  ordinarily  called  loose  cartilages,  are  found  in  joints  and  are  most  com- 
mon in  the  knee,  yet  are  met  with  in  the  elbow-,  ankle-,  and  other  joints.  They  are, 
doubtless,  generally  developed  in  the  sub-synovial  cellular  tissues,  and  as  they  increase 


ijxtsi:  cAirni..i<;j:s  i.\  riir:  .lofx'rs.  !>43 

in  size  cncroacli  u|m)u  the  i-iivity  nf  the  iidiit  liy  |)U^llillJr  the  syimvial  iiiemhraiie  heforc 
them,  jiihI  appear  as  warty  or  iiKire  or  h'ss  peduiieiihitefl  IViti^'ed  frrowth.s  liaii^'iiij:  into 
the  eiivity.  They  may  l»e  siiiiiK-  or  multiple  an<l  of  all  nizes  iip  to  that  of  a  small  walnut. 
When  one  of  tlfe  masses  lieeonu's  detached,  "  a  loose  eartila^'e"  is  said  to  be  present.  Jcjliii 
II (inter  tautrht.  and  ivokitansky  helieved.  that  they  are  formed  by  the  orpinization  ol' 
fibrinous  coaL'ula  ;  but  evidence  is  wanting;  to  jtrove  this  view,  for  most,  as  pointe*!  out 
by  Kainey,  contain  ill-furmed  eartilatre  cells,  and  ossitic  matter  and  true  bonc-lacuniu  are 
at  limes  present  (  Ki-r.  (ill').  I'ajret  { .SV.  Jin,//,,  //osj,.  Rrj,.,  iSTOj  has 
recently  given   fjood   evidcnci"  of  the  truth  of  Teales   su<r<.^estion  that  Im.VA'l. 

some  of  these  bodies  are  really  se<(uestra,  and  that  "just  as  a  blow  on 
bone  or  tooth  may  imluce  lu'crosis  and  exl'oliation  ^\''ithout  sij:ns  of 
destructive  inflammation,  so  may  it  with  articular  cartilage;  and   th'  .  v 

characteristics  of  these  eases  wiil   be  that  after  injury  to  a  previous! -.     ■    .  % 

healthy  joint  a  loose  body  is  found  in  it,  having  the  shape  and  general    V^ttfcl^:;  '^'l^/ 
aspect  and  texture  of  a  piece  of  articular  cartilage,  with  or  without        Wii" u iiJ-=i->— ^ 
some    portion  of   subjacent    bone,  and   with   its   cartilage   corpuscles  ""^fyi^y"  rJ.,,J;,'"^';j'  \-'/^^^^^^^ 
arranged  after  the   manner  of  the  articular  cartihiire."     Dr.  Adams     Knee,    d'rep.  v.u.*", 
of   Dublin  connects  their  presence  with  osteo-arthritis. 

A  report  upon  these  bodies,  with  microscopical  drawing  kindly  etched  for  me  by 
Dr.  (Joodhart,  will  help  to  the  solution  of  some  of  these  points: 

"  The  term  '  loose  cartilage'  is  applied  to  two  conditions  whicb  are  totally  distinct — 
the  one  where  a  portion  of  the  normal  articular  cartilage  has  been  detached  by  injury  to 
the  joint  and  lies  loo.se  in  its  cavity  ;  the  other  where  bodies  of  more  or  less  consistence, 
often  cartilaginous  or  bony,  are  found,  and  which  are  new  formations. 

"  Hecent  observations  seem  to  show  that  the  former  of  the.se  two  is  by  no  means  of 
infrequent  occurrence,  but  it  possesses  no  pathological  interest  whatever  and  needs  no 
description.  A  very  good  specimen  of  this  form  is  to  be  found  in  the  Guy's  Hospital 
Museum  (1344*-).  The  latter,  however,  has  frequently  excited  discussion  among  pathol- 
ogists; so  we  will  give  in  a  few  words  what  appears  to  be  its  usual  composition  and  our 
conclusions  therefrom  as  to  its  mode  of  origin.  Eoughly  speaking,  loose  cartilages  are 
generally  more  or  less  smooth,  of  grayish  color,  and  look,  as  their  name  suggests,  like 
pieces  of  cartilage  ;  but  they  may  be  nodulated  and  composed  almost  entirely  of  bony 
material  (Fig.  ()42  and  Prep.  y5()B,  Hunterian  Mus.).  Even  in  that  case,  however,  they 
have  a  thin  film  of  filn-ous  material  over  them  still,  obscuring  the  bone  and  rendering 
them  cartilaginous-looking  on  their  external  .surface. 

''  The  cases  (five  in  all)  that  we  have  had  an  opportunity  of  examining  have  also 
shown  more  or  less  calcareous  matter  ;  they  were  never  pure  cartilage.  One  case  in  the 
Guy's  Museum  (1344''"),  while  appearing  cartilaginous,  cut  with  a  creaking  sensation,  and 
\inder  the  microscope  irregular  deposits  of  calcareous  matter  and  bone  were  found  in  all 
directions  in  its  sub.stance.  In  another  (Hunterian  Museum  Cat.,  957a)  one  surface  is 
tuberculated  and  composed  of  hard  nodules  of  ivory-like  bone,  while  in  a  concavity  thus 
formed  is  a  cartilaginous  mass.  The  bone  on  the  surface  in  this  specimen  can  only  be 
compared  to  the  nodulated  excrescences  found  at  the  margins  of  the  articular  cartilages 
in  cases  of  osteo-arthritis. 

"  The  microscopical  characteristics  vary  in  each  to  a  certain  extent :  some  show  fibro- 
cartilage,  calcareous  matter,  and  bone  ;  others  are  entirely  bony.  The  cartilage  in  the 
specimens  which  we  have  examined  was  verv  fibrous  and  the  cartilage-cells  small.  The 
calcareous  matter  had  evidently  not  formed  after  any  definite  method  or  in  any  purposive 
direction,  as  should  occur  in  the  building  up  of  normal  bone-tissue,  and  the  bone  had  no 
regular  sy.stem  of  Haversian  canals  or  bone  corpuscles.  The  former  occur  as  spaces  of 
irregular  shape  and  position,  and  the  corpuscles,  with  but  few  canaliculi,  are  often  more 
like  calcified  cartilage  corpuscles  and  have  no  arrangement  in  relation  to  them. 

'■  From  this  short  description,  and  al.so  from  Fig.  G43.  it  will  be  seen  that  the  speci- 
mens exhibit  the  formation  of  bone  in  its  various  stages  :  they  show  the  primary  cartilage 
stage,  the  secondary  calcareous  stage,  and  its  ultimate  issue  in  true  bone,  the  bone  being, 
as  might  be  expected,  of  a  somewhat  irregular  build. 

"  Having  thus  regard  to  their  general  structure,  it  would  then  seem  most  probable 
that,  since  they  are  in  their  essence  bony,  loose  cartilages  must  form  in  connection  with 
bone-forming  tissue,  and  these,  so  far  as  is  known,  are  found  in  the  involutions  of  the 
synovial  membrane  at  the  edges  of  the  articular  cartilages.  This  view  is  consistent  also 
with  the  appearances  found  in  certain  joints  in  cases  of  osteo-arthritis — such,  for  instance, 
as  a  case  recorded  by  Mr.  Wagstaife  in  the  Pat  hob  nj  leal  Society's  Transactions  (vol.  xxiv., 


944 


DISEASES   OF  THE  JOINTS. 


187o,  p.  192),  or  specimens  954— 95Gb  in  the  museum  of  the  Koyal  College  of  Surgeons. 
In  all  these  the  formations  may  be  seen  in  situ.  It  is  also  in  accord  with  the  gener- 
ally-received opinion  as  to  the  more  usual  formation  of  loose  cartilages  at  the  present 
time. 

"  But  in  connection  witli  this  subject  the  so-called  ■  melon-seed  bodies    found  in  joints 
and  in  the  synovial  sheaths  of  tendons  and  on  bursa;  must  be  considered.     As  is  well 

Fig.  643. 


^%>~- 


Microscopical  Appeal  ance  of  Loose  Cartilage,    a,  Calcareous  matter.    6,  Small-celled  cartilage,  in  parts  more  fibrous 

than  represented,    c,  Bone. 

known,  thev  are  generally  abnormal  developments  of  the  synovial  fringes,  sometimes 
inflammatory,  sometimes,  perhaps,  as  was  suggested  by  Rokitansky.  due  to  cystic  dilata- 
tion of  the  synovial  folds,  or  perhaps  to  distension  and  coagulation  within  obstructed  fol- 
licles. But  whether  originating  in  one  or  all  of  these  various  ways,  being  all  in  common 
due  to  changes  in  the  synovial  membrane  and  sub-synovial  tissue,  it  is  evident  that  they 
are  loose  cartilages  in  miniature  and  only  want  size  and  the  further  change  into  cartilagi- 
nous matter  to  be  true  loose  cartilages.  But  I  have  lately  had  an  opportunity  of  making 
a  very  careful  examination  of  some  of  these  '  melon-seed  bodies '  from  one  of  the  sheaths 
of  a  tendon  on  the  dorsum  of  the  hand,  which  suggested  the  possibility,  not  to  say  proba- 
bility, of  another  mode  of  origin.  I  failed  to  find  in  any  of  them  an}'  evidence  of  organ- 
ized tissue  whatever.  They  contained  no  nuclei  or  cell  elements  and  were  entirely  com-- 
posed  of  a  faintly  fibrillated  hyaline  substance  characteristic  of  coagulated  mucus  or 
fibrin.  Hence  it  seems  to  be  quite  possible  that  loo.se  cartilages  may  originate  in  a 
nucleus  of  fibrin  precipitated  in  the  course  of  a  chronic  inflammation,  and  that  they  subse- 
quently grow  by  accretion,  becoming  calcareous  by  central  petrifaction.  On  this  point 
may  be  consulted  a  very  interesting  case  of  a  loose  body  in  the  peritoneum  recorded  in  the 
Path.  Soc.  Trans,  by  Dr.  Greenhow  (vol.  xxiii.  p.  241).  This  specimen,  in  conjunction 
with  '  melon-seed  bodies,'  makes  one  reconsider  whether  the  opinion  formed  originally  by 
John  Hunter  may  not  be  correct — that  loo.se  bodies  in  the  joints  are  sometimes  formed 
from  the  '  living  pjrinciple  of  the  blood.'  "  ' 

Symptom.s. — Loose  bodies,  however  formed,  give  rise  to  very  similar  symptoms,  pro- 
duced by  the  foreign  body  becoming  fixed  and  pinched  between  the  articular  surfaces  of 
the  bones.  The  presence  of  one  of  them  is  usually  discovered,  when  the  patient  is  walk- 
ing or  moving  the  joint,  by  some  sudden  inability  to  move  the  articulation  and  a  severe 
and  sickening  pain,  which  is  relieved  only  by  the  cartilage  slipping  from  between  the 
bones,  which  it  usually  does  by  a  characteristic  snap. 

Some  stiffness  and  slight  inflammation  of  the  joint  may  follow  this  injury,  which  by 
rest  and  treatment  will  subside  in  a  few  days,  to  be  renewed  upon  a  recurrence  of  the 
accident.  In  such  a  joint  as  the  knee  the  cartilage  may  as  often  as  not  be  felt  on  manip- 
ulation, although  readily  slipping  away  under  pressure. 

Treatment. — The  treatment  may  be  described  as  palliative  or  operative.  By  the 
former  the  cartilage  is  left  untouched  in  the  articulation,  and  by  the  latter  it  is  removed 
or  fixed  in  an  unoffending  position.  In  a  general  way.  the  palliative  treatment  is  the  cor- 
rect one  to  be  enforced  ;  for.  knowing  how  destructive  inflammation  of  a  joint  following  a 
wound  too  often  proves,  few  surgeons  would  venture  upon  an  operation  without  an  abso- 

'  For  further  information  vide  Virchow's  Krankhafien  GeschwiilMe  (vol.  i.)  ;  Marsh,  .Si.  Earth. 
Bo.'<p.  Eeports. 


niihiMATic  on  ciinnxfc  osriyjAirnrniTis.  !M5 

Into  iieci'Msitv.  uikI  Mifh  scldoin  t-xists,  for  liy  rrstrainiiifx  the  mnvciiifiits  of  the  joint  hy 
soiiio  k-atluT,  felt,  or  otiier  li;.'lit  easing  tlic!  foreijrn  body  may  Ixjconie  tixetl,  and  eonse- 
(|uentlv  iiiMoeiioiis.  Indeed,  liy  sueli  treatment  Hilton  Iia.s  .«hown  ((tiii/it  Rr/torfu,  IHIJH) 
that  tliese  eartiiaj^es  may  lieettme  absorbed.  He  fixes  the  kmjhc  body  by  means  of  a  jtad 
and  strappin^i  at  the  most  convenient  spot,  and  places  the  limb  upon  a  splint.  By  this 
practice  pain  is  prevented  ;  the  peduncle  of  the  cartilage  cannot  be  stretclied  or  the  carti- 
lage slip  between  the  semi-flexed  bones.  In  1S77  I  thus  treated  a  woman  who  had  a 
liiiise  cartilage  the  size  of  a  large  almond,  and  in  three  months,  under  observation,  it 
gradually  lessened  until  it  disappeared.  When  inflammation  of  the  joint  follows  one  of 
the  attacks  of  pain,  it  should  be  treated  on  ordinary  principles.  When,  however,  the  car- 
tilage by  its  presence  produces  such  serious  inconvenience  as  to  destroy  the  value  or  use 
of  the  joint,  whether  I'rom  the  IVe(|UtMicy  of  the  attacks,  the  auutunt  of  inflammation  that 
follows,  or  the  dread  connecteil  with  the  aflcction.  some  operative  interference  mav  be  jus- 
tifiable, ami  the  cartilage  should  be  rciiKivcd  by  either  direct  or  subcutaneous  incision  ;  no 
ojieratiou  .should  be  undertaken  till  all  inflammatory  action  has  ceased  and  the  joint  is  in 
a  (juioscent  state.  With  the  view  of  removing  the  off'ending  body  by  direct  incision — a 
practice  which  has  gained  ground  in  recent  times — a  splint  should  be  applied  and  worn 
for  at  least  a  week  ;  the  loose  body  should  then,  by  mani])ulation  or  by  such  niovemcnt 
of  the  joint  as  the  patient  from  experience  knows  will  bring  the  cartilage  under  the  sur- 
geon's control,  be  brought  up  to  one  side  of  the  joint  (and  in  the  knee  its  usual  seat  is  on 
one  side  of  the  patella),  where  it  may  be  fixed  with  the  finger.  The  surgeon  may  then 
draw  the  skin  over  it  to  one  side  and  cut  down  directly  upon  the  cartilage,  the  incision 
being  large  en<»ugh  to  allow  of  its  escape.  The  wound,  having  been  well  washed  with  an 
antisejttic  lotion,  should  be  closed  by  sutures  dressed  with  iodoform  or  carVjolic  gauze,  and 
the  limb  kept  upon  a  splint  till  repair  has  been  perfected. 

The  removal  by  subcutaneous  incision  consists  in  the  fixing  of  the  cartilage  by  means 
of  a  grooved  or  harpoon-shaped  needle  inserted  into  its  su)>stance  through  the  skin  ;  of, 
next,  the  introduction  of  a  tenotomy  knife  beneath  the  skin  down  to  the  cartilage,  and 
the  division,  by  a  free  sweep  of  the  knife,  of  all  the  subcutaneous  tissues  covering  it  in  ; 
then  of  the  dislodgment  of  the  cartilage  by  the  application  of  strong  digital  pressure  or 
tilting  it  by  means  of  the  grooved  needle  into  the  cellular  tissue  of  the  parts  around,  and 
the  application  of  a  pad  of  lint  over  the  spot  where  the  cartilage  escaped  from  the  joint; 
finally,  absolute  rest  of  the  limb  upon  a  splint  must  be  subse(juently  enforced  and  an  ice- 
bag  applied  over  the  joint.  After  this  operation  a  small  blister  may  be  applied  over  the 
cartilage  in  the  cellular  tissue,  Synie  having  found  that  by  such  means  the  foreign  body 
becomes  fixed  in  its  new  position  and  suksequently  absorbed.  To  remove  it  by  a  subse- 
quent operation  is  a  recognized,  though  rarely  a  required,  measure.  Mr.  W.  J.  Square  of 
Plymouth  adojits  the  indirect  operation,  but.  instead  of  s((ueezing  the  cartilage  com]»letely 
through  the  subcutaneous  wound,  he  is  satisfied  by  simply  pressing  the  foreign  body  into 
the  subcutaneous  opening  and  fixing  it  there  by  compress  and  strapping.  At  the  Brit. 
Med.  Assoc,  for  1871  he  related  twenty-four  successful  cases.  The  subcutaneous  opera- 
tion has  hitherto  been  considered  the  safer  of  the  two  described,  but  with  our  improved 
methods  of  treating  wounds  the  operation  by  direct  incision  is  said  to  be  equally  safe. 
We,  however,  want  facts  to  establish  this  point. 

M.  Larey's  statistics  (Gaz.  chs  JlOpitaux,  No.  G7)  fairly  support  the  indirect  method: 
Out  of  129  cases  operated  upon  by  the  direct  method,  28  were  fatal,  and  only  5  out  of 
the  38  by  the  indirect.  He  concludes,  after  a  careful  analysis  of  cases,  that  the  opera- 
tion is  a  serious  one  when  practised  by  direct  incision  and  a  difficult  one  by  the  subcuta- 
neous method,  while  extraction  is  more  dangerous  than  the  persistence  of  the  affection. 
He  believes  the  operation  is  indicated  by  the  complete  mobility  of  the  foreign  body 
within  the  joint ;  the  persistence  of  the  accidents  caused  by  its  presence — viz..  pain, 
arthritis,  and  lameness ;  the  failure  of  acupressure  and  other  means  for  fixing  the  posi- 
tion of  the  foreign  body  ;  and  the  free  con.sent  of  the  patient  after  having  been  made 
aware  of  its  dangers. 

RHEUMATIC   OR  CHRONIC   OSTEO-ATHRITIS. 

This  affection,  originally  described  by  J.  Haygarth  (  Clinical  Uisfonj  of  tlie  Xodositi/ 
of  Joints,  1813),  and  accurately  depicted  by  C'ruveilhier  in  his  PdtiiolfHjicdl  Amttomy 
(1813),  is  now  a  well-recognized  aflfection.  thanks  to  the  labors  of  the  late  Dr.  R.  Adams 
of  Dublin  and  his  splendid  monograph  published  in  1857,  to  Prof.  Smith  of  Dublin,  and 
Canton  of  London.  It  is  chieflv  seen  in  the  middle-aired  or  the  old,  though  occasionally 
60  '  ^  ■  J 


946 


DISEASES  OF  THE  JOINTS. 


in  young  people.  It  may  attack  any  joint,  but  is  most  common  in  the  hip  and  shoulder, 
and  generally  comes  on  without  any  definite  cause  ;  yet  in  not  a  few  I  have  known  it  fol- 
low directly  upon  some  injury.  A  large  number  of  cases  put  up  as  unreduced  dislocations 
in  the  different  mu.seums  are  doubtless  examples  of  this  affection,  the  displacement  of  the 
head  of  the  bones  being  the  result  of  the  disease.  It  is  unfortunately  called  "  rheumatic," 
although  it  has  no  apparent  connection  with  what  is  generally  called  '•  rheumatism."  It 
has  probably  acquired  the  name  from  its  chief  local  symptom  of  aching  pain  in  the  joint, 
aggravated  at  night  and  in  damp  weather.  The  disease  is  at  first  associated  with  a  dry- 
ness of  the  joint,  but  subsequently  with  excess  of  secretion,  even  to  a  great  extent ;  with 
some  thickening  and  expansion  of  the  head  of  the  bones  entering  into  its  formation,  some 
eburnation  of  the  articular  lamella  of  bone  with  disappearance  of  its  inter-articular  carti- 
lage after  it  has  undergone  the  fibrous  degeneration;  and  with  what  is  still  more  peculiar 

Fig.  644. 


Fig.  645. 


Si'iiiilunci 
lailllaifc 


Ost€o-Arthritis  of  Knee-joint.    (Drawing  33«.) 


Wearing  away  of  tlie  Head  of  the  Tibia  in  Osteo-Artliriti 


— the  deposition  of  new  crests  (osteophytes,  as  they  are  called)  or  plates  of  bone  around  the 
margins  of  the  articular  facets  and  in  the  ligaments  and  synovial  membrane.  These  crests 
often  appear  as  ridges  of  bone  which  can  readily  be  made  out,  and  the  plates  may  simuhite 
a  second  patella  when  the  knee  is  the  joint  involved.  In  the  case  from  which  Fig.  644 
was  taken  all  these  conditions  were  readily  distinguishable,  the  bones  and  synovial  capsule 
being  enormously  enlarged ;  the  ligaments  were  so  stretched  as  to  allow  of  .some  lateral 
movements  in  the  joint,  and  the  characteristic  rough,  crackling  sensation  which  move- 
ment of  the  joint  always  gives  was  most  marked. 

In  still  more  extreme  or  neglected  cases  the  end  of  one  indurated  bone  will  grind  away 
in  time  that  of  its  contiguous  bone,  the  condyle  of  the  femur  having  in  the  case  from 
which  Fig.  645  was  taken  ground  down  the  head  of  the  tibia  for  at  lea.st  an  inch.  The 
preparation  was  made  from  the  amputated  limb  of  a  man  jet.  36,  the  leg  having  been 
taken  off"  at  the  knee-joint,  because  the  limb  was  a  flail  and  the  joint  threatened  to 
become  disorganized,  and  an  excellent  stump  was  left. 

When  the  hip-joint  is  diseased,  the  head  of  the  bone  flattens  down,  the  neck  .shortens, 
the  cup  of  the  acetabulum  becomes  saucer-like,  and  around  its  margin,  as  well  as  around 
that  of  the  head  of  the  femur,  an  irregular  crust  of  bony  outgrowths  forms  (Fig.  646)  ; 
the  cartilage  likewise  disappears,  and  the  articular  surface  of  the  bones  presents  a  dense 
eburnated  appearance.  In  the  knee-joint  one  or  both  of  the  condyles  of  the  femur 
become  elongated  and  expanded,  the  head  of  the  tibia  flattened,  the  patella  enlarged,  and 
osteophytea  of  variable  forms  and  dimensions  fringe  the  margins  of  the  bones.  The  syno- 
vial membrane  also  will  be  thickened,  and  at  a  late  stage  of  the  affection  expanded  from 
effusion,  the  ligaments  in  this  way  becoming  elongated  and  the  joint  di.slocated.  Adams's 
"  additamentary  bones,"  or  new  plates  of  bone  of  different  .sizes,  are  found  within  the 
synovial  membrane,  with  probably  some  pedunculated  bodies  upon  its  inner  surface. 

In  its  early  stage  the  disease  is  characterized  by  local  jiain.  stiffness  or  rigidity  of  the 
joint,  and  local  thickening  and  development  of  bony  outgrowths,  every  movement  of  the 
joint  giving  rise  to  a  characteristic  crackling.  In  the  later  stage  the  same  pain  manifests 
itself  with  thickening,  bony  outgrowths,  effusion,  greater  mobility,  and  even  dislocation, 
and  finally  disorganization. 

I  have  a  lady  under  observation  in  whom  this  disease  is  so  developed  in  both  knee- 


JOIST   IHSKASE  ASSOC/. \TJ:1>    with   \h'R  vol's   AFI'l-J'TIOSS. 


047 


joints  tliut  the  lejis  ari'  us  fliiils,  tlie  hones  being  enormously  expantlcd  and  the  joints  dis- 
temh'd,  additainentary  hones  and  osteophytes  existing.  She  can  stand  only  hy  means  of 
artiiit'ial  su|>i>orts. 

Tkkat.mknt — Little  can  he  done  hy  means  of  medicine  to  ch(!<;k  the  jirogress  of  this 
afl'ection  beyond   attention   to  the  general   condition   of  the  j)atient.      In   the   iodide  of 


Fi(i.  (!4<j. 


I"i(i.  (i47. 


Changes  in  the  Ilia. I  an.l  Nick  of  the  Femur  and  in  the  Acetahuhini  in 
Osteo-Arihiiiis.    ^i'reparatiou  113l!>9,  Guy's  Hosp.  Mus.) 


External  Appearances  of  the  Ankle 
the  Seat  of  this  Disease. 


potassium  we  possess  a  drug  that  certainly  relieves  pain,  and  also,  I  believe,  retards  the 
progress  of  the  di.sease,  the  liquid  extract  of  bark  or  other  tonic  being  a  valuable  adjunct. 
When  pain  is  severe,  anodynes  may  be  given,  such  as  Dover's  powder,  or  the  bromide  of 
potassium  in  doses  of  gr.  x  or  gr.  xv,  this  drug  going  well  with  the  iodide.  Profe.ssor 
Smith,  who  has  paid  so  much  attention  to  this  disease,  thinks  well  of  an  electuary  of 
guaiacum,  sulphur,  the  bitartrate  and  cai'bonate  of  potash,  ginger,  and  rhubarb.  Dr. 
Adams  prescribes  the  diluted  phosphoric  acid.  Warm  bathing  is  of  use,  as  are  also  the 
mineral  springs  of  Germany.  This  disease,  although  locally  a  painful  one,  does  not 
appear  to  have  a  fatal  tendency,  and  unless  very  neglected  rarely  goes  on  to  the  di.sor- 
ganization  of  the  joint.  To  maintain  rest  is  not  a  recommendation  to  be  attended  to,  as 
it  tends  to  make  the  joint  stiffen  in  the  early  stage  of  the  affection  without  arresting  its 
progress.  In  the  more  advanced  stage,  when  "  hydrops  articuli  "  is  present  and  the  liga- 
ments are  so  loose  as  to  allow  of  the  displacement  of  the  joint,  some  mechanical  appliance 
is  called  for,  such  as  that  afforded  by  simple  strapping,  or  of  some  firm  leather,  felt,  or 
other  casing.     In  extreme  cases  excision  or  amputation  may  be  required. 


JOINT  DISEASE  ASSOCIATED  WITH   NERVOUS  AFFECTIONS. 

It  has  been  known  for  some  years  that  joint  affections  which  simulate  those  called 
rheumatic  have  been  met  with  in  the  subjects  of  diseases  of  the  nerve  centres,  as  well  as 
in  those  who  have  had  injuries  to  large  nerve  trunks.  Indeed,  from  a  recognition  of 
this  connection.  Dr.  J.  K.  Mitchell  of  Philadelphia  in  1831  originated  the  theory  that 
rheumatism  was  a  spinal  neurosis  (^Amer.  Jonni.  of  Med.  Science,  vol.  viii.),  and  his  argu- 
ment had  something  in  it.  At  the  present  day  attention  has  been  more  particularly 
drawn  to  the  connection  by  Charcot,  Weir  Mitchell,  Clifford  Allbutt,  Buzzard,  and  others, 
and  abundant  evidence  has  been  publi.shed  to  prove  that  in  fabes  (hrsa/ia  or  locomotor 
ataxia  there  is  a  peculiar  joint  affection  which  approaches  in  some  of  its  characters  the 
osteo-arthritis  just  described,  and  yet  in  others  differs  from  it  in  a  very  marked  manner. 

Symptoms. — It  may  appear  early  in  the  progress  of  the  nerve  disease — that  is,  with 
the  characteristic  '•  lightning  pains  " — or  it  may  not  show  itself  till  these  pains  have 
become  well  marked.  It  usually  first  shows  itself  in  one  of  the  joints  of  the  lower 
extremity. 

The  joint  trouble  begins  with  effusion  into  the  joint,  some  swelling  of  the  limb,  and 
crackling  of  the  joint  on  movement ;  but  with  the.se  symptoms  there  are  usually  no 
increase  in  the  temperature  of  the  part,  no  pain,  and  no  constitutional  disturbances. 

These  sj'mptoms  may  last  for  a  few  days  or  weeks  and  then  disappear,  and  leave 
nothing  behind  except  either  some  crackling  of  the  articulation  or  a  joint  deformed  from 
relaxation  of  its  ligaments,  or  even  dislocated.     In  extreme  cases  an  articular  facet  of 


948  DISEASES  OF  THE  JOINTS. 

bone  becomes  worn  away  and  the  head  of  the  bone  so  altered  in  shape  as  to  be  unrecog- 
nizable. There  may  be  false  bodies  to  the  joint,  and  in  some  cases  osteophytic  outgrowths 
from  the  articular  surfaces ;  but  these  are  never  so  well  marked  as  they  are  in  osteo- 
arthritis. There  is  never  in  this  affection  any  eburnation  of  the  articular  surface  of  bone, 
so  constant  in  osteo-arthritis. 

At  the  same  time  there  is  a  strong  analogy  between  the  two  affections,  and  I  am  dis- 
posed to  think  that  the  differences  between  the  two  classes  of  cases  are  to  be  explained 
by  the  fact  that  in  the  case  of  osteo-arthritis  the  disease  invades  tissues  in  which  nerve 
influence  has  its  normal  power,  whereas  in  the  other  there  is  clearly  a  deficiency  of  such 
power. 

In  osteo-arthritis  there  is  more  new  bone  thrown  out  in  the  shape  of  osteophytes  and 
plates  than  in  the  arthropathy  of  nervous  disorders,  because  the  action  in  the  part  is  of 
a  more  sthenic  type,  and  for  the  same  reason,  in  the  arthropathies  now  under  considera- 
tion, the  bone,  from  being  ill-nourished  and  containing  a  diminished  quantity  of  phos- 
phate of  lime  and  an  excess  of  fat,  is  more  readily  worn  down  by  attrition  and  made  to 
disappear  than  in  the  osteo-arthritis  of  the  more  sthenic  kind,  in  which  the  bone,  from  its 
hardness,  becomes  eburnated,  and  is  only  slowly  ground  down  by  attrition.  More  know- 
ledge is,  however,  required  respecting  both  these  affections  before  they  can  find  their  right 
place  in  pathology. 

Treatment. — Little  more  can  be  done  in  these  cases  than  to  keep  the  joint  quiet  by 
means  of  splints,  and  so  to  prevent  movement,  attrition,  and  displacement.  In  the  state 
of  joint  effusion  well-applied  pressure  is  of  use,  and  that  applied  by  means  of  an  elastic 
or  rubber  bandage  over  cotton-wool  is  to  be  recommended.  When  dislocation  exists,  some 
immovable  casing  to  the  joint  is  of  use. 

ACUTE  BURSITIS  AND  SUPPURATION  AROUND  JOINTS. 

I  have  placed  these  two  headings  together,  as  there  is  good  reason  to  believe  that  sup- 
puration about  the  cellular  tissue  external  to  a  joint  is  most  frequently  the  consequence 
of  an  acute  inflammation  of  some  superficial  bursa,  and  that  it  is  only  in  exceptional 
instances  such  a  connection  cannot  be  traced.  Over  the  knee-  and  elbow-joints,  where 
this  suppuration  is  generally  met  with,  some  blow,  fall,  or  punctured  wound  may  origin- 
ate an  acute  inflammation  in  the  bursfe  of  these  parts,  while  the  thick  integument  cover- 
ing them  prevents  the  inflammatory  products  making  their  escape  externally  and  favors 
their  lateral  extension  :  the  abscess,  consequently,  in  one  case,  after  covering  the  knee, 
burrows  backward  into  the  popliteal  space,  or  in  the  other  comes  forward  in  the  arm  into 
its  flexure ;  more  commonly,  however,  it  shows  itself  as  a  painful  phlegmonous  inflam- 
mation over  and  around  the  patella  or  olecranon  process.  In  some  examples  the  suppura- 
tion is  confined  to  the  bursa,  while  in  most  the  inflammation  will  be  found  to  radiate  from 
these  well-known  points.  In  children,  however,  the  connection  between  the  suppuration 
and  bursitis  is  not  so  readily  made  out,  and  there  can  be  little  doubt  that  at  times  it  does 
not  exist. 

The  severe  cases  of  suppuration  around  a  joint  are  most  frequently  met  with  in  chil- 
dren of  delicate  and  feeble  frames  and  in  the  badly  fed,  who  are  disposed  to  rapid  exten- 
sion of  suppurative  inflammation  when  started  by  any  slight  accident,  blow,  fall,  or  strain. 
When  these  large  abscesses  appear  around  the  shoulder — a  joint  that  is  less  liable  to  di.s- 
ease  than  any  other — it  has  probably  been  caused  by  some  strain  or  injury  when  the  child 
is  dragged  along  by  a  careless  or  violent  companion,  or  it  may  be  that  the  muscles  of  the 
parts  are  injured.  At  times  it  is  the  epiphysial  cartilage  placed  between  the  epiphysis 
and  the  shaft  of  the  humerus  which  has  suffered. 

Diagnosis. — The  diagno.sis  of  these  cases  of  suppuration  external  to  the  joint  is  not 
difiicult.  On  examination  it  will  be  seen  that  the  swelling  is  external  to  the  joint,  cover- 
ing in  the  well-known  points  of  bone  ;  in  the  knee  the  soft  parts  probably  will  be  raised 
from  the  patella,  and  fluctuation  will  be  felt  above  and  around  it.  There  will  be  much 
local  pain,  but  not  so  much  constitutional  disturbance  as  would  exist  with  a  suppurating 
joint ;  the  joint,  moreover,  will  be  capable  of  some  amount  of  movement  without  pain — 
a  condition  which  would  be  impossible  if  the  seat  of  the  disease  were  in  and  not  around  it. 

Treat.ment. — There  is  only  one  form  of  treatment  on  which  reliance  can  be  placed 
in  these  cases,  and  this  consi.sts  in  giving  free  exit  to  the  pws.  A  free  incision,  conse- 
quently, should  be  made  into  the  abscess  over  the  seat  of  the  bursa  as  soon  as  any  pus 
can  be  detected.  The  limb  should  be  raised,  the  joint  preserved  at  rest  by  splints,  and 
warm-water  dressing  or  a  poultice  applied  ;  and  the  joint  should  be  kept  absolutely  quiet 


ishi..\MM.\rii)S  or  liosi:.  '.>40 

till  repair  has  \wv\\  fom|>lete<l.  Wiicn  tlie  powers  of  tin?  puticiit  are  feel)le,  tonics  should 
he  {^iveii.  When  tlic  al»sress  is  not  opt'iuMl  early,  it  may  o|m'Ii  into  the  jtjint  and  produce 
an  acute  sup|)uration.  I  have  known  this  liappi-n  in  the  kne»?  with  a  fatal  result.  In  the 
knee  it  is  often  m-eessary  to  make  a  free  incision  on  either  side  of  the  joint,  as  well  as 
over  the  patella,  in  order  to  prevent  hurrowinj;. 


CHAPTKU    XXXITI. 
DISEASES    OF    THE    1'.  (  K\  E  S 

General  Remarks. 


In  a  pathological  .sense  diseases  of  the  bone  are  identical  with  those  of  other  tissues, 
while  such  differences  as  exist  are  due  to  their  anatomical  and  physiological  peculiarities, 
diseased  action,  under  all  circumstances,  being  materially  modified  by  texture.  In  the 
bones  diseased  action  is  thus  modified  by  the  presence  of  the  inorganic  material  which 
they  contain,  two-thirds  of  their  constituents  being  earthy  and  one-third  animal.  This 
animal  texture  includes  a  fibrous  periosteal  membrane  with  cellular  tissue  beneath,  as  well 
as  a  finer  endosteal  membrane  which  lines  the  medullary  canal.  These  two  membranes  are 
intimately  connected  together  by  delicate  vascular  and  membranous  links  permeating  the 
Haversian  canals  and  canaliculi  of  the  bone  itself.  The  exterior  of  the  bone  is  dense,  and 
derives  most  of  its  nourishment  from  ve.s.sels  ramifying  in  the  periosteum  ;  the  intn-ior  of 
the  bone  is  porous  or  cancellated,  and  derives  its  supply  of  blood  from  a  distinct  nutrient 
artery  which  runs  in  the  endosteum  ;  while  the  capillaries  of  both  anastomose  freely 
through  the  bone  canals.  The  long  bones  also  are  built  up  of  shafts  (diaphyses)  and 
epiphyses,  the  epiphyses  being  distinct  from  the  .shafts  during  the  early  years  of  life  and 
having  their  own  vascular  supply.  The  shafts  and  epiphy.ses  are  connected  together  by 
means  of  a  layer  of  epiphysial  cartilage,  through  which,  as  proved  by  Prof.  Humphry, 
the  shafts  mainly  grow,  though  interstitial  expansion  has  an  influence  in  bone  as  in  other 
parts.  The  epiphyses  themselves  are  covered  with  articular  cartilage  that  derives  its 
nutritive  supply  from  them.  The.se  anatomical  points  thus  briefly  sketched  are  import- 
ant to  remember  when  the  pathological  are  considered,  as  most  of  the  peculiarities 
of  bone  disease  are  explicable  by  them.  Thus,  when  a  bone  is  inflamed,  it  can  be  so  only 
through  its  soft  tissues,  its  inorganic  matter  being  affected  secondarily.  The  periosteal  and 
endosteal  membranes  being  intimately  connected,  inflammation  originating  in  one  is  very 
liable  to  extend  to  the  other;  and  in  proportion  to  the  nature  or  amount  of  this  exten- 
sion will  the  inflammation  be  periosteal  or  endosteal  and  the  affection  either  periostitis  or 
ostitis. 

In  long  bones,  when  disease  attacks  the  .shaft,  it  may  become  arre.*<ted  by  the  epiph- 
ysis or  epiphysial  cartilage,  the  articular  ends  of  the  bones,  and  consequently  the  joints, 
escaping.  In  periostitis,  however,  such  a  result  is  not  always  secured,  for  the  .synovial 
membrane  of  a  joint,  in  a  clinical  point  of  view,  may  be  regarded  as  a  continuation  of  the 
periosteum,  and  pus  beneath  this  membrane  may  burrow  into  the  neighboring  articu- 
lation, or  the  inflammation  may  spread  by  continuity.  When  the  disease  attacks  the 
epiphysis,  the  inflammation  may  spread  into  the  joint. 

\\  ith  these  remarks  the  diseases  of  bones  may  be  considered,  dividing  them  into  the 
inflammatory  affections,  tumors  of  bone,  atrophy,  hypertrophy,  rickets,  and  mollities  ossium. 

INFLAMMATION  OF  BONE 

may  be  divided  into  the  acute  and  the  chronic. 

The  acute  uiay  be  idiopathic  or  the  result  of  some  injury,  the  division  of  a  bone  by 
operation,  or  a  compound  fracture  ;  it  may  end  in  local  abscess  of  bone,  in  diffused  sup- 
puration, or  in  the  more  or  less  complete  death  of  the  bone.  When  originating  in  the 
periosteum  and  not  wholly  involving  the  endosteum  or  medullary  membrane,  the  outer 
surface  of  the  bone  alone  may  die  ;   when  originating  in  the  endosteum  and   not  wholly 


950 


DISEASES  OF  THE  BOXES. 


involving  the  periosteum,  the  inner  portion  of  the  bone  may  die  and  the  shell  escape,  the 
whole  bone  dying  when  both  membranes  have  been  equally  involved,  whether  commen- 
cing in  one  or  the  other.  The  extent  and  the  depth  of  the  destruction  of  bone,  or  its 
'•  necrosis."  are  determined  by  the  extent  and  intensity  of  the  inflammatory  action  and 
the  degree  in  which  the  membranes  covering  and  lining  the  bone  have  been  involved. 
Thus,  on  the  one  hand,  the  superficial  necrosis  of  the  frontal  bone  of  a  child  may  ensue 
after  its  exposure  from  a  lacerated  wound  caused  by  the  gnawing  of  a  ferret  (vide  Fig. 
648),  in  another  case  a  large  thin  shell  of  bone  may  exfoliate  from  the  tibia  after  an  acute 
periostitis  (Fig.  649),  in  both  of  these  cases  the  life  of  the  bone  having  been  sacrificed 


Fk;.  r,4,s. 


Fir;.  649. 


Superficial  Xecrosis  of  Frontal  Bone  following  Wound 

caused  by  the  Gnawing  of  a  Ferret.    (Delsey  W , 

St.  7  months,  June,  1874.^ 


Shell  of  Bone  Exfoliated  as  a 
Ilesult  of  Acute  Periostitis. 
(Periosteal  Necrosis. 


through  the  death  of  the  periosteum  alone.  Fig.  650  represents  a  sequestrum  the  result 
of  an  acute  endostitis.  osteomyelitis,  or  ostitis  (for  all  these  terms  are  synonymous)  sur- 
rounded by  a  reparative  shell  of  bone  newly  formed  by  the  uninjured  periosteum  ;  while 

Fig.  650. 
firode    fi/ue/iin^  ione  tfyrei^f/7i  Cloaca 


Death  of  Bone  the  Piesult  of  Acute  Ostitis,  the  Sequestrum,  composed  of  the  Shaft  of  the  Tibia, 
being  surrounded  by  .Shell  of  New  Bone. 

Fig.  651  illustrates  the  appearance  of  the  limb  so  aflfected,  taken  from  life,  with  the 
sinuses  open  leading  from  the  surface  of  the  limb  through  the  soft  parts  of  the  shell  of 

Fi&.  6ol. 
Jirohcs  touching  hone  tlirnu^h.    Cloacce 


External  Appearance  of  Limb  the  Seat  of  Acute  > 
leading  down  to  1 


Shaft  of  tht  libia,  with  Cloacje 


new  bone  to  the  sequestrum.  Fig.  652  represents  a  section  of  a  bone  which  died,  nearly 
as  a  whole,  from  inflammation  of  both  membranes,  and  upon  the  upper  surface  of  which 
no  new  bone  formed,  the  periosteum  having  been  completely  destroyed,  although  at  the 
lower  part,  where  the  membrane  was  sound,  bone  has  been  renewed. 


isi'i.AMMATHis  nr  iiDSi:. 


:>.jl 


Vfif  fKin'  tfrifntfi  /^riaatritm        f/rri)l  tout 


In  all  tlii'se  rases  the  iiifla)ii«'*l  heme  dit'il  wludly  <»r  in  part  f'ntm  an  afiiti-  infiaiiiiiiation, 
the  Ikmh-  liy  the  iiiflaiiiiiialinii  haviii;^  been  deprived  of  its  vascular  supply  tlir<iuj.'h  a 
hidckiu','  (»r  its  eapillari«'s.  its  death 
resulting;  I'mni  hhxid  stasis.  These 
ehaii;j:es,  Imwevi'r.  (hi  not  always 
ensue,  tor  the  aeut(>  intlainMiatiiiii 
ill  some  eases  may  terminate  in  an 
aeiite  ahscess  of  Imiie  with  or  with 
out  necrosis,  and  in  other  cases  iii 
acute  ahseesscs.  I  have  in  the 
tiliia  met  with  three  centres 
>ujipiiralion  the  r<>ult  ol'  aeute 
inriaiiimatioii.  When  acute  iiitlammatiou  attacks  an  epiphysis,  the  same  patlmhjgical 
chanjres  ensue.  The  whole  ej»ipliysis  may  die  and  be  cast  off',  or  it  may  be  the  seat  of 
an  abscess  or  (tf  a  local  necrosis;  and  wlien  the  local  necrosis  is  confined  to  the  articular 


if     Necrosis  of  the 


.■"huft   of  111.-  'ril.ia   111"    l;.-iill 
rerioslitis.    (I'rep.  1J4;J*'. i 


>f  .NciiK-  (Kiitis  and 


Fio.  653. 


'V^Hv^J^'j 


Necrosis  of  tin-  .Xniciihir  Lamella  of 
Tone,  Willi  liegeiieration  of  Cartilage 
covering  il  in. 


lamella  of  bmie,  the  joint  will  become  involved,  as  well  illustrated  in  Fig.  653.     In  Fig. 
W'.VJ   the  head   ami   neck  of  the  radius  necrosed  and  gave 
rise  to  su]iiiiiratioii. 

In  chronic  inflamni'ation  of  the  articular  extremities  of 
the  long  or  spongy  Itoiies  other  changes  occur.  They  may 
be  described  as  tollows,  <(Uoting  my  own  words  written  in 
185'J  (on  di.seases  of  joints)  :  Tn  the  earliest  condition 
simple  vascularity  will  be  the  priiiciiial  morbid  appearance, 
the  cancelli  containing  more  serum  than  natural  ;  but  as 
the  disea.se  advances  the  bone  becomes  larger  than  natural, 
this  enlargement  in  some  cases  being  very  great.  Upon 
making  a  section  of  the  bone  the  saw  will  break  through 
its  structure  more  easily  than  in  a  healthy  specimen,  its 
earthy  constituents  having  diminished ;  and  on  comparing  the  structure  of  the  di.seased 
with  a  healthy  bone  it  will  be  observed  that  its  cancelli  are  much  enlarged  and  the  col- 
umns radiate  from  the  shaft  in  a  palm-like  fashion,  as  if  they  had  been  spread  out  from 
downward  pressure.  When  the  inflammatory  process  is  of  a  tolerably  healthy  character, 
parts  of  the  bone  will  appear  denser  and  more  indurated  than  the  remainder,  from  the 
organization  of  the  inflammatory  deposit,  this  deposit  in  bone  always  becoming  osseous; 
fref|uently,  however,  the  death  of  the  bone,  with  a  small  or  large  .sequestrum  or  a  local 
or  difl"used  abscess,  is  the  result.  If  the  denser  portion  of  bone  forming  the  shell  is 
examined,  it  will  lie  found  thinner  than  natural  and  appear  as  if  it  had  been  dilated,  in 
.some  cases  crackling  on  firm  pressure.  Where  the  articular  extremity  joins  the  shaft 
some  new  bone  may  be  detected,  thrown  out,  as  it  were  to  support  its  dilated  body.  The 
articulating  surfaces  of  the  bones  will  in  some  parts  appear  more  vascular  than  normal, 
whilst  in  other  more  advanced  cases  portions  having  been  thrown  off  like  a  .slough  will 
be  found  loo.se  and  lying  in  the  joint,  the  denser  portions  of  bone,  as  a  result  of  articular 
ostitis,  dying  more  rapidly  than  the  cancellated. 

The  cartilages  at  th.e  same  time  undergo  degenerative  changes  and  separate  from  their 
bony  attachments  more  or  less  rapidly,  in  some  cases  being  cast  off  as  a  slough  or  shed 
as  a  nail  or  cuticle.     T'nder  these  circumstances  joint  disease  occurs. 

In  chronic  inflammation  of  the  shafts  of  bones  changes  similar  to  these  are  equally 
manifest,  the  bone  in  the  early  stage  first  expanding,  and  in  subjects  of  better  power  sub- 
sequently thickening,  from  the  organization  of  the  inflammatory  exudation,  the  bones 
thus  becomint;  solid  and  dense  and  the  subject  of  a  condition  known  as  sclerosis  (Fig. 
G54).  ■ 

In  ca.ses  of  inflammation  of  bone  when  the  periosteum  is  not  morbidly  involved  a 
layer  of  new  tissue  secreted  from  the  pei-iosteum  is  poured  out  upon  the  bone,  and  at 
first  is  soft  and  fibrinous,  and  subsequently  hard  and  osseous,  the  new  material  being 
reparative  in  its  nature  and  that  from  which  the  new  bone  will  be  formed.  It  may  be 
only  a  few  lines  in  thickness,  though  at  times  it  is  even  half  an  inch  (Fig.  656)  ;  and 
before  it  becomes  osseous  it  can  readily  be  peeled  off  the  bone  by  means  of  the  handle  of  a 
scalpel  or  perio.steal  elevator.  It  is  to  this  tissue  M.  Oilier  alludes  when  he  recommends 
the  sub-periosteal  resection  of  the  shaft  or  articular  ends  of  bone,  for  it  is  mainly  upon 
.such  that  the  regeneraticm  of  a  bone  or  part  of  a  bone  depends.  Changes  analogous  to 
those  described  as  going  on  in  the  periosteum  occur  in  the  endosteum  or  medullary  mem- 
brane of  the  bones,  although  not  so  well  seen.     The  products,  therefore,  of  a  periostitis 


952  DISEASES  OF  THE  BONES. 

or  endostitis  vary  with  the  character  and  intensity  of  the  inflammatory  process,  precisely 
in  the  same  way  and  under  the  same  conditions  as  the  products  of  inflammation  vary  in 
the  softer  tissues.  In  very  intense  inflammation  the  death  of  the  inflamed  part  is  the 
result — death  of  the  periosteum  with  the  bone  depending  upon  it  for  its  nourishment,  of 
the  endosteum  with  its   bony  fabric,  or  of  the  whole  bone  when  both  membranes  are 

Fig.  654. 


Sclerosis  of  Bone  the  IJesult  of  rhrouic  Inflammation.     (From  Prep.  Guy's  Mus.) 

equally  involved.  When  the  bone  does  not  die  in  mass,  it  may  in  detail,  and  as  a  result 
of  the  inflammation  local  abscess  of  bone  or  diff'used  suppuration  may  ensue,  with  or 
without  necrosis  or  a  sequestrum  ;  when  the  suppuration  is  around  the  bone,  it  is  seen 
as  a  periosteal  abscess — a  condition  which  is  mostly  followed  by  a  more  or  less  extensive 
necrosis. 

The  character  of  the  pus  in  these  cases  of  bone  abscess  is  of  diagnostic  importance. 
Pus  the  result  of  perio.stitis  difibrs  in  no  respect  from  that  found  in  other  tissues,  but  pus 
the  result  of  endostitis,  ostitis,  and  o.steo-myelitis  is  freely  mixed  with  oil  globules.  In  a 
striking  case  of  this  latter  affection  in  a  girl  jet.  10,  which  was  under  my  care,  where  a 
free  incision  was  made  down  to  the  tibia,  the  surface  of  the  fluid  evacuated  was  covered 
with  oil  cells.     Roser  has  made  a  like  observation. 

Acute  Inflammation  of  Bone, 

whether  periosteal  or  endosteal,  is  chiefly  found  during  the  growing  period  of  bone,  before 
puberty,  and  is  a  very  grave  affection.  It  occurs  in  the  feeble  and  cachectic  and  in  those 
termed  scrofulous,  in  the  shafts  of  the  long  bones  as  well  as  in  the  epiphysis,  and  in  such 
as  are  most  exposed,  as  the  tibia  and  ulna,  although  it  is  almost  as  frequently  seen  in  the 
femur.  The  bones  of  the  upper  are  probably  more  rarely  affected  than  those  of  the  lower 
extremity.  It  is  often  the  result  of  some  local  injury  or  exposure,  though  as  often  as  not 
no  such  exciting  cause  can  be  made  out. 

Symptoms. — The  disease  is  generally  ushered  in  with  a  deep  aching  pain  in  the  bone, 
with  local  tenderness,  often  a  rigor,  followed  by  intense  constitutional  disturbance  and 
increase  of  temperature.  The  pain  in  the  limb  is  speedily  followed  by  swelling,  which  at 
first  is  deeply  placed  and  not  marked  by  any  external  evidence  of  inflammation,  such  as 
redness ;  as  the  swelling  increases  the  soft  parts  covering  it  become  tense  and  oedematous 
and  the  veins  of  the  part  look  full,  such  symptoms  indicating  deep-seated  obstruction, 
while  any  attempt  at  movement  or  pressure  causes  suffering.  When  the  disease  is  situ- 
ated in  the  articular  end  of  a  bone,  it  is  constantly  mistaken  for  rheumatic  fever. 

If  the  disease  is  pen'oateal  in  its  origin,  the  skin  soon  becomes  involved  and  local  red- 
ness appears,  the  slightest  touch  exciting  pain.  If  endosfeal  at  the  onset,  gentle  manipu- 
lation will  be  allowed,  and  many  days  will  pass  before  redness  and  other  external  signs 
of  inflammation  show  themselves,  these  appearing  only  when  the  disease  has  spread  to  the 
periosteum  and  through  it  to  the  soft  parts  around.  When  suppuration  ensues,  the  skin, 
from  being  tense  and  oedematous,  becomes  inflamed,  and  the  constitutional  disturbance 
worse  ;  rigors  become  more  frequent,  pain  is  more  intense  ;  sleeplessness,  and  probably 
delirium,  with  a  feeble  pulse,  appear;  and  unless  relief  be  afforded  by  a  free  incision 
down  to  the  bone,  death  by  exhau.stion,  and  probably  by  blood-poisoning,  is  apt  to  occur, 
since  the  connection  between  acute  inflammation  of  bone  and  septicaemia  is  very  close. 
(  Virle  Chapter  I.) 

When  the  inflammation  is  essentially  ^enosto?/,  more  or  less  well-formed  pus  mixed 
with  blood  will  be  effu.sed.  though  in  feeble  subjects  it  may  be  only  a  blood-stained  serum 
containing  lymph.  In  some  of  the  worst  cases  of  this  disease  I  have  seen  this  effusion 
was  very  copious. 

Endostitis  is  particularly  prone  to  be  accompanied  by  blood-poisoning  ;  it  is,  therefore. 
a  far  more  serious  disea.se  than  periostitis,  whether  as  a  primary  affection  or  as  consequent 
upon  the  latter. 

Acute  periostitis,  ostitis,'  or  endostitis  may  attack  the  cranial,  carpal,  and  tarsal  bones, 
the  shafts,  articular  ends  of  bones,  or  epiphyses ;  and.  according  to  its  seat  or  extent,  it 
may  terminate  in  recovery  or  in  the  complete  death  of  either  the  centre  or  the  shell  of 


isi  LAMM  Arms  or  nosi:.  953 

hone.  Tlie  host  instance  of  death  of  the  hone  from  periosteul  infiaiiiination  is  seen  in  the 
unL;ual  phahmx  of  the  tinirer.  the  hone  dyin^'  as  a  whoh-  some  five  or  six  weeks  after  the 
first  onset  of  the  inthiinmation,  without  any  attempt  at  its  re-lormation.  Siieli  eases  are, 
f^eiierally,  hut  wroii;;ly,  hioketl  upon  as  uliitlmrs.  Of  the  tarsal  liones.  it  is  most  common 
in  the  os  calcis,  hirye  set|uestra  heinir  ol'ten  met  with  in  this  hone;  peri(»steal  necrosis  is, 
however,  comparatively  rare  in  the  cah-is,  except   as  a  result  of  injury  tr)  its  tuherositv. 

When  this  disease  attacks  the  articuhir  ends  of  the  hones,  acute  joint  mischief  is  the 
jreiieral  result  ;  and  when  it  follows  the  division  r)f  hone,  hy  either  amputation  or  resec- 
tion or  after  compountl  fracture,  jrunshot  or  otherwise,  it  is  a  common  cause  of  death  and 
too  fre<|uently  is  the  preeursijr  of  septicjumia.  Sir  .J(jseph  Kayrer.  who  has  drawn  atten- 
tion to  this  fact  in  his  Annnh  nf  Mi<l.  Srii nc  (ISt)')),  looks  upon  the  prominent  fun<rous 
mass  of  irranulations  that  is  often  .seen  eoverin<r  the  end  of  an  amputated  bone  as  indica- 
tive of  the  artection.  and  helieves  that  the  facility  with  which  the  surgeon  passes  a  probe 
well  into  the  medullary  cavity  throuirh  these  <;ranulations  establishes  the  diafrnosis.  He 
gives  the  general  symptoms  as  pain  in  the  part,  a'dema,  and  swelliiifr  extending  down  the 
limb,  general  fever,  with  <|uick  pulse  and  increa.sed  temperature,  and  more  especially  the 
recession  of  the  soft  ]>arts.  including  the  periosteum,  from  the  bone,  which  is  then  left 
denuded  at  the  bottom  of  the  wound. 

Jules  Koux  of  Toulon  first  drew  attention  to  this  affection,  and  gave  it  the  name 
"  ostco-myelite."      It  is.  however,  essentially  an  endostitis,  only  of  traumatic  origin. 

Trkatmknt. — In  all  cases  of  acute  inflanunation  of  bone  or  periosteum,  in  which  of 
necessity  there  must  be  effusion  beneath  the  dense  fibrous  periosteal  layer,  there  is  no 
treatment  eijual  to  that  of  a  free  incision  down  to  the  bone  ;  and  if  the  di.sease  is  not 
arresteil  or  modified  by  this  practice,  immense  relief  to  pain  is  rapidly  afforded.  There  i.s 
good  reason  to  believe,  too.  that  by  such  treatment  the  disease  is  often  limited,  and  even 
arrested,  as  well  as  the  death  of  the  bone  averted ;  for  bone,  like  other  tissue,  is  very- 
prone  to  die  when  subjected  to  the  compressing  influence  of  a  confined  effusion.  When 
the  upper  part  of  the  shaft  or  the  articular  end  of  a  bone  is  the  seat  of  disease,  this  prac- 
tice is  very  important. 

Before  making  an  incision  there  is  no  need  for  the  surgeon  to  wait  for  the  formation 
of  pus,  as  to  do  this  is  generally  to  wait  too  long.  The  object  of  the  incision  is  to  relieve 
tension  ;  consequently,  it  should  be  carried  out  as  soon  as  tension  clearly  exists.  In  cases 
of  acute  disease  of  the  tibia,  with  severe  local  pain  and  constitutional  disturbance.  I  have 
opened  the  periosteum  on  the  third  or  fourth  day,  before  any  external  evidences  of  inflam- 
mation showed  themselves,  except  turgid  veins  and  bone  enlargement.  The  incision  gave 
vent  to  blood-stained  serum,  but  it  was  followed  by  immediate  relief  to  all  local  and  con- 
stitutional disturbance  and  by  a  rapid  recovery.  If  the  incision  does  not  save  the  life  of 
the  bone,  it  relieves  symptoms,  and,  what  is  more,  it  may  limit  the  disease  by  preventing 
the  pus  from  burrowing  beneath  the  periosteum  covering  the  shaft  of  the  bone  into  the 
neighboring  joint.  This  liability  to  joint  complication  is.  indeed,  one  of  the  strongest 
arguments  in  favor  of  the  practice.  The  limb,  at  the  same  time,  should  be  elevated  and 
hot  fomentations  applied  ;  pain  should  be  relieved  by  opium,  morphia,  chloral,  or  any 
other  sedative,  and  the  general  powers  kept  up  by  abundance  of  nutritious  food,  such  as 
milk ;  while  stimulants  .should  be  cautioush*  administered. 

When  the  inflammation  ends  in  necrosis,  it  requires  to  be  treated  according  to  the 
mode  to  be  referreil  to  in  a  later  page. 

Occasionally,  as  an  effect  of  acute  inflammation  of  the  periosteum,  much  blood  is 
effused  between  the  membrane  and  the  bone.  I  believe  this  result  to  be  mechanical  and 
due  to  the  rapid  separation  of  the  periosteum  ;  it  is  met  with  only  in  acute  cases. 

Acute  Abscess  in  Bone. 

Abscess  in  bone  is  the  result  of  a  local  inflammation,  and  may  or  may  not  be  associ- 
ated with  the  death  of  a  small  piece  of  bone.  In  some  cases  it  is  acute,  but  more  gene- 
rally chronic. 

In  the  acute  some  necrosis  is  generally  associated  with  it ;  in  the  chronic  such  an  a.s.so- 
ciation  is  more  rare. 

Not  long  ago  I  treated  a  boy  aet.  17  who  after  intense  pain  in  the  head  of  his  tibia  for 
three  days  had  local  swelling  and  severe  con.stitutional  disturbance  that  had  been  regarded 
as  due  to  rheumatism.  At  the  en<l  of  a  month,  when  I  saw  him.  I  made  a  free  inci-sion 
down  to  the  bone,  to  relieve  pain  and  give  vent  to  any  pus  that  might  have  found  its  way 
externally.     A  week  later  pus  appeared,  evidently  from  the  bone,  for  a  probe  could  be 


954  DISEASES  OF  THE  BONES. 

passed  through  the  wound  into  a  cavity.  Two  weeks  hiter,  or  six  weeks  from  the  com- 
mencement of  the  symptoms,  I  enUxrged  my  opening,  and  through  the  aperture  in  the 
head  of  the  bone  from  which  the  pus  had  flowed  I  removed  three  pieces  of  bone,  together 
making  one  the  size  of  a  nut,  which  rested  in  a  cavity  lined  with  velvety  granulations 
such  as  are  so  characteristic  of  an  abscess.  A  complete  recovery  ensued.  In  another 
boy,  aet.  10,  in  which  severe  local  and  constitutional  symptoms  had  arisen  early,  I  removed 
a  similar  piece  of  bone  from  a  like  cavity  in  the  end  of  the  radius,  and  with  a  similar 
good  result.  In  both  cases  acute  inflammation  of  bone  had  ended  in  the  formation  of  a 
local  abscess  with  circumscribed  necrosis,  and  recovery  rapidly  followed  the  surgical  treat- 
ment. 

A  few  years  ago  a  child  was  brought  to  me  who  had  received,  when  asleep,  an  injury 
to  the  tibia,  from  a  playfellow  having  attempted  to  drive  a  pin  into  the  bone.  Nothing 
beyond  some  slight  local  pain  had  followed  the  injury  for  a  few  days,  when  severe  pain 
and  swelling  appeared,  with  fever,  etc.  I  cut  down  upon  the  part  with  a  view  of  giving 
relief,  when  the  point  of  my  knife  went  with  a  crackle  through  a  thin  layer  of  bone  into 
a  cavity,  which  gave  vent  to  a  teaspoonful  or  more  of  pus.  Immediate  relief  followed 
the  operation,  and  a  good  recovery  took  place. 

These  three  cases  sufl&ce  to  illustrate  the  fact  that  acute  abscess  in  bone  is  met  with, 
and  to  show  its  symptoms  and  treatment. 

Chronic  Abscess  in  Bone. 

In  1773,  William  Broomfield,  surgeon  to  St.  George's  Hospital,  in  his  CMrnrgical 
Obst'Tvatioxs,  wrote :  "  Whenever  a  patient  complains  of  a  dull,  heavy  pain  deeply  situ- 
ated in  the  bone,  possibly  consequent  to  a  violent  blow  received  in  the  part  some  time 
before,  and,  though  at  the  time  the  patient  complains  of  this  uneasiness  within  the  bone, 
the  integuments  shall  appear  perfectly  sound  and  the  bone  itself  not  in  the  least  injured, 
we  have  (jreat  reason  to  susj^ect  an  abacess  in  the  meduUay  In  182-1,  Sir  B.  Brodie  ampu- 
tated a  limb  for  incurable  pain  in  the  tibia ;  and  in  this  case — which  Sir  W.  Fergusson 
has  described  "as  one  of  the  beacon-lights  of  surgery  never  to  be  forgotten" — "the 
lower  end  of  the  tibia  is  enlarged  and  the  surface  presents  marks  of  great  vascularity; 
the  bone  in  the  preparation  is  divided  longitudinally,  and  just  above  the  articulating  sur- 
face there  is  a  cavity  as  large  as  a  small  chestnut.  This  cavity  was 
Fig.  655.  filled  with  dark-colored  pus.     The  inner  surface  of  it  is  smooth. 

The  bone  immediately  surrounding  it  is  harder  than  natural." 

In  these  two  extracts,  written  at  an  interval  of  fifty  years, 
are  embodied  the  clinical  and  pathological  facts  connected  with 
this  subject  which  are  now  recognized  by  surgeons. 

Sir  B.  Brodie  in  1846  published  a  valuable  paper  on  this  sub- 
ject, and  to  him,  oddly  enough,  the  full  credit  of  recognizing 
these  cas^s  has  been  wrongly  attributed.      He  probably  first 
Bji-hhusia/j^^xr^^mii  •  "ly      heard  of  them  from  John   Hunter. 

CaHiiaje ''^vSi^pFJ  If  This  chronic  abscess  is  generally  met  with  in  the  articular 

ends  of  bones — that  is,  in  their  cancellous  tissue — more  particu- 
larly in  the  two  ends  of  the  tibia.  I  have,  however,  seen  it  in 
the  condyle  of  the  femur  and  the  humerus  and  in  the  shafts  of 
the  ulna,  radius,  and  tibia.  It  may  also  occur  in  any  bone.  In 
Fig.  655  the  cavity  of  such  an  abscess  is  illustrated,  and  in  Fig. 
63-1  is  seen  its  opening  into  the  joint.  The  history  of  these  cases 
Abscess  In  Head^fTibia,  follow-  is  generally  obscure,  an  injury  at  times  being  its  assigned  cause, 
ed  by  Disorganization  and  Dis-       " SYMPTOMS. — The  most  characteristic  symptoms  are  a  fixed 

location  of  the  Joint.    (Prep.        ,  .  ...  ,,    ,  .     ,     •  in  ^1^.1 

Guy's  Hosp.  Mus,  i24.55<i)  achuig  pain  in  the  part,  '•  the  pam  being  a  dull  one,  rather  tend- 

ing to  produce  sickness  than  to  rouse '"  (John  Hunter)  ;  exacer- 
bations occur  in  its  progress,  when  the  pain  becomes  acute,  fixed,  and  of  a  burning  pul- 
sative  kind — "  like  the  falling  of  drops  of  molten  lead,"  as  a  patient  once  described  it  to 
me ;  there  will  likewise  be  local  circumscribed  tenderness  or  pain  on  firm  pressure,  with 
probably  some  evident  enlargement  of  bone  and  the  sense  of  local  heat. 

In  more  advanced  cases  the  soft  parts  over  the  bone  will  be  oedematous,  and  on  firm 
pressure  over  the  painful  spot  a  sensation  of  yielding  will  be  given  to  the  finger.  In  still 
more  neglected  cases  the  abscess  may  make  its  way  into  a  joint,  while  under  fortunate  cir- 
cumstances it  may  advance  forward  and  discharge  itself  externally. 

Treatment. — "  Abscess  in  bone  may  find  its  way  to  the  surface,"  but  "  the  crown  of 


INFLAMMATlnS   oF  liOSK 


955 


the  trephine  is  often  necessary  in  Dnlcr  to  m*t  at  the  seat  of  uVjscess,"  sai<l  .Inlm  llutitrr 
in  ITS"  (MS.  lectures).  At  the  present  (hiy  si  like  treatment  is  to  he  advised,  as  iiothin}^ 
less  than  the  o|)eniii^  of  the  ahseess  in  tlie  hone  is  of  any  nse  ;  and  this  is  usually  done 
hy  nu'aiis  «>f  a  small  trephine.  The  point  to  he  .seleeted  for  the  operation  is  the  painful 
spot,  which  should  he  marked  hefore  the  patient  is  ansesthetieized  ;  the  s(»ft  parts  should 
then  he  divided  hy  a  erueial  ineision  and  turncfl  hack  and  the  hone  itself  freely  peHor- 
ated.  with  the  ])eriosteum  eoverinj;  it.  When  the  instrument  has  opened  the  ahseess, 
pus  will  well  up  at  onee  ;  the  rinir  fif  hone  raised  hy  the  elevator  oufrht  then  to  he  taken 
away  ;  the  eavity,  whieh  is  j;enerally  lined  with  smooth,  velvety  granulations,  is  rarely 
very  large  and  the  (|uantity  of  pus  .seldom  ahove  a  drachm,  althoujrli  scjmetimes  there 
may  he  more.  After  the  operation  the  parts  have  only  to  he  left  alone  to  heal,  recovery 
being  very  general. 

It  is  not  always  necessary,  however,  to  trephine  a  hone,  as  a  less  .severe  operation  is 
at  times  all  that  is  re<|uired,  and  that  is  its  simple*  puncture  by  means  of  a  drill ;  when 
the  .scat  of  the  abscess  is  not  very  accurately  defined,  the  drill  is  probably  the  better 
instrument  to  use.  In  a  .striking  case  I  had  in  the  spring  of  IHTO  I  carried  out  this  oj)e- 
ration  and  punctured  the  head  of  the  tibia  of  a  man  who  had  all  the  external  evidence  of 
local  ostitis  and  su|)puration,  such  as  pain,  bone  expansion,  etc.  I  cut  down  upon  the 
painful  expanded  part  and  made  two  punctures  with  a  drill,  one  of  which  clearly  went 
into  a  cavity  in  the  bone,  as  evinced  by  the  sudden  loss  of  resi.stance.  No  pus,  however, 
was  seen  to  well  up  in  the  wound  at  the  time,  though  soon  after  the  operation  a  free  dis- 
charge took  place.  The  operation  was  followed  by  complete  relief  from  all  pain,  and  in  a 
month  the  man  left  (ruys  (|uite  restored,  and  three  ijionths  later  he  remained  so.  More 
recently  I  arrested  disease  in  the  femur  of  a  boy  ajt.  IS  by  trepliining  the  trochanter 
major  and  puncturing  the  bone  with  a  drill  through  the  opening. 

This  operation  of  drilling  the  bone  .*<eems  to  be  good  either  for  supposed  suppuration 
or  for  chronic  ostitis.  It  is  less  formidable  than  trephining  and  may  be  done  in  cases 
where  the  latter  is  inapplicable  or  not  to  be  entertained ;  indeed,  the  two  means  may  be 
employed  together  when  the  trephine  has  failed  to  open  the  ab.scess.  Holmes's  sugges- 
tion is  good — viz.,  to  pierce  the  walls  of  the  trephine-hole  in  several  directions  with  a 
sharp-pointed  instrument,  in  order  to  remove  the  bone  freely  with  a  chisel  if  a  drop  of 
pus  follow  any  of  these  punctures. 

Chronic  Periostitis  and  Endostitis. 

Chronic  periostitis  and  ostitis  are  very  common  affections,  more  particularly  involving 
the  shafts  of  the  long  bones.  These  affections  may  be  modified  by  syphilis,  scrofula,  or 
rheumatism  and  may  originate  from  some  local  cau.se  or  injury,  but  in  all  their  course  is 
the  same,  the  disease  varying  only  in  the  rapidity  of  its  progress,  extent  of  its  influence, 
and  results.  In  one  case  complete  recovery  may  take  place,  the  effusion  being  reab- 
sorbed ;  in  another  the  effusion  may  become  organized  as  a  superficial  node  or  bony  out- 
growth (Fig.  656)  or  as  an  enlarged,  elongated  area  of  dense  bone  (Fig.  654).     In  excep- 

FiG.  ()o6. 


iAellof  done  .- ^    __.-a:;::^^..t«gr--~— ^~^^^ 


EfTects  of  Periostitis. 


tional  cases  local  suppuration  may  occur,  giving  rise  to  a  chronic  periosteal  or  endosteal 
abscess  ;  in  a  large  proportion  of  instances  the  bone  dies,  and  thus  gives  rise  to  local  necro- 
sis ;  whilst  in  some  few  the  bone,  either  upon  its  surface  or  upon  its  interior,  undergoes 
a  chronic  disintegrating  process  known  as  caries. 

In  local  perio.stitis  a  small  portion  of  bone  alone  may  die.  and.  as  Sir  James  Paget 
has  shown  (  C/in.  Soc.  Tnnis.,  1870),  remain  quiescent  under  a  puffy  or  suppurating 
swelling. 

Sy.mptoms. — The  symptoms  of  chronic  periostitis  and  ostitis  (endostitis)  are  in  their 
nature  very  similar  to,  though  less  severe  than,  those  of  the  acute,  the  most  constant 
being  a  dull,  aching  pain  in  the  part,  of  a  persistent  kind,  aggravated  at  intervals  and 


956  DISEASES  OF  THE  BOXES. 

on  hanging  down  the  limb,  tlie  pain  being  almost  always  worse  at  night,  more  particu- 
larly in  syphilitic  affections.  The  constitutional  symptoms  vary  according  to  the  severity 
of  the  local  condition,  febrile  disturbance  and  intensity  of  local  action  running  hand  in 
hand. 

In  penmtitis  the  pain  is  generally  local  and  attended  with  swelling  at  an  early  period 
of  the  affection — indeed,  within  a  few  days  of  its  onset.  In  endoAtitia  the  pain  is  gener- 
ally more  diffused  through  the  whole  bone,  and  will  continue  for  weeks  or  months  with- 
out any  external  evidence  of  enlargement,  being  too  often  regarded  as  "  rheumatic  "  or 
'•  growing  pains."  In  periostitis  tenderness  on  manipulation  is  an  early  and  constant 
symptom.  In  emlostitis  the  bone  may  be  manipulated  with  gentleness  without  exciting 
pain  ;  firm  pressure,  however,  almost  always  causes  suffering.  In  periostitis  the  enlarge- 
ment generally  shows  itself  as  a  boss}-  or  undulatory  swelling  on  the  surface  of  the  bone, 
with  one,  two,  or  more  nodes  upon  the  bone ;  syphilitic  periostitis  is  generally  multiple 
and  undulatory,  traumatic  and  other,  forms  of  nodes  usually  single.  In  endostitis  the 
enlargement  appears  as  a  general  expansion  of  the  bone  in  all  directions ;  in  rare  ca.ses, 
as  a  distinct  elouejation.  In  periostitis,  when  suppuration  is  about  to  take  place,  external 
evidence  will  appear  in  the  form  of  increased  swelling  and  tenderness,  while  redness  of 
the  skin,  cedema  of  the  tissues  covering  in  the  node,  and  fluctuation  will  be  present.  In 
endostitis  terminating  in  abscess  there  will  be  a  great  aggravation  of  local  pain,  with  con- 
stitutional disturbance,  and  often  rigors ;  and  when  oedema  of  the  soft  parts  over  the 
bone  and  external  evidence  of  inflammation  appear,  the  absce.ss  is  making  its  way  exter- 
nally through  the  periosteum.     (Vide  "Abscess  in  Bone.") 

In  necrosis  of  a  long  bone  the  result  of  periostitis  and  endostitis  by  extension  the 
hope  of  a  new  bone  being  formed  is  forlorn,  as  the  periosteum — the  chief  bone-forming 
membrane — has  been  destroyed,  while  in  the  necrosis  of  endo.stitis  there  is  every  hope 
of  a  complete  restoration  of  the  bone  through  its  perio.steal  covering  taking  place  on  the 
removal  of  the  dead  portion  or  sequestrum. 

In  necrosis  of  the  skull,  which  is  always  periosteal,  no  new  bone  is  formed,  as  the 
perio.steum  is  destroj'ed.  When  following  an  injury  to  the  skull,  it  is  preceded  by  "the 
puffy  tumor  of  Pott."     In  .syphilis  it  follows  a  suppurating  node. 

In  a  rare,  if  not  unique,  preparation  (Guy's  Museum)  of  necrosis  after  amputation, 
taken  from  a  patient  of  my  own,  the  end  of  the  divided  femur  died,  and  at  a  later  period 
the  periosteal  sheath  of  new  bone  that  formed  around  it  also  died,  one  sequestrum  being 
found  within  the  other  on  their  withdrawal  from  the  stump. 

Treatment. — In  chrouic  periostitis,  when  suppuration  does  not  take  place,  fomenta- 
tions, with  the  elevation  of  the  limb,  sedatives  to  allay  pain,  and  the  internal  use  of  the 
iodide  or  bromide  of  potassium,  with  or  without  tonics,  according  to  the  special  require- 
ments of  the  patient,  are  the  most  efficient  means.  In  still  more  chronic  cases  the  use 
of  a  blister  or  the  repeated  application  of  the  compound  tincture  of  iodine  is  of  value. 
If  rheumatism  seem  to  influence  the  morbid  action,  colchicum  has  a  beneficial  tendency'. 
When  nocturnal  pain  is  great,  be.sides  the  internal  administration  of  opium  or  other 
sedatives,  the  external  application  of  belladonna  certainly  gives  relief.  When  pain  is 
severe  and  unrelieved  by  such  treatment,  a  subcutaneous  section  of  the  periosteum  with 
a  tenotomy  knife  is  advisable.  When  suppuration  threatens,  the  warmth  of  a  poultice  or 
hot  fomentation,  with  or  without  the  application  of  leeches,  may  sometimes  arrest  it ;  a 
blister  at  times  seems  to  check  its  progress.  When  pus  has  formed,  it  is  wi.se,  as  a  rule, 
to  let  it  out,  but  the  surgeon  should  be  in  no  hurry  to  do  this  unless  the  pain  is  great  and 
the  abscess  has  a  disposition  to  spread,  as  pus  may  be  reabsorbed,  and  opening  a  perio.steal 
abscess  renders  bone  exfoliation  more  probable. 

Chronic  ostitis  is  an  affection  most  troublesome  to  treat  with  any  effect,  and  the  same 
means  that  have  been  recommended  for  periostitis  may  be  tried  in  this.  In  a  general  way, 
however,  they  do  little  more  than  give  relief  and  have  but  slight  effect  on  the  progress  of 
the  disease,  it  being  far  too  common  for  a  bone  in  a  state  of  chronic  inflammation  to  become 
necrosed.  When  treated  early,  however,  success  is  not  unfrequent.  When  the  disease  is 
steadily  progressing  and  remedies  appear  to  have  no  influence  on  its  progress,  the  operation 
of  drilling  the  bone  in  one  or  more  points,  according  to  the  extent  of  the  disease,  is  an  ope- 
ration to  be  recommended;  when  this  fails,  that  of  trephining  may  be  employed;  for  if 
taking  away  a  piece  of  bone  or  drilling  it  does  not  arrest  the  disease — which  it  undoubt- 
edly often  does — it  at  any  rate  gives  relief  to  local  pain.  Pain  in  endostitis  or  periostitis 
is  due  to  tension  caused  by  pent-up  inflammatory  effusion,  whether  fibrinous,  purulent,  or 
serous,  and  relief  can  be  afforded  only  by  its  removal.  When  a  new  growth,  cystic  or 
otherwise,  occupies  the  centre  of  a  bone,  a  like  pain  is,  however,  experienced. 


SECROSIS.  057 


NECROSIS 


moans  •■  tin-  (loath  of  hono,"  and  it  is  as  a  riilo  the  result  of  an  acute  periostitis  or  endoa- 
titis.  tlu-  elironio  action  being  shown  in  the  process  of  exfoliation — /. «.,  in  tlie  separation  of 
the  (U-ad  from  the  living  hone;  for  in  this  process  a  considerahle  time  is  often  expended, 
no  dcHiiite  period  having  been  hitherto  recognized,  as  the  rate  of  j»rogress  differs  in  every 
case.  It  niav  Ix-  of  the  sliaft  of  a  hone  or  of  an  epiphysis;  it  may  h»*  of  the  shell  or 
Compact  tissue,  of  the  inside  or  cancellous  tissue,  or  of  both  comhined.  It  may  occur 
idiopathically  without  known  cause  or  as  the  result  of  fever,  injury  from  sj»rain.  concns- 
sioii,  contusion,  fracture,  or  gunshot  wound.  I  have  alrea<ly  related  a  case  in  which  local 
necrosis  of  the  articular  extremity  of  the  tihia  took  place  in  six  weeks,  and  it  is  well 
known  that  jdialaiiges  necrose  and  exloliate  in  five  or  six  ;  in  fact,  in  acute  necrosis,  a 
month  or  six  weeks  is  full  time  for  hone  to  die  and  he  thrown  off.  This  process  is,  how- 
ever, at  times  very  chronic.  In  the  necrosis  of  the  lower  jaw  from  jihosphoriis  the  .same 
truth  is  exemplified. 

The  process  of  exfoliation  is  a  very  beautiful  one.  and  is  the  same  in  bone  as  in  the 
soft  parts,  only  slower. 

••  When  a  j»ortion  of  bone  is  to  die,"  writes  Holmes  in  an  admirable  article  in  his 
Si/atnn  (vol.  ii.  Hd  ed.  p.  294),  "the  first  phenomenon  is  the  cessation  of  circulation  in  it. 
This  leaves  it  hard,  white,  and  sonorous  when  struck.  It  does  not  bleed  when  exposed 
or  cut  into,  and  is  insensible.  Occasionally,  when  the  dead  heme  is  exposed  to  the  air 
and  acted  on  by  the  presence  of  putrid  pus.  its  c<»lor  becomes  nearly  or  quite  black;  large 
surfaces  of  hard  black  necrosed  bone  are  s(tmetimes  left  exposed  by  the  sloughing  of  the 
skin  over  the  tibia.  The  dead  bone  at  first  retains  its  connection  to  the  bone  around,  as 
well  as  to  the  periosteum  or  whatever  part  of  the  nutrient  membrane  may  belong  to  it ; 
but  the  presence  of  a  dead  part  is  never  long  tolerated  by  the  living  tissues,  and  accord- 
ingly the  proccs.ses  which  are  to  eliminate  it  soon  become  perceptible  in  both  these  struc- 
tures. The  perio.steum  or  medullary  membrane,  as  the  ca.se  may  be,  separates  from  the 
dead  bone  and  becomes  inflamed ;  a  quantity  of  ossific  deposit  (more  or  less,  according  to 
circumstances^  is  poured  out  between  it  and  the  dead  bone,  and  this  deposit  .soon  becomes 
converted  into  new  bone,  forming  a  .sheath  over  the  dead  portion,  by  which  the  latter  is 
enclosed,  or  incnginated^  as  the  technical  term  is.  The  dead  part  is  now  called  a  seques- 
trum— a  name  only  properly  applied  to  it  when  loose  and  invaginated.  though  often  incor- 
rectly used  of  any  piece  of  dead  bone.  While  this  sheath  is  being  formed  from  the  mem- 
brane coating  the  dead  bone  changes  are  going  on  in  the  living  bone  to  which  it  was 
attached.  When  the  latter  has  been  previously  diseased — /.  e..  when  the  necrosis  has 
been  of  inflammatory  origin — the  inflammatory  deposit  which  surrounds  the  sequestrum 
softens,  pus  is  formed,  and  a  groove  of  ulceration  is  produced  at  the  expense  of  the  circle 
of  inflamed  bone  which  forms  the  margin  of  the  sequestrum.  If  the  surrounding  bone 
has  been  previously  healthy,  the  sequestrum  acts  as  an  irritant  upon  it,  setting  up  first 
inflamnuition  and  thickening  to  a  variable  distance,  and  then  ulceration.  Thus  a  groove 
is  traced  round  tke  sequestrum,  and  the  formation  of  the  groove  is  accompanied  by  sup- 
puration. •  the  pus  containing  much  earthy  matter  from  the  disintegrated  tissue,  B.  B. 
Cooper  stating  two  and  a  half  per  cent,  of  phosphate  of  lime.'  The  pus  formed  in  the 
neighborhood  of  the  dead  parts  makes  its  way  to  the  nearest  surface,  and  in  so  doing 
interrupts  the  formation  of  the  periosteal  sheath,  leaving  sinuses  or  chacse  passing  through 
this  sheath  from  the  sequestrum  to  the  surface  of  the  body,  or  sometimes  into  a  neigh- 
boring joint  or  serous  cavity.  The  presence  of  such  sinuses  leading  through  the  shell  of 
bone  to  hard,  smooth,  sonorous  bone  at  the  bottom  of  the  cavity  is  the  distinguishing 
mark  of  necrosis"  (Fig.  651). 

Where  the  periosteum  has  been  destroyed,  no  investing  sheath  of  bone  will  exist  to 
interfere  with  the  separation  and  casting  off  of  the  sequestrum  (Fig.  (!52 )  :  where  it  is 
nearly  perfect,  the  shell  of  new  bone  will  be  complete  (Fig.  05U).  Under  these  circum- 
stances the  casing  thickens  and  Vjecomes  den.se.  The  amount  of  thickening  around  the 
se«|uestrum  depends  mueh  upon  the  extent  of  new  bone  poured  out  by  the  periosteum 
and  the  duration  of  the  process:  its  density  also  turns  upon  the  length  of  time  the  seques- 
trum has  been  invaginated  and  the  character  of  the  inflammation.  The  bony  shell  in  its 
early  condition  is  soft  and  readily  cut,  broken  down,  or  peeled  off;  in  its  later  stages  it 
becomes  almost  as  hard  as  ivory  and  is  most  difiicult  to  cut.  To  reach  the  .sequestrum 
in  the  thigh  I  have  cut  through  a  bony  sheath  upward  of  an  inch  in  thickness. 

The  whole  .shaft  or  any  portion  of  a  long  bone  may  become  necrosed,  the  epiphyses 
often   saving  the  joints  (Fig.  652).  but.  as  a  rule,  some  portion  of  the  shaft   remains 


958  DISEASES  OF  THE  BONES. 

attached  to  one  or  other  of  the  epiphyses.  Occasionally  the  epiphyses  themselves  are 
the  seat  of  necrosis.  In  the  tarsal  bones,  during  infant  life,  the  ossific  centre  of  the 
bones  may  die  and  exfoliate.  There  is  also  good  reason  to  believe  that  necrosis  of  the 
shaft  of  a  bone  often  originates  after  a  sprain  from  inflammation  started  by  the  injury  in 
the  epiphysial  cartilage  connecting  it  with  the  epiphysis.  The  subperiosteal  sheath  is 
never  seen  in  necrosis  of  the  skull  or  in  short  cancellous  bones. 

When  the  cloaca?  of  the  bone  case  are  large  and  fortunately  placed  toward  the  end 
of  the  sequestrum,  natural  efforts  may  be  sufficient  of  themselves  to  get  uid  of  the  foreign 

body,  the  granulations  filling  the  cavity  gradu- 
FiG.  657.  ally  pressing  upon  the  dead  bone  and  mechan- 

ically extruding  it  from  its  bed.  In  this  way 
large  masses  of  bone  are  sometimes  discharged 
by  natural  processes.  After  amputation  this 
result  is  frequently  seen.     Some   years   ago  I 

Upper  Half  of  the  Shaft  of  the  Humerus  thrown  off    saW  witll  Mr.   Cock  and  Dr.   Iliff  of  Kenuincirton 
at  its  .Tuuetion  with  the  t  pper  Epiphysis  bv  Katu-  ■  i-i.i  ,       n     ^         too 

rai  Processes.    (Prep.  iiu4'>'.)  '  a  case  in  wliich  the  upper  part  of  the  shaft  of 

the  humerus,  which  had  separated  at  its  upper 
epiphysis,  was  gradually  pressed  out  from  below  through  the  deltoid  muscle  and  pro- 
jected outside  the  acromion  process  for  about  an  inch  ;  Mr.  Cock  had  only  to  complete 
the  process  which  nature  had  so  well  commenced  and  draw  out  the  bone,  which  was  four 
inches  long  (Fig.  057). 

Every  surgeon  is  familiar  with  a  somewhat  similar  act  in  other  cases  where  large 
pieces  of  bone,  and  far  more  frequently  small  ones,  are  sometimes  discharged  by  natural 
processes,  but  such  succe.s.sful  natural  efforts  are  rare  in  comparison  with  the  failures ; 
surgical  art  is  demanded,  as  a  rule,  to  assist  in  a  cure. 

When  the  dead  bone  has  been  .shed  and  the  sequestrum  extruded  by  natural  efforts 
or  removed  by  surgical  .skill,  the  bone  granulates,  and  thus  heals.  When  this  process 
takes  place  upon  its  surface,  the  steps  are  very  visible  ;  and  when  the  sequestrum  has 
been  removed  from  a  cavity,  the  same  process  goes  on,  but  with  it  the  gradual  contrac- 
tion of  the  periosteal  shell  of  new  bone  that  surrounds  the  se(iuestrum.  A  bone  in  this 
way  is  re-formed  and  repaired. 

Treatment. — When  the  presence  of  dead  bone  has  been  made  out,  its  removal  is  the 
only  sound  practice,  since  the  longer  it  is  left  in  its  cavity,  the  thicker  and  denser  will 
become  the  periosteal  bony  sheath  ;  consequently,  the  probabilities  of  a  natural  cure  are 
lessened  and  the  difficulties  of  a  surgical  operation  greatly  increased.  The  sequestrum, 
however,  cannot  be  taken  away  until  it  has  been  thrown  off  or  loosened  from  the  living 
tissues,  although  as  soon  as  this  result  has  been  effected  the  sooner  the  operation  for  its 
removal  is  performed,  the  better.  To  interfere  too  soon  before  this  process  has  been 
completed  is  sometimes  injurious  and  always  futile ;  to  wait  too  long  is  simply  to  add  to 
the  difficulties  of  the  case  and  to  postpone  recovery.  Bones  that  are  not  loose  may, 
however,  often  be  detached  by  a  good  twist  with  a  pair  of  forceps  or  raised  by  an 
elevator. 

When  the  dead  bone  is  found  to  be  loose  by  means  of  a  probe,  by  being  made  to  move 
in  its  sheath,  there  should  be  no  hesitation  on  the  part  of  the  surgeon  as  to  interfering, 
though  when  this  movement  cannot  be  made  out  the  same  treatment  may  be  justifiable, 
as  the  sequestrum  may  be  so  tightly  impacted  or  shut  in  by  granulations  as  to  be 
immovable,  though  still  separated.  Under  these  circumstances  the  history  of  the  case, 
and  more  particularly  the  duration  of  the  disease,  will  be  of  great  help  as  a  guide  ;  for  if 
many  months  have  passed  since  the  inflammation  that  killed  the  bone  set  in,  the  proba- 
bilities of  the  sequestrum  being  loose  are  gi-eat.  as  most  sequestra  are  shed  in  four,  five, 
to  ten  months.  I  have  seen  a  sequestrum  in  acute  disease  thrown  off  in  six  weeks,  and 
have  removed  a  large  portion  of  the  shaft  of  the  tibia  three  months  after  the  first  onset 
of  the  symptoms,  while,  on  the  other  hand,  the  dead  bone  may  be  found  fixed  at  a  far 
more  distant  date  than  that  named.  All  know  that  a  necrosed  phalanx  is  generally  loose 
and  ready  for  removal  at  the  end  of  five  weeks,  and  in  most  cases  the  surgeon  is  justified 
in  performing  the  operation  for  necrosis  (sequestrotomy)  within  the  year.  English  sur- 
geons, as  a  rule,  are  disposed  to  wait  till  the  evidence  of  the  sequestrum  being  quite  loose 
is  clearly  marked,  whilst  many  continental  surgeons,  and  particularly  the  German,  excise 
diseased  bone  within  three  months  of  the  first  manifestation  of  disease  by  what  is  called 
a  subperiosteal  operation — that  is,  the  peeling  off  of  the  periosteum  and  the  resection  of 
the  shaft  of  inflamed,  dying,  or  dead  bone.  But  in  doing  this,  as  nature  has  not  yet  indi- 
cated the  limit  to  the  disease  or  separated  the  dead  from  the  living  bone,  much  good  bone 


Ni-ynosrs. 


909 


must  of  m'cossity  hv  often  rcinovcd  with  the  diseased  or  iiiucli  of  the  di>case<l  liorie  h*fl 
liehiiid,  hoth  of  whieh  are  iiii(h'sira))h'  ohje<'ts.  In  Kiijilisii  jiraetice  tlie  cure  is  often  too 
lonj;;  |>ostpoiied.  and  the  ditVieultics  (»f  the  o|H'ration  are  iiu*reasf<l.  In  the  coiititieiitul 
more  may  l>e  done  l»y  operative  interference  than  is  needed  or  less  than  is  required,  tlie 
new  formation  of  Ixme  by  the  periosteum  at  the  same  time  being  necessarily  interfered 
witli. 

The  best  practice,  ])robably,  is  to  be  found  between  the  two.  ami  that  is  sur<rical 
interference  about  three  to  si.\  months  after  the  first  appearance  of  symptoms — in  acute 
disease  and  in  small  and  narrow  bones  early,  but  in  ehronie  disease  and  in  lartre  and  thick 
bone-  late,  iuterlerenee. 

The  Operation  of  Sequestrotomy. — There  is  no  (.peration  in  surgery  more 
satisfactory  than  this,  as  it  is  usually  unattended  with  danger  and  followed  by  eompleti* 
success.  In  many  ca.ses  it  is  simjile,  while  in  others  it  is  complicated,  the  ingenuity  of 
the  surgeon  being  often  ta.xed  to  devise  nieans  to  carry  out  the  oljject  in  view — viz..  the 
removal  of  the  se<|uestrum.  Taking  as  a  tyj)e  of  the  affection  the  tibia  in  which  the 
whole  shaft  or  diajdiysis  is  the  seat  of  niisdiief.  many  cloacjc  or  fistuhe  leading  down  to 
the  dead  bone  through  the  ])eriosteal  bony  case  will  probably  be  present,  as  is  .shown  in 
Fig.  t!51  ;  and  with  a  jirobe  introduced  through  an  opening  at  one  end  and  a  .second  probe 
at  the  other  end  the  .surgeon  may  make  his  incision  between  the  two  down  to  the  bone — 
that  is,  down  to  the  new  case  of  bone  that  envelops  the  old  ;  and,  having  done  this,  he  may 
peel  back  the  periosteum  with  a  raspatory  or  periosteal  retractor,  cut  tlirough  the  new 
bone  that  prevents  the  dead  from  being  seized,  by  means  of  cutting  jjliers  or  chisel,  and 
thus  expo.se  tlie  necrosed  shaft.  The  dead  piece  may  then  be  seized  by  a  pair  of  seques- 
trum f(n-cej)s,  and,  where  practicable,  withdrawn,  f^hould  it  be  too  long  to  extract  througli 
the  wound,  or  should  the  opening  in  the  bony  case  correspond  to  its  centre,  the  seques- 
trum may  be  divided  with  a  pair  of  cutting  forceps  and  its  two  halves  separately  removed. 
At  times  a  good  elevator  is  of  u.se  to  raise  the  sequestrum  from  its  bed  or  to  pry  it  from 
its  attachment.  Occasionally  a  good  deal  of  the  new  casing  of  bone  requires  removal 
before  the  surgeon  can  get  at  the  dead  portion,  and  in  the  femur,  where  the  whole  shaft 
is  necro.sed,  the  upper  part  being  larger  than  the  lower,  it  may  be  necessary  to  chisel  off' 
or  remove  nearly  the  whole  surface  of  the  new  shell  of  bone  to  admit  of  the  removal  of 
the  sequestrum,  it  being  impossible  to  withdraw  through  the  lower  orifice  a  piece  of  bone 
of  larger  diameter.     In  one  case  the  simple  enlargement  of  one  of  the  cloacje  may  be  suf- 

Fio.  658. 


Instriimeuts  L'sed  in  Sequestrotomy. 


ficient  to  enable  the  surgeon  to  seize  and  remove  the  bone,  while  in  another  it  is  neces- 
sary to  lay  two  or  more  cloacfe  into  one.  The  operation  should  be  done  with  as  little 
interference  with  the  soft  parts  and  bony  .sheath  as  possible.  The  object  having  been 
obtained,  the  parts  have  only  to  be  kept  clean,  raised,  and  left  alone  to  fill  up  and  heal, 


960 


DISEASES  OF  THE  BONES. 


Fig.  659. 


when  a  good  recovery  will  gciierally  follow.  The  iiif^tnuiieiits  employed  for  seques- 
trotomy  are  illustrated  in  Fig.  058.  In  all  cases  Esmarch's  elastic  tourni(|uet  should  be 
employed  to  prevent  hemorrhage. 

When  the  whole  shaft  of  a  bone  has  been  removed  in  early  life,  some  shortening  of 
tlie  new  bone  or  arrest  of  growth  may  be  looked  for,  and  in  the  case  Fig.  G59  such  a 
result  took  place.  The  drawing  was  taken  from  a  young  woman  act.  25, 
from  whom,  at  the  age  of  11,  I  removed  the  whole  shaft  of  the  tibia.  The 
bowing  of  the  limb  was  due  to  the  bending  of  the  fibula,  which  had  grown 
naturally  and  bent  to  adapt  itself  to  the  shortened  tibia. 

When  the  sequestrum  cannot  be  raised  from  its  bed,  it  had  better  be  left 
alone,  the  opening  made  not  being  lost,  as  through  it  the  sequestrum  may 
subsequently  be  taken  away  or  expelled  naturally. 

Dead  bone  the  result  of  periosteal  disease  that  is  not  covered  in  by  new 
bone  regularly  exfoliates  and  rarely  requires  more  than  its  simple  removal 
by  forceps,  the  soft  parts  covering  it  being  divided  ;  in  this  way  large  por- 
tions of  the  skull  may  be  removed.  I  have  taken  away  nearly  half  the 
frontal  bone  in  a  child,  and  also  in  an  adult  after  syphilitic  periostitis,  I 
have  removed  large  portions  of  all  the  cranial  bones  forming  the  vault. 
In  one  case  large  portions  of  the  parietal,  occipital,  and  frontal  bones 
were  removed. 

When,  after  necrosis  of  a  bone,  the  se((uestrum  presses  upon  an  artery, 

fatal  hemorrhage    may  ensue.     Thus,  Poland    has    recorded  (Giri/>>  Ilof^p. 

Rep.)  three  cases  where  such  a  result  took  place  in  necrosis  of  the  femur, 

'^"'',p,"!^™f  *"'*  the    popliteal    artery    in    each    having    been    wounded.     Holmes    has   also 

removal  of  Dead  recorded  a  case  where  a  fatal  hemorrhage  from  the  lingual  artery  followed 

Shaft  ^Vmrteen  (jiggj^gg  gf  ^he  jaw,  and  another  in  which  bleeding  from  the  aorta  occurred 

in  caries  of  the  spine.     A  preparation  in  the  Guy's  Museum  (1243'^°)  also 

shows  a  piece  of  necrosed  tibia  that  perforated  the    anterior  tibial    artery  and  set  up 

hemorrhage,  necessitating  the  application  of  a  ligature  to  the  femoral  artery. 

When  necrosis  occurs  in  a  joint,  profuse  suppuration  and  disorganization  must  ensue. 
Where  this  does  not  prove  fatal  and  repair  goes  on,  recovery  may  be  prevented  by  the 
presence  of  diseased  bone ;  and  when  this  can  be  detected,  its  removal  is  the  best  prac- 
tice. I  have  done  this  in  the  knee  in  three  cases,  and  in  the  hip-,  ankle-,  shoulder-,  and 
elbow-joints,  with  good  result,  having  in  each  one  removed  large  pieces  of  dead  bone 
through  sufficiently  large  incision  (Laiicef,  Feb.  6,  1875). 

Such  cases  as  these  must  be  looked  upon  as  cases  of  necrosis,  the  joint  having  lost 
its  special  features  by  previous  disease. 

Necrosis  of  the  carpal  and  tarsal  bones  is  a  common  affection,  for  these  bones  die  like 
the  flat  bones,  no  new  sheath  of  bone  preventing  their  exfoliation  or  removal.  They  may 
be  treated  freely,  such  incisions  being  made  as  will  allow  of  their  removal.  The  os  calcis 
is  the  bone  most  commonly  affected,  and  I  have  removed  a  large  portion  of  it  on  many 
occasions  with  complete  success.  The  epiphysis  of  the  heel  is  not  rarely  affected.  The 
scaphoid  is  sometimes  involved,  even  at  a  very  early  period.  The  cuneiform  and  cuboid, 
separately  or  together,  are  also  found  diseased.  Not  long  ago  I  removed  from  a  boy's 
foot  by  two  incisions  the  whole  row  of  these  bones,  and  an  excellent  foot  was  left — so 
good,  indeed,  that  it  was  difficult  to  believe  that  so  much  bone  had  been  taken  away 
(Fig.  (518).  The  same  may  be  said  of  the  carpal  bones.  Indeed,  in  these  cases  true  con- 
servative surgery  is  of  great  value.  The  removal  of  dead  bone,  however  extensive,  is  a 
very  safe  operation,  and  followed  by  results  which  are  often  startling  by  their  success. 
There  is  no  limit  to  the  removal  of  necrosed  bone,  wherever  found,  or  to  the  amount  of 
natural  repair.  To  amputate  a  limb,  foot,  or  hand  for  necrosed  bone  until  the  surgeon 
has  proved  that  the  removal  of  the- diseased  partis  impossible  or  the  simple  removal 
proved  unsucces.sful  is  scarcely  a  justifiable  proceeding. 

To  gouge  away  bone  that  is  inflamed  and  not  dead  or  to  excise  inflamed  bones  that 
may  undergo  repair  is  a  proceeding  which  is  practically  bad  and  scientifically  unrea- 
sonable ;  for  all  bone  that  is  not  dead  is  reparable,  and  to  interfere  with  it  mechanically 
is  bad  surgery. 

The  great  success  of  the  operation  for  necrosis  Tsequestrotomy)  is  unquestionably  due 
to  the  introduction  of  anaesthetics.  Prior  to  their  introduction  the  operation  was  dif- 
ficult and  dangerous ;  indeed,  it  was  rarely  performed,  amputation  having  been  too  often 
substituted. 


CARIES.  961 


CARIES. 


N">  W(inl  in  Kurircry  lias  been  used  with  L'lcattT  carelessness  and  with  a  proater 
variety  nt"  meanings  than  "  carios,  "  nor  is  thiTc  one  that  now  ronveys  a  les«  dfrinitc 
idea.  In  this  section  it  will  lie  apjilicd  to  an  nnhculthy  inflammation  of  bone,  chiefly  of 
cancellous  hone.  When  snjierticial.  it  appears  as  ulceration  or  molecuhir  dt-ath  of  hone; 
when  deeply  jdaced  or  central,  it  is  often  associated  with  necrosis  or  suppuration  and  may 
or  mav  not  he  due  to  syphilis  or  struma.  It  is  jHif/iolnt/icn/li/  remediable  an<l  rejiarable, 
ami  whenever  fiiund  i.s  mixeil  up  with  reparativi'  jUftcesses.  In  jtatietits  of  feeble  power 
and  some  constitutional  cachc.\ia.  or  where  the  disease  is  very  extensive,  it  may.  however. 
cllniciilli/  he  incurable.  an<l  thus  re((uire  surjrical  interference.  Nevertheles.-i.  in  its  natun* 
it  is  inflammatory,  and  should  be  looked  upon  as  a  curable  afl\>ction  depemling  more  upon 
constitutional  than  upon  local  causes.      In  this  respect  it  differs  from   necrosis. 

A  bone  i.s  said  to  be  curi/nis  on  its  sur/nci-  when,  Vjeing  expo.sed,it  presents  an  irregular 
and  worm-eaten  appearance,  is  suppurating,  and  the  .sore  throws  off"  a  .serous,  more  or  less 
(tft'ensive  purulent  discharge  which  contains  excess  of  phosphate  of  lime  mixed  with 
small  fragments  of  bone  tissue.  This  affection  is  generally  as.^ociated  with  an  ulcer  or 
open  sore  of  the  skin  over  the  parts  and  more  or  less  thickening  of  the  perio.steum  and 
bone  around  and  beneath  tlie  disea.sed  ])ortion.  It  is  always  vascular  and  readily  bleeds 
on  being  touched.  It  is  occasionally  painful.  At  times  the  V»one  is  soft  and  yields  to  tHe 
pressure  (»f  the  probe  ;  in  other  cases  it  is  hard.  When  it  attacks  the  articular  surface 
of  a  bone,  it  often  forms  pits  with  sharp,  well-defined  edges  ;  and  under  these  circum- 
stances has  been  looked  upon  as  scrofulous,  but  with  what  amount  of  truth  it  is  difficult 
to  say.  When  it  is  a.ssociated  with  syphilis,  it  follows  the  suppuration  of  a  node.  At 
times  it  is  complicated  with  the  tubercular  thickening  of  the  surface  of  the  bone  itself  or 
with  what  Paget  has  de.scril>ed  as  annular  ulcers,  in  which  a  spot  of  ulceration  is  .seen 
which  goes  on  to  form  a  circular  trench  round  a  worm-eaten  surface.  This  trench 
increases  in  width  and  depth  and  at  last  loo.sens  a  sequestrum,  which  separates  and  leaves 
a  circular  depression.  In  bones  of  the  skull  this  ulcer  may  involve  one  or  both  tables. 
Thlx  ulcer  may  subsequently  heal,  leaving  a  permanent  depression.  Oirits.  in  fact,  is 
inflammation  and  ulceration  of  ])one  ;  nrcro^o'a  in  its  death  en  nmsse. 

A  bone  carious  in  its  interior  is  vascular,  although  softened  sometimes  almost  to  rot- 
tenness, and  ea.sily  breaks  down  ;  it  discharges  often  a  thin,  sanguineous,  fetid,  .semi-puru- 
lent fluid  which  contains  fragments  and  elements  of  bone ;  absces-ses  which  generally 
communicate  externally  through  the  soft  parts  often  coexist  in  and  about  the  bone  and 
are  occasionally  combined  with  necro.sis.  In  the  spine,  where  it  is  the  more  commonly 
met  with,  it  is  often  unassociated  with  any^  external  suppuration  or  discharge,  though  the 
bone,  with  the  intervertebral  substance,  softens  down  and  undergoes  extensive  molecular 
death,  much  loss  of  bone  taking  place,  the  particles  being  apparently  reabsorbed  and  car- 
ried away,  and  complete  recovery  following  without  any  external  discharge.  Around  the 
inflamed  or  carious  bone  the  cancellous  tissue  is  generally  infiltrated  with  more  or  less 
organizable  inflammatory  lymph,  the  nature  of  which  depends  much  upon  the  character 
of  the  inflammation.  In  feeble  and  strumous  subjects  the  fluid  will  be  of  a  serous,  oily, 
and  non-plastic  kind  (Black  On  Tubt-rcnlous  Bon' .  Edinburgh.  1S59).  the  cancellous  bone 
becoming  more  cellular  and  lighter.  In  more  healthy  types  the  eff"u.sion  will  be  plastic 
and  organizable,  the  bone  becoming  more  compact.  In  one  case  no  consolidation  of  the 
surroumling  bone  will  be  present,  while  in  another  condensation  of  the  bone  to  a  greater 
or  less  extent  will  be  found. 

Under  all  circumstances  the  nature  of  the  inflammatory  action  turns  much  upon  the 
constitutional  power  of  the  patient,  the  disease  tending  in  strumous  and  feeble  subjects 
to  widen,  but  not  to  repair,  while  in  more  healthy  subjects  it  inclines  to  a  local  action  and 
recovery. 

In  rare  examples  genuine  tubercle  may  coexist  with  the  inflammation. 

Treatment. — Looking  upon  caries  as  an  inflammatory  affection,  and  consequently  a.s 
curable,  it  is  to  be  treated  on  somewhat  similar  principles  as  inflammation  of  other  parts. 
When  the  general  powers  of  the  patient  are  feeble,  they  ought  to  be  stimulated  by  tonic 
medicine  and  regimen  :  local  pain  is  to  be  soothed  and  torpid  action  stimulated,  but  all 
mechanical  and  surgical  interference  should  be  avoided,  except  for  the  removal  of  dead 
bone.  In  superficial  caries  or  ulceration,  when  rest,  elevation,  soothing,  or  possibly  stimu- 
lating, applications,  with  tonics,  fail  to  induce  a  healthy  reparative  action,  local  stimulants 
are  sometimes  of  use,  and  the  local  application  of  such  acids  as  the  acetic,  nitric,  or  sul- 
phuric, strong  or  diluted,  has  often  a  beneficial  action.  Mr.  Le  Gros-Clark  strongly  recom- 
61 


962 


DISEASES  OF  THE  BONES. 


mends  acetic  acid  as  the  best  solvent  of  the  inorganic  constituents.  He  uses  as  a  dress- 
ing one  part  of  Beaufoy's  No.  11  acid  to  five  parts  of  water.  George  Pollock  speaks 
highly  of  the  value  of  sulphuric  acid,  at  first  diluted  with  equal  parts  of  water,  and  sub- 
sequently pure.  ^;he  acid  de.stroying  the  diseased  bone  to  which  it  is  applied  and  setting 
up  a  more  healthy  action  in  the  parts  beneath,  thus  hastening  recovery.  Boinet  advocates 
the  use  of  iodine,  at  first  diluted,  and  then  strong;  others  recommend  phosphoric  acid. 
Dr.  Fitzpatrick  applies  the  Vienna  paste  or  potassa  cum  calce  to  the  surface  of  the 
inflamed  bone,  as  well  as  to  its  deeper  parts  after  puncturing  them.  The  actual  or  galvanic 
cautery  has  also  been  employed,  and  in  superficial  caries  it  seems  to  be  valuable.  In  deep- 
seated  or  endosteal  caries  some  speak  highly  of  operative  interference,  either  by  the  goug- 
ing out  of  the  diseased  tissue  or  by  the  excision  of  the  inflamed  or  carious  bone ;  but  I 
allude  to  this  treatment  only  to  condemn  it.  since  I  believe  it  to  be  both  unnecessary  and 
injurious.  It  is  unnecessary,  as  in  the  majority  of  cases  recovery  can  be  secured  without  it ; 
it  is  injurious,  since  gouging,  as  a  rule,  adds  to  the  irritation,  and  thus  tends  to  the  spread 
of  the  disease,  and  often  excites  more  general  inflammation  in  the  bone  or  endosteum. 

Excision  of  the  di-seased  bone  is  not  an  operation  that  can  be  highl}-  recommended, 
yet  it  may  be  done,  doubtless,  with  .success,  as  in  the  tarsus ;  and  many  an  inflamed  or 
carious  os  calcis  has  been  successfully  excised.  There  is  however,  a  strong  doubt  as  to 
the  necessity  of  the  operation.  When  the  bone  dies,  the  necrosed  bone  may,  and  should, 
be  removed  ;  but  in  all  other  conditions  it  is  reparable  under  constitutional  treatment  and 
local  applications.  Surgeons  who  interfere  surgically  with  carious  bones  usually  jirefer 
excision  to  any  partial  operation.  Sui^erficial  or  perio.steal  caries  may  be  regarded  and 
treated  as  an  indolent  ulcer  in  other  parts,  the  repair  being  more  chronic  in  bones  than  in 
soft  tissues  ;  deep-seated  caries  or  inflammation  may  be  also  considered  much  in  the  same 
light.  When  syphilis  complicates  the  case,  iodine  in  full  doses,  in  one  of  its  forms,  com- 
bined with  any  tonic  that  may  appear  to  be  needed,  and  as  a  local  application,  is  of 
great  use. 

TUMORS  OF  BONE. 

Tumors  of  bone  vary  but  little  in  their  pathology  from  tumors  of  other  parts,  and 
whatever  difiierences  exist  arise  from  the  peculiarity  of  the  tissue  in  or  around  which  they 
grow.  Tumors  of  bone,  as  of  .soft  parts,  partake  of  the  nature  of  the  tissue  in  which 
they  are  developed ;  thus,  a  tumor  that  in  a  fibrous  organ  would  be  more  or  less  fibrous 
when  originating  in  or  upon  a  bone  is  mixed  with  bone,  and  a  carcinomatous  tumor  of  soft 
parts  becomes  a  malignant  osteoid  cancer  of  a  bone.  In  addition  to  these,  there  are 
special  tumors  known  as  the  myeloid  and  the  cartilaginous. 

Excluding,  therefore,  enlargements  of  bone  due  to  inflammation,  there  are  bony  out- 
growths or  exostoses,  cartitaginous  and  mydo'ul  tumors,  all  being,  as  a  rule,  of  an  innocent 
nature  ;  there  are  the  osfeo-sarcomatous  tumors,  or  fibrous  tumors  of  bone,  including 
those  that  have  a  periosteal  as  well  as  an  osteal  origin,  the  fibrous  and  osseous  elements 


Fig.  660. 


^^ 


.i^fe*'-^^ 


^.    \ 


Tumor  as  I>isfhart;til  fr^'in  (  a\  ity  in  Fig. 
660.  (Weight  nearly  l.i  oz. ;  circumfer- 
ence 11  bv  9  inches."  Mr.  Hilton's  case. 
Prep.  Guv's  Mus.  1666«.) 


predominating  in  various  degrees  ;  and,  lastly,  there  are  the  malignant  tumors  of  honr^ 
whether  of  the  soft  or  the  hard  kind,  osseous  matter  being  mixed  up  largely  with  both, 
the  disease  acquiring  the  name  "  osteoid  cancer"  when  the  bony  elements  predominate. 
These  tumors  grow  from  the  periosteum  as  well  as  from  the  bone. 

Exostoses  may  grow  from  almost  every  bone  ;  from  the  cranium  inside  and   out, 
as  well  as  from  the  bones  of  the  trunk  and  extremities.    Those  of  the  cranium  are  usually 


TUMOIiS  OF  BOSK. 


Fig.  002. 


very  cU-iisf  and  ol"  ivory-Iikc  hanliu-.x."* ;  iiitlet'cl,  they  are  oftt'ii  called  "  ivory  exostoses," 
aiitr  suiiutiiiies  are  .sii  liaril  that  they  eaiiiuit  be  ivinoved.  They  may  have  hroad  buses, 
but  at  times  are  pediiiieiilated,  and  in  sin^^ular  examples  they  occur  as  loose  growths; 
these  latter  havi-  t^cnerally  occurred  in  tin-  frontal  sinus  and  should  be  described  as  nton- 
tosts.  Mr.  Hilton  has  recorded  an  interesting:  ease  {(Jnij'x  liip.,  vol  i.)  in  which  .such  a 
bony  tumor,  of  twenty-three  years'  staiidiii-:  (Fig.  tiUlj,  fell  out  of  a  lar-.'e  cavity  in  the 
sujterinr  maxillary  boiie  (Fiji.  (»(>()).  The  man  in  IHC.'),  thirty  years  after  the  operation, 
was  well,  althoULtii  distitrured  by  the  hole  in  whi<'li  the  tiinior  had  rested  ;  and  in  a  former 
paj;e  (')!•">  i  I  have  recorded  a  ease  of  the  .xamc  afl'ection  and  ti<;ured  it  (Kigs.  :541,  VA'l). 
These  bony  growths  are  nuire  common  about  the  orbit  and  air  cells  of  the  liead  than  else- 
where. True  ivory  exostoses  of  these  parts  do,  however,  occur,  and  at  times  attain  a 
large  size.  Hirkett  has  related  {Onyx  Rrp..  IHIIH)  such  a  case  of  Dr.  V.  Hruns,  in  which 
an  ivory  tumor  of  seventy-four  years'  existence,  weighing  ten  pounds,  grew  from  I  lie 
oecipitai  bone  td"  a  man  :et.  SO.  Exostcses  fntm  the  jaws — or,  rather,  alveoli — are  often 
calleil  •■  ejiulis." 

Exostosis  on  the  extremities  are  not  uncommon,  and  arc  apt  to  spring  from  the  point 
of  junction  of  the  shaft  with  the  epiphysis  (Virchow  considering  this  as  the  usual  seat) 
ami  at  the  attachment  of  mu.scles.  They  are  mostly 
outgrowths  of  bone  capped  with  cartilage,  by  which 
they  grow  (Kig.  ••<»-) ;  exostoses,  however,  of  long 
standing  have  an  osseous  shell.  They  have  at  times 
broad  bases,  but  more  frequently  narrow  peduncles. 
They  are  often  curved  or  crested,  assuming  odd  shapes, 
and  may  grow  to  a  large  size.  In  exceptional  instances 
they  may  die  or  necrose  without  any  known  cau.se,  and 
as  a  result  of  accident  they  may  be  broken  from  their 
attachment.  I  have  seen  this  in  an  outgrowth  from  the 
femur  of  a  girl  ret.  12  who  received  a  kick  from  a 
donkey,  and  a  second  case,  in  a  patient  of  3Ir.  Birkett, 
with  an  exostosis  of  the  tibia.  When  bi'oken  oif  from 
their  bony  attachments,  they  may  in  exceptional  in- 
stances wither,  but,  as  a  rule,  they  will  again  adhere.  In  a  patient  of  Mr.  Maunder,  in 
whom  an  exostosis  of  the  femur  was  subcutaneously  separated  from  the  bone,  adhesion 
took  place,  although  at  a  better  angle.  At  times  exostoses  are  multiple.  In  a  girl  aet. 
16  I  found  exostoses  of  different  sizes  on  both 
tibiiv  and  both  hands,  one  humerus,  one  radius, 
and  ilium,  and  in  two  patients,  nine  and  six- 
teen years  of  age  respectively,  five  bones  were 
80  affected. 

Some  exostoses  have  &  periosteal  origin,  the 
result  of  organized  inflammatory  products,  when 
they  are  usually  diffused.  Fig.  663  .shows  this 
well  and  was  taken  from  a  patient  of  my  father,  the  late  Mr.  T.  E.  Bryant. 

Ungual  exostoses  deserve  a  special  notice,  since  they  are  even  now  too  often 
mistaken  for  what  is  called  "ingrowing  toe-nail."  They  are  generally  found  on  the 
distal  phalanx  of  the  great  toe  (Fig.  64,  page  177),  but  Prep.  1287,  Guy's  Museum, 
shows  a  specimen  from  the  little  toe.  and  I  have  had  under  care  two  cases  in  which  an 
exo.stosis  grew  from  the  ungual  phalanx  of  the  thumb,  and  one  in  which  it  was  attached 
to  the  index  finger.     Liston  in  1825  first  drew  attention  to  the  nature  of  these  cases. 

The  osteophytes  and  the  outgrowths  of  osteo-arthritis  are  not  classed  amongst  the 
exostoses. 

Treatment. — When  surgical  interference  is  called  for,  nothing  but  the  removal  of 
these  growths  can  be  entertained,  their  bases  being  well  levelled  down  to  the  bone,  or 
even 'scooped  out.  When,  however,  they  are  placed  near  joints,  this  practice  should  be 
well  considered.  In  a  case  in  which  an  exostosis  projected  from  the  inner  condyle  of  the 
knee  I  divided  its  base  subcutaneously  with  a  chisel  and  pres.sed  it  back  into  the  popliteal 
space,  where  it  remained  without  giving  trouble.  In  cranial  exostosis  this  operation  may 
be  not  only  difficult,  but  impossible ;  still,  the  attempt,  wherever  it  can.  should  be  made, 
for  many  successful  attempts  have  ended  in  procuring  the  death  of  the  exostosis  and  its 
subsequent  exfoliation.  In  such  a  ca.se.  treated  by  Mr.  Cock,  where  the  removal  of  the 
whole  from  the  orbit  was  impossible  from  its  hardness,  a  part  was  removed,  and  what 
remained  subsequently  died  and  sloughed  out. 


Exostosis  of  the  Femur. 


Fig.  6G.3. 


Periosteal  Exostosis.   (Prep.  \\\V'\  Guy's  Hosp.  Mus.) 


964 


DISEASES  OF  THE  BONES. 


Intracranial  exostoses  are  rarely  made  out  during  life,  and  are  at  times  associated  with 
epilepsy. 

The  following  analysis  of  1 20  cases  of  exostoses  will  show  the  seat  of  these  growths. 
45  were  tabulated  by  my  colleague,  Mr.  Birkett,  in  Guys  Reports,  and  the  remainder  are 
from  my  private  notes.     Cases  of  epulis  are  excluded. 


Frontal  bone 3 

Upper  jaw 1 

Lower  jaw 3 

Bodies  of  cervical   vertebrae  1 

Sacrum 1 

Kibs 3 

Ilium 1 

Scapula 10 


Clavicle 3 

Humerus        lo 

Ulna 1 

Radius 2 

Fingers 5 

Ungual  phalanx  of  thnmb  .  2 

Femur 18 

Tibia    .     .     .• 18 


Fibula 4 

Patella 1 

Tarsal  bone 1 

Metatarsal 1 

Ungual    phalanx    of    great 

toe .25 

Sole  of  foot 1 


Three  of  the  cases  tabulated  were  examples  of  multiple  exostosis ;  when  the  radius 
was  affected,  it  was  in  common  with  other  bones. 

Enchondromatous  or  cartilaginous  tumors  of  bone  are  most  commonly  met  with 
in  the  phalanges  and  metacarpal  bones.  They  are,  however,  seen  surrounding  bones  hav- 
ing a  periosteal  origin  or  growing  from  the  bones  of  the  upper  jaw.  A  remarkable 
instance  of  this  has  been  recorded  in  Chapter  XIII.  and  figured  in  Fig.  241.  It  would 
appear  that  such  cartilaginous  tumors  are  more  prone  to  attack  the  scapula  than  any 
other  bones,  and  I  have  seen  several  such  cases.  Mr.  Birkett  has  recorded  and  figured  a 
fine  specimen  in  the  Guys  Reports  (1866). 

The  bones  of  the  pelvis  are  at  times  the  seat  of  such  growths.  I  have  the  records  of 
a  remarkable  instance  in  which  the  pelvic  surface  of  the  ilium  was  the  seat  of  the  affec- 
tion, and  of  another  in  which  a  middle-aged  woman  had  an  enormous  cartilaginous  out- 
growth the  size  of  a  cocoanut  springing  from  the  pelvis  and  occupying  the  inner  side  of 
the  right  thigh,  beneath  the  adductor  muscles.     The  case  from  which  Fig.  664  was  taken 


FiG.  664. 


Fig.  665. 


Enchondroma  of  Pelvis. 


Enchonflroiuatous  Tumors.    (From  a 
model  in  the  Guy's  Museum.) 


occurred  in  the  practice  of  my  friend  Mr.  Knaggs  of  Huddersfield.  It  was  of  twenty 
years'  growth.  Cartilaginous  tumors  of  bone  usually  originate  in  it,  and  are  found  in 
young  subjects  when  the  bone  is  growing.  They  are  generally  covered  by  a  sliell  of  the 
bone  in  which  they  originate ;  the  shell  is  at  times  expanded  in  all  directions,  but  more 
usually  in  one.  In  Fig.  665,  taken  from  a  model  in  Guy's  Museum,  this  mode  of  growth 
is  seen.     In  Fig.  22  the  section  of  such  a  growth  is  well  illustrated. 

These  cases  are  occasionally  multiple,  congenital,  and  hereditary.  Thus,  in  1881  a 
man  fet.  53  came  under  my  care  for  a  fracture  of  his  thigh.  He  had  at  least  a  dozen 
outgrowths  of  bone  or  cartilage  (ossifying  enchondromata)  upon  his  body,  connected  with 


Ti'Miijis  or  I  to  si:. 


965 


the  shafts  of  his  \^m\z  honos.  IK-  was  Ikitii  with  tht-iii.  His  fath(!r  had  three  or  four 
/growths  of  (hf  same  kind  as  eon^'eiiital  imiiors,  and  his  son  was  literally  eovereil  witli 
them  from  hirth.  some  ltein<^  iis  hirj;e  us  <iran^es.  My  friend  Or.  Shuttlewortli  nl'  Lan- 
caster has  piildished  a  like  ease  in  the  lint.  .!/»(/.  Juitrn.  (Deeemher  17,  iSSlj. 

(^irtthi<;inous  tumors  are  usually  of  slow  f;rowth  and  paiidess,  with  a  smooth  outline. 
At  times  they  un(h'r<;o  deeay  and  soften  down,  diseharj^inj^  a  hrown-colored  sentus  fluid 
unlike  any  other  tumor,  and  under  such  circiimstanees  are  proiu;  to  di.sseminate  like  can- 
cer. At  other  times  thev  ossify  antl  turn  into  liony  tumors,  the  "  hullious  exostosis" 
bein<;  often  an  ossified  eneliondroma. 

TuK.VTMKNT. — Where  it  can  he  dune  a  cartilaginous  tumor  .should  be  scooped  out  of 
a  hone,  and  in  the  j)lialan<j:es  ami  metacarpal  hones  this  practice  is  usually  successful. 
I^xtreine  example^  of  the  disease  demand  amjiutation   or  excision  of  the  afl'ected  hone. 

Knchnndrcunatiius  tumors  are  at  times  recurrent,  and  in  rare  examples  return  a.s 
malignant  tumors  in  uther  jiarts  of  the  hndy.  Such  ^Towths,  havin<r  a  jieriosteal  orifrin, 
are  usually  r)«pid  in  their  increase  and  diffused.  True  cartilajrinous  tumors  oi"  hone  are 
usually  circuuiscrilK'(l,  and  often  multiple.  The  hones  of  the  hand  are  at  times  niiuh 
involved. 

OsteO-SarCOma  i>^  n  term  of  broad  signification,  and  is  usually  applied  to  the 
fibrous  tumor  of  lione  in  which  fibre  tissue  and  bone  elements  predominate  in  various 
degrees.  Wilks  believes  *•  that  they  are  altogether  comparable  to  the  fibrous  tumors  of 
soft  parts."  They  usually  have  a  periosteal  origin — ijcriosteid  sdrcomn — and  even  in 
exaggerated  examples  the  shaft  of  the  affected  bone  may  be  clearly  traced  through  the 
growth.  The  tumor  is  usually  circumscribed,  with  a  fibrous  capsule  and  divided  by 
fibrous  or  ossitic  rays  into  different  portions;  at  times  the  fibrous  elenient  predominates, 
at  others  the  osseous.  The  disease  is  usually  .seen  attacking  the  ends  of  the  shafts  of 
bone,  and  not  the  epiphy.ses.     All  these  points  are  well  seen   in   Fig.  GOO. 

Cartilage  is  often  found  to  be  mixed  uj)  with  the  fibrous  and  os.seous  elements  and  in 
proportion  to  the  amount  of  bone  matter  entering  into  the  formation  of  the  tumoi  it  may 


Fifi.  r.nr,. 


Fig.  667. 


Periosteal  Osleo->.tii..iiia.    .Drawing    20, 
Guy's  IIosp.  Mus.    Key's  case.) 


Fig.  668. 


Appearance  of  Limb  affected 
witli  Osteo-Chondronia. 


Osteo-Chondronia  of  remur. 
(Drawing  &•'.) 


be  regarded  as  innocent  or  otherwise  ;  bony  periosteal  growths  are  rarely  cancerou.'i. 
When  fibrous  tissue,  and  more  jiarticularly  the  softer  forms,  pred<iminate,  the  tumor  is 
prone  to  recur  at   the  same    spot  or  in  some  other  organ,  as  is  the  case  with  cancer. 

Osteo-chondroma  is  applied  to  a  tumor  involving  bone  and  made  up  of  carti- 
lage and  bony  elements  in  variable  degrees,  the  cartilage  taking  the  place  of  the  fibrous 
tissue  of  the  osteo-sarcomatous  tumor.  In  one  case  bone  will  predominate ;  in  another, 
cartilage.  The  disease  is  usually  of  slow  growth  and  simple  in  its  nature.  In  the  case 
of  a  woman  aet.  34,  from  which  Fig.  667  was  taken,  the  disease  had  cxi.<;ted  for  three 
years.     Fig.  668  represents  the  same  tumor,  taken  during  life. 

Myeloid  tumors  of  bone   are   probably   innocent,  exceptional   instances  being 


966 


DISEASES  OF  THE  BONES. 


ou  record  in  which  a  return  in  the  part  or  in  internal  organs  took  place.     They  usually 
attack  also  either  the  epiphyses  or  the  epiphysial  ends  of  the  shafts  of  bones  (Fig.  G69). 


Fig.  670. 


Fig.  CfiO. 


Expansion  of  Condyles  of  Femur 
from  Myeloid  Tumor. 


Myeloid  Tumors  Expanding  Bone.  (Guy's  IIosp    Mus.) 

I  have  seen  the  disease,  however,  involving  the  shaft  of  the  radius  and  upper  jaw,  and 
Paget  has  described  it  as  attacking  the  breast.  It  begins  commonly  in  the  centre  of  the 
bone,  which  it  expands,  forming  a  globular  shell  of  bone — the  spina  ventosa  of  the  older 
writers  (Fig.  670).  The  interior  of  this  shell  is  made  up  of  fibre  tissue,  or  it  may  be 
cystic,  the  cavity  being  divided  by  means  of  fibrous  septa  into  more  or  less  well-marked 
cystic  divisions.  The  spaces  themselves,  or  loculi,  contain  the  characteristic  myeloid 
material — "  an  opaque  white,  intermixed  with  a  semi-transparent  gelatinous-looking  sub- 
stance of  a  clierry-red  color'' — and  their  substance  is  made  up  of  the  characteristic  poly- 
nucleated  and  irregular  myeloid  cells. 

When  the  tumor  encroaches  on  the  joint,  the  cartilage  is  usually  spread  out  over  the 
tumor,  but  intact.  These  tumors  were  originally  mixed  up  with  the  cancerous  or  fibro- 
plastic of  Lebert.  They  are  fouiul,  likewise,  in  the  gums  as  "  epulis,"  and  in  other  parts. 
In  a  specimen  of  myeloid  tumor  of  the  upper  jaw  which  I  removed  from  a  girl  ret.  8  the 
structure  was  very  dense  (^Guys  Rep.,  1873,  1874,  1877). 

Cancers  of  bone,  as  of  other  parts,  show  their  malignancy  in  effecting  the  utter 
destruction  of  the  bones  in  which  they  are  developed.  They  may  originate  in  the  peri- 
osteum or  in  the  bone,  but  in  either  case  both  tissues  will  be  eventually  affected.  When 
they  originate  from  the  periosteum,  the  bone  may  be  found  in  parts  running  through  the 
mass  and  with  cancerous  elements  surrounding  the  shaft  (Fig.  672)  ;  hut  when  the  dis- 
ease has  existed  for  any  period,  the  same 
Fig.  671.  cancerous  elements  will  be  found  in  the 

shaft  itself  and  destroying  it.  When  the 
disease  begins  in  the  bone,  it  is  usually  in 
the  medulla  by  one  or  more  different  cen- 
tres, which  by  their  increase  expand  the 
bone  and  utterly  destroy  it  (Fig.  671). 
The  bones  under  these  circumstances  are 
very  brittle  and  apt  to  break  on  the  slight- 
est force,  even  by  ordinary  muscular  ac- 
tion, the  fracture  probably  being  the  first 
indication  of  the  presence  of  the  cancer- 
ous disease.  I  have  known  fracture  to 
occur  under  these  circumstances  by  a  patient  turning  in  bed,  crossing  a  street,  or  walking 
down  stairs.  In  the  majority  of  eases  of  cancer  of  bone,  bone  elements  have  little  to  do 
with  the  disease,  though  in  what  is  called  the  true  osteoid  cancer  masses  of  bone  of  a  con- 
densed kind  appear  in  the  medulla,  and  gradually  grow  until  a  large  osseous  mass  of  dis- 
ease is  formed. 

In  Fig.  673  this  form  of  disease  is  well  .seen,  and  was  taken  from   a  patient  of  Mr. 


Fracture  of  the  Femur  from  Muscular  Action  at  the  Seat  of  a 
Local  Cancer  in  a  Man  set.  '2S. 


Tl  Molts   (iF   HOSE. 


1)G7 


A.sliin  Key  iut.  iJtl  in  whom  inasst's  ut"  ImiK!  iiiid  ciirtiluj^iiKJUS  tuln-rcltiM  wt-ii;  Iniiml  in  the 
luii<;s.  |ileuni.  uiitl  Ivniiiliatic  ■;hiii(ls  alUM-  tli-ath. 

'V\w.  piiioHtnil   liinii   of  caiic-or  (^Kig.  »J7-)  ^rows   more   rapidly  tliaii   tlie   ciulortteal   or 
intorstitiul,  very  ijuickly  assumes  a  large  size,  and  is  not  ol'teii  aceompanieil  hy  pain  ;  the 

Fi(i.  1)72. 


Periosteal  Cancer  oi  \iiv   i  una. 


swelling  is  rarely  srlobular  in  its  outline,  but  loses  itself  both  above  and  below  in  the  sur- 
rounding parts;  and  in  the  integument  covering  it  large  full  veins,  from  obstruction  to 
the  deep  veins,  will  likewise  be  seen.  It  will  possess  a  semi-elastic  feel  and  often  yield 
to  the  touch  an  uneijual  sensation  as  to  density.  Endostial  cancer  is  commonly  attended 
with  a  dull  aching  pain  due  to  the  expansion  of  the  bone.  Its  increase  is  at  first  slow  ; 
but  wlien  it  has  so  destroyed  the  bone  as  to  have  reached  the  periosteum,  pain  will  be 
lessened,  while  the  increase  of  the  tumor  will  be  more  rapid.  This  form  of  cancer  is  more 
frequently  secoiulary  than  primary. 

rriniarv  cancer  of  bone  or  periosteum  is  more  common  in  children  than  in  adults. 

Epithelial  cancer  niay  attack  a  bone  by  the  extension  of  the  disease  from  the 
soft  parts,  as  seen  when  cancer  of  the  lips  spreads  to  the  jaws,  and  skin  cancer  may  also 


Fig.  <)7;;. 


Fig.  G74. 

fvrneerOKjs.M',^"''  tn  tibia 


\:;fe^:^i 


(  aiiLL-r  AuuukiiiL;  Xecrotseii  TiWia. 

extend  downward  into  a  bone  of  an  extremity  and  cause 
great  destruction.  At  times  a  bone  that  has  been  the  sub- 
ject of  necrosis  may  become  the  seat  of  cancer,  and  within 
a  short  time  I  had  three  such  cases  under  care,  in  two  of 
which  the  tibia  was  the  seat  of  the  disease,  necrosis  having 
existed  in  both  for  upward  of  twenty  years,  and  in  the 
third,  although  the  femur  apparently  became  necrosed 
twenty-two  years  before  the  man  came  under  my  observa- 
tion, the  cancer  evidently  began  in  the  skin  over  it  and 
extended  down  the  sinuses  into  the  bone.  Fig.  675  was 
taken  from  the  limb  of  this  patient  during  life ;  Fig.  674 
was  taken  from  the  limb  after  amputation  at  the  knee-joint  in  another  case.  In  a  man  I 
treated  years  ago  the  os  calcis  and  the  soft  parts  over  it  were  the  seat  of  the  disea.se.  and 
the  bone  after  amputation  was  found  infiltrated  with  cancerous  epithelial  elements :  and 
more  recently  (187'^)  I  amputated  the  foot  of  a  woman  which  had  been  the  seat  of  cancer 
for  twenty-five  years,  and  of  necrosis  for  ten.  For  other  cases  see  Lnixet.  February  23. 1 884. 
Diagnosis  of  Timors  of  Bone. — In  most  cases  only  an  approximation  to  truth  can 
be  made. 

A  globular  tumor  situated  in  the  articular  end  of  a  bone,  and  expanding  it.  but  not 
involving  the  joint,  of  slow,  steady,  and  often  painless  growth  in  a  young  subject  or 
adult,  is  probably  myeloid. 


Osteoid  (aiicer  of   Knee-joint. 
(Prep.  Guy's  Hosp.  Mus.,  116)5o.) 


968 


DISEASES  OF  THE  BONES. 


A  more  elongated  or  ovoid  tumor  situated  in  the  shaft  of  a  bone  of  more  rapid  growth, 
with  full  veins  in  the  soft  parts  covering  it,  and  a  semi-elastic,  unequal  feel,  in  a  young 
subject,  is  probably  a  periosteal  cancer. 

A  jinu^JihroHs  growth  of  a  somewhat  globular  form,  of  gradual  increase  and  unequal 
surface,  fibrous  in  one  s})ot,  bony  in  another,  in  an  adult,  is  probably  an  osteo-sai'coma, 


Fig.  (i 


6c/ie 


I'af-dla 


Cancer  of  the  Skin  .Spreading  to  the  Bone.    (From  Edward  Abrahams,  set.  42.) 

while  a  more  indurated  growth  with  a  botryoidal  outline  and  a  similar  clinical  history  is 
probably  an  osteo-chondroma. 

Pain,  rapid  and  diffused  growth,  with  unequal  density,  glandular  enlargement,  venous 
obstruction,  and  wasting,  generally  indicate  cancer. 

Gradual,  painless  increase,  a  defined  contour,  globular,  botryoidal,  or  in  ridges,  with 
no  venous  obstruction,  glandular  enlargement,  or  disturbance  of  the  general  health, 
usually  indicate  a  benign  tumor.  The  more  globular  the  outline,  the  greater  the  prob- 
ability of  the  growth  being  myeloid  ;  the  older  the  patient  and  the  more  botryoidal  the 
growth,  the  greater  the  chance  of  its  being  enchondromatous  ;  the  slower  the  growth,  the 
more  local  and  divided  into  septa,  the  greater  the  chance  of  its  being  osteo-sarcoma. 

When  a  tumor  is  periosteal,  by  making  firm  pressure  below  the  tumor  the  bone  will 
be  made  out  to  be  on  a  lower  level  than  the  growth  ;  when  the  tumor  is  endosteal  and 
the  bone  expanded,  on  making  firm  pressure  below  the  surface  of  the  bone  the  bone  will 
be  felt  to  rise  gradually  from  the  unaffected  part  over  the  surface  of  the  growth,  so  as  to 
form  a  shell  for  it. 

Treatment. — A  tumor  of  bone  can  be  effectually  treated  only  by  excision  ;  and 
when  it  involves  the  articular  end  of  the  bone  and  encroaches  upon  a  joint,  amputation  is 
too  often  necessary.  When  the  whole  bone  is  involved,  as  in  a  cancer,  nothing  but  ampu- 
tation can  be  entertained  ;  and  it  is  usually  well  to  amputate  high  above  the  disease.  If 
the  tumor  is  placed  in  the  head  of  the  tibia,  an  amputation  at  the  knee-joint  may  be  per- 
formed, or,  where  this  is  inexpedient,  just  above  the  condyles.  If  the  condyles  of  the 
femur  are  the  seat  of  the  disease,  the  amputation  should  be  at  the  centre  of  the  shaft,  it 
being  justifiable  to  amputate  at  the  hip-joint  only  when  the  disease  is  too  extensive  to 
allow  of  an  amputation  through  the  bone,  for  the  hip-joint  operation  is  most  fatal  and 
should  be  performed  only  when  any  less  severe  measure  is  impossible.  In  an  evident 
cancer  of  the  lower  half  of  the  femur,  where  amputation  is  to  be  performed,  it  had  better 
be  at  the  hip-joint,  though  in  doubtful  cases  the  limb  may  be  removed  just  above  the  growth. 

In  the  upper  extremity,  however,  where  amputation  at  any  of  the  joints  is,  as  a  rule, 
successful,  it  is  wise  in  cancerous  disease  to  remove  the  Avhole  of  the  aff'ected  bone  and 
amputate  at  the  artictilation  above.  In  periosteal  cancers  the  whole  bone  should  always 
be  removed.  Amputation  for  myeloid  and  simple  tumors  is  generally  successful,  and  a 
young  woman  for  whom  I  amputated  the  thigh  for  myeloid  disease  in  1861  was  still  well 
seventeen  years  after  the  operation. 

If  a  tumor  involve  the  shaft  of  a  bone  or  the  extremity  of  its  diaphysis,  but  not  the 
epiphysis,  and  the  growth  appears  to  be  local,  and  probably  simple,  an  attempt  should 
first  be  made  to  deal  with  it  locally,  to  scoop  or  to  turn  it  out,  the  more  severe  measure 
of  excision  or  amputation  being  alone  had  recourse  to  should  the  minor  fail.  In  the  case 
of  the  enchondromatous  and  fibrous  tttmors  of  bone,  the  minor  measure  is  usually  suc- 
cessful. In  fact,  in  the  treatment  of  tumors  of  bone,  when  the  disease  can  be  removed 
without  making  any  great  sacrifice  of  other  parts,  the  attempt  sliould  be  made.  Ampu- 
tation as  a  primary  measure  should  be  reserved  for  clearly  cancerous  cases  or  diffused 
growths,  or  for  sucli  as  involve  the  articular  ends  of  the  bones,  and,  consequently,  the 


TiMons  or  r.osi:. 


9Gli 


joint.  Sciino  iiiterestin*;  cases  illustrating'  tlic  !i(lviiiit;i;.'('  i»l' excising'  portions  of  tlu-  long 
bdiu'S  when  tlu'  scat  of  niV»'loi<l  and  otlicr  tumors  liavc  hccn  n-conliMl  liy  Mi-ssrs.  Lucus 
and  .Moni<  in  tlic  tenth  vulninc  ol'  tlu-   C/iin'raf  Sucir/i/s  Trniisttcliniis. 

Pulsatile  tumors  of  bone  art-  fanccrou.-.  as  a  rule,  thoiij^'h  they  niay  1»(;  aneur- 
isinal.  t'ant-erous  tumors  id"  the  skull  are  fVe(|uenlly  pulsatile,  ami  in  one  widl-marked 
ease  I  had  iintler  care  some  time  ajro.  in  whicdi  the  frontal  hone  was  the  seat  of  the  <lis- 
ease,  this  pulsatile  condition  was  its  early  symptom,  the  swellin;.'  hein^'  eomparativdy 
unnotieed.  All  jmlsatile  hom-  tumors  have  an  interstitial  ori^^iii  ami  expand  the  hone, 
the  new  {growth  reeeivinj;-  its  imjiulse  from  the  lar;,;e  arteries  that  supply  it.  firay  ( Mnf.- 
(^/lir.  Trillin.,  vol.  xxxix.)  has  recorded  an  example  of  pulsatiufj^  myeloid.  True  eases  of 
(istro-iiiinin'sni  are  rare.  Mr.  Hickersteth  of  liiverpool  has  recorded  such  a  ease,  and  I 
had  the  pleasurt-  of  exaniinin«i:  it  carefully  with  Mr.  \V.  Adams  and  rejiorting  u[ion  it  to 
the  l'atholoL:ieal  Soei»'ty  (vol.  xix.).  It  was  undouhtedly  a  genuine  case  (»f  this  disease 
involving  the  tihia.  Mr.  Mapother  (DiiUIn  Mid.  Tnins..  isti."^,)  has  recorded  anrtther. 
These  eases  are  made  up  o\'  exjianded  hone  from  aneurismal  dilatation  of  the  vessels  of 
the  hone. 

Tkk.vT.MF.NT. —  Pulsatile  caiK-erotis  tvmiors  of  hone,  like  the  iioii-piil.-atile,  ought  to  he 
treated  by  amputation  ;  true  osteo-aneurisms  of  a  limited  size,  when  they  can  he  made 
out,  should  he  dt^alt  with  by  local  extirpation  or  by  destroying  them  by  means  of  the 
actual  or  galvanic  cautery,  and  when  very  extensive  by  amjiutation.  l>r.  Mapother 
cured  his  by  the  actual  cautery,  and   Mr.    Biekersteth  by  amjiutation. 

Cysts  in  bone  are  occasionally  met  with,  and  may  be  serous,  sanguineous,  or 
hvdatid.  The  ibrmer  two  are  most  comrnoidy  met  with  in  the  jaws,  and  in  Chapter 
XI 11.  attention  has  been  directed  to  them.  Whether  they  ever  occur  in  the  long  bones 
is  an  open  ((uestion,  though  in  1870  I  trephined  the  enormously  enlarged  and  expanded 
shaft  of  the  tibia  of  a  man  aet.  30  for  gradually  progressive  disease  of  fifteen  years'  stand- 
ing, the  bone  having  been  the  seat  of  a  fixed  pain  in  its  centre.  I  did  so  under  the 
impression  that  the  ca.<e  was  one  of  abscess,  but.  having  perforated  a  dense  shell  of  bone 
an  inch  thick,  I  came  upon  a  cavity  the  size  of  an  egg  which  contained  no  pus.  though  it 
was  lined  with  the  soft  velvety  material  usually  met  with  in  abscess,  and  what  escaped 
from  it  was  not  to  be  distinguished  from  the  blood  that  flowed  during  the  operation. 
The  operation  was  ({uite  successful,  and  a  rapid  cure  ensued.  I  believe  this  case  to  have 
been  owe  of  cyst  in  the  bone. 

Hydatids  are  found  in  bone,  and  in  Guy's  3Iuseum  there  is  the  head  of  a  tiliia  con- 
taininu'  a  cvst  or  echinococcus  which  holds  many  smaller  cysts  within  it ;  ahso  another 
specimen  illu.strating  the  existence  of  hydatids  in  the  vertebra?.  In  1869  I  treated  with 
Dr.  Freund  a  case  in  which  a  large  hydatid  escaped  from  the  expanded  condyle  of  the 
humerus  after  a  puncture  in  front  of  the  joint.  The  hydatid  had  clearly  made  its  way 
from  the  bone  into  the  elbow-joint  and  through  this  externally  ;  a  good  recovery  with  a 
stift"  joint  ensued. 

Hypertrophy  and  atrophy  of  bone  are  pathological  realities,  although  during 
life  it  may  be  a  dithciilt.  if  not  an  impossible,  task  to  recognize  such  conditions.  Hyper- 
trophies and  chronic  inflammatory  changes  are  consequently  often  mistaken  the  one  for 
the  other,  although  in  the  former  the  enlargement  is  gradual  and  painless  and  in  the 
latter  as.sociated  with  local  pain  and  other  evidence  of  inflammation.  In  some  cases  the 
bone  is  enlarged  and  its  cancellous  structure  expanded  (porous  hyperostosis) :  in  another 
it  is  enlarged,  but  at  the  same  time  more  dense  (sclerotic  hyperostosis).  The.se  changes 
are  best  seen  in  the  calvaria  (Fig.  OTG).  In  Prep.  1068"'^  in  Guy's  Museum  the  bone  is 
at  least  double  its  normal  thickness.  In  rare  cases 
the  hypertrophy  is  clearl}'  due  to  increase  of  func- 
tion, as  shown  in  another  preparation  in  Guy's 
Museum  (1000'^),  taken  from  a  man  who  was  a 
paralytic  and  who  had  u.sed  his  arms  for  progression  : 
here  the  bones  of  the  u])per  extremity  are  larger  than 
those  of  the  lower.  In  the  majority  of  ca.ses.  how- 
ever, the  sclei'osis  of  bone  is  due  to  inflammation,  and 
in  the  case  which  Sir  P.  Ilewett  mentioned  in  his 
well-known  Coihge  Lecture's^  where  the  mans  skull 
increased  so  imperceptibly  year  by  year  as  to  be 
recognized  only  by  the  gradual  increase  in  the  size 
of  his  hat,  the  disease  was  traced  to  an  injury. 

This  aff"ection  is  pathologically  interesting,  though  surgically  nothing  can  be  done  for  it. 


Afropliy 


Hypertroihy  and  Atrophy  of  the  Bone. 
(From  preji.  in  (jiiy's  Museum.) 


970  DISEASES  OF  THE  BONES. 

Atrophy  is  most  commonly  met  with  in  the  shafts  of  bones  that  have  not  been 
used  for  many  years,  as  in  paralytic  subjects  and  persons  who  'have  been  the  subject's  of 
joint  disease,  in  the  bones  of  the  aged,  and  in  those  that  have  been  injured.  The  bone 
may  become  a  mere  shell,  its  cancellous  tissue  being  expanded  and  its  cells  filled  with  a 
fatty  matter. 

When  atrophy  follows  injury,  Curling's  suggestion  (Med.-Chir.  Trans.,  vol.  xx.)  that 
the  causes  may  be  found  in  injury  to  the  medullary  artery  is  probably  right.  This  prob- 
ably happened  in  the  case  of  a  man  who  came  to  me  with  an  ununited"  fracture  of  the 
humerus,  in  whom  I  found  the  bone,  on  exposing  its  ends  for  operation,  to  be  a  mere 
shell  and  not  half  its  normal  thickness.  It,  however,  cannot  be  the  only  explanation,  as 
Norris  has  recorded  {American  Journ.  of  Med.  Sri.,  1842)  a  remarkable  case  in  which, 
after  a  double  fracture  of  the  humerus  about  its  centre,  the  whole  bone  disappeared,  the 
fore-arm  subsequently  swinging  as  a  thong,  while  the  arm  became  shortened  six  inches ; 
the  bone  disappeared  •'  by  the  gradual  action  of  the  absorbents." 

In  these  eases  spontaneous  fracture  or  fracture  from  slight  mu.scular  action  is  very 
prone  to  occur. 

These  cases  of  hypertrophy  or  atrophy  must  not  be  confused  with  the  elongation  of 
the  shaft  of  a  bone  which  is  due  to  inflammation,  or  to  the  shortening  of  a  bone  from 
arrest  of  its  growth  following  disease  or  the  removal  of  the  shaft,  or  to  some  injury  to 
the  epiphysial  cartilage  that  connects  the  shaft  with  the  epiphysis ;  for  it  cannot  be  too 
strongly  impressed  upon  the  student's  mind  that  any  disease  or  injury  which  interferes 
in  any  way  with  the  nutrition  of  the  epiphysial  cartilage  through  which  the  long  bones 
mainly  grow  will  be  followed  by  arrest  of  the  bone's  "growth,  and  consequently  by  the 
shortening  of  the  limb — that  is.  when  the  disease  or  accident  occurs  in  early  life  during 
the  period  of  growth.  I  have  before  me  the  notes  of  several  cases  where  this  result 
ensued.  In  one  in  adult  life  the  tibia  was  an  inch  shorter  than  its  fellow  after  the 
removal  of  a  necrosed  shaft  in  childhood  {vide  Fig.  659),  in  another  nearly  the  same 
amount  of  shortening  followed  an  injury  to  the  superior  epiphysial  line  of  the  tibia,  and 
in  a  third  the  same  result  followed  a  displacement  of  the  lower  epiphysis.  In  all  these 
cases  the  fibula  was  curved  outward,  the  shaft  of  the  bone  bent,  and  the  outer  malleolus 
much  lower  than  the  inner,  the  bone  having  grown  as  the  others.  In  one  case  the  head 
of  the  fibula  was  partially  displaced  outward. 

Mollities  OSSium,  or  OSteo-malacia,  is  a  rare  affection,  and  its  cause  is 
wrapped  in  obscurity.  It  is  found  in  men  in  about  one  ca.se  in  ten  of  the  affection,  and 
in  women  is  usually  discovered  during,  even  if  it  does  not  originate  in.  pregnancy.  It 
chiefly  attacks  subjects  who  from  some  cause  or  other  have  been  subjected  to  prolonged 
depressing  influences,  more  particularly  upon  the  nervous  system. 

My  colleague,  Mr.  Durham,  in  an  able  paper  on  the  subject  {Gvy's  Rep.,  1864),  writes 
"that  mollities  ossium  is  to  be  regarded  as  a  particular  expression,  as  it  were,  of  a  general 
morbid  condition  of  the  system,  rather  than  as  a  special  disease  of  the  bones  themselves;" 
and  I  believe  there  can  be  little  doubt  as  to  the  soundness  of  the  opinion.  It  should 
never  be  confounded  with  rickets  or  with  the  fragility  of  the  bones  met  with  in  the  aged 
or  demented. 

Symptoms. — "The  first  symptom  of  the  disease,"  writes  Durham,  "is  pain,  more  or 
less  peculiar  in  character,  always  deep-seated,  and  greatly  increased  by  pressure  or  motion, 
sometimes  coming  on  suddenly  and  with  extreme  severity,  sometimes  commencing  vaguely 
and  insidiously,  and  gradually  becoming  almost  insupportable;  sometimes  wandering,  at 
other  times  fixed  for  a  period  to  some  particular  spot,  and  subsequently  spreading  to  other 
parts;  sometimes  intermitting,  at  other  times  unceasing.  In  the  majority  of  cases  the 
pain  appears  to  have  been  first  felt  in  the  lower  half  of  the  spine,  the  pelvis,  and  loins, 
but  in  some  it  commenced  in  the  feet,  knees,  or  other  parts  of  the  lower  extremities;  the 
pains  are  often  looked  upon  as  rheumatic.  Associated  with  the  pain  there  has  always 
been  noticed  on  the  part  of  the  patient,  at  a  very  early  period  of  the  malady,  a  feeling 
of  general  lassitude  and  disinclination  to  do  anything.  This  feeling  has  increased  more 
or  less  uniformly,  until  it  has  ended  in  actual  inability  to  make  any  exertion  whatever ; 
and  with  the  early  local  changes  are  associated  an  uncertain,  feeble  gait  and  continual 
fear  of  falling." 

Symptoms  that  are  more  or  less  directly  associated  with  the  softening  and  absorption 
of  the  bones  are  the  next  to  appear,  such  as  diminution  of  stature,  deformity  of  the 
spine  or  pelvis,  some  curvature  or  fracture  of  one  or  other  of  the  long  bones  ;  and  as 
time  progresses  these  indications  multiply.  flexihiUty  conjoined  with  fragility  being  the 
distinguishing  character  of  the  bones  in  this  disease. 


RICKETS. 


!)71 


TIu'  urine  altiiDst  alvviiys  contains  a  cuiisidijrahlc  excess  of  lime  salts.  The  (li>ease 
is  rarelv  attciidfd  with  any  ^'eneral  or  local  symptoms  of  inflammation.  The  changes 
ohservctl  in  the  hones  are  carefully  dcscrihed  hy  Durham.  Increased  vascularity  appears 
to  he  an  early  symptom,  the  lar^e  irrooves  seen  in  the  cranial  hones  hein;;  very  striking; 
next,  the  honv  matter  is  seen  to  he  more  (»pa(jue  and  less  uniform  than  natural  ;  some- 
tinu's  it  is  irregularly  granular,  "as  if  some  disunion  must  have  taken  place  hi-lween  the 
etmiponent  idenu'Uts  of  the  hony  nuitter. 

The  lamiiuition  of  the  hones  next  hec<uncs  Ic.-s  di.stinct  ;  the  lamin:e  of  the  Haversian 
system  appear  more  or  less  fused  together;  the  hone  corpuscles  hecome  wider,  although 
not  with  certainty  more  numerous.  At  a  later  date  the  earthy  uuittcr  hecomcs  absorhed  ; 
the  Haversian  canals  hecome  surrounded  hy  a  transjiarent  ring  of  animal  matter,  which 
ring  then  hecomes  disintegrated  and  absorhed.  By  this  process  the  Haversian  system 
ln'1'iunes  destroyed,  the  bone  assuming  a  hollowed-out,  porous,  or  somewhat  sponge-like 
appearance.  The  contrast  between  the  healthy  and  diseased  bone  is  well  seen  in  Fig.s. 
(J77,  07S. 

Fio.  G77.  Fig.  678. 


^'■^ 


^'pi'T-i^ 


Section  of  Normal  Occipital  Hone. 


Section  Affected  witli  ^^<)llities 


iDurhani,  Guy's  Rep.,  1SG4.) 


The  same  changes  occur  in  the  cancellated  as  in  the  compact  tissue.  In  the  more 
advanced  stage  the  bone  disintegrates  rapidly  ;  debrh  of  tissue,  such  as  the  remains  of 
blood  vessels,  shreds  of  membrane,  fat  and  oil  globules,  with  '-marrow  cells."  fill  up  the 
large  spaces. 

ChemicaUi/,  the  inorganic  constituents  are  greatly  diminished  and  chemical  disunion 
and  physical  disunion  coexist,  the  earthy  matter  being  more  readily  dissolved  out  of  the 
diseased  than  out  of  normal  bone.  ''In  healthy  bone."  writes  Durham,  '-the  constituents 
are  combined ;  in  diseased  bone  they  seem  rather  to  be  mixed.  The  animal  constituents 
are  likewise  more  fatty  and  less  nitrogenized  than  in  normal  bone ;  the  fat  is  more  free. 
In  the  mineral  constituents  the  proportion  of  the  carbonate  of  lime  to  the  phosphate  is 
much  diminished." 

ProciXosis  and  Treatmext. — The  prognosis  in  these  cases  is  always  bad.  although 
the  possibility  of  a  cure  should  not  be  doubted.  Trousseau  relates  eases  in  which  a  good 
result  was  obtained  under  the  combined  influence  of  rest,  warmth,  good  food,  and  cod-liver 
oil.  the  deformity,  of  course,  remaining.  Lime  salts  ought  not  to  be  given  in  these  cases, 
as  they  cannot  be  retained ;  and  to  give  them,  adds  Durham,  is  only  to  throw  additional 
work  upon  the  excreting  organs. 

Rickets  is  an  afllection  of  early  childhood,  or  rather  of  young  life,  since  it  has  been 
kncnvn  to  att'ect  animals,  as  proved  by  a  skeleton  of  a  West  African  baboon  shown  at  the 
Pathologica.1  Society  of  London  in  1883  which  exhibited  the  characteristic  changes  in  the 
epiphyses  of  the  long  bones,  and  by  the  head  of  a  monkey  which  was  a  fine  example  of 
craniotabes.  In  neither  of  these  cases  could  syphilis  be  said  to  have  had  any  influence. 
It  is  more  of  an  acquired  than  an  hereditary  affection,  but  it  may  attack  a  fa?tus  in  utero. 
It  is  said  by  Sir  W.  Jenncr  to  be  the  commonest  of  the  diathetic  affections  among  the 
London  poor.  It  is,  however,  found  in  the  families  of  the  higher  classes,  and  it  is  essen- 
tially due  to  some  malnutrition  of  the  body,  connected,  proliably,  with  bad  feeding  and 
the  use  of  farinaceous  in  lieu  of  animal  food,  the  bones  during  their  period  of  growth 
expanding  at  their  epijihysial  ends  and  bending  in  their  shafts,  and  being  very  prone  to 
incomplete  or  green-stick  fracture. 

Symptoms. — ••  Di.splacement  and  oblir|uity  of  the  epiphyses  may  ensue,  from  softness 
and  flexibility  of  the  layer  of  bone  uniting  it  to  the  diaphysis,  as  is  seen  more  especially 


972  DISEASES  OF  THE  BOXES. 

in  the  ribs,  but  a  slighter  degree  of  epiphysial  obliquity  is  noticed  in  many  of  the  joints 
of  the  long  bones,  such  as  the  knee  or  ankle  ;  the  weight  of  the  body  is  thus  thrown 
unequally,  so  that  one  set  of  ligaments  has  to  bear  more  traction  than  another.  These 
ligaments  then  yield  and  the  joints  become  loose,  so  that  rachitic  knock-knee  {genu  valgum) 
or  bow-legs  {genu  varum)  is  formed. 

••  From  sustaining  the  weight  of  the  body  the  femur  bends  forward,  the  tibia  usually 
forward  and  either  inward  or  outward,  the  greatest  amount  of  yielding  being  where  the 
bone  is  thinnest  and  weakest.  In  many  cases  we  find  the  os  femoris  bent  forward,  with 
anterior  and  outward  curvature  of  the  tibia,  knock-knee  and  flat-foot  being  coexistent  in 
the  same  individual.  Just  so  far  as  the  rachitic  condition  extends,  so  may  we  look  for 
abnormities  of  form  ;  thus,  the  2)elc is  may  acquire  some  of  those  well-known  contractions 
of  its  outlet  which  are  matters  of  such  grievous  moment  to  women  at  the  period  of  par- 
turition." the  pelvis  either  retaining  in  adult  life  the  small  size  and  imperfect  develop- 
ment of  infancy  or  becoming  narrowed  as  to  its  cavity  in  one  or  other  of  its  diameters. 

The  chest  also  undergoes  allied  changes,  and  Mr.  Shaw  has  well  pointed  out  (Holmes  s 
Si/sd-m,  vol.  iii.  p.  820)  how  ''  pigeon-brea.st "  is  one  of  the  effects  of  the  disease,  atmo- 
spheric pressure  bending  in  the  bones  that  have  lost  their  elasticity  and  become  softened, 
and  causing  a  projection  of  the  sternum  and  lateral  flattening  of  the  che.st. 

In  the  spine  a  general  curving  of  the  whole  column  is  the  more  usual  deformity, 
"lordosis,"  or  anterior  projection  of  the  lumbar  vertebrae,  as  a  compensating  curve,  being 
found  when  pelvic  obliquity  is  present. 

In  all  cases  of  rickets  Humphry  has  shown  (J/<?'^7.-C//*V.  Tram.,  1862)  that  deficiency 
of  growth  coexists  with  deformity,  the  lower  limbs  juore  than  the  upper  indicating  this  in 
their  proximal  segment.  In  severe  cases  all  the  bones  are  more  or  less  deformed,  the 
cranium — often  large — presenting  a  quadrilateral  aspect,  with  sutures  widely  open  till  a 
late  period  of  life,  or  even  subsequently  reopening,  the  bone  either  remaining  thin  or  sub- 
sequently thickening.  The  periosteum  in  these  cases  is  also  usually  thickened,  in  the  flat 
as  well  as  in  the  long  bones. 

The  general  symptoms  of  rickets  are  those  of  debility,  muscular  and  general  weakness 
of  the  whole  frame  gradually  passing  into  that  of  rickets  ;  dentition  is  retarded  and  teeth 
decay  or  drop  out.  Sir  W.  Jenner  lays  great  stress  upon  profuse  per.spiration  of  the  head 
during  the  night,  a  tendency  to  kick  off  bedclothes,  fetid  stools,  and  general  tenderness 
of  surface  as  constant  symptoms  of  the  early  stage. 

Pathology. — Tomes  and  De  Morgan  inform  us  that  a  rickety  bone  has  the  structural 
arrangement  of  normal  bone  without  the  earthy  salts.  Jenner  (Jlcd.  Times,  1860),  how- 
ever, describes  an  enlargement  of  the  lacunae  generally,  the  effu.sion  of  a  red  pulpy  sub- 
.stance  in  the  cancellous  tissue,  and  a  thickening  of  the  periosteum,  while  Gee  (<SV.  Bart. 
Rep.,  1868).  Dickinson  (Jfed.-Chir.  Trans.,  1852).  and  others  have  pointed  out  how  the 
viscera  undergo  some  "  albuminoid  "  changes  unlike  the  waxy  or  lardaceous  disease. 

In  normal  bone  there  is  37  per  cent,  of  organic  and  63  per  cent,  of  inorganic  matter. 
In  rickets  the  proportion  is  79  per  cent,  of  organic  and  21  per  cent,  of  inorganic  matter. 
Bones  that  have  been  solid  may  become  pliable  when  this  disease  begins. 

Rickets  is  a  curable  affection — that  is,  if  taken  before  it  has  far  advanced  ;  and  it  is 
remarkable  to  what  an  extent  the  deformities  are  remediable  under  natural  processes,  and 
how  curved  or  bent  shafts  of  bone  recover  their  natural  shape  on  taking  off  downward 
pressure  and  improving  the  general  powers  of  the  child.  In  more  severe  cases,  where  the 
curvature  cannot  be  remedied,  the  bone  consolidates  and  becomes  strengthened  by  but- 
tresses of  bone  along  the  concavity,  and,  although  the  stature  may  be  diminished  and  the 
limbs  deformed,  the  general  powers  of  the  patient  may  be  restored  and  a  sound  recovery 
take  place. 

Treatment. — The  medical  treatment  of  rickets  .should  be  conducted  on  reasonable 
principles — fresh  air  and  abundance  of  it,  simple  nutritious  food  such  as  may  suit  the 
conditions  of  the  digestive  organs  being  essentials :  milk  and  beef  tea  for  young  children 
should  be  mo.stly  relied  upon,  and  meat  in  moderation  for  the  older.  Cod-liver  oil.  iron, 
and  quinine  are  also  very  valuable  drugs.  The  bowels  should  be  carefully  attended  to, 
while  all  violent  purgatives  ought  to  be  avoided. 

The  surgical  treatment  in  the  early  stages  is  the  prevention  of  deformity,  and  in  the 
later  the  remedying  of  it.  By  way  of  prevention,  the  child  should  be  restrained  from 
any  prolonged  standing  or  sitting  position  ;  the  horizontal  posture  should  be  observed  as 
far  as  possible  ;  exercise  should  be  allowed  and  followed  by  rest,  the  two  alternating 
according  to  the  powers  of  the  patient  and  the  necessities  of  the  case.  As  the  general 
health  and  powers  improve  more  liberty  may  be  sanctioned.     In  spinal  cases  these  obser- 


OSTKITIS   DEIOllMASS.  973 

vatiiMis  arc  more  especiiilly  Idmliiiir,  anil  in  tliiiii  iiii)val)le  couches  and  spinal  chairs  are 
of  ;;rcat  .-.crvicc. 

Where  iuo«KTate  deformity  exists,  more  particularly  in  the  lower  extremities,  it  is 
often  interestinir  to  ohserve  how,  hy  the  above  means,  the  bones  recover  their  normal 
sliape,  and  children  "  };row  out  "  of  their  deformity  us  their  health  improves  if  otdy  the 
surgeon  takes  care  it  is  not  increased  by  nejilect. 

in  still  worse  cxam})les,  and  where  exercise  is  es.sential  and  intertnittent  rest  will  not 
be  (d)served,  splints  and  instruments  may  be  bound  to  the  le;rs.  Tw«j  long  side-splints 
reachinj;  to  the  <;roun<l.  carefully  boun<l  to^rethcr  and  removed  at  nijrht,  are  as  p»od  as 
unv.  or  an  irnii  splint  with  j(»iiits  at  the  knee  and  ankle.  Some  surj^eons  prefer  an  outer 
splint  for  knock-knee  and  an  inner  one  for  bow  lej;s. 

When  the  curvature  of  the  shafts  of  the  lejr  bones  is  very  great  or  acute.  Mr.  II. 
March  has  adoj)ted  the  ]ilan  of'  forcibly  strai<:litenin<r  the  bones  when  the  patients  are 
undt-r  chloroform.  He  tliinks  little  of  the  risk  of  breaking  the  bone.  knr»wing  how  rick- 
etv  bones  unite  (.SV.  Ii<iilli.  lu/i.  for  ISyOj.  He  believes  the  plan  more  adapted  for  acute 
than  for  chronic  ca.ses.  In  extreme  cases  an  osteotomy  niay  be  performed,  or  a  wedge  of 
bone  may  be  removed  from  the  shaft.  I  performed  this  latter  operation  in  IHJJH  on  the 
leg  of  a  child  between  four  and  five  years  of  age,  and  Mr.  Little  has  more  recently 
repeated  the  operation  with  advantage.  It  should  be  done  only  in  extreme  instances  of 
deformity  an<l  when  no  hope  of  improvement  by  other  means  can  be  entertained.  0.ste- 
ottiuiy  fcir  this  attection  is  now  a  common  operation. 

Acute  rickets  has  been  described,  but  Dr.  Barlow  in  a  very  able  paper  (Mfil.-Chir. 
Tr<in:i.,  vol.  Ixvi..  iSSi^j  has  clearly  .sliown  that  such  cases  are  a  combination  of  scurvy 
and  rickets,  and  that  they  should  be  called  "  infantile  scurvy,"  the  scurvy  being  an  essen- 
tial and  the  rickets  a  variable  element.  He  carefully  analyzes  31  cases.  The  invasion 
of  the  disease  may  be  gradual  or  abrupt,  with  more  or  less  swelling  of  the  legs,  with  pale, 
tense,  shining  skin,  but  irif/iunf  increase  of  heat.  There  may  be  some  redness  of  the 
part  and  s<ime  cedema  extending  up  the  thigh.  The  tenderness  on  ])ressure  is  extreme,  .so 
that  the  child  cries  even  in  anticipation  of  being  touched.  In  severe  cases  the  child 
moans  constantly ;  there  is  also  some  pseudo-paralysis  of  the  affected  limbs.  When  the 
disease  affects  the  thigh,  all  the  local  symptoms  will  be  the  same,  only  higher  in  the 
limb.  Other  bones  may  become  affected  simultaneously  or  by  subsequent  involvement. 
In  most  of  the  cases  there  is  head-sweating,  and  in  some  the  bones  of  the  cranium  appear 
thickened  near  the  sutures.     In  rare  ca.ses  purpuric  symptoms  appear. 

There  is  rarely  very  great  increase  in  bodily  temperature,  and  this  seems  to  turn 
more  upon  the  tension  of  the  affected  bone  and  soft  parts  over  it  than  anything 
else. 

In  almost  all  these  ca.ses  there  is  sponginess  of  the  gums,  and  in  many  stomatitis. 

The  disease  is  a  dangerous  one.  no  less  than  7  out  of  Barlow's  31  having  died. 

The  pnfJio/oi/ic'il  coiiih'fi'on  of  the  affected  bones  is  very  marked.  The  perio.^teum  is 
separated  from  the  bones,  and  the  shafts  of  the  bones  from  the  epiphyses ;  a  layer  of 
uiaroon-colored  blood-clots  surrounds  the  bone.  The  bones  affected  may  die  in  part,  but 
not  wholly,  as  in  inflammatory  affections.  It  was  this  condition  that  induced  Mr.  T. 
.Smith,  who  was  the  first  to  record  a  case  of  this  disea.se  (Fafh.  Trans.,  1876),  to  describe 
it  as  one  of  hemorrhagic  periostitis.  The  periosteum  may  be  thus  separated  from  the 
cranial  or  any  bone. 

There  is  no  reason  to  believe  that  syphilis  has  anything  to  do  with  this  affection. 

The  disease  tends  spontaneously  toward  recovery  under  proper  treatment. 

Treatment. — The  treatment  recommended  by  Barlow  is.  hnnJly^  during  the  acute 
stage,  wet  compresses  and  avoidance  of  movement,  at  a  later  period  careful  shampooing 
and  douches;  internally.^  the  use  of  raw-meat  juice,  fresh  milk,  and  orange-juice  or  of 
some  fresh  raw  vegetable,  and  from  the  first  the  access  of  as  much  free  air  as  is  possible. 

Osteitis  Deformans. 

This  name  has  been  given  by  Sir  James  Paget  to  a  remarkable  disease  which  he  has 
described  in  papers  published  in  vol.  Ix.  of  the  Trans,  of  the  Royal  Medical  tnnl  Chirur- 
gical  Society  (1877)  and  in  vol.  Ixv.  (1882).  I  have  recorded  in  the  Guys  Ilo.tp.  Reports 
for  1877  a  good  example  of  it,  and  have  .seen  three  since. 

It  begins,  writes  Paget,  in  middle  age  or  later,  is  very  slow  in  progress,  may  continue 
for  many  years  without  influence  on  the  general  health,  and  gives  no  other  trouble  than 
that  which  is  due  to  the  changes  of  shape,  size,  and   direction  of  the  diseased  bones. 


974 


DISEASES  OF  THE  BONES. 


Even  when  the  skull  is  hugely  thickened  and  all  its  bones  exceedingly  aiicied  in  struc- 
ture, the  mind  remains  unaffected. 

The  disease  affects  most  frequently  the  long  bones  of  the  lower  extremities,  the  clavi- 

The  bones  enlarge  and  soften,  and  those 
bearing  weight  yield   and  become  un- 


cles, and  the  skull,  and  is  usually  symmetrical 
Fig.  G79. 


naturally  curved   and   misshapen,  suj 
gesting    the    proposed    name,  "  osteitis 
deformans." 

The  spine,  whether  by  yielding  to 
the  weight  of  the  overgrown  skull  or 
by  change  in  its  own  structures,  may 
sink  and  seem  to  shorten,  with  greatly 
increased  dorsal  and  lumbar  curves  ;  the 
pelvis  may  become  wide  and  the  necks 
of  the  femora  become  nearl}^  horizontal. 
But  the  limbs,  however  misshapen,  re- 
main strong  and  fit  to  support  the  trunk. 
(Vif/e  Fig. '679.) 

In  its  earlier  periods,  and  sometimes 
through  all  its  course,  the  disease  is 
attended  with  pains  in  the  affected 
bones — pains  widely  various  in  severity 
and  variously  described  as  rheumatic, 
gouty,  or  neuralgic,  not  especially  noc- 
turnal or  periodical.     It  is  unattended 

Drawing  of  a  Man  suffering  from  Osteitis  Deformans.     (Taken  „-i.i-.     .p„„„,.        \T„     „l,„^„^+^^;c.+i«     «^v^/i; 

from   Author's  case,   G„y%  Jie/,.,   1877.     This  patient   is   now  ^"th     tever.       JNo     characteristic     COndl- 

(May,  1884)  dying.     He  is  blind  and  bloodless,  and  can  hardly  tions  of  Urine  Or  feces  have  been  found 

raise  his  limbs  on  account  of  their  weight.)  .      .,  ...  .    ,     ^        .,^ 

in  it,  nor  is  it  associated  with  any  con- 
stitutional disease,  unless  it  be  cancer.  Three  out  of  the  twelve  cases  recorded  by 
Paget  have  ended  in  connection  with  this  affection. 

The  bones  examined  after  death  show  the  consequences  of  an  inflammation  affecting 
in  the  skull  the  whole  thickness — in  the  long  bones  cliieflythe  compact  structure  of  their 
walls,  and  not  only  the  walls  of  their  shafts,  but  in  a  very  characteristic  manner  those  of 
their  articular  surfaces. 

"  The  changes  of  structure  produced  in  the  earliest  periods  of  the  disease  have  not 
yet  been  observed,  bat  it  may  be  believed  that  they  are  inflammatory,  for  the  softening 
is  associated  with  enlargement,  with  excessive  production  of  imperfectly  developed  struc- 
tures, and  with  increased  blood  supply. 

"  Whether  inflammation  in  any  degree  continues  to  the  last,  or  ■whether,  after  many 
years  of  progress,  any  reparative  changes  ensue,  after  the  manner  of  a  so-called  consecu- 
tive hardening,  is  uncertain." 

The  disease  does  not  apparently  have  any  shortening  influence  on  first  life,  for  in  Sir 
J.  Paget's  case  it  had  existed  for  twenty  years,  and  in  my  own  the  man  is  now  sixty-seven, 
the  symptoms  having  shown  themselves  about  eleven  years.  The  patient  is  now  amauro- 
tic and  so  feeble  that  he  cannot  raise  his  heavy  limbs.  He  is  anaemic,  but  shows  no  other 
signs  of  disease. 

In  May,  1877,  I  saw  a  second  example  of  this  affection  in  the  person  of  a  married 
lady  aet.  54,  who,  although  in  the  enjoyment  of  excellent  health,  was  quite  unable  to  walk 
without  crutches,  on  account  of  the  weight  and  weakness  of  her  legs.  The  disease  had 
been  gradually  coming  on  for  six  years,  and  the  pains  in  the  thighs  had  given  her  great 
trouble.  When  I  saw  her.  she  came  into  my  room  on  crutches  and  sat  down  with  the 
arched  back  so  peculiar  to  this  affection  ;  her  thigh-bones  were  enormously  thickened  and 
bent ;  the  necks  of  the  femora  were  horizontal,  as  proved  by  the  test  line  of  the  ilio- 
femoral triangle  (Fig.  569),  and  the  knees  were  far  apart,  from  the  bowing  of  the  legs. 
The  bones  of  the  upper  extremity  were  also  clearly  enlarged.  I  could  not  make  out  that 
the  cranial  bones  were  involved.  The  lady  informed  me  that  she  was  at  least  an  inch 
shorter  this  year  than  she  was  last ;  the  changes  in  the  necks  of  the  femora  would,  how- 
ever, account  for  this  fact. 

She  had  had  two  sisters  ;  one  died  from  cancer  of  the  breast,  while  the  second  was 
an  imbecile  and  had  died  in  an  asylum. 

This  case  well  supports  the  observations  that  have  been  made. 

Sir  J.   Paget  regards  the   disease  as   inflammatory.      Dr.  Goodhart   brings  forward 


ON  aussiinr  i.wjrnihx  97o 

aiuitlicr  liyiKitlii'sis.  IIo  doi's  iint  think  the  tiTin  "  iiiflaiiiniiitury  "  <iMi  be  coiisidcri'il  as 
piKpi'ilv  tlcscrijitivi-  (if  this  (list-asc,  |iartly  h»'<-ausf  to  jrivc  •  iiiHaiiiiiiatiori  "  ho  wiile  a 
im-aiiinu:  as  wmihl  i'iiil)raci'  a  <r»'iuTal  hy|ifrtni|iliy  <>f  all  the  hutM^s  as  ((lie  of  its  resultM 
wnuhl  be  til  (li'|irivo  tlu'  tiTiii  (if  all  sij^niticaiicf,  anil  also  because  it  is  still  less  a|i|ilieable 
t(i  (ither  diseases  allied  to  the  inie  in  (piestidn. 

I>r.  (Jdddhart  ediisiders  that  hy|ier(istdsis  is  essentially  a  new  frniwth — or.  as  he 
expresses  it.  a  jreneralizcd  lidiie  tunmr — and  adduces  in  suppdrt  (d"  this  view.  1st.  The 
ilinical  histdry  dt'  the  disease  ;  its  cuexistencc  with  dtherwise  jrodd  health  :  the  absence 
id'  pain;  its  intraetabilitv  under  treatun-nt  ;  its  tVeijuenl  assdciatidu  tdward  its  chise  with 
siinie  dther  f'orni  ut'  ni:ilii:naiit  tuiiKtr.  lid.  Its  peculiar  parallelism  with  nidlluscuni  fibro- 
suiu  and  a  fdriu  dt'  elephantiasis,  whiidi  is  a  c(irrcspdiidiii;r  disease  in  the  subcutaneous 
(ir  Hlini-celliilar  cunnective  tissue  td  this  in  bune  cdnnective  tissue.  There  is  certainly  a 
^udd  deal  td  be  said  in  i'av(ir  dt'  this  view.  and.  thdu^h  Sir  James  I'a<:et  does  not  see  his 
way  td  adiiptiiii:  it  as  the  more  jirdbable.  I  am,  (in  a  review  dt"  the  whdle  subject  and 
unl'ettered  by  any  partiality  for  a  theiiry  (if  my  nwn.  inclined  td  think  with  my  cdlleairue. 

No  trciitiiitiit  seems  ti>  have  tlu;  slitrhtest  iiittiicnce  (in  the  progress  ot"  this  attection. 


CHAPTER   XXXIV. 
ON    GUNSHOT    INJUKIES. 


"GuNsiKiT  injuries."'  writes  Professdr  Ldn^iudre,  "are  the  injuries  which  result  from 
the  action  (if  missiles  set  in  mutidn  \ty  a  fdrce  which  is  derived  from  the  i<:;nitidn  of  explo.*'- 
ive  comjiounds.  They  comjireliend  every  kind  and  degree  of  liurt  which  is  capable  of 
tieing  produced  on  the  human  frame  by  the  mechanical  im|iulse  of  obtuse  bodies."'  He 
informs  us.  moreover,  that  in  every  hundred  casualties  there  are  twenty  killed  to  eighty 
wounded,  and  that  of  the  wounded  one-third  of  the  cases  are  .severe  and  two-thirds 
.-light. 

The  wounds  vary  much  in  their  character  and  nature,  one  caused  by  a  rifle  ball  differ- 
ing from  that  by  a  cannon  ball  or  shell ;  and  the  direct  effect  of  a  mis.sile  upon  a  part 
ditfej-s  from  that  produced  ImUrectly  by  the  scattering  of  stones  or  any  other  hard  sub- 
stance caused  by  cannon  shot  or  shell.  Guns/iof  contuduns  of  tissues,  although  apparently 
trivial,  are,  as  in  civil  life,  often  associated  with  severe  deep-.seated  injuries,  and  sujierticial 
wounds  apparently  unimportant  are  often  attended  with  or  followed  by  serious  accidents. 
Gunshot  Wounds  are  always  of  the  coiituscil  class;  those  of  civil  life,  however  severe,  are 
rarely,  if  ever,  attended  with  that  complete  attrition  and  displacement,  and  even  total 
removal  of  substance,  which  are  so  con.stantly  characteristic  of  wounds  produced  by  gun- 
shots, particularly  in  those  of  recent  times.  Gunshot  wounds,  moreover,  are  also  prone 
to  be  complicated  by  the  introduction  into  the  wound  of  some  foreign  bddy,  such  as  some 
portion  of  the  soldier's  dress  pressed  into  the  wound,  or  some  part  of  the  wadding,  shot, 
or  shell  itself. 

It  should  also  be  known  that  "  substances  of  very  low  degrees  of  density,  such  as 
plugs  of  tallow,  light  wood,  cork,  wads  of  paper,  and  others,  will  serve  to  inflict  penetrat- 
ing wounds  in  the  softer  .structures  of  the  body  having  all  the  characters  of  wounds 
inflicted  by  denser  projectiles  if  sufficient  velocity  be  impressed  upon  them.  But  the 
necessary  force  to  accomplish  this  result  can  only  be  executed  within  very  limited  di.«- 
tances"  (Longmore). 

"The  external  distinguishing  signs  of  penetrating  gunshot  wounds  are  generally 
manifest  enough.  The  general  dimensions  of  the  opening  made  by  the  shot  sufficiently 
show  whether  it  has  been  made  by  a  small-arm  bullet,  a  large  grapeshot.  or  a  still  larger 
gunshot;  its  shape,  whether  it  has  been  made  by  a  round  projectile,  by  a  fragment  of  a 
shell,  or  an  irregular  splinter  of  some  secondary  missile  ;  while  the  aspect  and  condition 
of  the  lips  of  the  wound  and  of  the  structures  immediately  surrounding  it  sufliciently 
mark  it  as  not  being  one  inflicted  by  a  stabbing  or  cutting  instrument." 

Gunshot  wounds  differ  considerably  in  appearance,  these  differences  depending  upon 
the  forms  of  the  missiles  causing  the  injury,  and  their  speed,  as  well  as  the  part  of  the 
body  struck  and  the  position  of  the  patient  relative  to  the  projectile  at  the  time  of  injury. 
When  part  of  the  body  is  carried  away  by  a  gunshot  a.t/itfl  speed,  the  surface  of  separa- 


976 


ON  GUNSHOT  INJURIES. 


tion  will  present  a  level  yet  contused  and  almost  pulpified  aspect ;  when  the  speed  is  less 
7-ajnd,  the  soft  parts  where  the  separation  has  taken  place  will  be  moi'e  lacerated  and  the 
bone  comminuted  ;  and  when  the  speed  in  sjient  or  the  direction  oblique,  either  the  injured 
parts  will  be  crushed  more  or  less  deeply,  or,  with  little  or  no  evidence  of  external  injury, 
the  deeper  parts  may  be  irreparably  disorganized. 

Again,  bullets,  "when  at  full  speed,  perforate  or  penetrate ;  but  when  at  less- 
ened speed,  they  cru.sli  and  lacerate.  When  a  gun  is  discharged  near  the  body,  the  parts 
around  the  wound  of  entrance  will  be  blackened  and  burned,  while  the  wound  of  entrance 
appears  as  if  punched  out.  When  the  discharge  of  the  musket  takes  place  a  feu-  inchfs 
from  the  hody,  the  injured  tissues  will  be  more  or  less  scorched,  blackened,  and  studded 
with  grains  of  unexploded  powder,  and  the  wound  of  entrance  large,  ragged,  and  exca- 
vated. 

Wounds  from  bullets  not  at  full  speed,  and  fired  at  a  distance  of  two  or 
three  hundred  yards,  will  present  an  opening  the  size  of  the  projectile,  or  possibly  smaller, 
circular  in  shape,  with  serrated  (inverted),  undermined,  puckered,  and  flabby  edges  ;  at 
times,  however,  a  flap  of  skin  is  found  at  the  opening. 

The  margin  of  the  opening  will  appear  as  if  contused,  the  evidences  of  bruising  fad- 
ing away  into  the  surrounding  tissues. 

When  the  i^pced  of  the  hidlet  is  mxch  diminished,  no  skin  may  be  carried  away,  the 
diminished  speed  of  the  missile  simply  sti'etching  and  tearing  asunder  the  tissues  to  allow 
of  entrance. 

When  wadding  or  other  foreign  substance  has  been  carried  into  the  wound  of  entrance, 
this  will  of  necessity  be  more  lacerated  and  appear  larger  than  it  would  otherwise  be  ; 
and  the  same  conditions  may  be  found  to  exist  when  a  ball  enters  the  body  where  bone  is 
only  covered  with  thin  integument. 

In  modern  warfare,  where  the  rifle  bullets  are  of  a  cylindro-conoidal  form  (Fig.  680), 
soft  parts  are  more  readily  penetrated  and  bones  more  generally  split  or  splintered  than 


Fig.  680. 


English  and  Foreign  Bullets  now  ICnipluyed.     (Natural  Siz 


was  found  of  old  from  the  impact  of  round  balls.  In  the  late  Franco-German  war  these 
points  were  generally  observed,  and,  although  the  Prussian  and  Bavarian  balls  were  said 
to  be  larger  than  those  of  the  French,  the  wounds  produced  by  all  were  very  much  alike  ; 
if  anything,  however,  the  wound  from  the  needle-gun  produced  the  wider  tract  and  larger 
opening. 

Indeed,  in  the  "  seton  wounds,"  or  wounds  penetrating  the  soft  parts  alone,  of  all 
these  balls  it  was  often  difficult  to  make  out  the  wound  of  entrance  from  the  wound  of 
exit.  When  they  traversed  the  soft  parts  alone,  they  often  ran  so  cleanly  through  them 
that  only  slight  suppuration  followed  and  repair  was  rapid,  these  modern  balls  causing 
less  severe  lesions  of  the  soft  parts  than  the  old  spherical  balls.  Billroth  asserts  that 
wounds  with  split-like  exits  were  remarkable  for  the  amount  of  suppuration  that  followed. 
When  bones  were  struck,  no  matter  what  the  form  of  ball,  the  injury  was  alike:  there 
was  comminution,  vertical  splintering,  and  at  times  almost  pulverization.  Indeed,  in  civil 
life  there  is  nothing  like  the  splintering  and  comminution  of  bones  seen  in  wounds  from 
rifle  bullets. 

The  amount  of  alteration  in  form  which  the  projectiles  assume  after  striking  a  bone 


uy  (n'ysjiuT  j.\.ji'nij:s.  977 

is  verv   rcniarkiildt',  hoiiu'   ItciiiL^  cimiplctcly   llultciicil.  nthcrs   str:iiiL'<'ly   cMntortccl.  while 
luuny  are  sjilit. 

i)r.  Ktifstt-r  (if  the  Au.u'u.sta  Hospital.  Berlin,  however,  has  ]trove<l  l)y  exi)eriiiieiit 
(1S74)  that  the  ainoiiiit  of  injury  the  hones  and  soft  parts  sustain  in  a  ^'unshot  wound 
depends  niueh  upon  the  softness  or  hardness  of  tin-  Itullet,  a  hard  <»nc  ^'oiiiir  throu":!!  a 
part  and  leaviiij;  a  "  seton  wound."  when-  a  soft  one  would  prodiiei-  fri;.ditful  dfstru(ti«Mi 
of  tissue.  He  explains  this  fact  hy  the  lead  of  the  softer  ))ull('ts  heeoiniii^'  heated  hy  col- 
lision with  hone  and  luoken  up  (not  melted;.  The  Martini-Henry  bullet  is  a  hard  one 
and  made  of  twelve  parts  hard  lead  and  one  tin.  The  bullet  of  the  (iras  rifle,  the  weajton 
of  the  French  army,  is  likewise  liard.  The  C'ha.s.sepot  and  the  others  are  all  made  of  soft 
lead,  and  conse«|ueiitly  break  up  and  flatten  out  aijainst  bone,  thereby  causin<<  large  aper- 
tures of  exit  and  great  laceration  of  tissue. 

When  the  head  of  a  b(»ne  is  struck,  it  is  probaldy  coniniinutt'd.  When  bones  are  not 
bn»ken.  but  only  bruised,  acute  periostitis  and  endoslitis  are  very  common,  the  concussion 
of  the  bone  being  generally  so  severe  us  to  excite  acute  action. 

With  the  rifle  ball  the  course  is  more  frequently  direct  than  with  tliat  from  the  old 
smooth-lmrcd  musket.  Tortuous  courses  are  even  now  met  with,  but  less  frer|ucntly.  the 
weight  of  the  ball  and  the  extreme  velocity  with  which  it  flitjs  producing  a  more  direct 
route.  It  penetrates  the  soft  tissues  in  a  direct  line,  and  when  it  strikes  bone  either  runs 
through  or  splinters  it,  entering  it  like  a  wedge.  It  will  often  ap])ear.  writes  hongmore, 
that  tlie  track  of  a  bullet,  even  at  full  speed,  is  widely  removed  from  a  straight  line.  But 
it  usually  is  not  diflicult  to  reconcile  the  apparent  irregularity  in  the  course  the  projectile 
has  taken  if  the  many  varied  positions  in  which  the  body  and  its  parts  are  liable  to  be 
placed  are  called  to  mind,  and  if,  when  making  the  examination,  the  surgeon  takes  care 
to  place  the  patient  in  a  similar  position  to  that  which  he  was  in  when  struck. 

The  injury  imparted  to  soft  parts  by  what  are  called  spent  balls  or  r ('a x.fict  ahots  is  the 
most  destructive,  and  large  projectiles  roNin;/  ovn-  the  surface  of  a  part  or  moving  at  low 
rates  of  speed  po.ssess  a  force  which  will  cru.sh  all  parts,  even  whole  extremities,  with 
which  they  happen  to  come  in  contact,  and  rupture  internal  organs  in  a  way  peculiar  to 
themselves. 

A  conical  rifle  ball,  when  partially  spent,  may  lodge  in  a  part,  either  in  a  bone  or  .some 
soft  tissue.  It  may  take  some  unusual  path  and  lodge  where  the  surgeon  cannot  find  it 
or  cannot  remove  it,  and  under  these  circumstances  it  may  rest,  become  encysted,  and 
give  but  little  trouble.  But,  on  the  other  liand,  it  may  set  up  a  chronic  inflammatory 
action  in  the  part  and  give  rise  to  local  suppuration.  Bullets,  however,  rarely  lodge  in 
the  soft  parts  without  giving  rise  to  suppuration,  although  in  bones  they  may  do  so. 
Such  ca.ses  .should  not,  however,  induce  the  surgeon  to  leave  them  alone  when  they  can 
be  removed ;  they  should  always  be  extracted  if  possible,  unless  they  have  penetrated 
any  of  the  great  cavities  of  the  body.  Billroth  speaks  very  strongly  on  this  point.  In 
all  blind  tracks  in  the  extremities  the  finger  should  be  passed  into  the  wound  and  the 
foreign  body  looked  for,  the  external  wound  being  enlarged  when  needed  for  this  purpose  ; 
and  in  nun-pciiclratiini  wounds  of  the  head,  chest,  abdf)men.  and  pelvis  the  same  practice 
may  be  observed.  The  removal  of  the  ball  as  the  cause  of  irritation  has  not  only  a  bene- 
ficial influence  on  the  body  of  the  patient,  but  it  has  an  e(|ually  beneficial  influence  upon 
the  mind  ;  for  as  long  as  the  ball  remains  lost  in  the  tissues  the  soldier  naturally  regards 
it  as  a  serious  impediment  to  his  recovery,  and  there  is  no  eftoct  e(jual  to  that  caused  by 
its  removal.  Billroth  has  found  much  assistance  from  Nclaton's  sound  in  doubtful  cases, 
but,  as  a  rule,  he  says,  projectiles  that  cannot  be  reached  by  the  fingers  can  rarely  be 
extracted,  the  bullet-forceps,  even  the  American,  being  of  small  value. 

When  a  part  of  the  body  is  carried  away  by  a  cnimou  hall  at  full  sppecf,  the  stump  will 
present  a  level  surface  of  contused  and  almost  pulpified  tissues.  The  muscles  and  integu- 
ment will  not  have  retracted;  the  extremity  of  the  broken  bone  will  probably  stand  out, 
small  fragments  of  bone  being  scattered  over  the  surface  of  the  wound. 

When  the  same  result  follows  the  contact  of  (t  cainii»)  haU  the  force  of  ichich  is  par- 
tially e.rprtithd^  there  will  l)e  evidence  of  more  dragging  and  laceration  of  the  soft  parts, 
more  irregularity  of  the  wound,  more  hanging  of  the  muscles,  greater  comminution  of  the 
bone,  and  greater  injury  to  the  soft  ])arts  above  the  .seat  of  separation,  and  probably 
greater  splintering  of  the  bone  upward. 

When  the  force  of  the  cannon  hall  is  still I'ss  or  spent,  there  may  be  no  separation  of 

impaired   parts,  but  a  general   contusion,  cru.shing.  or  disorganization.     In   some  cases, 

where  the  force  is  obli(jue,  there  may  be  no  external  evidence  of  injury,  this  want  of 

external  evidence  being  too  coinuiuidv  associated  with  broken  bones  or  severe  internal 

fi2 


978  ON  GUNSHOT  INJUETES. 

laceration  of  viscera  or  other  soft  parts.  Such  cases  were  formerly  set  down  as  due  to 
"wind  contusions  "  or  the  "brush  of  a  shot,"  but  are  now  believed  to  be  caused  by  con- 
tusions of  nearly-spent  cannon  balls  or  glancing  blows  from  some  projectile. 

Shell  wounds,  as  a  rule,  produce  severe  laceration  of  soft  parts  ;  and  though  they  may 
penetrate  tissues,  yet  they  very  rarely  pass  through  them. 

The  ^founds  produced  hy  rifle  haJh  at  full  speed  at  the  point  of  entrance  are  often  small, 
circular,  clean  cut,  and  with  inverted  edges,  but  at  the  point  of  exit  large,  irregular,  and 
with  everted  edges. 

As  the  distance  from  the  weapon  increases  and  the  velocity  of  the  ball  diminishes,  so 
the  wound  of  entrance  becomes  less  circular  and  regular,  larger  and  more  contused,  the 
wound  "  sometimes  consisting  of  three  triangular  flaps,  which  on  being  lifted  up  can  be 
made  to  meet  at  their  apices  in  the  centre  of  the  opening  "  (Longmore). 

When  the  ball  has  passed  through  the  part,  the  wound  of  exit  will  probably  be  larger 
than  the  projectile,  more  irregular,  torn,  and  everted  than  that  of  entrance,  the  subcu- 
taneous fat  often  projecting.  At  times,  however,  with  the  cylindro-conoidal  bullet  dis- 
charged at  full  speed,  it  is  difficult  to  distinguish  by  its  appearance  the  wound  of  entrance 
from  that  of  exit.  In  the  patient's  clothing,  when  the  wound  of  entrance  is  punctured, 
that  of  exit  will  be  lacerated. 

The  j)rn'«  caused  by  a  gunshot  wound  depends  upon  the  parts  that  are  injured.  In  a 
general  way  it  is  not  severe,  and  when  so  is  evanescent.  Writers  tell  us  that  it  is  often 
described  as  being  like  the  sudden  stroke  of  a  cane  or  the  shock  of  a  heavy  blow.  Some- 
times soldiers  are  unaware  of  their  wounds.  When  the  trunks  of  nerves  are  pushed  aside 
and  injured,  intense  pain  may  be  felt,  but  not  locally.  Longmore  relates  the  case  of  an 
officer  who  from  his  sensations  thought  his  arm  was  broken,  but  on  examination  no  such 
injury  existed  ;  a  ball  had  passed  from  right  to  left  through  his  neck,  which  probably 
injured  some  of  the  cervical  or  brachial  plexus  of  nerves,  thereby  giving  rise  to  his  error. 
More  pain  is  occasionally  felt  at  the  wound  of  exit  of  a  bullet  than  at  that  of  entrance. 

Shock. — "  When  a  large  bone  is  suddenly  shattered,  a  cavity  penetrated,  an  import- 
ant viscus  wounded,  or  a  limb  carried  away  by  a  round  shot,  the  most  prominent  symptom 
is  the  general  perturbation  and  alarm  which  in  most  cases  instantaneously  supervenes  on 
the  injury.  This  is  generally  described  as  the  '  shock  '  of  the  gunshot  wound.  The  patient 
trembles  and  totters,  is  pale,  complains  of  being  faint,  perhaps  vomits.  His  features 
express  extreme  anxiety  and  distress.  This  emotion  is  in  great  measure  instinctive  and 
seems  to  be  sympathy  of  the  whole  frame  with  the  part  subjected  to  serious  injury 
expressed  through  the  nervous  system.  This  shock  is  more  or  less  persistent  according 
to  circumstances.  Examples  seem  to  show  that  it  may  occasionally  be  overpowered  alto- 
gether, even  in  most  severe  injuries,  by  moral  and  nervous  action  of  another  kind,  by  a 
state  of  mental  tension  ;  but  this  can  rarely  happen  when  the  injury  is  a  vital  one.  Panic 
may  lead  to  similar  symptoms  of  shock,  although  the  wound  is  of  a  less  serious  nature. 
A  soldier,  having  his  thoughts  carried  away  from  himself,  his  whole  frame  stimulated  to 
the  utmost  height  of  excitement  by  the  continued  scenes  and  circumstances  of  the  fight, 
when  he  feels  himself  wounded  is  suddenly  recalled  to  a  sense  of  personal  danger ;  and 
if  he  be  .seized  with  doubt  whether  his  wound  is  mortal,  depression  as  low  as  his  excite- 
ment was  high  may  immediately  follow.  This  depression  will  vary  in  degree  according 
to  individual  character  and  intelligence,  state  of  health,  and  other  per.sonal  peculiarities; 
for  while,  on  the  one  hand,  in  every  action  numerous  examples  occur  of  men  walking  to 
the  field  hospital  for  as-si.stance  almost  unsupported  after  the  loss  of  an  arm  or  other  such 
severe  injury,  on  the  other  men  whose  wounds  are  slight  in  proportion  are  cjuite  over- 
come and  require  to  be  carried. 

"As  a  general  rule,  however,  the  graver  the  injury,  the  greater  and  more  persistent  is 
the  amount  of  '  shock.'  A  rifle  bullet  which  splits  up  a  long  bone  into  many  longitudinal 
fragments  inflicts  a  very  much  more  serious  injury  than  the  ordinary  fracture  effected  by 
the  ball  from  a  smooth-bore  musket,  and  the  constitutional  shock  bears  like  proportion. 
When  a  portion  of  one  or  both  of  the  lower  extremities  is  carried  away  by  a  cannon  bnll, 
the  higher  toward  the  trunk  the  injury  is  inflicted,  the  greater  the  shock,  independent  of 
the  loss  of  blood.  When  a  ball  has  entered  the  body,  though  its  course  be  not  otherwise 
indicated,  the  continuance  of  shock  is  a  sufficient  evidence  that  some  organ  essential  to 
life  has  been  implicated  in  the  injury  '"  (Longmore). 

Hemorrhage. — The  amount  of  hemorrhage  attending  a  gunshot  wound  varies 
according  to  the  size  and  situation  of  the  wounded  vessels.  When  large  vessels  are 
involved,  death  is  rapid,  and  such  cases  do  not  come  under  the  notice  of  the  army 
surseon. 


o.v  I!  r  SSI  Kit  is.ni:ii:s.  979 

Tn  the  (•a«i('s  that  coiiir  into  tlie  Miri^'cun's  liaiids  in  a  jrcncral  \vay  tliere  has  hecn  an 
attack  iif  li('Miitrrlia;:<'  dirrctly  after  the  injury,  l>ut  little  nmre  ;  po^^ilily  some  oozin;.'.  but 
rarely  niueli,  may  exist. 

When  a  limb  is  shot  ofi",  there  is  rarely  more  lilecdin;;  than  when  it  has  betMi  torn  off 
by  machinery,  as  seen  in  civil  life.  liar^re  vessels,  wlieii  torn  or  twisted,  seldom  bleed. 
In  these  cases  the  jduj.'.ixe<l  pulsatinir  extremity  of  the  lacerated  artery  will  <:enerally  bo 
fouml  projcctinjr  from  the  wound. 

In  the  wounds  caused  by  rijh  hitlls  vessels  escape  in  a  marvellous  manner,  the  ^'reat 
resiliency  (d"  larire  vessels  and  the  freedom  with  which  they  slip  away  under  pressure 
from  their  loose  cellular  connections  allowint;  a  ball  to  jiass  alonj;  or  across  their  course 
without  wouiidinjr  them.  At  times  the  ves.sel  may  be  .«(»  contused  as  to  become  obstructed 
and  obliterated.  (  IVr/r  I*rep.  at  N'etley.)  Nevertheless,  a  rifle  ball  occasionally  may 
directly  divide  a  larjre  artery  and  cause  instantaneous  death.  In  the  American  war, 
amon<;  tin-  cases  of  primary  ;;unshot  lesions  of  the  arteries  that  came  under  treatment, 
it  was  found  that  in  most  r»nly  a  ])ortion  of  the  calibre  of  the  vessel  had  been  carried 
away,  and  that  ret ractimi  had  thu<  been  jirevented. 

Secondary  hemorrhage  i^  common  in  <run.shot  wounds,  and  is  due,  probably,  a.s 
a  rule,  to  tin-  reopeninir  of  a  wound  in  a  vessel  temporarily  closed,  or  to  the  .sloughing  of 
some  part  of  its  walls  that  had  been  injured.  In  the  former  case  the  new  ti.s.sue  that  had 
stopped  for  a  time  the  flow  of  blood  gives  way  under  some  sudden  movement  or  local 
mechanical  force,  such  as  some  foreign  body  in  the  wound,  or  breaks  down  during  the 
suppurative  or  sloughing  process  ;  in  the  latter^  the  injured  coats  of  the  artery  are  ca.'^t 
ofl^,  having  been  destroyed  by  some  ccmtusion  or  other  violence.  In  either  case  the  throm- 
bus or  clot  in  the  vessel  is  not  sufficiently  well  formed  or  organized  to  resist  the  force  of 
the  blood  current  from  behind.  When  such  a  clot  organizes,  there  will,  of  course,  be  no 
bleeding.  ■■  The  great  fre(|uency  of  secondary  hemorrhage  has  for  its  chief  causes  the 
absence  or  faultiness  of  sanitary  conditions  and  the  debility  of  the  patient  due  to  priva- 
tion of  nourishing  food  and  to  exposure.  The  means  calculated  to  remove  or  anticipate 
such  evils  will,  if  applied,  be  of  more  value  than  is  the  ligature  in  coping  with  secondary 
bleeding  after  gunshot  iniur\  '"  (MacCormac). 

With  respect  to  the  treatment  of  secondary  hemorrhage  after  gunshot  wounds,  it  is 
in  principle  similar  to  that  which  the  civil  surgeon  follows.  Styptics,  where  large  vessels 
are  concerned,  are  worse  than  useless.  Pressure  is  applicable  only  for  temporary,  not  for 
curative,  purposes,  and  thus  the  surgeon  is  driven  to  cut  down  upon  the  wounded  artery, 
to  tie  or  twist  both  ends,  or  to  apply  the  .same  practice  to  the  vessel  in  its  continuity 
leading  to  the  seat  of  bleeding -when  the  former  operation  is  too  difficult  or  dangerous. 
Billroth  advocates  dealing  with  the  main  trunk  of  the  bleeding  vessel  at  an  early  period 
of  the  hemorrhage,  and  not  wasting  time  by  delav'.  He  says  that  out  of  23  cases  in 
which  he  applied  a  ligature  to  large  arteries  for  hemorrhage,  death  took  place  in  7  from 
bleeding  on  the  .separation  of  the  ligature,  when  no  clot  was  found  in  the  ves.sel ;  in 
12  from  hemorrhage  and  p3aMnia,  of  which  no  examination  was  made;  and  7  alone 
recovered. 

In  the  late  continental  war  Stromeyer  and  MacCormac  maintain  that  the  result  of 
such  operations  was  uniformly  unfavorable.  Out  of  12  cases  which  Stromeyer  saw,  only 
2  recovered.  '•  I  think,"  he  says.  "  we  must  decide  to  amputate  oftener  in  cases  of  sec- 
ondary hemorrhage." 

Possibly  a  better  result  might  have  followed  torsion  of  the  arteries,  for  after  such  a 
practice,  when  bleeding  has  been  arrested,  there  is  nothing  to  set  up  fresh  mi.schief  in  the 
artery,  no  foreign  body  like  the  ordinary  ligature  to  excite  anj'  ulcerative  or  disorganiz- 
ing process  through  which  hemorrhage  may  take  place,  the  thrombus  that  forms  in  the 
vessels  after  torsion  being  allowed  to  go  on  undisturbed,  to  organize  and  become  incor- 
porated with  the  incurved  middle  arterial  coat  into  one  firm  organized  fibrinous  mass. 
The  catgut  ligature,  however,  may  possibly  be  of  use  in  these  ca.ses. 

Tre.\tment. — In  the  front  of  the  battlefield  little  more  can  be  done  in  the  way  of 
treatment  of  gunshot  wounds  than  the  application  of  the  ''first  field  dressing"  some 
pressure  or  tourniquet  to  arrest  hemorrhage  when  the  vessel  cannot  be  at  once  secured, 
some  splint  or  other  available  support  to  prevent  extra  injury  being  inflicted  by  move- 
ment to  the  field  hospital.  The  wounds  of  the  soldier  must  not  be  manipulated  by  the 
surgeons  in  the  front.  No  examination  of  the  wound  is  to  be  made  by  probe  or  finger  in 
the  battlefield  or  dressing  station.  ''  The  one  line  of  treatment  to  be  adopted  by  the  sur- 
geons in  the  front."  writes  Professor  C.  Reyher,  "  is  to  occlude  the  wound  provisionally, 
to  lay  the  wounded  part  in  a  suitable  position  in  the  litter,  and  to  render  it  provisionally 


980  ON  GUNSHOT  INJURIES. 

immovable  ;"  for  tlie  surgeon  is  to  remember  tliat  a  proper  and  thorough  examination  of 
the  wound  will  take  place  at  the  field  hospital. 

The  first  field  dressing  was  introduced  during  the  Crimean  war  in  1853  by  Professor 
Longmore  for  the  first  time  in  any  service ;  '•  and  since  that  period,"  writes  Longniore, 
"  it  has  been  copied  by  every  civilized  power  in  the  world — the  principle  of  every  man 
carrying  on  his  person  the  means  of  dressing  his  wound  if  he  should  eventually  meet 
with  that  calamity."' 

What  the  first  field  dressing  should  be  is  not  yet  determined,  but  to  carry  out  the 
practice  efficiently  it  is  necessary  that  the  bearer  companies  should  be  well  organized,  and 
the  men  of  which  they  should  be  composed  must  be  expert  dressers.  The  appliances  at 
hand  for  their  use  must  also  be  effective,  simple,  portable,  and  last,  but  not  least,  cheap. 
That  they  should  be  of  an  antiseptic  nature  all  surgeons  will  now  admit ;  that  they  should 
be  absorbent  is  equally  essential.  Iodoform,  absorbent  antiseptic  cotton,  and  gauze  and 
a  bandage  are  probably  the  three  best  essentials ;  and  if  a  piece  of  protective  or  water- 
proof material  is  added  to  the  list,  so  much  the  better.  Before  examining  a  wound  the 
clothes  that  cover  it  should  be  carefully  looked  to.  and  more  particularly  the  garment 
next  the  skin  ;  for  "  it  occasionally  happens  that  a  bullet  will  have  sufficient  force  to  pene- 
trate the  body  to  a  limited  distance,  at  the  same  time  carrying  a  portion  of  the  wounded 
man's  shirt  before  it,  while,  owing  to  the  yielding  nature  of  the  material,  it  fails  to  tear 
a  piece  out  of  it.  The  bullet  will  then  lie.  as  it  were,  at  the  bottom  of  a  pouch  of  the 
shirt  like  the  finger  in  a  glove ;  and  when  the  shirt  is  taken  out.  the  bullet  will  be  brought 
awav  with  it.'"  Longmore,  in  his  recent  work  on  gunshot  injuries,  relates  several  instances 
of  the  kind. 

At  the  field  hospital  the  wound  should  be  thoroughly  and  carefully  examined,  and  to 
€ff"ect  this  the  patient  should  be  placed,  when  practicable,  as  near  as  possible  in  the  posi- 
tion he  occupied  when  he  received  it.  All  foreign  bodies  must  be  taken  away  ;  bleed- 
ing vessels  ought  to  be  ligatured  or  twisted ;  and  when  necessary  the  wound  should  be 
enlarged  for  the  purpose.  No  makeshift  of  pressure  or  other  temporizing  means  should 
be  employed.  When  great  collapse  or  "  shock  "  exists,  some  gentle  stimulant  may  be 
given.  The  true  condition  of  parts  is  to  be  made  out  at  once  and  the  plan  of  treatment 
laid  down,  soft  parts  being  adjusted,  operative  interference  decided  upon  when  necessary, 
and  right  appliances  employed.  To  clean  the  wound  some  antiseptic  lotion  should  be 
used.  Iodine  lotion  made  up  to  strength  of  a  dark  sherry  color  is  the  most  available  and 
as  good  as  any.  and  in  this  I  have  the  support  of  Professor  Lister ;  but  carbolic  or  sal- 
icylic acid  may  be  employed.  The  spray  in  military,  if  not  in  civil,  surgery  may  fairly 
be  said  to  have  been  set  aside  by  common  consent.  Brun.  A'olkmann.  and  Billroth 
amongst  German  surgeons  have  all  abandoned  it,  and  Sir  J.  Lister  has  said.  "  I  do  not 
desire  that  the  spray  should  be  used  in  military  practice  :  /  heVuvf  essentiidhj  the  same 
results  can  he  got  icithout  it.''  So  now  all  surgeons  are  on  the  same  platform  as  to  prin- 
ciples, and  diff"er  only  in  points  of  detail. 

By  far  the  best  instrument  with  which  to  explore  a  wound  is  the  finger,  and  for  this 
purpose  the  external  opening  through  the  fascia  may  always  be  enlarged.  '•  Probes 
should  seldom  or  never  be  used ;  the  finger  is  by  far  the  best  instrument  if  the  wound 
will  admit  it"  (John  Hunter,  MS.  lect.,  1787).  "No  artificial  instrument  can  give  the 
same  amount  of  information  or  afford  information  so  precise  with  regard  to  the  lodgment 
of  foreign  bodies  and  their  nature  as  the  surgeon's  finger  can  give.  The  surgeon  should 
not  withdraw  the  finger  until  the  course  the  projectile  has  taken,  the  injury  it  has  done, 
the  complications  of  the  wound,  such  as  the  presence  of  foreign  bodies,  and  in  such  a 
case  their  kind  and  situation,  have  been  decided  by  him:  the  exploration  will  then  be 
completed  by  one  operation,  and  a  second  insertion  of  the  finger  for  the  purpose,  which 
is  always  irritating  to  a  patient,  will  be  avoided.  The  knowledge  gained,  moreover,  will 
be  definite  and  of  special  utility  in  determining  the  proceedings  to  be  afterward  adopted. 
The  exploration  is  often  as.sisted  by  pressing  the  soft  parts,  especially  if  the  wound  be  in 
one  of  the  extremities,  from  an  opposite  direction  toward  the  finger  end."  Sometimes, 
when  a  lodged  ball  cannot  otherwise  be  discovered,  it  may  be  found  by  passing  the  flat 
palm  of  the  hand  down  the  limb.  "  Sometimes,"  writes  Longmore,  '•  it  may  be  detected 
simply  by  relaxing  the  muscular  tissues,  so  as  to  give  a  loose  and  pendulous  condition  to 
the  parts  concerned,  and  then  lightly  tossing  up  the  flesh  at  diff"erent  points  from  below 
with  the  tips  of  the  fingers.  When  the  finger  passes  through  an  opening  in  fascia  or  a 
deep  aponeurosis,  the  track  will  feel  constricted  ;  when  through  muscles  and  connective, 
expanded. 

When   sufficient  information   cannot  be  acquired  through  the  finger,  either  from   the 


ov  r,r.v,s7/oy  i.\.n-nn:s. 


981 


length  of  tin-  wouinl  or  iVoiii  its  turtiidsitics,  j»n»l)cs  must  he  used.  NV'laton'.s  (Fig.  681). 
with  a  small  liall  of  |Mireflaiii  at  the  cud,  is  frctinl,  and  .so  also  is  Sayre's  suak(i-joiuted 
probe  with  a  like  cud.      Louguiure   pnl'crs  a  loug  silver  probe  which  can  be  bent   to  any 


^ntfi^rira 


!•  i(..  C.sl. 

(^'Trffrsllallit  f^xtmrlar. 


Lccomle's  Styli't-l'iiict':  '/,  (  iiniila  iii.iviiiir  cnir  '/,  <  Nil  >\v\  I  rml  with  closed  curettt's  at  end,  (ixe<l  in  h:iii<llc  r,  the  glid- 
inH  of  tlie  Limiilii  lU'teriniiiiiiK'  tlie  oiK'iiing  <pr  ilo.>.ii^  of  the  curettes;  </,  curettes  open,  (.'nispini;  hullet. 

angle,  but  speaks  highly  of  Hr.  Lecon)te's  stylet-pince.  It  responds  as  an  indicator  with 
even  more  distinctness  than  the  Xelaton  probe  in  all  cases  in  which  the  test  would  be  of 
service,  while  it  answers  for  a  variety  of  other  ease.s  in  which  Xelatons  jirobe  w<mld  give 
no  indication  at  all.  By  it  .small  particles  of  the  suVj.stance  imbedded  in  the  tissues  can 
be  extracted  for  examination,  and  many  foreign  substances  altogether  removed. 

In  gunshot  fractures  of  the  .shafts  of  bones  which  are  to  be  treated  conservatively 
Stromeyer  advises  that  no  probing  ought  to  be  performed,  and  in  doubtful  or  in  opera- 
tion cases  it  ought  only  to  be  done  just  before  the  operation  or  under  chloroform. 

Electric  indicators  have  been  employed,  and  some  are  most  ingenious  and  possibly 
valuable,  but  they  are  not  portable.  The  appliance  of  Mr.  de  Wilde,  in  which  contact 
with  the  metal  of  a  ball  is  notified  by  the  sound  of  a  bell,  is  particularly  taking,  and  a 
very  useful  apparatus  has  also  been  made  by  Messrs.  Krohne  and  Sesemann.  Professor 
Longmore  speaks  highly  of  both,  but  prefers  the  latter.  It  is  designed  to  ascertain  with 
absolute  certainty  if  a  substance  lodged  in  the  body  and  admitting  of  being  touched  with 
the  probe  or  grasped  with  the  forceps  is  a  bullet,  a  fragment  of  a  projectile,  or  other 
metallic  sub.stancc.  The  probe  is  elastic,  and  follows  the  track  of  any  projectile  more 
readily  than  a  stiff  probe.  In  it  are  concealed  two  sharp  needles,  which  when  a  hard 
body  is  felt  are  pu.shed  forward  one  after  the  other.  This  is  done  by  pressing  the  small 
buttons  on  the  handles  toward  the  probe.  As  soon  as  the  two  points  touch  the  foreign 
substance,  if  it  be  metal,  the  electric  current  passes  through  the  instrument — a  fact  imme- 
diately indicated  by  the  hand  on  the  dial.  The  hand  moves  actively  toward  either  the 
right  or  the  left  side.  The  forceps  possess  this  principal  advantage — that  they  can  be 
also  used  as  a  probe,  thereby  dispensing  in  many  cases  with  the  use  of  the  elastic  probe 
altogether.  The  extremities  are  furnished  with  Assalini's  points,  with  which  particles 
of  clothing  can  be  removed  if  such  should  l»e  before  the  projectile.  If  a  foreign  body  is 
touched  with  the  forceps,  it  should  be  gently  grasped  between  both  blades.  If  it  be  a 
bullet  or  any  piece  of  metallic  projectile,  the  electric  current  passes  through  it.  and  the 
hand  on  the  dial  moves  again  actively,  as  described  above.  It  is.  of  course,  necessary  to 
fix  the  connecting  wires  of  the  instrument  into  the  brass  heads  on  each  side  of  the  dial. 
In  the  drawer  below  the  dial  there  is  a  small  battery  charged  with  sulphate  of  mercury. 
If  the  charge  has  become  too  dry  and  weak,  it  should  be  moistened  with  a  few  drops  of 
water,  and  a  few  pinches  of  sulphate  of  mercury  should  be  added.  It  is  to  be  observed 
that  the  zinc  plate  touches  the  platinum  points  in  the  trough. 

In  exceptional  and  chronic  ca.ses.  where  time  has  been  allowed  to  pass,  these  instru- 
ments are  of  greater  use  than  in  primary  cases. 

It  need  hardly  be  reasserted  that  when  a  ball  has  penetrated  any  of  the  cavities  of  the 
body,  such  as  the  head,  chest,  or  abdomen,  it  is  not  to  be  sought  for  on  any  account. 

When  a  foreign  body  has  been  detected,  it  should  be  removed ;  at 

least,  this  is  tlir  rule.  I'nxetrr's  extractor.  r<ini|ni>c(l  of  a  scodji  fnr  liMldinf:  and  a  pin  for 
fixing  the  bullet,  has  been  highly  praised  (Fig.  tiSl).  Instruments  with  blades  cannot  be 
recommended,  as  they  necessitate  the  dilatation  of  the  wound. 

MacC'ormac  writes.  -'The  bullet  forceps  I  preferred  was  one  with  claw  points  at  a  right 
angle  with  the  handle  and  slightly  overlapping,  so  as  to  admit  of  easy  ingress.  When 
these  catch  the  bullet,  they  rarely  let  it  slip.    The  extraction  of  bullets,  however,  requires 


D82 


OS  GUXSHOT  INJURIES. 


fckill  and  patience;  much  injur\-  may  be  inflicted  on  surrounding  parts  by  the  incautious 
use  of  the  bullet  forcej^s." 

When,  from  the  smallness  of  the  wound  of  entrance,  force  is  required,  it  is  better  to 
enlarge  than  to  stretch  the  wound.  When  the  foreign  body  rests  beneath  the  skin,  an 
opening  through  it  may  be  made. 

When  balls  lodge  in  bone,  they  should  be  removed  as  from  .soft  parts ;  when  they  can 
be  raised  from  their  bed  by  an  elevator,  such  an  instrument  should  be  employed.  When 
forceps  are  wanted  for  extraction,  Luers  '•  sharp-pointed  bullet  forceps,  which  bite  into 
and  secure  a  most  firm  grasp  of  the  object,  will  best  accomplish  the  extraction."  To  aid 
extraction  the  gouging  away  of  some  part  of  the  bone  may  be  necessary. 

As  a  rule,  however,  with  rifle  balls,  the  bone  is  splintered;  and  under  these  circum- 
stances, when  the  epiphysis  of  the  bone  is  involved,  excision  of  the  joint  is  called  for 
when  the  joints  of  the  upper  extremity  or  the  head  of  the  femur  is  involved,  and  ampu- 
tation when  the  knee  and  ankle  are  injured. 

After  the  removal  of  all  foreign  bodies  from  the  wound,  and  when  the  parts  have  been 
cleansed,  they  should  be  carefully  adjusted,  placed  at  rest  in  an  easy  position,  and  pro- 
tected by  wet  or  dry  lint ;  union  by  adhesion  is  out  of  all  question,  and  that  by  granula- 
tion alone  can  take  place. 

To  hermetically  seal  a  wound  is  not  a  practice  to  be  generally  recommended.  Some 
gentle  support  by  means  of  a  bandage  not  only  gives  comfort,  but  is  beneficial. 

When  suppuration  has  taken  place,  the  greatest  care  is  needed  to  prevent  burrowing. 
As  soon  as  abscesses  form  they  should  be  lanced,  and  that  freely.  When  the  wounds  of 
entrance  and  exit  are  opened,  the  intervening  sinus  may  be  syringed  with  advantage,  some 
medicated  lotion  such  as  iodine  water,  Condys  solution,  or  carbolic  acid,  one  part  to  a 
hundred,  being  used. 

Under  all  circumstances  thorough  cleanliness  should  be  observed  and  good  food  with 
tonics  and  sedatives  given,  fresh  air  being  allowed  to  circulate  freely  around  the  beds. 
Stimulants  should  be  administel-ed  with  great  caution,  enough  only  being  allowed  to  assist 
the  digestion  of  solid  food. 

Gunshot  wounds  of  soft  parts  usually  suppurate  about  the  third  or  fourth  day,  sloughs 
mostly  separate  about  the  tenth  or  fourteenth,  and  recovery  takes  place  in  five  or  six 
weeks,  the  wound  of  exit,  as  a  rule,  closius:  before  that  of  entrance. 


Gunshot  Wounds  of  the  Head. 

A  gunshot  wound  of  the  head  received  from  a  rifle  ball  at  full  speed  produces  a  dif- 
fused injury  to  the  skull  and  its  contents;  when  caused  by  a  spent  ball  or  by  a  fragment 
of  shell,  the  injury  may  be  localized. 

In  the  former  cases  the  external  evidence  of  injury  bears  no  comparison  with  the  real 
mischief  the  patient  has  sustained ;  in  the  latter  the  external  evidence  may  be  greater 
than  the  internal.  Thus,  the  experience,  says  Pi'ofessor  Longmore,  of  the  military  sur- 
geon leads  him  always  to  hesitate  in  forming  a  prognosis,  however  limited  a  gunshot 
injury  ma}'  appear  to  be  at  first  observation. 

Gunshot  injuries  are,  moreover,  .specially  prone  to  be  followed  by  diff'used  meningitis, 
encephalitis,  and  the  formation  of  deep-seated  abscesses,  this  proneness  to  traumatic  inflam- 
mation being  clearly  due  to  the  injury  the  brain  itself  with  its  membranes  has  sustained, 

for  in  head  injuries  with  Avhich  the 
Fig.  682.  Fig.  683.  civilian  is  familiar  this  tendency  to 

traumatic  encephalitis  bears  a  direct 
proportion  to  the  injury  of  the  cra- 
nial contents. 

The  opening  made  into  the  skull 
by  a  pistol  ball  when  at  full  speed 
is  clean  and  defined  ;  that  of  exit, 
larger  and  bevelled  outward.  They 
are  rarely  complicated  with  fissures. 
When,  however,  the  velocity  of  the 
ball  is  in  a  manner  modified,  there 
may  be  the  same  amount  of  "  star- 
ring "  at  the  wound  as  is  seen  by  the 
civil  surgeon. 
In  military  as  in  civil  practice  the  inner  table  of  the  skull  is  always  fractured  to  a 


cf  Ent. 


Ji'ound  cfJTxit. 


GuysifoT  wor.sDs  of  nth:  ui:m> 


983 


jrrfaltT  i-xliiit  than  tlie  oiittr  wIumi  tin-  hull  eiiurt  from  without  (ri*«/«ir  Fij^s.  G82,  GH3, 
tuki'ii  from  I<<tti];mori>'.s  uriifir  in  //o'mt/,'»  Sj/Htnn).  hiit  the  oppo-nito  comlitioii  exinti*  when 
till-  hall  |iu>.Hc>  ihroii^'h  tlu'  xktill  mi  thr  opposite  .tide  of  the  crutiiitm,  the  tuhle  of  the  hLuU 
i->irrf.Hpiiii{liii;;  to  the  point  of  exit  of  the  hull  siifierin^  the  mo>t  in  hoth  ca.Het*. 

In   inilitury   as  in  eivil   pruetiee  the  ainonnt  of  external  injury  i^  no  iniiieution  of  the 

ml  of  internal  mi.sehief.      A  >«|ient  hall,  u  fragment  (*f  whell,  a  f*tone,  may  ••auM-  what 

ir«t  to  \h'  only  a  eontiision  itf  the  scalp,  yet  a  frai-lure  nuiy  coexist  with  .sueh  a  eontu-> 

>i.<ii,  and  a  eonxiijeruhle  amount  of  intrueranial  miscdiief  follow.      "The  amount  of  hruitt- 

in^'  ohvinus  to  ^i;:ht  uinl  the  de;:ree  of  eoneu<««ion  may  have  .seeme»l  triflin;r.  and  yet  the 

remote  eon>ei|Uenee.s  may  he  serious  enoui.di      (  LoU'^niore  i. 

('«uitu>ed  j;un«>hot  injurii-.s  without  any  external  ovideiiee  of  eranial  mi^ehief  are  at 
times  a.t.soeiatetl  with  sueh  intraeranial  injury  a>  to  }»«•  followed  hy  a  .»|ieedv  death. 
*•  Contusiu'i  and  irlaneinjr  .shot.s."  say.s  Dr.  .\eudi»rfer  of  l'ra;:uf  in  his  Mnmnil  >,/  MUllini/ 
Siiiytiy.  "  will  either  ocea.sion  fissure.^,  fraeture.'^,  or  depre.s.^ion.s  or  not  interfere  with  the 
inteirrity  of  the  .skull  at  all,  aecordiiif;  to  the  velocity  of  the  projectile  and  the  elasticity 
and  power  of  resistance  of  tlie  hoiu's." 

Severe  scalp  wounds  are  jrenerally  eau.se<l  hy  the  impact  of  a  projectile  at  an  acute 
anirle.  I'nder  such  circumstances  the  hone  i.s  often  left  intact,  and  little  or  no  injury  to 
the  hrain  results. 

At  a  less  acute  anj;le  the  hone  may  l»c  hruised.  scratched,  or  furmwed.  fissured,  .starred, 
or  comminuted:  and  with  these  several  conditions  more  or  less  .severe  hrain  svuiptoms  may 
be  associated,  the  ^'ravity  of  the  symi>toms  dependiiiir  on  the  severity  of  tlie  concussion. 
Concussion  in  military  as  in  civil  experience  means  either  a  temporary  !4U.spension  of 
brain  functions,  a  contusion  or  laceration  of  the  hrain  structure,  or  a  more  or  less  severe 
extravasation    of    Ijlood    upon    or 

into  the  brain  itself,  a  severe  con-  ^'^'  *''^^-  ^^o.  685. 

tusion  of  the  skull  without  frac- 
ture beini:  <|uite  i-apahle  of  ]>ro- 
ducinsr  a  fatal  laceration  of  a 
villus. 

'•  A  simple  observation  of  the 
injury  to  the  outer  table,  whether 
by  sight  or  touch,  will  by  no  means 
necessarily  lead  to  a  knowledire  of 
the  amount  of  injury  or  chan>ri 
of  position  in  the  injier  table' 
(LouLrmore).  Indeed,  it  is  <|uite 
possible  for  a  piece  of  the  inner 
taltle  of  the  skull  to  be  fractured 
and  detached  without  any  fracture 
of  the  external  takin>:  j)lace.  This 
is  illustrated  in  Figs.  084,  i'>'<7), 
taken  from  the  drawing  of  what  is  Ixdieved  to  be  a  unitjue  specimen  (2:]1.3  A.  31.  AI)., 
in  the  United  States  Museum,  published  in  circular  No.  G. 

When  the  external  table  has  been  ploughed  off  by  the  projectile,  care  should  be  taken 
not  to  mistake  such  an  injury  for  a  fracture  of  both  tables  with  depression. 

In  military  as  in  civil  practice,  too.  Jissureil  /racfnna  are  nio.stly  the  result  of  bhiws 
by  heavy  projectiles,  and  fissures  of  the  inner  table  without  external  evidence  of  the 
injury  occasionally   occur. 

Contmiinif'd  /ractiireii  in  both  military  and  civil  experience  are  also  chieflv  local 
injuries,   the   fune   <A'  the   'ill   ..r   blow   expending   itself  ..n    tli.-   injiin-d   ^jM.t 

Wounds  complicated  with  fracture  and  depressed  bone  without 

lodgment  of  the  projectile  are  most  serious.  Of  7<i  cases  recorded  after  the 
Ciiin.an  .anq.aigii.  .").")  pr.pved  tatal.  and  of  the  21  survivors.  12  had  to  W  invalided. 
*•  The  .severe  concussi(»n  of  the  whole  osseous  sphere  by  the  stroke  of  the  projectile,  the 
bruising  and  injury  to  the  bony  texture  immediately  surrounding  the  spot  against  which 
it  has  directly  impinged,  as  well  as  the  contusion  of  the  external  soft  parts,  so  that  the 
Wound  cannot  clo.se  by  the  adhesive  process,  constitute  very  important  differences  lietween 
gunshot  injuries  on  the  one  side  and  others"  (  Lon;:more). 

Fractures  of  the  cranium  from  gunshot  wonn<ls  are  not  unfrei|uently  »</my»/«V<f/'»/  irith 
t/u  rtftnfioii  of  f/i"  pnjcch'h-.  It  may  be  that  the  ball  has  been  flattened  against  the  bone 
and  lodged  in  the  wound,  or  it  may  be  that  it  has  been  split  against  the  fractured  cranium, 


Fiir.  '  - 1  — I  \;.ri..r  \  i.-w  of  the  inentione'l  <ip«>oinh 
Fig.  (.8-">.— Fracture  of  the  vitreou.s  table  of  the  frontal  bone  without 
frnetiire  of  the  external. 

(Circular  Nu.  '".,  Figs,  i  and  •",  Washineton.) 


984  ON  GUNSHOT  INJURIES. 

one  portion  entering  the  skull  and  the  other  the  integument.  Under  either  circumstance 
the  segment  that  enters  the  skull  may  either  lodge  between  the  Vjone  a)id  the  dura  mater 
or  lacerate  the  membranes  and  enter  the  brain.  Longmore  gives  a  case  in  which  there 
■was  a  fissured  fracture  with  slight  depression,  but  no  hole  in  the  skull,  where,  after  death, 
half  the  rifle  bullet  was  found  in  the  brain,  the  hole  through  which  the  half  bullet  had 
forced  admittance  having  closed  as  soon  as  it  had  entered  the  skull.  He  gives,  also, 
another  precisely  similar,  which  reflects  great  credit  upon  the  surgeon,  Dr.  B.  Howard 
of  the  United  States,  in  which,  from  the  presence  of  a  single  hair  protruding  from  within 
the  broken  bone,  it  was  inferred  that  a  solid  substance  had  entered  the  skull.  Trephin- 
ing was  performed,  a  distorted  Minie  ball  removed,  and  recovery  ensued. 

Rifle  bullets  at  the  usual  speed,  however,  in  the  majority  of  cases  enter  the  cerebral 
mass,  to  make  their  exit,  in  some  instances,  at  the  opposite  .side  of  the  skull,  in  others  to 
rest  beneath  the  opposite  wall ;  at  times  the  ball  takes  a  circuitous  route.  In  all  death 
follows,  as  a  rule,  no  exception  to  this  fact  having  been  reported  from  the  Crimean  war. 

Treatment. — To  do  nothing  active  when  death  appears  imminent  is  a  duty  the 
student  has  to  learn,  but  in  the  primary  treatment  of  head  injuries  in  the  stage  of  col- 
lapse, in  military  as  in  civil  practice,  there  is  no  more  stringent  rule  than  to  abstain  fnan 
interference — to  wait  and  to  watch.  The  patient  should  be  relieved  of  all  unnecessary 
dress,  no  tight  belts  or  garment  being  allowed  to  interfere  with  the  respiration.  He 
should  be  placed  in  the  horizontal  position  ;  and  when  moved  from  necessity,  it  should  be 
done  as  gently  as  possible.  When  the  extremities  are  cold,  extra  covering  may  be  applied, 
and  artificial  warmth  when  possible. 

As  the  case  develops  its  sui'gical  treatment  ought  to  be  conducted  on  precisely  similar 
principles  to  those  laid  down  in  former  chapters.  Practice  is  to  be  established  on  the 
preventive  principle,  to  ward  off  intra-cephalic  inflammation,  perfect  quiet,  cold  appli- 
cations to  the  head,  and  liquid  food  being  the  three  essentials.  Foreign  bodies  are  to  be 
searched  after  and  removed  with  extreme  caution.  When  they  have  entered  the  skull, 
and  still  more  the  brain,  all  search  is  forbidden ;  but  when  situated  at  the  external  orifice, 
they  should  be  taken  away,  and  the  sooner,  the  better.  If  a  ball  be  so  impacted  as  to  lie 
immovable,  the  wound  in  the  broken  bone  may  be  enlarged  to  favor  its  extraction,  but  no 
unnecessary  interference  with  the  cranium  or  its  contents  .should  be  entertained.  All 
foreign  bodies  in  the  integuments  out.side  the  skull  ought  to  be  taken  away  as  soon  as 
discovered. 

The  opinion  of  most  surgeons  is  decidedly  against  the  operation  of  trepln'nlng  in  gun- 
shot wounds  of  the  head.  When  the  operation  is  entertained,  it  .should  only  be  in  com- 
pound fractures  with  depression  attended  with  brain  symptoms.  The  experience  of  the 
Crimean  war,  of  our  own  as  well  as  of  French  surgeons,  of  the  Schleswig-Holstein  and 
Franco-Prussian  wars  as  recorded  by  Stromeyer,  of  the  Indian  war  as  told  us  by  Dr. 
Williamson,  is,  without  doubt,  decidedly  against  this  operation.  In  the  Crimean  cam- 
paign the  trephine  was  successfully  employed  in  only  4  out  of  28  cases  in  our  own  army, 
and  among  the  French  it  was  for  the  mo.st  part  fatal. 

The  late  American  war,  however,  gives  us  a  more  favorable  result — 85  recoveries  to 
115  deaths;  but  the  report  itself  states  that  "the  data  are  not  sufficiently  complete  to 
admit  of  fair  comparative  analysis,"  so  judgment  must  be  withheld. 

In  compound  fracture  loose  fragments  may  always  be  removed.  In  all  penetrating 
wounds  of  the  skull  with  lodgment  of  the  projectile  operative  interference  is  out  of  all 
question. 

As  a  rule,  writes  MacCormac,  ''  the  largest  proportion  of  good  results  will  obtain 
amongst  those  cases  where  the  amount  of  operative  surgery  has  been  at  a  minimum." 

Summary. — By  way  of  summary,  it  may  be  remembered  that  cerebral  concussion, 
rupture  of  one  of  the  cerebral  sinuses,  and  fatal  intra-cranial  hemorrhage  may  take  place 
from  a  gun.shot  projectile  without  any  external  marks  of  injury,  and  that  a  gunshot  injury 
of  the  head  followed  by  a  scalp  wound,  without  any  cerebral  symptom,  may  be  followed 
by  inflammation  of  the  bone  and  meningitis. 

The  vitreous  or  inner  table  of  the  skull  may  be  fissured,  depressed,  and  even  detached, 
without  nvij  fractvre  of  the  external  table.  The  drawings  taken  from  Circular  6  of  the 
War  Department  at  Wa.shington  illustrate  the  fact  (Figs.  G84,  685),  such  accident  being 
probably  the  result  of  a  small  projectile  striking  the  cranium  very  obliquely.  Fissure 
of  the  internal  table  may  also  coexist  with  a  linear  fissure  of  the  external  table. 

A  ball  may  gouge  out  a  portion  of  the  external  table  of  the  skull  without  injuring 
the  cranial  contents. 

A  fragment  or  the  whole  of  a  ball  may  partially  penetrate  the  skull  and  fall  out  or 


aussnnr  wnrsits  of  rui-:  <iii:st.  imo 

Ik'  rctiiiiifd  or  pass  tlir()ii;;li  it,  tlic  wnmid  of  exit  thnMij:h  the  tliickiu-ss  nf  Iikhc  or 
tlirou<;li   tilt!  two  sides  liciiij;  lar;.M'r  than    tin-   wound  of  entrance. 

Penetratiiij;  and  perforatin;;  fractures  *A'  liie  cranium  terminate  favorahly  in  (|uitc 
oxceittioiial   instances. 

Hernia  or  l'un;j:iis  cercliri  mav  take  |iiace  alter  ^'unsliof  as  alter  otiier  injuries,  and 
recovery  in  tliese  cases  may  occur,  tiie  ex|ierience  of  surjreons  in  tlie  American  war 
clearly  sliowiiiij  that  this  result  is  more  likely  to  take  jdace  without  than  with  compres- 
sion or  operative  intttrference. 

Trephining;  may  l>c  undertaken  only  with  a  fair  pros[iect  of"  success  in  local  fractures 
with  depressiiin  and  hrain  symptoms,  lo(»se  frairineuts  of  hone  heiiit;  always  removed  in 
nil  compound  wouuils. 

Gunshot  Wounds  of  the  Chest, 

These  arc  returned  as  1  in  10  amonji;  the  nfticers  and  1  in  IT  amongst  the  men  in  the 
Crimean  war;  ahout  80  per  cent  of  these  died;  in  the  American  war  the  mortalitv  was 
73  per  cent. 

Non-penetrating  frunshot  wounds  jrenerally  recover,  althou<:h  they  are  slow  in  healing, 
on  account  of  the  natural  movements  of  the  rihs  interrupting  the  process  of  repair.  They 
are,  moret)ver,  apt  to  be  followed  !iy  jdeuritis,  on  account  of  the  fre((uencv  of  the  ball 
taking  a  circuitous  course  beneath  the  skin  round  the  walls  of  the  chest.  When  the  chest 
has  been  severely  contused  from  a  spent  ball  or  a  heavy  fragment  of  shell,  abscesses,  or 
even  necro.sis  of  the  ribs,  are  prone  to  follow  the  accident  ;  and  from  the  same  character 
of  accident,  where  there  is  no  fracture,  the  lungs  may  be  injured,  this  result  being  like- 
wise met  with  in  young  subjects  in  civil  practice  when  the  chest  is  stjueezed.  Profe.s.sor 
Longmore  states  that  ••  ecchyniosis,  or  at  least  congestion  of  the  lung  itself,  to  a  partial 
extent,  in  all  probability  follows  every  non-penetrating  gunshot  wound  of  the  chest  of 
much  severity."'  The  ribs  may  likewise  be  broken  and  "driven  in,  as  in  the  direct  blow.s 
of  civil  life. 

Pmetiiiting  gunshot  wounds  are  generally  fatal,  scarcely  more  than  one  in  ten  sur- 
viving, while  death  generally  results  directly  from  hemorrhage  or  from  the  consequences 
of  secondary  inflammation  of  the  thoracic  organs.  The  difficulties  of  diagnosis  in  the.se 
cases  are  as  great  as  they  are  in  civil  practice,  especially  if  the  bullet  be  small  and  has 
entered  obliquely  near  the  scapula,  or  if  the  track  of  the  bullet  is  covered  by  sound  skin. 
"  It  is  only,"  says  Longmore,  "  by  a  combination  of  symptoms,  rather  than  by  the  pres- 
ence of  any  one  or  other  .symptom,  that  a  lung  wound  can  in  many  instances  be  diag- 
nosed." Penetrating  w^ounds  w'ith  lodgment  of  the  ball  are  more  fatal  than  perforating 
wounds,  and  a  fracture  of  the  rib  at  the  wound  of  entry  renders  a  penetrating  wound 
more  dangerous.  When  the  lung  has  been  wounded  by  a  penetrating  .shot,  shock.  C(d- 
lapse,  escape  of  air,  hemorrhage  from  the  external  wound  and  from  the  lung,  ha^mo- 
thorax,  and  dyspnoea  are  characteristic  symptoms.  The  shock  is,  however,  frequently 
less  in  penetrating  than  in  non-penetrating  wounds  when  the  latter  are  attended  with 
general  concussion.  It  is  remarkable  that  a  lung  may  at  times  be  completely  traversed 
by  a  ball  and  beyond  the  haemoptysis  and  dy.spncca  of  the  first  few  days  be  followed  by 
only  the  most  trivial  symptoms. 

Extrrnal  blee<J!tiif  in  chest  injuries  is  also  said  to  be  more  commonly  due  to  laceration 
of  an  intercostal  or  the  internal  mammary  artery  than  to  a  wounded  lung. 

Internnl  hieeduuj  is  the  chief  cause  of  death,  but  the  surgeon  has  no  means  at  his  dis- 
posal to  make  out  the  exact  source  of  the  hemorrhage.  A  gush  of  blood  from  the  mouth 
indicates  the  opening  of  a  large  vessel,  but  in  more  chronic  cases  the  sources  of  the  bleed- 
ing may  be  pulmonary  m-  ]iarietal.  "The  situation  of  the  wound  of  entrance  or  the 
course  the  ball  has  taken,  inferred  from  the  relative  positions  of  the  wounds  of  entrance 
and  exit,  will  greatly  help  to  determine  the  probable  site  of  the  bleeding,  and  to  some 
extent  its  probable  dcfrrec  of  gravity.  Internal  bleeding  from  a  wounded  intercostal 
artery  is  very  rare."' 

Gunshot  wounds  of  the  heart  are  always  fatal,  although  not  always  immedi- 
ately. In  a  case  recorded  in  Circular  No.  ?>  of  the  War  Department  at  Washington  the 
patient  survived  fifty  hours,  the  pistol  ball  having  wounded  the  right  auricle. 

Treat.ment. — To  arrest  hemorrhage,  to  remove  fragments  of  bone  or  foreign  bodies, 
and  to  do  nothing  that  can  interfere  with  nature's  reparative  processes,  are  the  three 
great  principles  of  practice  to  be  observed.  They  are.  indeed,  precisely  similar  to  those 
the  civil  surgeon  follows.     In  bleeding  from  an  intercostal  artery  the  best  plan  is  to  plug 


986  OX  GUNSHOT  INJURIES. 

the  opening;  at  least,  so  says  Professor  Longmore.  Tliis  may  be  done  in  the  following 
way  :  "A  large  piece  of  linen  is  laid  upon  that  part  of  the  chest  in  which  the  wound  is 
placed,  and  the  middle  portion  of  this  linen  is  pressed  into  the  wound  by  the  finger,  so  as 
to  form  a  kind  of  pouch.  This  pouch  is  then  distended  by  sponge  or  lint  pushed  into  it 
until  the  pressure  arrests  the  bleeding;  on  stretching  out  the  corners  of  the  cloth  the  pres- 
sure of  the  plug  will  be  increased.'" 

If  the  wound  is  not  attended  with  hemorrhage,  it  should  be  cleaned  and  lightly 
closed,  the  side  being  strapped  up  to  restrain  movement.  Hermetically  sealing  gunshot 
wounds  of  the  chest  is  reprehensible.  The  patient  should  be  laid  on  the  wounded  side 
with  the  wound  downward,  to  allow  of  the  escape  of  discharges. 

In  all  other  respects  the  treatment  of  gunshot  wounds  is  similar  to  that  of  others,  and 
the  remarks  already  made  are  applicable  to  them.  Venesection  is  less  commonly  employed 
now  than  it  was  by  the  surgeons  of  the  Peninsular  war,  and  in  the  American  war 
appears  to  have  been  abandoned.  The  dangers  of  inflammation  of  the  contents  of  the 
chest  are  the  chief  source  of  the  surgeon's  anxiety,  and  his  aim  ought  to  be  to  prevent 
them  if  pos.sible,  and  when  present  to  check  them.  Hemorrhage  should  be  treated  by 
the  application  of  cold,  perfect  rest,  and  the  administration  of  opium.  When  empyema 
follows  as  a  secondary  result,  a  free  outlet  may  be  made  for  the  accumulated  fluid. 

Gunshot  Wounds  of  the  Abdomen. 

These  are  mostly  penetrating,  and  non-penetrating  wounds  ai'e  often  associated  with 
some  injury  of  the  abdominal  viscera.  Longmore  informs  us  that  in  the  Crimean  cam- 
paign, out  of  115  non-penetrating  wounds  and  contusions,  22  deaths  occurred,  these  cases 
including  those  of  injured  viscera.  "When  death  follows  a  non-penetrating  wound,  it  is, 
as  a  rule,  from  sloughing  of  the  abdominal  walls. 

Penetrating  (jinishot  ahdominal  v:ovnih  are  generally  fatal,  9  out  of  10  of  the  Crimean 
cases,  French  and  English,  having  been  so  recorded.  In  the  American  campaign  the 
mortality  was  74  per  cent.  Shock  is  always  very  great,  and  collapse  from  hemorrhage 
the  most  striking  symptom.  This  is,  indeed,  says  Longmore,  "  sometimes  the  only  symp- 
tom which  will  enable  the  surgeon  to  diagnose  that  the  viscera  are  perforated.  The  mind 
remains  clear,  but  the  prostration,  oppressive  anxiety,  and  restlessness  are  intense. 
Should  life  be  prolonged,  signs  of  peritonitis  will  soon  appear. 

In  musket-shot  wounds,  it  is  exceptional  for  any  of  the  abdominal  contents  to  escape 
from  the  opening ;  but  when  they  do,  the  nature  of  the  wounded  viscus  will  be  indicated. 
The  swelling  of  the  margins  of  the  wound  accounts  for  this  fact. 

Wounds  of  the  Jiver  are  attended  with  a  large  mortality  and  are  always  complicated. 
Shock  and  hemorrhage  are  the  usual  immediate  causes  of  death  ;  but  when  life  is  pro- 
longed, peritonitis.  Longmore  saw  only  1  case  of  recovery  in  tlie  Crimea,  while  Dr.  Otis 
records  4  recoveries  in  America  out  of  32  cases  of  this  form  of  injury.  In  Circular  No. 
3  of  the  War  Department  at  Washington,  -1  cases  of  recovery  out  of  15  from  this  injury 
are  recorded,  and  in  1  the  gall-bladder  was  wounded.  Wounds  of  the  spleen  are  almost 
always  fatal  from  hemorrhage,  and  are  generally  complicated  with  other  injuries.    ' 

Grunshot  wounds  of  the  stomach  are  not  always  fatal.  They  are  made  out  to  exist 
when  the  contents  of  the  organ  escape  externally,  or  when,  from  the  extent  of  wound, 
the  viscus  can  be  seen.  They  are  always  a.ssociated  with  vomiting  of  blood.  Hennen 
records  two  good  cases  of  recovery  which  occurred  at  Waterloo,  and  the  well-known 
American  case  of  Alexis  St,  Martin,  reported  by  Beaumont,  is  another.  Dr.  Peters  of 
the  L^nited  States  army  has  also  reported  a  case  that  occurred  in  the  American  war. 
Guthrie  and  Cooper  gives  nine  or  ten  others. 

Treatment. — When  the  wound  is  incised,  it  should  be  stitched  up.  Opium  should 
be  administered,  with  nutrient  enemata.  Nothing  should  be  given  by  the  mouth  for 
some  days. 

Gunshot  wounds  of  the  intestines  are  not  necessarily  fatal,  although 
instances  of  recovery  are  rare.  Wounds  of  the  large  are  not  so  bad  as  wounds  of  the 
small  intestines.  Hemorrhage,  and,  if  not,  peritonitis,  is  the  usual  cause  of  death. 
Longmore  relates  one  case  in  which  recovery  took  place.  Dr.  Hamilton  of  New  York 
(18G5)  quotes  eight  cases  of  fecal  fistula  which  terminated  in  recovery  by  natural  pro- 
cesses, all  having  taken  place  in  the  late  American  war,  and  in  the  older  writers  many 
more  might  be  found.  Dr.  Haber.shon  has  recorded  a  most  interesting  case  of  gunshot 
wound  of  the  colon  through  the  right  loin,  the  patient  dying  four  years  subsequently 
from  albuminuria  (Gv>/'s  Reports,  1859). 


aiwsii'i'r  w'niwDs  or  ■nii:  i:i..ii>i>i:i:,  face,  a.\i>  .\j:(k.  5)87 

TllHAT.MKNT. — AliMiliilr  <|iiii't  is  the  iiinsl  csx-iit iiil  point  to  Ik?  oh.servcil  in  these  as  in 
all  (itlicr  i"isfs  lit"  iil»<lnniinal  injuiii's.  'I'lu-  icciinilicnt  positiiMi  sliDiiid  l»c  cnlorci'd  and 
inaiiitainiHl  imuUt  all  circiinistanft's.  Opium  or  nmipliia  slmuld  alxi  he  ;_'ivi'n  in  repeated 
(loses,  no  (Iru!;  Iiavini;  a  lutter  infiiience  in  peritoneal  intlaniniatioii.  Absolute  cleanli- 
ness of  the  wonnil  shoiihl  also  he  ohsi-rved,  hut  there  should  he  no  strappin;:  or  closing 
of  the  orifice.  Simple  nutritious  food  may  he  allowed,  and  as  the  case  proL^resses  solids 
uiuy  firadnally  he  taken. 

tWdl  fistiihr  appear  to  liave  a  tendency  to  c-lose  hy  theni.seivcs.  In  the  American 
cases  thov  ^uve,  in  tjeneral,  hut  little  inuilile  in  lliiir  mana;r<'nicnt  (Circ.  No.  (I,  S.  (I.  <)., 

ist;.-)). 

With  reL:ard  to  explorini:  the  track  nf  tlic  wound,  the  surp-on  should  never  for^'ct, 
.savs  liidell  {^Ann  in  itn  (Jiimi.,  iSliT).  "that  in  the  manajrement  ol"  these  cases  Art,  t<i  he 
useful,  must  he  the  servant  of  Nature,  and  must  seek  to  do  <::ood  by  assisting:  licr  ini.s- 
tress  in  the  elVorts  to  repair,  and  not  hy  the  introduction  of  new  and  violent  measures 
which  are  liahle  to  airirravate  the  original  injury."  lie  helievcs  that  neither  the  finger 
iior  any  instrument  should  ])e  used  i'or  exjiloratory  purposes,  except  in  special  cases.  Dr. 
Otis,  however,  in  Circular  No.  :>  of  the  War  J>epartment  at  Washington,  issued  in  ISTI  (p. 
87),  says  that  "the  mortality  of  the.se  cases  is  so  great  as  to  furnish  an  additional  argu- 
ment in  hehalf  of  Legouest's  proposition  to  incise  the  abdominal  walls  and  exjtlore  the 
track  of  the  ]>rojectiIe  in  certain  ])enetrating  wounds.  Thus  only  can  the  patient  exchange 
the  probability  of  inevitable  death  for  the  ])ossibility  of  recovery,  either  through  the  pre- 
vention of  extravasation  by  enterorrhapliy  or  the  bringing  of  the  wounded  viscus  into 
ap]>osition  with  tlie  abdominal  walls.  For  one,  I  am  free  to  assert  that  where  there  is 
evidence  that  internal  henuirrhage  or  fecal  extravasation  is  going  (jii,  what  may  l)e  termed 
the  '  ostrich  plan  "  of  giving  opium  and  making  the  patient  comff>rtable  should  he  aban- 
doned;  and  I  believe  that  prejudices  similar  to  those  that  ovariotomy  has  successfully 
overcome  in  the  last  (|uarter  of  a  century  will  be  dispelled  by  the  results  of  exploratory 
incisions  in  gunshot  wounds  of  the  abd(nnen  liefore  many  years  have  elapsed." 

Gunshot  Wounds  of  the  Bladder 

do  not  appear  to  be  so  fatal  as  the  cases  of  ruptured  bladder  met  with  in  civil  life. 
Lidell  reports  two  such  cases  where  a  good  recovery  followed,  the  projectile  in  both  hav- 
ing passed  completely  through  the  organ.  Guthrie  has  related  six,  in  all  of  which  recov- 
ery took  place.  MaeCormac  records  a  case  in  which  the  ball  pa.ssed  through  the  rectum 
and  bladder,  the  feces  for  a  time  passing  through  the  posterior  opening  and  the  urine 
through  the  anterior.  Both  wounds  closed  by  natural  processes  in  seventeen  days.  In 
all  of  these  the  urine  escaped  externally  through  the  wound  made  by  the  projectile*  and 
thus  prevented  fatal  peritonitis  from  taking  place.  Such  instances  as  these  indicate  the 
proper  practice  to  be  pursued  in  all  cases  of  ruptured  bladder — viz.,  cy.stotomy,  as  for 
lateral  lithotomy.  When  foreign  bodies  have  been  carried  into  the  bladder,  they  should 
be  removed,  as  a  ball  may  remain  in  tlje  bladder  and  become  the  nucleus  of  a  calculus. 
Guthrie,  llennen.  Cheselden,  and  Garengeot  have  given  such  cases,  and  Ballingall  has  col- 
lected in.  In  Circular  No.  o  of  the  War  l)e]iartmeut  at  Washington  8  cases  are  recorded 
in  which  calculi  were  removed  which  had  formed  on  bullets.  1  where  a  stone  had  concreted 
upon  an  arrow-head,  and  1  on  necrosed  bone. 

Gunshot  Wounds  of  the  Face 

are  serious  from  the  fact  that  they  are  so  frequently  followed  by  secondary  hemorrhage ; 
and,  as  the  deep  vessels  are  usually  its  source,  the  difficulties  of  controlling  it  are  always 
great.  When  this  complication  does  not  destroy  life,  good  recoveries  take  place,  wounds 
of  the  face  always  healing  kindly  and  with  little  scar.  When  there  is  much  loss  of  tis- 
sue, some  secondary  plastic  operation  may  be  required,  and  many  are  the  instances  of 
success  following  this  practice. 

Gunshot  Wounds  of  the  Neck 

are  serious  according  to  the  nature  of  the  parts  involved.  When  the  large  vessels  and 
nerves  are  injured,  a  fatal  result  generally  takes  place  ;  and  when  the  larN'ns  or  trachea 
is  implicated,  the  risks  of  suffocation  are  great — not  only  from  the  direct  result  of  the 
injur}',  but  from  secondary  oedema  ;  when  this  latter  complication  occurs,  tracheotomy 


988  ON  GUNSHOT  INJURIES. 

should  at  once  be  performed.  Wounds  of  the  neck  are  very  liable  to  be  followed  by 
septicaemia. 

Wounds  involving  the  vertehrse,  are  usually  fatal,  those  cases  alone  recovering  where 
the  spinous  or  transverse  processes  are  the  parts  injured. 

GUNSHOT  WOUNDS  OF  THE  EXTREMITIES 

include  flesh  wounds  and  contusions,  fractures  which  are  rarely  simple  and  compound 
fractures,  wounds  of  joints  and  compound  fractures  into  joints. 

All  these  may  be  complicated  with  some  injury  to  the  vessels  and  nerves  of  the  part 
and  the  lodgment  of  foreign  bodies  or  projectiles.  Grunshot  flesh  wounds  usually  do  well 
unless  complicated  with  lesions  of  the  vessels  and  nerves. 

Fractures  from  Gunshot  Wounds 

are  sometimes  simple,  but  more  commonly  compound.  When  simph',  they  are  generally 
caused  by  blows  from  spent  balls  or  other  projectiles,  the  bones  usually  being  split  or 
comminuted  and  contused,  not  rarely  split  vertically  into  a  neighboring  joint,  the  soft 
parts  equally  suffering.  When  compound,  the  same  comminution  and  splintering  of  the 
bone  is  commonly  present,  associated  with  other  complications,  such  as  severe  laceration 
of  the  soft  parts,  involving  arteries,  veins,  or  nerves,  with  their  attendant  dangers,  lodg- 
ment of  fragments  or  the  whole  of  the  foreign  body  in  the  bone  or  soft  parts,  and  some 
joint  complication  from  the  splitting  of  the  bone  into  the  joint  or  from  direct  injury  to 
the  joint. 

Military  surgeons,  however,  writes  Professor  Longmore  (in  Holmes's  Systevi),  meet 
with  cases  of  partial  fracture:  "  1.  Removal  of  portion  of  a  bone  by  the  projectile  mak- 
ing a  furrow  in  its  passage  across  its  surface,  grooving  it.  2.  Removal  by  splintering 
olF  longitudinal  fragments  from  the  external  cylindrical  part  of  a  bone.  3.  Removal  of 
part  of  the  bone  by  completely  punching  out  a  portion,  thus  leaving  a  hole  through  the 
entire  substance  of  the  bone.  4.  Partial  fracture  by  driving  inward  part  of  the  external 
cylinder  and  causing  the  fragment  to  lodge  in  the  cancellated  structure,  with  or  without 
lodgment  of  the  projectile." 

Of  complete  fractures,  the  peculiarity  consists  in  the  comminution  and  vertical  splint- 
ering of  the  bone,  and  of  the  complete  removal  of  some  part  of  the  shaft  of  the  bone,  the 
term  "resecting  fractures"  being  applied  to  such.  One  curious  fact  occasionally  pro- 
duced by  the  heavy  conoidal  ball  is  noticed  in  Circular  No.  6  of  the  War  Department  at 
Washington,  in  which  the  bone  is  fissured  and  comminuted,  though  less  than  is  common, 
at  the  point  at  which  the  ball  impinges,  while  at  two  or  three  inches  above  or  below  this 
point  a  nearly  transverse  fracture  of  the  shaft  is  produced.  In  some  of  the  specimens 
the  transverse  fracture  is  not  connected  by  fissures  with  the  fracture  produced  by  the 
ball.     These  injuries,  probably,  are  due  to  balls  fired  at  short  ranges. 

When  conoidal  bullets,  writes  Longmore,  happen  to  strike  on  or  below  the  trochanters 
of  the  femur,  they  usually  leave  the  head  and  neck  of  the  bone  intact,  but  cause  fissures, 
which  often  extend  to  a  long  distance  down  the  shaft ;  when  they  pierce  the  head  of  the 
bone,  all  the  parts  below  usually  escape  fracture  ;  when  the  neck  is  perforated,  the  frac- 
ture generally  extends  both  upward  and  downward.  The  same  rule  holds  good  with 
regard  to  the  upper  extremity  of  the  humerus,  although  not  in  so  marked  a  manner. 

In  all  these  fractures,  from  the  comminution  of  the  fragments  and  the  concussion  the 
bone  has  sustained,  o.steoniyelitis  and  septicaemia  are  liable  to  occur,  as  pointed  out  in 
1860  by  Jules  Roux  of  Toulon  (^BidJetin  d^  r Academic  Imperiale  dc  JIedcci)ie\  and  by 
Longmore  (Med.-CJu'r.  Trans.,  1865).  J.  A.  Lidell  showed  that  gunshot  contusions  of 
long  bones  are  more  fatal  from  this  cause  than  comminuted  gunshot  fractures  (^American 
Journcd,  vol.  xlix.). 

Fractures  of  the  lower  extremity  are  more  liable  to  be  followed  by  such  blood  poison- 
ing than  those  of  the  upper,  the  susceptibility  being  much  determined  by  the  size  of  the 
venous  canals ;  the  larger  and  more  numerous  the  veins  of  a  part,  the  greater  the  danger 
of  septicaemia. 

In  gunshot  wounds  of  the  pelvic  bones  Stromeyer  believes  the  liability  to  pysemia  to 
be  very  great,  and  that  cold  and  exposure  favor  its  development. 


GUNSHOT   WolMfS   (H-    TIIK  KXTliKMlTIES.  989 

Gunshot  Fractures  of  the  Upper  Extremity 

are  fur  l(.'>>  I'lital  than  tliitsi-  of  tin-  luwi-r.  "  I'liles.s  the  hoxut  he  extensively  iiijun.'il  l»y  a 
luiissive  pmjeetile  or  loii^itiiiliiial  (•oimiiiinitinii  exists  tn  a  ^reut  extent,  espeeialiy  il"  also 
iiivolvinj;  a  jdint,  or  the  state  (if  the  patient's  hcaltli  he  very  unfavdrahh',  attempts  should 
always  l»e  made  to  save  the  limh  "  (  |jiin;/niore ). 

TitKATMKNr. — When  tlu'  hone  is  niu(di  splintered,  an  examination  hy  the  Hn;:er  for 
foreii^n  hndies  or  detacdied  pieees  of  hone  should  he  made  ami  their  removal  ert'eeled. 
Sharp  points  of  projeetitiir  spieuhe  shouhl  he  sawn  off.  the  most  dependent  wound  heing 
extended  when  iieeessary,  or  u  fresh  incision  made  lor  the  jiurpose  in  a  <lependent  posi- 
tion when  only  one  wound  exists,  the  ease  heinir  then  treated  as  an  ordinary  eompound 
fraeture. 

If  the  shoulder  and  elhow-joint  be  opened  and  the  condition  of  the  soit  parts,  vessels, 
etc.,  is  not  suidi  as  to  neee.ssitate  amputation,  excision  of  the  joint  .should  he  performed, 
the  experience  of  the  American  war,  as  of  all  recent  campaigns,  very  strongly  indicating 
this. 

Gunshot  Wounds  ol'tlie  wrist  too  often  demand  amputation  :  excision  is  not  expedient, 
hut  where  the  major  operation  is  not  imperatively  demanded  attempts  to  save  the  limh 
should  he  made. 

The  same  remarks  apply  to  injuries  to  the  lingers  and  hand,  and  only  such  portions  as 
are  irreparalily  damaged  should  he  removed  ;  for  the  value  of  a  piece  of  thumh  and  one 
finger,  of  whatever  kind,  is  hardly  to  he  overestimated,  and  every  effort  should  he  made 
to  preserve  whatever  parts  can  possihly  he  saved. 

Gunshot  Fractures  of  the  Lower  Extremity 

are  far  more  grave  accidents  than  those  of  the  upper.  LongUK^'e  lays  it  down  as  a  gen- 
eral rule  that  ordinary  fractures  below  the  knee  from  rifle  balls  -should  never  cause  pri- 
mary amputation,  while,  excepting  in  certain  special  cases,  in  fracture  above  the  knee 
amputation  is  held  by  most  military  surgeons  to  be  a  wcessun/  virfisure. 

The  special  cases  are  gunshot  fractures  of  the  upper  third  of  the  femur,  especially  if 
it  be  doubtful  whether  the  liip-joint  is  implicated  or  not.  as  in  these  the  danger  attending 
amputation  is  so  great  that  the  ([uestion  is  still  open  whether  the  i^afety  of  the  patient  is 
best  consulted  hy  excision  of  the  injured  portion  of  the  femur,  hy  removal  of  detached 
fragments  and  trusting  to  natural  effects  for  union,  or  by  resorting  to  amjnitation. 

The  decision  of  the  surgeon  must  generally  rest  upon  the  extent  of  injury  to  the  soft 
parts,  the  age  and  the  condition  of  the  patient,  and  the  surrounding  circumstances.  If 
the  femoral  artery  and  vein  have  been  divided,  any  attempt  to  preserve  the  limh  will  cer- 
tainl)-  prove  fatal. 

Amputation  at  the  hip-joint  for  gunshot  wounds  is  generally  fatal — so  fatal,  indeed, 
that  it  ought  to  be  undertaken  only  when  the  lower  limb  is  so  mutilated  as  to  render  it  a 
necessity  or  when  the  great  vessels  have  been  injured.  When  any  doubt  exists  as  to  the 
probability  of  saving  the  limb,  the  operation  should  be  postponed,  and  undertaken,  if 
neces.sary,  as  a  secondary  amputation. 

The  experience  of  all  Uritish  and  continental  surgeons  fairly  endorses  Longmore's 
conclusion.s — that  while  in  gunshot  fractures  of  the  thigli  the  propriety  of  jtractising  con- 
servatism in  the  upper  third  is  clearly  indicated,  amputation  is  the  safest  practice  in  gun- 
shot fractures  of  the  middle  and  lower  third. 

M.  Legouest.  in  an  essay  jiublished  in  the  Mtm.  of  the  Society  of  Surgfona  of  Paris, 
believes  that  amputation  at  the  hip-joint  should  be  reserved  for  compound  fractures  com- 
plicated with  injuries  to  the  great  vessels,  and  he  advocates  the  postj>onement  of  the 
operation  as  long  as  possible. 

Ill  gunshot  fracture  of  the  head  of  the  femur,  where  the  soft  parts  are  not 
greatly  injured  or  the  bone  comminute<l.  i.icision  of  the  hone  may  be  performed,  the  only 
case  of  recovery  in  the  American  war  from  such  an  injury  being  where  this  practice  was 
adopted.  In  Circular  Xo.  3  two  such  successful  cases  are  recorded  out  of  three,  and  they 
induce  Dr.  Otis  to  "  add  that  these  instances  must  place  excision  at  the  hip  for  gunshot 
injury  amongst  the  established  ojierations  of  surgery."  Out  of  eighty-seven  excisions  at 
the  liip  for  injury  in  America,  eight  recovered. 

In  fracture  of  the  thigh  the  evil  of  transporting  a  patient  is  so  great  that  Stro- 
meyer  says,  "  1  have  during  the  last  campaign  lived  to  see  what  I  expressed  a  desire  for 
some  years  ago  when  I  wrote,  '  Above  all  things  it  appears  to  me  to  be  necessary  that 


990  ON  GUSSHOT  ly JURIES. 

cases  of  gunshot  fracture  of  the  thigh  should  not  be  transported  to  a  distance,  but  should 
be  carried  on  a  stretcher  to  the  nearest  house  and  the  treatment  carried  out  there.'  "  He 
speaks  most  highly  of  the  conservative  treatment  of  all  gunshot  fractures.  When  opera- 
tion is  called  for,  primary  measures  should  always  be  preferred  for  both  amputation  and 
excision. 

In  fracture  of  the  leg  conservatism  has  even  a  better  chance — that  is,  -nhere  the 
shaft  of  the  bone  alone  is  implicated  ;  for  when  the  knee  is  involved,  amputation  is  gener- 
ally held  to  be  the  rule  of  treatment.  Excision  should  not  be  entertained,  the  results  of 
experience  condemning  the  attempt.  Langenbeck  recommends  conservative  treatment  in 
gunshot  wounds  of  the  knee,  amputation  being  alone  required  when  the  soft  parts  are 
severely  injured  and  the  bones  shattered.  He  also  lays  the  greatest  stress  upon  the 
necessity  of  fixing  the  limb  in  some  immovable  apparatus  from  the  moment  of  the  injviry 
to  its  cure  (the  plaster-of-Paris  splint  being  preferred),  coupled  with  the  application  of  ice 
to  the  part.  In  gunshot  fracture  of  the  shaft  of  the  leg  bones  not  involving  joints  the 
same  rules  of  practice  are  applicable  as  have  been  laid  down  for  the  treatment  of  fracture 
of  the  humerus,  etc. 

In  gunshot  wounds  involving  the  ankle-jOint  amputation  is  the  best  practice.  In 
exceptional  instances  where  the  injury  is  slight — that  is,  where  the  bone  is  simply  split 
into  the  joint — an  attempt  to  save  the  limb  may  be  justifiable.  Excision  as  a  primary 
operation  is  not  desirable ;  as  a  secondary  one,  where  an  attempt  to  save  the  limb  has 
been  made  and  failed,  Langenbeck's  experience  is  in  favor  of  excision,  nine  out  of  eleven 
cases  in  which  he  did  it  after  the  Bohemian  war  having  recovered,  but  to  obtain  this 
result  he  asserts  that  the  complete  immobility  of  the  parts  involved  by  means  of  the 
plaster-of-Paris  splint  or  one  of  its  congeners  is  indispensable. 

With  respect  to  amputation  in  gunshot  fractures,  every  surgeon  since 
Guthrie's  time  believes  that  the  ji  rim  a /y  should,  as  a  rule,  be  preferred  to  the  secondary. 
This  primary  amputation  should  also  be  performed  as  soon  after  the  accident  as  possible. 
There  is  no  necessity  to  wait  for  the  effects  of  the  shock  of  the  accident  to  pass  away,  and 
unless  the  collapse  be  very  .severe  the  hand  of  the  surgeon  need  not  be  stayed.  When, 
however,  the  collapse  is  great,  some  little  delay  had  better  be  observed,  for  it  is  then 
more  than  probable  that  some  internal  injury  or  other  complication  exists  to  prevent 
reaction. 

Chloroform  or  any  other  anaesthetic  may  be  used  in  military  as  freely  as  in  civil  prac- 
tice. It  has  a  powerful  influence  in  preventing  shock  and  allowing  prolonged  or  double 
operations  to  be  performed  which  could  not  otherwise  be  undertaken — at  least,  without 
extra  risk.  In  military  practice  it  should  be  remembered  that  a  limb  must  often  be  sac- 
rificed when  in  civil  practice  it  might  be  saved,  and  that  amputation  is  often  substituted 
for  excision  on  account  of  the  impossibility  of  giving  the  part  the  necessary  amount  of 
absolute  rest  and  the  patient  the  attention  that  can  be  found  only  in  a  civil  hospital, "  for 
when  active  operations  are  proceeding  and  it  is  necessary  to  carry  the  wounded  to  any 
distance,  the  advantage  of  early  removal  of  shattered  limbs  is  obvious,  especially  when 
means  of  rendering  the  limbs  immovable  during  the  transport  are  defective  or  the  trans- 
port itself  has  to  be  conducted  over  rough  roads  or  in  unsuitable  vehicles,  and  the  hopes  of 
success  from  conservative  treatment  are  thereby  reduced  almost  to  zero  "  (Longmore). 

Dr.  Gordon,  the  British  commissioner  accredited  to  the  French  army  in  the  late  war 
between  France  and  Prussia,  informs  us  that  the  conclusions  the  bulk  of  surgeons  arrived 
at  as  regards  amputation  were  that  it  was  more  suited  than  excision  or  resection  when  its 
subject  had  to  be  carried  on  with  the  army  ;  that  excision  and  resection  were  much  more 
likely  to  be  successful  when  practised  in  the  upper  than  in  the  lower  extremity  ;  that 
excision  of  the  knee  as  a  .substitute  for  amputation  in  case  of  gunshot  wounds  of  that 
articulation  has  sadly  fixiled ;  that  the  practice  of  conservative  surgery  in  stationary  hos- 
pitals furnishes  no  criterion  of  its  suitability  in  movable  hospitals,  its  requirements 
involving  such  attention  from  the  surgeon  as  can  alone  be  fully  carried  out  when  there 
are  comparatively  few  cases  of  .severity  to  attend  to ;  and  that  in  many  cases  where  the 
limbs  are  saved  they  are  relatively  of  little  use. 

MacCormac  urges  that  the  mortality  after  primary  is  so  verj^  much  .smaller  than  that 
attendant  on  secondary  amputation  that  this  point  cannot  be  too  .strongly  insisted  upon. 

The  Surgical  His^tory  of  the  American  War,  as  prepared  by  the  late  Surgeon  Otis  and 
published  by  the  American  government,  is  a  mine  of  practical  information  on  gunshot 
and  other  injuries  incident  to  warfare. 


OSTi:<)Tn.M  Y.    iinsi:-si:iTis<;.  OUl 


OSTEOTOMY. 


Wlii'ii.  ill  1H70,  Mr.  W.  Adams  re|M)rtiMl  his  first  Hucci;s.sfiil  Cii.se  of  .subcutaiiuous 
division  of  tin*  neck  of  tlu'  fciiiur  for  tlio  ctiri.'  of  u  deformity  the  result  of  .some  old  hip 
disea.se,  he  iiitrodiun-d  to  the  notice  of  IJrilish  surgeons  an  operation  (»f  frreat  value  and 
of  wide  application,  and  which,  under  the  name  of  "  «»steotomy,  "  has  already  won  a  hif:h 
positidii  in  practical  siir'rery.  Mr.  Adams,  however,  did  not  sufrjrest  the  operation,  l»ut 
followed  lianjrenhcck,  who  in  the  winter  of  iSjIi  first  [>erformed  it.  and  later  on  applied 
it  to  eases  of  rachitic  dct"iirniity  of  the  lej^s  and  (tthers.  At  the  present  time  Adains.s 
o]»eration,  as  first  dcscrihcd  or  with  certain  slight  modifications,  is  the  one  emjdovfd  for 
the  reclificatiiin  iA'  dcfurmitics  in  most  liip  cases.  In  ()gst(»irs  and  Maeeweiis  operation 
for  the  cure  of"  had  cases  of  iiciiu  valgum  osteotomy  is  fully  recognized.  In  the  division 
of  curved  or  Kent  hones  the  result  of  rickets  it  is  constantly  lieiiig  performed,  and  as  a 
means  of  correcting  the  deformities  due  to  badly  united  fractures  or  unreduced  disloca- 
tiidis  it  has  a  luight  future. 

Indeed,  experience  has  fairly  ]iroved  that  hones  deformed  by  accident  or  disease  may 
be  divided  by  the  saw  or  chisel  through  a  small  skin  W(Uind  with  an  amount  of  safety 
which  is  somewhat  startling,  and  that  the  operation  has  apparently  attached  to  it  a  smaller 
number  of  risks  than  many  others  of  a  so-called  minor  character. 

Whether  the  saw  or  chisel  be  used  is  a  matter  of  .small  importance,  so  long  as  either 
instrument  is  used  carefully.  For  my  own  part,  I  prefer  the  saw  ;  it  was  the  one  I  origin- 
ally employed  in  my  early  hip  cases,  and  I  have  greater  confidence  in  cleanly  dividing 
the  bone  I  approach  with  the  saw  than  with  the  chisel.  When  the  saw  is  inapplicable, 
as  in  the  division  of  bones  above  the  ankle  for  badly  united  fractures,  the  chisel  may  be 
employed. 

The  wound  must  be  kept  clean  during  the  operation,  and  for  this  purpose  I  hold  wicli 
my  left  hand,  when  grasping  the  bone  operated  upon,  a  sj)onge  fiiirly  filled  with  warm 
iodine  water,  but  carbolic  lotion  may  be  used  instead.  When  the  bone  is  divided  and  the 
limb  brought  into  the  I'cijuired  jiosition,  the  wound  may  be  closed  and  covered  with  iodo- 
form or  carbolic  gauz.e.  The  limb  should  then  be  at  once  fixed  by  some  immovable  splint, 
such  as  Croft's  or  other  pla.ster-of-Paris  bandage,  in  the  position  in  which  it  is  eventually 
to  be  brought. 

In  the  majority  of  cases  repair  goes  on  quietly  and  quickly,  and  in  five  or  .six  weeks 
the  required  result  is  brought  about.  In  exceptional  cases  suppuration  has  taken  place 
In  the  line  of  bone  section,  and  in  a  still  fewer  number  one  of  the  accidents  appertaining 
to  wounds,  however  trivial,  has  brought  about  bad  results.  Accidents  to  deep  vessels 
have  likewise  been  recorded,  and  in  one  a  spiculum  of  the  diseased  bone  perforated  a 
large  artery  and  necessitated  a  series  of  operative  proceedings  which  ended  sadlv.  Still, 
all  these  evil  results  are  very  exceptional.  They  should,  however,  be  rememl)ered  as 
warnings  against  surgeons  being  too  strong  in  their  assertions  of  the  absolute  safety  of 
the  measure  under  consideration,  and  to  remind  them  that  interference  with  such  tissues 
as  living  flesh,  bone,  and  blood  has  its  ow'n  dangers  and  risks,  which  exist  in  .spite  of  the 
skill  which  may  be  brought  to  bear  upon  the  case  by  the  operating  surgeon  or  the  theory 
under  which  the  treatment  of  the  wound  may  be  carried  out. 

Osteotomy  as  an  exten.sion  of  subcutaneous  surgery  to  bones  is  a  great  advance,  and 
if  not  practised  rashly  is  a  valuable  operation.  Its  special  application  to  special  cases 
has  received  consideration  in  former  chapters. 

BONE-SETTING. 

Bone-setters  have  acquired  a  position  in  this  country,  and  the  fact  must  be  accepted 
as  conclusive  evidence  that  surgeons  have  in  a  manner  failed  to  give  to  the  public  the 
relief  that  has  unquestionably  been  given  by  their  unqualified  and  so-called  ignorant 
fellow-workers,  rather  than  as  an  additional  testimony  to  the  acknowledged  preference 
which  a  large  number  of  the  public  undoubtedly  have  for  the  .strong  assertions  and  pro-  . 
fessed  power  of  charlatans  and  quacks  over  the  calmer  views  and  less  dogmatic  dicta  of 
the  scientific  school. 

With  this  feeling  I  propose  to  con.sider  briefly  where  it  is  that  our  faults  lie  and  how 
it  is  that  they  are  to  be  remedied.  And,  first  of  all,  where  is  it  that  surgeons  have 
failed?  That  the  failure  belongs  more  to  the  surgery  of  the  joints  than  anywhere  else 
is  a  truism,  for  the  f\^vorite  expression  of  the  bone-.setter  that  he  has  "  put  in  '  what  was 
"  out  "  before  is  a  well-known  phrase,  and  that  the  process  of  putting  in  is  some  sudden 


902  ON  GUNSHOT  INJURIES. 

forcible  movement  of  the  joint  in  the  way  it  sliould,  hut  would  not,  go,  with  free  move- 
ments of  the  joint  in  all  possible  directions,  is  a  well-recognized  form  of  practice. 

The  conclusion  therefore  is  tolerably  clear  that  where  success  follows  the  bone-setter's 
effort  movement  is  given  to  a  joint  in  which  little  or  but  impaired  movement  previously 
existed,  and  that  this  is  effected  by  the  breaking  down  of  adhesions,  either  in  the  joint 
itself  or  in  the  muscles  and  soft  parts  about  the  joint.  In  fact,  his  operation  consists  in 
the  sudden  rupture  or  freedom  of  parts  that  forbade  the  free  movement  of  the  articulation. 

Nothing  need  be  said  about  the  clicks,  snaps,  and  sounds  which  are  made  to  tickle  the 
ears  of  the  patients  and  to  make  them  understand  how  something  that  Avas  out  went  into 
place,  since  these  are  only  "tricks  of  the  trade,"  adjuncts  to  the  empiric's  art,  employed 
to  secure  the  patient's  belief  in  his  assertions. 

In  one  case  a  tendon,  a  rigid  muscle,  or  a  nerve  is  doubtless  freed  where  it  was  before 
fixed.  In  another  an  old  adhesion  which  gave  pain  when  extended  is  suddenly  snapped. 
In  a  third  possibly  some  displaced  tissue  or  slipped  tendon  is  restored  to  its  right  place, 
some  fibro-cartilage  in  a  joint  is  replaced.  In  rarer  cases,  after  fracture,  some  osseous 
union  is  broken  through.  In  all,  however,  the  result  is  the  same :  movement  is  given 
where  before  it  did  not  exist  or  free  movement  is  acquired  where  painful  movement  was 
previously  experienced. 

The  experience  of  general  surgeons  could  produce  ample  proof  that  there  are  evils 
connected  with  the  practice.  The  present  writer  has  seen  many  ill  results.  In  one  an 
impacted  fracture  of  the  neck  of  the  femur  undergoing  natural  repair  was  ruthlessly 
broken  up  and  comminvited  and  the  man  rendered  an  irremediable  cripple.  In  another  an 
elbow  which  had  been  dislocated  and  reduced,  and  in  which  some  stiffness  followed,  was 
hoplessly  disorganized  by  rough  and  needless  manipulation.  A  hip-joint  undergoing  a 
good  cure  with  anchylosis,  having  been  broken  down,  underwent  suppuration,  which  ended 
in  the  death  of  a  valued  life  which  would  otherwise  have  been  spared. 

These,  and  more  than  these,  speaking  cases  illustrate  the  dangers  of  a  practice  which 
has  much  good  in  it  if  rightly  directed,  and  likewise  much  evil  if  wrongly  and  recklessly 
undertaken,  especially  if  undertaken  without  knowledge  of  or  care  for  a  scientific  diag- 
nosis before  treatment. 

It  is,  however,  the  surgeon's  duty,  in  these  as  in  all  other  cases,  to  seize  the  good  and 
avoid  the  evils  of  a  practice  which — doubtless  by  chance — at  times  does  much  good,  and 
there  is  no  doubt  that  for  fear  of  doing  harm  surgeons  often  let  the  good  go,  and  thus 
allow  their  patients  to  pass  into  the  hands  of  charlatans. 

The  surgeon  ought,  therefore,  in  cases  of  stiff  joint,  more  particularly  after  sprains 
and  injuries,  when  all  signs  of  overaction  or  inflammation  have  subsided,  gave  an  anaes- 
thetic and  employ  sudden  forcible  movement.  He  ought  to  guard  against  stiff  joints  in 
the  treatment  of  those  injuries  by  employing  passive  movements  earlier  in  the  progress 
of  the  case  than  he  has  been  wont  to  do.  In  many  obscure  affections  of  joints  and  limbs 
the  result  of  twists,  sprains,  or  injuries,  he  ought,  for  diagnostic  as  well  as  curative  pur- 
poses, to  give  an  anajsthetic  and  so  to  manipulate  the  joint  and  limb  as  to  discover  if  pos- 
sible, and  to  dislodge  or  replace  if  present,  what  evidently  interferes  with  motion  at  the 
time  and  may  continue  to  do  so  in  the  future. 

In  cases  of  limited  disease  of  the  joints  there  is  no  doubt,  also,  that  much  may  be 
done  to  prevent  stiffness  and  to  correct  it  when  present,  but  in  such  cases  a  great  appre- 
ciation of  the  changes  in  and  about  the  joint  which  preceded  the  stage  of  stiffness  is  all- 
important — first,  as  a  guide  to  know  what  prospects  there  may  be  of  giving  the  move- 
ment that  is  so  desired ;  and  secondly  as  to  the  risks  tJiat  must  be  run  to  obtain  it. 

When  the  anchylosis  or  stiffness  has  been  brought  about  by  a  long  series  of  joint 
changes,  any  attempt  to  break  down  united  parts  must  of  necessity  be  difficult,  futile, 
and  dangerous  in  the  extreme. 

When  it  is  probably  due  to  some  peri-articular  inflammation,  the  prospects  of  obtain- 
ing a  good  result  are  better.  At  the  same  time,  it  is  to  be  admitted  that  the  ultimate 
results  of  breaking  down  adhesions  about  or  in  joints  that  are  the  result  of  disease  with 
the  view  of  giving  movement  are  not  satisfactory.  Movement  for  a  time  may  be  secured, 
but  the  state  of  immobility  is  again  soon  reached. 

On  the  whole,  by  way  of  summary,  it  may  be  said  that  the  stiffness  of  a  joint  follow- 
ing a  sprain  or  injury  may  generally  be  treated  with  success  by  rapid  manipulation,  fol- 
lowed up  by  passive  movements  through  the  entire  range  of  joint  movements,  whereas 
the  stiffness  of  a  joint  due  to  disease  can  rarely  be  so  treated  without  harm. 

But  in  no  case  should  forced  flexion  or  movement  be  employed  when  any  local  signs 
of  inflammation  are  present. 


A  y. ESTHETICS.  li"J3 

C'llAPTKK    XXXV. 
A.\  j:st  II  i;t  I  cs. 

General  Remarks. 

WiiK.N  Sir  II.  |);ivv's  attfiitiuii  was  diawii  in  IT'.'S  to  Priestley's  nitrou.s  oxide  f:as  by 
Ih".  .Nliti-lu'll  .-^  tliiMtry  that  this  ;^as  •*  wa.s  the  |iriiici|»le  of  eoDta^'iuii  and  cajialde  <if"  yro- 
dueinjj  the  must  terrihle  eHuets  when  resjiired  liy  aiiiiual.s  in  the  minutest  (juantities,  or 
even  when  upplii-d  to  the  skin  or  museular  tihre,''  and  when  he  with  Southey,  the  then 
poet-hiureate,  and  Coleridjre,  the  ]diilusoi»her,  inhaled  it  with  suffieient  l're<|uency  "to 
estahlish  the  t'aet  that  the  ga.s  i)osses.st'.s  an  into.vieating  quality  to  whieh  the  enthusia.sm 
of  persons  submitting  to  its  ojieration  ha.s  imparted  a  eharacter  of  e.xtravajrance  wholly 
ineonsistrnt  with  truth"  ( //('/'■  <>/  V'l'i/.  by  Paris,  ISIJlj — he  little  thouj_'ht  he  was  then 
layini:  the  basis  of  experimental  iuvestiLMtions  that  were  t(»  form  an  epoch  in  the  hi.story 
of  the  world — or,  rather,  of  mankind — and  to  end  in  the  introduction  into  jiractice  of  a 
new  ]>ower,  which,  being  of  inestimaliie  value  ty  the  general  jiublic,  is  of  nearly  e(|ual 
value  to  the  medical  jirofessiun,  and  has  been  the  means  of  revolutionizing  surgery  to  an 
extent  of  which  few  are  aware;  for  the  -most  terrible  effects"  with  which  thi.s  gas  wa.s 
credited  have  been  transformed  into  the  beneticial  effects  brought  about  l»y  anaesthetics. 

In  th.e  ju'esent  work  I  have  neither  .space  nor  inclination  t(t  go  fully  into  the  history 
of  the  subject.  To  the  works  of  Snow,  Sir  James  Simi>.son.  Saiisom,  J)ruitt.  Holmes.  Dr. 
Marion  Sims,  and  MM.  Perrin  and  Lallemand  I  must  refer  the  reader  for  full  [larticular.s 
on  this  subject.  I  shall  content  my.self  by  recording  the  fact  that  Dr.  Crawford  W.  Long 
of  Athens.  Georgia,  was  the  first  surgeon  who,  in  March,  1842,  performed  a  surgical  ope- 
ration while  the  patient  was  completely  anaesthetized  by  the  inhalation  of  sulphuric  ether. 
Dr.  Marion  Sims  (  Viiyinin  Mediial  MmitliJi/,  May.  1877)  remarks  '"that  the  honor  of  the 
first  public  and  authentic  trial  of  surgical  amvsthesia  by  the  aid  of  means  newl}-  dis- 
covered belongs  to  an  entirely  obscure  dentist,  Horace  Wells  of  Hartford.  Connecticut " 
(M.  Perrin),  this  dentist  having  emjiloyed  Davy's  nitrous  oxide  gas  in  dentistry  in  184tr 
with  an  excellent  result.  In  lS4(i.  Morton,  Wells's  late  partner,  introduced  into  practice 
at  the  Massachusetts  Hospital  the  use  of  sulphuric  ether,  probably  on  the  suggestion  of 
Dr.  Jackson.  In  1S47  our  own  Lawrence  of  St.  Bartholomew's,  on  the  suggestion  of  a 
student — Mr.  Furnell.  now  principal  of  ^Madras  Medical  College — used  chloric  ether  for 
the  same  purpose  (Ilofi)irs's  S^sf..  vol.  v.  2d  ed),  and  in  the  autumn  of  the  same  year  Sir 
James  Simpson  gave  to  the  profession  the  active  principle  of  the  chloric  of  ether,  the 
chloroform,  on  the  suggestion  of  Mr.  Waldie  of  Liverpool,  and  since  then  this  drug  or 
ether,  separately  or  combined,  has  been  in  general  use. 

Other  anaesthetics,  however,  have  been  introduced,  the  bichloride  of  methylene  being 
the  most  popular. 

How  aujvsthetics  act  upon  the  body  is  not  yet  determined,  although  it  is  tolerably 
certain  that  the  ultimate  result  is  al>.solute  paraly.sis  of  the  nerve  centres,  cerebral  and 
spinal.  To  this  end  a  patient  pas.ses  through,  frsf,  a  stage  of  cerebral  excitement  ;  »'.//, 
cerebral  insensibility  and  loss  of  sensation  ;  fhin////.  loss  of  voluntary  motion  ;  and  Insf/i/, 
loss  of  reflex  action,  the  brain  losing  its  power  before  the  spinal  cord,  absolute  paralvsis 
and  anaesthesia  existing  only  when  both  nerve  centres  are  completely  under  the  influence 
of  the  inhaled  drug,  the  nerve  supply  of  the  respiratory  and  circulatorv  .systems  alone 
excepted.  Indeed,  it  is  upon  this  fact  that  the  practical  value  of  all  antvsthetics  is  based, 
the  surgeon  aiming  at  producing  paralysis  of  the  mu.scles  of  the  trunk  and  extremities 
only,  and  not  those  of  the  respiratory  or  circulatory  .sy.stems.  In  a  general  way.  there  is 
a  wide  interval  between  the  two  effects.  In  exceptional  instances  this  interval  is  abridged; 
in  such  the  heart  and  respiratory  .system  suddenly  become  affected,  and  it  is  under  these 
circumstances  that  sudden  death  takes  place. 

Chloroform,  like  many  other  drugs,  does  not  act  alike  in  all  individuals,  some  beinir 
very  susceptible  to  its  influence,  whilst  others  are  the  reverse.  Like  all  anfe.sthetics,  it 
at  first  increases  the  force  of  the  heart's  action,  although  this  effect  is  slight  and  transient, 
the  heart  acting  with  less  than  its  natural  force  when  complete  anaesthesia  is  produced. 
When  a  patient  is  brought  quickly  under  the  influence  of  an  anaesthetic,  the  hearts 
action  may  be  suddenly  arrested.  Brown-Sequard  believing  that  under  such  circumstances 
63 


994  ANESTHETICS. 

'•it  is  by  the  reflex  influence  due  to  the  sudden  irritation  of  the  branches  of  the  par 
vagum  in  the  lungs  that  chloroform  has  killed  in  the  very  rare  cases  in  which  the  hearts 
action  had  been  stopped  before  the  respiration"  (Li^ct.  on  Phi/.-i.  of  Nerve  Si/Hfem). 

Moderate  doses  of  chloroform  tend  to  weaken  the  heart's  action  after  their  first  stimu- 
lating effects  have  passed  away,  the  respiratory  act  usually  ceasing  before  the  circulatory 
when  death  is  the  result.     Thus,  danger  increases  with  the  degree  of  stupor  produced. 

Ether  is  said  not  to  depress  the  action  of  the  heart  to  the  same  extent  as  chloroform. 
Of  late  it  has  grown  rapidly  into  favor,  and  it  is  said  by  its  advocates  to  be  more  safe 
than  any  other  ansesthetic.  It  should  be  given  with  sufficient  freedom  to  bring  the 
patient  under  its  influence  before  the  blood  becomes   saturated. 

When  the  upper  eyelid  can  be  raised  without  muscular  re.sistance  and  no  muscular 
contraction  is  caused  by  touching  the  cornea,  the  patient  is.  as  a  rule,  sufficiently  under 
the  influence  of  the  anaesthetic  for  surgical  purposes. 

Respiration  generally,  but  not  invariably,  ceases  before  the  action  of  the  heart,  and 
death  may  be  due  either  to  the  failure  of  the  heart's  action  or  to  that  of  the  respiratory 
function. 

After  death  all  the  cavities  of  the  heart  are  distended,  the  cases  in  which  the  left  side 
is  empty  being  only  exceptional.  Chloroform  is  more  commonly  fatal  in  the  struggling 
stage  than  in  any  other. 

Billroth  asserts  "  that  during  the  stage  of  excitement  violent  muscular  efforts  may 
give  rise  to  apoplexy,  especially  in  individuals  with  disease  of  the  heart,  rigid  arteries,  or 
emplrvsema.  Of  mo.st  consequence  in  this  stage,  however,  are  the  contractions  of  the 
muscles  of  mastication  and  the  posterior  muscles  of  the  tongue.  By  means  of  the 
stylo-glossi  and  the  glosso-pharyngei  the  tongue  is  drawn  spasmodically  backward,  press- 
ing the  epiglottis  down  so  as  to  close  mechanically  the  aperture  of  the  larynx.  Such 
patients  become  blue  in  the  face  and  die  suffocated — not  through  the  direct  action  of  the 
chloroform,  but  from  the  mechanical  privation  of  air."  unless  the  tongue  be  well  drawn 
forward  or  the  chin  tilted  upward. 

Anaesthetics  affect  the  brain  of  different  people  in  as  many  ways  as  drunkenness.  One 
will  be  quarrelsome,  a  second  violent,  a  third  sentimental,  and  others  maudlin,  melan- 
cholic, or  merry. 

In  epileptic  subjects  I  have  seen  patients  pass  through  some  epileptic  convulsions 
during  their  progress  toward  narcosis. 

The  best  rules  for  the  administi-ation  of  chloroform,  ether,  or  any  anaesthetic  are  those 
given  by  the  chloroform  committee  of  the  Royal  Medical  and  Chirurgical  Society  of 
London  (1864).  It  was  my  privilege  to  act  as  one  of  the  members  of  that  body,  and  all 
my  subsequent  experience  has  convinced  me  of  the  value  of  the  suggestions  then  laid 
down.     I  quote  them  in  full,  with  only  a  few  modifications. 

Rules  relating  to  the  Administration  of  Anesthetics. 

Anaesthetics  .should  on  no  account  be  given  carelessly  or  by  the  inexperienced ;  and 
when  complete  insensibility  is  desired,  the  attention  of  the  administrator  should  be  exclu- 
sively confined  to  the  duty  he  has  undertaken. 

Under  no  circumstances  is  it  desirable  for  a  person  to  give  an  anjesthetic  to  himself. 

It  is  not  advisable  to  give  an  anfesthetic  after  a  long  fast  or  soon  after  a  meal,  the 
best  time  for  its  administration  being  four  or  five  hours  after  food  has  been  taken. 

If  the  patient  is  much  depressed,  there  is  no  objection  to  his  taking  a  small  quantity 
of  brandy,  wine,  or  ammonia  before  commencing  the  inhalation. 

Provision  for  the  free  admission  of  air  during  the  patient's  narcotism  is  absolutely 
necessary. 

The  recumbent  position  of  the  patient  is  preferable  ;  the  prone  position  is  inconvenient 
to  the  administrator,  but  entails  no  extra  danger.  In  the  erect  or  .sitting  po.sture  there  is 
danger  from  syncope.     Sudden  elevation  or  turning  of  the  body  should  be  avoided. 

An  apparatus  is  not  essential  to  safety  if  due  care  be  taken  in  giving  the  anesthetic. 
Free  admixture  of  air  with  the  anjesthetic  is  of  the  first  importance,  and.  guaranteeing 
this,  any  apparatus  may  be  employed.  If  lint  or  a  handkerchief  or  a  napkin  is  used,  it 
should  be  folded  as  an  open  cone  or  held  an  inch  or  an  inch  and  a  half  from  the  face. 

Chloroform  should  invariably  be  given  slowly.  Sudden  increase  of  the  strength  of 
the  anaesthetic  is  most  dangerous.  Three  and  a  half  per  cent,  is  the  average  amount, 
and  four  and  a  half  per  cent.,  with  ninety-five  and  a  half  of  atmospheric  air,  is  the 
maximum  of  the  anaesthetic  which  can  be  required,  given  cautiously  at  first,  the  quantity 


A  N.ESTIIKTICS.  !»!»5 

within  tliis  limit  ln-iiiL.'  >l<>\vly  iiificuNfil  acfonliii;;  to  tliu  iit;i!L'.s>itii's  of  tlu;  cum.',  the 
ailiiiiiii.stnitor  h«-iii<;  ^iiidt-d  niori'  hy  its  etf'ect  on  tliu  patietit  than  by  tlie  amount  cxliih- 
itftl.      KthtT  may  he  jrivi-ii  mori'  Ixthlly. 

'IMio  aihiiinistrator  .shwiihl  watch  tht*  rusiiitutimi  ot'  hi>  patient,  ami  iniist  keep  mie  hand 
free  fur  earefiil  ohservatinn  of  the  pulse. 

When  palient.s  hohi  their  hreath,  more  air  should  he  admitted;  and  when  the  move- 
ment of  swallowing  is  seen,  it  should  hi-  accepted  as  evidence  that  the  an.esthetic  i.s 
.Htroni;er  than    necessary.      On   any   soiiml   of  stertor   IVesh   air  sliouhl    he   admitted. 

The  patient  who  apjtears  likely  to  vomit  whilst  he^innin^  to  inhale  the  an;i'sthetic 
must   at    once  he  hroiijiht    I'ully  under  its   influence;    tlu;   tendency  to  sickness  will  then 


ceas* 


The  occurrence  duriuL'  the  ailministration  of  an  aujosthetic  of  sudden  pallor,  lividity 
of  the  patient's  countenance,  or  sudih-n  failure  or  flickeriuir  of  the  ]»ulse,  or  fcehlo  or 
shallow  respiratittns,  indicates  danger  and  necessitates  immediate  withdrawal  «jf  the  an;es- 
thotic  until  su(di  svinptoms  have  disappeared.  The  chin  should  he  raised  as  much  as 
possible  fnun  the  sternum  ,  and  if  this  movement  fail  to  open  the  larynx,  tlie  toiifjuc 
»huuld  he  jniUeil  forward  and  the  head  drawn  back. 

Nelaton  and  Marion  Sims  advise  the  inversion  of  tlie  body,  with  the  view  of  throwing 
what  blood  there  is  wholly  to  the  brain,  on  the  theory  that  death  IVoni  chloroform  is,  as 
a  rule,  due  to  syncope  or  to  cerebral  amvmia.  In  the  more  threateiiiii'.''  cases  commence 
instantly  with- artificial  respiration,  whether  the  respiration  has  failed  alone  or  the  jiulse  and 
the  res]>iration  together.  (Jalvanism  may  be  used  in  addition  to  artificial  res])iration,  but 
artificial  respiration  is  on  no  account  to  be  delayed  or  suspended  in  order  tluit  galvanism 
may  be  tried. 

In  extreme  cases  larynj^otijmy  may  be  re(|uired. 

Few.  if  any.  are  insuscei)tible  to  the  influence  of  anivstlietics.  from  two  to  ten  minute.s 
beiui;  rei|uired  to  induce  aiutsthesia.  The  time  varies  accordinir  to  atre,  temperament,  and 
habits. 

The  mixture  of  alcohol  (jne  part,  chloruform  two  ])arts,  and  ether  three  jiarts,  which 
should  be  mixed  fresh  before  use,  should  be  given  in  the  same  way  as  chloroform  alone, 
care  being  taken,  when  lint  or  a  handkerchief  is  u.sed,  to  prevent  the  too  free  escape  of 
the  vapor. 

In  Vienna  the  favorite  mixture  is  three  parts  of  ether  to  one  of  chloroform.  Billroth 
employs  chloroform  three  parts,  ether  one  part,  and  alcohol  one  part. 

Use  of  Anesthetics  in  Surgical  Operations. 

Any  person  fit  for  a  severe  operation  is  a  fit  subject  for  an  anaj.sthetic,  but  no  one  i.s 
so  free  from  danger  that  care  in  watching  its  effects  can  be  dispensed  with.  The  cases 
rer|uiring  the  greatest  vigilance  are  not  the  young  and  delicate,  for  whom  a  small  dose 
suffices,  but  the  strong,  who  inhale  deeply  and  struggle  much.  Ether  is  probablv  better 
for  those  suspected  of  fatty  degeneration  of  the  heart,  although,  as  a  rule,  such  cases  are 
eminently  satisfactory  under  chloroform. 

In  phthisis,  when  an  operation  is  unavoidable,  antx^sthetics  may  be  given  with  impunity. 

For  all  iiperations  upon  the  jaws  and  teeth,  the  lips,  cheeks,  and  tongue,  anaesthetics 
may  be  inhaled  with  ordinary  .safety.  By  care  and  good  management  the  patient  may  be 
kept  under  their  influence  to  the  completion  of  the  operation.  In  these  ca.ses  blood,  "as  it 
escapes,  if  not  voided  by  the  mouth,  passes  into  the  pharynx.  If  any  small  (|uaiitity 
finds  its  way  through  the  larynx,  it  is  readily  expelled  by  coughing.  In  ojierations  u])on 
the  soft  palate,  fauces,  pharynx,  and  posterior  nares,  if  .sudden  or  severe  hemorrhage  is 
likely  to  occur,  it  is  not  advisaltle  to  induce  deep  insensibility.  In  ca.'*es  re((uiring  larvn- 
gotomy  and  tracheotomy  anaesthetics  may  be  employed  with  safety  and  advantatre. 

For  operations  upon  the  eye  involving  the  contents  of  the  globe  the  use  of  an.fstheties 
is  open  to  objection,  on  account  of  the  damage  which  the  eye  may  sustain  from  muscular 
straining  or  vomiting.  If  employed,  profound  in.sensibility  should  be  induced.  Keeent 
experience  tends  rather  to  prove  that  ansesthetics  may  be  used  without  fear  in  most  eye 
operations. 

In  operations  for  hernia  and  in  the  application  of  the  taxis  ansesthetics  act  most  bene- 
ficially. For  most  operations  about  the  anus  and  perinwum  profound  anaesthesia  is 
positively  demanded. 

In  the  condition  of  shock  or  of  great  depression,  as  after  hemorrhage,  the  careful 
administration  of  ana;sthetics  diminishes  the  risk  of  an  operation. 


996 


ANESTHETICS. 


In  all  cases  other  than  those  sj^ecially  referred  to  it  is  sufficient  to  state,  so  far  as  a 
mere  surgical  operation  is  concerned,  that  anaesthetics  may  invariably  be  administered. 

The  continuous  vomiting  occasionally  induced  by  and  following  upon  the  inhalation 
of  anaesthetics  may  be  injurious  by  consequent  exhaustion  as  well  as  by  mechanically 
disturbing  the  repair    of  a  wound.     With  this  reservation,  they  do  not  appear  to  inter- 
fere   with    the    recovery  of   patients   from 
surgical  operations. 

The  results  of  2586  capital  operations 
performed  before,  and  of  1847  performed 
since,  the  introduction  of  anaesthetics,  which 
I  collected  from  all  authentic  available 
sources,  show  that  the  rate  of  mortality 
has  not  been  increased,  even  though  much 
graver  operations  have  been  done  under 
the  influence  of  anaesthetics.  The  risk 
attending  the  inhalation  of  chloroform  is 
-  very  small,  being  about  1  in  3000  admin- 
istrations. This  is  enough  to  forbid  its  use 
in  trivial  cases,  but  not  enough  to  do  so  in 
cases  of  capital  operation  or  where  it  is  re- 
quired for  purposes  of  diagnosis.  In  chil- 
dren it  is  very  safe. 

The  best  instrument  for  the  administra- 
tion of  chloroform  I  believe  to  be  that  of  Junker  (Fig.  686).  In  it  a  drop  of  chloroform 
vapor  is  vaporized  by  each  full  compression  of  the  air-ball  and  a  stronger  vapor  cannot 
be  given.  It  may  be  employed  without  the  mouth-piece.  If  the  ball  is  compressed 
before  each  insi^iration,  no  vapor  will  be  lost.  I  use  nothing  but  this  in  my  own  practice. 
The  older  instrument  which  I  introduced  at  Gruy's  in  1864  (Fig.  687)  is,  however,  porta- 
ble and  good.  It  is  not  complicated  by  any  valves,  but  is  merely  a  mouth  and  nose-piece 
lined  with  lint,  with  openings  to  admit  air  freely.  Within  the  last  few  years  Skinner's 
inhaler,  composed  of  a  framework  of  wire  covered  with  a  layer  of  flannel,  fastened  to  the 
frame  by  a  gusset  and  tape,  and  a  handle,  has  found  much  favor  and  is  very  useful. 

Clover's  apparatus  is,  however,  very  good  when  it  can  be  obtained.  It  is  composed  of 
an  india-rubber  bag  into  which  chloi'oform  or  any  other  anaesthetic  is  pumped,  mixed  with 
atmospheric  air.  Clover  employs  three  or  four  per  cent,  of  chloroform.  It  is,  however, 
a  cumbersome  apparatus  and  cannot  be  at  universal  command.     When  he  gives  nitrous 


Junker's  Chloroform  Inhaler. 


Fig.  6S 


Fig.  688. 


Chloroform  Inhaler. 


Inhaler  with  Bottles  and     Perforated  Inhaler  as  Ap- 

Strap  Complete.  plied.    (Rendle"slnlialer, 

as  improved  by  Morris.) 


oxide  gas  at  flrst  and  follows  it  up  by  ether,  his  apparatus  is  equally  satisfactory.  For 
ether  or  the  anfesthetic  A.  C.  E.  mixture  the  leather  bottle-shaped  apparatus,  as  sug- 
gested by  Dr.  Golding  Bird,  or  the  one  figured  above  as  made  for  Mr.  Eendle  and 
improved  by  3Iorris  (Fig.  688),  is  very  valuable. 

The  bichloride  of  methylene  is  recommended  to  our  notice  as  an  anre.sthetic  of 
great  power.  Patients  are  said  to  be  brought  under  the  influence  of  the  drug  in  twenty 
or  thirty  seconds,  and  to  recover  from  it  rapidly  with  little  inconvenience.  No  sickness 
or  headache  is  said  to  follow  its  use,  unless  the  inhalation  has  been  continued  for  many 
minutes  or  a  second  dose  is  given  to  keep  up  the  effect.  Of  course,  if  the  inhalation  be 
prolonged,  the  after-eff"ects  resemble,  though  in  a  less  degree,  those  of  chloroform,  .save 
the  one — absence  of  muscular  excitement. 


AS.r.sTiiiyriCS.  007 

Dr.  Bouchut  ((itixittc  (ha  Ilnplttiiu)  recuiuinciiils  tlio  use  of  chloral  as  an  aiifi'sthctic 
for  i-liiltlrcii.  lit'  ^ivcs  one  dosi;,  not  fXCfiMJiii;,'  rnrlv-live  jrrain.s,  in  rliililrcn  umlcr  tiiree 
yoars  of  aj^o.  In  half  an  hour  the  patient  is  ash'i'|i.  anti  in  an  hi»ur  insfn.sihle.  The  anius- 
thesia  lusts  fnnii  three  tn  six  hours  and  is  l'i)ll()\vetJ  hy  no  nM|ili'asant  eonser|iienees. 
Thirty  j^rains  may  he  t^iven  without  dan;;er,  liouehut  suys,  tn  cliililitn  lietwcen  twn  and 
five  years  id'  ajre  (  lin't.  Mni.  ,/inini.,  Novenilier  HI,  1H7.S). 

In  ahdouiinal  surjxery,  such  as  ovariotuniy,  Keith  has  said  that  ether  is  less  prone  to 
he  followed  liy  sickness  than  chloroform  ;  and  if  the  success  of  an  operation  is  any  ar^ru- 
inent  in  its  I'avor,  Keith's  must  he  ((uoted.  I  have  for  some  years  emplr)yed  the  mixture 
recommendetl  hy  the  chloroform  committee — of  alcohol,  chloroform,  and  ether — and  think 
wtdl  of  it.  I  helieve  it  to  he  as  •rimd  as  chloroform,  and  less  likely  than  any  other  t<j  he 
followed  hy  that  hane  of  all  amesthetics,  vomitinLT. 

In  the  operations  of  dentistry  and  all  short  measures  the  nitrous  oxide  gas  is  of  great 
value. 

After  the  use  of  any  an;esthetic  everything  should  he  given  cold  for  twelve  or  tweiitv- 
four  hours,  to  prevent  sickness;  ice,  indeed,  may  he  sucked  with  advantage,  ami  ic(;  and 
milk  form  a  very  favorite  mixture.  If  hot  food  he  given,  vomiting  is  far  more  likely  to 
appear  or  to  he  aggravated. 

Secondary  Uses  of  Anesthetics. 

Anjesthetics,  however,  have  other  uses  than  tlie  destruction  of  pain.  As  aids  to  diag- 
nosis they  are  of  priceless  value,  both  to  the  jjhysician  and  to  the  surgeon.  To  the  sur- 
geon they  have  al.so  opened  up  new  fields  for  his  scientific  art  which  were  formerly  hut 
little  known.  I  shall  point  them  out,  liowever,  but  briefly,  quoting  from  a  lecture  I  had 
the  honor  of  delivering  at  the  Ilunterian  Society  in  1<S70  : 

"  Chloroform  as  an  aid  to  diagnosis  stands  second  to  no  means  which  we  have  at  our 
disposal.  T(t  the  physician  who  has  a  difficult  case  of  abdominal  tumor,  what  facilities  it 
gives  him  for  its  thorough  investigation  !  Suspected  tumors  become  jdiantoms  :  so-called 
movable  kidneys  slide  away  and  indefinite  conditions  become  clear  and  intelligible.  With 
how  much  greater  certainty  a  physician  can  think  over  a  doubtful  case,  decide  upon  its 
nature,  deliver  his  opinion,  and  treat  it,  when  he  has  adopted  this  means  of  investigation  ! 
In  hysterical  subjects  it  renders  a  thorough  abdominal  examination  a  possibility  when  no 
such  otherwise  existed,  and  in  what  class  of  cases,  may  I  ask,  is  it  more  necessary  to 
make  a  positive  diagnosis  than  in  this  ?  In  my  own  practice  it  enabled  me  on  one  occa- 
sion to  make  out  a  pregnancy  when  an  ovarian  tumor  had  been  diagnosed  by  men  whose 
authority  was  undoubted,  and  in  a  patient  who.se  position  in  life  rendered  the  suspicion 
of  pregnancy  almost  a  libel.  Indeed,  the  ovarian  nature  of  the  disease  was  looked  upon 
as  so  decided  that  my  aid  was  sought  solely  for  the  operation.  In  this  ca.se  an  examina- 
tion of  the  abdomen  was  impossible,  from  hysterical  sensibility  ;  but  under  chloroform  all 
difficulties  disappeared.  To  the  physician-accoucheur  may  I  not  also  assert  it  to  be 
e(|ually  valuable  for  diagnostic  ])urpo,ses?  To  answer  this  fully  is  out  of  my  province, 
but  I  have  known  a  case  of  cystic  disea.se  of  the  uterus  which  was  about  to  be  operated 
upon  as  an  ovarian  tumor  made  out  ))y  the  use  of  the  uterine  .sound,  with  the  patient 
under  chloroform,  when  an  examination  by  the  .same  in.strument  made  before  had  failed 
to  yield  any  such  evidence.  In  the  surgical  diseases  of  children  is  it  possible  to  overesti- 
mate its  value  ?  With  what  gentleness  can  difficult  examinations  be  now  made  of  injured 
limbs !  and  with  what  certainty  can  we  now  apply  our  treatment  !  In  sounding  for  stone 
what  facilities  it  affords !  In  general  surgery  what  new  fields  has  it  not  opened  ?  Would 
nephrotomy  or  nephrectomy  have  been  entertained  ?  Where  would  ovariotomy  have 
now  been,  may  I  ask,  had  not  chloroform  been  in  use?  Would  it  have  been  an  estab- 
lished operation  in  surgery  ?  Could  it  have  been  so  succes.sful  ?  The  answers  to  the.'se 
questions.  I  think,  are  plain  :  they  must  be  in  the  negative.  It  is  true  the  operation  had 
been  performed  before  its  introduction  ;  it  had  been  succe.ssful  in  a  few  cases,  but  it  had 
almost  fallen  out  of  practice  ;  its  revival  was  due,  without  doubt,  to  chlorofm-m,  and  its 
present  estal>lished  position  to  the  general  use  of  that  drug.  Xo  operation  re(|uires  more 
gentleness  and  nicety,  and  how  could  these  essential  points  of  practice  be  apjilied  with  a 
patient  writhing  under  the  agonies  of  an  abdominal  section?  To  all  abdominal  surgery 
the  same  observations  are  applicable,  although  they  may  not  tell,  perhaps,  with  the  same 
force.  Without  anaesthetics  could  Bigelow  have  perfected  his  rapid  lithotrity  ?  and 
would  Thompson  have  practised  so  boldly  his  operation  of  cystotomy  for  the  removal  of 
bladder  tumors  ? 


998  ANJESTHETICS. 

"  Let  us  now  refer  to  another  class  of  cases — to  that  Large  one.  known  as  belonging  to 
plastic  surgery.  How  many  cases  of  vesico-  or  recto-vaginal  fistula  were  successfully 
treated  by  operation  before  chloroform  was  introduced  ?  At  Guy's  Hospital  I  can  find 
no  record  of  such.  The  physician-accoucheur  used  to  cauterize  the  margins  of  the  fis- 
tula, it  is  true,  but,  1  fear,  with  poor  success ;  for  I  have  never  heard  of  a  case  of  any 
size  being  so  cured.  At  the  present  day  these  cases  are  now  to  be  cured  by  operation 
with  as  much  certainty  as  any  other  class.  They  have,  in  truth,  been  removed  from  the 
incurable  to  curable  affections.  And  yet  these  instances  of  plastic  surgery  are  only  a 
portion  of  those  which  I  might  enumerate. 

"  In  the  treatment  of  deformities  about  the  mouth,  nose,  and  eye.  in  the  division  of 
cicatrices  after  burns,  in  the  ti'eatment  of  ruptured  perineum  with  all  its  complications, 
what  innumerable  cases  might  be  quoted  now,  against  the  few  of  former  times ! 

"  Again,  in  the  operations  on  bones  and  joints,  how  many  of  the  improvements  in  our 
practice  are  there  that  may  not  be  put  down  to  the  use  of  chloroform — operations  for 
necrosis  in  particular?  How  rare  these  were,  and  how  unsatisfactory  they  must  have 
been,  before  its  introduction  !  I  can  recall  a  few  which  I  saw  in  my  student's  days  with 
no  pleasant  feeling.  How  common  they  are  now,  and  how  successful !  Taking  Guy's  as 
a  type  of  the  metropolitan  hospitals,  an  operation  for  necrosis  can  always  be  found  for 
operating  days,  the  operation  is  so  frequent  and  so  satisfactory.  In  the  removal  of  bone 
from  joints,  in  the  excision  of  joints,  it  is  only  fair  to  believe  that  a  great  part  of  the 
success  which  now  attends  the  practice  is  to  be  attributed  to  the  use  of  an  anaesthetic. 
How  many  hands  and  feet  which  would  formerly  have  been  sacrificed  are  now  saved  by 
the  removal  of  diseased  bone  it  is  difficult  to  estimate.  Would  Sir  W.  Fergusson  have 
framed  the  phrase  '  conservative  surgery,'  and  could  it  have  been  adopted,  before  the 
introduction  of  chloroform  ? 

"  In  the  treatment  of  aneurisms  have  not  like  improvements  to  be  recorded  ?  Has 
not  chloroform  rendered  possible  the  cure  of  aneurism  by  pressure  ?  Has  it  not  also 
rendered  the  practice  of  torsion  of  arteries  for  the  arrest  of  hemorrhage  a  practical  suc- 
cess, thus  simplifying  surgery  ?  How  many  cases  of  strangulated  hernia  are  now 
reduced  which  in  former  times  would  have  been  submitted  to  strange  treatment  and  to  a 
delayed  operation  !  How  simple  it  has  comparatively  rendered  the  reduction  of  recent 
dislocations  !  Whei-e  are  now  the  pulleys,  the  ropes,  and  the  other  frightful  mechanical 
appliances  that  were  used  of  old  for  the  reduction  of  dislocations  of  the  hip-,  shoulder-, 
and  other  joi«ts?  Are  they  not  decaying  in  the  lumber-rooms  of  our  hospitals?  and 
has  not  the  use  of  chloroform  made  the  reduction  of  dislocations  by  manipulation  a 
reality?  On  one  occasion  I  reduced  with  ease,  by  manipulation,  a  dislocation  of  the 
elbow-joint  backward,  complicated  with  fracture  of  the  humerus,  which  would  pi'obably 
have  been  left  unreduced  before  the  introduction  of  the  anjesthetic,  and  more  recently 
the  head  of  the  humerus  dislocated  on  to  the  dorsum  of  the  scapula,  complicated  with 
fracture  through  the  tuberosities. 

"  Let  us  contrast  for  one  moment  the  operation  of  perineal  section  for  stricture  as  it 
was  and  is  now  performed.  Do  we  not  all  remember  it  as  one  of  the  most  unsatisfactory 
and  unsuccessful  of  surgical  operations?  Do  not  we  know  it  to  be  one  of  the  most  satis- 
factory and  successful?  Indeed,  I  might  continue  the  contrast  between  the  pre-an£es- 
thetic  period  and  the  present,  but  I  think  I  have  said  enough  to  show  that  to  the 
introduction  of  chloroform  many  of  our  best  improvements  in  surgical  practice  are  to  be 
attributed.  For  the  surgeon  it  does  away  with  all  excuse,  if  any  ever  existed,  for  huriy 
in  an  operation.  He  can  take  his  steps  in  it  with  deliberation  and  make  it  a  certainty. 
We  never  s-ee  now,  happily,  a  theatre  full  of  spectators  observing  the  operation  watch  in 
hand,  and  I  trust  there  are  few,  if  any,  surgeons  who  at  the  present  day  sacrifice  safety 
and  certainty  in  their  operations  for  expedition  and  display.  The  use  of  anaesthetics  has 
rendered  the  practice  of  surgery  safer,  surer,  and  more  scientific.  It  has  removed  dif- 
ficulties from  the  practice  of  our  art  which  before  were  insurmountable,  and  has  rendered 
possible  innumerable  things  that  could  not  in  former  times  have  been  entertained." 

Local  anaesthesia  may  be  brought  about  \)\  freezing  a  part,  as  suggested  by  Dr. 
J.  Arnott,  or  by  means  of  the  rapid  evaporization  of  pure  anhydrous  ether,  as  practised 
by  Dr.  B.  W.  Richardson.  Both  are  valuable  means  of  diminishing  pain  where  anaes- 
thesia by  inhalation  is  forbidden  or  inapplicable.  Arnott's  plan  is  carried  out  by  mixing 
up  finely-pounded  ice  in  a  gauze  net  or  thin  translucent  india-rubber  bag  with  half  its 
bulk  of  powdered  salt,  the  net  being  placed  over  the  part  to  be  benumbed.  If  well 
applied,  it  renders  the  skin  at  once  pale  and  bloodless ;  and  if  continued,  of  a  tallowy, 
death-like  aspect.     When  too  long  applied,  it  may  produce  frost-bite  or  chilblain. 


AMi'CJ.irios.  999 

|)r.  Uirliiinlsdn's  ttlicr  spray  is  a  iimrf  t'Ir;:atit,  as  it  is  a  more  cflTi'Ctual,  ni(»(k'  of 
ap|»lyiii;;  Ideal  aii:t'sllif>ia  than  icr.  It  is  workcil  l»y  liis  wctll-kiuiwii  a|i])aratus,  con- 
sist iiii;  of  a  tiilK'  with  iiulia-nililicr  hall  and  .second  sprinj;  hall  to  make  the  current  con- 
tinuous, the  air  hein>;   pumped  in    through 

this   tuhe   into   a   hottle    ennfainiuL:   anhy-  I'l'i-  'i^O. 

(Irons    ether   of  a    sp.   ;:r.   ^K~'-'.\   and    ot"  a  . 

hoilinti-lioint   of*  '.>(i°    Kalir.      Throujih   the  /• 

stopperi'tl  neck  ol"  this   hottle  a  ^lass   tuhe  ,i. "' 

is  ]>assed.  whitdi  rea(du'S  at  one  end  nearly  ^"^"^Nv/l^ 
t(t  the  hottom  of  the  hottle  and  at  the  other 
is  fitted  with  a  point  with  one  or  more  per- 
forations, throuuh  which  the  ether  is  forced 
in  a  fine  spray,  this  spray  lieinir  directed 
upon  the  ]»art  to  he  Itenumhed  (  Fi":.  (iS9). 

For  openinir  ahseesses.  takin--  out  snnill  ,„  ,;i,.|,ar,i.so..'s  Apparatus. 

tumors,  the  removal  of  external  )»ilcs,  and 

other  minor  o]>eratioiis.   this  local   an;csthesia   is  of  frrcat  value,  hut   in  graver  surfrical 
act.s  it  is  inapplicahle,  as  it  affects  only,  the  surliice  and  is  but  skin-deep  in  its  influence. 


CHAPTER    XXXVI. 

AMPUTATION. 

General  Remarks. 


When  a  limb  is  saved  by  the  excision  of  a  joint,  and  life  prolonged  by  the  application 
of  a  ligature  to  or  the  torsion  of  a  wounded  or  diseased  artery,  surgical  science  claims  a 
triumph  ;  and  surely  an  ef(ual  triumph  ought  to  be  accorded  to  her  when,  by  the  removal 
of  a  part  that  interferes  with  its  duties,  life  is  rendered  more  valuable,;  or  by  the  amputa- 
tion of  a  limb  that  is  irreparably  injured  or  diseased  death  is  averted.  To  say  that  ampu- 
tation is  an  opprobrium  of  our  art  is  to  take  a.  narrow  view  of  its  objects,  since,  as  the  first 
object  of  the  surgeon  is  (o  save  life,  the  necessary  sacrifice  of  a  limb  becomes  the  truest 
coiisorvadRm.  To  sacrifice  a  limb  unnecessarily  is  an  error  which  the  surgical  mind  would 
never  willingly  commit,  although  to  sacrifice  life  in  the  feeble  effort  to  save  a  limb  is  one 
of  far  greater  magnitude.  It  is  an  error,  however,  that  timid  surgeons  are  too  likely  to 
fall  into  when  inoculated  with  the  narrow  views  of  a  spurious  conservatism,  since  to  leave 
a  limb  alone  with  the  hope  of  saving  it  is  a  passive  act  of  the  professional  mind  that 
refjuires  no  effort,  wliilc  to  make  up  the  mind  to  act  recjuires  courage  backed  up  with 
knowledge  and  a  full  sense  of  responsibility.  The  operation  of  amputation  itself  re(|uires 
nicety  and  well-a]iplied  mechanical  skill,  but  to  determine  upon  its  necessity  or  other- 
wise requires  a  high  order  of  knowledge,  a  careful  lialancing  of  probabilities,  and  much 
deci.sion. 

It  is  not  my  intention  to  discuss  in  the  present  chapter  the  conditions  under  which 
amputation  may  be  called  for,  since  these  have  been  fully  considered  in  the  difierent 
chapters  devoted  to  such  injuries  and  diseases  as  may  require  this  treatment.  I  propose 
simply  to  consider  amputation  as  an  operation,  to  point  out  the  best  modes  of  its  perform- 
ance under  the  different  conditions  in  which  it  may  be  demanded,  and  to  describe  the 
various  forms  of  operation  as  applicable  to  different  parts. 

To  supply  the  history  of  amputation  would  be  an  interesting  but  a  too  extended 
process.  In  Cooper's  Sun/irn/  Dictiovnn/  and  Hohness  Si/stein  two  able  ax"ticles  will  be 
found  upon  the  subject  which  contain  all  that  can  be  desired.  For  the  present  purpose 
it  will  be  enough  to  state  that  the  first  amputations  were  performed  by  the  clrcuhtr  method, 
the  soft  parts  being  divided  down  to  the  l)one  by  a  circular  sweep  of  the  knife  {ri<h  Cel- 
sus),  the  hemorrhage  being  arrested  by  the  red-hot  iron  and  the  bone  divided  by  a  .saw. 

About  1718,  J.  L.  Petit,  the  French  surgeon  who  improved  the  tourniquet  now  known 
by  his  name,  as  well  as  our  own  great  surgeon,  Cheselden,  suggested  that  the  skin  and  fat 


1 000  AMP  UTA  TIOX. 

of  the  limb  to  be  removed  should  be  first  cut  throuuh  and  retracted  and  then  the  muscles 
and  bones  divided  as  high  as  they  were  exposed.  Still  later,  Louis  of  Paris  adopted  the 
practice  of  dividing  by  the  first  cut  the  skin  and  superficial  layer  of  muscles,  by  the  second 
the  deeper  muscles  down  to  the  bone  at  the  line  of  the  retracted  superficial  layer,  and 
lastly  the  bone  itself.     He  also  used  a  retractor. 

In  1779,  Alanson  of  Liverpool  made  a  still  further  advance  by  cutting  the  integument 
as  usual  and  allowing  it  to  retract  and  then  dividing  the  muscles  obliquely  upward,  cutting 
from  without  down  to  the  bone,  more  after  the  modern  flap  operation,  the  bone  being  sub- 
sequently divided.  The  soft  parts  in  this  operation  on  being  brought  down  formed  a  con- 
ical cavity  with  the  bone  at  the  apex,  Alanson's  object  having  been  to  prevent  the  sugar- 
loaf  stump.  Still  later,  Benjamin  Bell  of  I']dinburgh  and  Hey  of  Leeds  secured  the  same 
end  by  first  dividing  the  integument  with  a  circular  cut  and  dissecting  it  up,  then  the  mus- 
cles at  a  higher  level,  and  lastly  the  bone,  this  being  divided  at  a  point  considerably  above 
the  line  of  the  retracted  muscles.  Hey,  moreover,  in  the  thigh  amputations  suggested  the 
expediency  of  dividing  the  posterior  muscles  longer  than  the  anterior,  to  compensate  for 
their  greater  retraction. 

The  flap  operation  is  more  modern  than  the  circular,  and  to  Mr.  James  Young 
of  Plymouth  is  due  the  credit  of  having  first  published,  in  1G78,  the  method  which  he 
informs  us  he  had  "  from  a  very  ingenious  brother  of  ours,"  Mr.  C.  Lowdham  of  Exeter. 
He  made  one  flap  only  of  skin,  divided  the  muscles  by  the  circular  plan,  and  stitched  the 
parts  together.  Eighteen  years  later  Verduin  of  Amsterdam  made  the  first  muscular  and 
skin  flap  by  perforating  the  limb  and  cutting  outward  (tran.sfixion). 

To  Liston  must  be  attributed  the  credit  of  having  fully  established  the  flap  operation, 
and  in  the  pre-anas.sthetic  period,  when  time  was  a  point  of  consideration,  the  expedition 
with  which  amputation  could  be  performed  by  transfixion,  compared  with  the  tediousne.ss 
of  the  circular  operation,  tended  much  toward  this  end.  It  was  thought,  moreover,  that 
a  large  mass  of  muscle  formed  a  good  covering  to  the  bone  and  yielded  a  better  stumj) 
than  that  in  the  circular.  Experience  soon  proved,  however,  that  this  opinion  was  not 
supported  by  facts — that  the  supposed  advantages  were  not  real  and  did  not  compensate 
for  the  larger  extent  of  wound  caused  by  the  flap  operation  and  for  the  evil  of  often  hav- 
ing to  tuck  in  the  projecting  ends  of  the  divided  muscles  before  the  integuments  could  be 
adjusted.  Liston  saw  this  before  he  died,  and  was  led  with  Syme  to  modify  his  operation, 
making  in  muscular  subjects  two  lateral  crescentic  skin  flaps  with  their  convexity  down- 
ward and  dividing  the  muscles  as  in  the  circular  method.  This  operation  is  by  far  the 
best  for  all  amputations  of  the  leg  and  fore-arm. 

In  more  modern  times  Lowdham  and  Young's  practice  has  found  expression  in  Car- 
den's  operation,  while  Teale's  amputation  must  be  regarded  as  a  modification  of  the  flap. 
Both  these  gentlemen,  however,  advocated  the  long  anterior  flap  in  preference  to  all  others, 
Teale  making  two  rectangular  flaps  of  unequal  length  of  skin  and  muscle  (Fig.  695),  and 
Garden  a  rounded  anterior  flap  of  skin  alone  (Fig.  696)  ;  and  under  certain  conditions 
nothing  can  be  better  than  the  results  obtained,  the  line  of  cicatrix  being  posterior  to  the 
extremity  of  the  stump  and  out  of  harm's  way,  thereby  allowing  the  patient  to  rest  part, 
if  not  all,  of  his  weight  upon  the  stump. 

The  chief  objections  to  the  operation  consist  in  the  tendency  there  is  for  a  long  skin 
flap  to  slough  and  the  necessity  of  dividing  the  bone  at  a  higher  level  than  would  be 
required  in  the  circular  operation,  when  a  long  flap  cannot  otherwise  be  made.  In  mus- 
cular subjects  this  last  objection  is  serious  and  fatal  to  the  operation  in  many  thigh  ampu- 
tations, for  it  is  a  truth  that  cannot  be  too  forcibly  recognized  that  in  the  thigh  the  danger 
to  life  is  increased  with  every  inch  of  bone  removed.  The  surgeon  who  invariably  prac- 
tises Teale's  amputation  will  often  sacrifice  a  large  portion  of  a  limb  that  might  otherwuse 
be  saved  and  have  to  amputate  at  a  higher  point  than  the  necessities  of  the  case  demand, 
thereby  often  adding  to  the  danger  of  the  case  as  well  as  performing  a  needless  and  unjus- 
tifiable operation.  The  surgeoa  who  removes  such  portions  of  the  body  as  require  removal, 
and  no  more,  by  such  a  flap  as  allows  the  cicatrix  to  be  placed  behind  the  stump  and  out 
of  harm's  way,  pei'forms  a  good  and  scientific  operation. 

LTnder  all  circumstances  any  form  of  amputation  must  be  looked  upon  with  favor  that 
takes  away  onlj/  what  needs  removal  and  provides  sufficient  integument  to  cover  the  end 
of  the  stump,  that  ensures  the  cicatrix  being  out  of  harm's  way,  and  that  no  nerves  are 
likely  to  be  involved  in  the  cicatrix  or  fixed  to  the  end  of  the  amputated  bone.  Any 
forni  of  amputation  must  be  regarded  with  disfavor  that  requires  the  removal  of  more 
of  the  body  than  is  essential  to  carry  out  the  surgeon's  primarv  aim  and  increases  the 
risk  of  the  operation,  however  good  may  be  the  .stump  secured.     To  provide  sufficient 


AMITTATIUS.  KlOl 

inte<;iiiiicnt  to  cover  the  stiiinii  is  !i  \vi>c  aixl  ncces.'sary  measure,  and  to  fail  in  this  wlien 
circiinisianoes  do  not  coni|Ml  must  l»e  re^iarded  as  ha<l  surpTV  ;  yet  in  eertain  eases  of 
injury,  disease,  or  ^'anirrene  of  the  extremities,  where  it  is  advisal)le  to  take  away  tlie 
diseased  or  injured  |>art>  and  no  sound  skin  is  h-ft  fnuu  which  to  make  a  fla|).  amputation 
.shouhl  lie  |ierformed  with<uit  rejjanl  to  a  eoverin;.'  for  the  stump,  as  douhth-ss  it  is  hetter 
to  remove  tlie  ilisi-aseil  part  tliat  is  hastening  on  the  end  and  h-ave  the  stumji  to  ;rranulate 
than  to  allow  the  tlisi-ase  to  have  its  way  and  saeritiee  life.  At  the  hip-  and  shoulder-joints, 
where  this  eontin^eney  is  most  likely  to  oeeur.  the  adoption  id"  this  practice  i.s  not  rarely 
called  for.  ami  at  other  parts  is  eijually  appliealile.  for.  knowing  what  frood  Htumpri  are 
often  obtainetl  when  the  skin  and  std't  jiarts  that  at  the  time  of  tlie  operation  covered  in 
the  hone  suhse»juently  slouirhed.  I  am  convinced  that  in  certain  injuries  to  the  arm  and 
le<;  the  surjreon  had  hetter  amputate  with  a  ])oor  flap  at  the  elhow-  <»r  knee-joints,  leaving 
the  rest  to  nature,  tlian  risk  life  hy  amputating  higher  up — /'.'..  thnmgh  the  shafts  of  the 
humerus  or  femur.  I  have  on  many  occasions  acted  on  this  principle,  and  to  prevent  the 
necessity  of  amputating  ahove  a  joint  in  order  to  make  a  goo<l  >tump  with  a  skin  cover- 
ing amputated  at  a  joint  or  Itelow,  utilizing  even  injured  skin  or  hrui.<ed  tissues,  and 
rarely  have  heeu  disapj)ointed  in  the  result,  the  stump  suh.se(|uently  granulatini:  well 
even  when  the  flaps  themselves  sloughetl.  In  injuries  to  the  leg  this  ]»oint  is  of  great 
importance,  sitwe  the  mortality  of  am])utation  of  the  thigh  for  injuries  is  very  great. 
As  an  admirable  illustration  of  the  value  of  this  practice  a  case  may  be  referred  to 
(Circ.  No.  3.  Depart,  of  War,  Washington,  page  '2\\>)  in  which  recovery  ensued  after  all 
four  limbs  of  a  man  ji»t.  2(j  were  amputated  on  account  of  fro.st-bite.  A  month  after  the 
injury,  when  the  line  of  demarcation  had  exposed  the  bones,  Dr.  Muller,  in  order  to  .save 
lo.ss  of  blood,  which  would  have  been  serious  in  the  patients  weak  condition,  dissected  as 
much  healthy  flesh  from  the  radius  and  ulna  as  the  line  of  demarcation  would  admit  with- 
out cutting  any  blood  vessels,  and  then  sawed  through  the  bone.  This  operation  was  per- 
formed on  both  arms  with  hardly  the  loss  of  an}-  blood.  On  the  third  day  both  legs  were 
amputated  in  the  same  manner.  In  this  ca.se  not  one  of  the  four  stumps  could  be  covered 
with  suflicieut  skin,  and  much  had  to  be  left  to  self-reparation,  which  took  place  to  an  extra- 
ordinary extent,  the  stumps  healing  over  with  healthy  granulations,  some  little  exfoliation 
of  bone  taking  place  in  two. 

Again,  is  it  always  necessary  to  amputate  through  healthy  tissues?  or,  to  gain  this 
end.  is  it  expedient  to  amputate  higher  up  than  would  otherwise  be  nece.s.sary?  I  unhes- 
itatingly answer  that  such  practice  is  not  called  for.  To  amputate  through  tissues  infil- 
trated with  cancer  or  other  new  growths  would,  of  course,  be  futile  and  bad  surgery,  but 
to  cut  through  tissues  that  are  merely  infiltrated  with  inflammatory  products,  that  are 
pathologically  reparable  and  of  u.se,  is  a  wise  and  conservative  process.  In  di.sease  of 
the  knee-joint,  when  suppuration  has  spread  up  the  thigh  into  the  soft  parts,  amputa- 
tion may  often  be  performed  through  the  condyles  or  just  above  them  and  a  good  stump 
secured  when  by  following  another  practice  a  much  higher  amputation  would  be  called 
for,  and  con.serjuently  increased  risk  to  life  incurred.  Tissues  infiltrated  with  inflamma- 
tory lymph  often  unite  rapidly  and  well ;  indeed.  I  have  seen  ■•  brawny  flaps  "  unite  by 
primary  uniim  (juite  as  vf-aW  as  others  not  so  infiltrated. 

I  am  convinced,  too.  that  however  desirable  it  may  be  to  obtain  good.  long,  and  healthy 
flaps  in  all  amputations,  the  advantages  of  such  are  not  .so  great  as  to  justify  the  surgeon 
in  sacrificing  more  of  the  body  than  is  e.s.sential.  thereby  adding  to  the  risks  of  the  case, 
and  more  particularly  in  amputating  above  a  joint.  It  is  true  that  by  one  form  ofampmta- 
tion  a  better  stump  under  most  favorable  circumstances  is  often  secured  than  another,  but 
it  is  e({ually  true  that  ijood  stumps  are  often  obtained  under  the  most  unftivorable  condi- 
tions and  that  bad  stumps  follow  the  amputation  of  a  limb  in  which  the  state  of  the  flaps 
promised  to  bring  about  a  favorable  result.  To  as.sert  that  the  form  of  amputation — or, 
rather,  that  the  shape  of  the  flaps,  etc. — has  anything  to  do  with  the  relative  mortality  of 
different  amputations  is  incorrect.  What  evidence  exists  points  to  a  diflferent  conclusion, 
for  the  success  of  an  amputation,  as  of  any  other  operation,  turns  more  upon  what  in 
recent  times  seem  to  have  been  forgotten — viz..  the  conditions  of  the  visara,  the  ft^e, 
and  the  general  state  of  the  subject,  accepting  the  facts  that  the  older  the  patient,  the 
greater  the  danger,  and  the  more  of  the  body  that  is  removed,  the  greater  the  risk.  My 
own  conviction  is  that,  however  desirable  it  mav  be  to  obtain  a  model  stump,  the  end  is 
not  sufficiently  certain  or  important  to  justify  the  surgeon  in  adding  one  tittle  to  the  ri.sk 
of  the  operation  or  in  sacrificing  more  of  the  limb  tlian  the  necessities  of  the  ca.se  demand. 
I  regard  it  as  bad  and  unjustifiable  surgery  to  perform  a  Syme's  or  a  Pirogoflf's  amputa- 
tion when  a  Chopart's  will  suffice ;  to  amputate  a  leg  when  the  removal  of  a  foot  at  the 


1002  AMPUTATION. 

joint  will  answer  the  purpose;  to  remove  a  leg  or  thigh  an  inch  higher  than  is  absolutely 
called  for,  in  order  to  execute  what  may  be  looked  upon  as  a  good  operation  or  to  gratify 
a  fancy  ;  to  amputate  through  the  condyles  of  the  femur  when  an  amputation  at  the 
knee-joint  can  be  performed,  or  through  the  shaft  of  the  femur  when  the  like  end  may 
be  secured  by  cutting  thnuigh  the  condyles.  The  surgeon  must  ever  look  upon  the  ope- 
ration of  amputation  as  an  unfortunate  necessity,  and  should  bear  in  mind  that  it  is  to  be 
undertaken  only  to  save  or  to  prolong  life  or  to  add  to  life's  usefulness.  With  these  ends 
in  view,  he  should  not  add  one  jot  to  its  dangers  or  take  away  an  inch  more  of  the  body 
than  is  essential.  The  beauty  of  a  stump  may  be  something  in  itself,  but  is  nothing  if 
it  is  to  be  obtained  by  increased  danger,  and  the  brilliancy  of  an  operation  is  a  snare  that 
should  never  be  allowed  to  draw  the  surgeon  away  from  the  main  object — the  preserva- 
tion of  life — which  alone  gives  the  operation  of  amputation  a  high  and  scientific  po.sition 
in  surgical  practice. 

The  mortality  of  amputation  is  determined  more  by  age  than  by  anything  else,  and 
the  credit  of  having  statistically  proved  this  fact  is  dueto  Mr.  Holmes  (,SV.  Geonjcf. 
Hof<p.  Rep.,  1866  and  1877;.  In  aiy  own  paper  on  the  causes  of  death  in  amputation 
(Med.-Chir.  Tn(ii.'<.,  vol.  xlii.,  1859)  this  point  was  overlooked,  but.  following  Mr.  Holmes's 
example,  I  reanalyzed  the  cases  on  which  it  was  based,  and  have  been  somewhat  startled 
at  the  very  definite  conclusions  brought  out  by  my  analysis.  Thus,  out  of  103  cases 
under  twenty  years  of  age,  10  died,  or  1  in  10 :  out  of  111' cases  between  twenty-one  and 
forty  years  of  age,  21  died,  or  1  in  5  ;  out  of  74  eases  over  forty  years  of  age.  22  died,  or 
1  in  3j,  the  mortality  of  amputation  between  the  ages  of  twenty  and  forty  being  exactly 
twice  as  great  as  before  twenty  years  of  age. 

Mr.  Callender  {Med.-Chir.  Trans.,  vol.  xlvii.,  1864)  and  Mr.  Holmes's  combined 
statistics  reveal  the  same  results : 

Cases  under  twenty  years  of  age.    Between  twenty  and  forty      Over  forty  years  of  age. 

years  of  age. 

Callender's 61  cases,  3  died.  92  cases,  20  died.  74  cases,  30  died. 

Holmes's 130     '■      22     "  215      "     68     "  J^o      "      6S     " 

191  cases,  25  died,  307  cases,  88  died,  229  ca.ses.  98  died, 
<                                                             or  1  in  72.                       or  1  in  3h.  or  1  in  2J. 

Fifty-two  deaths  having  occurred  in  250  cases  reported  by  Mr.  Holmes  in  subjects  under 
thirty  years,  and  106  deaths  in  250  cases  operated  upon  after  thirty  years  of  age. 

If  the  causes  of  amputation  are  looked  at  in  the  same  light,  the  results  become  still 
more  marked ;  for.  dividing  them  into  amputations  for  disease,  for  accident,  and  for 
expediency,  the  latter  term  including  amputations  for  tumors,  deformity,  etc.,  the  follow- 
ing facts  are  elicited : 

Cases. 
Under  twenty  years  of  age  .     .  68 
Between  twenty  and  forty    .     .  66 
Over  forty 33 

Amputations  for  acute  suppurative  disease  are  most  fatal  and  should  be  undertaken 
only  when  a  strong  necessity  exists.  I  pointed  this  out  in  1859.  but  it  is  not  a  fact 
sufficiently  recognized. 

Amputation  in  young  life  for  chronic  disease  is  mo.st  successful,  being  three  times 
more  so  than  at  a  later  period,  1  only  in  ever}'  17  dying;  amputation  for  accident  increases 
in  fatality  with  age.  and  amputations  of  expediency  are  as  dangerous  at  all  periods  of  life 
as  traumatic  amputations  are  in  the  aged. 

Mr.  Callender  has  also  well  shown  ( Sf.  Barth.  Hoq).  Rep..  1869)  that  the  mortality 
of  amputations  is  much  alike,  whether  performed  in  country  ho.spitals,  in  country  private 
practice,  or  in  country  cases  in  London.  In  amputations  on  London  subjects,  as  in  the 
subjects  of  all  large  towns,  the  mortality  is  somewhat  higher. 

Dr.  Steele  has,  however,  gone  farther  and  proved  by  figures  that  amputations  per- 
formed in  London  for  injury  on  country  patients  are,  as  a  rule,  more  favorable  than  when 
performed  in  town  cases,  the  diiFerence  between  the  two  classes  being  far  less  marked  in 
amputation  for  disease  than  in  that  for  injury  {Gvi/'ss  Roup.  Rfp..  1869-70). 

The  causes  of  death  after  amputation  are  as  follows,  taking  these  conclusions  from 
my  paper  on  the  subject  {Med.-Chir.  Tram.,  1859),  to  which  the  reader  must  be  referred 
for  further  details  :  Shock  and  exhaustion  claim  one-third  of  the  fatal  cases,  and  one- 
twelfth  of  all  amputations;  ptyxmia  was  the  cause  of  death  in  forty-two  per  cent,  of  the 


)is< 

jases. 

Expediency. 

Accident. 

Died. 

Cases.            Died. 

Ca.ses. 

Died. 

4, 

or  1  in 

17. 

9     3,  or  1  in  3. 

26 

3,  or  1  in  9. 

12, 

or  1  in 

5A. 

15     4  or  1  in  4. 

30 

5.  or  1  in  6. 

5, 

or  1  in 

6J 

9     3,  or  1  in  3. 

32 

14,  or  1  in  2^ 

DIFFKIIILST  M<tl)i:s   OF  AMl'lJAll'J.W  lOO.'i 

filial  cast's,  and  in  niic-tiiitli  ul"  all  aiii|iutatiuiiM  ;  iwrDiiilnn/  In  ninrrlmifi  in  s(!Vcii  per  ccfit. 
nt"  til*'  latal  fasi's,  or  unc  aiitl  a  liall"  prr  rent,  of"  the  whole  iiunihtT.  Some  riniijiliriitinn^ 
crri'hral,  tliorafic,  or  alKloininal,  causes  ileal li  in  about  lour  per  (;ent.  oi"  all  eases.  I'va-iiiia 
is  nearly  twiei'  as  fatal  al'ter  amputations  of  expedieiii-y  as  iifter  tliose  fur  disease  or  pri- 
niarv  amputations,  hut  is  less  fatal  after  seeoiulary  amputati(»ns  than  any  others.  In 
amputation  ol"  the  le^  it  is  twice  as  destructive  as  in  that  of  the  thi^'h,  the  larger  section 
of  lion«f  heinir  the  more  dan;rerou.s.  In  primary  amputation  of  the  le;r  it  is  more  latal 
than  when  performed  for  disease. 

How  far  the  «leaths  from  secondary  hemorrhage  will  he  dimini.>hed  when  the  practice 
of  torsion  of  arteries  is  uiore  f^eneral  remains  to  he  proved,  althou<:h  from  the  experience 
we  have  had  at  (iuy's  Hospital  the  promise  of  a  better  result  is  very  jrreat.  I'p  to  the 
end  of  1S74  we  have  had  liOO  consecutive  cases  of  amputations  of  the  thifrh,  leg,  arm, 
and  lore-arm  in  whi(di  all  the  arteries  had  been  twisted  (11((  of  them  havinj:  Ijeen  of  the 
femoral  artery),  and  no  case  of  secondary  liemorrhajrc?  ;  indeed,  riur  house-sur<reons  never 
expect  to  be  called  to  cases  of  secondary  heiiiorrhaL^i'  now  that  torsion  is  the  general 
practice  of  the  hospital. 

Double  amputations  are  of  grave  import  and  are  very  fatal.  They  are  mostly 
imdertakeM  lor  •  sni.islics  or  bad  com))ouud  fractures.  Out  of  18  cases  collected  by  my 
dres.ser,  Mr.  W.  Hlight,  from  the  <iuy"s  records,  I  can.  however,  record  5  successful  cases, 
or  27.7  per  cent,  of  the  whole  number.  One  occurred  in  my  own  practice  in  a  woman 
ait.  3')  who  had  a  Symes  amputation  on  one  foot  and  a  Iley  s  on  the  other.  1'wo  i»ccurred 
in  the  practice  of  Mr.  Durham,  and  both  in  men — one,  fct.  18,  amputation  of  both  thighs, 
and  the  other,  xi.  19,  amputation  in  one  thigh  and  fore-arm.  Mr.  Davies-Colley  toiik  off 
both  legs  of  a  boy  fet.  8  with  a  good  result,  and  Mr.  Jacob.son  took  off  one  leg  in  the  thigh 
and  one  below  the  knee  in  a  man  aet.  30  with  a  like  result.  Thirteen  cases  died  soon  after 
the  operation. 

The  operation  of  amputation  may  be  called  for  on  account  of  some  incurable  disea.se 
or  incurable  injury.  When  performed  for  the  fir.st  cause,  the  operation  has  been  described 
as  a  patliolof/icdl  amputation  ;  when  for  the  second,  traumatic.  Both  classes  are  also  sub- 
divided, the  pathological  into  amputations  for  supjnirative  disease  of  })ones  and  joints — 
pure  i>at]inh,(j'ical  amputation ;  and  into  tho.se  for  talipes,  tumors,  deformities,  etc. — ampu- 
tations of  expediency. 

Traumatic  amputations  performed  during  the  first  twentj'-four  hours  after  the  acci- 
dent, before  any  inflammatory  complications  have  set  in,  are  called  ^>//?>ja/y;  the  term 
sccomlan/  is  applied  to  the  .same  class  of  cases  after  suppuration  has  appeared,  the  word 
intermediate  being  employed  to  designate  amputations  performed  twenty-four  hours  after 
the  accident,  but  before  suppuration  has  declared  it.self.  This  distinction,  however,  is  not 
a  satisfactory  one. 

Some  statisticians  have  classed  the  secondary  amputations  with  the  pathological,  but 
this  practice  is  clearly  wrong. 

The  Different  Modes  of  Amputation 

may  be  divided  into  three  great  classes — 1st.  the  circular ;  2d.  the /iap  operation,  whether 
by  transfixion  or  cutting  from  without  inward — Teales  amputation  (consisting  of  one 
long  anterior  skin  and  muscular  flap,  and  short  posterior)  being  looked  upon  as  a  modifi- 
cation of  the  ordinary  flap  operation  ;  3d.  the  mixed  /arm  of  amputation — skin  flap  and 
circular  cut  through  muscles — Cardens  operation  being  included  in  this  series.  Into  one 
or  other  of  these  classes  almo.st  every  form  of  amputation  may  be  brought,  although  prac- 
tically there  are  innumerable  modifications  of  each,  more  particularly  of  the  flap. 

The  old  circular  operation,  as  already  described,  is  now  fairly  abandoned.  It  has 
no  advantages  over  the  more  modern  mixed  form  of  amputation,  and  will  not  take  the  place 
of  the  flap  where  the  latter  is  applicable.  In  small  limbs,  where  there  is  but  little  mus- 
cular tissue  and  a  single  bone  to  divide,  it  may  be  performed,  but  cannot  be  recomiuended. 
It  is  more  practi.sed  abroad  than  in  this  country. 

The  flap  operation  doubtless  owes  its  popularity  as  much  to  Liston.  Lisfranc.  and 
Velpeau.  who  were  its  strong  suiiporters,  as  to  the  facility  with  which  it  is  performed  and 
the  satisfactory  ajtpearance  of  the  flaps  at  the  time  of  the  operation.  Before  anfe.sthetics 
were  introduced  expedition  was  of  importance,  and  it  was  the  surgeons  aim  to  remove  a 
limb  as  rapidly  as  possible.  '•  The  surgeon,  operating  by  the  watch,  took  off  a  limb  by 
the  flap  operation  in  as  many  seconds  as  there  were  minutes  occupied  in  the  old  circular 
method"  (Sir  W.  Fergusson).     Since   1846,  however,  when  ancBsthesia  came  into  vogue, 


1 004  AMP  VTA  TlOy. 

this  necessity  has  ceased  to  exist,  and  surgeons  hare  been  led  away  more  from  the  flap 
operation  to  what  may  now  be  described  as  the  mixed. 

In  certain  parts,  however,  the  flap  operation  still  holds  its  ground,  and  in  a  general 
sense  it  may  be  said  that  in  operations  where  the  shafts  of  migU  bones  or  some  joints  are 
involved  it  is  the  best  method,  while  in  some  localities,  as  at  the  shoulder-  and  hip-joints, 
it  is  the  only  one  open  to  the  surgeon. 

The  objections  to  the  flap  operation  are  the  large  surface  that  is  exposed,  the  danger 
of  puncturing  or  slitting  the  main  artery  of  the  part,  the  inconvenience  of  bleeding,  the 
leaving  of  the  main  artery  and  nerves  in  one  of  the  flaps,  and  the  disadvantage  of  a  thick 
mu.scular  flap. 

The  flap  amputation  has.  however,  one  great  advantage,  and  that  is  its  capability  of 
innumerable  modifications.  Thus,  both  flaps  may  be  made  by  transfixing — the  old  plan  ; 
both  may  be  made  by  cutting  from  without  inward  :  one  flap,  the  anterior,  may  be  made 
by  the  latter  method,  and  the  second,  or  po.sterior,  by  transfixion  ;  or  lateral  flaps,  single, 
or  double,  or  oval  flaps,  may  be  made. 

The  advnntnges  of  transfixing  the  flap  consist  in  the  rapidity  and  cleanliness  with 
which  the  section  of  the  mu.scles  and  the  deeper  parts  is  made  ;  its  ilisodmntoges,  in  the 
irregularity  with  which  the  skin  is  too  often  divided  from  the  elastic  integuments  stretch- 
ing before  the  knife.  By  the  plan  of  cutting  the  flap  from  without  inward  this  disad- 
vantage is.  however,  neutralized,  while  an  extra  advantage  is  gained,  for  the  .surgeon 
can  often  cut  a  longer  skin  than  muscular  flap,  which  in  large  limbs  is  a  matter  of 
importance. 

In  some  amputations,  as  of  single  bones,  the  operation  may  be  performed  by  cutting 
the  anterior  flap  from  without  inward,  and  the  posterior  by  transfixing.  In  the  arm  and 
thigh,  when  I  select  the  flap  amputation,  this  method  is  that  which  I  usually  adopt.  In 
cutting  the  flap  by  transfixion,  particularly  in  the  thigh,  the  surgeon  should  always  sup- 
port it  with  his  left  hand,  and  when  a  sufficient  flap  has  been  made  cut  sharplv  outward 
(Fig.  691). 

Sir  W.  Fergusson  says,  with  respect  to  the  flap  operation.  '•  If.  in  transfixing,  the  flaps 
be  made  purposely  short,  and  then,  retraction  being  made,  the  knife  be  carried  round  the 
expo.sed  tissues  which  cover  the  bone,  a  cone  will  be  formed  resembling  that  in  the  ordi- 
nary circular  operation,  and  thus  by  a  combination,  a  compromise,  of  the  two  methods 
fthe  circular  and  the  flap),  a  covering  to  the  end  of  the  bone — in  other  words,  a  .stump — 
will  be  left,  superior,  in  my  estimation,  to  any  other."  though  he  adds  that  ••  cutting  from 
without  inward  is  in  manv  instances  followed  bv  the  best  results"  (Ltct.  on  Prog,  of 
Surg..  1867). 

Besides  the.se  recognized  forms  of  amputation,  many  others  are  performed,  the  surgeon 
having  too  often  "to  cut  the  flap  according  to  the  tissues."  particularly  in  cases  of  injury. 
He  has  to  utilize  what  skin  there  is  left  uninjured,  in  order  to  prevent  the  neces.sity  of 
amputating  higher  up ;  it  may  be  that  one  external  or  internal  flap  can  be  made,  one 
anterior  or  po.sterior ;  in  fact,  any  form  or  combination  of  flaps  the  surgeon  maybe  called 
upon  to  make  to  carry  out  the  object  he  has  in  hand — viz..  the  removal  of  the  part  that 
mu.st  be  removed,  and  no  more,  with  the  least  sacrifice  of  parts.  Indeed,  as  already 
stated,  under  rare  circumstances  an  amputation  may  best  be  performed  without  flaps  or 
with  poor  ones,  it  being  a  safer,  and  I  believe  a  sounder,  practice  to  take  off  a  part  that 
mimt  h^  removed  to  save  life  immediately  above  the  seat  of  injury,  even  with  bad.  poor, 
or  no  flaps,  than  for  the  sake  of  making  flaps  that  may  slough  to  amputate  higher  up, 
possibly  with  the  sacrifice  of  a  joint,  and  by  so  doing  to  incur  an  unneces.sary  danger  to 
the  life  we  are  operating  to  .save,  Petits  fundamental  rule  being  far  from  true — that  "  as 
little  of  the  flesh  should  be  cut  away  as  possible ;  but  the  more  bone  is  removed,  the 
better"  (  Traiti  Jes  Malad.  Chir..  tom^  iii.  p.  250). 

As  a  variety  of  the  antero-posterior  flaps  the  surgeon  may  at  times,  by  transfixion, 
make  the  posterior  one  first,  and  then,  taking  between  his  fingers  and  thumb  all  the  soft 
parts  not  included  in  the  posterior  flap,  complete  the  operation  either  by  passing  the  end 
of  the  knife  beneath  these  tissues  and  cutting  outward  or  by  cutting  from  without  inward, 
as  in  the  former  case.  This  plan  is  most  expeditious  and  was  the  one  generally  adopted 
by  the  late  Mr.  Morgan  of  Guy's. 

In  some  cases  two  lateral  flaps  may  be  made  by  either  transfixion  or  cutting  from 
without  inward. 

The  Flap  Operation. — The  surgeon,  having  decided  upon  the  operation  and 
obtained  the  consent  of  the  patient  or  of  his  friends  to  its  performance,  should  see, 
unless  time  presses,  that  any  fecal  accumulation  is  removed  by  either  a  mild  aperient  or 


Diri-KllllSr  MohKS   OF  AMJ'LTATIuy. 


KlOo 


nn  I'neina  lulininistcrL'd  thirty-six  hours  hi-ftirfhuiid.  and  that  as  ^rood  a  iin-al  as  the  ]iatieiit 
can  takf  hf  jrivt'U  lour  or  fivt!  Iiours  hrl'on-  tlic  liuic  tixt-d  lor  llic  o|ii-ratioii.  Tlie  meal 
should  hi'  of  lucat  whrrr  possihle,  with  souii'  stiinuhiut,  or.  whni  solids  arc  not  acceptable, 
of  u  mixturt'  of  uiilk.  ejr^.  and  hrandy  ;  for,  assuuiirijr  that  chlorcd'orni  or  souie  aiwesthetic 
is  to  he  adujiiiistfrt'd.  it  is  essential  to  ;;uard  against  sickness  and  to  have  the  process  of 
di;ri-stion  fairlv  completed  heforehand.  since  vomiting  is  more  prone  to  take  place  with  a 
full  than  with  an  empty  stomach.  The  ])art  to  he  operute<l  u]ion  should  be  well  washed 
previously  and  when  nundi  hair  is  present  also  shaved  before  the  patient  is  placed  upon 
the  operatinj;  table. 

All  instruments  and  drcssinir  applian<"es  should  be  arranj^ed  rtut  of  the  patients  .sight 
before  the  time  of  the  operation,  and  a  suflicielit  number  of  assistants  provided  and  spe- 
cial duties  allotted  to  them. 

Thus,  on  one  tray  there  should  be  a  ttturiiitjuet  or  elastic  bandage,  to  prevent  hemor- 
rhaire  ;  irood  torsion  forceps  to  twist,  or  ligatures  to  tie.  the  vessels;  amputating  knives 
of  sufficient  length  and  size,  with  a  bistoury  or  catlin  to  divide  the  .soft  parts,  and  saw 
and  lione  forceps  for  tlie  treatment  of  the  bone;  a  tenaculum  should  likowi.se  be  at  liand, 
to  take  up  vessels  tliat  have  retracted  ;  there  should  be  also  a  pair  of  scissors  and  a  linen 
retractor.  The  torsion  forceps  I  employ  (Fig.  137)  are  as  good  for  taking  up  an  artery 
to  tie  as  for  twisting. 

On  a  second  tray  every  api)liance  for  the  dressing  of  a  stump  .should  be  arranged, 
such  as  suture  needles  armed  with  waxed  silk,  wire,  or  carbolized  catgut ;  .strapy>ing  cut 
into  sufficient  lengths  and  breadths ;  lint  for  pads  or  dressings,  and  .splints  wlien  applic- 
able ;  a  can  for  hot  water,  to  heat  the  strapping,  should  not  be  omitted  ;  hot  and  cold 
water  in  abundance,  c/cun  sponges,  supplied  by  the  surgeon,  well  washed  in  iodine  water 
and  .s<|ueezed  dry.  and  soft  towels,  so  arranged  as  to  be  always  at  the  surgeons  command 
during  the  operation,  must  be  jirovided. 

With  respect  to  a.ssi.stants,  one  to  give  the  anaesthetic  is  a  necessity  ;  and  when  po.ssi- 
ble  he  should  be  an  expert  to  whom  the  surgeon  can  resign  his  patient  with  confidence, 
as  it  is  trying  and  somewhat  risky  for  the  operator,  when  otherwise  engaged,  to  have  an 
eye  to  the  anaesthetist.     A  second  is  wanted,  to  hold  the  limb  above  and  to  command 

Fig.  690. 


Surgeon  and  his  Assistants  arranged  for  an  Amputation. 

the  artery  of  the  limb  to  be  amputated  ;  a  third,  to  hold  the  limb  below  till  it  is  removed, 
and  subse(|uently  to  sponge  and  help  to  twist  or  tie  the  ves.sels :  while  a  fourth  is  of 
essential  service  in  amputation  of  the  thigh  and  leg  to  hand  the  instruments,  sponge,  or 
to  do  what  may  be  required,  etc.     They  should  be  placed  as  .shown  in  Fig.  690. 

The  nurse  should  be  near,  to  take  away  and  clean  all  sponges  as  they  are  u.sed.  and  to 
replace  them  with  others  squeezed  quite  dry. 

When  the  operation  has  to  be  performed  by  daylight,  the  table  should  be  placed  where 
the  best  light  can  be  obtained  ;  and  when  by  candlelight,  sufficient  provision  nni.st  be  made. 
A  good  operating  lamp  is  of  great  use,  as  well  as  a  hand-glass  to  throw  light  upon  any 
one  part. 


1006 


AMPUTATION. 


Fig.  691. 


The  operating  table  should  be  narrow  and  steady,  a  kitchen  table  with  flaps  being  the 
best  and  always  available.      In  hospitals  there  ought  always  to  be  a  special  table. 

In  amputations  of  the  upper  extremity  the  patient  should  be  brought  well  to  the  side 
of  the  table,  and  in  amputations  of  the  lower  extremity  well  downward,  the  opposite 
limb  being  secured  by  a  turn  of  a  bandage  or  strap  to  the  leg  of  the  table. 

In  amputating,  the  surgeon  should  always  stand  on  the  riffht-hand  side  of  the  part  to 
be  amputated,  in  order  with  his  left  hand  to  keep  full  control  of  the  flaps  during  the  ope- 
ration, and  po.ssibly  of  the  main  arteries,  and  afterward  of  the  stump.  He  should,  more- 
over, see  that  the  tourniquet  is  so  fixed  as  to  control  the  vessel  when  tightened,  which 
should  on  no  account  be  done  until  the  operation  is  about  to  be  commenced.  Before  fix- 
ing the  tourniquet  the  limb  to  be  amputated  should  be  emptied  of  its  venous  blood  by 
raising  its  end  for  one  or  two  minutes  and  smoothing  the  veins  from  below  upward  by 
pressure  with  the  hand.  The  limb  should  then  be  constricted  high  up  by  a  tourniquet  or 
Esmarch's  elastic  bandage. 

In  the  flap  operation,  now  being  considered  (and  for  the  sake  of  illustration  I  will  sup- 
pose it  to  be  a  thigh),  the  surgeon  should  mark  out  with  his  eye  the  point  at  which  he 

proposes  to  divide  the  bone,  and,  with  his 
thumb  on  one  side  of  the  limb  and  his  fingers 
on  the  other,  grasp  it  at  a  spot  corresponding 
to  the  base  of  the  anterior  flap  he  is  about  to 
make,  cutting  from  without  inward,  taking 
care  that  the  Lasr  of  this  flap  is  at  least  an 
inch  lower  down  than  the  point  at  which  the 
bone  is  to  be  divided.  The  anterior  flap,  which 
should  be  cut  first  and  consist  of  skin,  ought 
to  be  as  long  as  the  soft  parts  below  will  allow 
and  large  enough  to  cover  half  the  stump,  or 
rather  more  than  half  the  diameter  of  the 
limb ;  but  when  possible,  it  may  be  longer, 
since  it  is  now  generally  admitted  that  the 
long  anterior  flap  forms  the  best  stump.  The 
skin  flap  should  be  broad  and  cut  s({uare,  with 
the  angles  rounded  off",  but  not  pointed.  The 
muscles  should  then  be  divided  down  to  the 
bone  with  a  clean  cut  of  the  knife,  made  from  heel  to  point  and  reflected  with  the  skin 
flap.  The  anterior  flap  having  thus  been  made,  the  point  of  the  knife  ought  then  to  be 
passed  through  the  wound  beneath  the  bone  and  the  limb  so  transfixed  as  to  include  all 
the  tissues  that  remain  undivided.  The  knife  should  then  be  made  to  run  downward 
parallel  to  the  bone,  far  enough  to  make  a  flap  of  the  required  length,  and  then  turned 
backward,  the  outward  cut  being  made  sharply  (Fig.  691). 

During  this  stage  of  the  operation  the  surgeon  should  with  his  left  hand  support  the 
under  surface  of  the  posterior  flap.  When  the  anterior  flap  has  been  made  of  only  suffi- 
cient length  to  cover  half  the  face  of  the  stump,  the  posterior  must  be  cut  long,  to  allow 
the  two  to  meet.  When  the  anterior  flap  has  been  a  long  one — two-thirds  of  the  length 
required  to  cover  the  stump — the  posterior  flap  need  be  only  half  the  length  of  the  ante- 
rior.    Long  flaps  always  yield  the  most  satisfactory  results. 

When  the  flaps  have  been  made  they  should  be  carefully  held  away  from  the  bone, 
which  is  to  be  bared  upward  for  about  an  inch  above  their  base,  where  it  is  to  be  divided 
and  two  periosteal  flaps  cut  and  pressed  upward.  The  soft  parts  ought  to  be  carefully 
held  awa}'  from  the  bone,  to  escape  injury,  and  for  this  purpose  the  linen  retractor  is  of 
great  value.  The  saw  must  then  be  applied,  the  bow  saw  (Fig.  G90)  being  probably  bet- 
ter than  the  flat.  It  should  be  used  from  heel  to  end  with  a  firm,  decided,  free  movement, 
too  much  pressure  upon  it  being  likely  to  cause  splintering  of  the  bone.  During  these 
steps  of  the  operation  the  assistant  who  holds  the  limb  must  be  careful  neither  to  elevate 
nor  to  depress  it,  for  he  will  cause,  by  the  former  act,  the  surgeon's  saw  to  become  locked, 
and  by  the  latter  splintering  of  the  lower  border  of  the  bone.  The  best  plan  for  the  assist- 
ant to  adopt  is  to  apply  extension  to  the  limb  in  the  axis  of  the  bone  to  be  divided,  as  if 
to  draw  the  patient  downward,  though  not  Avith  sufficient  force  to  eff"ect  this  result. 

When  any  splintering  of  the  bone  has  taken  place,  the  rough  margin  ought  to  be 
carefully  smoothed  down  with  the  cutting  forceps,  care  being  observed  not  to  tear  away 
the  periosteum. 

Dr.  McGill  of  the  United  States  army  has  suggested  the  propriety  of  making  the 


Aniputatioii  of  the  Thigh  by  Flap  Operation. 


nirri:i:i:sr  Mni>i:s  of  amitiaiios. 


l(j()7 


jtoriostoul  flaps.  US  (IcsciilnMl  almve.to  i-ovcr  in  tin-  eml  fiftlie  dividcfl  Ixnic  in  ani|>ututioii, 
and  trivt's  tliriT  casrs  in  wliifli  this  was  done  with  excollciit  ctt'vct  (Ciru.  No.  'A).  I  liave 
adii|itt>(|  till'  |dan  on  many  occasions  witli  satisfactory  results,  tlic  end  of  tin-  divided  lemur 
bein^  in  some  eases  capped  with  a  ma>s  of  new  Itone. 

'hic  bone  beinj;  sawn  tliroULcli,  the  stump  is  to  he  raised  and  the  main  artery  at  once 
.seized  ;  the  vossid  should  be  drawn  out  of  its  slieath,  lirmly  held  with  fon^eps  (Fig.  1-^7 j,  and 
.sharply  twisted  sullicii'ntly  often  for  the  sur;.;eon  to  I'eel  that  resistance  has  gone.  The  end 
ouiiht  not  to  be  twisteil  ofl".  The  snniller  arteries  .should  be  treated  in  the  same  way  ;  it  is 
possibly  the  best  practice  to  twist  ofl'  the  ends  of  the  small  mu.scnlar  and  cutaneous  branches. 

When  ligatures  are  preferred,  they  may  Ix-  used,  the  carb(»lizc(l  catgut  prolnibly  Iteing 
the  b,.>t. 

As  soon  as  the  chief  ve.s.sels  have  been  secured  the  tourni(|Uct  should  be  taken  away 
and  the  stump  i-levated,  to  assist  tlie  venous  circulation,  the  assistant  being  ready  with 
his  finger  to  compress  the  main  artery  of  the  lind)  if  any  vessel  remain  unsecured.  Any 
nerve  trunks  that  have  been  cut  long  in  the  flaps  should  be  renioved  to  a  level  with  the 
bone.  A  stream  of  iodine  water  may  then  be  made  to  pass  over  the  end  of  the  .stump, 
to  cleanse  it  of  all  blood  and  check  ca]»illary  bleeding,  and  the  surface  should  ne.\t  be 
dried  with  a  s])onge  .s(|ueczed  dry  out  of  hot  iodine  water,  the  surgeon  satisfying  himself 
that  the  vessels  are  all  safely  .secured.  1'he  edges  of  the  flaps  may  then  be  adjust eil,  and 
kept  in  apjjosition  by  sutures,  which  must  not  be  put  in  too  closely,  but  inserted  about 
half  an  inch  from  the  margin  of  the  wound  and  made  to  perforate  the  skin  and  fat 
oblii|uely  to  the  free  border  of  the  flap;  the  most  dependent  corner  of  the  wound  should 
be  left  open  for  the  introduction  of  a  drainage  tube. 

A  posterior  splint  ought  then  to  be  tixed  on  the  stump  (Fig.  C!)2),  with  pads  of  lint 


Fig.  093. 


Fig.  692 


Fig.  694. 


Thigh  Stuiap,  with  .Siiliut.  Thigh  Stump  with  Splint  for  Extension. 

or  sponge,  to  maintain  steady  pressure  upon  tlie  ba.se  of  the  flaps,  though  not  on  the 
wound,  and  a  piece  of  iodoform  or  carbolic  gauze,  through  which  a  hole  has  been  cut 
for  the  end  of  the  drainage  tube,  is  to  be  applied  to  the  surface  of  the  wound. 

A  square  of  (janigee  tissue  should  then  be  bound  over  the  stump,  or  a  good  large 
sponge,  either  of  these  materials  forming  a 
firm  elastic  compress  which  keeps  the  flaps 
well  in  apposition  and  checks  bleeding,  due 
care  being  taken  to  keep  the  end  of  the  drain- 
age tube  exposed.  To  seal  a  wound  com- 
pletely and  not  to  leave  a  drainage  opening 
must  always  be  regarded  as  bad  practice. 
With  well-adjusted  flaps,  good  drainage, 
and  rest,  as  secured  by  the  application  of 
a  splint,  most  stumps  may  be  expected  to 
do  well. 

The  stump  may  be  raised,  as  in  Fig.  C02, 
for  the  first  day  after  the  operation,  but  sub- 
sequently placed  in  a  horizontal  position. 
It  should  not  be  dressed  for  three  or  four 
days  unless  it  becomes  uncomfortable  or 
there  is  any  evidence  of  retained  secretion, 
for  the  le.ss  the  parts  are  disturbed  during 
the  early  days,  the  better,  repair  going  on 
much  more  satisfactorily  when  left  alone 
than  when  the  dressings  are  too  frequently 
changed.  To  dross  a  stump,  the  trough,  water-can,  and  tube,  as  illustrated  in  Fig.  694, 
are  to  be  recommended. 


Vidcr  can 
Svsfiendeil  to  hook 
of  ied  curtain  hooji 


Trough  and  Water-C.in  for  Dressing  .Stuuip. 


1008 


AMPUTATION. 


Fig.  695, 


contain 
formed 


When  anything  like  retraction  of  the  flaps  exists,  extension  may  be  applied  by  means 
of  a  splint  of  perforated  zinc,  as  seen  in  Fig.  693. 

Before  chloroform  was  introduced  it  was  the  practice  of  the  late  Mr.  Aston  Key,  as 
well  as  that  of  JMr.  Syme,  to  leave  the  stump  open  for  a  few  hours  before  its  flaps  were 
brought  together ;  and  doubtless  the  measure  was  good,  for  in  that  time  every  bleeding 
vessel  showed  itself  and  the  surface  of  the  wound  became  glazed,  and  therefore  in  a 
state  good  for  repair ;  but  since  anaesthetics  have  been  in  use  this  practice  has  fallen 
into  desuetude.  The  application  of  the  wet  sponge,  squeezed  dry  out  of  hot  iodine  lotion, 
renders,  moreover,  such  a  practice  unnecessary. 

The  stitches  may  be  taken  away  on  the  third  or  fourth  day,  when  the  parts,  if  they 
gape  or  if  union  is  not  solid,  should  be  supported  by  strapping.  The  wound  may  be 
dressed  with  the  mixture  of  terebene  one  part  and  olive  oil  three  parts,  or  iodoform  gauze 
and  Gamgee  tissue. 

For  the  dressing  of  wounds  the  reader  must  refer  to  an  early  chapter. 

Teale's  Amputation,   a  Modification  of  the    Skin  and    Muscular 

Flap. — This  was  introduced  "  to  procure  a  more  useful  stump  and  in  the  hope  of  some- 
what diminishing  the  mortality  of  the  operation.  It  is  proposed  to  amputate  by  a  long 
and  a  short  rectangular  flap,  the  long  flap  folding  over  the  end  of  the  bone  being  formed  of 
parts  generally  devoid  of  large  blood  vessels  and  nerves,  whilst  those  important  structures 

are  contained  in  the  short  flap.  The  size  of  the 
long  flap  is  determined  by  the  circumference  of  the 
limb  at  the  place  of  amputation,  its  length  and  its 
breadth  being  each  equal  to  half  the  circunifer-, 
ence.  The  long  flap  is  therefore  a  perfect  square, 
and  is  long  enough  to  fall  easily  over  the  end  of 
the  bone.  In  selecting  the  structures  for  its 
formation  such  parts  must  be  taken  as  do  not 
the  larger  blood  vessels  and  nerves.  A  flap  so 
will  be,  for  the  most  part,  anterior  in  position,  as 
far  as  regards  the  general  aspect  of  the  body,  but  superior 
when  the  patient  is  in  the  recumbent  position,  as  during 
the  after-treatment.  The  short  flap,  containing  the  chief 
vessels  and  nerves,  is  in  length  one-fourth  of  the  other 
(Fig.  695).  The  flaps  being  formed,  the  bone  sawn,  and 
the  arteries  tied  or  twisted,  the  long  flap  is  folded  over  the 
end  of  the  bone  and  each  of  its  free  angles  fixed  by  sutures 
to  the  corresponding  free  angle  of  the  short  flap.  One  or  two  more  sutures  may  be 
required  to  complete  the  transverse  line  of  union  of  the  flaps  and  to  unite  the  side  of  the 
short  to  the  corresponding  portion  of  the  long,  as  well  as  the  reflected  portions  of  the 
long  flap  to  its  unreflected.  Thus,  the  transverse  line  of  union  is  bounded  at  each  end 
by  a  short  lateral  line  at  right  angles  to  it." 

In  making  this  long  anterior  flap  the  surgeon  should  be  careful  not  to  scarify  it  with 
his  knife,  more  particularly  when  it  is  chiefly  skin,  as  in  the  leg,  since,  on  account  of  its 
length,  it  is  very  prone  to  slough,  and  if  scarified  this  tendency  is  increased.  Indeed, 
this  sloughing  of  the  long  flap  is  the  great  disadvantage  of  the  operation,  for  in  an  ordi- 
nary thigh,  twelve  inches  in  circumference,  a  flap  of  six  inches  would  have  to  be  made. 
To  secure  a  cicatrix  away  from  the  extremity  of  a  stump  is  a  point  of  great  practical 
value,  and  to  do  so  by  a  long  anterior  flap  is  doubtless  an  advantage ;  but  this  often 
requires  more  soft  parts  than  are  generally  at  the  surgeon's  disposal,  unless  more  of  the 
limb  be  taken  away  than  requires  removal.  This  object  may,  however,  sometimes  be 
secured  by  making  a  shorter  anterior  flap  than  Teale  suggests  and  dividing  the  bone  one 
or  two  inches  above  the  line  of  the  skin  flaps.  In  fact,  as  long  as  the  anterior  flap, 
whether  rectangular  or  oval,  is  of  sufiicient  length  to  be  drawn  over  the  end  of  the  stump 
to  its  posterior  aspect,  the  principle  of  Teale's  operation  is  observed. 

Mr.  Spence  in  his  Surgery  (1871),  p.  749,  tells  us  that  he  acted  much  upon  this  prin- 
ciple in  1858,  making  one  long  anterior  skia  and  mnscular  flap^  with  a  short  posterior, 
clearing  the  bone  for  nearly  two  inches  before  dividing  it. 

The  Mixed  Form  of  Amputation. — The  mixed  form  of  amputation  as  illus- 
trated by  Garden's  operation  will  now  claim  attention.  In  principle  it  includes  a  combi- 
nation of  the  circular  and  flap,  already  described. 

"  The  operation  consists  in  reflecting  a  rounded  or  semi-oval  flap  of  skin  and  fat  from 
the  front  of  the  joint  (knee),  dividing  everything  else  straight  down   to  the  bone,  and 


Teale's  Amputation. 


hll'Fl.ni'.Si  MnDKS   OF  AMITTATIOS. 


1009 


Yio.  696. 


suwiiij;  the  Imhu-  .sli;^litlv  alinvc  I  lie  iilaiif  nl'  tlic  iiiiimIcs,  thus  lurmiii^'  a  liat-lacccl  .siiuiip 
witli  II  homii't  (if  iiitt'jriiiiu'iit  (o  full  over  it.  'I'lic  i)p(;rati<>ii  i.s  .siiiipli;.  'J'lif  opeiutor, 
staiidiii;;  oil  tlu'  /•/'//(/  .side  nl"  tlii'  liiiil).  seize."*  it  between  liis  left  l'iire-jiiiji;er  and  tliuiiil)  at 
tlie  .spot  selected  lor  the  lia.se  of  the  Hap,  and  enters  the;  point  of  the  knife  eh>he  to  hi.s 
tiii;{er,  ljrinj;iiig  it  round  lhrouj,'h  skin  and  fat  helow  tlie  patijlhi  to  the  spot  pressed  by  hi.s 
thiinih  ;  then,  turning  the  edjje  downward  at  a  ri^dit  aiijrle  with  the  line  of  the  liiiih,  he 
j)asses  it  tlin»ut;h  In  tlu-  spot  where  it  first  entered,  eiitlin;:  outward  thioii;:h  everything 
behiinl  the  hone.  The  flap  is  then  leHeeled  and  the  rtmiaimler  of  the  soft  parts  divided 
.straight  down  to  the  hone;  tlii'  imiseles  are  then  slightly  cleared  upward  and  the  saw  is 
applied.  Or.  the  linili  being  held  as  before,  the  hand  and  knife  may  be  brought  round 
under  the  limb,  as  in  the  circiil.ir  operation,  and  the  blaile  entered  near  the  thumb  and 
drawn  round  to  the  op]»osite  sidt,-,  when  the  ham  may  be  cut  across  by  turning  the  edge 
of  the  knife  upward,  and  the  operation  comjdeted  as  before.  In  amputating  through  the 
<M)iidvles  the  ])atella  is  <lrawii  down  by  tle.xing  the  knee  to  a  right  angle  before  dividing 
the  soft  parts  in  front  of  the  bone  ;  or,  if  that  be  iiicoiiveiiient,  the  patella  may  be  reflected 
downward"  {lirii.  Mfd.  Jonriinl^  April,  iStilj. 

This  operation  of  Mr.  Carden's  is  very  valuable,  not  only  a.s  applicalde  to  the  knee- 
joint,  to  which  it  was  originally  apjilicd,  but  on  account  of  the  principle  of  practice  it 
embodies — that  of  making  skin  flajis  and 
the  circular  division  of  the  muscles.  The 
practice,  however,  was  not  new  ;  for  when 
Mr.  Cardeii  began  it,  in  184G,  Mr.  8yme 
had  puljlished  in  the  Edin.  Moufh.  Jotirii. 
of  Med.  Sci'  nee  of  the  same  year  his  modi- 
fication of  the  circular  method  of  amjuita- 
tion  in  the  lower  third  of  the  thigh  l»y  mak- 
ing two  semilunar  skin  lateral  flaj)s  an<l  ob- 
lique .section  of  the  muscles  down  to  the 
bone,  dissecting  the  skin  fla})S  an  inch  or 
more  upward,  and  cutting  the  muscles  on  a 
level  with  the  retracted  skin.  Liston  also, 
in  1839,  preferred  skin  flaps  alone  in  mus- 
cular subjects. 

Accepting  it  as  an  operation  for  the  re- 
moval of  a  limb  through  the  condyles  of  the 
femur,  I  have,  however,  found    it  advisable 

to  make  a  slightly  longer  posterior  flap  than  Carden  advises  (m/r  Fig.  GOG),  making  it 
only  of  skin,  and  taking  care  to  make  the  long  anterior  flap  broad,  with  a  base  correspond- 
ing to  the  ))osterior  border  of  the  lateral  surfaces  "of  the  condyles. 

In  this  operation  there  is  but  a  .slight  section  of  the  muscular  tissue,  and,  beyond  the 
popliteal  artery,  few  vessels  of  importance  are  divided.     The  stump  that  remains  is  like- 

FiG.  697. 


("ardcn's  Amputation,  with  Long  Posterior  Flap. 


Amputation 


liy  the  >rixed  Method. 


wise  remarkably  good,  being  long  and  broad.  u]t(iti  which  patients  can  bear  their  weight 
without  pain.  This  operation  is,  I  ])elieve,  applicable  to  a  far  larger  number  of  cases 
than  i^s  generally  thought,  and,  with  Li.ster,  I  look  upon  it  as  a  great  advance  in  surgerv 
It  is,  moreover,  far  safer  than  amputation  through  the  .shaft  of  "the  femur. 

The  object  sought  in  all  these  long  anterior  flap  operations  is  to  procure  a  cicatrix 
that  is  placed  behind  the  stump  out  of  harm's  way.  and  .so  long  as  this  end  can  be  secured 
without  .sacrificing  more  of  the  body  than  is  ab.s'olutely  required  by  the  exigences  of  the 
case  the  amputation  is  good,  and  it  is  a  matter  of  small  importance"  whether  the  reetanjru' 
lar  and  muscular  flaps  of  Teale,  the  convex  skin  flaps  of  Carden,  or  the  .skin  and  muscle 
as  practised  by  Spence,  be  employed.  I  prefer  Carden's  flap,  with  the  modifications 
fi4 


1010 


SPECIAL  AMPUTATIONS. 


Fig.  698. 


described,  to  any  other,  and  when  applied  to  the  knee,  where  it  is  most  applicaVjle,  regard 
it  with  high  favor. 

This  "  mixed  method  of  amputation  "  has,  however,  a  wider  application  than  to 
operations  about  the  knee,  and  I  believe  it  to  be  by  far  the  best 
operation  in  all  amputations  of  the  leg  and  fore-arm.  It  combines 
the  advantages  of  the  circular  and  the  flap  without  the  disadvantages, 
and  rarely,  if  ever,  calls  for  the  sacrifice  of  more  of  the  extremity  than 
is  absolutely  required.  In  its  performance  the  two  lateral  skin  flaps 
should  be  made  sufficiently  long  to  meet  over  the  stump  without  stretch- 
ing, the  surgeon  by  his  eye  judging  their  required  length,  while  the 
muscles  should  be  divided  by  a  circular  sweep  an  inch  below  the  base 
of  the  retracted  flaps,  the  bones  being  bared  to  this  extent  before  they 
are  divided  (Fig.  GOT).  Mr.  Cock  includes  the  muscles  in  the  flap,  but 
I  hardly  think  this  necessary  unless  the  skin  is  very  thin.  When  the 
flaps  are  brought  together,  a  pretty  stump  is  seen,  and  subsequently  it 
turns  out  to  be  a  very  good  one  (Fig.  G98). 

In  amputation  of  the  fore-arm  the  mixed  form  is  the  operation,  the 

putation    of    the  skin  flaps  being  made  from,  the  anterior  and  posterior  aspects  of  the  limb, 

jfe^hcKi.'^  ^^  '  '^^^'    the  flap  amputation  executed  by  transfixion  being  very  unsatisfactory,  on 

account  of  the  tendons  of  the  fore-arm  (Fig.  708). 

In  amputation  at  the  wrist  and  elbow-joints  nothing  can  be  better  than   this  mixed 

method  (Figs.  701,  702),  the  surgeon  having  it  in  his  power,  according  to  circumstances, 

to  make  one  long  anterior,  posterior,  or  lateral  flap  cover  the  stump,  and  thus  to  secure 

the  cicatrix  being  out  of  harm's  way.    One  of  the  best  stumps  of  this  kind  I  ever  obtained 

was  at  the  elbow-joint,  in  which  I  made  a  long  skin  posterior  flap,  the  cicatrix  sub.sequently 

being  placed  above  the  condyles  of  the  bone  and  in  front  (Fig.  702). 


Stump  after  an  Am- 


SPECIAL  AMPUTATIONS. 

The  subject  of  amputations  as  a  whole  having  been  considered,  I  propose  now  to 
describe  them  in  detail  as  applicable  to  diff'erent  parts  of  the  body,  and  begin  with  the 
upper  extremity. 

Amputations  at  the  Shoulder-Joint. 

This  operation  may  be  called  for  in  cases  of  injury  when  the  arm  has  been  so  irrepar- 
ably injured  as  to  render  amputation  through  the  tuberosities  impossible  or  excision  inap- 
plicable, or  for  disease  when  too  extensive  to  be  taken  away  by  a  less  severe  measure,  the 
surgeon  always  bearing  in  mind  that  large  portions  of  the  humerus  may  be  resected  with 
advantage  so  long  as  the  chief  vessels  and  nerves  of  the  arm  are  intact,  and  that  amputa- 
tion through  the  humerus,  however  high,  leaves  a  far  better  .stump  than  at  the  joint. 

After  this  operation,  when  performed  for  injury,  1  out  of  3  cases  die;  but  when  for 
disease,  1  in  2. 

The  operation  is  best  performed  by  means  of  the  double  flap  operation.  A  good 
assistant  is  required,  to  compress  the  subclavian   artery  above  the  clavicle  or  to  take 

charge  of  the  axillary  in  the  lower 
flap.  When  the  right  arm  has  to  be 
amputated  the  surgeon  should  stand 
behind,  and  when  the  left  in  front, 
of  his  patient  (Fig.  G99) ;  under 
both  circumstances  a  deltoid  flap 
shoiild  be  fir.st  made,  cutting  from 
without  inward  between  the  poste- 
rior part  of  the  axilla  and  an  inch 
in  front  of  the  acromion  process, 
this  incision  including  in  its  sweep 
the  whole  deltoid  muscle.  Having 
reflected  this  flap  with  a  few  bold 
sweeps  of  the  knife,  the  head  of  the 
humerus  should  be  disarticulated, 
the  knife  being  kept  close  to  the 
Amputation  at  the  Shoulder-Joint.  |,Qj,p    ^,^j  d^g  lo^gj.  fljjp  made,  three 

or  four  inches  long,  by  cutting  from  within  outward.     If  this  part  of  the  operation  is  done 


Fig.  699. 


SPECfA  L   A MrilTA  TIOSS. 


1011 


with  can',  tin-  main  artory  ••f  tlif  liiiil)  will  lie  diviiled  (Jiily  on  the  cuiiiplction  of  the  Kcoond 
tlap,  when  the  siirp'oii  wi(h  his  h'ft  hand  can  secure  it  between  lii.s  firi^'cr  and  thumb  until 
it  fan  In-  either  twisted  or  tied. 

hurinj;  the  Hist  step  ol' tliis  amputation  tin-  arm  >hniil<l  l»c  held  well  out  by  an  assist- 
ant, liut  durinir  tlie  seeond  at  first  near  th»;  body  ;  and  when  the  knife  has  jjassed  beneath 
the  head  cd"  the  binu',  it  sliouhl  be  abchieted.  A  very  jrood  stump  usually  follows  this 
ojnTation.  At  no  joint  of  the  body,  however,  is  the  surj:eon  more  compelled  to  form  his 
flaps  aeeonlini:  to  the  eireumstanees  of  tlu;  ease  than  at  the  shoulder,  sinei;  the  majority 
t>f  eases  of  amputation  at  this  part  are  fur  injury  where  the  arm  has  been  wholly  or  par- 
tially torn  olV.  when  the  sur<;eon  must  make  the  best  flap  he  can,  and  at  times  no  flap  at 
all.  As  <;ooil  a  stump  as  any  I  have  made  at  this  joint  was  one  in  which  a  piece  of  intej^u- 
inent  from  the  posterior  part  of  the  arm  was  alone  available.  I  have  .seen  many  ca.ses  in 
whit  h  the  flaps  slouirhed  and  yet  good  cicatrices  followed,  the  soft  parts  being  readily 
drawn  forward  by  the  cicatricial  process. 

In  this  amputation  some  surgeons  prefer  makitig  an  anterior  and  posterior  flap  by  per- 
forating in  front  of  the  posterior  axillary  fold  to  make  the  posterior  flap,  disarticulating 
and  dividing  the  axillary  artery  in  the  anterior  flap  ;  but  the  operation,  although  good,  is 
not  so  eflicient  as  the  former. 


Amputation  at  the  Arm. 

Kxcision  of  the  elbow-joint,  even  when  three  or  lour  inches  of  the  humerus  are  taken 
away,  is  such  a  very  succes.sful  operation  that  amputation  at  the  arm  is  never  called  for 
when  excision  can  be  entertained  ;  and  this 
observation  applies  as  forcibly  to  cases  of 
injury  of  the  elbow-joint  as  seen  in  civil 
and  military  practice  as  it  docs  to  cases  of 
disease. 

When,  however,  the  fore-arm  and 
elbow-joint  are  hopelessly  injured,  gan- 
grenous, or  diseased,  amputation  may  be 
demanded,  and,  therefore,  as  the  very 
worst  eases  are  included  in  this  category, 
the  mortality  of  the  operation  is  great — 
viz.,  1  in  3  for  injuries,  and  1  in  10  for 
disease. 

The  flap  operation,  as  already  de- 
scribed, is  the  best  in  this  region,  the 
anterior  flap  being  made  by  cutting  from 
without  i-nward  toward  the  bone,  excluding  the  brachial  artery,  and  the  posterior  by 
transfixing  all  that  remains.  In  a  very  large,  muscular  arm  the  skin  flap  and  circular  cut 
thro\igh  muscle — I.e.,  the  w/.rer/ operation — may  be  performed.  Amputating  by  double 
flaps  and  tran.sfixion  is,  however,  excellent  (Fig.  700). 


Amputation  of  Ami  by  Flap  Operation. 


Fig.  701. 


Fig.  702. 


Amputation  at  the  Elbow-Joint 

is  a  capital  operation,  and  ought  always  to  be  performed  in  preference  to  any  higher 
operation  when  amjiutation  above  the  fore-arm 
is  imperative,  if  the  condition  of  the  soft  parts 
will  allow.  By  this  operation  an  excellent  .stump 
is  obtained,  and.  as  in  other  amputations  at  joints, 
less  constitutional  disturbance,  and  probably  less 
risk  to  life,  is  incurred  than  after  amputation 
through  the  bones.  I  have  had  a  patient  up 
and  about  on  the  seventh  day  after  such  an  ope- 
ration, the  wound  having  united  without  any 
traumatic  fever  or  other  disturbance. 

It  should  be  performed  by  the  mixed  metliod 
of  amputating,  by  anterior  and  posterior  skin 
semi-circular  flaps,  beginning  and  ending  at  the 
lower  extremities  of  the  condyloid  ridges,  the 
muscles  being  divided  transversely  on  complet- 
ing   the    disarticulation    (Fig.    701) 


-I-  1       Amputation  at  EII>ow-Joint 

in      tne  by  Mixed  Method. 


Stump  after  Amputa- 
tion at  Elbow-Joint. 


1012  AMPUTATIOX. 

drawing  of  the  stump  (Fig.  702)  the  posterior  flap  was  made  longer  than  the  anterior  in  order 
that  the  cicatrix  might  be  out  of  harms  way.  I  have  performed  tliis  operation  on  six 
occasions,  and  the  resuh  in  all  was  so  good  that  I  cannot  too  strongly  advocate  it  when- 
ever the  injur}'  or  disease  will  allow  ;  in  fact,  it  ought  to  be  performed  whenever  enough 
integument  can  be  saved  to  cover  the  bone  and  the  disease  or  injury  for  which  amputa- 
tion is  called  for  has  not  attacked  the  humerus. 

Amputation  at  the  Fore-Arm. 

This  is  comparatively  a  rare  operation,  modern  surgeons  doing  their  utmost  to 
save  the  hand.  It  is,  consequently,  performed  only  when  the  hand  is  hopelessly  crushed 
or  so  extensively  diseased  as  to  forbid  any  other  treatment  being  entertained.  At 
Guy"s  Hospital  it  was  performed  only  8-1  times  in  thirty  years  ending  1874 — on  44 
occasions  for  injury,  9  patients  dying,  or  1  in  5,  and  on  40  occasions  for  disease,  with 
5  deaths,  or  1  case  in  8 — the  operation  being  used  in  the  ver}-  worst  cases.     Amputa- 

FiG.  703. 


Amputation  of  Fore-Arm  by  Mixed  Method. 

tion  of  the  fore-arm  ought  always  to  be  performed  by  the  mixed  method,  the  one  by 
transfixing  being  very  unsatisfactory,  the  many  tendons,  etc.,  of  the  part  causing  ragged 
flaps,  and  thus  favoring  suppuration.  Two  well-cut  and  fairly-long  semi-circular  .skin 
flaps  and  a  clean  circular  section  of  the  muscles  are  preferable  to  the  flap  operation  and 
yield  a  good  stump  (Fig.  703).  The  skin  is  usually  too  thin  for  one  long  skin  flap,  and 
there  are  too  many  tendons  for  a  Teale's. 

Amputation  at  the  Wrist-Joint. 

I  have  never  performed  this  operation  or  seen  it  done,  but  I  have  seen  two  cases  in 
which  it  had  been  performed  years  before  for  injury,  and  in  both  the  stumps  were  con- 
stant sources  of  trouble  to  their  owners  during  the  winter  months,  from  their  being  the 
seat  of  chilblains  and  ulcerations  on  account  of  the  feebleness  of  the  circulation  through 
the  thin  cutaneous  covering,  and  in  neither  could  a  good  hand  be  fitted  with  comfort. 
Both  patients  likewise  regretted  that  the  amputation  had  not  been  performed  higher  up. 

Under  these  circumstances  I  am  disposed  to  follow  the  opinion  of  my  patients,  and 
cannot  advocate  the  operation.  If.  however,  it  be  called  for,  it  .should  be  performed 
with  skin  flaps  and  the  circular  division  of  the  deeper  tissues  or  by  the  pure  circular 
operation. 

Amputation  of  the  Thumb  and  Fingers. 

A  knowledge  of  the  shape  of  the  articular  ends  of  the  bones  and  of  the  position  of  the 
diflBrent  articulations  of  the  hand  is  of  importance  in  all  operations  on  these  parts,  and  I 
have,  therefore,  supplied  a  figure  to  illustrate  these  points  as  much  as  possible  (Fig.  704). 

The  surgeon  should  remember  that  with  the  hand  closed  the  knuckles  are  formed  by 
the  heads  of  the  metacarpal  bones,  the  bases  of  the  phalanges  being  in  front,  and  that  in 
the  second  and  third  rows  the  same  arrangement  holds  good.  To  open  any  of  these  joints, 
consequently,  the  line  of  incision  should  be  anterior  to  the  knuckles  on  the  dorsal  aspect 
and  in  the  fold  of  the  fingers  on  the  palmar.  In  the  figure  it  will  be  ob.served,  also,  that 
the  two  distal  joints  are  concave,  with  the  concavity  looking  toward  the  ends  of  the  fin- 
gers, while  at  the  metacarpal  joints  the  concavity  points  the  other  way.  the  heads  of  the 
metacarpal  bones  being  round ;  from  the  palmar  surface  the  metacarpo-phalangeal  joints 
are  more  than  half  an  inch  behind  the  clefts  of  the  fingers,  corresponding  pretty  nearly 
with  the  palmar  furrow  of  the  hand  ;  this  furrow  likewise  corresponds  with  the  upper 
limit  of  the  synovial  sheaths  of  the  flexor  tendons  and  with  the  bifurcation  of  the  digital 
arteries. 

In  amputating  at  the  phalangeal  joints  (Fig.  704,  C)  or  through  the  bones,  anterior 
and  posterior  semicircular  flaps  are  better  than  one  long  flap,  although  this  may  at  times 


Sri.clAL   AMi'l'TM'IOSS. 


1013 


Fig.  705. 


bo  iHTlun.M.l  with  a.lvantaire,  ouo  Uvz  a..t<ri..r  fl:ip  (H).  after  opening  the  joint  Iru.n  its 
.h.rUl  asiu.rt  (  .1 ),  hcii.-  tlu>  !i.n>t  .uiMinuu  shapi- ;  hut  the  surgeon  must  in  these  cum-s  be 
„,„,b  .M.i.hMl  by  what  skin  he  has  tu  utili/.e.  As  a  rule,  it  l.s  wise  „ot  to  take  ott  the 
heail  ..?•  the  i.n.'xiinal  b..iu-,  thou^'h  when  there  is  iH.t  suttieient  tta).  U>  ever  it  the  surgeon 
niuv  h.-  iustilie.l  in  ivinoviug  its  li.-a.l  witli  b(.ne  foreeps.  ,    .    .    ^  .  , 

Amputation  of  the  fingers  at  their  metacarpal  jomts  requires  mueh 

nhvU  ami  in  all  the  linp-rs  th.  su,-...,,  shuuhl  nnu.u.l..r  that  he  is  on  no  aeeount, 
unle.ss  absolutely  required,  to  interfere  with  th.-  palm  of  the  hand  his  .m-,.s,..n  ,n  the 
palmar  surfaee  must  never  go  beyond  the  iold  of  the  joint.  In  performing  this  opera- 
Ib.n  the  surgeon  is  to  take  eliarge  of  the  amputat.-d  member,  an  assistant  holding  he 
hand,  separating  the  fingers,  and  eompressing  the  radial  and  ulnar  ve.ssel.s.  ^\  ith  the 
hand  prl.nated^ivertieal  ineision  about  one  ineh  long  slim,  d  be  made  with  a  strong 
'  ...ah,,.}   over  the  dorsal   aspeet  of  the  head  of  the  metacarpal 

bone,  and  from   its  distal  end  over  the  joint  the  knife  shc.uld 
be  made  to  pass  u].  one  cleft  of  the  finger  close  to  the  bone  to 
be  removed,  round  the  palmar  surface  of  the  finger  in  the  fold, 
and  through  the  sieoiid  cleft  to  the  point  from 
which  the  circular  iiici.sion  started,  the  tendons 
and  liiraments  being  divided  as  cleanly  as  pf>s- 
sible  (Fig.  7(»4).      The  joint  can  then  be  0}.ened 
and  the  finger  removed.      In  a  laboring-man  it 
is  wise  not  to  remove  the  head  of  the  metacar- 
pal bone  unless  diseased,  although  in  the  higher 
classes  it  is  sometimes  expedient  to  take  it  away 
with  bone  forceps,  to  allow  the  neighboring  fin- 
gers to  be  brought  closer  together,  and  thereby 
To  improve  the  aspect  of  the  hand.     With  the 
same  object  it  is  at  times  wise  to  take  off  the 
head  of  the  metacarpal  bone  of  the  little  or  in- 
dex finger  obliquely — /'.  e.,  in  a  direction  sloping 
upward  away  from  the  median  line  of  the  hand. 
In  amputating  either  the  little  or  the  index  fin-  Hand  after  Ampu- 
ger  at  this  joint  the  same  form  of  incision  may     Thuin^   index, 

Outline  Diagram   for  Amputation  i:„  „,aflp   the  OUtcr  flai)  under  both  circumstances      and    two    (Jiiter 
of  the  Thuiiib  and  Fingers.         uc  iiirtuc,  mc  vm..-  '         ,  i       •  •  i  Fingers. 

"•  ^  bein^  somewhat  lar<rer  than  the  inner,  in  order 

that  the  cicatrix  may  be  placed^'close  to  the  adjoining  finger  and  thus  out  of  all  harm's 
way  If  the  incision  be  so  made  as  to  allow  the  scar  to  fall  over  the  exposed  aspect  of 
the  hand,  the  result  is  very  inconvenient,  and  often   painful,  as  the  hand  naturaUy  rests 

on  its  outer  borders.  „    ,       , ,  i  i  ^         i 

The  same  arguments  apply  to  the  amputation  of  the  thumb,  «>"e  long  externa 
skin  flap  adjusted  to  a  shorter  flap  in  the  cleft  being  far  superior  to  the  palmar  and  dorsal 
flaps  usuall'y  adopted.  But  it  may  here  be  .stated  that  amputation  of  the  thumb  ought  to 
be  a  very  rare  operation,  as  it  is  far  better  practice  in  all  cases  of  injury  to  the  thumb, 
where  there  is  no  possibility  of  saving  it.  simply  to  cut  off  any  .sharp  point  of  bone,  trim 
UP  the  .soft  parts,  and  allow  the  stump  to  granulate  than  to  make  what  is  sometimes  called 
a  -ood  job  of  it  by  amputating  the  organ  higher  up;  for  any  stump  of  a  thumb,  how- 
ever short  or  ugly,  is  of  use.  In  the  hand  here  figured  (Fig.  70;>)  the  man  was  an 
engineer,  and  he  has  been  able  for  years  to  f.dlow  his  occupation  with  but  little  incon- 

venience.  „    ,      ,       i   •  \  „  lu 

To  describe  other  amputations  of  different  parts  of  the  hand  is  unnecessary  As  lit- 
tle, as  possible  should  be  taken  away,  and  this  by  making  skin  flaps  only,  care  being 
always  observed  to  divide  the  tendons  by  a  clean  cut  and  as  high  up  as  possible,  ihe 
ingenuity  of  the  surgeon  and  the  wants  of  the  individual  case  will  suggest  the  best  means 
by  whicii  the  latter  can  be  supplied. 

Amputations  of  the  Lower  Extremity. 

These  are  of  more  importance  than  those  of  the  upper,  fron,  their  greater  severity. 
Tliev  are.  m.n-eover,  larirer  operations,  more  dangerous,  and  possibly  more  dithcult. 

Amputation  of  the  thigh  at  the  hip-joint, is  a  formidable  operation  and  is 
ju.stma^l?  only  under  desperate  ?.nditio„s.  wlu-n  a  limb  is  irreparably  crushed  or  diseased 
and  resection  of  the  head  of  the  femur  with  more  or  less  of  its  shaft  is  out  of  question. 


1014 


AMPUTATTOy. 


Fig.  706. 


Lister's  Abdominal  Tonmiquet. 


Fig 


When  performed  for  accident,  it  is  almost  always  fatal,  not  ten  per  cent,  recovering :  for 

disease,  however,  it  is  more  successful,  the  risk  being 
about  equal,  although  after  resection  of  the  head  of  the 
femur  which  has  failed  it  is  somewhat  better.  The  best 
flaps  where  F.  Jordan's  method  cannot  be  carried  out 
appear  to  be  the  external  and  internal.  The  patient 
being  brought  to  the  edge  of  the  table,  with  the  tuber- 
osities of  the  ischium  in  view  and  hemorrhage  controlled 
by  Jordan  Lloyd's  method  (]>.  1015^  or  Listers  tournifjuet 
(Fig.  TOGj,  the  surgeon  should  then  make  the  extf-rnal 
skin  flap  by  means  of  a  semicircular  incision,  starting 
from  the  tuberosit}-  of  the  i.schium,  downward  and  out- 
ward one  hand's  breadth  Vjelow  the  great  trochanter,  and 
then  upward  and  forward  to  the  centre  of  the  groin  (on 
the  outer  side  of  the  femoral  vessels).  This  flap  should  then  be  reflected  upward,  so  as 
to  expose  the  trochanter  and  allow  the  joint  to  be  opened  and  disarticulation  to  be  com- 
pleted, the  limb  being  forcibly  adducted  by  an  assistant  to  facilitate  this  .step.  In  doing 
this  no  vessels  of  any  importance  are  divided,  while  the  most  difficult  part  of  the  opera- 
tion is  performed. 

The  inner  flap  now  remains  to  be  made,  which  is  readily  done  by  transfixing  the  thigh 
on  the  inner  side,  inserting  the  knife  ^twelve  inches  long;  in  the  anterior  wound,  passing 
backward  close  to  the  inner  side  of  the  neck  of  the  femur,  and  bringing  it  out  near  the 
tuberosity  of  the  ischium  where  the  external  incision  was  commenced,  and  then  cut- 
ting out  through  the  .soft  parts,  including  the  adductors,  etc.  (Fig.  707).    In  doing  this 

all  the  pelvic  muscles  are  separated  from  the  thigh- 
bone at  one  clean  sweep,  and  a  few  touches  of  the 
knife  complete  the  amputation.  Should  there  be 
much  cau.se  to  fear  lo.ss  of  blood,  the  common 
femoral  artery  may  be  ligatured  in  the  wound 
before  the  second  flap  is  made,  or  it  may  be  divided 
and  twLsted.  The  ve.s.sels  can  then  be  secured  in 
the  way  the  surgeon  proposes  and  the  parts  brought 
together,  the  two  flaps  usually  forming  an  excellent 
covering  to  the  acetabulum.  Tlie  wound  being  an 
antero-f»osterior  one.  and  therefore  good  for  drain- 
age, a  good  scar  results. 

This  operation  I  Vjelieve  to  be  better  than  the 
anterior  and  posterior  flap  usually  advised,  and 
which  is  thus  described  by  Erichsen:  "If  the 
operation  be  on  the  left  side,  the  knife  ^twelve 
inches  long)  should  be  entered  about  two  fingers' 
breadth  below  the  anterior  spine  of  the  ilium  and 
carried  deeply  in  the  limb  behind  the  ve.s.sels  directly 
across  the  joint,  its  point  being  made  to  issue  ju.st  above  the  tuberosity  of  the  ischium. 
In  transfixing  on  this  side  care  must  be  taken  not  to  wound  the  scrotum  or  the  opposite 
thigh  ;  the  back  of  the  knife  must  run  parallel  to,  but  not  again.st.  the  pelvis,  and  the 
point  must  not  be  held  too  high,  le.st  it  enter  the  obturator  foramen.  The  anterior  flap 
must  then  be  rapidly  cut  downward  and  forward  about  five  inches  in  length.  The  limb 
mu.st  now  be  forcibly  ah»ducted  and  everted,  the  cap.sule  of  the  joint  opened.  So  soon  as 
this  is  done  the  head  of  the  femur  must  be  pushed  up  by  forcibly  depressing  and  abduct- 
ing the  limb,  so  that  it  may  start  out  of  the  acetabulum  :  the  heel  of  the  knife  is  then 
pas.sed  behind  it.  the  remainder  of  the  capsule  cut  across,  and  the  posterior  flap  rapidly 
fashioned  by  carrying  the  knife  downward  and  backward  through  the  thick  mu.scles  in 
this  situation  :  the  posterior  flap  may  be  about  four  inches  long.''  The  operation  is  then 
to  be  completed  as  the  former.  In  both  these  operations  good  as.sistants  are  needed  to 
compress  the  bleeding  vessels  as  they  are  divided,  for  hemorrhage  and  the  .shock  of  the 
operation  are  the  great  evils  to  be  feared.  Lister's  compressor,  however,  has  rendered 
this  serious  operation  safer  than  it  was. 

Furneaux  Jordan's  Method.' — This  excellent  surgeon  of  Birmingham  has 
described  a  method  of  amputation  at  the  hip-joint  which  must  be  regarded  as  a  far  better 
operation  than  any  that  has  been  hitherto  described,  and  it  .seems  to  be  generally  appli- 

^  .Surgical  Inquiries,  1880. 


Ampntation  at  Hip-Joint  by  External  and 
Internal  Flaps. 


SI'lK  lAL   AMl'l  TA  770A.V. 


1015 


Fkj.  tow 


faiili',  t'xcliiiliiij;  only  cases  (»f  new  ^'mwtli  in  wliicli"  the  soft  parts  aroiiii)!  the  Itoiie  are 
iiivtilvcd  in  the  dist-ast'  It  cimsists  in  an  incision  alon^r  the  outer  side  of  the  thi^h,  exteiid- 
ini;  (hivvnwanl  from  the  top  of  tiie  trochanter  lor  six  or  more  inclies.  the  enueleutioii  of  the 
head  of  tlie  femur  from  tlie  acetal)nlum  and  tlie  separation  of  part  of  the 
shaft  from  its  niuscuhir  attachments,  and  tinally  a  circiihir  divi>ion  of 
the  soft  parts  (hiwn  to  the  hone  at  any  line  thouu;ht  desirahle.  Tlie 
suriretui  may.  if  he  choose,  make  the  circular  sweep  tlirou<;ii  the  soft 
jiarts  hefore  the  shal't  of  the  hone  is  turned  out. 

The  periosteum  should  he  saved  from  the  shaft  of  the  femur  if  prjs- 
sihle,  ami  the  attacdiments  of  the  muscles  thus  saved,  when,  as  shown  hy 
Mr.  Shuter's  case,  a  firni  and  movahle  stump  may  he  ohtained  to  fit  into 
the  hucket  of  an  artificial  limh  and  assist  iJroLM-essiiui. 

It  is  hetter.  says  its  autlnu\'  to  enucleate  the  femur  where  it  is  most 
thinly  cttvered,  ami  cut  across  the  liinh  where  it  is  smaller  and  J'arther 
removed  from  the  trunk  ;  it  is  better,  moreover,  not  to  touch  the  hulky 
soft  jiarts  at  the  inner  an<l  upper  ]»arts  of  the  thiLjh. 

In  this  I  (|uite  concur,  and  from  what  I  have  seen  of  this  operation — 
and  it  has  lieen  performed  at  least  five  times  at  (ruy's — I  cordially 
recommend  its  adoption,  aiul  more  particularly  with  the  improvement, 
as  made  hy  Shuter,  in  ])reservint;  the  perio.steum  as  much  as  pcssihle. 

Mr.  Jordan  Lloyd,  also  of  Birmin<;liam.  has  suirjrested  an  excellent 
method  of  eontrollin<r  hemorrhatje  in  am])utation  at  the  hip-joint  which 
deserves  a  notice.  I  have  .seen  it  eni]doyed  with  marked  success.  It 
is  to  be  a])plied  as  follows  :  The  limb  to  be  amputated  having  been 
emptied  of  its  blood  by  elevation  and  friction  toward  the  trunk,  ''  a  strip  of  black 
india-rublter  bandage  about  two  yards  long  is  to  be  douV)led  and  passed  between  the 
thighs,  its  centre  lying  hrtirecn  tlic  fnh/r  lacJiit'  of  the  aide  to  ln'  openifed  on  and  the 
anus.  A  common  calico  thigh  roller  niu.st  next  be  laid  lengthways  over  the  external 
iliac  artery.  The  ends  of  the  rubber  are  now  to  be  firmly  and  .steadily  drawn  in  a 
direction  upward  and  outward,  one  in  front  and  one  behind,  to  a  point  above  the  centre 
of  the  iliac  crest  of  the  same  side.  They  must  be  pulled  tight  enough  to  check  pulsation 
in  the  femoral  artery.  The  front  part  of  the  band,  passing  across  the  compress,  occludes 
the  external  iliac  and  runs  parallel  to  and  above  Poupart's  ligament.  The  back  half  of 
the  band  runs  across  the  great  sacro-sciatic  notch,  and  by  compressing  the  vessels  passing 
through  it  prevents  bleeding  from  the  branches  of  the  internal  iliac  artery.  The  ends  of 
the  bandage,  thus  tightened,  must  be  held  by  the  hand  of  an  a.ssistant  placed  just  above 
the  centre  of  the  iliac  crest,  the  back  of  the  hand  being  against  the  patient's  body.  To 
prevent  the  bandage  slippintr.  it  .><hould  be  fastened  bv  a  safety-pin  to  the  roller"  (Laucet, 
May  20,  1883). 


Furiii-aux  .Ionian's 
M.  thcd  of  Ainnu- 
talion  at  the  Hip- 
Joint. 


Amputation  at  the  Thigh. 

Primary  amputations  of  the  thigh,  taken  as  a  whole,  are  very  serious,  and.  calculating 
ca.'^es  at  all  ages,  more  than  half  die.  In  subjects  under  twenty  years  of  age.  however, 
better  results  can  be  recorded,  the  mortality  being  about  half  this  amount,  whilst  in  those 
over  forty  the  average  is  worse,  age  having  here,  as  elsewhere,  a  striking  influence  on 
results.  Primary  amputations,  however,  in  the  upper  third  of  the  thigh  are  more  fatal 
than  those  in  the  middle,  and  these;,  again,  are  more  fatal  than  amputations  above  the 
knee,  amputations  through  the  condyles  or  at  the  knee-joint  being  better  than  all.  The 
nearer  the  operation  ai)proaches  the  body,  the  greater  is  the  risk.  Still,  even  in  the  worst 
cases  of  compound  fracture  of  the  thigh,  when  death  seems  inevitable,  the  surgeon  should 
operate  when  by  so  doing  any  reasonable  ho])e  of  saving  life  can  be  entertained. 

In  amputations  for  diseases  a  better  account  can  be  given. 

In  am]nitation  of  the  thigh  for  cliriDu'r  joint  di'srose  at  all  ages  the  mortality  is  about 
1  in  4,  but  under  the  age  of  twenty  1  in  17,  while  over  that  period  it  is  1  in  3.  the  differ- 
ence in  the  mortality  of  the  operation  at  the  two  periods  being  very  great.  Thus,  taking 
all  cases  of  chronic  disease  toirether.  out  of  8f)  of  mv  own,  13  died  ;  of  99  of  rallender's, 
28;  of  54  of  MacCormac's  ( DnUn,  Journal.  18()8),  10:  and  of  106  of  Holmes's,  30; 
making  a  total  of  348  cases,  of  whicli  81  died,  or  1  in  4.  In  subjects  under  twenty 
years  of  age,  out  of  G9  cases  of  Callender's  and  my  own,  4  died,  or  1  in  17:  and  of 
119  cases  over  twenty  years  of  age,  38  died,  or  1  in  3;  amputation  of  the  thigh  for 

'  Clin.  Soc.  Trans.,  18S3. 


1016  AMPUTATION. 

chronic  joint  disease  being  nearly  six  times  more  successful  in  early  than  in  middle 
life. 

This  operation  in  the  upper  or  middle  third,  when  the  muscles  are  thick,  is  best  per- 
formed by  means  of  anterior  and  posterior  skin  flaps  and  the  circular  division  of  the 
muscle,  or  by  the  flap  operation  as  illustrated  in  Fig.  (J91,  the  anterior  flap  being  made  by 
cutting  from  without  inward,  and  the  posterior  by  perforating.  The  operation  by  lateral 
flaps,  whether  made  of  skin  or  muscle,  or  skin  alone  and  circular  muscle,  is  not  satisfac- 
tory, the  bones  having  a  tendency  to  appear  at  the  upper  angles  between  the  flaps.  In 
amputation  at  the  lower  third  one  long  anterior  flap  may  be  made,  and  a  short  posterior, 
as  previously  described  under  (larden's  operation  (Fig.  GOG). 

Mr.  W.  Stokes  of  Dublin  advocates  (Mrd.-Chir.  Trans.\  ISTO  ;  Diib/in  Joiirti.  of  Med. 
Sci.,  1875)  the  supra-coiidj/k/id  ampufa/ion  of  the  thigh,  in  which  the  femur  is  divided  at 
least  half  an  inch  above  the  antero-superior  edge  of  the  condyloid  cartilage,  and  the 
patella,  deprived  of  its  cartilaginous  surface,  is  applied  to  the  same  surface  and  fixed 
there  with  earbolized  catgut  sutures.  The  antei"ior  skin  flap  is  made  oval,  and  the  poste- 
rior fully  one-third  of  the  length  of  the  anterior. 

I  have  performed  this  operation  in  one  case  with  a  good  result,  and  have  seen  it  per- 
formed on  several  previous  occasions  by  my  colleagues  with  success.  I  think  well  of  it, 
and  would  suggest  its  wider  trial.  My  colleague,  Mr.  Jacobson,  has  written  an  interest- 
ing paper  on  it  (Gin/s  liosp.  Reps.,  1878). 

This  operation  diff"ers  from  what  is  known  as  Gritti's  in  the  section  of  the  femur 
being  about  one  inch  higher  up. 

Amputation  at  the  Knee-Joint. 

This  is  an  excellent  operation  in  all  ways,  and  one  that  should  always  be  performed  in 
preference  to  any  higher  amputation  when  the  special  circumstances  of  the  case  will 
allow.  It  is  apparently  attended  with  less  risk  to  life  than  when  a  section  of  the  bone 
is  made,  and  yields  an  excellent  and  serviceable  stump  on  which  the  weight  of  the  body 
can  generally  be  sustained.  Velpeau  revived  the  operation  in  1830,  while  Mr.  Pollock 
recalled  the  attention  of  London  surgeons  to  the  subject  {Med.-Chir.  Tram'.,  1870).  In 
his  paper  he  states  that,  up  to  1870,  48  cases  of  the  kind  had  taken  place  in  England, 
and  that  12  died,  or  one-fourth,  but  since  then  the  operation  has  been  more  common. 

I  have  now  performed  it  upward  of  23  times — on  7  occasions  for  compound  fracture 
of  the  leg,  6  of  which  recovered  ;  in  13  cases  for  chronic  disease  of  the  knee-joint  or  leg, 
11   of  which  recovered;  and  in  3  cases  for  gangrene  of  the  leg 
Fig.  709.  from  arterial  obstruction.  1  of  which  alone  recovered,  the  operation 

in  the  other  2  having  failed  to  save  life.  In  only  2  or  3  of  the 
cases  did  I  I'emove  the  patella.  In  all  the  successful  cases  excel- 
lent stumps  were  obtained  (Fig.  709). 

In  performing  this  operation  a  long,  broad,  anterior  flap  should 
be  made,  which  must  of  necessity  be  of  skin,  and  also  a  tolerably 
long  posterior,  for  it  is  remarkable  to  what  an  extent  the  posterior 
flap  always  retracts.  I  prefer  to  make  my  posterior  flap  about 
two-thirds  the  length  of  the  anterior  and  of  skin  only,  and  to 
divide  the  muscles  and  deeper  structures  by  cutting  from  behind 

Ptuiiip  ;ili('r   Amputation  ut    „  ,       ,  •      i      i     i  xi        •    •    j.  j       i?  j.i        a-x,-  i  j. 

tii(>  Lfit  Knee-Joint.  forward  about  an  inch  below  the  joint  end  oi  the  tibia,  and  not 
after  disarticulation,  the  popliteal  artery  being  thus  divided  low 
down,  where  it  is  readily  secured.  The  patella  should  not  be  removed  except  when 
diseased. 

When  the  operation  has  been  completed  and  the  articular  surface  of  the  femur  is 
found  not  to  be  healthy  or  reparable,  or  the  flaps  too  short,  the  condyles  should  be  taken 
away,  a  thin  rounded  section  of  bone  being  removed,  or  more  if  the  necessities  of  the 
case  demand. 

After  the  operation  a  troublesome  suppuration  occasionally  takes  place  in  the  synovial 
bursa  beneath  the  extensor  muscles  of  the  thigh  ;  and  when  it  occurs,  it  should  be  dealt 
with  by  free  incisions. 

Stephen  Smith  of  New  York  has  suggested  (Amer.  Joinii.  of  Med.  Sci.,  January, 
1870)  the  formation  of  two  lateral  skin  flaps  for  this  amputation,  each  flap  to  be  formed 
by  an  incision  commencing  one  inch  below  the  tubercle  of  the  tibia  and  carried  down- 
ward and  forward  over  the  side  of  the  leg  (vide  Fig.  710)  until  it  reaches  the  under  sur- 
face, when  it  is  curved  toward  the  median  line.     I  have  adopted  this  method  on  ten  occa- 


.S7'AV  7.1/.    A  MIT  T\  TfOXS.  1 0 1  7 

sioiis  witli  cxcclltiit  rt'siilts,  aiitl  iim  di-pn-.i!  lu  tiiiiik  it  tin-  liest.  'I'lic  .«tinu|»  li-ft  is  very 
j^oud,  the  cicatrix  liciii;.'  vertical  aii<l  placnl  well  IkImikI  tin-  lowrr  rii<l  ol"  the  Iciiiiir 
(Fig.  711). 

Amputation  at  the  Leo. 

Aiiiputatitm  of  the  leg  tor  (li.seiisc  is  a  very  successful  o|terutioti,  only  about  1  case  in 
12  prnving  iatal.      in  young  life  it  is  mure  successful  than  at  a  later  period. 

Auiputatious   for  injury  are,  however,  very  unsuccessful,  at  least  sixty  per   cent.,  or 

Flo.  711. 

Vui.  71(1. 


."^tt'phon  Sinitli's  Mcilii.il  ol"  .Aiiiimlating.  Posterior  Aspect  of  Stump  aftfr  S.  Smith's  Am- 

putation at  KiieL'-.Joint,sliowiii)j;<icatrix. 

nitire  than  half  the  cases,  dying.  Pyjuniia  i.s  a  more  eummdii  cause  of  death  after  this 
form  of  amputation  than  oven  after  amputation  of  the  thigh,  it  being  fairly  jiroved 
that  the  larger  the  section  of  the  shaft  of  a  bone,  the  greater  the  liability  to  blood- 
poisoning. 

Amputations  of  ex}iediency  in  the  leg  are  as  dangerous  as  those  for  injury. 

This  operation  in  the  upper  two-thirds  is  doubtless  best  performed  by  the  mixed 
method,  by  two  skin  lateral  flaps  and  the  circular  division  of  the  muscles,  as  already 
described  (Fig.  (.i97).  When  the  condition  of  the  soft  parts  forbids  such  an  operation, 
other  flaps  may  be  made,  any  form  being  allowable  to  avoid  sacrificing  more  of  the  limb 
than  is  necessary.  In  the  lower  third  of  the  leg  Teale's  amputation  is  good,  the  long 
anterior  flap  not  being  too  long  or  so  liable  to  slough.  The  long  muscular  flaps,  and  more 
particularl}'  the  posterior  calf  flap,  cannot  be  recommended.  In  the  lateral  flap  opera- 
tion, Mr.  Cock,  who  always  includes  the  muscles  and  makes  the  flaps  long,  turns  out 
excellent  stumps.  Some  surgeons,  in  this  mixed  method,  make  anterior  and  posterior 
skin  flaps,  but  they  possess  no  advantage  over  the  lateral,  while  the  anterior  flap,  falling 
over  the  edge  of  the  tibia,  is  apt  to  slough  or  to  form  unpleasant  adhesions.  In  dividing 
the  tibia  its  anterior  edge  should  be  rounded  oflf  with  the  saw. 

Amputations  of  the  Foot. 

In  no  part  of  the  body  has  an  improvement  in  surgery  shown  to  greater  advantage 
than  in  the  foot,  for  in  none  has  so  much  been  done  in  the  way  of  conservatism.  Whereas 
formerly  amputation  of  the  whole  foot  was  common,  we  have  now  Hey's,  Chopart's. 
Syrae's.  Pirogoff"'s  (the  subastragaloid),  and  Hancock's  operations,  all  based  upon  the  well- 
established  position  that  governs,  or  oni/ht  to  ijaveni,  all  amputation.s — viz..  that  no  more 
of  the  body  sht»uld  be  removed  than  the  necessities  of  the  individual  ca.se  require,  or.  in 
other  words,  upon  the  principle  of  •'  the  least  sacrifice  of  parts."  To  amputate  a  foot 
where  anything  less  would  suflice  is  in  the  present  age  regarded  as  almost  criminal,  and 
surgeons  generally  accept  Hancock's  well-put  ((uestion  in  his  valuable  lectures  at  the  col- 
lege in  IStiO:  "  Can  anything  be  more  unphilosophical  than  to  advocate  the  sacrifice  of 
any  bone  or  joint  of  the  foot  for  no  other  reason  than  that  a  particular  operation  should 
be  performed?"  (^Lanat,  18()t)).  Indeed,  this  principle  of  practice  should  be  uppermo.st 
in  the  mind  of  every  surgeon  called  upon  to  treat  any  local  disease,  and  in  the  hand  and 
foot  it  should  be  so  pre-eminently.  Accepting  this  teaching,  Hancock's  three  other  dicta 
necessarily  follow : 

That  we  should  perform  our  operation  as  close  to  the  diseased  or  damaged  structure 
and  preserve  as  much  of  the  foot  as  we  possibly  can  do  with  safety  to  our  patient. 

That  where  practicable  we  should  cut  through  the  tarsal  bones  with  a  saw  in  prefer- 
ence to  disarticulating  them. 

That  we  should  avoid  the  destruction  of  parts  whenever  we  can  do  so. 

These  views  of  Hancock  accord  so  closely  with  those  I  have  attempted  to  lay  down 
as  guides  to  the  surgeon  in  the  surgery  of  other  parts  of  the  body  that  I  have  given 
them  in  his  own  words  and  placed  them  as  leading  principles  of  practice  to  be  observed 


1018 


AMPUTATION. 


Fig.  712. 


Foot  after  Amputation  of  the  Four  Outer  Toes 
with  their  Metatarsal  Bones,  Two  External 
Cuneiform,  and  Cuboid  Bones.  (Key's  case, 
Guy's  Hosp.  Rep.,  1836.; 


in  the  surgery  of  the  foot.  I  believe  them  to  be  of  great  practical  value,  and  desire  that 
the  student  should  have  them  always  before  him  in  the  treatment  of  every  case  of  local 
injuryordisea.se.  The  principle  embodied  in  the  least  2>ossihle  sacrifice  of  parts  is  one 
upon  which  most  of  the  operations  of  the  foot  should  be  undertaken  ;  and  it  is  well  to 
remember  that  of  the  different  amputations  that  have  been  recommended,  while  none  of 
them  are  called  for  until  minor  measures  have  altogether  failed,  each  succeeding  one  is 

only  a  degree  more  severe  than  the  preceding.  The 
surgeon  in  the  present  day  takes  away  di.^^eased  bone 
or  bones  without  fear,  and  leaves  nature  to  repair  the 
breach  with  every  confidence.  I  have  taken  away, 
in  one  case,  the  whole  second  row  of  tarsal  bones, 
and  in  another  the  three  cuneiform,  scaphoid,  and 
cuboid,  with  excellent  results.  I  have  i-emoved  the 
necrosed  os  calcis  with  so  little  deformity  that  the 
loss  could  hai-dly  be  detected,  and  taken  away  on 
several  occasions  the  upper  articulating  surface  of 
the  astragalus  for  disease  with  a  result  which  has 
a.stonished  me,  no  extei-nal  deformity  remaining  and 
movement  of  the  ankle  being  almost  complete.  Mr. 
Key  in  1836  took  away  the  whole  of  the  outer  part  of  the  foot  for  injury,  leaving  only 
the  OS  calcis,  astragalus,  scaphoid,  inner  cuneiform  bone,  and  great  toe  (^vlde  Fig.  712; 
Guys  Rep.^  18.36),  from  a  boy  fet.  17  who  subsequently  had  a  useful  and  sound  foot. 
More  recently  Mr.  Birkett  has  done  the  same  with  a  like  success.  Single  metatarsal  and 
tarsal  bones,  when  irreparably  diseased,  may  be  removed  with  some  confidence  of  a  good 
result  being  obtained,  and  any  of  the  operations  I  am  about  to  describe  should  be  under- 
taken only  w4ien  less  severe  measures  are  inapplicable. 

Upon  this  principle  the  amputations  of  Hey  and  of  Lisfranc  were  hailed  with  satis- 
faction, Hey's  consisting  of  the  disarticulation  of  the  metatarsal  bones  from  the  tarsal,  or 
the  section  with  the  saw  of  the  metatarsal  or  tarsal  bones,  Lisfranc  suggesting  their  dis- 
articulation. Chopart's  amputation,  again,  at  the  medio-tarsal  joints,  Syme's  amputation 
at  the  ankle-joint,  and  Pirogoff's,  which  is  a  modification  of  Syme's,  a  part  of  the  os  cal- 
cis being  preserved,  have  all  the  same  end  in  view.  The  sub- 
astragaloid  amputation,  as  recorded  by  Malgaigne,  to  save  the 
astragalus  and  ankle-joint,  is  based  upon  the  same  principle, 
and  Hancock's  amputation  to  .save  the  posterior  part  of  the 
OS  calcis  with  the  astragalus  goes  still  farther  in  the  way  of 
conservatism. 

All  these  operations  have  their  own  value  and  each  is 
applicable  to  its  own  class  of  cases.  Where  the  minor  measure 
will  suffice  the  major  is  out  of  all  question,  the  principle  of  the 
least  possible  sacrifice  of  parts  being  the  one  upon  which  they, 
as  all  other  amputations,  should  be  based. 

Before  considering  the  different  forms  of  ami)utation  it  will 
be  well  to  consider  briefly  the  surgical  guides  to  the  foot  as 
expressed  by  its  anatomy,  for.  although  in  cases  of  disease 
these  guides  are  greatly  obscured,  they  are  still  of  value,  and 
in  cases  of  injury  they  are  always  reliable.  The  accompanying 
figure  will  help  the  student. 

On  the  inner  side  of  the  foot,  not  far  from  the  inner  mal- 
leolus, the  tubercle  of  the  scaphoid  {A)  is  to  be  felt  as  a 
marked  prominence ;  about  half  an  inch  in  fiont  of  this  will 
be  found  the  articulation  with  the  cuneiform  bone  (jB),  and 
one  inch  beyond  this  the  joint  which  the  surgeon  will  have  to 
open  in  Li.?franc's  or  Hey's  operation  (f):  just  above  the  tuber- 
cle of  the  scaphoid  will  be  found  the  articulation  with  the  astrag- 
alus, the  line  of  Chopart's  amputation  (/)). 

On  the  outer  side  of  the  foot,  one  inch  below  the  external 
malleolus,  a  sharply-defined  projection  will  always  be  felt,  which  is  the  peroneal  tubercle 
(E'),  and  half  an  inch  in  front  of  this  will  be  found  the  joint  which  separates  the  os  calcis 
from  the  cuboid,  this  joint  forming  the  outer  circle  to  Chopart's  amputation.  Half  an 
inch  in  front  of  this,  again,  or  one  inch  from  the  tubercle,  the  prominence  of  the  fifth 
metatarsal  bone  is  always  to  be  felt  (//),  the  line  above  this  prominence  indicating  the 


Fig.  713. 


Surgical  Guides  to  Foot  as  ex- 
pressed by  Anatomy. 


SrilClM.    AMITTATIOSS. 


lOlO 


Fig.  71  1 


nrtioulatinri  with  the  cuhoid  hmu-  wliitli  lnriii>  the  oiitir  houiKhiry  of  tin-  iiicisinn  for 
llov's  or    IjislVaiic'>  i>|u'i-ati(iii. 

All  tlit'si'  |M(iiit.s  slmuhl  lif  hiiikoil  i'ur  in  a  licalthy  I'lxit,  ami  learnt  sn  as  to  In-  n*a<Jily 
ri'coj;ni/AMl  in  the  injnreil  nr  discasftl. 

Hey's  Amputation  (Lisfranc's).— 'I'hc  credit  of  introilucinj:  this  oj)eration 
must  he  aeemded  t(i  lley,  l(ir  the  date  of  the  first  case  that  he  imhlisiied  was  17!'7, 
whereas  liisfrane's  ]ia|ier  was  oidy   piihlished  as  a  su<^^estioii  in    1!S15. 

The  operation  consists  in  tlie  removal  of  all  the  toes  with  the  metatarsal  hones  hy  di.-r- 
artieulatiun,  althnuirh  it  seems,  fmni  readini:  lley's  ohservations  (lH14j,  that  disarticula- 
tion id'  tlu'  metatarsal  ho?ies  was  nut  essential,  sinci'  in  one  of  the  two  cases  recorded  the 
euhitid  hone  was  reni(tved  with  smne  part  u\'  the  astrajralus,  and  in  the  second  "the  jiro- 
jeetiniT  j)art  of  the  first  eunt'iforni  hone  which  supports  the  jrreat  toe  was  divided  with  a 
saw  ;"  and  in  others  he  stated  that  he  sawed  tliroui;h  the  metatarsal  hones  when  the  joints 
were  not  removed. 

•'The  (tperatur."  writes  .Maliiaiune  in  dcscriliinL:-  it.  '' shouM  use  a  small  knife  with  a 
.solid  stron<r  hack  and  only  one  edue.  In  o|»eratin;;  on  the  ritrht  foot  the  patient  should 
lie  on  his  hack,  and  the  surgeon,  facing  the  foot,  should  frrasj)  it 
with  his  left  hand,  ti;e  thumb  and  finger  respectively  resting  on 
the  well-marked  bony  projection  of  the  metatarsal  bone  of  the 
little  toe,  and  the  base  of  that  of  the  great  toe  placed  one  inch 
in  front  of  the  tubercle  of  the  scaphoid.  Half  an  inch  in  front 
of  these  points  an  incision  with  its  convexity  downward  is  to  be 
made  across  the  dorsal  aspect  of  the  foot,  dividing  all  the  soft 
parts  down  to  the  bones  liy  a  second  cut.  The  ])lantar  flajt  is 
then  to  be  made  by  two  lateral  inci.sions  carried  from  the  liase 
of  the  dor.sal  flap 'along  the  metatar.sal   bones,  and  joined  bv  a   •'-tuiui.  alter  ii.-y^  .vmr-utation. 

,   .       .    .  11-1  1     1        1     11      i>     1  ■  (Iroin  IKy  >  \\.,rk.i 

curved  incision   made  on  a  line  heyonu  the  ball  ot   the  great  toe. 

This  flap  is  to  be  longer  on  the  inner  than  on  the  outer  side,  because  the  internal  cunei- 
form bone  is  thicker  than  the  cuboid,  and  it  is  to  include  all  the  tissues  down  to  the  bones. 
l)isarticulation  has  next  to  be  performed,  and  this  is  l)est  done  from  the  dor.sal  region 
when  the  parts  are  put  firmly  on  the  stretch  l)y  de])ressing  the  toes.  The  operator  then 
places  the  point  of  the  knife  on  the  outside  of  the  joint,  and,  carrying  its  edge  inward,  he 
opens  it  as  far  as  the  third  metatarsal  bone.  Around  here  he  carries  the  knife  half  a  line 
forward,  incises  almost  transversely,  and  thus  reaches  the  second  metatarsal.  Here  he 
must  above  all  things  remember  the  general  precept  not  to  engage  his  knife  in  the  joint, 
but  to  work  only  with  its  point  and  to  confine  himself  to  the  division  of  the  ligaments. 
When  this  instrument  has  reached  the  second  metatarsal  bone,  he  quits  this  side  of  the 
articulation  to  attack  the  inner  side.  This  is  well  done  by  inserting  the  knife  between  the 
shafts  of  the  first  and  second  metatarsal  bones  with  its  edge  upward,  and  with  a  backward- 
and-forward  motion  dividing  the  ligaments  holding  the  second  bone  in  place,  this  fact 
being  indicated  by  the  sudden  loss  of  resistance  which  the  surgeon  feels  when  pressing 
the  toes  downward,  and  by  the  sudden  separation  of  the  tarsus  from  the  metatarsus. 
Disarticulation  is  then  to  be  completed  and  the  plantar  flap  .shajied  by  cutting  forward 
close  to  the  bone.    A  long  dorsal  flaj)  may  be  made  when  the  plantar  flap  must  be  short." 

The  parts  are  then  to  be  brought  together  by  sutures,  after  securing  the  vessels  by 
torsion  or  the  ligature  and  cutting  oiF  ragged  tendons.  The  foot  should  be  fixed  upon  a 
splint,  with  the  leg  semiflexed  upon  its  outer  side,  and  treated  on  ordinary  principles. 

The  stump  left  after  this  operation  is  good,  and  the  operation  one  that  ought  to  be 
pcrfonncd  when  the  toes  and  metatarsal  bones  alone  require  removal. 

Chopart's  amputation  is  an  excellent  and  valuable  operation,  and  should  always 
be  ])erformeil  in  jirct'erence  to  any  higher  measure  when  disease  or  injury  is  confined  to 
the  fore  part  of  the  foot.  The  great  theoretical  objection  brought  again.st  it — the  sub.se- 
quent  drawing  up  of  the  heel  and  the  consequent  pointing  of  the  stump — has  really  little 
weight,  since  it  can  be  provided  against  by  the  division  of  the  tendo  Achillis  at  the  time 
of  the  operation,  or  sub-seijuently.  should  the  difiiculty  occur.  In  many  cases  of  my  own 
the  tendons  have  never  been  divided.  My  colleague.  Mr.  Cock,  who  has  performed  this 
operation  many  times,  thinks  most  highly  <jf  it.  and  never  has  had  to  amputate  subse- 
quently on  account  of  the  pointing  of  the  stump.  He  believes  that  this  can  always  be 
prevented  or  cured  by  the  division  of  the  tendo  Achillis  on  the  first  indication  of  such  a 
malformation.  It  was  introduced  into  English  practice  in  1828  by  the  late  Mr.  James 
of  Exeter,  and  to  the  notice  of  Scotch  surgeons  by  Professor  8yme.  who  subsequently, 
however,  renounced  it  in  favor  of  his  own  operation  at  the  ankle-joint.     He  did  so  on 


1020 


AMPUTATION. 


account  of  the  objection  already  .stated,  and  because  in  such  partial  amputations  the  part 
of  the  tarsus  left  behind,  though  apparently  sound  at  the  time,  may  become  affected  M'ith 
the  same  disease  at  a  later  period.  But  such  an  argument  may  be  brought  against  all 
operations  less  than  the  removal  of  a  diseased  part  far  from  the  seat  of  mischief,  and  is 
now  fairly  repudiated  by  modern  surgeons.  In  fact,  all  excisional  and  conservative  sur- 
gery is  based  upon  an  opposite  supposition,  the  local  nature  of  disease  becoming  daily 
more  acknowledged  and  acted  upon. 

Operation. — The  operation  may  be  described  as  the  amputation  of  the  fore  part  of 
the  foot  anterior  to  the  astragalus  and  os  calcis,  or  as  the  medio-tarsal  amputation.     On 
the  right  foot  it  should  be  commenced  by  making  a  slightly 
convex  flap  from  the  dorsal  aspect  of  the  foot,  commencing  Fig.  716. 

half  an  inch  behind  the  prominence  of  the  metatarsal  bone 
of  the  little  toe  and  terminating  at  the  tubercle  of  the  sca- 

Fm.  71.".. 


Chopart'.s  Aiuputation. 


Stump  after  Chopart's  Amputation. 


phoid,  the  surgeon  grasping  the  foot  with  his  index  finger  on  one  point  and  his  thumb  on 
the  other.  The  skin  is  the  first  part  to  be  divided,  and  subsequently,  on  the  level  of  its 
retraction,  all  the  tendons,  etc.,  are  cut  through  down  to  the  bones  or  joints  ;  the  articu- 
lations are  then  opened,  beginning  at  the  scaphoid  joint ;  the  foot  should  be  forcibly  bent 
downward,  to  facilitate  this  part  of  the  operation  ;  the  plantar  flap  is  to  be  made  by  cut- 
ting forward,  and  in  doing  this  care  should  be  observed  to  keep  the  knife  close  to  the 
bones  on  the  sole  of  the  foot,  in  order  that  the  soft  parts  may  be  divided  with  as  clean  a 
cut  as  possible ;  the  flap  should  be  long  and  extend  as  far  as  the  balls  of  the  toes,  and 
longer  on  its  inner  than  on  its  outer  aspect  (Fig.  715).  All  ragged  tendons  may  be  cut 
off"  short  and  the  parts  brought  together.  If  there  be  any  difficulty  in  bringing  up  the 
fore  part  of  the  stump  or  any  retraction  of  the  heel,  the  tendo  Achillis  should  be  divided 
at  once ;  but  if  no  such  difficulty  is  experienced,  such  a  measure  is  unnecessary.  In 
dressing  the  stump  a  good  opening  for  drainage  should  be  left.  Fig.  71  (i  illustrates  the 
condition  of  the  stump  a  year  after  the  operation,  in  which  the  tendo  Achillis  was  not 
divided. 

On  one  occasion  I  performed  this  medio-tarsal  operation  for  injury,  making  two  lateral 
flaps  from  the  dorsum  and  sides  of  the  foot,  the  integument  of  the  sole  having  been 
destroyed.     A  good  stump  resulted. 

Tripier's  Amputation.— The  amputation  of  the  foot  devised  by  Tripier  of  Lyons 
as  a  substitute  for  Chopart's  claims  a  notice,  since  it  professes  to  possess  all  the  advan- 
tages of  the  Chopart  and  none  of  its  disadvantages.  It  includes  a  horizontal  section  of 
the  OS  calcis  on  a  level  with  the  sustentaculum  tali  (Fig.  717,  A),  and  gives  a  flat  sur- 
face to  stand  upon  instead  of  the  posterior  part  of  the  os  calcis  and  the  unsupported 
anterior  extremity  of  the  bone. 

The  operation  is  described  in  the  Bn'f.  Med.  Jonrn.  (February  26,  1881),  but  I  prefer 
the  description  of  it  aiven  by  P.  Hayes  of  Dublin  in  the  Dublin  Jovrnal  (December  1, 
1881). 

Operation. — The  surgeon's  knife  is  caused  to  take  the  following  course :  Com- 
mencing at  the  outer  edge  of  the  tendo  Achillis,  on  a  level  with  the  external  malleolus 
(Fig.  717,  C),  a  skin  wound  is  to  be  made  in  a  direction  at  first  downward  and  forward, 
and  afterward  forward,  so  as  to  pass  two  fingers'  breadths  below  the  malleolus,  and  then 
to  approach  to  wuthin  a  finger's  breadth  the  upper  part  of  the  base  of  the  fifth  metatarsal 
bone.     From  this  point  the  incision  is  to  be  carried  upward,  forward,  and  inward,  so  as 


si'i.ciAL  AMrriw'j'ioys. 


021 


tn  rcai'li  llu'  iiiiuT  iii!irL;iii  of  tin-  tciiduii  (.f  ilu'  rxt(!tis(ir  lialluci.s  prMpiiiis  just  h.-liiud  tlic 
first  iiK'tutursal  articulation.  Tlie  kiiilV-  .sliuulJ  now  hi;  made  to  cut  downward  and  I'or- 
ward,  so  a,s  to  t-ntiT  tlu-  solo  ol"  tin-  loot  a  lini:fr's  lnvadtli  in  iVont  oi'  tlu;  dor>al  wound. 
The   incision   is   then   to  l)o  carried  witli  a  L:«'iitli'   I'orward  curve;  outward  and   backward 

l'"iu.  717. 


Tripier's  Aniputatiidi  of  tlit-  I'uot. 

iintil  it  can  be  made  continuous  witli  the  first  jiortion  of  the  wound  below  the  outer  mal- 
leolus (Fig.- 717,  D).  The  divided  integument  having  undergone  some  degree  of  retrac- 
tion, the  dorsal  and  plantar  structures  are  to  be  divided  hall"  an  inch  behind  tlie  super- 
ficial wound  ;  the  soft  parts  are  then  to  be  separated  from  the  bones,  extreme  care  being 
taken  to  preserve  uninjured  the  vessels  contained  in  the  inner  part  of  the  plantar  flaj). 

The  surgeon  will  find  it  convenient  at  this  stage  to  disarticulate  the  cuboid  and  sca- 
phoid from  the  os  calcis  and  astragalus,  just  as  in  Ohopart's  amputation.  Having  done 
so,  he  will  proceed  to  divide  and  separate  the  ])eriosteum  from  tlie  under  surface  and  pos- 
terior extremity  of  the  os  calcis  up  to  the  level  of  the  sustentaculum  tali,  where  the  bone 
is  to  be  sawn  through  in  a  direction  from  behiiul  and  within,  forward  and  outward,  so  as 
to  leave  a  surface  which  will  be  at  right  angles  with  the  axis  of  the  tibia  when  the  limb 
is  caused  to  assume  the  ordinary  position  for  walking  or  standing  (Fig.  717,  A). 

All  sharp  bone  edges  and  angles  should  now  be  rounded  off".  The  posterior  tibial 
nerve  is  to  be  exposed  in  the  plantar  flap  and  divided  as  high  as  possible,  with  a  view  to 
prevent  risk  of  neuroma.  The  vessels  having  been  secured  and  drainage  tubes  having 
been  inserted,  the  flaps  are  to  be  brought  together  and  the  limbs  so  dressed  as  to  secure 
moderate  flexion  of  the  ankle-joint  during  the  period  of  repair.  M.  Tripier  attaches 
importance  to  the  preservation  of  the  periosteum  covering  the  under  surface  of  the  os 
calcis   when   it   is  jiossible  to  do  so.      The  stump  yielded  is  a  good  one  (Fisr.  717,  B). 

Subastragaloid  amputation  follows  next  in  order  amongst  the  amputations  of 
the  foot,  and  is  the  removal  of  as  much  as  is  taken  away  in  Chopart's  amputation,  with 
the  addition  of  the  os  calcis.  It  has  been  performed  when  the  disease  for  which  an  ope- 
ration is  re(iuired  involves  these  parts  and  yet  leaves  the  astragalus  and  ankle-joint  sound. 
It  seems,  according  to  Velpeau  (^Optratlvt>  Surgeri/,  1839),  to  have  been  first  performed 
by  M.  de  LigneroUes,  and  subsequently  by  Textor,  although  Malgaigne  in  184G  described 
the  operation  as  his  own  without  mentioning  these  facts. 

It  is  made  by  a  heel  flap,  as  in  Syme's  amputation,  and  a  dorsal  flap,  as  in  Chopart's, 
the  foot  being  removed  bv  opening  the  joints  between  the  scaphoid  and  astragalus,  and 
that  between  this  latter  bone  and  the  calcis. 

"  The  stumj)  resulting  from  the  subastragaloid  amputation  appears  to  me."  writes 
Hancock,  "  to  be  perfect  ;  it  is  round  and  of  good  form,  the  cicatrix  is  firm  and  well  up 
in  front,  and  the  bottom  of  the  stump  is  perfectly  covered  by  the  natural  heel  tissue." 
Nt^laton  says  this  form  of  amputation  ''has  been  found  to  surpass  all  amputations" 
((7//h.  Siny.y 

I  am  surprised  at  these  opinions,  for  in  the  two  cases  I  have  had  of  it,  though  the 
repair  was  good,  the  stumps  were  not  to  be  compared  with  tlio.se  of  a  Chopart,  a  Piro- 
goff",  or  a  Syme.     I  .shall  never  do  it  again. 

Hancock's  operation  must  be  looked  upon  as  a  modification  of  the  subastraga- 
loid, in  the  same  way  as  Pirogoff's  is  a  modification  of  Syme's ;  for  Hancock  saves  the 
tuberosity  of  the  os  calcis  and  turns  it  up,  to  be  united  to  the  lower  surface  of  the  astrag- 


1022  A  MP  UTA  TION. 

alu8,  from  which  he  takes  a  slice  of  bone.  It  ma}'  be  adopted  when,  in  hi.s  attempt  to 
perform  the  subastragaloid  operation,  the  .surgeon  finds  the  lower  surface  of  the  astraga- 
lus diseased  and  the  os  calcis  sound.  Mr.  Hancock  performed  it  in  ISG-t  with  an  excel- 
lent result.  The  incisions  are  very  similar  to  those  required  in  the  suba.stragaloid,  the 
end  of  the  os  calcis  being  divided  in  a  line  corresponding  to  the  heel  flap,  instead  of  the 
flap  being  reflected.  In  the  Lancet  for  1866  full  particulars  of  Hancock's  operation  may 
be  read,  as  described  by  him  in  a  lecture  at  the  College  of  Surgeons. 

Syme's  Operation. — This  consists  in  the  removal  of  the  whole  foot  with  the 
articular  surfaces  of  the  bones  of  the  leg  just  above  the  malleoli,  a  covering  for  the  osse- 
ous surfaces  being  provided  from  the  integument  of  the  heel,  the  result  being,  adds  Lis- 
ter, "  a  stump  admirably  fitted  for  bearing  the  weight  of  the  body.  At  the  same  time, 
the  parts  likeh'  to  originate  carious  disease  are  completely  got  rid  of;  so  that  this  opera- 
tion is  calculated  to  super.sede  entirely  that  of  Chopart.  besides  taking  the  place  of  ampu- 
tation of  the  leg  in  the  majorit}-  of  cases  formerly  supposed  to  demand  it"  (Holmes's 
Si/sf.,  vol.  iii.,  3d  ed.,  p.  715). 

This  view  of  the  operation,  which  was  also  held  by  its  originator,  emanating  from  one 
who  was  so  closely  connected  with  Syme,  professionally  and  otherwise,  is  doubtless  far 
too  sanguine. 

That  the  operation  is  good  no  surgeon  will  deny  when  amputation  of  the  whole  foot 
is  called  for,  but  to  say  that  it  will  supersede  entirely  Chopart's  operation  is  to  say  what 
I  trust  never  will  be  true  ;  for  when  the  bones  of  the  ankle-joint  and  the  joint  itself  are 
sound,  no  surgeon  ought  to  take  away  the  whole  foot  if  an}-  minor  measure  will  suffice. 
AVhei'e  Choparts  amputation  is  applicable  Syme's  ought  not  to  be  entertained.  As  an 
amputation  of  the  foot  where  the  whole  foot  must  be  sacrificed  it  is  admirable,  but  under 
no  other  circumstances  can  it  be  recommended ;  that  it  is  superior  to  amputation  of  the 
leg  mo.st  surgeons  will  admit,  upon  the  same  principle  that  Chopart's  is  superior  to  it — 
on  the  principle  of  the  least  possible  .sacrifice  of  parts. 

It  is,  however,  a  succes.sful  operation,  Hancock  reporting  (Lauaf.  1866)  that  out  of 
219  cases  only  17  died,  or  7?  per  cent. ;  181  were  operations  for  disease,  and  of  these  11 
died,  or  65  per  cent. ;  32  for  accidents,  of  which  6  died,  or  13  per  cent.  The  experience 
of  the  American  war  speaks  also  in  its  favor,  for  out  of  67  cases  only  9  died,  or  13^ 
per  cent. 

Operation. — The  operation  is  performed  as  follows  (I  give  it  in  Syme's  own  words)  : 
"The  foot  being  held  at  a  right  angle  to  the  leg,  the  point  of  a  common  straight  bistoury 
should  be  introduced  immediately  below  the  fibula,  at  the  centre  of  its  malleolar  projec- 
tion, and  then  carried  across  the  integuments  of  the  sole  in  a  straight  line  to  the  same 
level  on  the  opposite  side.  The  operator,  having  next  placed  the  fingers  of  his  left  hand 
upon  the  heel  and  inserted  the  point  of  the  thumb  into  the  incision,  pushes  in  the  knife 
with  its  blade  parallel  to  the  bone  and  cuts  close  to  the  osseous  surface,  at  the  same  time 
pressing  the  flap  backward  until  the  tuberosity  is  fairly  turned,  when,  joining  the  two 
extremities  of  the  first  incision  by  a  transverse  one  across  the  instep,  he  opens  the  joint, 
and,  carrying  his  knife  downward  on  each  side  of  the  astragalus,  divides  the  lateral  liga- 
ments so  as  to  complete  the  disarticulation.  Lastly,  the  knife  is  drawn  rovmd  the  extrem- 
ities of  the  tibia  and  fibula,  so  as  to  expose  them  sufiiciently  for  being  gra.sped  in  the  hand 
and  removed  by  the  saw.  After  the  vessels  have  been  tied  (twisted),  and  before  the  edges 
of  the  wound  are  stitched  together,  an  opening  should  be  made  through  the  posterior  part 
of  the  flap  where  it  is  thinnest,  to  afford  a  dependent  drain  for  the  matter,  as  there  must 
always  be  too  much  blood  retained  in  the  cavity  to  permit  of  union  by  the  first  intention. 
The  dressings  should  be  of  the  lightest  description.  That  the  flap  may.  and  probably 
will,  still  occasionally  slough  is  unhappily  too  true,  but  this  result  is  always  owing  to  an 
error  in  the  mode  of  performance  ;  for  as  the  integument,  being  detached  from  its  sub- 
jacent connections,  can  derive  nourishment  only  from  the  anastomosing  of  vessels,  it  is 
evident  that  if  scored  crossways,  instead  of  being  separated  by  cutting  parallel  to  the  sur- 
face, the  flap  must  lose  its  vitality." 

Instead  of  dissecting  the  heel  flap  from  the  calcis  at  an  early  period  of  the  operation, 
it  is  a  better  and  simpler  practice  to  do  this  after  the  foot  has  been  disarticulated,  the  sur- 
geon, with  the  foot  in  his  hand,  readily  separating  the  heel  flap  from  above. 

In  Syme's  first  operation,  in  1842  (  Obsn-vations  in  Clinkdl  Surr/eri/.  1861).  he  simply 
took  away  the  malleolar  projections  and  did  not  remove  the  articulating  surface  of  the 
tibia,  as  sub.sequently  advLsed  ;  and  it  is  still  an  open  question  whether  any  advantage  is 
gained  by  this  extra  section  of  bone.  I  have  performed  this  operation  b}'  Syme's  original 
method  with  an  excellent  result. 


SPK( 7. 1 /.  . 1 .1//' ^ "/I Tioys. 


1(12;  J 


Fig.  718. 


Anipiitutiiiii. 
(From  FergusjiOD.) 


Tlie  .stump  I'lilldwiiig  till'  aiii|iiituti(iii  is  fxccllcnt.  Fi;^.  71H,  taken  IVnin  FergusKon's 
lectures  on  the  pntgreHs  of  surgery,  illustrute.s  it  adiniralily  :  "The  very  Vjit  of  soft 
material  on  whieh  we  naturally  stand  is  still  presi-rved  for  the  future 
basis  <it"  this  support. J 

Some  surgeons,  and  I'irrie  amongst  tht-m,  pfrfnrni  the  operation  Ky 
.siwing  through  the  tiltia  and  Khula  without  disarticulating  the  font. 
TIic  innditicatinn  is  lt'i'mI. 

Roux's  amputation  differs  from  Symes  only  in  the  flap  being 
made  from  the  inner  and  under  side  of  the  heel.  I  have  on  one  occasion 
made  a  long  anterinr  flap — the  oidy  one  the  eimdition  of  the  parts  per- 
mittt'd — witli  siHcos. 

PirOgofif 'S  Amputation. — This  operatif»n  is  to  he  regarded  as  a 
niodifleaticm  id' Symes.  and  was  introduced  by  its  distinguished  originator 
during  the  Crimean  war.  The  merit  he  clainis  for  it  is  the  novel  osteo- 
plastic principle  that,  a  portion  of  one  bone  remaining  naturally  connected 
with  sdft  parts,  readily  unites  with  another,  and  at  the  .same  time  .serves 
to  lengthen  the  limb  and  increase  it.s  utility.  It  differs  from  Synie's  in 
leaving  the  tuberosity  of  the  os  calcis  in  the  heel  flap  instead  of  dis.secting  stump  afteTs} me's 
it  out  and  bringing  up  its  exposed  cut  surface  to  unite  to  the  divided 
extremities  of  tlie  tibia  and  fibula.  I  have  fre(|uently  performed  it,  and 
in  every  instance  with  a  good  result.  Busk  was  the  first  surgeon  who  did  it  in  thi.s 
country,  in  IX.u. 

The  limb  is  longer  than  after  Syme'.s  amputation,  and  the  stump  is  not  to  be  excelled 
(Fig.  721),  since  a  patient  can  walk  upon  it  as  well  as  if  no  amputation  hail  been  per- 
formed. The  incisions  are  the  same  as  in  Syme's, 
but  no  heel  flap  is  dissected  up.  After  disarticulat- 
ing and  dividing  the  lateral  ligament  sufficiently  far 
for  the  OS  calcis  to  become  visible  behind  the  astrag- 
alus, the  surgeon  has  to  saw  through  the  os  calcis 
in  the  line  of  the  heel  and  remove  the  foot,  subse- 
quently taking  off  the  ends  of  the  tibia  and  fibula. 

Dr.  Kben  Watson,  after  having  made  the  heel 
flap,  prefers,  before  going  farther,  to  saw  off  as 
much  of  the  os  calcis  as  he  wants  to  save  ;  but  there 
is  an  objection  to  this  practice,  as  I  have  known  the 
incision  through  the  bone  to  be  made  too  far  for- 
ward into  the  astragalo-calcanean  joint,  and  a  second 
slice  have  to  be  removed.  Dr.  Watson  also  adopts 
Pirrie's  practice  of  dividing  the  tibia  and  fibula  with- 
out   previous    disarticulation    of  the    foot  (Figs.  720    PiroKoffs  Amputation.    (Heel  flap  with  raids.) 

and  721). 

When  this  method  is  employed,  the  surgeon  should  make  a  more  oblique  section  of 
the  OS  calcis  from  below  backward. 


Fig.  720. 


Pirogoflf's  Amputation.     (Division  of  malleoli.    Takeu 
from  T.  Smith's  work.) 


Stump  after  Pirogoffs  Amputation. 


1024 


AMPUTATION. 


I  regard  Pirogoff's  amputation  as  very  good,  and  it  yields  an  excellent  stump  (Fig. 
721)  ;  it  ought  always  to  be  preferred  to  Syme's  when  the  os  calcis  is  sound.  If  the  bone 
at  the  time  of  the  operation  be  found  to  be  bad,  it  must  be  removed,  the  operation 
resolving  itself  into  a  Syme's ;  but  when  the  bone  is  good,  it  appears  to  be  a  grave  error 
to  take  away  what  makes  so  good  a  point  of  support  to  the  body. 

Hancock  records  58  cases  of  this  operation  as  performed  by  British  surgeons ;  5  only, 
or  9  per  cent.,  died. 

Amputation  of  the  toes  may  be  performed  in  the  same  way  as  amputation  of 
the  fingers  already  described,  equal  care  being  observed  not  to  interfere  with  the  plantar 
surface  of  the  foot.  In  amputating  the  great  or  little  toes  the  same  oval  flaps  should  be 
made  as  were  recommended  in  amputation  of  the  thumb  and  little  finger  (page  1012). 
They  should  always  be  large  and  as  much  skin  saved  as  the  case  will  allow. 


Stumps,  and  their  Morbid  Conditions. 

To  secure  a  good  stump  is  desirable,  although  to  obtain  it  by  taking  away  more  of 
the  body  than  is  required  by  the  exigency  of  the  case  no  increased  risk  to  life  should  be 
incurred.  Many  of  the  most  promising  stumps  after  an  amputation  often  turn  out  badly, 
while  the  least  promising  end  well,  the  result  depending  more  probably  on  their  subse- 
quent dressing  than  on  the  condition  of  the  flaps  at  the  time,  it  being  quite  certain  that 
bad  dressing  may  destroy  the  best  stumps  and  good  dressing  improve  the  bad.  Still,  the 
character  of  the  stump  is  much  determined  by  the  form  of  amputation  that  has  been  per- 
formed. 

The  stump  after  a  circular  amputation  (Fig.  722)  is  not  so  good  as  that  obtained  after 
a  flap  (Fig.  723).     The  stump  left  after  the  mixed  form  of  amputation  of  the  leg  leaves 


Fig.  722. 


Fig. 


Fig.  724. 


Thigh  Stump  after  a  Circular 
Amputation  of  Thigh. 


After  a  Flap. 


Stump  after  Amputation  at 
the  Knee-joint. 


Fig.  725. 


nothing  to  be  desired  (Fig.  698),  and  that  which  is  met  with   after  amputation  at  the 
knee-joint  when  the  patella  is  left  is  unexceptionable  (Fig.  724). 

A  conical  stump  (Fig.  725)  is  always  regarded  as  a  bad  one,  and  yet  most  thigh  and 
arm  (single-bone)  stumps  after  primary  amputation  become  conical  by  time,  the  soft  parts 
and  muscles  wasting,  except  in  very  fat  subjects.  When  double  bones  exist,  this  evil  is 
rarely  seen,  nor  is  it  after  amputation  at  the  joints.  Knee  and  elbow 
stumps  and  Pirogoff"'s  are  the  best  we  see. 

A  stump  that  looks  well  after  an  operation,  with  a  mass  of  muscle 
covering  it,  is  sure  to  undergo  a  change  ;  the  muscles  will  degenerate, 
and  after  losing  all  their  characteristic  features  turn  into  fibro-cellular 
tissue,  of  which,  and  of  fatty  tissue,  a  good  stump  is  formed.  The 
end  of  the  bone  will  become  rounded  off"  and  its  medullary  canal  filled 
up  ;  the  nerves  of  the  stump  also  will  become  bulbous  to  a  degree,  but 
painful  only  when  they  are  involved  in  the  cutaneous  cicatrix  or  bound 
down  to  the  bone. 

At  times,  however,  stumps  grow  and  become  conical,  and  in  the 
amputations  of  childhood  this  condition  must  be  expected.  It  is  best 
seen  in  the  leg,  as  it  so  happen.^  that  the  shafts  of  bones  grow  most 
where  they  come  in  contact  with  the  larger  epiphyses,  and  in  the  leg 
the  one  entering  into  the  knee-joint  is  the  larger.  In  the  case  of  a 
boy  xt.  7  whose  leg  I  had  to  amputate,  with  some  irregular  skin  flap, 
for  a  compound  fracture,  just  below  the  knee,  I  have  had  to  take  away  on  two  occasions, 
at  intervals  of  three  years,  two  pieces  of  bone  at  least  an  inch  long,  purely  from  the  growth 
of  the  bone  during  childhood;  and  it  was  interestina;  to  notice  that  the  tibia  on  both  occa- 


Conical  Stump. 


SVFA'I.  I  /.    .  1  MITT.  I  770.V.V. 


1020 


It'ast  twice   as    niucli    as  the   lili 
111(1  an 


my  scciiikI   (ppcratiiiii    I   m-vcr 


sioiis  had  "_Mu\vii  at 
tuiii-lit'(l  tlic  liliiila. 

Painful  stumps  iin-  hk'sI  llistI•('sslll^^  ami  arc  c((iiiiiiniily  caused  riy  smiic  increase 
in  the  IiiiHmiiis  cninlitiiiii  nt'  tlio  (livi(h'il  nerves,  tlie  nerve  being  incluiKMl  in  the  cicatrix 
tir  prosetl  ii|M(ii  liy  the  Irone  ;  and  nnihr  sucli  circuinstaiiCL'S  a  cure  is  readily  effected  by 
the  removal  ol'  the  hulhous  nerve.  IJut  in  others  the  extreme  jiaiii  seems  to  he  due  to 
hyjiera'sthesia  \vhi(di  is  often  called  hysterical,  the  sli^rhtest  tonch  of  tlie  end  of  the 
stump  hein;^  suffii-ient  to  cause  convulsive  t\vitchinp;s  of  the  limb  and  pain  flyinjr  up  the 
stump.  Ill  these  cases  operative  interference  cannot  be  recommcndcMl,  althou;xh  nerve 
stretchiiiir  has  been  advocateil.  The  {reiieral  condition  of  the  body  usually  associated 
with  this  attectioii  re(|uires  attention  ;  tonics  are  always  recjuired,  with  local  soothin<r  ano- 
dyne ai(|ilicatinns  such  as  lielladonna,  ojiiiim,  or  stramonium  ointments,  etc. 

Necrosis  of  the  stump  is  a  common  condition,  and  it  is  often  due  to  too  great  a 
separation  nl"  the  periosteum  from  the  bone  at  the  time  of  the  operation  by  the  forcible 
traction  of  the  flaps  backward,  and  at  times  U)  a  distinct  endostitis  (»f  the  divided  bone 
(osteo-mvelitis).  In  the  former  case  the  necrosis  is  limited  and  will  jirobably  show  it.self 
only  as  a  ring  "if  bone,  which  may  come  away  by  itself  or 

be  removed.      In   the  latter  more  or  less  of  the  shaft  of  Fjg.  726, 

the  bone  dies  and  subse(|uently  exfoliates,  the  i)erio,stenm 
forming  a  new  casing  or  sheath  of  bone  to  suj)ply  the  dead 
bone's  place,  as  in  cases  already  described  in  the  chapter 
on  ostitis.  The  largest  seciuestrum  I  was  ever  called  upon 
to  remove  from  a  stump  was  from  the  femur  of  a  man 
who.se  lower  extremity  I  amputated  for  di.sease  of  the  knee- 
joint  consecutive  to  acute  necrosis  of  the  tibia.  The  femur 
became  inflamed  by  endostitis  after  the  amputation,  and 
ended  in  endosteal  necrosis.  The  sequestrum  was  five 
inches  long.     I  drew  it  out  of  the  end  of  the  stump  some  Necrosis  of  a  stump, 

months  after  the  amputation,  and  an  excellent  stump  was 

left.  I  have  had  also  a  similar  case  in  a  child  about  six  years  old,  necrosis  of  the  stump 
following  amputation  for  acute  necrosis  of  the  tibia  extending  into  the  knee-joint.  The 
stump  united  after  the  operation  by  primary  union,  but  the  bone  subsequently  appeared 
in  the  wound  as  a  necrosed  mass,  this  change  being  attended  with  sligbt  con.stitutional  dis- 
turbance. In  exceptional  cases  the  soft  parts  slip  away  from  the  bone  and  retract  as 
a  whole,  the  stump  bone  suddenly  protruding  through  them  for  some  inches  (Fig. 
726).  In  these  cases  the  periosteum  covering  the  bone,  having  inflamed,  retracts  with 
the  soft  parts,  and  so  leaves  the  bone,  which,  deprived  of  its  periosteum,  projects  from 
between  the  flaps  as  a  dead  or  dying  portion,  the  result  of  periosteal  necro.sis.  ruder 
these  circumstances  the  .stump  must  be  reopened  and  the  end  of  the  bone  removed  high 

Sir  Joseph  Fayrer  tells  us  (Clin.  Surg.,  1866)  that  in  India  this  o.steo-myelitis  of  the 
ends  of  stumps  is  a  common  affection,  and  often  attended  with  severe  constitutional  symp- 
toms such  as  are  well  known  to  accompany  all  cases  of  acute  eiujoatitis  with  or  without 
amputation.  He  regards  the  aflrectit)n  as  so  serious  that  he  advocates  the  reamputation 
of  the  limb  above  the  next  joint  as  soon  as  the  earliest  symptoms  of  systemic  infection 
appear,  blood  poisoning  being  the  chief  danger  of  the  disease.  '■  The  proper  time,  "  he 
writes,  '"for  amputation  in  cases  of  diff'used  osteo-myelitis  is  as  soon  as  possible  after  you 
have  ascertained  that  the  bone  is  affected,  and  the  mode  of  arriving  at  this  knowledge  is 
simply  the  passage  of  a  long  probe  down  the  medulla.  Should  it  impinge  on  healthy  and 
bleeding  medulla  near  the  surface,  you  may,  if  the  con.stitutional  s3'mptoms  permit,  wait 
and  see  if  nature  is  about  to  limit  the  suppuration  and  throw  off"  the  diseased  bone,  which 
is  a  rnre  result.  Should  it  pass  well  up  the  bone,  its  whole  death  is  certain.  In  cases  of 
incipient  inflammation  the  medulla  will  be  found  protruding  like  a  fungus  from  the  cen- 
tral cavity  and  the  bone  surrounding  it  exposed  to  a  greater  or  le.sser  extent;  at  a  later 
period  the  end  of  the  medulla  is  found  already  dead,  blackened,  and  encrusted,  but  within 
it  is  a  putrid  mass  of  bone,  (fehris,  and  pus.  In  the  former  stage  you  can  watch  the 
progress  of  the  case.  In  the  latter  interference  is  immediately  necessary  ;  and  that.  I  fear, 
can  be  nothing  short  of  amputation,  either  about  the  next  joint  or  perhaps,  in  a  young 
subject,  at  the  epiphysis.  The  condition  of  the  .soft  parts  must  not  deceive  ;  the  condi- 
tion of  the  bone  and  the  constitutional  .symptoms  must  be  the  guide  as  to  the  time  and 
necessity  for  operations."'     I  have  made  this  long  extract  from  Sir  Joseph  Fayrer's  paper 

63 


1026 


AMPUTATION. 


Fia. 


because  it  is  through  him  that  in  recent  times  the  subject  lias  been  brought  prominently 

under  notice,  though  Longmore  and   Holmes  in  this  country  have  ably  dwelt  upon  it, 

and  lioux  of  Toulon  made  it  the  subject  of"  a  special  report. 

In  acute  cases  there  can  be  little  doubt  as  to  the  wisdom 
of  the  practice  suggested,  but  in  English  practice  they  are 
not,  however,  of  great  fre(iuency,  the  cases  of  necrosis  of 
stumps  met  with  being  generally  of  a  more  chronic  or  sub- 
acute kind,  of  either  periosteal  or  endosteal  origin,  and  not 
requiring  such  active  treatment. 

Aneurismal  enlargement  of  the  arteries  of  a  stump  lias 
been  described  by  Erichsen  on  Cadge's  authority,  and  is  an 
accidental  association. 

Cancer  may  also  attack  a  stump.  In  December,  1871,  I 
removed  the  leg-stump  of  a  man  aet.  58  for  extensive  cancer- 
ous disease  of  two  years'  standing,  which  attacked  the  cicatrix 

that  had  been  formed  fifty-four  years  (vide  Fig.  34,  p.  13G).     In  this  case  amputation  of 

both  legs  had  been  performed  for  gangrene  of  the  limb  when   the   patient  was  a  child 

four  years  old. 

When  the  end  of  the  bone  in  a  stump  is  not  well  covered  and  is  subjected  to  pressure, 

a  bursa  at  times  forms  as  a  protective  agent.     This  occurred  in  the  case  from  which  Fig. 

727  was  taken.     I  amputated  the  end  of  the  humerus  with  the  bursa,  and  a  good  stump 

was  left. 


r-lionc 


pet.  ir,, 


Removed  from  .John  S 
who   had  had   his  Arm  Ampu 
tated  Four  Years  previously  for 
ail  Accident. 


To  Prepare  and  Clean  Sponges. 


Having  shaken  them  to  get  rid  of  sand,  and  washed  them  to  remove  dirt,  place  them 
in  water  acidulated  strongly  with  muriatic  acid,  and  there  let  them  remain  until  all  effer- 
vescence has  ceased  and  chalk  is  removed.  For  this  purpose  it  may  be  necessary  to 
renew  the  acid  several  times. 

Let  them  then  be  well  washed  in  plain  water. 

To  bleach  them,  wash  them  repeatedly  in  a  solution  of  binoxalate  of  potash  ^j,  ad  Oj 
of  tepid  water. 

After  an  operation  they  should  be  washed  in  cold  water  free  from  bbxid,  and  then 
placed  in  a  solution  of  carbolic  acid,  one  in  eighty,  and  there  left  for  twenty-four  hours. 
They  are  then,  after  another  washing  in  pure  water  or  carbolized  water,  ready  for  use. 
When  not  at  once  required,  they  should  be  squeezed  dry  and  suspended  in  a  warm  room 
in  a  porous  bag  to  dry. 

Sponges  should  not  be  placed  too  near  a  fire,  since  dry  heat  hardens  them,  nor  should 
they  be  washed  in  a  solution  of  soda  unless  they  are  very  greasy,  since  alkalies  dissolve 
spongine  or  horny  tissue  and  makes  it  soft  and  incapable  of  absorbing  moisture. 


^' 


1 N  D  K  X . 


AllItOMFN.  injuries  of,  483 
(liiij;iicisis  in,  -ISI 
ciintiisioiis  III',  IS.'i 

|)iMH'triUinK  wdiinds  of,  |S| 

gun.xlicit  wounds  of,  ItSG 

tii|.i)in;;,  oL'l 
Abdomiiiai  jmriotos,  wound:"  of,  492 

visooni,  wounils  of,  4'.M 

j)rotrusion  of,  J'.l.'i 
Alxluction  of  lu>r  in  liip  disuuso,  914 
AI>noi-uiiil  iiiius,  49a 
Absci'ss,  ti7 

chronic,  t>S 

niveoliir,  473 

nun  I,  .i()S 

in  bone,  95.'{ 

in  bruin,  209 

of  brcHst,  7()6 

f.-ciil.  49() 

iiiiul)ar,  210 

spinal,  :j;59 

l.erineal,  084,  094 

of  tongue,  42;i 

of  kidney,  0:50 

of  prostate,  040 

of  joints,  929 

about  joints,  948 

opening,  09 

Hilton's  method,  70 
Abscess  knife,  ()9 
Abscission,  .SI 4 
Absorbent  inflammation,  182 
Accoininodation,  200 

diseases  of,  204 
Acetabulum,  fracture  of,  884 

impaction  of  femur  in,  884 

necrosis  of,  931 
Acromion,  fracture  of,  872 
Actual  cautery,  348 
Acupressure,  340 
Acute  internal  strangulation.  501 
Adams's  operation  on  hip,  92j 

for  deformed  nose,  587 

for  contracted  fingers,  823 
Adduction  of  leg  in  hip  disease,  914 
Adenitis,  ISl 

sy|ihilitic,  721 
Adenoma,  129 

of  breast,  770 
cystic,  772 
statistics  of,  773 
Adhesion,  primary,  20 

secondary,  29 

repair   by  primary   or  second- 
ary. 33 
Adhesions  of  iris,  280 

of  labia,  750   . 

peritoneal.  789 
Adipose  tumors,  126 
Air  in  veins,  402 
Air  passages,  foreign  bodies  in,  600 

wounds  of,  698 

operations  on,  605 
Albuminuria,  052 

with  shock,  225 


Alcoholic  dressing  of  wounds,  51 
Alimentation,  rectal,  5S4 
Ailnr!oii's  o|ieration  for  stone,  077 
Alveolar  aliscess,  4  74 
Amalgams,  409 
Amaurosis,  285 
Ametropia,  201 
Amputation,  999 

in  collapse,  220 

in  joint  disease,  929.  942 

or  excision  of  knee,  934 

difl'ercnt  varieties  of,  1000 

mortality,  1002 

of  the  tliigh  for  diseases  of  the 
knee,  1002 

causes  of  death  in,  1002 

double,  1003 

modes  of,  1003 

instruments  required  in,  1005 

position  of  assistants  in,  lOOC 

flap  operation.  1005 

its  history,  lOOIl 

circular  operation,  999 

value  of  splints  after,  1007 

Teale's.  lOOS 

Garden's,  10119 

mixed  form,  1009 

at  shoulder-joint,  1009 

arm,  1011 

at  elbow- joint,  1011 

of  fore-arm,  1012 

of  thumb  and  fingers,  1012 

at  wrist-joint,  1012 

at  hip-joint,  1013 

by  Furneau.\  .Jordan's  method, 
1015 

of  thigh,  1015 

at  knee-joint.  1010 

of  leg,  l"ol7 

of  foot,  1017 

in  gangrene,  SI 

.in  gunshot  injuries,  989 

in  compound  fractures.  836 

dressing  stunij)  after,  1007 
Amussat's  operation,  512 
Anal  abscess.  508 
Antesthesia,  local,  999 
Anassthetics,  action  of,  993 

rules  for  the  administration  of, 
994 

value  of,  as  aids  to  diagnosis, 
997 

improvements  in  practice  due 
to.  997 

in  eye  surgery,  290 
.Anastomosis,  aneurism  by,  376 
Anatomical  tubercle,  101 
Anchylosis  of  spine,  246 

oV  hiji,  915,  924 

of  knee,  928 
Anel's  ojteration  for  aneurism,  369 
Aneurism.  ;157 

pathology  of,  357 

diagnosis  of.  300 

diffused,  357,  373 


Aneurism — 

dissecting,  357 

traumatic,  373 

false,  357 

true,  357 

varicose,  375 

rupture,  360 

spontaneous  cure  of,  359 

by  anastomosis,  370 

fusilorm,  357 

arterio-venous,  374 

cirsoid,  .'170 

special,  3sO 

treatment  of,  301 

by  ligature,  369 
by  compression,  303 
by  manipulation,  371 
by  injection,  372 
Aneurism  needle,  382 
Aneurismal  sac,  relations  of,  to  ar- 
tery, 357 

vari.\,  375 
Angeio-lcucitis,  181 
Angular  curvature  of  spine,  245 
Animal  jioisons,  100 
Ankle-joint,  dislocations  of,  850 

diseases  of.  918 

siij)])uration  of,  937 

excision  of,  937 

amjiutation  at,  1021 
Ankyloglopsis.  418 
Annular  urethral  stricture,  683 

rectal,  581 
Antiseptic  irrigation,  33,  51 

ligature,  342 
Antrum,  diseases  of,  442 

dropsy  of,  442 

suppuration  of.  442 
Antyllus,  operation  of,  for  aneur- 
ism, 371 
Anus,  artificial,  495 

abnormal.  495 

imperforate,  500 

diseases  about,  565 

fistula  aI)out.  508 

])ainful  ulcer  of,  507 

j)ruritus  of,  578 
Aorta,  abdominal  aneurism  of,  383 

ligature  of,  383 

compression  of.  3S3 
Aphasia  after  head  injury,  200 
Aphthous  stomatitis,  415 
Apiioea,  018 
Arachnitis,  207 

s])inal,  234 
Arachnoid  cysts,  203 
Arch,  |ialmar.  wounds  of.  393 
Arm.  amputation  of.  1011 
Arrest  of  growth  after  fracture.  876 

of  inflammation  by  obstruction 
of  artery.  71 
Arrows,  wounds  from,  156 
Arterial  or  anieraic  gangrene,  81 

pyivmia,  355 
Arteries,  diseases  of,  352 
1027 


1028 


INDEX. 


Arteries — 

inflainuiiition  of.  352 

atheroma  of,  3y,'i 

injuries  of,  340 

contusion  of,  341 

torsion  of,  341 

statistics  of,  34S 

ligature  of,  342 

general   rules  for   the  ligature 
of,  381 

occlusion  of,  341 

subcutaneous  rupture  of,  341 

hemorrhage  from,  340,  343 
Arterio-venous  aneurism,  ;!74 
Arteritis  and  atheroma,  351 
Artery  constrictor,  34S 
Arthritis,  gonorrhceal,  717 

osteo-,  946 
Articular  ends  of  bones,  disease  of, 
908 

necrosis  of,  951 
Artificial  anus,  495 

leech,  291 

pupil,  305 

respiration,  (520 
Asphyxia,  020 
Aspirator  in  abscess,  69 
Astragalo-calcanean   joint,   disease 
of,  918 

dislocation  of,  852 
Astragalus,  dislocation  of,  853 

fracture  of,  902 

excision  of,  855 
Atheroma,  353 
Atlas,  disease  of,  247 

dislocation  of,  239 
Atrophy  of  bone,  969 

of  muscle,  800 
Atropine  in  iritis,  280 
Aural  polypi,  330 
Auricle,  malformations  of,  322 

tumors  of,  323 
Axillary  artery,  ligature  of,  390 

BACK,  injuries  of,  232 
sprains  of,  242 
Balanitis,  717 
Bandage,  spica,  542 
suspensory,  735 
immovable,  865 
Barbadoes  leg,  1  78 
Base  of  skull,  fractures  of,  193 
Basedow's  disease,  185,  318 
Bath,  calomel,  1 13 
Bavarian  immovable  flannel  splint, 
805 

for  knee,  927 
Bedside  experience,  19 
Bed-sores,  79 
Bellocq's   instrument  for  plugging 

nose.  5SS 
Bending  of  bones.  971 
Biceps  tendon,  rupture  of,  797 
Bigelow's  lithotrity,  665 
Bites,  serpent,  102 
Bladder,  diseases  of,  631 

ruy)turc  of,  490 

irritable.  6:!  I 

in  women.  763 

inflammation  of,  634 

sacculated.  634 

washing  out,  635 

ulceration  of,  636 

tumors  of,  637 

villous  growths  of,  637 

cancer  of,  637 

atony  of,  642 

tubercular  disease  of,  636 

paralysis  of,  643 

stone  in,  660 


Bladder- 
foreign  bodies  in,  681 
malformations  of,  711 
gunshot  wounds  of.  988 
on  bladder  puncturing  through 
rectum,  703 

above  pubes,  705 
Bleeding,  arrest  of.  in  wounds,  33 
the  operation  of.  407 
in  he-.id  injuries,  20S.  211 
in  wound  of  lung,  612 
Blepharo-phymosis,  295 
'•  Block,  reduction  en."  543 
Blood  cysts  in  skull,  203 
Blniid-i)oisoning,  91 

prevention  of.  98 
Blood  tumors  of  scalp,  189 
Bodies,  loose,  in  joints,  942 
in  bursa-,  S06 
in  ganglia,  SIO 
Boils,  169 

Delhi,  172 
Bone,  atroph.y  of,  969 
abscess  of,  954 
contusions  of,  of  skull,  191 
diseases  of,  947 
inflammation  of,  950 
elongation  of.  from  inflamma 

tion,  970 
fractures  of,  858 
hypertrophy,  970 
caries  of,  961 
necrosis  of,  950 
sclerosis  of,  951 
tumors  of,  962 

diagnosis  of,  967 
pulsatile  tumors  of,  969 
cysts  in,  969 
hydatids  in,  969 
cancer  of,  966 

amputation  in,  968 
Bone-setting,  991 

Bowel,    internal    strangulation    of, 
501 
ruptured,  487 
Brachial  artery,  ligature  of,  391 
Brain,  bruised,  198 

hemorrhage  from,  198 

from  meningeal  artery,  202 
concussion  of,  197,  210 
compression  of,  204,  210 
hernia  of,  207 
inflammation  of,  207 
suppuration  of,  210 
wounds  of,  206 
Brain  and  its  membranes,  injuries 

of,  201 
Brasdor's  operation,  369 
Breast,  diseases  of,  763 

Creighton's  views  of  their  pa- 
thology, 767 
hypertrophy  of,  770 
engorgement  of,  764 
inflammation  of,  764 
abscess  of,  765 

submammary  abscess  of,  766 
chronic  induration  of,  766 
irritable,  766 
tumors  of,  766 
adenoma  of,  767 

statistics  of,  766 
cancer  of,  771 
open  cancer  of,  776 

statistics  of,  773 
colloid  cancer  of,  774 
cystic  disease  of,  773 
cystic  cancer,  776 
sarcoma  of,  776 
milk  tumor  of,  775 
hydatids  of.  776 
retracted  nipple  in,  777 


Breast — 

discharge  from  nipple  in,  777 
enlarged  glands  in,  778 
infiltration  of  skin  in.  778 
chronic  eczema  of  nipple  pre- 
ceding cancer,  777 

excision  of,  778 

tumors  of,  diagnosis  of,  768 
Broad  ligament,  cysts  of.  782 
Bronchocele,  186 
Bronchotomy,  60S 
Bruise,  155 
Bubo,  in  clap,  717 

in  chancre.  719 

in  syphilis.  721 
Bubonocele.  527 
Bullets,  varieties  of,  976 

extractor,  981 
Bunion,  174 
Burns  and  scalds,  157 

statistics  of.  159 

cause  of  death  in,  158 

pathology  of.  159 

of  larynx,  603  > 

Burrowing  of  abscess,  68 
]5ursa\  diseases  (jf,  S05 

of  svnovial,  806 

of  pojiliteal,  807 

acute,  inflammation  of,  Su5,  948 

loose  bodies  in,  8II() 
Button  suture,  36 


CACHEXIA,  21 
Caecum,  abscess  about,  496 
rupture  of,  504 
hernia  of,  527 
Calcis,  fractures  of,  902 

necrosis  of.  960 
Calculus,  nasal.  590 
salivarj',  41  7 
in  tonsil.  438 
renal,  626,  655 
prostatic,  649 
vesical.  655 
urethral,  706 
in  female,  679 
Callisen's  operation,  512 
Callous  ulcers,  74 
Callus,  provisional,  S67 
Calomel  bath  in  syphilis.  113 
Canaliculi.  obstruction  of,  295 
Cancer,  132.  153 
structure,  153 
causes,  138 
heredity  in,  138 
clinical  features,  133 
treatment,  139 
scirrhous.  134 
medullary,  135 
osteoid,  147 
epithelial,  136 
colloid,  i;-18 
villous,  139 
of  V\\K  412 
of  nose,  590 
of  cesophagus,  478 
of  tongue,  427 
of  tonsil,  433 
of  rectum,  579 
of  bladder,  638 
of  prostate,  650 
of  penis,  710 
of  breast,  771 
of  testicle,  744 
of  thyroid  gland,  187 
of  bone,  966 
of  scrotum,  753 
treatment  by  excision,  140 
by  caustics,  140 
Cancrum  oris,  415 


fM>r:x. 


l(»J9 


Cannon  bnllt,  blowi  from,  077 
Ciirboli/.cil  li((atur«»,  :tl2 
Carlmiiclu,  Itlil 

tiuiiil,  171.  116 
(.'arcinitiiiii,  i:t:i,  Ijit 
Cur<l(>ir«  nnt|)utittii>n,  inou 
(.'artiinul  poinis  ( xix  t  l<>  (»•  oligorvod 
ill  (Ih<  triMitiiiciii  lit'  wuiuutii, 

;u 

Ciirio.«,  IMU 

i-iiiiMtif  tiPiif iiiciil  lit',  '.M'l'J 

of  ti'ftti.   H'lT 
Cnrotiil  iirliT.v,  li-xiirnri'  of,  IJ84,  386 
Car|ius.  iliKliK-iitinii  nf,  S(0 

(liM-UMts  of,  '.l-JI.  <.l|l 
Ciirr's   Mpliiit   for  fnioture  of  foro- 

nriii,  Ss(» 
C!irtili»;50,  discrtdeg  of,  907 

tlislocutiiin.i  of   iiitcr-iirtiouliir, 
Sj(» 

tuiiiorx  of.  127.  I  17,  '.'tU 

fnioturp  of  CDstiil,  t'l  |  4 
t'iivtiliijfe!!,  loose,  ill  joints,  ',H2 

.sterno-oostnl.  t'nu'turi'  of,  tH4 
(.'nstration,  "-I".' 
Cuturnot,  .iOtl 

o|ii'rntioiis  fur.  .'ios 

ai'i'iili'nts  ilurinij.  .'tI2 
nfter-treatiiient,  .112 

glft8.««8,  :{i;{ 
Catarrh  of  tympanank  ."JS-? 
CiUarrlini  coniiinotivitig,  2ftS 
Catjrut  siiiuri'.s,  :'.7 

li>;atui-e,  earbolized,  342 
Ciithcterti.  OSj 

on  pas.sing.  685 

tyiiii?  in,  tJSti 

Eustachian,  334 
Caustii-s,  141) 
Cautery,  actual.  34S 

galvanic,  in  fi.^tula,  570 
in  piles,  574 
in  !-kin  cancer,  141 
in  ovariotomy,  79U 
Cell  ilovi-lopiiient.  2f, 
Cellular  membranous  sore,  74 
Cellulitis.  St) 
Cervical  cysts,  142 

vertebra;,     diseases      of,     246, 
2.ill 
Cervi.x  femoris,  fracture  of,  885 
Chancre,  718 

of  li]..  414 

infecting,  71 S 

complieations  of.  720 
Charbon.    or     malignant     pustule, 

lliS 
Charcot's  disease  of  joints,  947 
Cheiloplasiic  operations,  412 
Cheloid  tumors.  lt)3 

of  ear.  324 
Chest,  injuries  of,  611 

deformities  of.  616 

gunshot  injuries  of,  9S5 

wounds  iif.  614 

of  large  vessels  of,  339 

tapping,  616 
Chii^oe.  180 
Chilblain,  167 
Children,  hydrocele  in,  724 

irritable  bladder  in,  632 

incontinence  in,  644 

lithotomy  in,  663 

retention  in,  699,  701 

extravasation  in,  640 
Chiuiney-sweeji's  cancer,  753 
Chloroform,  993 

value  of,  in  strangulated  her- 
nia, 535 
Choked  disc,  289 
Chopart's  amputation,  1019 


Chordee,  716 

Choroid,  hypuriviiiiu  of,  281 

injiirieK  of.  2^2 
Choroidiiiit.  2Sl 
('hrofiie  aliitevnH,  6s 
I  lironie  iiileHtinal  obMtruction,  A03 
t'ieiilrioeH,  ilii<eui<eH  of.  Kll 

diviition  of,  161 

eongenitiil.  Mil,  410 
Cicatricial  Ktrietiire  of  urethra,  C96 

of  iL-iiipliagus,  4S0 
Cieatrizatioli,  27 
Cireiimeitiioii,  7it9 
("irooid   aiieiiriKii),   15H 
Civiale's  litlmtrity,  (i63 
Clamp  for  ovariotomy,  790 

for  pile.M,  574 
Clavicle,  dislocation  of.  830 

fracture  of,  S70 
Claw-liku  extremities,  sl3 
Cleansing  wounds,  32 
Cleft  palate,  4:;2 
Clinical  history,  value  of,  18 
Clitorideetoiny,  75s 
Clitoris,  enlargement  of,  758 

cancer  of,  75S 
Cloaciv  in  bone,  950 
Clots,    ''active    and     passive,"    in 

ancunsm,  359 
Clover's  lithotrity  syringe,  626 
Clovo-hitch.  836" 
Clnh  foot,  .S14 
t^oapfatiiin  of  wounds,  35 
(/oeeyodynia,  919 
Coccygeal  joint,  disease  of,  919 

tumors,  231 
Cock's  operation  for  stricture,  691 
Cohnhcim's  views  on  inflammation, 

67 
Cold  as  a  local  ajiplication,  50 

as  a  styptic,  348 

as  an  anaesthetic,  999 
Cold  ulcers,  77 
Colectomy,  289 
(^'ole's  artery  compressor,  364 
Collapse,  224 

amputation  in.  226 
Collateral  circulation,  373 
Colics*  fracture.  877 
Colloid  canecr,  l;!S 
Coloboma,  278 
Colon,  ruj)ture  of.  488 
Colotomy,  511 

for  stricture.  583 

]tlug  for,  513 
Coma.  204 

Comminuted  fractures.  904 
Compound  fractures,  863 

of  skull,  191 

dislocation,  829 

of  slioulder,  837 
of  elbow,  840 
of  knee,  849 
of  ankle,  852 
Comjiress,  Di.x's,  wire,  346 
Compression  in  aneurism,  363 

of  brain,  204 

diagnosis  of,  205 
treatment  of,  210 

of  chest.  615 
Concussion  of  brain,  197 

hemorrhage  as  the  result 

of,-  198 
treatment  of,  210 
remote  etfects  of,  200 

of  spine,  232 
Condylomata,  114,  577 
Congenital  anomalies  of  eyelids,  266 
of  lips.  409 

malformations,  81 1 
of  joints,  856 


Congoniinl — 

liydro.-.dc.  724 

tuiiiori*,  231 

eii-atrices.  164,  410 

hernia,  547 

xyphiliN,  I IH 

m-baeeous  cyi»t»,  144 
Conical  cornea,  302 
(.'oiijiiiictivn,  diiieaBe  of,  268 

operation!*  on,  297 

injuries  of,  27  1 
Conjunctivitis,  vnricticK  of,  267 
Cun.'ititutional  eaiioeH  of  non-repair 
in  woundd,  31 

sorcH,  73 
Contagious  ophthalmia,  270 
Continuous  suture,  35 
Contraction  of  bowel,  505 

after  strangulation,  534 

of  Angers,  823 
Contrecoup,  193,  199,  207 
Contused  Wounds,  41 
Contusion,  155 

of  brain,  199 

of  scalj),   189 

of  bones  of  skull,  191 

of  chest,  611 

of  arteries,  34  I 
Convulsions   in    head   injuries,  193 

202,  204,  208 
Coracoid  jirocess,  fracture  of,  872 
Cord,  8|)erniatic,  varicocele  of,  750 
tumors  of,  751 
hydrocele  of,  722,  725 
hivmatocele  of,  730 

spinal,  injuries  of,  232 
Cornea,  inflammation  of,  272 

ulcers  of,  274 

conical,. 302 

opacities  of,  275 

tinting.  302 

wounds  of,  275 

burns  of,  276 

operations  on,  301 

foreign  bodies  in,  303 
Corns,  174 

Coronoid   process  of  jaw,   fracture 
of,  451 

of  ulna,  fracture  of.  882 
Cortical  cataract,  30" 
Cranium,  injuries  of,  192 

general  propositions  on,  192 

contusion  of,  191 

fracture  of.  192 

compound,  of.  194 

fracture  of  base  of,  193 
diagnosis  of.  194 

ineomjilete  fracture  of,  858 

gunshot  injuries  of.  982 
Crepitus  of  fracture,  860 
Croft's  splint,  866 
Croup,  606 
Crushing  ])iles,  575 
Curvature  of  spine.  243.  245 

Sayre's  jacket  in,  24S 
Cutaneous  cysts,  144 
Cut  throat,  .598 
Cutting  teeth,  460 
Cyclitis,  281 

Cynanohe  tonsillaris,  437 
Cystic  disease  of  breasts,  773 
of  antrum,  442 
of  testes.  742 
of  ovary,  780 
Cvstine  calculus,  657 
Cystitis,  034 
Cysts,  as  tumors.  142 

serous.  185 

simulating  eneephalocele,  217 

dentigerous,  443,  457,  463 

thyroid,  143 


1030 


IXDEX. 


Cysts- 

mucous,  143 
oil.  145 

sublingual,  416 
sebaceous,  144 
tarsal.  292 
of  orbit,  319 
labial,  757 


DAVIES-COLLEY'S  talipes 

splint,  819 

operation    for   talipes   equino- 
varus,  819 
Deaf-mutism,  337 
Decay  of  teeth.  467 
Deformities,  81 1 

heredity  of,  813 

of  nose,  5S6 

of  chest.  616 
Delhi  boil,  172 
Delirium  tremens,  222 
Dental  caries.  467 
Dental  irritation,  464 

remote  effects  of,  465 

surgery,  remarks  on,  453 
Dentigerous  cysts,  44.3,  457,  463 

tumors,  444 
Dentine,  secondary.  466 
Deposits,  urinarv,  6.02 
Depressed  fracture  of  skull.  19.3,  204 

trephining  for,  212 
Dermal  or  dermoid  cvsts,  292 

of  bladder,  640 
Diagnosis,  17 

by  exclusion,  17 
Diaphragm,  rupture  of,  491 
Diaphragmatic  hernia,  558 
Diathesis,  19 

scrofulous.  20 

hemorrhagic.  20 
Dieulafoy's  aspirator,  69 
Diffuse  cellular  inflammation,  86 
Diffused  aneurism.  357 
Digital    compression    of   aneurism. 

363 
Dilatation  of  stricture,  forcible.  687 
Diphtheritic  conjunctivitis,  271 
Direct  inguinal  hernia.  548 

ophthalmoscopic  examination, 
256 
Dislocations,  826 

of  spine.  237 

of  jaw.  449 

of  ribs,  614 

reduction  of  old.  828 
compound,  828 

of  clavicle,  830 

of  scapula,  832 

of  humerus,  S32 

of  elbow,  837 

of  wrist.  840 

of  radius,  840 

of  caijtal  bones,  841 

of  thumb  and  phalanges,  841 

of  hip,  s^i 
old,  847 

treatment  of,  846 

and  fracture  of  hip,  847 

of  patella,  848 

of  knee-joint,  849 

of  fibula.  S50 

of  foot  at  ankle.  850 

of  astragalus.  S48 

of  foot  off  astragalus,  853 

of  tarsal  joints,  855 

unreduced,  828 

reduction  of,  by  manipulation 
of  hip.  846 

of  humerus.  835 
Dislocation  and  fracture,  829 


Dislocation  and  fracture — 

of  humerus,  837,  876  | 

of  hip,  848  I 

Displaced  hernia,  543 

reduction  en  masge,  543 
other  varieties,  543 
Displacement  of  femur  in  hip  dis- 
ease, 914 
Dissecting  aneurism.  357 
Dissection  wounds,  100 
Distal  ligature,  371 

pressure,  367 
Dix's  wire  compress,  346,  367 
Dolbeau's  perineal  lithotrity,  677 
Dorsalis  pedis   arterv.  ligature  of, 

.398 
Dorsum  ilii.  dislocation  on,  843 
Double  splint  for  fracture  of  thigh, 
889 

statistics  of  results,  887,  892 
for  hip  disease,  923 
Douche,  nasal,  587 
Drainage  of  wounds,  38 
tubes,  38 

caution  in  their  use,  38 
in  abscess,  70 
after  amputation,  1007 
Dressing  wounds.  32 
second,  39 
later.  41 
Dropsy,  diagnosis  of  ovarian,  781 
Drowning,  618 

recovery  from,  619 
Dry  dressing  of  wounds,  51 

gangrene,  80,  81 
Duchenne's  disease,  801 
Dugas'  guide  to  diagnosis  of  dis- 
location of  humerus.  834 
Duodenum,  ulceration  of,  158 

rupture  of.  487 
Dura  mater,  injuries  of,  201 

inflammation   of,  after  ostitis, 

207 
blood  outside,  202 
within,  202 
Durham's  tracheotomy  cannia,  608 
Dyspeptic  ulcer  of  tongue,  424 
Dysphagia,  47S 


E 


AK,  external,  affections  of,  .322 
malformations  of,  322 
cutaneous  affections  of,  323 
injuries  of,  323 
tumors  of,  323 
cheloid  tumors,  324 
hfematoma,  323 
foreign  bodies  in,  325 
polypus  in.  330 
bleeding     from,    in     fractured 

skull,  195 
middle,  affections  of,  330 
catarrh  of,  3;-'.3 
Ear-ring  holes,  tumors  of.  324 
Earth-dressing  of  wounds,  51 
Ecchymosis,  155 
Echinococcus,  181 
Ectopion  vesicae,  711 
Ectropion,  293 
Eozematous  ulcer,  76 
Elastic  extension.  891 

ligature  in  fistula.  571 
Elbow-joint,  amputafion  at,  1011 
excision  of,  940 
dislocation  of.  837 
compound  dislocations  of, 

840 
compound'  fractures    into, 

881 
diseases  of.  920,  928 
Electric  indicators,  981 


Electrolysis  in  aneurism,  372 

in  stone,  663 
in  hydatid,  573 
Electro-puncture  of  aneurism,  371 
Elephantiasis  Arabum,  177 

Manson's  views  on,  178 

ligature  of  main  artery  in,  178 

of  scrotum,  752 

Graecorum,  177 
Embolism,  354 

pulmonary.  354 

fat,  in  fracture,  861 
Emigration  of  leucocytes,  26 
Emissions,  nocturnal,  755 
Emmetropia,  261 
Emphysema.  612 
Empyema,  616 

Encephalitis  after  injury,  207 
Encephalocele,  216 
Encephaloid  cancer,  135 
Enchondromata,  128,  148 

of  bone,  964 

of  jaw,  445 
Encysted  hernia,  54  7 

hydrocele,  728 
Endostitis,  955 
Enostosis,  595 
Enterocele,  527 
Entero-epiplocele,  527 
Enterotomy,  5li8 

in  malformations  of  rectum,  563 
Entropion,  293 
Enucleation  of  eyeball,  314 
Epidirlymitis,  733 

in  gonorrboaa,  716 
Epigastrium,  blows  on,  484 
Epiglottis,  wounds  of.  599 
Epilepsy,  trephining  in,  218 

after  injury.  212 
Epiphysial  cartilage,  disease  of,  in 

hip  disease,  914 
Epiphysis,  inflammation  of,  949 

displacement  of.  829 

of  humerus.  840,  873 

of  clavicle,  831 

of  radial,  877 

of  femur!  849 

arrest  of  growth  of  bone  from 
injury  of,  876 
Epiplocele,  527 
Episcleritis,  276 
;  Epispadias,  711 
Epistaxis.  587 

plugging  iKise  in,  588 

in  head  injuries,  196 
Epithelioma,  136 

of  bone,  966 

of  nose,  .''93 

of  lips.  412 

of  penis.  710 

of  scrotum,  753 

of  rectum,  579 

of  tongue,  427 

of  ceropbagus,  479 
Epulis,  441,  475 
Equinia,  or  glanders,  106 

mitis,  107 
Erectile  tumor,  377 
Erysipelas.  85 

thermograjiby  of,  85 

phlegmonous.  86 

pathological  appearance;  after 
86 

treatment  of,  88 
Erythema.  90 

nodosum.  90 

varieties  of.  90 
Esmarch's  bandage,  344 

in  aneurism.  365 

operation  for  closure  of  jaws, 
448 


i.\ni:x. 


1031 


Ether  upriiv.  WJ 

Eii!>itichiun  out  lifter,  nuiiiiago  of,  3,'S4 

Exi'iKJon  III"  joint!!,  Itis 

uf  tii|i,  m:',\ 

of  kno«>,  V'Mt 

of  II II kit",  V'M 

of  !<houlil(>r.  U38 

of  clliow.  u:i9 

of  wrixl,  U41 

of  larynx.  ftUT 
Exclufiioii,  rt-iiDonin);  by,  17 
Kxfoliiition  of  bonf.  D./n 
Exo|ibibitlinii-  bront-hocelc,  1S6 
Exostosis  '.til.J 

pcrioHtenl.  '.•('>:{ 

ornnial.  IM'.:', 

of  iinf^iinl  jihiiliinx,  177,  9l'i.°< 
stiitistic-s  of.  llt.l 

frncliire  of,  iMi;; 

of  orbit,  .'.IS 

of  inciilii^.  .■{2S 
External    nientiis,   exnininntion   of, 
324 

affei-iions  of,  .".24 

piles.  ..71 

urethrotomy.  ('iS'.i 
Extra-cii|isulHr  fracture,  SS5 
Extraction  of  cataract,  .'!••!• 

after-treatment  of,  312 

of  teeth,  4I>2,  47.J 
Extra va.'iat ion  of  blood,  155 

in  fracture,  902 

of  urine,  CiltS 

in  children.  705 
Extroversion  of  blaclder,  71 1 
Eye,  injuries  and  disea.ses  of,  255 
Eyeball,  exaiuination  of.  255 

operations  on.  21(0 

pfisitiun  of  patient  in,  290 

rupture  of.  321 

suppuration  of.  321 

extirpation  of,  313 

protrusion  of,  314 

tumors  of.  320 

vascular  protrusion  of,  316 
Eyelashes,  malposition  of,  292 
Eyelids,  diseases  of,  266 

tumors  of,  292 

injuries  of,  267 

examination  of,  255 

formation  of  new,  294 


FACIAL  artery,  ligature  of,  387 
carbuncle,  171 
nerve,  ]iaralysis  of,  195,418 
False  joint  after  dislocation,  827 

after  fracture,  868 
Farcy,  1<I6 

Fascia  of  palm,  contraction  of,  823 
Adams's  operation  for,  823 
Fat  embolism  in  fracture,  861 
Fatty  tumor,  126 
Fauces,  ulceration  of,  436 
Fecal  abscess,  496 
fistula.  495 
impaction,  502 
Feigned  disease,  227 
Female  genital  organs,  affections  of, 

756 
Female,  stone  in.  679 
Femoral  aneurism,  393 

artery,  ligature  of,  395 
hernia,  552 

diagnosis,  553 
str.ingulated,  553 
Femur,  dislocations  of  head  of,  843 
fractures  of.  *<85 
of  neck.  SS5 
of  shaft,  891 
of  condyles,  894 


Femur — 

in  cliildrcn,  s'.i4 
compound,  of,  SO,') 

reparation     of     ejiiphjiii     of 
hea<l,  SUO 

ot   tnichanter,  8110 
..f  c.n.lyleH,  siM 

ahfiorption  ot'  neck,  S90 
Fever,  intlnmiuatory,  6.'»,  91 

hectic,  US 

trnuniatic,  25,  92 
Fibrin,  execKs  of,  in  iiillamination, 

66 
Fibromata,  126 
Kibro-musciilar  tumor,  126 
Fibro-plastic  tumor,  K'.l 
Fibrous  )ioly)ius  of  jiharynx,  592 

tumors,  127 

of  uterus,  792 
Fibula,  dislocation  of  head  of,  849 

fracture  of,  SOS 
Fiel.l  dressing,  first,  9S(» 
Fingers,  compound  fracture  of,  882 

am]iutalion  of,  1012 

contracteil,  S23 

dislocation  of,  842 

webbed,  812 
First  intention,  union  by,  26 
Fissure  of  anus,  567 
Fissured  palate,  433 
Fistula,  71 

rectal,  568 

fecal.  495 

salivary,  417 

urinary,  695 

vaginal.  760 

vcsico-intestinal,  643 
Flap  amputation,  1000 
Flat  foot.  821 
Flexion  in  aneurism.  366 

in  reduction  of  dislocation  of 
hip,  846 
Fluctuation,  68 
Follicular  tumors,  141 
Foot,  fractures  of.  902 

dislocation  of.  S50 

perforating  ulcer  of.  171 

amputations  of.  1017 
Forceps,  artery,  345 

bone,  960 

bullet,  981 

lion,  445 

pharyngeal,  481 

tooth,  476 

tracheal,  603 

omental  clamp,  790 
Forcible  taxis.  536 
Fore-arm,  amputation  of,  1012 

fractures  of,  877 
compound.  8S2 
Foreign  boilies  in  conjunctiva,  271 

in  ear,  326 

in  nose,  590 

in  pharynx  and  cesophagus,  480 

in  air-passages,  600 

in  bladder,  6S1 

in  rectum,  565 

in  stomach  and  intestines-,  497 

in  gunshot  injuries,  982 

in  wounds.  30 
Fracture  bed.  863 
Fracture  of  exostoses,  963 

with  ruptured  artery,  373 
Fractures,  858 

incomplete,  858 

impacted,  858 

diagnosis  of.  859 

prognosis.  861 

treatment  of  simple,  861 

in  insane,  859 

compound,  863 


Fracture*— 

from  ({iiti'liot  injuric",  988 

rep'iir  of.  ,s67 

compound,  HS3 

delayed  union  in,  868 
of  arm.  Ks2 
of  ^kull.  I9t 
repair  of.  868 

ununiteil,  sr.s 

deformity  after,  869 

complicating  joints,  S63,  903 

extravasation  in,  902 

comminution  of  bone  in,  904 

spontancou",  H59 

fat  embolism  in  fracture,  861 

sjiecial,  of  jaws,  450 

of  nose,  jsf. 

of  skull.  192 

of  base  of  Rkull,  192 

of  spine.  237 

of  larvnx.  597 

of  ribs,  r.  11 

of  clavicle,  870 

of  scapula,  S71 

of  humerus,  S72 

of  radius  and  ulna.  877 

from  gunshot  injuries,  988 

of  metacarpal  bones.  881 

of  yjhalanges.  ssl 

of  lower  extremity.  884 
statistics  of,  861,  884 

of  pelvis,  883 

of  femur.  885 

of  leg,  898 

of  patella.  895 

of  foot,  902 

gunshot,  988 

splints  in,  864 

immovable  splints,  865 

Colles's.  877 

Pott's.  850 
Frontal  sinus,  diseases  of,  595 

distension  of.  595 

fracture  of,  587 

enostosis  of,  594 
Frostbite,  80,  168 
Fulminating  glaucoma,  284 
Fumigation,  mercurial,  113 
Fungous  foot  of  India.  172 
Furneaux  Jordan's  method  of  am- 
putation at  hip-joint,   1015 
Furuncles  of  ear,  327 
Furunculus.  or  boil.  169 
Fusible  calculus,  658 
Fusiform  aneurism,  357 


GiAG,  432 
r  Galactocele,  775 
(^all-bladder,  rupture  of,  489 
Gall-duct,  rupture  of,  489 
Galvanic  cautery,  in  fistula,  570 
in  cancer,  140 
in  naevus,  379 
in  piles,  574 
Galvano-puncture  in  aneurism,  372 
Ganglion,  s(i9 

diffused,  809 
Gangrene,  anajmic  or  arterial,  SO,  81 
static  or  venous,  81,  82 
from  col.l,  SO,  168 
traumatic.  79 
after  ligature,  369 
embolic,  354 
hospital.  83 
senile,  80 
amputation  in.  S2 
Gastrotomy  and  gastrostomy.  498 
Genitals,  female,  affections  of,  756 
wounds  of.  756 
foreign  bodies  in,  756 


1032 


INDEX. 


Genitals,  female — 

adherent  laliia,  75fi 
vulvitis,  75f) 
noma,  76fi 

labial  cysts,  etc.,  757 
labial  tumors,  757 
imperforate  hymen,  757 
double  vagina,  758 
vaginal  tumors,  758 

Genito-urinary  organs,  injuries  and 
diseases  of,  702 
malformations  of,  712 
development  of.  732 

Genuflexion  in  popliteal  aneurism, 
.366 

Glanders,  100 

Glands,  inflammation  of,  181 
in  erysipelas,  88 

Glandular  tumors,  129 

(ilaucoma,  283 

Gleet,  715 

Glioma,  320 

Glossitis,  423 

Glottis,  foreign  bodies  in,  600 
scalds  of,  603 

Gluteal  aneurism,  ligature  of  inter- 
nal iliac  in,  394 

Goitre,  184 

exophthalmic,  185,  318 

Gonorrhoea.  714 
in  female.  715 
complications  of.  716 

Gonorrhoeal  rheumatism.  717 

Gordon's  splint  for  fracture  of  ra- 
dius, 880 

Gouty  phlebitis.  401 
testitis,  738 

Gowan's  excision  saw,  931 

Grafting  skin,  164 

Granular  lids.  269 

Granulating  wounds,  28 

treatment  of,  42,  44 

Granulation  tumors,  713 

Granulations,  28 
diseases  of,  62 

Gravel,  655 

Green-stick  fracture,  858 

Gritti's  amputation,  1016 

Gross's  tracheal  forceps  603 

Growth,  arrest  of,  after  fracture,  876 
after  disease  of  hip,  916 

Guinea-worm,  179 

Gum  and  chalk  splint,  865 

Gum-boil,  489 

Gummata,  112 

Gums,  afi"ections  of,  489,  475 

Gunpowder,  burns  from,  159 

Gunshot  injuries,  975 
shock  in,  978 
hemorrhage  in,  978 
of  head,  982 
of  chest,  985 
of  heart,  985 
of  abdomen,  986 
of  intestines,  936 
of  bladder,  987 
fractures  from,  988 
of  upper  extremity,  989 
of  lower,  989 
amputation  in,  990 

Gustatory  nerve,  division  of,  429 


H.I:MATOCELE,730 
of  the  cord,  731 
HaMiiatoma  of  scalp,  189 

of  ear,  323 
Hasmaturia.  624,  638 
Haemophilia,  20 
Haemostatics,  340 
surgical,  341 


Haemothorax,  616 
Hainsby's  harelip  truss,  411 
Hammond's  splint,  for  fracture  of 

jaw, 452 
Hand,  amputation  of,  1012 

dislocation  of,  840 
Hancock's  operation  on  foot,  1021 
Hanging,  619 
Hard  cataract,  307 
Harelip,  410 

suture,  36 
Head,  injuries  of,  189 

general    propositions    on, 

192 
trephining  in,  212 
conclusions  on.  215 
gunshot  wounds  of,  982 
Headache  after  injury,  207 
Healing  process,  29 

in  wounds,  26 
in  muscle,  30 
in  nerve,  30 
defects  in,  61 
Heart,  wounds  of.  338 

gunshot  wounds  of,  985 
Heat  in  inflammation,  64 
Hectic  fever,  98 
Hemorrhage  343 
consecutive,  59 
secondary,  611,  349 
summary  of  its  treatment,  349 
general  treatment  of,  350 
in  wounds,  30 
in      contused     and     lacerated 

wounds,  42 
urethral,  625 
vesical,  625 
renal.  625 

in  gunshot  wounds.  978 
after  tooth  extraction.  476 
Hemorrhagic  diathesis,  20 
Hemorrhoids,  570 
Hereditary  syphilis.  155 
Hernia,  diagrams  of,  524 
abdominal,  525 
anatomy  of,  526 
irreducible,  529 
obstructed,  530 
inflamed,  530 
strangulated,  530 
])athological  changes  in,  532 
treutuient  of,  530 
rupture  of,  530 
labial,  756 
multij)le,  543 
displaced,  543 
inguinal,  547    , 
femoral,  552 
obturator,  554 
umbilical,  556 
other  forms  of,  557 
congenital,  547 
radical  cure  of,  549 
cerebri.  207 
testis,  741 
Hernial  sac,  526 

changes  in,  526 
absence  of,  527 
hydrocele  of.  528 
reduction  of,  543 
rupture  of,  545 
Herniotomy,  544 
Herpes  preputialis,  718 
Hey's  am])utation,  1019 
Hilton's  method  of  opening  an  ab- 
scess, 70 
Hip-joint,  amjmtation  at,  1013 

after  gunshot  injuries,  990 
disease  of,  911 
diagnosis  of,  913 
pathology  of,  912.  921 


Hip-joint — 

treatment  of,  922 

supjiuration  of.  923 

removal  of  necrosed  bone  from 
030 

excision  of,  931 

division  of  neck   of  femur  in 
disease  of,  925 

dislocation  of,  842 

old  dislocations,  S48 

congenital  malformation  of,  856 
Hodgen's  suspension  splint,  892 
Hodgkin's  disease  of  glands,  182 
Holt's  dilator,  688 
Hornv  growth  beneath  nail,  177 
Horn's.  145 

Hospital  gangrene,  83 
Housemaid's  knee,  805 
Howard's  "  direct  method  "  of  arti- 
ficial respiration.  020 
Humerus,  dislocation  of.  832 
statistics  of.  832 
reduction  of,  835 

unreduced  dislocations  of,  837, 
876 

fracture  and  dislocation  of,  837 

compound  dislocation  of,  837 

fracture  of.  873 

compound.  881 

impacted  fracture  of  neck.  872 
Hunterinn  chancre,  71 S 
Hunter's  operation  for  aneurism,  369 
Hydatids,  180 

abdominal,  522 

diagnosis  of,  522 

of  bone,  969 

of  breast,  776 

of  tongue.  423 

of  liver,  522 

tapping,  523 
Hydrocele  of  hernial  sac,  528 

of  cord  and  testes,  722,  725 
its  pathology,  723 

congenital.  723 

encysted,  728 

radical  cure  of,  727 

on  tapping,  726 

spontaneous  disappearance  o^ 
730 

ruptured,  730 

of  neck,  142 
Hvdro-nephrosis,  628 
Hydrophobia,  103 
Hydrops,  antri,  442 

articuli,  917 
Hydro-sarcocele.  739 
Hjdro-thorax,  616 
Hygroma.  143 
Hymen,  imperforate,  757 

rigid.  757 
Hypermetrojtia,  262 

as  cause  of  squint.  298 
Hypertrophy  of  extremities,  811 

of  bone,  969 

of  breast,  770 

of  lips.  414 

of  tongue.  419 

of  veins,  403 
Hypopyon.  274 
Hypos])adias.  713 
Hysteria,  227 

Hj-sterical  retention  of  urine,  706 
Hvsterectomv,  792 


ICE  in  hernia,  530 
poultice.  156 
Ichthyosis  linguae,  421 
Ileum,  rupture  of,  487 
Iliac  arteries,  ligature  of,  393 
Ilio-femoral  triangle,  887 


isni.'X. 


1033 


Ilio-iuiRtio  dialucation«  of  hip,  843  ! 
Ilium.  friK'tiirc  of,  sm{  | 

Itllllluililllc  Ulllnll,  '.'7 

Iuiiiii>l>ililv  ill  triMitiiiuiil  <>r  wiiuii>lii, 

Iroiiiovnblo  a|i|iiiriitiis   in   frui-turc, 

KtU 
Iin|iai.<ti'<l  friii-turi',  Sjl> 

of    llUIIKTUN.  H72 

of  riidiuM,  S77 
of  nook  iif  ilii({h  bone,  SH5 
of  uliaft  of  thij;li-bono,  yUl 
of  t.'i>th,  -It'C' 
Iiii|iikc(i  >ii  of  fci'i'.i,  JO'J 
Iiii|ii>rfMriitc  itiiu.i,  ^>lil 

byiiieii.  T.>7 
liiiIKTiiu'iiblo  strirtiire,  r>S2 
liii|n>lciu"e,  7-'>;! 
liu'uroori»ti'<l  liiTnia,  ;'».'tO 
Incised  wounils,  -';i 

blreiling  in,  24 
|>iiin  in,  2  t 
lociii  ertivts  of,  24 
Ini'i.siou  of  ini-iiibriinii  t_vin|)uni,  3.'!1 
Incoiii|ilote  fnicturt',  >S  JS 
hu>ontiiienee  of  urine.  •544 
Inilircet  ophthulmosoo|iic  examina- 
tion. 2.JS 
Indolent  S'lrei",  75 
Inf.intile  hernia,  547 
hydrocele,  72.S 
jmialvsis,  8(10 
s,v|iiiili!>,  115 
Influiuination,  (i4 

as  a  ciiu!>e  of  non-repair,  30 
absorbent,  ]S1 
asthenic  <i5 
])henouu-na  of,  (U 
ini.'reasc  of  temperature  in,  65 
local  effects  of,  00 
InHaininatory  fever,  65 
Inilation  of  tyni|)anum.  322 
Inirrown  toe-nail,  175 
Inguinal  hernia,  547 

direct  and  obliijue,  547 
diagnosis  of,  548 
Inhaler,  chloroform.  '••90 
Innominate  artery,  ligature  of,  383 
Inoculation,  syphilitic,  118 
vaccino-syphilitic.  119 
Insanity  after  head  injury,  201 
Insect  stings,  101 
Intention,  union  by  first,  26 

by  second,  28 
Inter-arti'Milar   cartilages  of   knee, 

subluxation  of,  850 
Internal  ear,  diseases  of,  336 
Interruplcd  suture,  35 
Interstitial  keratitis.  272 
Intestinal  obstruction,  500 
diagnosis  of,  500 
causes  of,  501 
acute,  501 
chronic.  503 
from  contractions.  504 
from  stricture,  504,  535 
following  hernia,  530 
Intestines,  rupture  of.  486 
protrusion  of.  493 
obstruction  of.  500 
tapping  of.  520 
gunshot  wounds  of,  986 
Intra-capsular    fracture   of   femur, 

885 
Intra-cranial  suppuration.  207 
Intra-parietal  sac  in  hernia,  543 
Intra-uterine  fracture,  858 
Intussusce])tion.  506 

operative  interference  in,  507 
Inversion  of  body  in  foreign  body 
in  air-passages,  601 


Iridectomy,  303 

in  glaucoma,  2h5 
Irido  rli..roidili».  2S| 
Iridoloiny,  :Wi\ 
Iriit,  congcniial  uiioinaliuH  of,  278 

intliiiiimation  of,  27''^ 

wouihIh  of,  2.sti 

coloboma  of,  278 
Iritis  27H 

Irreducible  hernia,  529 
Irrigation  of  wouiidx,  33,  49 
Irritable  blad<l<'r,  032 

in  Women,  763 

mamma,  707 

ulcer,  72 
Ii<chiatic  hernia,  558 
Ischio-rectal  abscess,  568 


JA\V,  deformities  of,  449 
fracture  of,  450 

treatment  of,  450 
rlislocalion  of,  419 
necrosis  of,  4S9 
excision  of.  445 
tumors  of.  442.  444 
closure  of,  449 
Jejunum,  rupture  of,  4S7 
Joint    allVctions    after    wounds    of 
nerves,  251 
disease  and  nerv(jus  affections, 
947 
Joints,  contusions  of,  825 

compound  fracture  into,  863 
dislocation  of,  827 
diseases  of,  820 

svniptonis  of.  910 
p"athology  of,  906 
treatment  of,  921 
amputation  and  excision  of,  928 
false.  S09 
wounds  of,  826 
neuralgia  of,  229 
sprains  of,  825 
anchylosis  of,  916,  924,  928 
loose  cartilages  in,  942 
acute  suj)puration  round,  948 
necrosis  of,  913.  931,  938,  939 
Jugular  vein,  wounds  of,  399 
opening,  399 


t KELOID,  162 
^  of  ear,  324 
Kelotomy,  537 
Keratitis,  272 
Key's  lithotomy,  671 
Kidneys,  injuries  of,  489,  624 
ta]>]iing.  028 
stone  in,  027 
malformations  of,  622 
abscess  in,  628 
operations  on,  627 
Knee,  amputation  at,  1016 
statistics  of.  934 
anchylosis  of,  928 
diseases  of.  916 

treatment  of,  926 
on  tap]>ing,  926 
mortality    of    amputation    at, 

1010 
dislocation  of.  849 
wounds  of.  826 
suppuration  of,  931 
excision  of.  934 

operation  of,  936 
Knock-knee.  821 

OgRton's  operation  for,  822 
Macewen's,  822 
Knot,  rei'f,  345 
granny, 345 


LA  HI  A,  adhcaion  of,  756 
tumorN  of,  757 
hypertrophy  of,  757 
Labyrinth,  nnuctiomi  of,  336 
Iiitceruled  woundx,  41 
Lachrymal    upparatui>,    diiteaHe    of, 

295 
Lachrymal  nac,  washing  out,  297 

obliteration  of,  29j 
Lamellar  caturHct,  307 
Laparotomy.  508 
Laryngitiit,  605 
Laryngoiicojiy,  604 
Laryiigotomy,  007 
Larynx,  disease  of,  004 

rei{uiring  tracheotomy.  604 

excision  of.  007 

foreign  bodies  in,  600 

wounds  of,  597 

tumors  of,  Omi 

syphilitic  >iisease  of,  114,  604 

s'calds  of,  003 

fracture  of,  59" 
Lateral  curvature  of  spine,  243 
Leech,  artificial,  291 
Leg,  amputation  of,  1008 

fracture  of  bones  of.  898 
statistics  of.  898 

compound  fracture  of,  901 
Leiler's  merallic  coil,  50 
Lembert's  suture,  494 
Lens,  affections  of.  277 

wounds  of.  277 

dislocation  of,  277 

diseases  of,  277 
Leucocytes.  26,  67 
Leucorrhoea.  715 

Ligature,  the  action  of,  on  arterv, 
342 

of  catgut,  342 

of  arteries,  345 

rules  to  be  observed  in,  381 

mode  of  applying.  345 

carbolized  catgut  in.  342 

in  aneurism,  .■!09 

of  abdominal  aorta,  383 

of  innominate.  383 

of  carotids.  384 

of  lingual.  387 

of  facial,  38 

of  arteries  of  upper  extremity, 
.387 

of  iliac  arteries,  393 

of  arteries  of  lower  extremity, 
393 
Lightning,  accidents  from,  160 
Lime  in  eyes.  271 
Linear  extraction  of  cataract.  310 
Lingual  artery,  ligature  of,  38" 

in  cancer  of  tongue,  429 
Lip,  congenital  fissures  of,  409 

cancer  of,  412 

chancre  of,  414 

cysts  of.  415 

tumors  of,  414 

na?vus  of.  415 

wounds  of.  409 

restoration  of,  413 

hare,  4S0 

phlegmonous  inflammation  of, 
415 
Lipoma,  126 

of  conjunctiva.  298 

of  nose,  5S9 

of  palm  of  hand.  810 
Lisfranc's  amputation,  1019 
Listerian      method      of      dressing 

wounds,  54 
Lithic  acid  deposits.  653 

calculus.  656 
Lithontriptics.  662 


1034 


IXDEX. 


Lithotomy,  670 

when  to  be  selected.  670 

causes  of  death  sifter.  679 

sources  of  difficulty  in,  675 

Key's  operation,  671 

median,  677 

bilateral,  678 

Buchanan's,  678 

recto-vesical.  678 

high  operation,  678 

in  female,  679 
Lithotomy  and  lithotrity  compared, 

663 
Lithotrity,  665 

when  to  be  selected,  665 

perineal,  677 
Littre's  operation,  56.'? 
Liver,  hydatids  in,  523 

ruptured.  486 
Lloyd's  (Jordan)   method    of  con- 
trolling hemorrhage,  1015 
Local  anaesthetics,  998 
Locked  jaw,  219 
Locomotor  atax}',  800 
Lodgment  of  balls,  977 
Loose,  cartilages,  942 

bodies  in  bnrsae,  806 
Lordosis,  243 

in  malformation  of  hip,  856 

in  hip  disea.-'e,  915 

in  rickets,  971 
Lower  jaw,  removal  of,  447 

tumors  of,  446 
Lumbar  abscess.  245 

colotomy,  51 1 
Lunatics,  fractures  in,  859 

fractured  ribs  in.  611 
Lungs,  condition  of.  in  apnoea,  618 
after  drowning,  618 

laceration  of.  615 

wounds  of,  612 

hernia  of,  615 
Lupus,  78 

of  nose,  589 
Lymphatics,  affections  of,  181 

wounds  of,  ISl 
Lymphoma.  149,  183 
Lyssi  in  hydrophobia,  106 


MACEWEN'S       operation       for 
knock-knee,  ^22 
Macintyre's  splint,  900 
Maeroglossia,  419 
Malformations,  Sll 

of  anus.  561 

of  ear,  322 

of  genitals,  710 

of  hip,  856 

of  kidnev,  631 

of  feet,  S"l2 
Malignant  pustule,  108 

tumors,  1.33,  153 
Mamma,  diseases  of,  764 

excision  of,  779 
Manipulation,  treatment  of  aneur- 
ism by,  371 

reduction  of  dislocation  of  hu- 
merus bv,  834 
of  hip,  846 
Marriage  after  syphilis.  118 
Masse,  "  reduction  en."  543 
Meatus,  external,  affections  of,  324 
Median  lithotomy,  677 
Medio-tarsal  disease.  918 
Medullary  cancer,  135 
Meibomian  glands,  obstruction  of, 

267 
Melanosis.  131 

of  eyeball,  320 
Membrana  tympani,  injury  to,  330 


Membrana  tympani — 

examination  of,  331 

perforation  of,  331 
Meningeal  artery,  rupture  of,  201 
Meningocele,  216 
Metatarsal       bones,       amputation 

through,  1019 
Microscopical  anatomy  of  tumors, 

145 
Milk  cysts,  775 
Mixed  calculus,  656 
Moles,  173 

Moliities  ossium.  970 
Molluscous  tumors  of  meatus,  328 
Moluscum  fibrosum,  127 
Mortification,  79 
Mosquito  bites,  101 
Mucous  cysts,  143 

of  lips,  415 
of  tongue,  143 
Mulberry  calculus,  657 
Multiple  herniae,  543 
Mumps,  418 

orchitis  in.  736 
Muscles,  injuries  of,  795 

tumors  of,  801 

vascular  tumors  of,  802 

rupture  of,  795 

compound  laceration  of,  796 

dislocation  of,  797 

degeneration  of,  801 
of  pectoral,  fill 

inflammation  of,  798 

of  sterno-mastoid,  799 

division  of.  SIO 

atrophy  of.  800 

rigid  atrophy  of,  823 

ossification  of,  S02 

hydatids  in,  801 

trichina  in,  801 
Mycetoma.  1 72 
Myeloid  tumor,  131,  966 
Mvoma,  127 
Mvopia.  262 
Myxoma,  132,  152 


Vf^VUS,  378 

W    degeneration  of. 


rS,  420 


of  scalp,  216 
Xails.  affections  of,  175,  177 
Nasal  douche,  335,  587 
Nasal  duct,  probing.  297 
Naso-pharvngeal  polypus,  592 
Neck  of  femur,  fracture  of.  885 

of  humerus,  fracture  of,  872 

of  scapula,  fracture  of,  872 
Necrosis,  957 

operation  for,  959 

of  jaws,  489 

of  stumps,  1025 

phosphorus.  44ii 

of  bones  of  skull.  218 

arrest  of  growth  in  bone  after, 
960 
Needles,  acupressure,  346 

aneurism.  382 

naevus,  380 

palate,  433 
N^laton's  probe,  9S1 

test  line  for  dislocation  of  hip, 
845 
Nephrectomv,  630 
Nephritis,  622 
Nephro-lithotomy.  629 
Nephrorraphj-,  631 
Nephrotomy,  629 
Nerves,  influence  of,  in  repair,  28 

repair  of.  30 

injuries  and  disease  of,  251 

wounds  of,  251 


'  Nerves — 

in  head  injuries,  199 
Nerve-stretching.  253 
Neuralgia.  253,  4r.6 
Neuritis,  optic,  289 
Neuroma,  253 
Nipples,  sore,  763 

chronic  eczema  of,  777 

retracted,  777 
Nitrous  oxide,  inhalation  of,  993 
Nodes,  956 
Noma,  756 
Nose,  affections  of,  586 

bleeding  from,  587 

dislocation    of    cartibges    of, 
587 

foreign  bodies  in,  590 

new  formation  of,  596 

fracture  of,  5^6 

obstructions  of,  790 

plugging  the,  588 

polypus  of,  591 

washing  out,  587 

wounds  of,  586 
Nuclear  cataract,  307 
Nystagmus,  272 


OBLIQUE  inguinal  hernia,  547 
Obstructed  hernia,  530 
Obstruction  of  intestine,  500 
Obturator  hernia.  554 
Obturator  foramen.  554 

dislocation  into,  844 
Occipital  artery,  ligature  of,  387 
Occluded  ears,  322 
Occlusion,  treatment  of  wounds  by, 

45 
Odontalgia,  464 
Odontoid  process,  displacement  of, 

239 
Odontomes.  441,  455 
(Edema  glottidis.  603 
(Esophageal  forceps,  481 

obstruction,  479 
(Esophagotomy.  482 
(Esophagus,  foreign  bodies  in,  481 

stricture  of,  480 

cancer  of,  479 
Ogston's  operation  for  knock-knee, 

822 
Oil  cysts,  145 
Olecranon  process,  fracture  of,  880 

bursa  over.  806 
Omental  sac  in  hernia,  527 

hernia,  strangulated,  532,  541 
Omentum,  protrusion  of,  493 

adhesions  of,  in    ovarian   dis- 
ease. 789 
Onychia,  175 

maligna.  175 
Open  treatment  of  wounds,  47 
Operative  interference  in  joint  dis- 
ease. 928 
Ophthalmia,  varieties  of,  268 

sympathetic,  282 
Ophthalmitis,  321 
Ophthalmoscope,  examination    by, 

256 
Opisthotonos.  220 
Optic  disc,  anomalies  of,  260 

nerve,  atrophy  of,  289 

neuritis,  289 
Orbit,  affections  of.  314 

inflammation  within.  315 

tumors  of,  319 

hemorrhage  into,  316 
Orchitis,  735 

chronic,  737 

gouty,  738 

syphilitic,  738 


iM)i:x. 


l();i5 


Orchitis— 

tubtTouliir.  740 
Oriciiiiil  Kort',  IT'i 
Orth<>i'U<lic  Mirncrv,  SI  I 
OtttvitiK  (lefuriniiii!'.  UT^t 
Osto.)  uitliriliH,  tlHi 
Ofli'ii  clnmilroiiia,  1»(56 
0^tl•^l  liiilllli'ill.  UTII 
Osteo-invclili",  U.)-' 

iit'liT  iiiii)iutiiiii>n.  1025 
Hl'tcr  nuiinlmt  injuries,  988 
0!<tiMi-siiri'"iiiii,  Olij 
0?tt<>.i.l  oiiiu'tT,  905 
Osteotomy,  090 

for  bii.lly-uiiitfcl  frncture,  863 
in  hip-joint  (license,  925 
in  ilot'oiniiiy  from  ricitets,  973 
in  knock-knee,  t*22 
Ostilis.  i».)0 

of  criinium,  217 
Otitis.  :i28 

me<liu,  XW) 
Ovarian  ovsfs.  ."ujijturiUing,  treat- 
ment of,  702 
Ovarian  iln>|>sy,  7S0 

(liaf^nosis  of,  7S1 
tapping;,  diagnostic  value 

of.  7S;{ 
pathology  of.  780 
statistics  of,  780 
tapjiing  in.  784 
treatment  of,  784 
Ovariotomy,  selection  of  cases,  787 
ojicration,  7S7 
adlioions  in,  780 
treatment  of  pedicle,  700 
on  sponging  out  (lelvis,  790 
treatment  of  wound,  791 
after-treatment,  701 
Oxalate  of  lime  as  gravel,  652 

as  calculus,  657 
Ozajua,  503 


PAliET'S  ilisease  of  nipple,  777 
Pain  in  inflammation,  t)4 

in  wounds,  23,  59 
Painful  subcutaneous  tumor,  254 
Palate,  cleft,  432 

tumors  of,  436 

wounds  of,  435 

ulcerations  of.  435 
Palmar  arch,  wounds  of,  593 
Panniis,  270 
Papillary  tumors,  130 

of  rectum,  578 
Paracentesis  abdominis,  362 

peru-ar^lii,  466 

thoracis,  616 

of  joints,  026 

in  ovarian  dropsy,  784 

of  cornea,  301 

of  kidney,  628 
Paralysis,  result  of  concussion,  205 

spinal,  232 

infantile,  800 

of  blad.ler,  643,  700 
Paraphimosis.  709 
Parasites,  17<J 
Parasitic  hivniaturia,  625 
Parotid,  inflammation  of,  418 

tumor  of,  418 
Patella,  dislocation  of,  848 

fracture  of,  805 

compound,  of,  897 

enlarged  bursa  over,  806 
Pathological  tubercle.  101 
Pectoral  muscle,  rupture  of,  611 
Pedicle   in   ovariotomv,    treatment 

of,  790 
Pelvic  joints,  diseases  of,  919 


Pelvi»,  fracture  of,  KK.'J 

urcthrni  laceration  in,  698, 

^h.■! 

ob»trucled  iliac  artery  in.  884 
Penetrating    wouniU    ol    abdnuien, 
491 

of  chest,  614 
of  cranium,  195,  206 
Penis,  amputation  of.  711 

malformalions  of,  7  10 

injuries  of,  7  I  I 

cancer  of,  7  10 

to  fasten  catheter  in,  687 

warts  on.  710 
Perforating  ulcer  of  foot,  171  ' 

of  palate,  435 

tumors  of  skull,  216 
Pericardium,  wounds  of,  338 
Perinieum,  rupture  of  female,  758 

operation  for,  758 
Perineal  abscess,  694 

hernia,  558 

fistula,  695 

section,  691 
Perinephritis,  624 
Periosteal  exostosis,  963 

cancer,  066 

flaps  in  amputation,  1006 
Periosteum,  acute  inflammation  of, 
952 

chronic,  955 
Periprostatic  abscess,  646 
Peritoneum,  inflammation  of,  485 

wounds  of,  491 
Peroneal  tendons,  dislocation  of,  797 
I'liagedicna,  76 

venereal,  721 
Phalangeal  joints,  diseases  of,  921 
dislocations  of,  842 
fracture  of,  882 
Pharyngeal  abscess,  246,  477,  605 

tumors,  605 
Pharynx,  aff'ections  of,  477 

foreign  bodies  in,  480 

wounds  of,  480 

tumors  of,  477,  592 
Phimosis,  709 

with  chancre,  720 
Phlebitis,  399 

and  pyicmia,  94 
Phlebolithes,  405 
Phlegmasia  doleus,  399 
Phlegmonous  erysipelas,  86 
Phosphatic  dejiosits,  653 

calculus,  650 
Phosphorus  disease  of  jaws,  440 
Phrenic  hernia,  558 
Phthiriasis,  266 
Pigeon-breast,  616 
Piles.  571 
Pinguiculye.  298 
Pirogoff's  amputation,  1023 

stump  after,  1023 
Pituitary  membrane,  thickening  of, 

592 
Pivoting  teeth,  470 
Plaster-of- Paris  splints,  864 
Plugging  nostrils.  588 
Pneumatic  occlusion  of  wounds,  52 
Pneumocele,  615 
Pneumothorax,  616 
Poisoned  wounds,  100 
Politzer's  nietho<l  of  inflating  tym- 
panum. 322 
Polypus  of  antrum,  444 

of  bladder,  637 

of  ear,  330 

of  nose.  590 

of  palate,  436 

of  vagina.  758 

of  rectum,  577 


Popliteal  artery,  ligation  of,  396 
Poiiition  of  lower  extremity  in  hip 

(liHeaiie,  013 
Pott'H  fracture,  H50 
Poultice,  ice,  156 
Prepuce,  operations  on,  708 

tumor  of,  7  1 1 
Presbyopia,  277 

Pressure  in  the  treatment  of  wounds, 
343 
to  Ktop  bleeding,  343 
in  cure  of  aneurism,  362 
Primary  or  epiick  union,  26 
how  to  help  it,  34 
Probang, 4K2 

Projectiles,  woumis  caused  by,  976 
I'rola])RU8  of  rectum,  57i» 
Proptosis  oculi,  1S4,  .''.15 
Prostate  gland,  affections  of,  645 
retention  in,  701 
inflammation    and    suppu- 
ration of,  615 
hypertrophy  of,  647 
calculi  of,  640 
cancer  of,  650 
Protection  of  wounds,  39 
Pruritus  ani,  57S 
Psoas  abscess,  246 
Psoriasis  of  nails,  177 
Pseudo-hypertrophic  j>aralysi?,  801 
Pterygium,  275,  207 
Ptosis,  295 

Pubes,  dislocation  of  hip  on,  844 
Pubic  symphysis,  disease  of,  910 
Pulleys  in  dislocation,  82S 
Pulmonary  embolism,  355 
Pulpy    degeneration    of     synovial 

membrane,  90'! 
Pulsatile  bone  tumors,  969 
Puncta  lachrymalia,  obstruction  of, 

295 
Puncture  of  bladder   from    rectum, 

703 
Punctured  wounds.  43 
Pupil,  artifleial,  3m5 
Purulent  ophthalmia,  270 

catarrh  of  ear,  333 
Pus,  67 

absorption  of,  68 
Pustule,  malignant,  108 
Puzzle  toy,  value  of,  in  dislocations, 

841 
Pyaemia.  91 

analyses  of  cases  of,  93 
post-mortem    appearances    in, 

93 
not  hospital  disease,  96 
arterial,  95 
Pyelitis,  622 
Pylorus,  excision  of,  520 


Q 


HILLED  suture,  36 
Quinsy,  437 


RABIE.S,  103 
Rachitic    afifections    of    bones, 
971 
Radial  artery,  ligation  of,  392 
Radical  cure  of  hernia,  549 

of  hydrocele,  728 
Radicular  odontonies.  456 
Radio-ulnar  joint,  disease  of.  921 
Radius,  dislocations  of,  840 
fractures  of,  880 

compound,  of,  882 
Ranula,  416 

Rattlesnake,  bites  of.  102 
Reaction  after  collapse,  25 
Rectal  alimentation,  584 


1036 


IXDEX. 


Rectal  dilator,  fi40 

Rectangular  staff  in  lithotomy,  678' 

Recto-vaginal  fistula,  Ttil 

Uectotou>_v,  linear,  5s2 

Rectum,  affections  of,  504 

how  to  examine  patient  in, 
565 

injuries  of,  564 

rupture  of,  564 

prolapse  of,  576 

stricture  of,  578,  580 

excision  of.  583 

foreign  bodies  in,  565 

malformations  of,  561 

painful  ulcer  of,  567 

abscess  of,  568 

polypus  of,  577 

dilatation  of,  584 
Recurrent  growths,  130 
Redness  in  inflammation,  64 
Reduction  of  dislocations,  823 

of  hernia,  535 
Refraction,  261 
Re-fracture  of  bone,  869 
Regeneration  of  nerve,  30 
Relaxed  uvula,  436 
Renal  surgery,  628 

calculus,  627 

removal  of,  629 

hematuria,  625 
Repair  of  wounds,  27 

causes  of  failure  in,  30 

of  subcutaneous  wounds,  57 

of  wounded  arteries,  340 

of  fractures,  867 
Reporting  eases,  headings  for,  21 
Resection  of  joints,  'J'2S 

of  false  joints,  869 
Resolution  of  inflaminution,  66 
Respiration,  artificial,  619 
Rest  in  treatment  of  aneurism,  359 

in  ununited  fracture,  868 
Retained  testis.  749 
Retention  of  urine,  700.  702 
hysterical.  643 
from  adherent  prepuce,  701 
from    cicatricial    stricture, 
702 
Retina,  hypersemia  of,  2S6 

atrophy  of.  288 

embolism  of,  287 

displacement  of,  288 
Retinitis,  286 
Retraction  of  nii)ple,  777 
Rheumatic  arthritis,  946 

iritis,  279 
Rheumatism,  gonorrhoea!,  717 
Rhinoplasty,  596 
Rhinoscopy,  589 
Ribs,  fracture  of.  611 

dislocation  of,  614 
Richardson's  sprav-producer,  999 
Rickets.  971 

acute.  973 

operative  treatment  in,  973 
Rider's  bone.  802 
Rifle-ball  wounds,  976 
Rigg's  disease,  473 
Rodent  ulcer,  137 
Roussel's    method    of    transfusion, 

350 
Roux's  amputation,  1023 
Rudimentary  fingers  and  toes,  812 
Rupia.  syphilitic,   1 10 
Rupture,  abdominal,  525 

of  abdominal  viscera,  483 

of  aneurism,  373 

of  artery,  341 

of  bladder,  489 

of  eyeball,  313 

of  muscle,  795 


Rupture — 

of  rectum,  564 
of  urethra,  698 


SAC,  aneurismal,  357 
suppuration  of,  370 
hernial,  526 
omental,  527 

kelotomy  external  to,  538 
Sacculated  bladder,  634 
Sacral  tumors,  231 
Sacro-coccvgeal    joint,    disease   of, 

919" 
Sacro-iliac  joint  disease,  919 
.Salivary  calculus,  417,  474 

fistula,  417 
Salter's  swing,  900 
Sarcoma,  13(1 

melanotic,  131,  511 
Sayre's  jacket,  248 
Scab,  union  under,  29 
Scalds,  157 

of  the  glottis,  603 
Scalp,  affections  of,  216 
contusion  of.  189 
wounds  of,  190 
sebaceous  cysts  of,  144 
Scapula,  dislocation  of,  832 
fracture  of,  872 

of  neck  of,  872 
Sciatic    notch,    dislocation    of    hip 
into,  844 

hernia  through,  558 
Scirrhus,  134 

Scissors  for  skin-grafting,  164 
Sclerosis  of  bone,  951 
Sclerotic,  inflamed,  276 

injuries  of,  276 
Sclerotomy.  303 
Scorbutic  ulcers,  77 
Scoop  extraction.  311 
Scrofula.  20 

Scrotal  tumors,  diagnosis  of,  748 
Scrotum,  affections  of,  752 
cancer  of,  753 
injuries  of.  752 
tumors  of,  752 
elephantiasis  of,  752 
Scurv}',  77 
Sebaceous  cysts,  144 
on  head. 145 
fungating.  141 
sublingual,  416 
.Second  intention,  healing  by,  28 
Secondary  adhesion,  29 

treatment  for,  45 
Semi-lunar  cartilages  of  knee,  sub- 
luxation of,  850 
Seminal  duct,  inflammation  of,  733 

obstruction  of,  733 
Senile  cataract,  307 
gangrene,  80 

amputation  in,  82 
Separation  of  epiphysis   of  femur, 
849,  873,  890  " 
of  humerus,  840  . 
of  clavicle,  832 
of  radius,  877 
Sef)ticjemia,  91 

Septum  of  nose,  malformations  of, 
592 

injuries  of,  587 
diseases  of,  592 
Sequestrum,  removal  of,  959 
Sero-cystic  disease  of  breast,  773 

of  testicle,  742 
Serous  cysts,  142 
Serpents'  bites,  102 
,  ."Serpiginous  chancre,  118 
I  Seton  in  temple,  291 


staphy- 


Setting  fractures,  862 
Sexual  hypochondriasis,  754 
Sharp-hook  extraction,  311 
Shock  and  collapse.  25,  224 

operations  during.  226 
after  gunshot  injuries,  97!: 
Shoulder,  amputation  at,  lUlO 

dislocations  at,  832 

excision  of,  938 

diseases  of,  920,  938 
Sickness,  chloroform,  995 
Silkworm-gut  for  sutures,  37 
Sinus,  71 
Skin,  formation  of  new,  27 

transplantation  of.  164 
SliuU.  contusion  of.  192 

fissure  of,  192 

fracture  of.  192 

incomplete  fracture  of.  853 

gunshot  wounds  of,  982 

perforating  tumors  of,  216 
.Sloughing  phagedasna,  76,  79 

chancre.  720 
Smith's  (Xathan)  wire  splint.  901 
Smith's  (Thomas)  gag  for 

lorraphy,  432 
Snake  bites.  102 
Smifflcs.  45,  590 
Soft  cntaract,  307 

chancre,  718 
Softening  of  bone  (mollities),  970 
Solution  of  cataract.  308 
Solvents  for  stone.  663 
Soot  cancer,  137,  753 
Sores,  varieties  of,  73 

healing,  74 

indolent,  75 

inflamed,  76 
Sore  throat,  syphilitic,  1 11 

sloughiug.  11 1 
Sounding  for  stone,  660 
Spasmodic  retention.  699 
Spastic  contractions,  814 
Speculum,  ear,  324 

rectal,  567 

laryngeal,  605 

urethral,  female,  763 

vaginnl.  761 
Speir's  artery  constrictor,  348 
Spent  balls.  977 
Spermatic  cord,  hydrocele  of,  725 

yaricocele  of,  750 
Spermatocele,  728 
Spermatorrhoea,  754 
Spermatozoa  in  encysted  hydrocele, 

729 
Sphacelus,  79 

Sphincter  ani,  spasm  of,  568 
Spica  bandage,  542 
Spina  bifida,' 229 

tumors  simulating,  229 
Spinal  abscess.  246 

instruments,  248 

cord,  wounds  of.  242 
Spine,  concussion  of,  232 

diseases  of,  245 

fracture  and  dislocation  of,  237 

curvature  of.  243 

railway  injuries  of.  234 
Spleen,  rupture  of.  486 
Splints  in  treatment  of  wounds,  37. 
862 

immovable,  865 

for  hip  disease,  923 

for  disease  of  knee,  927     . 

double  thigh.  889 

for  excision  of  elbow,  940 
of  knee.  936 
Sponge,  grafting.  167 

how  to  prepare  and  clean,  1026 
Spontaneous  cure  of  aneurism,  359 


iMn:x. 


lo.j? 


Spraii)!*  of  biiok.  213 

of  joiulf,  H'.'.') 
K(juiii(,  o|)oniti"iii!i  for,  21)5) 
Stnfl'  lilliotoiiiv.  07 1 
Stu|ih,vli>inik.  :III2 

I'ciiiiiviil  of,  275 
Slii|>hvl»rru|.li.v.  4Xi 
Stiirclifil  lminlil>co.  SCI 
Stiitio  or  \  CM10II-'  (fiiiiuiTiu'.  SI 
:^tntix(ic!<  of  iuii|iiitiilioiiH.  |002 

uf  )<iibfliiviiin  iiiM-ui'iniM,  ,'{88 

of  coiniiioii  enrol  ill,  .'18.') 

of  torsion.  .'US,  1003 

of  ncorosis  of  jiiw,  481i 

of  caii!<cH  of  inle^'tinui  obstnio- 
tion,  .'.(t| 

of  iinsi!  nlisoesH,  ii'iS 

of  exostosii'.  i)(il 

of  burns,  |.'>".l 

of  out  thront,  .'lilS 

of  artiliriiil  anus  after  hornin, 
J.'U 

after  i-olotoin  v.  .'>!  I 

of  frnctuivil  skull,  I'.Ml 

of  fatal  eases  of  pvii'uiia,  93 

of  |)vu'iiiia,  ()(> 

of  spinal  injuries',  239 

of  sjiiun  biliiln,  2-'<>^ 

of  fractureil  ribs,  till 

of  nc|ilire('toiiiv,  li.'ll 

of  epiiliilyinitis,  7.".4 

of  stricture,  (')S3,  fiS.i 

of  tetanus,  211) 

of  abiloiiiinal  injuries,  485 

of  hernia,  .T2t').  .").')'.t 

of  ftrieture  of  rectum,  581 

of  stone,  659 

of  lithotomy,  fi70,  fi"! 

of  retention  of  urine,  699,  702 

of  hyilrocele,  72.') 

of  cancer  of  testicles,  744 

of  ovilrian  disease,  780 

of  abscess  of  breast,  7fi4 

of  cancer  of  breast,  773 

of  adenoma.  769 

of  fracture.  861,  S85 

of  clislocations,  S2(i 

of  dislocation  of  humerus,  832 
of  head  of  femur,  843 

of  fracture  of  neck  of   femur, 
88.=),  887 

of  fracture  of  shaft.  891 

of  fractures  of  le-;.  898 

of  excision  of   heail  of   femur, 
930 

of  excision  of  knee,  934 

of  wounded   from   gunshot  in- 
juries, 976 

of  disease  of  knee,  917 

of  hip  disease,  912 

of  excision  of  hip.  930 

of  amputation  at  thi^h,  1015 
at  knee-joint,  101  0 
at  knee,  934 

of  ."Lyme's  amputation,  1022 
Steatoma,  126 
Sterility,  753 

Sterno-clavieular  joint,  diseases  of, 
920 

dislocation  of,  830 
Sterno-mastoid  muscle,  contraction 
of.  824 

induration  of,  798 
division  of,  824 
Sternum,  dislocation    and   fracture 

of,  614 
Stings,  insect,  102 
Stomach,  foreign  bodies  in,  497 

rupture  of,  487 

opening  the,  498 
Stomatitis,  415 


Stuno  in  Maildir.  t>5.'i,  66(1 
ill.  lr<M|Mcni'y,  659 
in  kidney,  627 
in  urethra.  OSJ,  70j 
in  women,  67'.' 
Stopping  teeth,  468 
.'^trubifmuH,  298 

operation  for.  299 
.Strangulated  hernia,  .').'! I 

inechunicm  .of,  ,^3I 
omental,  532 
treatment  of,  535 
.Strangulation,  internal.  501 

of  ovarian  tumor.  792 
.•stricture  and  rctenlion.  701) 
.•stricture  of  urethru,  lis;', 
results  of,  (is.) 
inflammatory,  700 
spasmodic,  700 
its  eomj)lications.  694 
traumatic     or    cicatricial, 

698 
treatment  of,  686 
summary  of.  686 
causes    of    death    in,    686, 
697 
of  intestine  after  hernia,  535 
of  cesophagu.s,  479 
of  rectum,  578,  580 
Stronieyer's  cushion,  882 
Stumps,  affections  of,  1024 
dressing  of,  1007 
conical,  1024 
bursie  over,  1025 
necrosis  of,  1025 
painful,  1024    ' 
Styes.  267 
Styptics,  348 
Subastragaloid  amputation,  1021 

<lislocati<m.  8.^)3 
Subclavian  aneurism,  387 

artery,  ligation  of,  389 
Subclavicular  dislocation  of  shoul- 
der, 831 
.Subcoracoiil    dislocation    of   shoul- 
!  der,  832 

Subcutaneous  contused  wounds,  42 
I  wounds,  56 

I  operations,  57 

treatment  of,  58 
!  haemorrhage.  341 

!  ligation  of  n;evus,  379 

.Subdiaphragmatic  abscess,  486 
Subglenoid  dislocation  of  shoulder, 
I  833 

.Sublingual  cysts,  416 
.'Submammary  abscess.  766 
I  Subpectoral  abscess.  616 
I  Subspinous  dislocation  of  shoulder, 
I  833 

I  Suction,    removal    of    cataract    bv, 
'  311 

'  Sulphuric  acid,  treatment  of  disease 

of  bone  by.  962 
j  .Supplemental  teeth.  458 


^•'I'l' 


)f  urine,  626 


."Suppuration,  66 

Supracondvloid       amputation       of 

thigh.   1016 
Suprapubic   puncture    of    bladder, 

705 
Surgical  cases,  how  to  investigate, 

21 
Suspensory  bandage,  735 

Morgan's.  751 
Sutures,  materials  for,  36 
button,  36 
harelip,  411 
dcef),  35 
continuous,  35 
interrupted,  35 


Suture* — 

<{uillei|,  35 

twihled,  '.'tj 

of  inteiitine,  37,  494 
Swelling  in  inlluaimation,  61 
."^ymblepharon,  21)4 
Kyme'x  amputation  of  foot,  1022 

operation  for  iineurii<iii,  371 
for  i<tricture,  6h9 
Sympathetic  oplithnlinia,  282 
.SymphysiH  pubi^,  diiiea»eH  uf,  919 
Syncope,  34.'» 
Synostofiix  of  hip,  916 
Synovial  cyKlf.  Xo* 

membrane,  (tiacares  of,  906 
Syphili.-".  los 

ui'ijuired,   1  Id 

sore  throat  in.  1  I  I 

afTections  of  tongue  in.  Ill,  425 

aflections  of  bone  in.  1 12 

|)athology  of,  112.  718 

treatment  of,  1 13 

hereclitary,    115 

teeth  in,  1 17 

serpiginous  ulceration  in.  117 

marriage  after.  1 18 

inoculaticin  in,  1 18 
Syphilitic  disease  of  rectum,  579 

of  iris,  279 

of  testicle,  738 

of  larynx,  114 

sores,  73,  77 

teeth,  458 
Syphilization,  119 
Syringing  ear,  326 


TAdlJACOTIAX  operations,  596 
Talipes,  different  forms  of,  814 
their  treatment,  816 
Tapping  abdomen,  521 

ovarian  cysts,  784 

h3'drocele,  726 

intestines.  520 

chest.  618 

hydatid,  523 

knee,  926 
Tarsal  cartilage,  tumors  of,  292 

cysts,  292 
Tarsus,  operations  on,  1017 

diseases  of.  918 

dislocations  of,  853 
Taxis,  536 

where  inadmissible,  536 
Teale's  amputation,  lOOS 

probe  gorget,  690 
Tear  passage,  operations  on.  296 
Teeth,  cvsts  containing,   443,  457, 
462 

syphilitic.  117 

diseases  of.  44."!.  467 

cutting  of.  460 

affections  of  pulp.  471 

of     alveolo-dental     mem- 
brane. 472 

local  dental  periostitis,  473 

fracture  of,  471 

supernumcr.ary,  458 

su|)pleniental.  458 

malformed,  458 

irregularity  of,  461 

impaction  of,  463 

absence  of,  463 

extraction  of,  475 
Temperature  in  inflammation,  65 

in  traumatic  fever.  25.  91 

in  spinal  injury,  234 
Temporal  artery,  ligation  of.  387 
Temporo-maxillary        articulation, 
diseases  of,  234 
dislocation  of,  449 


1038 


INDEX. 


TenJo    Achillis,    division    of,    798, 
818 

rupture  of,  797 
Tendons,  inflammation  of,  798,  803 

rupture  of,  797 

wounds  of,  798 

tumors  of,  808 

repair  of,  after  division,  81fi 

dislocation  of,  797 
Tenotomy,  817 

in  contracted  joints,  822 

in  fracture,  862,  894,  900 
Testicle,  its  development,  732 

malposition  of,  749 

disease  of,  732 

inflammation  of,  732 
acute,  735 
chronic,  736 

syphilitic,  738 

gouty,  738 

tubercular  disease,  740 

hernia,  741 

cystic  disease  of,  742 

cancer  of,  744 

excision  of,  749 

strapping.  749 
Tetanus.  219 

infantile,  219 

patb.dogy  of,  221 

statistics  of,  219 
Thecal  abscess,  804 
Thermograph  of  ervsipelas,  86 

of  traumatic  fever,  92 

of  enterotomy,  509 
Thigh,  amputation  of,  1015 
statistics  of,  1015 

fracture  of,  885 

compound,  895 
Thomas'  splints  for  knee,  926 

for  hip,  923 
Thorax,  injuries  of,  fill 

tapping.  61  6 

abscesses  al)out,  616 
Throat,  wounds  of,  598 
Thrombosis,  400 
Thumb,  dislocations  of,  798 

compound  fracture  of,  883 

amputation  of,  1012 

excision  of  joints  of,  942 
Thyroid,  cysts  of,  142,  186 

diseases  of,  185 

extirpation  of,  188 
Thyroid  foramen,  dislocation   into, 

884 
Tibia,  dislocation  of,  849 

fracture  of.  898 

V-shaped  fracture  of,  899 

arrest  of  growth  after,  898 
Tibial  artery,  anterior,  ligation  of, 
397 

posterior,  ligation  of,  396 
Tic  doloureux,  252 
Tinea  tarsi,  267 
Toe-nail,  ingrown,  175  ! 

horny.  1  77 
Toes,  amputation  of,  1024  I 

Tongue,    congenital    afiFections    of, 
419.  421 

diseases  of,  419 

hypertrophy  of,  419 

inflammation  of,  423 

extirpation  of,  430 

wounds  of,  419 

ulcers  of,  424 
cancers  of,  427 
ichthyosis  of,  421 
Tongue-tie.  418 
Tonsil,  disease  of,  437 
cancer  of.  488 
excision  of.  488 
Tooth,  development  of,  453 


Toothache,  464 
Tooth  cysts,  443,  457,  463 
tumors,  444 
wounds,  44 
Torsion  on  arteries,  effects  of,  342 
mode  of  doing  it,  347 
statistics  of,  348,  1003 
Torticollis.  824 
Tourniquet,  345 
Towne's  stereoscopic  test  for  retina, 

266 
Trachea,  foreign  bodies  in,  600 

wounds  of,  598 

subcutaneous  division  of,  598 
Tracheal  aspirator,  609 
Tracheotomy,  607 

its  complications,  60S 

for  disease  of  larynx.  604 

for  foreign  bodies,  601 

tubes,  608 

in  tetanus,  222 
Transfusion,  350 
Transplantation  of  skin,  164 
Traumatic  aneurism,  373 

delirium,  222 

fever,  26,  91 

gangrene,  80,  81 

stricture,  696 
Trendelenburg's    tracheal    tampon, 

436 
Trephining  skull,  212 

spine.  241 

long  bones,  954 
Trichiasis,  292 
Trichiniasis,  801 
Tripier's  amputations  of  the  font. 

1020 
Trismus  infantum,  219 
Troclianter,    fracture    of  epiphysis 

of,  825 
Trusses.  558 

fur  irreducible  hernia,  529 

to  measure  for,  560 
Tubercle,  20 

mucous,  111 
Tumors.  120 

innocent,  125 

semi-malignant,  130 

cancerous,  132 

sebaceous,  of  scalp,  144 

follicular,  141 

perforating,  of  skull,  216 

congenital,  of  sacrum,  231 

painful  subcutaneous,  254 

of  jaws.  442 

cystic,  142 

fatty,  126 

fibromata,  126 

myxoma,  132,  151 

fibrous,  127 

cartilaginous,  128,  965 

osseous,  129 

myeloid,  131 

glandular  or  .adenoid,  129 

pa]iillary,  130 

recurrent,  130 

sarcomata,  130 

melanotic,  131 

hard,  134 

soft,  135 

rodent  ulcer,  137 

colloid  cancer,  138 

villous,  138 

granulation,  141 

])ulsatile,  969 

cancerous,  132 

diagnosis  of,  132 

epithelioma.  136 

osteoma.  147 

sarcoma,  150 

adenoma,  148 


Tumors — 

carcinoma,  151 

lymphoma,  149 

colloid,  138 

thyroidal,  184 

microscopical  anatomy  of,  145 

of  bladder.  637 

of  bone.  962 

their  diagnosis,  969 
their  enucleation,  968 
exostosis.  963 
ungual,  177.  963 
cartilaginous,  965 
osteo-sarcoma    and    chon- 
droma, 965 
myeloid,  966 
cancers  of,  966 
epithelial,  of,  967 
]>ulsatile,  969 
hydatid,  969 
Tunica     vaginalis,    hydrocele     of, 

722 
Twisted  suture.  35 
Tymj)anuui,  inflating.  322 


ULCERATION,  73 
of  rectum,  566 
Ulcers,  73 

of  cornea,  275 
Ulna,  dislocation  of,  837 

fractures  of,  880 
Ulnar  artery,  ligation  of,  392 

nerve,  injuries  to.  251 
Umbilical  hernia,  556 
Umbilicus,  tumors  of.  523 
Ungual  exostosis,  177,  963 
Union  of  wounds,  26 

of  broken  bones,  867 

of  divided  tendons,  798.  815 
Unreduced  dislocations,  828 
Ununited  fractures.  868 
Up])er  jaw,  removal  of,  445 
Uraclius,  open,  523 
Urates  as  dejiosits,  653 
Ureter,  injuries  of,  489 

stone  in,  627 
Urethra,  ruptured,  698 

with    fracture    of    pelvis, 
883 

obstruction  of,  682 

stricture  of,  682 

calculus  in,  682,  705 

inflammation  of,  714 

aftections  of  female.  763 

tapping  in  perinivum,  691 
Urethrotomy,  internal,  689 

external.  689 
Urinary  abscess,  694 

fistula.  695 

deposits,  652 
Urine,  albuuiinous,  652 

healthy,  652 

deposits  in.  653 

blood  in,  624,  638 

incontinence  of.  644 

overflow  of,  644 

retention  of,  699 

suppression  of,  626 

extravasation  of,  695 
Uterus,  extirpation  of,  793 

prolapse  of,  761! 
Uvula,  elongation  of,  436 


■y'-SHAPED  fracture  of  tibia,  899 
V       Vaccinators,  instructions    for, 

119 
Vaceino-syphilis,  119 
Vagina,  foreign  bodies  in.  756 
malformations  of,  758 


iM>/:\'. 


mvj 


Xng'uia — 

injiiricd  of,  750 
Vu>;iiiiil     fistulii*.     o|ioratioo.4     for, 
700 

C.VKtoCl-lf.  oti-..  7iiii 

litlio'iiiuv,  f.si 
Villous,  SI  j 
Valnulva'.s  treatment  of  ancuri.^iii, 

;i(i2 
Vnricooele,  75(1 
Varicose  uiu-uri^'iu,  'Mb 

uloer,  7(\ 

voiii.s,  403 
Vuri.\,  lo:{ 

uiioiirisiiiikl,  .S75 
Vaooular  kerutiti*.  273 

lirutru.^ion  of  eyebull,  184,  316 

tumor.  37'.' 

of  gum.'<,  47;') 
Vault  of  skull,  fracture  of.  11*2 
Vein*,  wouuils  of.  3H8 

inj«-ction  into.  3.'>0 

iDJuries  iind  ilisea?es  of,  39S 

operation?  on.  40i5 

licmorrhage  from.  ."•JO 

entrance  of  air  into,  402 

varicose.  4(13 
Velum  palati,  woun'ls  of.  435 
Venereal  diseases,  local,  714 
Venesection,  operation  of,  4lt7 

in  chest  injuries.  fil3 

in  head  injuries,  208 
Venous  or  static  ganjjrene.  SI 
Ventral  hernia.  557 
Veruca.  173 

nei-rogenica.  101 
Vertical   extension   in    fracture    of 

thi^'h.  S'.t3 
Vesical  hemorrhage,  625 
Vesico-intestinal  fistula.  514,  643 
Vesico-prostatio  calculus,  64t> 
Vesico-vaginal  fistula,  760 
Vienna  paste.  141 
Villous  growths.  130 

of  bladder.  637 
of  rectum.  577 


Viscera,  ahdominal,  protrusion  of, 

rx.i 

rupture  ol,  4H6 

woumls  of.  494 
Vision,  field  of.  265 

anoinalieH  of,  2H6 
Vitreous  humor,  ufTectiuns  of,  2.S3 
Vol\  ulu...  500 
Vulva,  injuries  of,  756 
Vulvitis,  757 


AVAKDIIOP.S       operation       for 
\  1       aneurism,  369 
Wurts,  173 

anal,  578 

venereal,  173,  710 
Water  dri'ssing.  49 
Wax  in  ear,  326 
Weak  sores,  75 
Webbed  fingers  and  toes,  812 
Weight,  extension  by,  892 

jiressure  by,  363 
Wens,  144 
Wheelhouse's   operation    for    stric-' 

ture,  690 
Wincl|»ipe.  foreign  bodies  in,  600 
Women,  surgical  diseases  of  geni- 
tals in,  756 

stone  in,  679 
Wounds.  23 

local  effects  of,  24 

constitutional  effects  of,  25 

adhesion  in  primary,  26 

secondary,  29 

alcoholic  dressing  of,  51 

antiseptic  irrigation  of,  52 

arrest  of  bleeding  in,  30 

arrow.  156 

cicatrization  of.  27 

granulation  of,  23 

dressing  of.  32 

second  dressing  of.  39 

complications  of,  59 

coaptation  of.  35 

contused,  31,  41 


Woiindu — 

inciocd,  23 

treatment  of,  32 

laceruled,  31,  4  1 

ojien,  12 

treatment  of,  42,  44 

poisoned.  100 

punctured,  43 

rubcutuneouK,  56 

tooth.  44 

repair  in,  26 

by  primary   or   Kccondary  ad- 
hesion, 33 

non-repair  in,  30 

hemorrhage  in,  30 
treatment  of,  32 
six   cardinal  points   to  be 
ob-erved  in.  33 

Bpecial  treatment  of,  45 
by  occlusion,  45 
open  method,  47 
by  water  dressing,  48 
ilry  dressing.  50 
earth  dressing.  51 
alcoholic  dressing.  51 
by  jineumatic  occlusion,  52 
antis<'ptic  irrigation.  52 
Listerian  method.  53 

of  scalp,  19(1 

of  nerves.  251 
Wrist,  amputation  at.  1012 

dislocation  at.  840 

suppuration    and   excision    of, 
941 

diseases  of,  921 
Writer's  cramp,  801 
Wrv-neck,  824 


XANTHELASMA  of  lids,  292 
Xanthic  oxide  calculus,  658 


Z'^ 


INC,  chloride  of,  paste,  140 


THE   END. 


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12IUO.  volume  of  5<>1  pages,  with  229  illustrations.  Cloth, 
$2.00.    See  Sliidtiitx'  Sfrits  of  Manuals,  page  1. 

ROBERTSON'S  Physiological  Physics.  In  one  12mo. vol- 
ume of  .i;{7  pages,  with  21!)  illustrations.  Cloth,  ?2.00.  See 
Students'  Series  of  Manuals,  page  1. 

DRAPER'S  Medical  Phvsics.  In  one  octavo  volume  of 
73^1  pages,  with  37<)  illustrations.    Cloth,  HW. 

C  A  R  P  E  NT  ER'S  Principles  of  Human  Physiology.  Eighth 
edition.    Octavo. 

DALTON'S  Circulation  of  the  Blood.  In  one  12mo.  vol- 
ume of  293  pages.    Cloth,  ?2.00. 

LEH.M  ANN'S  Manual  of  Chemical  Physiology.  Clotb,t2.25. 


CH  EM  ISTRY— continued. 

ATTI<'li:i-l>'S  I  licnilslry,(i(ii(ral.  .Mcdl.al  and  PhamUk 
cciitlcal ;  iiichidiiig  the  (  liciiilsirv  of  the  I',  .s.  I'liarmoco- 
pd'la.  A  Manual  of  the  •  Iciicral  i'rlnclplci  (,f  ilic  .-Mlcnce, 
and  their  Apiillcatlon  to  .Medicine  and  l'hariiia(\ .  Twelfth 
edition,  specially  revised  by  the  Author  for  Aiiierliui.  In 
one  very  handsome  I2iii(i.  volume  of  771  pugen,  with  88 
Illustrations.    <:loth,  ?2.7.'.;  leatlier,  ^3.2.1. 


CHEMISTRY. 

BLOXAM'S  Chemistry.  Inorganic  and  Organic.  New 
American  from  the  flfth  London  e<lition.  In  one  very 
handsome  octavo  volume  of  727  pages.with  292  illustrations. 
Cloth,  $2,110;  leather,  $;{.00. 

FOWNES'  Manual  of  Chemistry;  Theoretical  and  Prac- 
tical; Inorganic  and  Organic.  A  new  American  edition. 
In  one  large  royal  12mo.  volume  of  1061  pages,  with  a 
colored  plate,  and  168  illustrations  on  wood.  Cloth,  $2.75; 
leather,  $:3.2o. 


I10FI'\>IANN  Jk  POWER'S  Chemical  Analysis,  as  Ap- 
plied to  till!  Kxaminalion  of  Medicinal  I 'hemlcalsand  their 
Preparations.  Third  edition,  tlioroiiphly  rewritten.  In 
one  octavo  volume  of  ii2I  pages,  with  179  illustrationB. 
Cloth,  $1.2;. 

RE.^ISICN'S  Theoretical  Chemistry.  With  special  reference 
to  the  ( 'onstitution  of  Chemical  Compounds.  New  c.id)  edi- 
tion, tlioroughlv  revised  and  rewritten.  In  one  12iuo.  vol- 
ume of  3lli  pages.    Cloth,  $2.(J0. 

SI.MON'S  JIanual  of  Chemistry.  New  (2d)  edition.  In  one 
«vo.  volume  of  47h  pages,  with  44  engravings  and  7  col- 
ored plates  of  deposits.    Cloth,  $:5.25. 

CIIARIiE.S'  Physiolotjical  and  Pathological  Chemistry. 
In  one  svo.  volume  of  If^i  pages,  with  3»  Illustrations  and 
1  colored  plate.    Cloth,  .«:t.50. 

FRANKIjAND  «fc  JAPP'.S  Inorganic  Chemistry.  In 
one  Hvo.  volume  of  677  pages,  with  51  illustrations  and  a 
colored  plate.    Cloth,  $:i.75;  leather,  $1.7.5. 

CliOWE.S'  p;iomentary  Treatise  on  Practical  Chemistry 
and  (iualitative  Inorganic  Analysis.  S|)ecially  adapted  for 
Use  in  the  I^aboratories  of  .schools  and  Colleges  and  by 
Beginners.  New  .Vmericaii  from  the  fourth  and  revised 
Knglisli  edition.  In  one  verv  handsome  royal  12mo.  vol- 
ume of  :!.'<7  pages,  with  .>5  illust.    Cloth,  $2..50. 

Cf/AS.silN'S  Kleinentary  Quantitative  Analysis.  Trans- 
liited  Willi  Additions,  by  Kdoak  I".  Smith,  A.M.,  Ph.D. 
In  one  liaiidsoiiie  roval  12mo.  volume  of  324  pages,  with 
illusti-Litioiw.     Clolh,  >-J.iX). 

RAI.KIO'S  Clinical  Chemistry.  In  one  12mo.  volume  of  314 
pages.with  Hi  illustrations.  Cloth,  $1..J0.  See  StudetiW 
-Vc/'iV.s  uf  Manuals,  page  1. 

GREENE'.S  Manual  of  Medical  Chemistry.  In  one  12mo. 
volume  of  310  pages,  with  74  illustrations.    Clolh,  $1.75. 

WOIILER  «fc  FITTICi'S  Outlines  of  Organic  Chemistry. 
Translated,  with  Additions,  from  the  eighth  fierman  eai- 
tion,  by  Iha  Bkmskn,  M.  i)..  Ph.  1).  In  one  handsome  royal 
12mo.  Volume  of  550  pages.    Cloth,  $3.00. 


DICTIONARIES. 

THE  NATIONAIj  Medical  Dictionary.  Including  in  one 
alphabet  all  current  medical  terms  in  Englisti,  French, 
German,  Italian  and  Latin,  with  definition,  pronunciation, 
accentuation  and  svnon\  lus.  and  a  series  ot  tables  of  useful 
data.  By  John  .sI  Bii.i.im^-^,  M.  D.,  LL.  D.,  I>.  C.  L  In 
two  very  handsome  royal  octavo  volumes  containing  1.574 
pages.  Per  volume,  clotli,  $<i.00;  leiither,  $7.00;  halt 
Morocco,  $8  50.  For  sale  by  subscription  only.  Specimen 
pages  on  application.    Address  the  publisher?. 

DUNGIilSON'S  Medical  Lexicon;  A  Dictionary  of  Medi- 
cal Science;  Containing  a  Concise  Kxplanation  of  the  vari- 
ous Subject  sand  Terms  of  Anatomy,  Physiology,  Pathology, 
Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Sur- 
gery, Obstetrics,  :Medi(!il  .lurisiirudence,  and  Deutistrj-; 
Notices  of  Climate  and  of  Mineral  Waters;  Formula;  for 
OlKcinal,  Empirical  and  Dietetic  Preparations;  with  the 
Accentuation  and  Etymology  of  the  Terms,  and  the  French 
and  other  Synonymes— so  ius"to  constitute  a  French  as  well 
as  an  English  Jledical  Lexicon.  By  Kobley  Duxglisox, 
M.  D.  A  new  edition,  thoroughly  revised,  and  very  greatly 
modified  and  augmented.  By  Rk.uaro  J.  Dl-xglison, 
M.  D.  In  one  very  large  and  handsome  royal  octavo  vol- 
ume of  Ii:!lt  pages.     Cloth,  $'i.50 ;  leather,  raised  bands,  $7..50. 

OOBLYN'S  Dictionary  of  the  Terms  used  in  Medicine  and 
the  L'ollateral  Sciences.  Revised, with  numerous  Additions, 
by  I.saac  Hays,  M.  D.  In  one  large  royal  12mo.  volume  or 
520  double-columned  pages.    Cloth,  $1.50;  leather,  $2.00. 


MANUALS. 

STUDENTS'  Series  of  Manuals.  A  series  of  manuals 
by  eminent  teachers  or  examiners.  Pocket-size  12mos.  of 
300--540  pages,  richly  illustrated.  The  following  are  now 
ready  :  Trkvks'  Maxlai.  of  Si'rgerv,  in  three  volumes, 
each,  $2;  Klkix's  Histology  (4th  Ed.  1,  $1.75;  Pkpfer'sj 
Surgical  Patuology,  $2;  Treve.s'  Surgical  Applied 
Anato.my,  $J;  Power's  IIcman  Physiology  (2d  Ed.), 
S1..50;  Kalkks  Clixical  Che>iistry,  $1.5o;  Clarke  & 
Lockwood's  DiasKCTORs"  MAXfAL,  $1.T<»;  Bruce's  Mate- 
ria Medica  axd  TiiEKAPKL'Ticsyth  Ed.),$1.50;  Robert- 
sox's  Physiological  Physics,  $2;  Gould's  Subgical 
DiAGXosis,  $2:  and  Bell's  Comparative  Physiology 
yvxD  Anatomy,  $2.  Pkpper's  Forensic  Medicixk 
(shortli/i.     For  separate  notices  see  various  subject-heads. 

HARTS^OI^NE'S  Conspectus  of  the  Medical  .Sciences; 
containing  Handbooks  on  Anatomy,  Physiology,  Chem- 
istry, Materia  Medica.  Practical  Medicine,  Surgerv  and 
Obs"tetrics.  In  one  large  royal  12ino.  volume  of  1028  closely- 
printed  pages,  with  477  illus.    Cloth,  $4.25;  leather,  $5.00. 


(10.  13.  0.) 


L.£A    BROTHERS    &    CO.,    PUBLISHERS,    PHII.ADEI.PHIA. 


Condensed  List  of  Lea  Brothers  &  Co.'s  Medical  Works. 


MANUALS— continued. 

SERIES  of  Clinical  Manuals.  A  collection  of  authoritative 
monographs  in  a  cheap  and  portable  form.  The  following 
volumes  are  now  ready:  Yeo  on'  Food  in  He.\lth  and 
Disease,  $2 ;  Broadbbn^t  on  the  Pulse,  ?1.7o;  Ballon 
Diseases  op  the  Rectum  and  Anus,  §2.15;  Carter  & 
Frost's  Ophthalmic  Surgery,  $2.25;  Hutchinson  on 
Syphilis,  $2.25;    Marsh  on  Diseases  of  the  Joints, 

f;  Morris  on  Surgical  Diseases  op  the  Kidney, 
.25;  Owen  on  Surgical  Diseases  of  Children,  $2; 
UTLiN  ON  the  Tongue,  $3..50;  Pick  on  Fractures 
AND  Dislocations,  $2;  Savage  on  Insanity  and 
Allied  Neuroses,  $2;  and  Treves  on  Intestinal 
Obstruction,  $2.  The  following  is  in  press:  Lucas  on 
Diseases  of  the  Urethra.  For  separate  notices  see 
various  subject-heads. 

NEILL  «&  SMITH'S  Analytical  Compendium  of  the 
Various  Branches  of  Medical  Science;  for  the  use  and 
examination  of  students.  In  one  large  royal  12mo.  volume 
of  974  pages,  with  374  woodcuts.  Cloth,  $4.00;  strongly  bound 
in  leather,  with  raised  bands,  $4.75. 

IjUDLiOW'S  Manual  of  Examinations  upon  Anatomy, 
Physiology,  Surgery,  Practice  of  Medicine,  Obstetrics, 
Materia  Medica,  Chemistry,  Pharmacy  and  Therapeutics. 
To  which  is  added  a  Medical  Formulary.  In  one  handsome 
royal  12mo.  volume  of  816  pages,  with  370  illustrations. 
Cloth,  $3.2.5;  leather,  $3.75. 

MATERIA  MEDICA  AND  THERAPEUTICS. 

STIliLiE  &;  MAISCH'.S  National  Dispensatory;  con- 
taining the  Natural  History,  Chemistry,  Pharmacy,  Actions 
and  Uses  of  Medicines,  including  those  recognized  in  the 
Pharmacopoeias  of  the  United  States,  Great  Britain  and 
Germany,  with  numerous  references  to  the  French  Codex. 
Fourth  edition,  with  appendix.  Revised  to  cover  the 
new  British  Pharmacopoeia.  In  one  magnificent  imperial 
octavo  volume  of  1794  pages,  with  311  accurate  illus- 
trations. Cloth,  $7.25;  leather,  $8.00;  half  Russia,  open 
back,  $9.00.  Furnished  with  Patent  Ready-Reference 
Thumb-letter  Index  for  $1.00  in  addition  to  price  in  any  of  i 
above  styles  of  binding. 

HARE'S  Text-Book  of  Practical  Therapeutics.  With  es- 
pecial reference  to  the  application  of  remedial  measures  to 
disease  and  their  employment  upon  a  rational  basis.  In 
one  handsome  octavo  volume  of  622  pages.  Cloth,  $3.75; 
leather,  $1.7.5.    (^Just  ready.) 

BRUNTON'S  Pharmacology,  Therapeutics  and  Materia 
Medica.  Third  edition,  in  one  handsome  octavo  volume 
of  1305  pp  ,  with  2:30  illustrations.   Cloth,  $5.50 ;  leather,  $6..50. 

PARRISH'S  Treatise  on  Pharmacy.  Designed  as  a  Text- 
book for" the  Student  and  as  a  Guide  for  the  Physician  and 
Pharmaceutist.  With  many  Formulse  and  Prescriptions. 
Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wiegand, 
Ph.  G.  In  one  handsome  octavo  volume  of  1093  pages,with 
2.56  illustrations.    Cloth,  $-5.00;  leather,  $6.00. 

FARQUHARSON'S  Guide  to  Therapeutics  and  Materia 
Medica.  Third  American  edition,  specially  revised  by  the 
Author,  and  edited,  with  additions,  embracing  the  U.  S. 
Pharmacopoeia.  New  edition.  In  one  royal  r2mo.  volume 
of  551  pages.    Cloth,  $2..50. 

MAISCH'S  Manual  of  Organic  Materia  Medica.  Being  a 
Guide  to  Slateria  Medica  of  the  Vegetable  and  Animal 
Kingdoms.  For  the  use  of  Students,  Druggists,  Pharma- 
cists and  Physicians.  New  (4th)  edition.  In  one  12mo.  vol- 
ume of  529  pages,  with  2.58  illustrations.    Cloth,  $3.00. 

EDES'  Text-book  of  Therapeutics,  and  Materia  Medica 
In  one  octavo  of  544  pages.    Cloth,  $3.50 ;  leather,  $4.50. 

STIIiliE'S  Therapeutics  and  Materia  Medica;  a  System- 
atic Treatise  on  the  Action  and  Uses  of  Medicinal  Agents, 
including  their  Description  and  History.  Fourth  edition, 
revised  and  enlarged.  In  two  large  and  handsome  octavo 
volumes  of  1936  pages.     Cloth,  $10.00;    leather,  $12.00. 

BRUCE'S  Materia  Medica  and  Therapeutics.  New  (fourth) 
edition.  In  one  r2mo.  volume  of  .591  pages.  Cloth,  $1.50.  See 
Students'  Series  of  Manuals,  page  1. 

HERMANN'S  Experimental  Pharmacology.  Translated, 
with  additions,  by  R.  Meade  Smith,  M.  D.  In  one  12mo. 
volume  of  199  pages,  with  32  illastrations.    Cloth,  $l..50. 

GRIFFIT  H'S  Universal  Formulary;  containing  the  Meth- 
ods of  Preparing  and  Administering  Officinal  and  other 
Medicines.  The  whole  adapted  to  physicians  and  pharmar 
ceutists.  Third  edition,  thoroughly  revised,  with  numerous 
additions,  by  John  M.  Maisch,  Phar.D.  In  one  large  octavo 
volume  of  775  pages.    Cloth,  $4.50;  leather,  $5.50. 

PATHOLOGY. 

PAYNE'S  General  Pathology.  Designed  as  an  introduction 
to  the  practice  of  medicine.  Very  handsome  octavo,  524 
pages,  153  engravings  and  1  colored  plate.     Cloth,  $3.50. 

COATS'  Pathology.  In  one  handsome  octavo  volume  of 
829  pages,  with  339  illustrations.    Cloth,  $5.50 ;  leather,  $6.50. 

VAUGHAN  «&  NOW  on  Ptomaines  and  Leucomaines,  or 
Physiological  and  Pathological  Alkaloids.  In  one  l2mo. 
volume  of  311  pages.    Cloth,  $1.75. 

GREEN'S  Pathology  and  Morbid  Anatomy.  New  (sixth) 
American,  from  the  seventh  revised  and  enlarged  Eng- 
lish edition.  In  one  handsome  octavo  volume  of  540 
pages,  with  167  illustrations.    Cloth,  $2.75.    {Just  ready.) 

SCHAFER'S  Essentials  of  Histology,  Descriptive  and 
Practical.  In  one  octavo  volume  or  2.52  pages,  with  281 
illustrations.    Cloth,  $2.25. 

KliEIN'S  Histology.  Fourth  edition.  In  one  12mo.  volume 
of  376  pages,  with  194  illustrations.  Cloth,  $1.75.  See 
Students'  Series  of  Manuals,  page  1. 

WOODHEAD'S  Practical  Pathology.  In  one  8vo.  vol.  of 
497_pages,  with  136  colored  illus.  in  the  text.     Cloth,  $6.00. 

PEPPER'S  Surgical  Pathology.  In  one  r2mo.  volume  of 
511  pages,  with  81  illustrations.  Cloth,  $2.00.  See  Students' 
Series  of  Manuals,  page  i. 


PRACTICE. 

A  SYSTEM  of  Practical  Medicine,  by  American  Authors. 
Edited  bj'  William  Peppi;r,  M.  D.,  LL.  D.  Complete 
work  now  ready.  In  five  e.ictra-sized  octavo  volumes,  con- 
taining 5573  pages,  with  198  illustrations.  Per  volume 
cloth,  $5.00;  leather,  $6.00;  half  Russia,  $7.00.  For  sale  by 
subscription  only. 

FL<INT'S  Treatise  on  the  Principles  and  Practice  of  Medi- 
cine; designed  for  the  use  of  Students  and  Practitioners 
of  Medicine.  Si.xth  edition.  Thoroughly  revised  by 
the  Author,  assisted  by  William  H.  Welch,  M.  D.,  and 
Austin  Flint,  Jr.,  M.D.  In  one  large  and  closely-printed 
octavo  volume  of  1160  pages,  with  5  woodcuts.  Cloth,  $.5.50; 
strongly  bound  in  leather,  with  raised  bands,  $6..50. 

BRISTOVVE'S  Treatise  on  the  Science  and  Practice  of 
Medicine.  Seventh  edition.  In  one  large  octavo  volume 
of  1325  pages.    Cloth,  $6..50;   leather,  $7.-50.    {Just  ready.) 

REYNOLD.S'  System  of  Medicine.  Edited  by  H.  Harts- 
HORNE,  M.D.  In  three  large  octavo  volumes  of  3056  closely- 
printed  double-columned  pages,  with  317  illustrations.  Per 
volume  in  cloth,  $5.00;  in  leather,  $6.00;  half  Russia,  $6.50. 
Sold  only  by  subscription. 

HART.SHORNE'S  Essentials  of  the  Principles  and  Prac- 
tice of  Medicine.  A  Handbook  for  Students  and  Practi- 
tioners. Fifth  edition,  revised  and  improved.  In  one 
handsome  roval  12mo.  volume  of  669  pages,  with  144  illus- 
trations.   Cloth,  $2.75;  half  bound,  $3.00. 

FOTHERGIIil/S  Practitioner's  Handbook  of  Treatment; 
or.  The  Principles  of  Therapeutics.  Third  edition.  In  one 
very  handsome  octavo  volume  of  661  pages.  Cloth,  $3.75; 
leather,  $4.75. 

THE  YEAR-BOOK  of  Treatment  for  1890.  A  CriticalRe- 
view  for  Practitioners  of  Medicine.  A  classified  summary 
of  medical  progress  by  '23  eminent  physicians  and  surgeons. 
Inoneoctavo  volume  of  329  pages.  Cloth,  $1.'25. 

THE  YEAR-BOOKS  of  Treatment  for  1886  and  1887. 
Similar  to  above.    12mo.,  3'20  pages.    Each,  cloth,  $1.25. 

WATSON'S  Lectures  on  the  Principles  and  Practice  of 
Physic.  A  new  American  from  the  fifth  revised  English 
edition.  Edited,  with  additions,  and  several  hundred  illus- 
trations, by  Henry  Hartshorne,  M.  D.  In  two  large 
octavo  volumes  of  1840  pages,  with  190  woodcuts.  Cloth, 
$9.00;  leather,  $11.00. 

RICHARDSON'S  Preventive  Medicine.  In  one  hand- 
some octavo  volume  of  7'29  pages.  Cloth,  $4.00;  leather,  $.5.00. 

BARTHOLOW  on  Electricity  as  Applied  to  the  Practice 
of  Medicine  and  Surgery.  New  (third)  edition.  In  one  8vo. 
volume  of  308  pages,  with  110  illustrations.    Cloth,  $'2.50. 

BROADBENT  on  the  Pulse.  In  one  r2mo.  volume  of 
317  pages.  Cloth,  $1.75.  See  Series  of  Clinical  Manuals, 
page  2. 

YEO  on  Food  in  Health  and  Disease.  In  one  l2mo.  volume 
of  590  pages.  C  loth.  $2.  See  iSeries  of  Clinical  Manuals, 
page  2. 

SCHREIBER  on  Massage.  Translated  by  Mendelson. 
In  one  8vo.  volume  of  274  pages,  with  117  illustrations. 
Cloth,  $2.75. 

FINLAYSON'S  Clinical  Manual  for  the  Study  of  Medical 
Cases.  For  the  use  of  Students  and  Practitioners  of  Medi- 
cine. New  edition.  In  one  12mo.  volume  of  682  pages, 
with  158  illustrations.    Cloth,  $2..50. 

TANNER'S  Manual  of  Clinical  Medicine  and  Physical 
Diagnosis.  Third  American  from  the  second  London  edi- 
tion.   In  one  12mo.  volume  of  362  pages.  Cloth,  $1.50. 

STURGES'  Introduction  to  Clinical  Medicine.  In  one 
r2mo.  volume  of  r27  pages.    Clothj  $1.'2.5. 

DAVIS'  Clinical  Lectures  on  Various  Important  Diseases. 
Second  edition.    In  one  r2mo.  vol.  of '287  pages.    Cloth,  $1.75, 

TODD'S  Clinical  Lectures  on  Certain  Acute  Diseases.  In 
one  octavo  volume  of  3'20  pages.    Cloth,  $2.50. 

FLINT'S  Essays  on  Conservative  Medicine  and  Kindred 
Topics.    In  one  12mo.  volume  of  210  pages.    Cloth,  $1.38. 

BARIiOW'S  Manual  of  the  Practice  of  Medicine.  Cloth, 
$2.50. 

LYONS'  Treatise  on  Fever.    In  one  octavo  volume  of  354 

_pages.    Cloth,  $'2.2.5. 

IlUDSON'S  Lectures  on  the  Study  of  Fever.  In  one  octavo 
volume  of  308  pages.    Cloth,  $2.50. 

LA  ROCHE  on  Yellow  Fever,  considered  in  its  Historical, 
Pathological,  Etiological  and  Therapeutical  Relations.  In 
two  large  8vo.  volumes  of  1468  pages.    Cloth,  $7.00. 

HOLLAND'S  Jledical  Notes  and  Reflections.  In  one 
octavo  volume  of  493  pages.    Cloth,  $;3.50. 


ORGANS  OF  RESPIRATION  AND  CIRCULATION. 

BROWNE'S  Practical  Guide  to  Diseases  of  the  Throat 
and  Nose,  and  Associated  Affections  of  the  Ear.  New  (3d) 
edition.  In  one  8vo.  volume  of  734  pages,  with  120  illus- 
trations in  color  and  235  woodcuts,  designed  and  executed 
by  the  author.    Cloth,  $6.50.    (Just  ready?) 

COHEN  on  Throat  and  Nasal  Passages.  New  edition.  In 
one  octavo  volume  of  750  pages,  with  200  illus.    {Pi-eparing.) 

SEILER'S  Handbook  of  Diseases  of  the  Throat,  Nose  and 
Naso-Pharynx.  New  (3d)  edition.  In  one  ]2mo.  volume 
of  373  pages,  with  101  engravings  and  2  colored  plates,  con- 
taining 10  figures.    Cloth,  $'2.'25. 

FLINT'S  Manual  of  Auscultation  and  Percussion;  of  the 
Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart 
and  of  Thoracic  Aneurism.  New  (5th)  edition.  Revised 
and  enlarged  by  James  C.  Wilson,  M.  D.  In  one  hand- 
some 12mo.  volume  of  274  pages,  with  12  illustrations. 
Clotli,  $1.7-5.     (Just  ready.) 

FLINT'S  Practical  Treatise  on  the  Physical  Exploration  or 
the  Chest  and  the  Diagnosis  of  Diseases  Affecting  the  Re- 
spiratory Organs.  Second  and  revised  edition.  In  one  hand- 
some octavo  volume  of  .591  pages.    Cloth,  $4.-50. 

FLINT  on  Phthisis;  its  Morbid  Anatomy,  Etiology,  Symp- 
tomatic Events  and  Complications,  Fatality  and  Prognosis, 
Treatment  and  Physical  Diagnosis;  in  a  series  of  Clinical 
Studies.    In  one  8vo.  volume  of  442  pages.    Cloth,  $3.-50. 


LEA    BROTHERS    &    CO.,    PUBLISHERS,    PHILADELPHIA. 


Condensed  List  of  Lea  Brothers  &  Co.'s  Medical  Works. 


ORGANS  OF  RESPIRATION,  etc.— continued. 

H.^IITII  (iiitDiisiiiiiiitloii:  lis  I'iiiilyiiriil  Iti'miMllaljloHtiiKL'S. 

In  iiiic  iiciuvd  vuluiiii'  u(  'S't^i  |iiiK<''H.    c'lotli,  f--'<^>- 
\VILIjIA.'>IM    on    I'ulntuniirv  ConHuinption;    its   Nature, 

ViirlcllcMuiKl  Tri'iitnn-nt.    With  an  AnalyMls  of  Onu  Tliou- 

HJind  t'a.M<>s  to  Kvi-niiillf\-  Its  Duration.    In  one  octavo  vol- 

UMH-  of  :ui:i  |.aK..s.    Cluih,  fl.:*). 
FriiljKK  on  I)lsfii.sr.Hof  till"  LuuKHanil  Air  I'lLs.saui'H ;  tholr 

I'atlioloKv,  I'h.VMlful  DIaKnoslH,  .Syniploni.s  anil  Treat nienl. 

SiHMinil  eillllon.     In  one  Hvo.  vol.  of  li.')  puKes.    Cloth,  ^i.V). 
I>A  IKM'IIK  on  I'neunionla.     In  one  octavo  volume  of -liW 

liaKCM.     Cloth,  S.I.1K). 
(JllOSS"  I'ractlcal   Treatise  on  Foreign  Rodle.s  In  the  Alr- 

1'a.HHaKes.     I  n  one  octavo  vohinie  of  Mi'l  pajfes,  with  .V.t  lllua- 

Irnlldiis.     Cloth,  fl~'y. 
SI.. Mil'',  nil  niplitiicrla.    In  one  rjnio.  volume.    Cloth,  fl.i"). 
AV.XI.SIIK  on  Ihe  lilseuM-s  iif  the  Heart  mid  Ureal  VciselB. 

Ill  one  iicluvo  \iilllllle  III'  in;  pHK'CS.     Cldlh,  ?;t.iK). 
FLINT'.'^    Practical  Treatise  on  the   DlaKiioslM,  Patliolojfy 

and  Treatment  of   DIseiuses  of  the  Heart.      .Second  and 

revised  edition.  In  one  octavo  vol.  of  550  pages.  Cloth,  |4.0U. 

ORGANS  OF  DIGESTION. 

STILTjK  on  Clicileru.  Its  Origin,  Causation,  Symptoms 
Prevention  ami  Trealnieiit.  In  one  I'.'mo.  volume  of  184 
JiiiKes,  uilh  ii  rliart.     Cloth,  Jl.'i'). 

H.VIlKKSIKirii  on  Diseiuses  of  the  Alimentary  Canal. 
Second  .Vmeriiiin  I'miii  the  third  and  enlarged  Kngllsh  edi- 
tion.    In  one  octavo  volume  of  .Wl  iiaijes.    Cloth,  ?;i..50. 

CH.4.1HIKK.S'  .Manual  of  Diet  in  Health  and  IJisease.  In 
one  liHlidsome  octavo  volume.     Cloth,  $'2.7.5. 

PAVV'.S  Treatise  on  the  Kunction  of  DiKe.stlon;  its  Dis- 
orders and  their  Treatment.  From  the  second  London  edi- 
tion.   In  one  handsome  volume,  small  octavo.    Cloth,  $2.00. 

VENEREAL   AND   SKIN    DISEASES. 

TA  YIjOR'S  Clinical  Atlas  of  Venereal  and  .Skin  DLsen-ses. 
Including  Dlai;nosis,  Prognosis  and  Treatment.  In  eight 
folio  parts,  measuring  14  x  l>t  inches  and  comprising  4:il 
pages  of  te.vt,  with  s.')  large  woodcuts  and '2ia  ligures  on  58 
l\i  11-page  colored  plates.  Price,  per  part,  ?2.60.  (Com- 
plete work  noic  ready.)  Bound  in  one  volume,  half  Bussia, 
y.'T.UO;  half  Turkey  Morocco, f28.00.  For  sale  by  subscription 
only.  Specimen  of  plates,  by  mail,  10  cents.  Address  the 
Publishers. 

HYDE  on  the  Skin.  Xew  C^d)  edition.  In  one  very  hand- 
some octavo  volume  of  HTG  pages,  with  85  illustrations, 
and    two    colored    plates.      Cloth,   $1.50;     leather,    ?.5.50. 

TAYLOR  on  the  Pathology  and  Treatment  of  Venereal 
DIsea.ses.  Ueing  the  si.xth  edition  of  Bum.stead  <fc  Tay- 
lor, completely  rewritten  by  Dr.  T.wlor.  In  one  very 
handsome  octavo  vol.,  prnfuselv  illustrated.    {Prijjarlng.) 

BIJ.1I.STK A I>  «fc  T.\YI.OR  on  the  Pathology  and  Treat- 
ment of  Venereal  Diseases,  including  the  results  of  recent 
investigations  upon  the  subject.  Si.xth  edition,  rewritten 
bv  Dr.  T.vyliir.    See  Tdi/lor,  above. 

CORNIL  on  Svnhilis.  Translated  by  J.  Hexry  C.  Simes, 
M.  D.,  and  J.  William  WiiiTK,  M.  D.  In  one  very  hand- 
some octavo  volume  of  4GI  pages,  with  84  beautiful  illustra- 
tions.   Cloth,  »;}.7.i. 

CULIiERIER'S  Atlas  of  Venereal  Disea-s&s.  Translated 
and  edited  by  Frekmax  J.  Bumstead,  M.  D.,  LL.  D.  In 
one  large  imperial  4to.volumeof  328  pages,  double  columns, 
with  '2()  iilates,  containing  about  1.50  figures,  beautifully 
colore<l,  many  of  them  the  size  of  life.  Strongly  bound  in 
cloth,  $17.00. 

HUTCHINSON  on  Syphilis.    In  one  l2mo.  volume  of  542 

Sages,   with   8   chromo-lithographic   plates.    Cloth,    $2.'25. 
ee  Series  of  Clinical  Manuals,  page  2. 
LEE'S  Lectures  on  Syphilis,  and  on  Some  Forms  of  Local 

Disease  AfTecting  Principally  the  Organs  of  Generation. 

In  one  handsome  octavo  volume  of  24e  pages.     Cloth,  ?2.2.5. 
HILL  on  Syphilis  and  Local  Contagious  Disorders.    In  one 

handsome  8vo.  volume.    Cloth,  $.3.2.5. 
FOX'.S    Epitome  of  Skin  Diseases,  with  Formulie.      For 

Students  and  Practitioners.    Third  edition,  revised  by  T.  C. 

Fox  M.  R.C.  S.  Inonel2mo.volumeof'2.'ispages.  Cloth, f  1.2.5. 
WILSON'S  Student's  Book  of  Cutaneous  Medicine  and 

Diseases  of  the  Skin.    In  one  12mo.  volume  of  535  pages. 

Cloth,  S3..50. 
HILLIER'S  Handbook  of  Skin  Diseases,  for  Students  and 

Practitioners.    Second  American  edition.     In  one  l2mo. 

volume  of  358  pages,  with  illustrations.    Cloth,  $2.25. 


DISEASES  OF  THE  URINARY  ORGANS. 

ROBERTS'  Practical  Treatise  on  Urinary  and  Renal  Dis- 
eiises,  including  Urinary  Deposits.  Fourth  American  from 
the  fourth  revised  London  edition.  In  one  large  octavo 
volume,  of  600  pages, with  81  illustrations.     Cloth, ?.3..50. 

PURDY  on  Bright's  Disea.se  and  Allied  Affections  of  the 
Kidneys.  In  one  handsome  8vo.  volume  of  288  pages,  with 
illustrations.    Cloth,  $'2.00. 

GROSS'  Practical  Treati.se  on  the  Diseases,  Injuries  and 
Malformations  of  the  Urinarv  Bladder,  the  Prostate  Oland 
and  the  Urethra.  Third  edition,  thoroughlv  revised  by 
SAJirKL  W.  GROS.S,  A.  M.,  M.  D.  In  one  handsome  8vo. 
volume  of  .574  pages,  with  170  illustrations.    Cloth,  f4.50. 

THOMPSON'S  Lectureson  Disea-ses  of  the  Urinary  Organs. 
Second  American  edition.  In  one  octavo  volume  of  203 
pages,  with  '2.5  woodcuts.    Cloth,  $2.'25. 

THOIIP.SON  on  the  Pathologj-  and  Treatment  of  Stricture 
of  the  Urethra  and  Urinary  Fistula.  From  the  third  Eng- 
lish edition.  In  one  octavo  volume  of  ;J59  pages,  with  2 
plates  and  47  woodcuts.    Cloth,  ?:S..50. 

LI' CAS  on  Disea.ses  of  the  Urethra.  In  one  12mo.  volume. 
( Prrpnring.)    See  Series  of  Clinical  ManuaU,  page  2. 

BIORllLS  on  Surgical  Diseases  of  the  Kidney.  In  one  12mo. 
volume  of  5-54  pages,  with  40  woodcuts  "and  6  colored 
plates.   Cloth,  ?2.25.  See  Series  of  Clinical  ^fanuat.1,pfigeZ 

B.VSHAM  on  Renal  Diseases:  a  Clinical  Guide  to  their 
Diagnosis  and  Treatment.  In  one  roval  12mo.  volume  of 
304  pages,  with  illustrations.    Cloth,  f2.i'iO. 


DISEASES   OF   THE    NERVES   AND   MIND. 

RO.SS'  Handbook  of  the  Dlsiases  of  tin- Nervous  System. 
In  one  octavo  volume  of  72<J  pugcH,  with  1«4  lllu.stratlous. 
Cloth,  frl..VI:  leather,  |.5..Vi. 

MITC'IIKLI/M  Lectures  on  niHeoHCH  of  the  XervouH Sys- 
tem, I'>(p<-<'lallv  In  Woiiii-n,  Secund  edition.  In  one  hand- 
some l2mo.  Vdliime  of '2^1  pages,  with  5  llllidgraplile  charUi. 

IIA.1IILTON  on  Nervous  Dlseiusr-s:  tlieir  Desirlptlon  and 
Treatment.  Seconil  edllidii,  tlidroiighlv  revlne*!  and  re- 
written. In  one  handsoiiie  octavo  volume  of  .5U8  paiCM, 
with  72  Illustrations,    cldih  fl.oo. 

CLOUSTON  dii  Insanity.  With  U.  S.  Laws  on  Cimtody  of 
Insane,  by  C.  F.  Foi.hom,  M.  D.  In  one  8vo.  volume  of  Ml 
nage,s,wlth  8  plates.  Cloth, $-l.oo.  Dr.  Folsom's  Atmtract  of 
Laws  for  sale  separately,  see  below. 

SAVAGE  on  In.sanlty  and  Alllerl  Neuroses.  In  one  12ino. 
volume  of  .551  pages,  with  Is  tvplc-al  illustrations.  Clotb, 
12.00.    .See  Series  of  flinicU  MdHiinls.  page  2. 

TIIKE  on  the  Influence  of  the  .Mind  Over  the  Body  In 
Health  and  Disease.  Second  edition.  In  one  octavo  vol- 
ume of  598  pages,  with  72  Illustrations.    Clotb,  |.3.00. 

GRAY'S  Practicjil  Treatl.se  on  Diseases  of  the  Nervoua 
System.  In  one  handsome  octavo  volume  of  about  000 
pages.     ( I'rciMiririfi.i 

PLAYFAIR  on  Nerve  Prostration  and  Hysteria.  In  one 
small  octavo  volume  of  97  pages.    Cloth,  ll.Ofj. 

FOLSO.II'.S  Abstract  of  Statutes  of  U.  S.  on  Custody  of 
Insane.  In  one  8vo.  volume  of  108  pages.  Cloth,  |1..50. 
Also  bound  with  Clou.ston  on  /n.wnf<i/, above. 

JONES'  Clinical  Observations  on  Functional  Nervous  Dis- 
orders.   In  one  8vo.  volume  of  340  pages.    Cloth,  ?3.25. 


GYNytCOLOGY. 

THE  AMERICAN  SystemsoffJynajcology  and  Obstetrics. 
In  treatises  by  various  authors.  G viia.'cologV  edited  bv  Mat- 
thew D.  Man-n,  M.  D.,  and  Obstetrics  edfted  by  Bartox 
C.  Hirst,  M.  D.  In  four  very  hand.some  super-royal  octavo 
volumes.  Complete  work  Is  nou'  reaily,  containing  3612 
pages,  1092  engravings  and  8  plates.  Per  volume,  cloth, 
$.5.00 ;  leather,  $6.00  r  half  Russia,  $7.00.  /br  sale  by  subscrip- 
tion  only. 

THOMAS'  Practical  Treatise  on  the  Disea-ses  of  Women. 
Fifth  edition  rewritten  and  greativ  enlarged.  In  one  large 
and  handsome  octavo  volume  of*  810  pages,  with  266  illus. 
Cloth,  $.5.00;  leather,  $6.00;   half  Ru.ssia,  rai.sed  bands,  $6..50. 

EMMET'.S  Principles  and  Practice  of  Gynaecologv.  For 
Students  and  Practitioners.  Third  edition,  revised  and  en- 
larged. In  one  large  octavo  vol.  of  880  pji.,  with  1.50  illus. 
Cloth,  $.5:  leather,  $(i.OO;  half  Russia,  raised  bands,  $6..50. 

DAVENPORT  on  Dise;i,ses  of  Women.  A  Manual  of 
non-surgical  Gynecology'.  Hand.some  12mo.,  .306  pages,  105 
engravings.    Cloth,  $l.-50. 

EDIS  on  Diseases  of  Women.  A  Manual  for  .Students  and 
Practitioners.  In  one  handsome  8vo.  volume  of  .576  pages, 
with  148  illustrations.    Cloth,  $3.00;  leather,  $4.00. 

MAY'S  JIanual  of  the  Diseases  of  Women.  Second  edition, 
edited  by  L.  S.  Rau.  M.  D,  In  one  l'2mo.  volume  of  360 
pages,  with  31  illustrations.    Cloth,  $1.75. 

TAIT  (Lawson)on  Diseases  of  Women  and  Abdominal  Sur- 
gery. In  two  octavo  volumes.  Volume  I.,  5.54  pages,  62 
engravings  and  3  plates,  just  ready.  Volume  IL  pre- 
pririnfj. 

BARNES'  Clinical  Exposition  of  the  Medical  and  Surgical 
Diseases  of  Women.  Third  American  from  the  third  Eng- 
lish edition.  In  one  handsome  octavo  volume  of  about  8«0 
pages,  with  about  200  illustrations.    (Preparing.) 

DUNCAN'S  Clinical  Lectures  on  the  Diseases  of  Women. 
In  one  octavo  volume  of  175  pages.    Cloth,  $1..50. 

HODGE  on  Diseases  Peculiar  to  Women;  including  Dis- 
placements of  the  Uterus.  Second  edition,  revised  and 
enlarged.  In  one  beautifully-printed  octavo  volume  of  519 
pages,  with  original  illustrations.    Cloth,  $4..5<). 

A!^H\VELL'S  Practical  Treatise  on  the  Diseases  Peculiar 
to  Women.    One  volume,  8vo.,  520  pages.    Cloth,  $3.50. 

WEST'.S  Lectures  on  the  Disea-ses  of  Women.  Third 
American  from  the  third  London  edition  In  one  octavo 
volume  of  543  pages.    Cloth,  $3.75;  leather,  $4.75. 


DISEASES  OF  CHILDREN. 

SMITH'S  Treatise  on  the  Disea-ses  of  Infancy  and  Child- 
hood. New  (seventh)  edition,  thoroughly  revised  and  re- 
written. In  one  hand.some  octavo  volumeof  881  pages,  with 
51  illustrations.     Cloth,  $4..50;  leather,  $5.50.    (Just  ready.) 

OWEN  on  Surgical  Diseases  of  Children.  In  one  12mo. 
volume  of  525  pages,  with  85  woodcuts  and  4  chromo- 
lithographic  plates.  Cloth,  $-2.00.  See  Series  of  Clinical 
Manuals,  page  2. 

WEST  on  Some  Disorders  of  the  Nervous  System  in  Child- 
hood.   In  one  volume,  small  12mo.    Cloth,  $1.00. 

CONDIE'S  Practical  Treatise  on  Diseases  of  Children. 
Sixth  edition.  In  one  octavo  volume  of  779  pages.  Cloth 
$5.25;  leather,  $6.2,5.  

OBSTETRICS. 

THE  AMERICAN  System  of  Obstetrics,  see  the  American 
Systems  of  Gvnwcolosry  and  Obstetrics,  above. 

Pli'AY FAIR'S  Treatise  on  the  Science  and  Practice  of 
Midwifery.  New  (fifth)  American  from  theseventh  English 
edition.  Edited,  with  additions,  by  Robert  P.  Harris, 
M.  D.  In  one8vo.  volumeof  664  pages, with  'XT  illustrations. 
Cloth,  $4.00;  leather,  $.5.00. 

LEI.SIIM.4N'S  System  of  Midwifery,  including  the  Dis- 
eases of  Pregnancy  and  the  Puerperal  State.  Third  Ameri- 
can from  the  third  and  revised  English  edition,  with  addi- 
tions, by  J.  S.  Parry,  M.D.  In  one  large  and  very  handsome 
8vo.  volume  of  740  pages,  with  205  Illustrations.  Cloth,  f4.50; 
leather.  $.5..50. 

PARVIN'.S  Treatise  on  Obstetrics  New  (2d)  edition.  In 
one  very  handsome  octavo  volume  of  701  pages,  with  239 
illustrations.    Cl<ith.  $4.25:  leather.  $o.'2.5.    (Jusl  ready.) 

BARNES'  System  of  Obstetric  Medicine  and  Surgery.  In 
one  large  octavo  volume  of  872  pages,  with  231  illustrations. 
Cloth,  f5.0<3;  leather,  $6.00. 


LEA    BROTHERS  &    CO..    PUBLISHERS,    PHILADELPHIA. 


Condensed  List  of  Lea  Brothers  &  Co.'s  Medical  Works. 


OBSTETRICS— continued. 

KING'S  ilanual  of  Obstetrics.  New  ifourth)  edition.  In 
one  handsome  l.mo.  volume  of  -iiZ  pages,  witli  141  illus- 
trations.   Cloth,  $•.;  50.     (Just  rtady.) 

LANUI.S  on  the  Management  of  Labor.  In  one  12mo.  vol- 
ume of  329  pages,  with  '2S  illustrations.    Cloth,  51.75. 

HODGE'S  Principles  and  Practice  of  Obstetrics.  In  one 
large  quarto  volume  of  542  double-columned  pages,  illus- 
trated with  large  lithographic  plates  containing  159  ligures 
from  original  photographs,  and  with  numerous  woodcuts. 
Stronglv  bound  in  cloth,  $14.00. 

RAMSIJOTHA]>rS  Principles  and  Practice  of  Obstetric 
Medicint'  and  Surgery,  In  Keference  to  the  Process  of  Par- 
turition. In  one  large  imperial  8vo.  volume  of  640  pages, 
with  (i4  lieautilul  plates,  and  43  woodcuts.    Leather,  $7.00. 

BARKElt'.S  Obstetrical  and  Clinical  Essays.  Inonelimo. 
volume  of  about  300  pages.    (I^-eparing.) 

TANNER  On  the  Signs  and  Diseases  of  Pregnancy.  From 
the  second  English  edition.  In  one  Svo.  volumeof  490  pages, 
with  4  colored  plates  and  16  woodcuts.    Cloth,  $4.25. 

WINt'KEIj  on  the  Pathology  and  Treatment  of  Childbed. 
A  Treatise  for  Physicians  and  Students.  From  the  second 
German  edition  by  Chadwick,  with  additions  by  the 
Author.    In  one  octavo  volume  of  484  pages.    Cloth,  ^.00. 

MEIGS  on  the  Nature,  Signs  and  Treatment  of  Childbed 
Fever.    In  one  Svo.  volume  of  340  pages.    Cloth,  $2.00. 

CHURCHIIiIi'S  Essays  on  the  Puerperal  Fever,  and  other 
Diseases  Peculiar  to  Women.  lu  one  Svo.  volume  of  464 
pages.    Cloth,  $2.50. 

PARRY  on  Extra-Uterine  Pregnancy;  its  Clinical  History, 
Diagnosis,  Prognosis  and  Treatment.  In  one  handsome 
octavo  volume  of  272  pages.    Cloth,  $2.50. 


OTOLOGY  AND   OPHTHALMOLOGY. 

BERRY  on  the  Eye.  A  Practical  Treatise  for  Students 
of  Ophthalmology.  Handsome  octavo,  6So  pages,  144 
illustrations,  of  which  62  are  exquisitely  colored,  cloth, 
|7.50. 

JUliER'S  Ophthalmic  Science  and  Practice.  In  one  Svo. 
volume  of  4ti0  pages,  with  125  woodcuts,  25  colored  plates, 
and  tests  for  color-blindness  and  sharpness  of  vision.  Cloth, 
$4.50;  leather,  $5.50. 

NETTLESHIP'S  Diseases  of  the  E.ve.  Fourth  and  revised 
edition.  With  an  appendix  on  the  detection  of  color-blind- 
ness, by  William  Thomsox,  M.  D.  In  one  12mo.  volume 
of  504  pages,  with  ICA  illustrations.  Cloth, $2.00.   (Just ready.) 

NORRIS  «fc  OLIVER'S  Text-book  of  Ophthalmologj'. 
In  one  octavo  volume  of  about  500  pages.    {In  press.) 

CARTER  &  FROST'S  Ophthalmic  Surgery.  In  one 
12mo.  volume  of  559  pages,  with  91  engravings.  Cloth,  $2.2?. 
See  S'  rics  of  Clinical  Jlamia/s,  page  2.  Color-blindness 
test,  test-tj'jies  and  dots,  and  appendix  of  formulae. 

BURNETT  on  the  Ear;  its  Anatomy,  Physiology  and  Dis- 
eases. A  practical  Treatise  for  the  use  of  Medical  Students 
and  Practitioners.  New  (second)  edition.  In  one  handsome 
octavo  volume  of  5s0  pages,  with  107  illustrations.  Cloth, 
p.OO;  leather,  $.5.00. 

POIilTZER  on  the  Ear.  For  Students  and  Practitioners. 
In  one  octavo  volume  of  800  pages,  with  257  original  illus- 
trations.   Cloth.  $5.50. 

liAURENCE  &  MOON'S  Hand.v-Book  of  Ophthalmic 
Surgery.  For  the  use  of  Practitioners.  Second  edition, 
revised  and  enlarged.  In  one  octavo  volume  of  227  pages, 
with  66  illustrations.    Cloth,  $2.75. 

liA^VSON  on  Injuries  to  the  Eye,  Orbit  and  Eyelids;  their 
Immetliate  and  Remote  Effects.  In  one  Svo.  volume  of  404 
pages,  with  92  illustrations.    Cloth,  $3.50. 


SURGERY. 

GROSS'  System  of  Surgery;  Pathological,  Diagnostic- 
Therapeutic  and  Ov>erative.  Sixth  edition,  thoroughly  re- 
vised. In  two  beautifully-printed  imperial  octavo  volumes  of 
23S2  pages,  with  1623  engravings.  Strongly  bound  in  leather, 
with  raised  bands,  $  15.00. 

HOLiME.S'  Principles  and  Practice  of  Surgery.  New  Am- 
erican from  fifth  English  edition.  Edited  by  T.  P.  Pick, 
F.  K.  C.  S.  Darge  octavo,  997  pages,  428  engravings.  Cloth, 
§6.00;  leather,  $7.00. 

HOLLIES'  System  of  Surgery,  Theoretical  and  Practical. 
In  Treatises  by  various  Authors.  First  American  from 
second  English  edition.  Thoroughlj'  revised,  with  numer- 
ous additions,  by  J.  H.  Packard,  M.  D.,  assisted  by  a  corps 
of  thirty-three  of  the  most  eminent  American  Surgeons. 
In  three  large  and  very  handsome  imperial  octavo  volumes 
of  3137  pages,  with  979  engravings  and  13  colored  plates.  Per 
volume  in  cloth,  $6.00;  leather,  $7.00;  half  Kussia,  raised 
bands,  $7.50;  For  sale  by  subscription  only. 

ERICHSEN'S  Science  and  Art  of  Surgery ;  being  a  Trea- 
tise on  Surgical  Injuries,  Diseases  and  Operations.  New 
American  trom  the  eighth  and  enlarged  English  edition. 
In  two  large  and  beautiful  octavo  volumes,  containing 
2316  pages,  with  984  engravings  on  wood.  Cloth,  $9.00; 
leather,  $11.00. 

ASHHURST'S  Principles  and  Practice  of  Surgery.    New  I 
(fifth)  and  revised  edition.     In  one  large  octavo  volume 
of  1144  pages,  with  642  illustrations.     Cloth,  $6.00;  leather, 
$7.00.  ' 

BRYANT'S  Practice  of  Surgery.  Fourth  American  from 
the  fourth  English  edition.  In  one  imperial  Svo.  volume  of 
1040  pages,  with  727  engravings.     Cloth,  $6.50;  leather,  $7.50. 

DRUITT'S  Principles  and  Practice  of  Modern  Surgerj'. 
From  the  twelfth  London  edition,  thoroiighlj-  revised  by 
Staxley  Boyd,  F.K.C.  S.  In  one  handsome  octavo  vol- 
ume of  965  pages,  with  373  illustrations.  Cloth,  $4.00; 
leather,  $.5.00. 

GANT'S  Student's  Surgerj\    A  Multum  in  Farvo.    In  one 
octavo  volume  of  84S  pages,  with  159  illustrations.    Cloth,  I 
$3.75.    {Just  ready.)  ' 


SURGERY— continued. 

TREVES'  Manual  of  Surgery.  In  treatises  bv  various 
authors.  Edited  by  Frederick  Treves,  F".  R.  C.  S. 
Three  12mo.  volumes,  containing  1866  pages,  with  213  illus- 
trations. Per  volume,  cloth,  $2.00.  See  ^Students'  Series  of 
Manuals,  page  1. 

ROBERTS'  Manual  of  Modern  Surgery.  In  one  hand- 
some octavo  volume  of  7^0  pages  with  501  illustrations. 
Cloth,  $4.50:  leather,  $5.50     (Just  ready.) 

GROSS'  Practical  Treatise  on  Impotence,  Sterility  and 
Allied  Disorders  of  the  Male  Sexual  Organs.  New  (fourth) 
edition.  In  one  handsome  Svo.  volume  of  176  pages,  with 
16  illustrations.    Cloth,  $1.50.    (Just  ready.) 

SENN'S  Surgical  Bacteriology.  New  isecond)  edition.  In 
one  octavo  volume  of  about  2.50  pages,  with  colored  plates. 
(I'reparina.) 

THE  AMERICAN  SYSTEM  OF  DENTISTRY.  In 
treatises  by  various  authors.  Edited  by  Wilbir  F.  Litch, 
M.  D.,  D.  D.  S.  The  complete  work  is  now  ready  in  three 
very  handsome,  exti'a-sized  octavo  volumes,  containing  3160 
pases,  with  1873  engravings  and  9  fiiU-jiage  plates.  Per 
volume,  cloth,  $6.00;  leather,  $7.00;  half  "Morocco,  $8.00. 
Ihr  sale  by  siibscrijHion  only. 

COLEMAN'S  Dental  Surgery  and  Pathologj-.  Revised  by 
Thomas  C.  Stellwagen,  M.  D.,  D.  D.  S.  In  one  handsome 
volume  of  412  pages,  with  331  illustrations.    Cloth,  $;j.25. 

STIMSON'S  Practical  Treatise  on  Fractures  and  Disloca- 
tions. In  two  octavo  volumes.  Volume  I.,  Fractures,  .582 
pages,  360  illus.  Volume  II.,  Dislocations.  .540  pages,  163 
illus.  Complete  work,  cloth,  $.5.50;  leather,  $7.50.  Either 
volume  separately,  cloth,  $;f.00;  leather, $4.00. 

STI3ISON'S  Manual  of  Operative  Surgery.  New  (second) 
edition.  In  one  12mo.  volume  of  503  pages,  with  342  illus- 
trations.   Cloth,  $2.50. 

SMITH'S  (Stephen)  Operative  Surgery.  New  (second) 
and  thoroughly  revised  edition.  In  one  verj'  handsome 
octavo  volume  of  892  pages,  with  1005  illustrations.  Cloth, 
$4;  leather,  $5. 

HAMILTON'S  Practical  Treatise  on  Fractures  and  Dislo- 
cations. Seventh  edition,  thoroughly  revised.  In  one  large 
and  handsome  octavo  volume  of  998  pages,  with  379 
woodcuts.    Cloth,  $5.50;    leather,  $6..50. 

GIBNEY'S  Orthopsedlc  Surgery.  In  one  Svo.  volume,  pro- 
fusely illustrated.    {Jr^-eiKirina.) 

TREVES  on  Intestinal  Obstruction.  In  one  12mo.  volume 
of  522  pages,  with  60  illustrations.  Cloth,  $2.00.  See  .Series 
of  Clinical  Jlfa;!i(«?s,  page2. 

PiCK.  on  Fractures  and  Dislocations.  In  one  l2mo.  volume 
of  530  pages,  with  93 illustrations.  Cloth,. $2.00.  See  Series  of 
Clinical  Maiiuals,  page  2. 

BALL  on  Diseases  of  the  Rectum  and  Anus.  In  one  12mo. 
volume  of  417  pages,  with  54  cuts  and  4  colored  plates. 
Cloth, $2.2.5.    See  Series  of  Clinical  Jfanuals,p.'2. 

BIARSH  on  Diseases  of  the  Joints.  In  one  12mo.  volume 
of  468  pages,  with  64  woodcuts  and  one  colored  plate.  Cloth. 
$2.00.    See  Series  of  Clinical  Mamials,  page  2. 

BtJTLIN  on  the  Tongue.  In  one  12nio.  volume  of  45$ 
pages,  with  8  colored  plates  and  3  woodcuts.  Cloth,  $3.50. 
See  Series  of  Clinical  Manuals,  page  2. 

GOULD'S  Surgical  Diagnosis.  In  one  12mo.  volume  of  589 
pages.    Cloth, $2.00.    See  StudeiUs'  Series  of  JIanuals,  page  1. 

PIRRIE'S  Principles  and  Practice  of  Surgery.  In  one 
Svo.  volume  of  784  pages,  with  316  illustrations.    Cloth,  $3.75. 

MILIiER'S  Principles  of  Surgery.  In  one  large  octavo 
volume  of  683  pages,  with  240  illustrations.    Cloth,  $3.75. 

MILLER'S  Practice  of  Surgery.  In  one  large  octavo  vol- 
ume of  682  pages,  with  364  illustrations.    Cloth,  $3.75. 

MEDICAL   JURISPRUDENCE. 

TIDY'S  Legal  Medicine.  Volumes  I.  and  II.  Imperial 
octavos,  containing  1193  pages.  Price  per  volume,  cloth, 
$6.00;  leather,  $7.00. 

TAYLOR'S  Medical  Jurisprudence.  In  one  large  octavo 
volume. 

TAYLOR  on  Poisons  in  Relation  to  Medical  Jurisprudence 
and  Medicine.  Third  American  from  the  third  revised 
English  edition.  In  one  large  octavo  volume  of  788  pages, 
with  1(H  illustrations.    Cloth,  $.5.50;  leather,  $ti.50. 

PEPPER'S  Forensic  Medicine.  In  one  12mo.  volume. 
{I^-ejMring.)    See  Students'  Sej-ics  of  Manuals,  page  1. 

PERIODICALS. 

THE  AMERICAN  JOURNAL  of  the  Medical  Sciences. 

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Alcoholic  Liquors  in  Health  and  Disease.  In  one  12mo.  vol- 
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HOLLAND'S  Medical  Notes  and  Rellectlons.  In  one 
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COLUMBIA  UNIVERSITY  LIBRARIES        j 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
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A  ninual  for  the  practice  of 
surge] y  . . .   4th  ed. 


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